University of Florida



HIE Supportive Care Management GuidelinesTable of Contents PagesI.Fluid and Electrolyte Management3 - 6What intravenous fluids should be initiated upon admission to the NICU?What should be the initial intravenous fluids rate?What should be the target glucose value for infants with HIE?What should be the target Magnesium level for infants with HIE?ReferencesII.Feeding Guidelines7 - 9What should be used for feeds?When should feeds be started and at what volume?How quickly should feeds be advanced?References III.Respiratory and Ventilator Management10 - 14What are the goal values for PaCO2 and PaO2 on Arterial Blood Gases (ABGs)?What parameters are recommended for FiO2 and oxygen saturations?What defines a patient who may be a candidate for ECMO?How should temperature correction factor into interpretation of blood gases?Should patients be extubated during the cooling or rewarming process?ReferencesIV.Cardiovascular Support 15 - 20What is the goal Mean Arterial Blood Pressure (MAP) for infants with HIE?What is the optimal method to manage hypotension with HIE?How does hypothermia affect hemodynamic status post asphyxia?When should an echocardiogram be obtain for infants with HIE?Should serum markers of cardiac injury be obtained in infants with HIE, what markers, and when should they be obtained?How should bradycardia associated with hypothermia be managed? References V.Neurologic and Seizure Management 21 - 25What Medications Should Be Used for Analgesia Infants Being Cooled for HIE?II.When and How Should Infants be Monitored for Seizures?How Should Seizures be Managed in Neonates with HIE?Optimal Time for Brain Imaging in Neonates with HIE?ReferencesNetwork StatementThe Florida Neonatal Neurologic Network support the following management guidelines for infants with HIE. We acknowledge a variety of management styles, consensus statements and scientific data exist in this area, however, these guidelines are based on the best available evidence and pooled expert opinions at the time of this document’s creation.-May 2011 I. Fluid and Electrolyte ManagementSection ContentsWhat intravenous fluids should be initiated upon admission to the NICU?What should be the initial intravenous fluids rate?What should be the target glucose value for infants with HIE?What should be the target Magnesium level for infants with HIE?ReferencesI. What intravenous fluids should be initiated upon admission to the NICU?Although no exact literature exists, the most common practice is to start intravenous D10W (10% dextrose solution) upon arrival to the NICU. Recommendations:Use D10W or D10W with protein as the initial intravenous fluid such as pre-mixed starter or day 1 TPN. May consider starting lipids at low concentrations. Neonates undergoing hypothermia may have delayed lipid processing. If lipids are used, monitoring of triglycerides should be considered and lipids titrated according to triglyceride results. Consideration should be given to the use of SMOF lipids instead of Intralipids if lipids are administered during hypothermia. Add electrolytes as required based on the results of serum electrolytes.May need to increase dextrose concentration to maintain adequate glucose delivery (glucose infusion rate) in light of fluid restriction (see below II).Level of Evidence: V- Expert opinion based on current review of the literature.II. What should be the initial intravenous fluids rate?No randomized trials have been performed to examine the initial rate of fluid therapy and long term outcomes. Current recommendations to limit the consequences of HIE include careful management of fluids, with avoidance of fluid overload and thus avoidance of cerebral edema ADDIN EN.CITE <EndNote><Cite><Author>Kecskes</Author><Year>2005</Year><RecNum>1511</RecNum><record><rec-number>1511</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd">1511</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kecskes, Z.</author><author>Healy, G.</author><author>Jensen, A.</author></authors></contributors><titles><title>Fluid restriction for term infants with hypoxic-ischaemic encephalopathy following perinatal asphyxia</title><secondary-title>Cochrane Database Syst Rev</secondary-title></titles><periodical><full-title>Cochrane Database Syst Rev</full-title></periodical><pages>CD004337</pages><number>3</number><edition>2005/07/22</edition><keywords><keyword>Asphyxia Neonatorum/*complications</keyword><keyword>Brain Edema/prevention &amp; control</keyword><keyword>*Fluid Therapy</keyword><keyword>Humans</keyword><keyword>Hypoxia-Ischemia, Brain/etiology/*therapy</keyword><keyword>Infant, Newborn</keyword></keywords><dates><year>2005</year></dates><isbn>1469-493X (Electronic)&#xD;1361-6137 (Linking)</isbn><accession-num>16034927</accession-num><urls><related-urls><url>;(1). Recommendations for fluid restriction in neonates are based on the experience of restricting fluid intake in adults or older children ADDIN EN.CITE <EndNote><Cite><Author>Kecskes</Author><Year>2005</Year><RecNum>1511</RecNum><record><rec-number>1511</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd">1511</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kecskes, Z.</author><author>Healy, G.</author><author>Jensen, A.</author></authors></contributors><titles><title>Fluid restriction for term infants with hypoxic-ischaemic encephalopathy following perinatal asphyxia</title><secondary-title>Cochrane Database Syst Rev</secondary-title></titles><periodical><full-title>Cochrane Database Syst Rev</full-title></periodical><pages>CD004337</pages><number>3</number><edition>2005/07/22</edition><keywords><keyword>Asphyxia Neonatorum/*complications</keyword><keyword>Brain Edema/prevention &amp; control</keyword><keyword>*Fluid Therapy</keyword><keyword>Humans</keyword><keyword>Hypoxia-Ischemia, Brain/etiology/*therapy</keyword><keyword>Infant, Newborn</keyword></keywords><dates><year>2005</year></dates><isbn>1469-493X (Electronic)&#xD;1361-6137 (Linking)</isbn><accession-num>16034927</accession-num><urls><related-urls><url>;(1). Recommendations: Suggested starting rate of 40-60 ml/kg/day which can be adjusted based on the neonates clinical presentation.Fluid management on subsequent days (past day 1) may be adjusted based on urine output, creatinine levels and electrolytes. Children with oliguria, hyponatremia, increasing creatinine levels, or severe HIE should continue to be restricted to the lower range of total fluid volume intake. In milder cases of HIE, with limited multi-organ system involvement, fluid volumes may be liberalized in an attempt to improve nutrition. Level of Evidence: IIIA- Systematic review and Expert opinion based on current review of the literature.III. What should be the target glucose value for infants with HIE?Under normal conditions, the human brain relies almost entirely on glucose to provide substrate for metabolism ADDIN EN.CITE <EndNote><Cite><Author>McGowan</Author><Year>2006</Year><RecNum>1512</RecNum><record><rec-number>1512</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd">1512</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McGowan, J. E.</author><author>Perlman, J. M.</author></authors></contributors><auth-address>Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA. jmcgowan@jhmi.edu</auth-address><titles><title>Glucose management during and after intensive delivery room resuscitation</title><secondary-title>Clin Perinatol</secondary-title></titles><periodical><full-title>Clin Perinatol</full-title></periodical><pages>183-96, x</pages><volume>33</volume><number>1</number><edition>2006/03/15</edition><keywords><keyword>Animals</keyword><keyword>Asphyxia Neonatorum/complications/*therapy</keyword><keyword>Delivery Rooms</keyword><keyword>Glucose/pharmacology/therapeutic use</keyword><keyword>Humans</keyword><keyword>Hyperglycemia/*complications</keyword><keyword>Hypoglycemia/*complications/drug therapy</keyword><keyword>Hypoxia-Ischemia, Brain/*etiology/prevention &amp; control</keyword><keyword>Infant, Newborn</keyword><keyword>*Resuscitation</keyword><keyword>Sweetening Agents/pharmacology/therapeutic use</keyword></keywords><dates><year>2006</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0095-5108 (Print)&#xD;0095-5108 (Linking)</isbn><accession-num>16533644</accession-num><urls><related-urls><url>(05)00120-X [pii]&#xD;10.1016/j.clp.2005.11.007</electronic-resource-num><language>eng</language></record></Cite></EndNote>(2). In newborn infants, cerebral glucose use may account for 70% of total glucose consumption ADDIN EN.CITE <EndNote><Cite><Author>McGowan</Author><Year>2006</Year><RecNum>1512</RecNum><record><rec-number>1512</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd">1512</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McGowan, J. E.</author><author>Perlman, J. M.</author></authors></contributors><auth-address>Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA. jmcgowan@jhmi.edu</auth-address><titles><title>Glucose management during and after intensive delivery room resuscitation</title><secondary-title>Clin Perinatol</secondary-title></titles><periodical><full-title>Clin Perinatol</full-title></periodical><pages>183-96, x</pages><volume>33</volume><number>1</number><edition>2006/03/15</edition><keywords><keyword>Animals</keyword><keyword>Asphyxia Neonatorum/complications/*therapy</keyword><keyword>Delivery Rooms</keyword><keyword>Glucose/pharmacology/therapeutic use</keyword><keyword>Humans</keyword><keyword>Hyperglycemia/*complications</keyword><keyword>Hypoglycemia/*complications/drug therapy</keyword><keyword>Hypoxia-Ischemia, Brain/*etiology/prevention &amp; control</keyword><keyword>Infant, Newborn</keyword><keyword>*Resuscitation</keyword><keyword>Sweetening Agents/pharmacology/therapeutic use</keyword></keywords><dates><year>2006</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0095-5108 (Print)&#xD;0095-5108 (Linking)</isbn><accession-num>16533644</accession-num><urls><related-urls><url>(05)00120-X [pii]&#xD;10.1016/j.clp.2005.11.007</electronic-resource-num><language>eng</language></record></Cite></EndNote>(2). Although, the newborn brain can use other substrates, such as lactate or ketones, as an energy source, the supply of these alternate substrates are usually unpredictable and may not compensate entirely for a decrease in glucose availability ADDIN EN.CITE <EndNote><Cite><Author>McGowan</Author><Year>2006</Year><RecNum>1512</RecNum><record><rec-number>1512</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd">1512</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McGowan, J. E.</author><author>Perlman, J. M.</author></authors></contributors><auth-address>Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA. jmcgowan@jhmi.edu</auth-address><titles><title>Glucose management during and after intensive delivery room resuscitation</title><secondary-title>Clin Perinatol</secondary-title></titles><periodical><full-title>Clin Perinatol</full-title></periodical><pages>183-96, x</pages><volume>33</volume><number>1</number><edition>2006/03/15</edition><keywords><keyword>Animals</keyword><keyword>Asphyxia Neonatorum/complications/*therapy</keyword><keyword>Delivery Rooms</keyword><keyword>Glucose/pharmacology/therapeutic use</keyword><keyword>Humans</keyword><keyword>Hyperglycemia/*complications</keyword><keyword>Hypoglycemia/*complications/drug therapy</keyword><keyword>Hypoxia-Ischemia, Brain/*etiology/prevention &amp; control</keyword><keyword>Infant, Newborn</keyword><keyword>*Resuscitation</keyword><keyword>Sweetening Agents/pharmacology/therapeutic use</keyword></keywords><dates><year>2006</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0095-5108 (Print)&#xD;0095-5108 (Linking)</isbn><accession-num>16533644</accession-num><urls><related-urls><url>(05)00120-X [pii]&#xD;10.1016/j.clp.2005.11.007</electronic-resource-num><language>eng</language></record></Cite></EndNote>(2).Hypoglycemia is the blood glucose concentration at which the glucose supply to the brain is less than the demand for substrate created by the rate of brain energy metabolism. Because this balance cannot easily be measured, the definition of hypoglycemia is based on statistical analysis of blood glucose concentrations measured over the first few days of life in specific neonates ADDIN EN.CITE <EndNote><Cite><Author>McGowan</Author><Year>2006</Year><RecNum>1512</RecNum><record><rec-number>1512</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd">1512</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McGowan, J. E.</author><author>Perlman, J. M.</author></authors></contributors><auth-address>Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA. jmcgowan@jhmi.edu</auth-address><titles><title>Glucose management during and after intensive delivery room resuscitation</title><secondary-title>Clin Perinatol</secondary-title></titles><periodical><full-title>Clin Perinatol</full-title></periodical><pages>183-96, x</pages><volume>33</volume><number>1</number><edition>2006/03/15</edition><keywords><keyword>Animals</keyword><keyword>Asphyxia Neonatorum/complications/*therapy</keyword><keyword>Delivery Rooms</keyword><keyword>Glucose/pharmacology/therapeutic use</keyword><keyword>Humans</keyword><keyword>Hyperglycemia/*complications</keyword><keyword>Hypoglycemia/*complications/drug therapy</keyword><keyword>Hypoxia-Ischemia, Brain/*etiology/prevention &amp; control</keyword><keyword>Infant, Newborn</keyword><keyword>*Resuscitation</keyword><keyword>Sweetening Agents/pharmacology/therapeutic use</keyword></keywords><dates><year>2006</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0095-5108 (Print)&#xD;0095-5108 (Linking)</isbn><accession-num>16533644</accession-num><urls><related-urls><url>(05)00120-X [pii]&#xD;10.1016/j.clp.2005.11.007</electronic-resource-num><language>eng</language></record></Cite></EndNote>(2). During asphyxia, anaerobic glycolysis accelerates the use of glycogen stores; as a consequence, hepatic glycogen stores are depleted, and hepatic glucose production rapidly becomes insufficient to meet cerebral metabolic demands ADDIN EN.CITE <EndNote><Cite><Author>McGowan</Author><Year>2006</Year><RecNum>1512</RecNum><record><rec-number>1512</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd">1512</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McGowan, J. E.</author><author>Perlman, J. M.</author></authors></contributors><auth-address>Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA. jmcgowan@jhmi.edu</auth-address><titles><title>Glucose management during and after intensive delivery room resuscitation</title><secondary-title>Clin Perinatol</secondary-title></titles><periodical><full-title>Clin Perinatol</full-title></periodical><pages>183-96, x</pages><volume>33</volume><number>1</number><edition>2006/03/15</edition><keywords><keyword>Animals</keyword><keyword>Asphyxia Neonatorum/complications/*therapy</keyword><keyword>Delivery Rooms</keyword><keyword>Glucose/pharmacology/therapeutic use</keyword><keyword>Humans</keyword><keyword>Hyperglycemia/*complications</keyword><keyword>Hypoglycemia/*complications/drug therapy</keyword><keyword>Hypoxia-Ischemia, Brain/*etiology/prevention &amp; control</keyword><keyword>Infant, Newborn</keyword><keyword>*Resuscitation</keyword><keyword>Sweetening Agents/pharmacology/therapeutic use</keyword></keywords><dates><year>2006</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0095-5108 (Print)&#xD;0095-5108 (Linking)</isbn><accession-num>16533644</accession-num><urls><related-urls><url>(05)00120-X [pii]&#xD;10.1016/j.clp.2005.11.007</electronic-resource-num><language>eng</language></record></Cite></EndNote>(2). Perinatal asphyxia also may be associated with hyperinsulinemia, which may impair hepatic glucose production further and contribute to cerebral energy depletion by increasing uptake of glucose by peripheral tissue ADDIN EN.CITE <EndNote><Cite><Author>McGowan</Author><Year>2006</Year><RecNum>1512</RecNum><record><rec-number>1512</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd">1512</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McGowan, J. E.</author><author>Perlman, J. M.</author></authors></contributors><auth-address>Division of Neonatology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA. jmcgowan@jhmi.edu</auth-address><titles><title>Glucose management during and after intensive delivery room resuscitation</title><secondary-title>Clin Perinatol</secondary-title></titles><periodical><full-title>Clin Perinatol</full-title></periodical><pages>183-96, x</pages><volume>33</volume><number>1</number><edition>2006/03/15</edition><keywords><keyword>Animals</keyword><keyword>Asphyxia Neonatorum/complications/*therapy</keyword><keyword>Delivery Rooms</keyword><keyword>Glucose/pharmacology/therapeutic use</keyword><keyword>Humans</keyword><keyword>Hyperglycemia/*complications</keyword><keyword>Hypoglycemia/*complications/drug therapy</keyword><keyword>Hypoxia-Ischemia, Brain/*etiology/prevention &amp; control</keyword><keyword>Infant, Newborn</keyword><keyword>*Resuscitation</keyword><keyword>Sweetening Agents/pharmacology/therapeutic use</keyword></keywords><dates><year>2006</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0095-5108 (Print)&#xD;0095-5108 (Linking)</isbn><accession-num>16533644</accession-num><urls><related-urls><url>(05)00120-X [pii]&#xD;10.1016/j.clp.2005.11.007</electronic-resource-num><language>eng</language></record></Cite></EndNote>(2). When hypoglycemia is coupled with asphyxia, the cerebral metabolic effects of the latter are magnified ADDIN EN.CITE <EndNote><Cite><Author>Salhab</Author><Year>2004</Year><RecNum>1514</RecNum><record><rec-number>1514</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd">1514</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Salhab, W. A.</author><author>Wyckoff, M. H.</author><author>Laptook, A. R.</author><author>Perlman, J. M.</author></authors></contributors><auth-address>University of Texas Southwestern Medical Center at Dallas, Department of Pediatrics, Neonatal-Perinatal Medicine, Dallas, Texas, USA.</auth-address><titles><title>Initial hypoglycemia and neonatal brain injury in term infants with severe fetal acidemia</title><secondary-title>Pediatrics</secondary-title></titles><periodical><full-title>Pediatrics</full-title></periodical><pages>361-6</pages><volume>114</volume><number>2</number><edition>2004/08/03</edition><keywords><keyword>Acidosis/*complications</keyword><keyword>Birth Weight</keyword><keyword>Gestational Age</keyword><keyword>Humans</keyword><keyword>Hydrogen-Ion Concentration</keyword><keyword>Hypoglycemia/*complications</keyword><keyword>Hypoxia-Ischemia, Brain/*etiology</keyword><keyword>Infant, Newborn</keyword><keyword>Logistic Models</keyword><keyword>Multivariate Analysis</keyword><keyword>Retrospective Studies</keyword><keyword>Seizures/*etiology</keyword></keywords><dates><year>2004</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1098-4275 (Electronic)&#xD;0031-4005 (Linking)</isbn><accession-num>15286217</accession-num><urls><related-urls><url> [pii]</electronic-resource-num><language>eng</language></record></Cite></EndNote>(3). In addition, hypoglycemia has been associated with impairment in cerebral autoregulation ADDIN EN.CITE <EndNote><Cite><Author>Salhab</Author><Year>2004</Year><RecNum>1514</RecNum><record><rec-number>1514</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd">1514</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Salhab, W. A.</author><author>Wyckoff, M. H.</author><author>Laptook, A. R.</author><author>Perlman, J. M.</author></authors></contributors><auth-address>University of Texas Southwestern Medical Center at Dallas, Department of Pediatrics, Neonatal-Perinatal Medicine, Dallas, Texas, USA.</auth-address><titles><title>Initial hypoglycemia and neonatal brain injury in term infants with severe fetal acidemia</title><secondary-title>Pediatrics</secondary-title></titles><periodical><full-title>Pediatrics</full-title></periodical><pages>361-6</pages><volume>114</volume><number>2</number><edition>2004/08/03</edition><keywords><keyword>Acidosis/*complications</keyword><keyword>Birth Weight</keyword><keyword>Gestational Age</keyword><keyword>Humans</keyword><keyword>Hydrogen-Ion Concentration</keyword><keyword>Hypoglycemia/*complications</keyword><keyword>Hypoxia-Ischemia, Brain/*etiology</keyword><keyword>Infant, Newborn</keyword><keyword>Logistic Models</keyword><keyword>Multivariate Analysis</keyword><keyword>Retrospective Studies</keyword><keyword>Seizures/*etiology</keyword></keywords><dates><year>2004</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1098-4275 (Electronic)&#xD;0031-4005 (Linking)</isbn><accession-num>15286217</accession-num><urls><related-urls><url> [pii]</electronic-resource-num><language>eng</language></record></Cite></EndNote>(3). The use of glucose as a therapy for HIE in animal models have shown conflicting results PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NY0dvd2FuPC9BdXRob3I+PFllYXI+MjAwNjwvWWVhcj48

