Editor's note: This text-based course is a transcript of the webinar, Pediatric Interventions For Hypoxic Ischemic Encephalopathy (HIE), presented by Aditi Mehra, DHSc, OTR/L.
*Please also use the handout with this text course to supplement the material.
Learning Outcomes
- After this course, participants will be able to recognize the different clinical presentations of HIE in children.
- After this course, participants will be able to analyze the impact of HIE on global development delay.
- After this course, participants will be able to compare and contrast current intervention trends and treatment modalities.
Introduction
Welcome, everyone, to this fascinating topic. Today, I’ll be discussing Hypoxic Ischemic Encephalopathy (HIE). HIE resonates deeply with me because I've encountered numerous clients affected by it. As occupational and physical therapists, we often manage a range of symptoms associated with HIE, but we may not always know the backstory or fully understand the origins of these cases. This is why I felt it was essential to bring attention to this topic.
My primary goal in this presentation is to broaden our understanding of HIE. Many of us treat children with this diagnosis, often focusing on the symptoms rather than understanding the initial cause or etiology. I want to ensure that we can recognize the various clinical presentations of HIE and understand its impact on global developmental delays. It’s easy to get sidetracked, thinking it's purely motor-related, but HIE affects multiple facets of development. I also hope to explore and compare current intervention trends and treatment modalities. As an OT, my focus is on fine motor skills, but I’m fully aware that broader motor aspects, along with other factors, influence my approach to intervention.
Even after over 20 years in this field, I always seek new strategies to address complex conditions like HIE. These cases are often multifaceted and demand a thoughtful, comprehensive approach. Let's explore this topic together.
Definition and Epidemiology
Let’s begin with a look at the definition and epidemiology of HIE. Hypoxic Ischemic Encephalopathy (HIE) typically occurs due to birth complications, leading to a reduction in oxygen and blood flow to the infant's brain. In the United States, the incidence of HIE is approximately 1.5 to 2 cases per thousand live births, translating to around 9,000 to 12,000 cases annually.
HIE presents in various ways, and as therapists, it’s crucial not only to identify and manage symptoms but also to understand how these symptoms develop. This deeper insight into the origins of HIE can guide our prognosis and inform more effective treatment approaches. The severity of HIE can range from mild cases, which may allow for a full recovery, though subtle deficits can sometimes persist, to moderate and severe cases that often lead to long-term neurological impairments. These impairments include cerebral palsy (CP), epilepsy, and other cognitive disabilities.
We frequently encounter HIE in children who have been diagnosed with CP, as cerebral palsy is a common presentation when managing cases with HIE. Understanding the nuances of each case—mild, moderate, or severe—helps us tailor our interventions and anticipate the challenges and potential progress each child may experience.
Prevalence
The prevalence of HIE is notably higher in countries with less developed healthcare systems, which face a significantly higher burden due to limited access to advanced medical care. This disparity was staggering to me when I learned about it. Birth asphyxia alone accounts for approximately 23% of all neonatal deaths worldwide. Growing up in Zambia, I saw this firsthand. My mother, an OB-GYN there, often shared stories about the cases she encountered and reflected on how improved healthcare infrastructure could have alleviated many of these tragic outcomes. The prevalence and impact of HIE and birth asphyxia are strikingly evident in these settings, highlighting the need for more accessible and advanced care globally.
Key Medical Markers
Let’s delve into some of the key medical markers associated with HIE. Due to oxygen deprivation and inadequate blood flow to the brain, significant issues can arise in infants, potentially occurring during prenatal, perinatal, or even postnatal periods. HIE isn’t confined to just the moment of birth. Tragically, by the age of two, about 60% of infants with HIE either pass away or experience severe physical and mental disabilities.
You'll often encounter some of these critical markers when taking a health history. The APGAR score is one of the main indicators, assessing the infant’s breathing, heart rate, muscle tone, reflexes, and skin color shortly after birth. In addition to the APGAR score, umbilical cord blood gas tests are commonly used to assess the level of oxygen deprivation the infant experienced.
Imaging tools like MRI and ultrasound are also used to evaluate brain injury severity. Another aspect to consider is the metabolic acidosis that can occur during HIE, reflecting a buildup of lactic acid due to inadequate oxygen, often coupled with respiratory distress. This may be less visible in our OT assessments, where we often focus more on motor impairments, but it's essential to recognize these underlying factors. These markers give us insight into the infant's early medical experiences and the potential for complex neurological outcomes.
