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IH/BA is also a causitive factor in cardiac and circulatory birth defects the sixth most expensive condition, as well as premature birth and low birth weight the second most expensive and it is one of the contributing factors to infant respiratory distress syndrome (RDS) also known as hyaline membrane disease, the most expensive medical condition to treat and the number one cause of infant mortality.
Mild and moderate cerebral hypoxia generally has no impact beyond the episode of hypoxia; on the other hand, the outcome of severe cerebral hypoxia will depend on the success of damage control, amount of brain tissue deprived of oxygen, and the speed with which oxygen was restored.
If cerebral hypoxia was localized to a specific part of the brain, brain damage will be localized to that region. A general consequence may be epilepsy. The long-term effects will depend on the purpose of that portion of the brain. Damage to the Broca's area and the Wernicke's area of the brain (left side) typically causes problems with speech and language. Damage to the right side of the brain may interfere with the ability to express emotions or interpret what one sees. Damage on either side can cause paralysis of the opposite side of the body.
The effects of certain kinds of severe generalized hypoxias may take time to develop. For example, the long-term effects of serious carbon monoxide poisoning usually may take several weeks to appear. Recent research suggests this may be due to an autoimmune response caused by carbon monoxide-induced changes in the myelin sheath surrounding neurons.
If hypoxia results in coma, the length of unconsciousness is often indicative of long-term damage. In some cases coma can give the brain an opportunity to heal and regenerate, but, in general, the longer a coma, the greater the likelihood that the person will remain in a vegetative state until death. Even if the patient wakes up, brain damage is likely to be significant enough to prevent a return to normal functioning.
Long-term comas can have a significant impact on a patient's families. Families of coma victims often have idealized images of the outcome based on Hollywood movie depictions of coma. Adjusting to the realities of ventilators, feeding tubes, bedsores, and muscle wasting may be difficult. Treatment decision often involve complex ethical choices and can strain family dynamics.
Treatment of infants suffering birth asphyxia by lowering the core body temperature is now known to be an effective therapy to reduce mortality and improve neurological outcome in survivors, and hypothermia therapy for neonatal encephalopathy begun within 6 hours of birth significantly increases the chance of normal survival in affected infants.
There has long been a debate over whether newborn infants with birth asphyxia should be resuscitated with 100% oxygen or normal air. It has been demonstrated that high concentrations of oxygen lead to generation of oxygen free radicals, which have a role in reperfusion injury after asphyxia. Research by Ola Didrik Saugstad and others led to new international guidelines on newborn resuscitation in 2010, recommending the use of normal air instead of 100% oxygen.
For newborn infants starved of oxygen during birth there is now evidence that hypothermia therapy for neonatal encephalopathy applied within 6 hours of cerebral hypoxia effectively improves survival and neurological outcome. In adults, however, the evidence is less convincing and the first goal of treatment is to restore oxygen to the brain. The method of restoration depends on the cause of the hypoxia. For mild-to-moderate cases of hypoxia, removal of the cause of hypoxia may be sufficient. Inhaled oxygen may also be provided. In severe cases treatment may also involve life support and damage control measures.
A deep coma will interfere with body's breathing reflexes even after the initial cause of hypoxia has been dealt with; mechanical ventilation may be required. Additionally, severe cerebral hypoxia causes an elevated heart rate, and in extreme cases the heart may tire and stop pumping. CPR, defibrilation, epinephrine, and atropine may all be tried in an effort to get the heart to resume pumping. Severe cerebral hypoxia can also cause seizures, which put the patient at risk of self-injury, and various anti-convulsant drugs may need to be administered before treatment.
There has long been a debate over whether newborn infants with cerebral hypoxia should be resuscitated with 100% oxygen or normal air. It has been demonstrated that high concentrations of oxygen lead to generation of oxygen free radicals, which have a role in reperfusion injury after asphyxia. Research by Ola Didrik Saugstad and others led to new international guidelines on newborn resuscitation in 2010, recommending the use of normal air instead of 100% oxygen.