UmVjTnVtPjE1MTI8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjE1MTI8L3JlYy1udW1iZXI+

PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSIwdnd3dzJ2dGpmMmRmMWV4ZXBhdng1

NXRzZjJkd2V4dmV2emQiPjE1MTI8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0i

Sm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0

aG9yPk1jR293YW4sIEouIEUuPC9hdXRob3I+PGF1dGhvcj5QZXJsbWFuLCBKLiBNLjwvYXV0aG9y

PjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48YXV0aC1hZGRyZXNzPkRpdmlzaW9uIG9mIE5lb25h

dG9sb2d5LCBUaGUgSm9obnMgSG9wa2lucyBVbml2ZXJzaXR5IFNjaG9vbCBvZiBNZWRpY2luZSwg

QmFsdGltb3JlLCBNRCAyMTI4NywgVVNBLiBqbWNnb3dhbkBqaG1pLmVkdTwvYXV0aC1hZGRyZXNz

Pjx0aXRsZXM+PHRpdGxlPkdsdWNvc2UgbWFuYWdlbWVudCBkdXJpbmcgYW5kIGFmdGVyIGludGVu

c2l2ZSBkZWxpdmVyeSByb29tIHJlc3VzY2l0YXRpb248L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+

Q2xpbiBQZXJpbmF0b2w8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVs

bC10aXRsZT5DbGluIFBlcmluYXRvbDwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjE4

My05NiwgeDwvcGFnZXM+PHZvbHVtZT4zMzwvdm9sdW1lPjxudW1iZXI+MTwvbnVtYmVyPjxlZGl0

aW9uPjIwMDYvMDMvMTU8L2VkaXRpb24+PGtleXdvcmRzPjxrZXl3b3JkPkFuaW1hbHM8L2tleXdv

cmQ+PGtleXdvcmQ+QXNwaHl4aWEgTmVvbmF0b3J1bS9jb21wbGljYXRpb25zLyp0aGVyYXB5PC9r

ZXl3b3JkPjxrZXl3b3JkPkRlbGl2ZXJ5IFJvb21zPC9rZXl3b3JkPjxrZXl3b3JkPkdsdWNvc2Uv

cGhhcm1hY29sb2d5L3RoZXJhcGV1dGljIHVzZTwva2V5d29yZD48a2V5d29yZD5IdW1hbnM8L2tl

eXdvcmQ+PGtleXdvcmQ+SHlwZXJnbHljZW1pYS8qY29tcGxpY2F0aW9uczwva2V5d29yZD48a2V5

d29yZD5IeXBvZ2x5Y2VtaWEvKmNvbXBsaWNhdGlvbnMvZHJ1ZyB0aGVyYXB5PC9rZXl3b3JkPjxr

ZXl3b3JkPkh5cG94aWEtSXNjaGVtaWEsIEJyYWluLypldGlvbG9neS9wcmV2ZW50aW9uICZhbXA7

IGNvbnRyb2w8L2tleXdvcmQ+PGtleXdvcmQ+SW5mYW50LCBOZXdib3JuPC9rZXl3b3JkPjxrZXl3

b3JkPipSZXN1c2NpdGF0aW9uPC9rZXl3b3JkPjxrZXl3b3JkPlN3ZWV0ZW5pbmcgQWdlbnRzL3Bo

YXJtYWNvbG9neS90aGVyYXBldXRpYyB1c2U8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHll

YXI+MjAwNjwveWVhcj48cHViLWRhdGVzPjxkYXRlPk1hcjwvZGF0ZT48L3B1Yi1kYXRlcz48L2Rh

dGVzPjxpc2JuPjAwOTUtNTEwOCAoUHJpbnQpJiN4RDswMDk1LTUxMDggKExpbmtpbmcpPC9pc2Ju

PjxhY2Nlc3Npb24tbnVtPjE2NTMzNjQ0PC9hY2Nlc3Npb24tbnVtPjx1cmxzPjxyZWxhdGVkLXVy

bHM+PHVybD5odHRwOi8vd3d3Lm5jYmkubmxtLm5paC5nb3YvZW50cmV6L3F1ZXJ5LmZjZ2k/Y21k

PVJldHJpZXZlJmFtcDtkYj1QdWJNZWQmYW1wO2RvcHQ9Q2l0YXRpb24mYW1wO2xpc3RfdWlkcz0x

NjUzMzY0NDwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48ZWxlY3Ryb25pYy1yZXNvdXJjZS1u

dW0+UzAwOTUtNTEwOCgwNSkwMDEyMC1YIFtwaWldJiN4RDsxMC4xMDE2L2ouY2xwLjIwMDUuMTEu

MDA3PC9lbGVjdHJvbmljLXJlc291cmNlLW51bT48bGFuZ3VhZ2U+ZW5nPC9sYW5ndWFnZT48L3Jl

Y29yZD48L0NpdGU+PENpdGU+PEF1dGhvcj5TYWxoYWI8L0F1dGhvcj48WWVhcj4yMDA0PC9ZZWFy

PjxSZWNOdW0+MTUxNDwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+MTUxNDwvcmVjLW51bWJl

cj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjB2d3d3MnZ0amYyZGYxZXhlcGF2

eDU1dHNmMmR3ZXh2ZXZ6ZCI+MTUxNDwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1l