Pathophysiology of HIE
The pathophysiology of HIE is complex and multifaceted, involving a cascade of biochemical events triggered by hypoxia and ischemia. Initially, I thought it might be straightforward, but researching it revealed just how intricate this process truly is—it took me back to my biochemistry days.
At the core, the lack of oxygen and glucose significantly reduces ATP (Adenosine Triphosphate) production, essential for cellular functions such as ion exchange and neurotransmitter recycling. This deficit leads to neuronal depolarization and an excessive release of glutamate, an excitatory neurotransmitter. The glutamate surge prevents neurons from resting, causing an overexcitation that further injures neural cells—a process that can be highly damaging.
The next phase, or secondary stage, begins when blood flow is partially restored. However, this phase presents its own risks, as the production of harmful molecules called reactive oxygen species damages cell membranes and mitochondria, exacerbating cellular injury. Finally, the tertiary stage—often referred to as the inflammatory stage—involves a heightened inflammatory response within the brain. This inflammation, fueled by edema, further complicates recovery and contributes to ongoing neural damage.
Key regions affected by this cascade include the basal ganglia, hippocampus, and cortex. Recognizing these areas of impact is crucial, as damage here can lead to a range of challenges beyond motor impairments, including cognitive and behavioral issues. This knowledge underscores that HIE has implications extending beyond the physical symptoms we often see in therapy, necessitating a comprehensive approach to treatment and support.
Levels of HIE
Let's now look at the levels of HIE.
Mild Hypoxic Ischemic Encephalopathy
In cases of mild HIE, the diagnosis might not even be apparent unless you thoroughly investigate the child’s history. You may notice slight increases in muscle tone, and deep tendon reflexes might be a bit brisk in the first few days, but these often normalize quickly. Behavioral signs can include poor feeding and irritability, which parents sometimes describe as resembling “failure to thrive.” Many children initially receive a failure to thrive diagnosis, with HIE being identified only later on. Thankfully, these symptoms in mild cases typically resolve within 24 hours. This subtlety highlights the importance of understanding early signs and keeping an eye on potential developmental nuances over time.
Moderately Severe Hypoxic Ischemic Encephalopathy
In moderate to severe HIE cases, infants often present as very lethargic, with notable hypotonia and diminished reflexes. Key reflexes like grasping, Moro, and sucking are typically sluggish or may even be absent. Sometimes, these reflexes emerge only after a significant delay. Additionally, apnea can occur, and seizures are a common marker, often appearing within the first 24 hours after birth.
Full recovery within one to two weeks is possible, which generally indicates a more favorable long-term outlook. However, even when recovery appears complete, lingering effects can still be observed, often as developmental delays or other subtle impairments. This reinforces the need to monitor these children closely, as even mild residual impacts can influence their developmental trajectory.
Severe HypoxicIschemic Encephalopathy
In cases of severe hypoxic ischemic encephalopathy, seizures may be delayed in onset but are often severe and resistant to conventional treatments. Breathing irregularities, pronounced hypotonia, and markedly depressed deep tendon reflexes are common indicators. Unlike in milder cases, the basic neonatal reflexes—such as rooting and sucking—are not just delayed; they are typically absent, which serves as a significant marker of severe HIE.
Additionally, disturbances in ocular motion are often evident. Signs such as eye deviation, nystagmus, and dilated or poorly reactive pupils suggest cranial nerve involvement, particularly affecting the oculomotor system. These ocular symptoms underscore the extent of the neurological damage and highlight the need for a comprehensive approach to immediate and long-term management in these cases.
Clinical Presentation and Diagnosis
Those are the levels of HIE, each with distinct clinical presentations and diagnostic considerations. As we've seen, the severity of symptoms can range widely, from variations in seizure activity and levels of consciousness to differences in active participation in development. Diagnostically, tools like MRI, EEGs, and specific biomarkers are commonly used to assess HIE.