Brain damage can occur both during and after oxygen deprivation. During oxygen deprivation, cells die due to an increasing acidity in the brain tissue (acidosis). Additionally, during the period of oxygen deprivation, materials that can easily create free radicals build up. When oxygen enters the tissue these materials interact with oxygen to create high levels of oxidants. Oxidants interfere with the normal brain chemistry and cause further damage (this is known as "reperfusion injury").
Techniques for preventing damage to brain cells are an area of ongoing research. Hypothermia therapy for neonatal encephalopathy is the only evidence-supported therapy, but antioxidant drugs, control of blood glucose levels, and hemodilution (thinning of the blood) coupled with drug-induced hypertension are some treatment techniques currently under investigation. Hyperbaric oxygen therapy is being evaluated with the reduction in total and myocardial creatine phosphokinase levels showing a possible reduction in the overall systemic inflammatory process.
In severe cases it is extremely important to act quickly. Brain cells are very sensitive to reduced oxygen levels. Once deprived of oxygen they will begin to die off within five minutes.
Well-designed clinical trials for stroke treatment in neonates are lacking Recent clinical trials show that therapeutic intervention by brain cooling beginning up to 6 hours after perinatal asphyxia reduces cerebral injury and may improve outcome in term infants, indicating cell death is both delayed and preventable
Pancaspase inhibition and Casp3-selective inhibition have been found to be neuroprotective in neonatal rodents with models of neonatal brain injury, which may lead to pharmacological intervention In a study done by Chauvier, "et al.", it is suggested that a Caspase inhibitor, TRP601, is a candidate for neuroprotective strategy in prenatal brain injury conditions. They found a lack of detectable side effects in newborn rodents and dogs. This may be a useful treatment in combination with hypothermia.
MRI has proven valuable for defining brain injury in the neonate, but animal models are still needed to identify causative mechanisms and to develop neuroprotective therapies. In order to model human fetal or neonatal brain injury, one needs a species in which a similar proportion of brain development occurs in utero, the volume of white to grey matter is similar to the human brain, an insult can be delivered at an equivalent stage of development, the physiological outcome of the insult can be monitored, and neurobehavioral parameters can be tested. Some animals that meet these criteria are sheep, non-human primates, rabbits, spiny mice, and guinea pigs.
Transplantation of neural stem cells and umbilical cord stem cells is currently being trialed in neonatal brain injury, but it is not yet known if this therapy is likely to be successful.
Some evidence suggests that magnesium sulfate administered to mothers prior to early preterm birth reduces the risk of cerebral palsy in surviving neonates. Due to the risk of adverse effects treatments may have, it is unlikely that treatments to prevent neonatal strokes or other hypoxic events would be given routinely to pregnant women without evidence that their fetus was at extreme risk or has already suffered an injury or stroke. This approach might be more acceptable if the pharmacologic agents were endogenously occurring substances (those that occur naturally in an organism), such as creatine or melatonin, with no adverse side-effects.
Because of the period of high neuronal plasticity in the months after birth, it may be possible to improve the neuronal environment immediately after birth in neonates considered to be at risk of neonatal stroke. This may be done by enhancing the growth of axons and dendrites, synaptogenesis and myelination of axons with systemic injections of neurotrophins or growth factors which can cross the blood–brain barrier.
Perinatal asphyxia is the medical condition resulting from deprivation of oxygen (hypoxia) to a newborn infant long enough to cause apparent harm. It results most commonly from a drop in maternal blood pressure or interference during delivery with blood flow to the infant's brain. This can occur as a result of inadequate circulation or perfusion, impaired respiratory effort, or inadequate ventilation. There has long been a scientific debate over whether newborn infants with asphyxia should be resuscitated with 100% oxygen or normal air. It has been demonstrated that high concentrations of oxygen lead to generation of oxygen free radicals, which have a role in reperfusion injury after asphyxia. Research by Ola Didrik Saugstad and others led to new international guidelines on newborn resuscitation in 2010, recommending the use of normal air instead of 100% oxygen.