PSJKb3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxh

dXRob3I+U2FsaGFiLCBXLiBBLjwvYXV0aG9yPjxhdXRob3I+V3lja29mZiwgTS4gSC48L2F1dGhv

cj48YXV0aG9yPkxhcHRvb2ssIEEuIFIuPC9hdXRob3I+PGF1dGhvcj5QZXJsbWFuLCBKLiBNLjwv

YXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48YXV0aC1hZGRyZXNzPlVuaXZlcnNpdHkg

b2YgVGV4YXMgU291dGh3ZXN0ZXJuIE1lZGljYWwgQ2VudGVyIGF0IERhbGxhcywgRGVwYXJ0bWVu

dCBvZiBQZWRpYXRyaWNzLCBOZW9uYXRhbC1QZXJpbmF0YWwgTWVkaWNpbmUsIERhbGxhcywgVGV4

YXMsIFVTQS48L2F1dGgtYWRkcmVzcz48dGl0bGVzPjx0aXRsZT5Jbml0aWFsIGh5cG9nbHljZW1p

YSBhbmQgbmVvbmF0YWwgYnJhaW4gaW5qdXJ5IGluIHRlcm0gaW5mYW50cyB3aXRoIHNldmVyZSBm

ZXRhbCBhY2lkZW1pYTwvdGl0bGU+PHNlY29uZGFyeS10aXRsZT5QZWRpYXRyaWNzPC9zZWNvbmRh

cnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+UGVkaWF0cmljczwvZnVs

bC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjM2MS02PC9wYWdlcz48dm9sdW1lPjExNDwvdm9s

dW1lPjxudW1iZXI+MjwvbnVtYmVyPjxlZGl0aW9uPjIwMDQvMDgvMDM8L2VkaXRpb24+PGtleXdv

cmRzPjxrZXl3b3JkPkFjaWRvc2lzLypjb21wbGljYXRpb25zPC9rZXl3b3JkPjxrZXl3b3JkPkJp

cnRoIFdlaWdodDwva2V5d29yZD48a2V5d29yZD5HZXN0YXRpb25hbCBBZ2U8L2tleXdvcmQ+PGtl

eXdvcmQ+SHVtYW5zPC9rZXl3b3JkPjxrZXl3b3JkPkh5ZHJvZ2VuLUlvbiBDb25jZW50cmF0aW9u

PC9rZXl3b3JkPjxrZXl3b3JkPkh5cG9nbHljZW1pYS8qY29tcGxpY2F0aW9uczwva2V5d29yZD48

a2V5d29yZD5IeXBveGlhLUlzY2hlbWlhLCBCcmFpbi8qZXRpb2xvZ3k8L2tleXdvcmQ+PGtleXdv

cmQ+SW5mYW50LCBOZXdib3JuPC9rZXl3b3JkPjxrZXl3b3JkPkxvZ2lzdGljIE1vZGVsczwva2V5

d29yZD48a2V5d29yZD5NdWx0aXZhcmlhdGUgQW5hbHlzaXM8L2tleXdvcmQ+PGtleXdvcmQ+UmV0

cm9zcGVjdGl2ZSBTdHVkaWVzPC9rZXl3b3JkPjxrZXl3b3JkPlNlaXp1cmVzLypldGlvbG9neTwv

a2V5d29yZD48L2tleXdvcmRzPjxkYXRlcz48eWVhcj4yMDA0PC95ZWFyPjxwdWItZGF0ZXM+PGRh

dGU+QXVnPC9kYXRlPjwvcHViLWRhdGVzPjwvZGF0ZXM+PGlzYm4+MTA5OC00Mjc1IChFbGVjdHJv

bmljKSYjeEQ7MDAzMS00MDA1IChMaW5raW5nKTwvaXNibj48YWNjZXNzaW9uLW51bT4xNTI4NjIx

NzwvYWNjZXNzaW9uLW51bT48dXJscz48cmVsYXRlZC11cmxzPjx1cmw+aHR0cDovL3d3dy5uY2Jp

Lm5sbS5uaWguZ292L2VudHJlei9xdWVyeS5mY2dpP2NtZD1SZXRyaWV2ZSZhbXA7ZGI9UHViTWVk

JmFtcDtkb3B0PUNpdGF0aW9uJmFtcDtsaXN0X3VpZHM9MTUyODYyMTc8L3VybD48L3JlbGF0ZWQt

dXJscz48L3VybHM+PGVsZWN0cm9uaWMtcmVzb3VyY2UtbnVtPjExNC8yLzM2MSBbcGlpXTwvZWxl

Y3Ryb25pYy1yZXNvdXJjZS1udW0+PGxhbmd1YWdlPmVuZzwvbGFuZ3VhZ2U+PC9yZWNvcmQ+PC9D

aXRlPjwvRW5kTm90ZT4AYQA1

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NY0dvd2FuPC9BdXRob3I+PFllYXI+MjAwNjwvWWVhcj48

UmVjTnVtPjE1MTI8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjE1MTI8L3JlYy1udW1iZXI+

PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSIwdnd3dzJ2dGpmMmRmMWV4ZXBhdng1

NXRzZjJkd2V4dmV2emQiPjE1MTI8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0i

Sm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0

aG9yPk1jR293YW4sIEouIEUuPC9hdXRob3I+PGF1dGhvcj5QZXJsbWFuLCBKLiBNLjwvYXV0aG9y

PjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48YXV0aC1hZGRyZXNzPkRpdmlzaW9uIG9mIE5lb25h

dG9sb2d5LCBUaGUgSm9obnMgSG9wa2lucyBVbml2ZXJzaXR5IFNjaG9vbCBvZiBNZWRpY2luZSwg

QmFsdGltb3JlLCBNRCAyMTI4NywgVVNBLiBqbWNnb3dhbkBqaG1pLmVkdTwvYXV0aC1hZGRyZXNz

Pjx0aXRsZXM+PHRpdGxlPkdsdWNvc2UgbWFuYWdlbWVudCBkdXJpbmcgYW5kIGFmdGVyIGludGVu

c2l2ZSBkZWxpdmVyeSByb29tIHJlc3VzY2l0YXRpb248L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+

Q2xpbiBQZXJpbmF0b2w8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVs

bC10aXRsZT5DbGluIFBlcmluYXRvbDwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjE4

My05NiwgeDwvcGFnZXM+PHZvbHVtZT4zMzwvdm9sdW1lPjxudW1iZXI+MTwvbnVtYmVyPjxlZGl0

aW9uPjIwMDYvMDMvMTU8L2VkaXRpb24+PGtleXdvcmRzPjxrZXl3b3JkPkFuaW1hbHM8L2tleXdv

cmQ+PGtleXdvcmQ+QXNwaHl4aWEgTmVvbmF0b3J1bS9jb21wbGljYXRpb25zLyp0aGVyYXB5PC9r

ZXl3b3JkPjxrZXl3b3JkPkRlbGl2ZXJ5IFJvb21zPC9rZXl3b3JkPjxrZXl3b3JkPkdsdWNvc2Uv

cGhhcm1hY29sb2d5L3RoZXJhcGV1dGljIHVzZTwva2V5d29yZD48a2V5d29yZD5IdW1hbnM8L2tl

eXdvcmQ+PGtleXdvcmQ+SHlwZXJnbHljZW1pYS8qY29tcGxpY2F0aW9uczwva2V5d29yZD48a2V5

d29yZD5IeXBvZ2x5Y2VtaWEvKmNvbXBsaWNhdGlvbnMvZHJ1ZyB0aGVyYXB5PC9rZXl3b3JkPjxr

ZXl3b3JkPkh5cG94aWEtSXNjaGVtaWEsIEJyYWluLypldGlvbG9neS9wcmV2ZW50aW9uICZhbXA7

IGNvbnRyb2w8L2tleXdvcmQ+PGtleXdvcmQ+SW5mYW50LCBOZXdib3JuPC9rZXl3b3JkPjxrZXl3

b3JkPipSZXN1c2NpdGF0aW9uPC9rZXl3b3JkPjxrZXl3b3JkPlN3ZWV0ZW5pbmcgQWdlbnRzL3Bo

YXJtYWNvbG9neS90aGVyYXBldXRpYyB1c2U8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHll

YXI+MjAwNjwveWVhcj48cHViLWRhdGVzPjxkYXRlPk1hcjwvZGF0ZT48L3B1Yi1kYXRlcz48L2Rh

dGVzPjxpc2JuPjAwOTUtNTEwOCAoUHJpbnQpJiN4RDswMDk1LTUxMDggKExpbmtpbmcpPC9pc2Ju

PjxhY2Nlc3Npb24tbnVtPjE2NTMzNjQ0PC9hY2Nlc3Npb24tbnVtPjx1cmxzPjxyZWxhdGVkLXVy

bHM+PHVybD5odHRwOi8vd3d3Lm5jYmkubmxtLm5paC5nb3YvZW50cmV6L3F1ZXJ5LmZjZ2k/Y21k

PVJldHJpZXZlJmFtcDtkYj1QdWJNZWQmYW1wO2RvcHQ9Q2l0YXRpb24mYW1wO2xpc3RfdWlkcz0x

NjUzMzY0NDwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48ZWxlY3Ryb25pYy1yZXNvdXJjZS1u

dW0+UzAwOTUtNTEwOCgwNSkwMDEyMC1YIFtwaWldJiN4RDsxMC4xMDE2L2ouY2xwLjIwMDUuMTEu

MDA3PC9lbGVjdHJvbmljLXJlc291cmNlLW51bT48bGFuZ3VhZ2U+ZW5nPC9sYW5ndWFnZT48L3Jl

Y29yZD48L0NpdGU+PENpdGU+PEF1dGhvcj5TYWxoYWI8L0F1dGhvcj48WWVhcj4yMDA0PC9ZZWFy

PjxSZWNOdW0+MTUxNDwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+MTUxNDwvcmVjLW51bWJl

cj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjB2d3d3MnZ0amYyZGYxZXhlcGF2

eDU1dHNmMmR3ZXh2ZXZ6ZCI+MTUxNDwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1l