Additionally, there is a grading scale known as the Sarnat classification, which you may encounter in a client’s medical history. This system is designed to classify the severity of HIE in neonates based on clinical signs, helping to predict outcomes and guide early interventions. For instance, interventions like therapeutic hypothermia are initiated within the first few hours of birth to mitigate damage, and the Sarnat grading is a key factor in guiding these early-stage treatments. While the Sarnat scale isn’t something we would apply ourselves, it’s valuable to understand its relevance when interpreting a client’s historical data and anticipating the potential course of interventions.
Seizures
One of the most prevalent and challenging facets of HIE we encounter is seizures. For children with HIE, seizures are often a prominent part of life, so it’s essential to recognize and understand the types you may encounter. Let’s go through a brief overview of the most common types.
Tonic seizures involve sustained muscle contractions, where body parts, like arms or legs, stiffen. Breathing may be briefly impacted, and while these seizures are usually brief—lasting only 10 to 20 seconds—they’re often associated with significant brain injury, particularly HIE. Myoclonic seizures, on the other hand, are characterized by brief, jerky movements due to sudden muscle contractions. Often described as muscle "twitching," these can occur in isolation or clusters, frequently indicating more severe brain injury and poorer neurological outcomes.
Febrile seizures, which are triggered by a rapid rise in body temperature, generally occur in children under five. This is something I always emphasize to early intervention teams: if a child with a history of febrile seizures has a fever, therapy may need to be postponed, as the combination could increase seizure risk. In such cases, we see generalized shaking or stiffness accompanying the fever. Atonic seizures, commonly called "drop attacks," are marked by a sudden loss of muscle tone, resulting in abrupt falls or even a quick head drop. I once observed this in a child we were working with in supported standing; the child unexpectedly collapsed, which can be quite alarming.
Absence seizures are brief episodes where the child stares blankly, appearing unresponsive. Focal seizures involve motor, sensory, or autonomic symptoms, often with twitching of a limb or abnormal sensory experiences, like increased heart rate. These seizures usually signal localized brain damage. Lastly, infantile spasms are clusters of sudden, brief neck, trunk, and limb contractions. These spasms, which are rarely isolated, typically occur in clusters and are often recognizable.
Whenever I present on topics like HIE, I strive to include a parent’s perspective. As clinicians, it’s easy for us to get absorbed in the pathophysiology, intervention options, and motor challenges. However, as occupational therapy practitioners, our responsibility is to maintain a holistic approach—not just focusing on what is wrong and what we can do to help but also understanding the family’s journey. This broader view enhances our interventions and allows us to support the child and family meaningfully.
Parent Perspective
Including a parent’s perspective is essential, and in this case, I was fortunate to connect with Katie, a parent I met through her TikTok channel. Katie has been incredibly open about her experiences raising her daughter, Jolene, who has HIE. She generously agreed to share her insights to help educate other therapists.
Video 1
Katie describes HIE in Jolene’s life: Jolene is four and a half years old, and her HIE was caused by a lack of oxygen during birth. Jolene also lives with epilepsy, cerebral palsy, hypertonia, cortical visual impairment (CVI), hearing impairment, two very fragile lungs, and requires round-the-clock care. Katie’s journey of learning about Jolene’s diagnosis and caring for her has been overwhelming, with much of the information coming only after leaving the NICU. She talks about how, as the primary caregiver, each day brings new challenges and lessons.
Katie expresses a profound need for emotional support beyond practical help. She wishes for more resources, support groups, and a space to vent—a hotline, perhaps—where she could be heard. The emotional toll is intense, and while therapy can be helpful, she describes a different need for support and empathy. Accessibility and affordability are also significant issues for her; essential items for Jolene’s care come with high price tags, creating financial stress and physical and emotional strain.
Watching Katie’s video, my first thoughts as an OTP naturally go to her daughter’s condition, but the physical and emotional impact also strikes me on Katie. I’m concerned about her body mechanics as she holds and carries Jolene and how this might affect her physical health in the long term. This brings up a critical point: therapists need to see the whole family unit, not just the child or patient. For Katie, I would consider how her physical needs could be supported to ease the physical demands of caregiving.
Katie’s words about parent education also resonate. We may feel ready to share information on the diagnosis, but each parent is at a different stage in processing, and not all are ready for an in-depth discussion right away. It reminds me that understanding a parent’s emotional readiness is crucial.