There is current controversy regarding the medicolegal definitions and impacts of birth asphyxia. Plaintiff's attorneys often take the position that birth asphyxia is often preventable, and is often due to substandard care and human error. They have utilized some studies in their favor that have demonstrated that, "...although other potential causes exist, asphyxia and hypoxic-ischemic encephalopathy affect a substantial number of babies, and they are preventable causes of cerebral palsy." The American Congress of Obstetricians and Gynecologists disputes that conditions such as cerebral palsy are usually attributable to preventable causes, instead associating them with circumstances arising prior to birth and delivery.
A 2008 bulletin from the World Health Organization estimates that 900,000 total infants die each year from birth asphyxia, making it a leading cause of death for newborns.
In the United States, intrauterine hypoxia and birth asphyxia was listed as the tenth leading cause of neonatal death.
Cord blood gas analysis can be used to determine if there is perinatal hypoxia/asphyxia, which are potential causes of hypoxic-ischemic encephalopathy or cerebral palsy, and give insight into causes of intrapartum fetal distress. Cord blood gas analysis is indicated for high-risk pregnancies, in cases where C-sections occurred due to fetal compromise, if there were abnormal fetal heart rate patterns, Apgar scores of 3 or lower, intrapartum fever, or multifetal gestation.
Evidence of brain injury related to the hypoxic-ischemic events that cause neonatal encephalopathy can be seen with brain MRIs, CTs, magnetic resonance spectroscopy imaging or ultrasounds.
Neonatal encephalopathy may be assessed using Sarnat staging.
Situations that can cause asphyxia include but are not limited to: the constriction or obstruction of airways, such as from asthma, laryngospasm, or simple blockage from the presence of foreign materials; from being in environments where oxygen is not readily accessible: such as underwater, in a low oxygen atmosphere, or in a vacuum; environments where sufficiently oxygenated air is present, but cannot be adequately breathed because of air contamination such as excessive smoke.
Other causes of oxygen deficiency include
but are not limited to:
- Acute respiratory distress syndrome
- Carbon monoxide inhalation, such as that from a car exhaust and the smoke's emission from a lighted cigarette: carbon monoxide has a higher affinity than oxygen to the hemoglobin in the blood's red blood corpuscles, bonding with it tenaciously, and, in the process, displacing oxygen and preventing the blood from transporting oxygen around the body
- Contact with certain chemicals, including pulmonary agents (such as phosgene) and blood agents (such as hydrogen cyanide)
- Drowning
- Drug overdose
- Exposure to extreme low pressure or vacuum to the pattern (see space exposure)
- Hanging, specifically suspension or short drop hanging
- Self-induced hypocapnia by hyperventilation, as in shallow water or deep water blackout and the choking game
- Inert gas asphyxiation
- Congenital central hypoventilation syndrome, or primary alveolar hypoventilation, a disorder of the autonomic nervous system in which a patient must consciously breathe; although it is often said that persons with this disease will die if they fall asleep, this is not usually the case
- Respiratory diseases
- Sleep apnea
- A seizure which stops breathing activity
- Strangling
- Breaking the wind pipe.
- Prolonged exposure to chlorine gas
Many studies of the mechanical properties of brain edema were conducted in the 2010, most of them based on finite element analysis (FEA), a widely used numerical method in solid mechanics. For example, Gao and Ang used the finite element method to study changes in intracranial pressure during craniotomy operations. A second line of research on the condition looks at thermal conductivity, which is related to tissue water content.
Overall, the relative incidence of neonatal encephalopathy is estimated to be between 2 and 9 per 1000 term births. 40% to 60% of affected infants die by 2 years old or have severe disabilities. In 2013 it was estimated to have resulted in 644,000 deaths down from 874,000 deaths in 1990.
Treatment approaches can include osmotherapy using mannitol, diuretics to decrease fluid volume, corticosteroids to suppress the immune system, hypertonic saline, and surgical decompression to allow the brain tissue room to swell without compressive injury.