PSJKb3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxh

dXRob3I+U2FsaGFiLCBXLiBBLjwvYXV0aG9yPjxhdXRob3I+V3lja29mZiwgTS4gSC48L2F1dGhv

cj48YXV0aG9yPkxhcHRvb2ssIEEuIFIuPC9hdXRob3I+PGF1dGhvcj5QZXJsbWFuLCBKLiBNLjwv

YXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48YXV0aC1hZGRyZXNzPlVuaXZlcnNpdHkg

b2YgVGV4YXMgU291dGh3ZXN0ZXJuIE1lZGljYWwgQ2VudGVyIGF0IERhbGxhcywgRGVwYXJ0bWVu

dCBvZiBQZWRpYXRyaWNzLCBOZW9uYXRhbC1QZXJpbmF0YWwgTWVkaWNpbmUsIERhbGxhcywgVGV4

YXMsIFVTQS48L2F1dGgtYWRkcmVzcz48dGl0bGVzPjx0aXRsZT5Jbml0aWFsIGh5cG9nbHljZW1p

YSBhbmQgbmVvbmF0YWwgYnJhaW4gaW5qdXJ5IGluIHRlcm0gaW5mYW50cyB3aXRoIHNldmVyZSBm

ZXRhbCBhY2lkZW1pYTwvdGl0bGU+PHNlY29uZGFyeS10aXRsZT5QZWRpYXRyaWNzPC9zZWNvbmRh

cnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+UGVkaWF0cmljczwvZnVs

bC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjM2MS02PC9wYWdlcz48dm9sdW1lPjExNDwvdm9s

dW1lPjxudW1iZXI+MjwvbnVtYmVyPjxlZGl0aW9uPjIwMDQvMDgvMDM8L2VkaXRpb24+PGtleXdv

cmRzPjxrZXl3b3JkPkFjaWRvc2lzLypjb21wbGljYXRpb25zPC9rZXl3b3JkPjxrZXl3b3JkPkJp

cnRoIFdlaWdodDwva2V5d29yZD48a2V5d29yZD5HZXN0YXRpb25hbCBBZ2U8L2tleXdvcmQ+PGtl

eXdvcmQ+SHVtYW5zPC9rZXl3b3JkPjxrZXl3b3JkPkh5ZHJvZ2VuLUlvbiBDb25jZW50cmF0aW9u

PC9rZXl3b3JkPjxrZXl3b3JkPkh5cG9nbHljZW1pYS8qY29tcGxpY2F0aW9uczwva2V5d29yZD48

a2V5d29yZD5IeXBveGlhLUlzY2hlbWlhLCBCcmFpbi8qZXRpb2xvZ3k8L2tleXdvcmQ+PGtleXdv

cmQ+SW5mYW50LCBOZXdib3JuPC9rZXl3b3JkPjxrZXl3b3JkPkxvZ2lzdGljIE1vZGVsczwva2V5

d29yZD48a2V5d29yZD5NdWx0aXZhcmlhdGUgQW5hbHlzaXM8L2tleXdvcmQ+PGtleXdvcmQ+UmV0

cm9zcGVjdGl2ZSBTdHVkaWVzPC9rZXl3b3JkPjxrZXl3b3JkPlNlaXp1cmVzLypldGlvbG9neTwv

a2V5d29yZD48L2tleXdvcmRzPjxkYXRlcz48eWVhcj4yMDA0PC95ZWFyPjxwdWItZGF0ZXM+PGRh

dGU+QXVnPC9kYXRlPjwvcHViLWRhdGVzPjwvZGF0ZXM+PGlzYm4+MTA5OC00Mjc1IChFbGVjdHJv

bmljKSYjeEQ7MDAzMS00MDA1IChMaW5raW5nKTwvaXNibj48YWNjZXNzaW9uLW51bT4xNTI4NjIx

NzwvYWNjZXNzaW9uLW51bT48dXJscz48cmVsYXRlZC11cmxzPjx1cmw+aHR0cDovL3d3dy5uY2Jp

Lm5sbS5uaWguZ292L2VudHJlei9xdWVyeS5mY2dpP2NtZD1SZXRyaWV2ZSZhbXA7ZGI9UHViTWVk

JmFtcDtkb3B0PUNpdGF0aW9uJmFtcDtsaXN0X3VpZHM9MTUyODYyMTc8L3VybD48L3JlbGF0ZWQt

dXJscz48L3VybHM+PGVsZWN0cm9uaWMtcmVzb3VyY2UtbnVtPjExNC8yLzM2MSBbcGlpXTwvZWxl

Y3Ryb25pYy1yZXNvdXJjZS1udW0+PGxhbmd1YWdlPmVuZzwvbGFuZ3VhZ2U+PC9yZWNvcmQ+PC9D

aXRlPjwvRW5kTm90ZT4AaQBp

ADDIN EN.CITE.DATA (2, 3). Human clinical observations have demonstrated a correlation between lower levels of serum glucose concentrations and higher Sarnat scores ADDIN EN.CITE <EndNote><Cite><Author>Basu</Author><Year>2009</Year><RecNum>1515</RecNum><record><rec-number>1515</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd">1515</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Basu, P.</author><author>Som, S.</author><author>Choudhuri, N.</author><author>Das, H.</author></authors></contributors><auth-address>Department of Biochemistry, Burdwan Medical College and Hospital, Burdwan, West Bengal, India. dr.pallab_basu@</auth-address><titles><title>Contribution of the blood glucose level in perinatal asphyxia</title><secondary-title>Eur J Pediatr</secondary-title></titles><periodical><full-title>Eur J Pediatr</full-title></periodical><pages>833-8</pages><volume>168</volume><number>7</number><edition>2008/10/10</edition><keywords><keyword>*Apgar Score</keyword><keyword>Asphyxia Neonatorum/blood/complications/*physiopathology</keyword><keyword>Female</keyword><keyword>Glucose/*metabolism</keyword><keyword>Hospitals</keyword><keyword>Humans</keyword><keyword>Hypoxia-Ischemia, Brain/blood/etiology/*physiopathology</keyword><keyword>Infant, Newborn</keyword><keyword>Linear Models</keyword><keyword>Male</keyword><keyword>Prospective Studies</keyword><keyword>Risk Factors</keyword><keyword>Severity of Illness Index</keyword><keyword>Uric Acid/*blood</keyword></keywords><dates><year>2009</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>1432-1076 (Electronic)&#xD;0340-6199 (Linking)</isbn><accession-num>18843505</accession-num><urls><related-urls><url>;(4). Further, initial hypoglycemia (≤40) is an important risk factor for perinatal brain injury in depressed neonates ADDIN EN.CITE <EndNote><Cite><Author>Salhab</Author><Year>2004</Year><RecNum>1514</RecNum><record><rec-number>1514</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd">1514</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Salhab, W. A.</author><author>Wyckoff, M. H.</author><author>Laptook, A. R.</author><author>Perlman, J. M.</author></authors></contributors><auth-address>University of Texas Southwestern Medical Center at Dallas, Department of Pediatrics, Neonatal-Perinatal Medicine, Dallas, Texas, USA.</auth-address><titles><title>Initial hypoglycemia and neonatal brain injury in term infants with severe fetal acidemia</title><secondary-title>Pediatrics</secondary-title></titles><periodical><full-title>Pediatrics</full-title></periodical><pages>361-6</pages><volume>114</volume><number>2</number><edition>2004/08/03</edition><keywords><keyword>Acidosis/*complications</keyword><keyword>Birth Weight</keyword><keyword>Gestational Age</keyword><keyword>Humans</keyword><keyword>Hydrogen-Ion Concentration</keyword><keyword>Hypoglycemia/*complications</keyword><keyword>Hypoxia-Ischemia, Brain/*etiology</keyword><keyword>Infant, Newborn</keyword><keyword>Logistic Models</keyword><keyword>Multivariate Analysis</keyword><keyword>Retrospective Studies</keyword><keyword>Seizures/*etiology</keyword></keywords><dates><year>2004</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1098-4275 (Electronic)&#xD;0031-4005 (Linking)</isbn><accession-num>15286217</accession-num><urls><related-urls><url> [pii]</electronic-resource-num><language>eng</language></record></Cite></EndNote>(3).For infants with hyperinsulinism such as infant of diabetic mothers, an operational threshold of 60mg/dl is appropriate for defining the lower limit of normal, as these neonates have very low levels of alternative fuels such as ketones and lactate at low blood glucose concentrations ADDIN EN.CITE <EndNote><Cite><Author>Deshpande</Author><Year>2005</Year><RecNum>1516</RecNum><record><rec-number>1516</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd">1516</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Deshpande, S.</author><author>Ward Platt, M.</author></authors></contributors><auth-address>Royal Shrewsbury Hospital, Mytton Oak Road, Shrewsbury, SY2 6SP, UK. deshpande@rsh.nhs.uk</auth-address><titles><title>The investigation and management of neonatal hypoglycaemia</title><secondary-title>Semin Fetal Neonatal Med</secondary-title></titles><periodical><full-title>Semin Fetal Neonatal Med</full-title></periodical><pages>351-61</pages><volume>10</volume><number>4</number><edition>2005/06/01</edition><keywords><keyword>Blood Glucose/analysis</keyword><keyword>Female</keyword><keyword>Glucose/*metabolism</keyword><keyword>Humans</keyword><keyword>Hyperinsulinism/diagnosis</keyword><keyword>Hypoglycemia/*diagnosis/prevention &amp; control/*therapy</keyword><keyword>Infant, Newborn/*metabolism</keyword><keyword>Infant, Small for Gestational Age/metabolism</keyword><keyword>Neonatal Screening/*methods</keyword><keyword>Pregnancy</keyword><keyword>Risk Assessment</keyword></keywords><dates><year>2005</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1744-165X (Print)&#xD;1744-165X (Linking)</isbn><accession-num>15922680</accession-num><urls><related-urls><url>(05)00019-3 [pii]&#xD;10.1016/j.siny.2005.04.002</electronic-resource-num><language>eng</language></record></Cite></EndNote>(5). Since HIE may be associated with hyperinsulinism, an ideal target of 60-70 mg/dl may be beneficial. Recommendations: Screen for hypoglycemia as early as possible.The target glucose range should be at least above 45mg/dl (in the first 24 hours of life) with an ideal target of 60-70mg/dl or higher.Avoid marked hyperglycemia (≥150 mg/dl). Level of Evidence: IV- Case Series and Expert opinion based on current review of the literature.IV. What should be the target Magnesium level for infants with HIE?Post asphyxia, during the secondary energy failure phase of HIE, there is an excessive release of glutamate which in turn opens NMDA channels within the brain. These open channels allow for excessive calcium influx into neurons which may result in sustained neuronal injury ADDIN EN.CITE <EndNote><Cite><Author>Choi</Author><Year>1993</Year><RecNum>1517</RecNum><record><rec-number>1517</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd">1517</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Choi, D. W.</author><author>Hartley, D. M.</author></authors></contributors><auth-address>Department of Neurology, Washington University School of Medicine, St. Louis, Missouri 63110.</auth-address><titles><title>Calcium and glutamate-induced cortical neuronal death</title><secondary-title>Res Publ Assoc Res Nerv Ment Dis</secondary-title></titles><periodical><full-title>Res Publ Assoc Res Nerv Ment Dis</full-title></periodical><pages>23-34</pages><volume>71</volume><edition>1993/01/01</edition><keywords><keyword>Animals</keyword><keyword>Calcium/*metabolism/pharmacology</keyword><keyword>Cell Death/*drug effects</keyword><keyword>Cerebral Cortex/cytology/*drug effects/physiology</keyword><keyword>Glutamates/*toxicity</keyword><keyword>Glutamic Acid</keyword><keyword>Models, Neurological</keyword><keyword>N-Methylaspartate/antagonists &amp; inhibitors</keyword><keyword>Neurons/cytology/*drug effects/physiology</keyword><keyword>Neurotoxins/*toxicity</keyword><keyword>Receptors, Glutamate/drug effects/physiology</keyword><keyword>Receptors, N-Methyl-D-Aspartate/drug effects/physiology</keyword><keyword>Receptors, Neurotransmitter/drug effects/physiology</keyword></keywords><dates><year>1993</year></dates><isbn>0091-7443 (Print)&#xD;0091-7443 (Linking)</isbn><accession-num>8093332</accession-num><urls><related-urls><url>;(6). Magnesium (Mg2+) is a known NMDA receptor antagonist which may block this calcium influx thereby reducing cortical damage ADDIN EN.CITE <EndNote><Cite><Author>Nowak</Author><Year>1984</Year><RecNum>1518</RecNum><record><rec-number>1518</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd">1518</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nowak, L.</author><author>Bregestovski, P.</author><author>Ascher, P.</author><author>Herbet, A.</author><author>Prochiantz, A.</author></authors></contributors><titles><title>Magnesium gates glutamate-activated channels in mouse central neurones</title><secondary-title>Nature</secondary-title></titles><periodical><full-title>Nature</full-title></periodical><pages>462-5</pages><volume>307</volume><number>5950</number><edition>1984/02/02</edition><keywords><keyword>Animals</keyword><keyword>Aspartic Acid/analogs &amp; derivatives/metabolism</keyword><keyword>Brain/embryology/*physiology</keyword><keyword>Cells, Cultured</keyword><keyword>Electric Conductivity</keyword><keyword>Glutamates/*physiology</keyword><keyword>Ion Channels/*physiology</keyword><keyword>Kinetics</keyword><keyword>Magnesium/*physiology</keyword><keyword>Membrane Potentials</keyword><keyword>Mice</keyword><keyword>N-Methylaspartate</keyword></keywords><dates><year>1984</year><pub-dates><date>Feb 2-8</date></pub-dates></dates><isbn>0028-0836 (Print)&#xD;0028-0836 (Linking)</isbn><accession-num>6320006</accession-num><urls><related-urls><url>;(7). The evidence for the use of Mg2+ as a neuroprotective agent in both animal models of HIE and human trials are inconclusive ADDIN EN.CITE <EndNote><Cite><Author>Bhat</Author><Year>2009</Year><RecNum>1519</RecNum><record><rec-number>1519</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd">1519</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bhat, M. A.</author><author>Charoo, B. A.</author><author>Bhat, J. I.</author><author>Ahmad, S. M.</author><author>Ali, S. W.</author><author>Mufti, M. U.</author></authors></contributors><auth-address>Department of Pediatrics, SKISrinagar, Kashmir, India 190011. mbhat47@</auth-address><titles><title>Magnesium sulfate in severe perinatal asphyxia: a randomized, placebo-controlled trial</title><secondary-title>Pediatrics</secondary-title></titles><periodical><full-title>Pediatrics</full-title></periodical><pages>e764-9</pages><volume>123</volume><number>5</number><edition>2009/04/08</edition><keywords><keyword>Asphyxia Neonatorum/blood/complications/*drug therapy/physiopathology</keyword><keyword>Brain Diseases/etiology</keyword><keyword>Calcium Channel Blockers/*therapeutic use</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>Magnesium/blood</keyword><keyword>Magnesium Sulfate/*therapeutic use</keyword><keyword>Male</keyword><keyword>Neurologic Examination</keyword><keyword>Neuroprotective Agents/therapeutic use</keyword><keyword>Prospective Studies</keyword></keywords><dates><year>2009</year><pub-dates><date>May</date></pub-dates></dates><isbn>1098-4275 (Electronic)&#xD;0031-4005 (Linking)</isbn><accession-num>19349375</accession-num><urls><related-urls><url> [pii]&#xD;10.1542/peds.2007-3642</electronic-resource-num><language>eng</language></record></Cite></EndNote>(8). However, there are several human study that support the infusion of Mg2+ sulfate post asphyxia to improve short-term neurodevelopmental outcome with no major adverse events associate with the infusion PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CaGF0PC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48UmVj