Katie’s call for emotional support brings me back to my own experience. I remember, years ago, taking my son, who had failure to thrive, to an early morning therapy session. While the therapist worked with him, I’d allow myself 15 to 20 minutes to cry, to release emotions I’d held in, knowing my son was in good hands. The emotional load parents carry is profound, and as therapists, we should recognize this as part of the care journey.
Katie’s point about affordability, inclusion, and ableism is another area where we, as therapists, can be more mindful. Often, our focus is on recommending the best equipment or tools for the child, only later considering cost and insurance. Katie’s story reminds me of the importance of involving case managers and checking coverage early in the process to avoid putting parents in the position of needing something crucial yet financially out of reach.
Katie’s video challenges us to consider our role beyond just therapeutic interventions. How can we approach our practice holistically when we work with children with HIE and their families? How can we better support the whole family, be attuned to their emotional needs, and consider the broader implications of our recommendations? This perspective is a powerful reminder of the multifaceted support families like Katie and Jolene need.
Case Study: Lee
Let’s take a closer look at a case study recently featured in an article by Anka et al. (2024). It centers on an 11-month-old boy, whom we’ll call "Lee," with a history of perinatal HIE. This study offers valuable insights into the developmental challenges a child like Lee might face, along with the interventions used and their outcomes, making it an ideal fit for this presentation.
When taking a medical history from Lee’s mother, his primary caregiver, her main concern was his lack of trunk control and delays in sitting and standing abilities compared to his peers. This is her second child, which gives her a point of comparison, and her insight is vital for understanding Lee’s unique needs. During labor, she experienced hypertension, and although Lee was born full-term, his birth weight was only around 2.4 kilograms (approximately 5.5 pounds), with an APGAR score of 4. Given this background, there are some significant concerns to address.
Postnatally, Lee has experienced frequent colds and fevers, leading to hospitalizations. The article didn’t confirm febrile seizures, but given his history, this possibility might warrant further investigation with a physician’s guidance. Lee’s responsiveness has improved, though he still requires ongoing medical treatment. By 11 months, he was referred for PT and OT services, with developmental assessments indicating he functions at an approximate developmental age of six months.
This case highlights Lee's specific physical delays, particularly in trunk control and mobility, and the broader context of his care needs. The mother’s role as primary caregiver, coupled with her experience of managing his ongoing medical treatments, provides essential context as we consider interventions that will support both Lee's and his mother’s needs.
Lee's Motor Skills
In an initial joint assessment by PT and OT, we would look comprehensively at various developmental aspects. One of the first questions for fine motor skills would be whether Lee is grasping objects effectively. He isn’t reaching for objects with both hands as expected for his age, though he can reach the midline. However, he doesn’t attempt to reach for objects beyond midline and hasn’t started mouthing or transferring objects. He has developed purposeful release by eight months, as he can drop objects.
From a gross motor perspective, his head control is at the level expected for a three-month-old, his rolling abilities are comparable to those of a nine-month-old, and he’s not yet sitting or crawling. These are key areas to focus on in our initial evaluation.
Additional areas I would assess as an OT include sensory processing aspects. I’d ask the mother about any observable sensory responses or difficulties. An aspect that isn’t often highlighted in literature but is relevant to consider is whether Lee underwent therapeutic hypothermia (cooling therapy), the primary treatment for hypoxic ischemic encephalopathy (HIE) in newborns. Exposure to extreme cold during such treatment could potentially impact sensory processing abilities, although there’s limited research on this. It’s a question worth exploring to understand how behavioral responses to sensory input might differ following hypothermia treatment and whether any further research supports this consideration.
What Else Was Assessed?
In evaluating Lee's developmental progress, we’d naturally want to assess his communication and social interaction skills. Important questions include whether he’s cooing, using any words, smiling, responding to sounds, or turning toward his mother’s voice. His general awareness of the environment is also crucial to observe.
The article details several intervention strategies employed to address Lee’s needs, and I’ll go through some of these. Recognizing and evaluating the effectiveness of these strategies is essential for understanding which approaches can best support developmental progress in cases like his.
Intervention Strategy 1. The first goal focused on improving head control. Gentle neck and upper body exercises were used to build strength, often incorporating a toy to engage Lee and encourage visual tracking—a key aspect in developing head stability. Additionally, a neck facilitation and Neuro-Developmental Treatment (NDT) approach was applied. This involved positioning Lee prone on a Swiss ball to promote neck extension and scapular retraction. Visualizing this setup, it’s easy to picture how supporting his upper body on the ball can facilitate these movements, allowing Lee to work on head control in a dynamic yet supported position.