The mortality rate of meconium-stained infants is considerably higher than that of non-stained infants; meconium aspiration used to account for a significant proportion of neonatal deaths. Residual lung problems are rare but include symptomatic cough, wheezing, and persistent hyperinflation for up to five to ten years. The ultimate prognosis depends on the extent of CNS injury from asphyxia and the presence of associated problems such as pulmonary hypertension. Fifty percent of newborns affected by meconium aspiration would die fifteen years ago; however, today the percent has dropped to about twenty.
High risk infants may be identified by fetal tachycardia, bradycardia or absence of fetal accelerations upon CTG in utero, at birth the infant may look cachexic and show signs of yellowish meconium staining on skin, nail and the umbillical cord, these infants usually progress onto Infant Respiratory distress syndrome within 4 hours. Investigations which can confirm the diagnosis are fetal chest x-ray, which will show hyperinflation, diaphragmatic flattening, cardiomegaly, patchy atelectasis and consolidation, and ABG samples, which will show decreased oxygen levels.
A study of aortic cross-clamping, a common procedure in cardiac surgery, demonstrated a strong potential benefit with further research ongoing.
Recent investigations suggest a possible beneficial effect of mesenchymal stem cells on heart and kidney reperfusion injury.
Cases of cerebral softening in infancy versus in adulthood are much more severe due to an infant's inability to sufficiently recover brain tissue loss or compensate the loss with other parts of the brain. Adults can more easily compensate and correct for the loss of tissue use and therefore the mortality likelihood in an adult with cerebral softening is less than in an infant.
Transient tachypnea of the newborn occurs in approximately 1 in 100 preterm infants and 3.6-5.7 per 1000 term infants. It is most common in infants born by Cesarian section without a trial of labor after 35 weeks' gestation. Male infants and infants with an umbilical cord prolapse or perinatal asphyxia are at higher risk. Parental risk factors include use of pain control or anesthesia during labor, asthma, and diabetes.
In medicine, cerebral softening (encephalomalacia) is a localized softening of the brain substance, due to hemorrhage or inflammation. Three varieties, distinguished by their color and representing different stages of the morbid process, are known respectively as red, yellow, and white softening.
TTN is a diagnosis of exclusion as it is a benign condition that can have symptoms and signs similar to more serious conditions, such as respiratory distress syndrome. A chest X-ray may show a radiopaque line - fluid - in the horizontal fissure of the right lung, fluid infiltrate throughout alveoli or fluid in individual lung lobes. The lungs may also appear hyperinflated.
Providers such as pediatricians and dentists can provide information to parents and caregivers about what food and toys are appropriate by age to prevent choking. The American Academy of Pediatricians recommends waiting until 6 months of age before introducing solid foods to infants. Caregivers can supervise children while eating or playing. Also, caregivers can avoid giving children younger than 5 foods that pose a high risk of choking such as hot dog pieces, cheese sticks, cheese chunks, hard candy, nuts, grapes, marshmallows, or popcorn. Parents, teachers, child care providers, and other caregivers for children get training in choking first aid and cardiopulmonary resuscitation (CPR).
In the US, manufacturers of children's toys and products must follow requirements to prevent choking and include appropriate warning labels. However, toys that are resold may not be marked with warning labels. Caregivers can try to prevent choking by considering the features of a toy (such as size, shape, consistency, small parts) before giving it to a child. Children's products that are found to pose a choking risk can be recalled.
Antenatal corticosteroids have a role in reducing incidence of germinal matrix hemorrhage in premature infants.
For children less than 1 year, the American Heart Association recommends performing cycles of 5 back blows (or slaps) followed by 5 chest compressions. These cycles of 5 back blows then 5 chest compressions are repeated until the object comes out of the infant's airway or until the infant becomes unresponsive. If the infant becomes unresponsive, the American Heart Association recommends starting CPR. The reason that abdominal thrusts are not recommended in children less than 1 year is because they can cause liver damage.