TnVtPjE1MTk8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjE1MTk8L3JlYy1udW1iZXI+PGZv

cmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSIwdnd3dzJ2dGpmMmRmMWV4ZXBhdng1NXRz

ZjJkd2V4dmV2emQiPjE1MTk8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91

cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9y

PkJoYXQsIE0uIEEuPC9hdXRob3I+PGF1dGhvcj5DaGFyb28sIEIuIEEuPC9hdXRob3I+PGF1dGhv

cj5CaGF0LCBKLiBJLjwvYXV0aG9yPjxhdXRob3I+QWhtYWQsIFMuIE0uPC9hdXRob3I+PGF1dGhv

cj5BbGksIFMuIFcuPC9hdXRob3I+PGF1dGhvcj5NdWZ0aSwgTS4gVS48L2F1dGhvcj48L2F1dGhv

cnM+PC9jb250cmlidXRvcnM+PGF1dGgtYWRkcmVzcz5EZXBhcnRtZW50IG9mIFBlZGlhdHJpY3Ms

IFNLSVNyaW5hZ2FyLCBLYXNobWlyLCBJbmRpYSAxOTAwMTEuIG1iaGF0NDdAcmVkaWZmbWFpbC5j

b208L2F1dGgtYWRkcmVzcz48dGl0bGVzPjx0aXRsZT5NYWduZXNpdW0gc3VsZmF0ZSBpbiBzZXZl

cmUgcGVyaW5hdGFsIGFzcGh5eGlhOiBhIHJhbmRvbWl6ZWQsIHBsYWNlYm8tY29udHJvbGxlZCB0

cmlhbDwvdGl0bGU+PHNlY29uZGFyeS10aXRsZT5QZWRpYXRyaWNzPC9zZWNvbmRhcnktdGl0bGU+

PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+UGVkaWF0cmljczwvZnVsbC10aXRsZT48

L3BlcmlvZGljYWw+PHBhZ2VzPmU3NjQtOTwvcGFnZXM+PHZvbHVtZT4xMjM8L3ZvbHVtZT48bnVt

YmVyPjU8L251bWJlcj48ZWRpdGlvbj4yMDA5LzA0LzA4PC9lZGl0aW9uPjxrZXl3b3Jkcz48a2V5

d29yZD5Bc3BoeXhpYSBOZW9uYXRvcnVtL2Jsb29kL2NvbXBsaWNhdGlvbnMvKmRydWcgdGhlcmFw

eS9waHlzaW9wYXRob2xvZ3k8L2tleXdvcmQ+PGtleXdvcmQ+QnJhaW4gRGlzZWFzZXMvZXRpb2xv

Z3k8L2tleXdvcmQ+PGtleXdvcmQ+Q2FsY2l1bSBDaGFubmVsIEJsb2NrZXJzLyp0aGVyYXBldXRp

YyB1c2U8L2tleXdvcmQ+PGtleXdvcmQ+RmVtYWxlPC9rZXl3b3JkPjxrZXl3b3JkPkh1bWFuczwv

a2V5d29yZD48a2V5d29yZD5JbmZhbnQsIE5ld2Jvcm48L2tleXdvcmQ+PGtleXdvcmQ+TWFnbmVz

aXVtL2Jsb29kPC9rZXl3b3JkPjxrZXl3b3JkPk1hZ25lc2l1bSBTdWxmYXRlLyp0aGVyYXBldXRp

YyB1c2U8L2tleXdvcmQ+PGtleXdvcmQ+TWFsZTwva2V5d29yZD48a2V5d29yZD5OZXVyb2xvZ2lj

IEV4YW1pbmF0aW9uPC9rZXl3b3JkPjxrZXl3b3JkPk5ldXJvcHJvdGVjdGl2ZSBBZ2VudHMvdGhl

cmFwZXV0aWMgdXNlPC9rZXl3b3JkPjxrZXl3b3JkPlByb3NwZWN0aXZlIFN0dWRpZXM8L2tleXdv

cmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHllYXI+MjAwOTwveWVhcj48cHViLWRhdGVzPjxkYXRlPk1h

eTwvZGF0ZT48L3B1Yi1kYXRlcz48L2RhdGVzPjxpc2JuPjEwOTgtNDI3NSAoRWxlY3Ryb25pYykm

I3hEOzAwMzEtNDAwNSAoTGlua2luZyk8L2lzYm4+PGFjY2Vzc2lvbi1udW0+MTkzNDkzNzU8L2Fj

Y2Vzc2lvbi1udW0+PHVybHM+PHJlbGF0ZWQtdXJscz48dXJsPmh0dHA6Ly93d3cubmNiaS5ubG0u

bmloLmdvdi9lbnRyZXovcXVlcnkuZmNnaT9jbWQ9UmV0cmlldmUmYW1wO2RiPVB1Yk1lZCZhbXA7

ZG9wdD1DaXRhdGlvbiZhbXA7bGlzdF91aWRzPTE5MzQ5Mzc1PC91cmw+PC9yZWxhdGVkLXVybHM+

PC91cmxzPjxlbGVjdHJvbmljLXJlc291cmNlLW51bT5wZWRzLjIwMDctMzY0MiBbcGlpXSYjeEQ7

MTAuMTU0Mi9wZWRzLjIwMDctMzY0MjwvZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+PGxhbmd1YWdl

PmVuZzwvbGFuZ3VhZ2U+PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+SWNoaWJhPC9BdXRo

b3I+PFllYXI+MjAwMjwvWWVhcj48UmVjTnVtPjY3OTwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1i

ZXI+Njc5PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBkYi1pZD0iMHZ3

d3cydnRqZjJkZjFleGVwYXZ4NTV0c2YyZHdleHZldnpkIj42Nzk8L2tleT48L2ZvcmVpZ24ta2V5

cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1

dG9ycz48YXV0aG9ycz48YXV0aG9yPkljaGliYSwgSC48L2F1dGhvcj48YXV0aG9yPlRhbWFpLCBI

LjwvYXV0aG9yPjxhdXRob3I+TmVnaXNoaSwgSC48L2F1dGhvcj48YXV0aG9yPlVlZGEsIFQuPC9h

dXRob3I+PGF1dGhvcj5LaW0sIFQuIEouPC9hdXRob3I+PGF1dGhvcj5TdW1pZGEsIFkuPC9hdXRo

b3I+PGF1dGhvcj5UYWthaGFzaGksIFkuPC9hdXRob3I+PGF1dGhvcj5GdWppbmFnYSwgSC48L2F1

dGhvcj48YXV0aG9yPk1pbmFtaSwgSC48L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+

PGF1dGgtYWRkcmVzcz5EZXBhcnRtZW50IG9mIFBlZGlhdHJpY3MsIE9zYWthIENpdHkgVW5pdmVy

c2l0eSBHcmFkdWF0ZSBTY2hvb2wgb2YgTWVkaWNpbmUsIE9zYWthLCBKYXBhbi4gaC1pY2hpYmFA

bWVkLm9zYWthLWN1LmFjLmpwPC9hdXRoLWFkZHJlc3M+PHRpdGxlcz48dGl0bGU+UmFuZG9taXpl

ZCBjb250cm9sbGVkIHRyaWFsIG9mIG1hZ25lc2l1bSBzdWxmYXRlIGluZnVzaW9uIGZvciBzZXZl

cmUgYmlydGggYXNwaHl4aWE8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+UGVkaWF0ciBJbnQ8L3Nl

Y29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5QZWRpYXRyIElu

dDwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjUwNS05PC9wYWdlcz48dm9sdW1lPjQ0

PC92b2x1bWU+PG51bWJlcj41PC9udW1iZXI+PGtleXdvcmRzPjxrZXl3b3JkPkFzcGh5eGlhIE5l

b25hdG9ydW0vKmRydWcgdGhlcmFweTwva2V5d29yZD48a2V5d29yZD5IdW1hbjwva2V5d29yZD48

a2V5d29yZD5IeXBveGlhLUlzY2hlbWlhLCBCcmFpbi8qcHJldmVudGlvbiAmYW1wOyBjb250cm9s

PC9rZXl3b3JkPjxrZXl3b3JkPkluZmFudCwgTmV3Ym9ybjwva2V5d29yZD48a2V5d29yZD5NYWdu

ZXNpdW0gU3VsZmF0ZS9hZG1pbmlzdHJhdGlvbiAmYW1wOyBkb3NhZ2UvKnRoZXJhcGV1dGljIHVz

ZTwva2V5d29yZD48a2V5d29yZD5UaW1lIEZhY3RvcnM8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0

ZXM+PHllYXI+MjAwMjwveWVhcj48cHViLWRhdGVzPjxkYXRlPk9jdDwvZGF0ZT48L3B1Yi1kYXRl

cz48L2RhdGVzPjxhY2Nlc3Npb24tbnVtPjEyMjI1NTQ5PC9hY2Nlc3Npb24tbnVtPjx1cmxzPjxy

ZWxhdGVkLXVybHM+PHVybD5odHRwOi8vd3d3Lm5jYmkubmxtLm5paC5nb3YvZW50cmV6L3F1ZXJ5

LmZjZ2k/Y21kPVJldHJpZXZlJmFtcDtkYj1QdWJNZWQmYW1wO2RvcHQ9Q2l0YXRpb24mYW1wO2xp

c3RfdWlkcz0xMjIyNTU0OTwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48L3JlY29yZD48L0Np

dGU+PENpdGU+PEF1dGhvcj5JY2hpYmE8L0F1dGhvcj48WWVhcj4yMDA2PC9ZZWFyPjxSZWNOdW0+

MTI2MDwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+MTI2MDwvcmVjLW51bWJlcj48Zm9yZWln

bi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjB2d3d3MnZ0amYyZGYxZXhlcGF2eDU1dHNmMmR3

ZXh2ZXZ6ZCI+MTI2MDwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFs

IEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+SWNo

aWJhLCBILjwvYXV0aG9yPjxhdXRob3I+WW9rb2ksIFQuPC9hdXRob3I+PGF1dGhvcj5UYW1haSwg

SC48L2F1dGhvcj48YXV0aG9yPlVlZGEsIFQuPC9hdXRob3I+PGF1dGhvcj5LaW0sIFQuIEouPC9h

dXRob3I+PGF1dGhvcj5ZYW1hbm8sIFQuPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3Jz