Intervention Strategy 2. The second strategy focused on rolling, which, while not always a primary goal in OT, can be essential for helping the child reach an object or engage in play, making it a functional skill to incorporate into interventions. Rolling exercises on the mat combined visual and tactile cueing, which I would also use to reinforce movement patterns. Additionally, utilizing a Swiss ball with lower extremity support facilitated trunk rotation and rolling, allowing Lee to develop these skills in a supported, controlled way. You can easily visualize guiding him on the ball to encourage this rotation, building his foundational movement skills for future functional play and mobility.
Intervention Strategy 3. The third intervention strategy targeted sitting and crawling milestones requiring core strength. We focused on core stability exercises and transitioning into a crawling position to facilitate sitting. Visualizing this, you’d be working with Lee to support sitting and guide pelvic and trunk tilts necessary for crawling.
Using a Swiss ball in a prone position promotes core engagement and single-hand weight bearing, helping him develop stability. Another technique I frequently use, and which was also highlighted in this intervention, is side sitting with weight shifting. Side sitting is particularly beneficial for young clients with limited core strength because it actively engages trunk muscles and supports the development of protective reactions—essential for safety and balance. While the case study didn’t specify, Lee likely hasn’t developed these protective reactions, making side-sitting a valuable component of his intervention plan.
Intervention Strategy 4. The fourth intervention strategy focused on developing Lee’s grasp reflex within normal parameters. To encourage grasping, placing objects in his hand can engage him, while gentle hand massages provide sensory input that may stimulate his grasp reflex. Although the case report didn’t mention seizure activity, this is still an important consideration, as seizures can influence motor control and reflexes. Keeping this possibility in mind allows us to remain flexible in our approach, making adjustments to his interventions if seizures later emerge as a factor affecting his grasping abilities.
Intervention Strategy 5. The fifth strategy is designed to enhance Lee's reaching and grasping abilities, targeting movements at midline, across midline, and unilaterally. To support his engagement with his environment, we’d implement various techniques that promote these skills. For an 11-month-old like Lee, placing pom-poms into a container slot can help develop isolated finger strength, while inserting chips into a container builds pincer strength and teaches purposeful “put-in” actions.
Cause-and-effect toys are also beneficial, reinforcing purposeful release, an important skill for grasp and release control. Ensuring Lee is positioned in a high chair for these activities provides trunk support, allowing him to focus on reaching and grasping without the added strain of stabilizing his core. Working in different planes of movement further aids in generalizing these skills across various positions, fostering strength and coordination comprehensively.
Intervention Strategy 6. The sixth strategy aimed to improve sensory awareness, and I was thrilled to see this included in the article, as sensory needs are often overlooked. This strategy involved both tactile and vestibular stimulation. For tactile input, the therapists used techniques like stroking Lee’s palms with various textures and exposure to different types of clothing, blankets, toys, and other sensory materials.
Vestibular stimulation was also a key focus, which is particularly crucial for children like Lee, who, due to limited movement experiences, have missed out on the natural vestibular input that typically developing children gain through transitioning between planes. A typical 11-month-old would actively move through various planes, experiencing vertical, sagittal, and other planes of motion shifts. Children with limited mobility, however, haven’t had these experiences, which impacts their vestibular development. So, when introducing activities like gentle bouncing on a ball, it’s essential to explain to parents the importance of this input for Lee's sensory processing and development.
Proprioceptive stimulation, including techniques like joint compressions, vibrations, and deep pressure, rounded out this strategy. These inputs provide Lee with awareness of his body in space, helping to build his sensory foundation. Educating parents about the purpose and benefits of these sensory interventions ensures they understand the value of activities that might seem unfamiliar, like bouncing on a ball, and reinforces their involvement in supporting their child’s sensory development.
Intervention Strategy 7. The seventh strategy focused on enhancing auditory awareness and encouraging head turning in response to sounds. This involved engaging Lee in auditory orientation exercises, such as having his mother sit in different locations while calling his name from the left, right, or other directions. Observing his responsiveness to these cues helps assess his auditory processing and orientation skills.
