This handout is for neonatal hypoxic-ischemic encephalopathy (hie). Your care team identified this based on: term/near-term neonate with low apgar + need for prolonged resuscitation + perinatal acidosis (cord ph <7.0 or be ≤ -16) (papile aap 2014 pmid 24864176).
Other reasons your team may use this plan: moderate-to-severe encephalopathy on sarnat staging (lethargy/stupor + abnormal tone + abnormal reflexes + seizures) within 6 h of life; abnormal amplitude-integrated eeg (aeeg) pattern in first hours of life (burst suppression, continuous low voltage, flat trace); sentinel event at delivery (cord prolapse, uterine rupture, placental abruption, shoulder dystocia with delay) (papile aap 2014).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| therapeutic_hypothermia_33_5C_x_72h | Whole-body cooling to esophageal/rectal target 33.5 °C ± 0.5 × 72 h, initiated within 6 h of life; slow rewarming 0.5 °C per hour over 6-8 h | cooling_blanket_or_servo_controlled_cap | continuous × 72 h then rewarm | Standard of care per NICHD whole-body cooling (Shankaran NEJM 2005 PMID 16221780) + TOBY (Azzopardi NEJM 2009 PMID 19797281) + CoolCap selective head cooling (Gluckman Lancet 2005 PMID 15721471); reduces death + moderate-severe disability NNT ~7-9 |
| phenobarbital | phenobarbital 20 mg/kg IV load over 20 min for neonatal seizure; maintenance 5 mg/kg/day divided BID | IV (load) then IV/PO maintenance | load once, then BID maintenance | First-line neonatal anticonvulsant per AAP / Neofax 2024; load achieves rapid serum levels; therapeutic 20-40 mcg/mL (Neofax 2024) |
| levetiracetam | levetiracetam 20-60 mg/kg IV load (start 20 mg/kg; escalate by 20 mg/kg if breakthrough seizure); maintenance 30-60 mg/kg/day divided BID | IV (load) then IV/PO | load once, then BID maintenance | Adjunct or alternative to phenobarbital in neonatal seizure; growing evidence for non-inferiority + better sedation profile vs phenobarbital (NEONATE trial Sharpe Pediatrics 2020 — PMID lookup pending; AAP Red Book 2024-2027; Neofax 2024) |
| morphine | morphine 0.05-0.1 mg/kg IV q4h PRN for shivering / discomfort during cooling; continuous infusion 5-10 mcg/kg/h if frequent dosing needed | IV | q4h PRN or continuous | Comfort during cooling reduces stress-induced metabolic increase; titrate to avoid masking neuro exam (Neofax 2024). Lactation: caution if mother breastfeeds — morphine transfers into milk; monitor infant for sedation / respiratory depression per AAP Section on Breastfeeding 2022 |
| avoid_hyperthermia_active_cooling_if_T_gt_37_5 | Maintain core T ≤ 37.5 °C even after rewarming completion; active cooling (turn off radiant warmer, fan) if T rises | passive_or_active_cooling | continuous monitoring | Hyperthermia worsens injury and reduces benefit of completed cooling; AAP / NICHD guidance |
Plan: Neonatal HIE — therapeutic hypothermia + seizure control + comfort (Papile AAP 2014 PMID 24864176; NICHD/CoolCap/TOBY)
Neurology + developmental peds follow-up at 3 + 6 + 12 + 18-24 mo (Bayley III). Hearing screen (AABR) + audiology at 3 mo. Ophthalmology if cortical visual impairment suspected. PT / OT / speech / feeding therapy as needed. Anticonvulsant taper / continuation per epilepsy status. Family / parental support + grief counseling for severe outcomes.
Guideline: Papile L-A et al — AAP 2014 Hypothermia and Neonatal Encephalopathy (Pediatrics 2014 PMID 24864176); NICHD (Shankaran NEJM 2005 PMID 16221780) + TOBY (Azzopardi NEJM 2009 PMID 19797281) + CoolCap (Gluckman Lancet 2005 PMID 15721471) demonstrate cooling efficacy.