PjxhdXRoLWFkZHJlc3M+RGVwYXJ0bWVudCBvZiBOZW9uYXRhbG9sb2d5LCBPc2FrYSBDaXR5IEdl

bmVyYWwgSG9zcGl0YWwsIEphcGFuLiBoLWljaGliYUBtZWQub3Nha2EtY3UuYWMuanA8L2F1dGgt

YWRkcmVzcz48dGl0bGVzPjx0aXRsZT5OZXVyb2RldmVsb3BtZW50YWwgb3V0Y29tZSBvZiBpbmZh

bnRzIHdpdGggYmlydGggYXNwaHl4aWEgdHJlYXRlZCB3aXRoIG1hZ25lc2l1bSBzdWxmYXRlPC90

aXRsZT48c2Vjb25kYXJ5LXRpdGxlPlBlZGlhdHIgSW50PC9zZWNvbmRhcnktdGl0bGU+PC90aXRs

ZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+UGVkaWF0ciBJbnQ8L2Z1bGwtdGl0bGU+PC9wZXJp

b2RpY2FsPjxwYWdlcz43MC01PC9wYWdlcz48dm9sdW1lPjQ4PC92b2x1bWU+PG51bWJlcj4xPC9u

dW1iZXI+PGVkaXRpb24+MjAwNi8wMi8yNDwvZWRpdGlvbj48a2V5d29yZHM+PGtleXdvcmQ+QXNw

aHl4aWEgTmVvbmF0b3J1bS8qZHJ1ZyB0aGVyYXB5L3BoeXNpb3BhdGhvbG9neTwva2V5d29yZD48

a2V5d29yZD5DaGlsZCBEZXZlbG9wbWVudC8qcGh5c2lvbG9neTwva2V5d29yZD48a2V5d29yZD5E

b3BhbWluZS9hZG1pbmlzdHJhdGlvbiAmYW1wOyBkb3NhZ2U8L2tleXdvcmQ+PGtleXdvcmQ+RmVt

YWxlPC9rZXl3b3JkPjxrZXl3b3JkPkh1bWFuczwva2V5d29yZD48a2V5d29yZD5JbmZhbnQ8L2tl

eXdvcmQ+PGtleXdvcmQ+SW5mYW50LCBOZXdib3JuPC9rZXl3b3JkPjxrZXl3b3JkPk1hZ25lc2l1

bSBTdWxmYXRlL2FkbWluaXN0cmF0aW9uICZhbXA7IGRvc2FnZS8qdGhlcmFwZXV0aWMgdXNlPC9r

ZXl3b3JkPjxrZXl3b3JkPk1hbGU8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHllYXI+MjAw

NjwveWVhcj48cHViLWRhdGVzPjxkYXRlPkZlYjwvZGF0ZT48L3B1Yi1kYXRlcz48L2RhdGVzPjxp

c2JuPjEzMjgtODA2NyAoUHJpbnQpPC9pc2JuPjxhY2Nlc3Npb24tbnVtPjE2NDkwMDc1PC9hY2Nl

c3Npb24tbnVtPjx1cmxzPjxyZWxhdGVkLXVybHM+PHVybD5odHRwOi8vd3d3Lm5jYmkubmxtLm5p

aC5nb3YvZW50cmV6L3F1ZXJ5LmZjZ2k/Y21kPVJldHJpZXZlJmFtcDtkYj1QdWJNZWQmYW1wO2Rv

cHQ9Q2l0YXRpb24mYW1wO2xpc3RfdWlkcz0xNjQ5MDA3NTwvdXJsPjwvcmVsYXRlZC11cmxzPjwv

dXJscz48ZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+UEVEIFtwaWldJiN4RDsxMC4xMTExL2ouMTQ0

Mi0yMDBYLjIwMDYuMDIxNjcueDwvZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+PGxhbmd1YWdlPmVu

ZzwvbGFuZ3VhZ2U+PC9yZWNvcmQ+PC9DaXRlPjwvRW5kTm90ZT4AAC8ALy==

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CaGF0PC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48UmVj

TnVtPjE1MTk8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjE1MTk8L3JlYy1udW1iZXI+PGZv

cmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSIwdnd3dzJ2dGpmMmRmMWV4ZXBhdng1NXRz

ZjJkd2V4dmV2emQiPjE1MTk8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91

cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9y

PkJoYXQsIE0uIEEuPC9hdXRob3I+PGF1dGhvcj5DaGFyb28sIEIuIEEuPC9hdXRob3I+PGF1dGhv

cj5CaGF0LCBKLiBJLjwvYXV0aG9yPjxhdXRob3I+QWhtYWQsIFMuIE0uPC9hdXRob3I+PGF1dGhv

cj5BbGksIFMuIFcuPC9hdXRob3I+PGF1dGhvcj5NdWZ0aSwgTS4gVS48L2F1dGhvcj48L2F1dGhv

cnM+PC9jb250cmlidXRvcnM+PGF1dGgtYWRkcmVzcz5EZXBhcnRtZW50IG9mIFBlZGlhdHJpY3Ms

IFNLSVNyaW5hZ2FyLCBLYXNobWlyLCBJbmRpYSAxOTAwMTEuIG1iaGF0NDdAcmVkaWZmbWFpbC5j

b208L2F1dGgtYWRkcmVzcz48dGl0bGVzPjx0aXRsZT5NYWduZXNpdW0gc3VsZmF0ZSBpbiBzZXZl

cmUgcGVyaW5hdGFsIGFzcGh5eGlhOiBhIHJhbmRvbWl6ZWQsIHBsYWNlYm8tY29udHJvbGxlZCB0

cmlhbDwvdGl0bGU+PHNlY29uZGFyeS10aXRsZT5QZWRpYXRyaWNzPC9zZWNvbmRhcnktdGl0bGU+

PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+UGVkaWF0cmljczwvZnVsbC10aXRsZT48

L3BlcmlvZGljYWw+PHBhZ2VzPmU3NjQtOTwvcGFnZXM+PHZvbHVtZT4xMjM8L3ZvbHVtZT48bnVt

YmVyPjU8L251bWJlcj48ZWRpdGlvbj4yMDA5LzA0LzA4PC9lZGl0aW9uPjxrZXl3b3Jkcz48a2V5

d29yZD5Bc3BoeXhpYSBOZW9uYXRvcnVtL2Jsb29kL2NvbXBsaWNhdGlvbnMvKmRydWcgdGhlcmFw

eS9waHlzaW9wYXRob2xvZ3k8L2tleXdvcmQ+PGtleXdvcmQ+QnJhaW4gRGlzZWFzZXMvZXRpb2xv

Z3k8L2tleXdvcmQ+PGtleXdvcmQ+Q2FsY2l1bSBDaGFubmVsIEJsb2NrZXJzLyp0aGVyYXBldXRp

YyB1c2U8L2tleXdvcmQ+PGtleXdvcmQ+RmVtYWxlPC9rZXl3b3JkPjxrZXl3b3JkPkh1bWFuczwv

a2V5d29yZD48a2V5d29yZD5JbmZhbnQsIE5ld2Jvcm48L2tleXdvcmQ+PGtleXdvcmQ+TWFnbmVz

aXVtL2Jsb29kPC9rZXl3b3JkPjxrZXl3b3JkPk1hZ25lc2l1bSBTdWxmYXRlLyp0aGVyYXBldXRp

YyB1c2U8L2tleXdvcmQ+PGtleXdvcmQ+TWFsZTwva2V5d29yZD48a2V5d29yZD5OZXVyb2xvZ2lj

IEV4YW1pbmF0aW9uPC9rZXl3b3JkPjxrZXl3b3JkPk5ldXJvcHJvdGVjdGl2ZSBBZ2VudHMvdGhl

cmFwZXV0aWMgdXNlPC9rZXl3b3JkPjxrZXl3b3JkPlByb3NwZWN0aXZlIFN0dWRpZXM8L2tleXdv

cmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHllYXI+MjAwOTwveWVhcj48cHViLWRhdGVzPjxkYXRlPk1h

eTwvZGF0ZT48L3B1Yi1kYXRlcz48L2RhdGVzPjxpc2JuPjEwOTgtNDI3NSAoRWxlY3Ryb25pYykm

I3hEOzAwMzEtNDAwNSAoTGlua2luZyk8L2lzYm4+PGFjY2Vzc2lvbi1udW0+MTkzNDkzNzU8L2Fj

Y2Vzc2lvbi1udW0+PHVybHM+PHJlbGF0ZWQtdXJscz48dXJsPmh0dHA6Ly93d3cubmNiaS5ubG0u

bmloLmdvdi9lbnRyZXovcXVlcnkuZmNnaT9jbWQ9UmV0cmlldmUmYW1wO2RiPVB1Yk1lZCZhbXA7

ZG9wdD1DaXRhdGlvbiZhbXA7bGlzdF91aWRzPTE5MzQ5Mzc1PC91cmw+PC9yZWxhdGVkLXVybHM+

PC91cmxzPjxlbGVjdHJvbmljLXJlc291cmNlLW51bT5wZWRzLjIwMDctMzY0MiBbcGlpXSYjeEQ7

MTAuMTU0Mi9wZWRzLjIwMDctMzY0MjwvZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+PGxhbmd1YWdl

PmVuZzwvbGFuZ3VhZ2U+PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+SWNoaWJhPC9BdXRo

b3I+PFllYXI+MjAwMjwvWWVhcj48UmVjTnVtPjY3OTwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1i

ZXI+Njc5PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBkYi1pZD0iMHZ3

d3cydnRqZjJkZjFleGVwYXZ4NTV0c2YyZHdleHZldnpkIj42Nzk8L2tleT48L2ZvcmVpZ24ta2V5

cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1

dG9ycz48YXV0aG9ycz48YXV0aG9yPkljaGliYSwgSC48L2F1dGhvcj48YXV0aG9yPlRhbWFpLCBI

LjwvYXV0aG9yPjxhdXRob3I+TmVnaXNoaSwgSC48L2F1dGhvcj48YXV0aG9yPlVlZGEsIFQuPC9h

dXRob3I+PGF1dGhvcj5LaW0sIFQuIEouPC9hdXRob3I+PGF1dGhvcj5TdW1pZGEsIFkuPC9hdXRo

b3I+PGF1dGhvcj5UYWthaGFzaGksIFkuPC9hdXRob3I+PGF1dGhvcj5GdWppbmFnYSwgSC48L2F1

dGhvcj48YXV0aG9yPk1pbmFtaSwgSC48L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+

PGF1dGgtYWRkcmVzcz5EZXBhcnRtZW50IG9mIFBlZGlhdHJpY3MsIE9zYWthIENpdHkgVW5pdmVy

c2l0eSBHcmFkdWF0ZSBTY2hvb2wgb2YgTWVkaWNpbmUsIE9zYWthLCBKYXBhbi4gaC1pY2hpYmFA

bWVkLm9zYWthLWN1LmFjLmpwPC9hdXRoLWFkZHJlc3M+PHRpdGxlcz48dGl0bGU+UmFuZG9taXpl

ZCBjb250cm9sbGVkIHRyaWFsIG9mIG1hZ25lc2l1bSBzdWxmYXRlIGluZnVzaW9uIGZvciBzZXZl

cmUgYmlydGggYXNwaHl4aWE8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+UGVkaWF0ciBJbnQ8L3Nl

Y29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5QZWRpYXRyIElu

dDwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjUwNS05PC9wYWdlcz48dm9sdW1lPjQ0

PC92b2x1bWU+PG51bWJlcj41PC9udW1iZXI+PGtleXdvcmRzPjxrZXl3b3JkPkFzcGh5eGlhIE5l

b25hdG9ydW0vKmRydWcgdGhlcmFweTwva2V5d29yZD48a2V5d29yZD5IdW1hbjwva2V5d29yZD48

a2V5d29yZD5IeXBveGlhLUlzY2hlbWlhLCBCcmFpbi8qcHJldmVudGlvbiAmYW1wOyBjb250cm9s

PC9rZXl3b3JkPjxrZXl3b3JkPkluZmFudCwgTmV3Ym9ybjwva2V5d29yZD48a2V5d29yZD5NYWdu

ZXNpdW0gU3VsZmF0ZS9hZG1pbmlzdHJhdGlvbiAmYW1wOyBkb3NhZ2UvKnRoZXJhcGV1dGljIHVz

ZTwva2V5d29yZD48a2V5d29yZD5UaW1lIEZhY3RvcnM8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0