A critical part of this strategy is pairing auditory cues with positive reinforcement. I always remind my team that while working on auditory responsiveness is essential, making it a positive experience is equally important. For instance, if Lee turns toward the sound when his name is called from the left, the experience should be rewarding. This could involve his mother’s presence or another pleasant stimulus that engages him, like a favorite YouTube video. Pairing auditory cues with something positive encourages Lee to attend to the sounds, building his responsiveness and interest in auditory interactions.
Intervention Strategy 8. The eighth strategy focuses on enhancing Lee's equilibrium during movement, often referred to as postural control or, as this article terms it, postural coordination. This is essential for developing foundational movement patterns, such as reflexive crawling. The exercise aimed to build the basic posture, coordination, and strength patterns for stable movement in young children.
Hand-over-hand guidance was frequently used to promote these skills, encouraging Lee’s body to engage in and learn these coordinated movements. This hands-on approach supports his body’s natural reflexes and motor learning, gradually helping him build the stability and coordination needed for crawling and other developmental milestones.
Intervention Strategy 9. The ninth and final strategy focused on retraining balance and coordination, utilizing the Neuro-Developmental Treatment (NDT) Bobath technique. If you’re familiar with the Bobath approach, you’ll recognize its emphasis on facilitating natural movement patterns and responses to improve motor function. In Lee’s case, they worked with him in a quadruped and imbalanced position. For instance, they positioned him on his back, then gently shifted his shoulders and pelvis sideways and forward, creating a slight imbalance.
This technique encourages Lee’s muscles to experience what an imbalance feels like and helps his body learn to respond appropriately. By challenging his postural control in this safe, guided way, Lee begins to develop an awareness of balance adjustments, which are foundational for building coordination and motor response skills. The Bobath approach allows him to practice these responses in a controlled, supportive environment.
Vojta Technique
The article introduces a technique called "Vojta" therapy, which I hadn’t encountered before, so I took some time to research it. This approach, developed by Czech neurologist Dr. Václav Vojta, involves positioning the child face down with the head turned to one side while one leg and the opposite arm move together. This setup encourages symmetrical, coordinated movements across both sides of the body.
Vojta therapy stimulates the brain to reflexively activate specific movement patterns, engaging neurological connections across the corpus callosum. This technique has been shown to support foundational locomotion components, like reflexive crawling and rolling, by facilitating neuromuscular activation in children with motor impairments. Research highlights its potential to improve gross motor function, dynamic movement, and even spatiotemporal parameters in children with spastic diplegia, underscoring its therapeutic value.
A unique aspect of Vojta therapy is the application of gentle resistance to activate targeted muscles, often performed in sets of three to encourage fluency. With a structured progression, this technique can adapt as the child’s motor abilities develop. For therapists working with clients like Lee, Vojta therapy offers an alternative approach to enhancing strength and motor control through bilateral coordination and sensory-motor integration.
Outcomes
The outcomes for Lee in this article highlighted the effectiveness of the Vojta technique, showing it to be particularly impactful. Reflex crawling, a core component of the technique, played a pivotal role in his development, significantly improving his crawling abilities. Since crawling is such a foundational skill, strengthening this area had a ripple effect on other developmental aspects, as we know that motor progress radiates outward from core stability.
Resistance is an important element of the Vojta technique, which enhances the child’s muscle activation and engagement. Reflecting on my own experience working with children with cerebral palsy, I realize that resistance is often underutilized in my positioning and intervention techniques. This aspect of Vojta therapy could add a valuable layer to my practice. For anyone interested, I’d recommend exploring the Vojta technique further, as it provides a unique approach to fostering core strength and motor development.
NDT Outcome
The NDT (Bobath) approach was another key component in Lee's intervention, particularly the quadruped imbalance exercise, which many OTPs, including myself, often use. This technique, also effective in side-sitting positions, focuses on developing postural control and balance. The article emphasized that a high number of repetitions was crucial for achieving therapeutic goals, underscoring the importance of fluency through consistent practice.
For optimal results, it’s not just about performing exercises several times a day but doing consecutive repetitions within each session. For instance, instead of just doing an activity two or three times a day, doing each exercise thrice in a row per session is beneficial, and then repeating those sessions throughout the day. This approach reinforces muscle memory and supports progress toward fluency in motor skills, which is essential for Lee's overall development.