ZXM+PHllYXI+MjAwMjwveWVhcj48cHViLWRhdGVzPjxkYXRlPk9jdDwvZGF0ZT48L3B1Yi1kYXRl

cz48L2RhdGVzPjxhY2Nlc3Npb24tbnVtPjEyMjI1NTQ5PC9hY2Nlc3Npb24tbnVtPjx1cmxzPjxy

ZWxhdGVkLXVybHM+PHVybD5odHRwOi8vd3d3Lm5jYmkubmxtLm5paC5nb3YvZW50cmV6L3F1ZXJ5

LmZjZ2k/Y21kPVJldHJpZXZlJmFtcDtkYj1QdWJNZWQmYW1wO2RvcHQ9Q2l0YXRpb24mYW1wO2xp

c3RfdWlkcz0xMjIyNTU0OTwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48L3JlY29yZD48L0Np

dGU+PENpdGU+PEF1dGhvcj5JY2hpYmE8L0F1dGhvcj48WWVhcj4yMDA2PC9ZZWFyPjxSZWNOdW0+

MTI2MDwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+MTI2MDwvcmVjLW51bWJlcj48Zm9yZWln

bi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjB2d3d3MnZ0amYyZGYxZXhlcGF2eDU1dHNmMmR3

ZXh2ZXZ6ZCI+MTI2MDwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFs

IEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+SWNo

aWJhLCBILjwvYXV0aG9yPjxhdXRob3I+WW9rb2ksIFQuPC9hdXRob3I+PGF1dGhvcj5UYW1haSwg

SC48L2F1dGhvcj48YXV0aG9yPlVlZGEsIFQuPC9hdXRob3I+PGF1dGhvcj5LaW0sIFQuIEouPC9h

dXRob3I+PGF1dGhvcj5ZYW1hbm8sIFQuPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3Jz

PjxhdXRoLWFkZHJlc3M+RGVwYXJ0bWVudCBvZiBOZW9uYXRhbG9sb2d5LCBPc2FrYSBDaXR5IEdl

bmVyYWwgSG9zcGl0YWwsIEphcGFuLiBoLWljaGliYUBtZWQub3Nha2EtY3UuYWMuanA8L2F1dGgt

YWRkcmVzcz48dGl0bGVzPjx0aXRsZT5OZXVyb2RldmVsb3BtZW50YWwgb3V0Y29tZSBvZiBpbmZh

bnRzIHdpdGggYmlydGggYXNwaHl4aWEgdHJlYXRlZCB3aXRoIG1hZ25lc2l1bSBzdWxmYXRlPC90

aXRsZT48c2Vjb25kYXJ5LXRpdGxlPlBlZGlhdHIgSW50PC9zZWNvbmRhcnktdGl0bGU+PC90aXRs

ZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+UGVkaWF0ciBJbnQ8L2Z1bGwtdGl0bGU+PC9wZXJp

b2RpY2FsPjxwYWdlcz43MC01PC9wYWdlcz48dm9sdW1lPjQ4PC92b2x1bWU+PG51bWJlcj4xPC9u

dW1iZXI+PGVkaXRpb24+MjAwNi8wMi8yNDwvZWRpdGlvbj48a2V5d29yZHM+PGtleXdvcmQ+QXNw

aHl4aWEgTmVvbmF0b3J1bS8qZHJ1ZyB0aGVyYXB5L3BoeXNpb3BhdGhvbG9neTwva2V5d29yZD48

a2V5d29yZD5DaGlsZCBEZXZlbG9wbWVudC8qcGh5c2lvbG9neTwva2V5d29yZD48a2V5d29yZD5E

b3BhbWluZS9hZG1pbmlzdHJhdGlvbiAmYW1wOyBkb3NhZ2U8L2tleXdvcmQ+PGtleXdvcmQ+RmVt

YWxlPC9rZXl3b3JkPjxrZXl3b3JkPkh1bWFuczwva2V5d29yZD48a2V5d29yZD5JbmZhbnQ8L2tl

eXdvcmQ+PGtleXdvcmQ+SW5mYW50LCBOZXdib3JuPC9rZXl3b3JkPjxrZXl3b3JkPk1hZ25lc2l1

bSBTdWxmYXRlL2FkbWluaXN0cmF0aW9uICZhbXA7IGRvc2FnZS8qdGhlcmFwZXV0aWMgdXNlPC9r

ZXl3b3JkPjxrZXl3b3JkPk1hbGU8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHllYXI+MjAw

NjwveWVhcj48cHViLWRhdGVzPjxkYXRlPkZlYjwvZGF0ZT48L3B1Yi1kYXRlcz48L2RhdGVzPjxp

c2JuPjEzMjgtODA2NyAoUHJpbnQpPC9pc2JuPjxhY2Nlc3Npb24tbnVtPjE2NDkwMDc1PC9hY2Nl

c3Npb24tbnVtPjx1cmxzPjxyZWxhdGVkLXVybHM+PHVybD5odHRwOi8vd3d3Lm5jYmkubmxtLm5p

aC5nb3YvZW50cmV6L3F1ZXJ5LmZjZ2k/Y21kPVJldHJpZXZlJmFtcDtkYj1QdWJNZWQmYW1wO2Rv

cHQ9Q2l0YXRpb24mYW1wO2xpc3RfdWlkcz0xNjQ5MDA3NTwvdXJsPjwvcmVsYXRlZC11cmxzPjwv

dXJscz48ZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+UEVEIFtwaWldJiN4RDsxMC4xMTExL2ouMTQ0

Mi0yMDBYLjIwMDYuMDIxNjcueDwvZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+PGxhbmd1YWdlPmVu

ZzwvbGFuZ3VhZ2U+PC9yZWNvcmQ+PC9DaXRlPjwvRW5kTm90ZT4AADAALT==

ADDIN EN.CITE.DATA (8-10). In the above referenced studies, mean Mg+2 serum concentrations were ≥ 2.15 mg/dL (1.2 mmol/L) for the treatment groups. Of note, normal term neonatal mean reference Mg2+ levels over the first five days of life are 1.92 mg/dL +/- 0.27 ADDIN EN.CITE <EndNote><Cite><Author>Constantine</Author><Year>1964</Year><RecNum>1520</RecNum><record><rec-number>1520</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd">1520</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Constantine, S</author></authors></contributors><titles><title>Serum Magnesium Levels in the Newborn</title><secondary-title>Pediatrics</secondary-title></titles><periodical><full-title>Pediatrics</full-title></periodical><pages>696-974</pages><volume>33</volume><dates><year>1964</year><pub-dates><date>1964</date></pub-dates></dates><urls></urls></record></Cite></EndNote>(11). Recommendations:1. Obtain Mg2+ level with the first set of electrolytes and then at least every 24 hours until stable.2. Maintain Mg2+ level within the normal range (1.7 to 2.2 mg/dL). 3. If Mg2+ level is < 1.7 mg/dL may infuse Mg2+Sulfate (25-50 mg/kg/dose) over 1-2 hours. Level of Evidence: IV- Case Series and Expert opinion based on current review of the literature.V. References ADDIN EN.REFLIST 1.Kecskes Z, Healy G, Jensen A. Fluid restriction for term infants with hypoxic-ischaemic encephalopathy following perinatal asphyxia. Cochrane Database Syst Rev 2005(3):CD004337.2.McGowan JE, Perlman JM. Glucose management during and after intensive delivery room resuscitation. Clin Perinatol 2006;33(1):183-96, x.3.Salhab WA, Wyckoff MH, Laptook AR, Perlman JM. Initial hypoglycemia and neonatal brain injury in term infants with severe fetal acidemia. Pediatrics 2004;114(2):361-6.4.Basu P, Som S, Choudhuri N, Das H. Contribution of the blood glucose level in perinatal asphyxia. Eur J Pediatr 2009;168(7):833-8.5.Deshpande S, Ward Platt M. The investigation and management of neonatal hypoglycaemia. Semin Fetal Neonatal Med 2005;10(4):351-61.6.Choi DW, Hartley DM. Calcium and glutamate-induced cortical neuronal death. Res Publ Assoc Res Nerv Ment Dis 1993;71:23-34.7.Nowak L, Bregestovski P, Ascher P, Herbet A, Prochiantz A. Magnesium gates glutamate-activated channels in mouse central neurones. Nature 1984;307(5950):462-5.8.Bhat MA, Charoo BA, Bhat JI, Ahmad SM, Ali SW, Mufti MU. Magnesium sulfate in severe perinatal asphyxia: a randomized, placebo-controlled trial. Pediatrics 2009;123(5):e764-9.9.Ichiba H, Tamai H, Negishi H, Ueda T, Kim TJ, Sumida Y, et al. Randomized controlled trial of magnesium sulfate infusion for severe birth asphyxia. Pediatr Int 2002;44(5):505-9.10.Ichiba H, Yokoi T, Tamai H, Ueda T, Kim TJ, Yamano T. Neurodevelopmental outcome of infants with birth asphyxia treated with magnesium sulfate. Pediatr Int 2006;48(1):70-5.11.Constantine S. Serum Magnesium Levels in the Newborn. Pediatrics 1964;33:696-974.II. Feeding Guidelines for Neonates with HIESection ContentsWhat should be used for feeds?When should feeds be started and at what volume?How quickly should feeds be advanced?References I. What should be used for feeds?Feeding should be started with breast milk if available. Although there is no evidence to directly support the claim that breast milk is better than formula for improving the outcome of neonates with HIE, evidence has shown that breast milk may improve cognitive abilities in term neonates ADDIN EN.CITE <EndNote><Cite><Author>Kramer</Author><RecNum>1449</RecNum><DisplayText>[1]</DisplayText><record><rec-number>1449</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd" timestamp="0">1449</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kramer, M. S.</author></authors></contributors><auth-address>Department of Pediatrics, McGill University, Canada. michael.kramer@mcgill.ca</auth-address><titles><title>&quot;Breast is best&quot;: The evidence</title><secondary-title>Early Hum Dev</secondary-title></titles><periodical><full-title>Early Hum Dev</full-title></periodical><pages>729-32</pages><volume>86</volume><number>11</number><edition>2010/09/18</edition><dates><pub-dates><date>Nov</date></pub-dates></dates><isbn>1872-6232 (Electronic)&#xD;0378-3782 (Linking)</isbn><accession-num>20846797</accession-num><urls><related-urls><url>(10)00207-0 [pii]&#xD;10.1016/j.earlhumdev.2010.08.005</electronic-resource-num><language>eng</language></record></Cite></EndNote>[1]. Although born at or near term, neonates who have suffered from HIE are at higher risk of developing necrotizing enterocolitis (NEC). Studies have demonstrated that breast milk feeding is associated with a lower incidence of NEC PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZSBIdWVyb3UtTHVyb248L0F1dGhvcj48UmVjTnVtPjE0

NTA8L1JlY051bT48RGlzcGxheVRleHQ+WzJdPC9EaXNwbGF5VGV4dD48cmVjb3JkPjxyZWMtbnVt

YmVyPjE0NTA8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSIw

dnd3dzJ2dGpmMmRmMWV4ZXBhdng1NXRzZjJkd2V4dmV2emQiIHRpbWVzdGFtcD0iMCI+MTQ1MDwv

a2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFydGljbGUiPjE3PC9y

ZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+TGUgSHVlcm91LUx1cm9uLCBJ

LjwvYXV0aG9yPjxhdXRob3I+QmxhdCwgUy48L2F1dGhvcj48YXV0aG9yPkJvdWRyeSwgRy48L2F1

dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PGF1dGgtYWRkcmVzcz5JTlJBLCBVTVIgMTA3

OSwgU0VOQUgsIEYtMzU1OTAgU2FpbnQtR2lsbGVzLCBGcmFuY2UuIElzYWJlbGxlLkx1cm9uQHJl

bm5lcy5pbnJhLmZyPC9hdXRoLWFkZHJlc3M+PHRpdGxlcz48dGl0bGU+QnJlYXN0LSB2LiBmb3Jt

dWxhLWZlZWRpbmc6IGltcGFjdHMgb24gdGhlIGRpZ2VzdGl2ZSB0cmFjdCBhbmQgaW1tZWRpYXRl

IGFuZCBsb25nLXRlcm0gaGVhbHRoIGVmZmVjdHM8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+TnV0

ciBSZXMgUmV2PC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0

bGU+TnV0ciBSZXMgUmV2PC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+MjMtMzY8L3Bh