Outcome Measures
The article used several outcome measures to evaluate Lee's progress. One primary tool was the Trunk Control Measurement Scale (TCMS), which assesses how effectively a child’s trunk provides a stable base for movement and functional activities. This tool seems valuable for gross motor skills and fine motor development, as stable trunk control is essential for effective upper extremity function. Lee’s pre-treatment TCMS score was 48, decreasing to 30 at the three-month follow-up. The article didn’t provide insight into why this score dropped, leaving us to wonder if other factors, such as a temporary setback or specific deficits, might have contributed.
Another assessment mentioned was the Ballard Score, which is used primarily to estimate the gestational age of newborns by examining aspects like skin texture, plantar creases, breast tissue, eye and ear formation, posture, tone, and reflexes. While more applicable in NICU settings, it provides insights into physical and neuromuscular maturity. For Lee, his pre-treatment Ballard score was 3, improving to 7 post-treatment.
Lastly, they used the Hammersmith Functional Motor Scale (HFMS), which monitors motor milestones and guides therapeutic interventions. Lee’s HFMS score improved from 34 to 44 post-treatment, indicating progress in motor skills.
Although the article noted some limitations, it didn’t clarify the cause of the TCMS score decrease, raising questions about the impact of other variables. Nonetheless, these outcome measures offer a structured way to track functional and developmental changes in children like Lee, helping guide ongoing intervention.
Parent Perspective 2
Video 2
Katie’s insights offer a valuable window into the parental perspective on therapy, emphasizing the importance of individualized, family-centered care. Her biggest frustration with therapy and medical services is feeling unheard, with interactions often reduced to checklists and assessments rather than personal engagement. She longs for a more holistic approach, where therapists ask, “What can Jolene do? What are her strengths and challenges?” This sentiment underscores the value of beginning each session by checking in with the parent or caregiver to understand how the child is doing that day and adapting goals accordingly. After hearing this, I realized I could better involve families by asking for their input on daily goals, which helps them feel empowered and engaged.
Katie also emphasizes the importance of adaptive equipment, sharing an impressive array of items Jolene uses, such as the Peapod chair, Rifton Activity Chair, and various mats, seating, and supportive tools. Each piece of equipment serves a specific purpose, from providing core stability to facilitating safe floor-based activities. She highlights the importance of finding the right fit for the child’s physical and sensory needs, noting that some equipment, like the gate trainer, doesn’t work well for Jolene due to sensory and stability issues.
This aligns with my experience: while PTs often lead on adaptive equipment, OTPs can contribute by assessing sensory components. For instance, Jolene dislikes a specific chair, which could be due to sensory discomfort or perceived instability. This is a great opportunity for OT and PT collaboration, where the OTP’s sensory insight complements the PT’s physical positioning knowledge, resulting in equipment choices that address both comfort and function.
Katie’s dedication to Jolene’s care reminds us that adaptive equipment isn’t a one-size-fits-all solution. The fit needs to be considered through both physical and sensory lenses, ensuring each item supports the child’s body and their comfort and emotional engagement. This collaborative approach can make a world of difference by ensuring that children like Jolene experience therapy and equipment in ways that are supportive, enjoyable, and conducive to their unique needs.
Summary
Early Intervention
The research emphasizes the critical importance of early intervention, a point we’re all familiar with, but it also highlights the need for a collaborative approach. Effective early intervention relies on coordinated efforts across disciplines, integrating input from OT, PT, speech therapy, and other specialists to create a holistic plan that addresses all aspects of a child's development. This collaboration ensures that each specialist brings expertise— motor skills, sensory processing, communication, or adaptive equipment—resulting in a comprehensive, family-centered approach that adapts to the child’s evolving needs.
Seizure Dogs
Seizure-alert dogs can be invaluable for families, especially those managing conditions like HIE and autism. In the case of my client, having a seizure-alert dog was a tremendous help, offering early warnings before seizures, which allowed her to prepare and position her son safely. This advance notice significantly reduced her anxiety and provided a sense of security. There is research supporting the effectiveness of seizure-alert dogs, so it’s a worthwhile area to explore further for anyone interested in understanding how these animals can support children with neurological conditions.
Long-Term Effects of CP and HIE
Children with cerebral palsy (CP) and hypoxic ischemic encephalopathy (HIE) are at an increased risk of developing long-term neurological problems, even if motor impairments are not prominent (Hayes et al., 2018). These challenges include cognitive delays, learning disabilities, attention deficits, and behavioral issues. Additionally, sensory processing difficulties, speech and language challenges, and epilepsy are potential concerns that may arise over time.
Considering these underlying factors in the long-term care of individuals with CP and HIE is important, as they often require comprehensive and ongoing support, even if initial motor abilities appear relatively unaffected.
New Research Links Birth Complications (Including HIE) to Increased Autism Risk
Recent research indicates that complications during pregnancy and delivery are associated with an increased risk of autism spectrum disorder (ASD) in children (Kaiser Permanente, 2017). A comprehensive meta-analysis found that certain prenatal and perinatal factors, such as maternal hypertension, cesarean delivery, and preterm birth, are linked to a higher likelihood of ASD.
Specifically, the study reported that complications during pregnancy are associated with a 22% increased risk of autism, while complications during delivery are linked to a 10% increased risk. When complications occur during both pregnancy and delivery, the risk of autism doubles to 44%.
These findings underscore the importance of monitoring and managing health during pregnancy and delivery to reduce the risk of ASD potentially. Healthcare providers should be vigilant in identifying and addressing complications to support optimal outcomes for both mother and child.
Early Intervention and Assessment
Early intervention is indeed essential for improving outcomes in children with conditions like CP and HIE. Effective intervention relies on comprehensive assessment tools that capture various developmental areas. Developmental screening and neuroimaging conducted by medical professionals form the foundation of initial evaluations. However, as the literature highlights, a truly effective approach requires a multifaceted, multidisciplinary team effort. This collaborative approach ensures that all aspects of the child’s development—motor, cognitive, sensory, and social-emotional—are addressed, providing a holistic pathway for optimal support and progress.
Long-Term Management
Long-term management is indeed crucial, especially in monitoring and addressing spasticity and cognitive impairment in children with HIE. While the literature often emphasizes physical and motor challenges, the behavioral and cognitive impacts of HIE deserve more attention. In my experience as a therapist, these cognitive-behavioral effects can be significant and may affect the child’s daily functioning and interactions, underscoring the need for further research in this area.
Support for families is equally essential as they navigate the complexities of long-term care and the emotional demands associated with HIE. Holistic, family-centered support, alongside comprehensive management strategies, can make a substantial difference in the quality of life for both the child and their caregivers.
Summary of Key Points
A multifaceted approach is essential for managing HIE, with occupational therapy practitioners (OTPs) playing a critical role in early intervention and long-term care. Staying current with research is crucial as new therapeutic strategies and findings continually emerge. I shared a new therapy strategy with you, which was also new for me.
Resources
Some helpful resources for parents include HopeforHIE.org and HIEHelpCenter.org, which provide valuable information and support. Katie, who shared her experiences with her daughter Jolene, is also available on TikTok if you’d like to connect with her insights further.
Exam Poll
1)Which is a key medical marker of hypoxic ischemic encephalopathy (HIE)?
D is the correct answer as these are all key medical markers.
2)Which level of HIE typically resolves in 24 hours?
Mild is the correct level.
3)Which is a TRUE statement of severe hypoxic ischemic encephalopathy?
The true statement is C.
4)What is a diagnostic tool mentioned for HIE?
All of the above is correct, as all of these diagnostic tools were mentioned.
5)What technique, using reflex crawling, has played a pivotal role in enhancing a child's postural coordination, basic movement patterns, and strength?
Vojta is the technique of using reflex crawling.
Questions and Answers
Is HIE-related symptomatology only present in newborns, or can these symptoms persist into toddlerhood?
Depending on the severity of HIE—mild, moderate, or severe—symptoms can certainly continue into toddlerhood. In cases like Jolene’s, who has a severe presentation, symptoms such as oculomotor issues are still visible as she gets older. While some symptoms may dissipate, especially in mild and moderate cases, severe HIE often presents lasting effects that persist into later stages of development. Generally, we see more long-term issues with HIE rather than short-term symptoms.
References
Please refer to the separate handout.
Citation
Mehra, A.(2023). Pediatric interventions for hypoxic ischemic encephalopathy (HIE). OccupationalTherapy.com, Article 5757. Available at www.occupationaltherapy.com