Z2VzPjx2b2x1bWU+MjM8L3ZvbHVtZT48bnVtYmVyPjE8L251bWJlcj48ZWRpdGlvbj4yMDEwLzA1

LzExPC9lZGl0aW9uPjxrZXl3b3Jkcz48a2V5d29yZD5BbmltYWxzPC9rZXl3b3JkPjxrZXl3b3Jk

PkJsb29kIEdsdWNvc2UvYW5hbHlzaXM8L2tleXdvcmQ+PGtleXdvcmQ+KkJyZWFzdCBGZWVkaW5n

PC9rZXl3b3JkPjxrZXl3b3JkPkRpYWJldGVzIE1lbGxpdHVzLCBUeXBlIDIvcHJldmVudGlvbiAm

YW1wOyBjb250cm9sPC9rZXl3b3JkPjxrZXl3b3JkPkRpYXJyaGVhL3ByZXZlbnRpb24gJmFtcDsg

Y29udHJvbDwva2V5d29yZD48a2V5d29yZD4qRGlnZXN0aXZlIFN5c3RlbS9ncm93dGggJmFtcDsg

ZGV2ZWxvcG1lbnQ8L2tleXdvcmQ+PGtleXdvcmQ+RW50ZXJvY29saXRpcywgTmVjcm90aXppbmcv

cHJldmVudGlvbiAmYW1wOyBjb250cm9sPC9rZXl3b3JkPjxrZXl3b3JkPkZlbWFsZTwva2V5d29y

ZD48a2V5d29yZD5IZWFsdGggUHJvbW90aW9uPC9rZXl3b3JkPjxrZXl3b3JkPipIZWFsdGggU3Rh

dHVzPC9rZXl3b3JkPjxrZXl3b3JkPkh1bWFuczwva2V5d29yZD48a2V5d29yZD5JbmZhbnQ8L2tl

eXdvcmQ+PGtleXdvcmQ+KkluZmFudCBGb3JtdWxhL2NoZW1pc3RyeTwva2V5d29yZD48a2V5d29y

ZD5JbmZhbnQgTnV0cml0aW9uYWwgUGh5c2lvbG9naWNhbCBQaGVub21lbmE8L2tleXdvcmQ+PGtl

eXdvcmQ+SW5mYW50LCBOZXdib3JuPC9rZXl3b3JkPjxrZXl3b3JkPkluZmxhbW1hdG9yeSBCb3dl

bCBEaXNlYXNlcy9wcmV2ZW50aW9uICZhbXA7IGNvbnRyb2w8L2tleXdvcmQ+PGtleXdvcmQ+SW50

ZXN0aW5lcy9taWNyb2Jpb2xvZ3kvcGh5c2lvbG9neTwva2V5d29yZD48a2V5d29yZD5LZXRvbmUg

Qm9kaWVzL2Jsb29kPC9rZXl3b3JkPjxrZXl3b3JkPk1pbGssIEh1bWFuL2NoZW1pc3RyeTwva2V5

d29yZD48a2V5d29yZD5OdXRyaXRpdmUgVmFsdWU8L2tleXdvcmQ+PGtleXdvcmQ+T2Jlc2l0eS9w

cmV2ZW50aW9uICZhbXA7IGNvbnRyb2w8L2tleXdvcmQ+PGtleXdvcmQ+UGFuY3JlYXMvcGh5c2lv

bG9neTwva2V5d29yZD48a2V5d29yZD5XZWlnaHQgR2Fpbjwva2V5d29yZD48L2tleXdvcmRzPjxk

YXRlcz48cHViLWRhdGVzPjxkYXRlPkp1bjwvZGF0ZT48L3B1Yi1kYXRlcz48L2RhdGVzPjxpc2Ju

PjE0NzUtMjcwMCAoRWxlY3Ryb25pYykmI3hEOzA5NTQtNDIyNCAoTGlua2luZyk8L2lzYm4+PGFj

Y2Vzc2lvbi1udW0+MjA0NTA1MzE8L2FjY2Vzc2lvbi1udW0+PHVybHM+PHJlbGF0ZWQtdXJscz48

dXJsPmh0dHA6Ly93d3cubmNiaS5ubG0ubmloLmdvdi9lbnRyZXovcXVlcnkuZmNnaT9jbWQ9UmV0

cmlldmUmYW1wO2RiPVB1Yk1lZCZhbXA7ZG9wdD1DaXRhdGlvbiZhbXA7bGlzdF91aWRzPTIwNDUw

NTMxPC91cmw+PC9yZWxhdGVkLXVybHM+PC91cmxzPjxlbGVjdHJvbmljLXJlc291cmNlLW51bT5T

MDk1NDQyMjQxMDAwMDA2NSBbcGlpXSYjeEQ7MTAuMTAxNy9TMDk1NDQyMjQxMDAwMDA2NTwvZWxl

Y3Ryb25pYy1yZXNvdXJjZS1udW0+PGxhbmd1YWdlPmVuZzwvbGFuZ3VhZ2U+PC9yZWNvcmQ+PC9D

aXRlPjwvRW5kTm90ZT4A

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZSBIdWVyb3UtTHVyb248L0F1dGhvcj48UmVjTnVtPjE0

NTA8L1JlY051bT48RGlzcGxheVRleHQ+WzJdPC9EaXNwbGF5VGV4dD48cmVjb3JkPjxyZWMtbnVt

YmVyPjE0NTA8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSIw

dnd3dzJ2dGpmMmRmMWV4ZXBhdng1NXRzZjJkd2V4dmV2emQiIHRpbWVzdGFtcD0iMCI+MTQ1MDwv

a2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFydGljbGUiPjE3PC9y

ZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+TGUgSHVlcm91LUx1cm9uLCBJ

LjwvYXV0aG9yPjxhdXRob3I+QmxhdCwgUy48L2F1dGhvcj48YXV0aG9yPkJvdWRyeSwgRy48L2F1

dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PGF1dGgtYWRkcmVzcz5JTlJBLCBVTVIgMTA3

OSwgU0VOQUgsIEYtMzU1OTAgU2FpbnQtR2lsbGVzLCBGcmFuY2UuIElzYWJlbGxlLkx1cm9uQHJl

bm5lcy5pbnJhLmZyPC9hdXRoLWFkZHJlc3M+PHRpdGxlcz48dGl0bGU+QnJlYXN0LSB2LiBmb3Jt

dWxhLWZlZWRpbmc6IGltcGFjdHMgb24gdGhlIGRpZ2VzdGl2ZSB0cmFjdCBhbmQgaW1tZWRpYXRl

IGFuZCBsb25nLXRlcm0gaGVhbHRoIGVmZmVjdHM8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+TnV0

ciBSZXMgUmV2PC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0

bGU+TnV0ciBSZXMgUmV2PC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+MjMtMzY8L3Bh

Z2VzPjx2b2x1bWU+MjM8L3ZvbHVtZT48bnVtYmVyPjE8L251bWJlcj48ZWRpdGlvbj4yMDEwLzA1

LzExPC9lZGl0aW9uPjxrZXl3b3Jkcz48a2V5d29yZD5BbmltYWxzPC9rZXl3b3JkPjxrZXl3b3Jk

PkJsb29kIEdsdWNvc2UvYW5hbHlzaXM8L2tleXdvcmQ+PGtleXdvcmQ+KkJyZWFzdCBGZWVkaW5n

PC9rZXl3b3JkPjxrZXl3b3JkPkRpYWJldGVzIE1lbGxpdHVzLCBUeXBlIDIvcHJldmVudGlvbiAm

YW1wOyBjb250cm9sPC9rZXl3b3JkPjxrZXl3b3JkPkRpYXJyaGVhL3ByZXZlbnRpb24gJmFtcDsg

Y29udHJvbDwva2V5d29yZD48a2V5d29yZD4qRGlnZXN0aXZlIFN5c3RlbS9ncm93dGggJmFtcDsg

ZGV2ZWxvcG1lbnQ8L2tleXdvcmQ+PGtleXdvcmQ+RW50ZXJvY29saXRpcywgTmVjcm90aXppbmcv

cHJldmVudGlvbiAmYW1wOyBjb250cm9sPC9rZXl3b3JkPjxrZXl3b3JkPkZlbWFsZTwva2V5d29y

ZD48a2V5d29yZD5IZWFsdGggUHJvbW90aW9uPC9rZXl3b3JkPjxrZXl3b3JkPipIZWFsdGggU3Rh

dHVzPC9rZXl3b3JkPjxrZXl3b3JkPkh1bWFuczwva2V5d29yZD48a2V5d29yZD5JbmZhbnQ8L2tl

eXdvcmQ+PGtleXdvcmQ+KkluZmFudCBGb3JtdWxhL2NoZW1pc3RyeTwva2V5d29yZD48a2V5d29y

ZD5JbmZhbnQgTnV0cml0aW9uYWwgUGh5c2lvbG9naWNhbCBQaGVub21lbmE8L2tleXdvcmQ+PGtl

eXdvcmQ+SW5mYW50LCBOZXdib3JuPC9rZXl3b3JkPjxrZXl3b3JkPkluZmxhbW1hdG9yeSBCb3dl

bCBEaXNlYXNlcy9wcmV2ZW50aW9uICZhbXA7IGNvbnRyb2w8L2tleXdvcmQ+PGtleXdvcmQ+SW50

ZXN0aW5lcy9taWNyb2Jpb2xvZ3kvcGh5c2lvbG9neTwva2V5d29yZD48a2V5d29yZD5LZXRvbmUg

Qm9kaWVzL2Jsb29kPC9rZXl3b3JkPjxrZXl3b3JkPk1pbGssIEh1bWFuL2NoZW1pc3RyeTwva2V5

d29yZD48a2V5d29yZD5OdXRyaXRpdmUgVmFsdWU8L2tleXdvcmQ+PGtleXdvcmQ+T2Jlc2l0eS9w

cmV2ZW50aW9uICZhbXA7IGNvbnRyb2w8L2tleXdvcmQ+PGtleXdvcmQ+UGFuY3JlYXMvcGh5c2lv

bG9neTwva2V5d29yZD48a2V5d29yZD5XZWlnaHQgR2Fpbjwva2V5d29yZD48L2tleXdvcmRzPjxk

YXRlcz48cHViLWRhdGVzPjxkYXRlPkp1bjwvZGF0ZT48L3B1Yi1kYXRlcz48L2RhdGVzPjxpc2Ju

PjE0NzUtMjcwMCAoRWxlY3Ryb25pYykmI3hEOzA5NTQtNDIyNCAoTGlua2luZyk8L2lzYm4+PGFj

Y2Vzc2lvbi1udW0+MjA0NTA1MzE8L2FjY2Vzc2lvbi1udW0+PHVybHM+PHJlbGF0ZWQtdXJscz48

dXJsPmh0dHA6Ly93d3cubmNiaS5ubG0ubmloLmdvdi9lbnRyZXovcXVlcnkuZmNnaT9jbWQ9UmV0

cmlldmUmYW1wO2RiPVB1Yk1lZCZhbXA7ZG9wdD1DaXRhdGlvbiZhbXA7bGlzdF91aWRzPTIwNDUw

NTMxPC91cmw+PC9yZWxhdGVkLXVybHM+PC91cmxzPjxlbGVjdHJvbmljLXJlc291cmNlLW51bT5T

MDk1NDQyMjQxMDAwMDA2NSBbcGlpXSYjeEQ7MTAuMTAxNy9TMDk1NDQyMjQxMDAwMDA2NTwvZWxl

Y3Ryb25pYy1yZXNvdXJjZS1udW0+PGxhbmd1YWdlPmVuZzwvbGFuZ3VhZ2U+PC9yZWNvcmQ+PC9D

aXRlPjwvRW5kTm90ZT4A

ADDIN EN.CITE.DATA [2]. In addition, breast milk is a rich source of multipotent mesenchymal stem cells ADDIN EN.CITE <EndNote><Cite><Author>Patki</Author><RecNum>1451</RecNum><DisplayText>[3]</DisplayText><record><rec-number>1451</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd" timestamp="0">1451</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Patki, S.</author><author>Kadam, S.</author><author>Chandra, V.</author><author>Bhonde, R.</author></authors></contributors><auth-address>Patki Research Foundation and Hospital, Shahupuri, Kolhapur, India.</auth-address><titles><title>Human breast milk is a rich source of multipotent mesenchymal stem cells</title><secondary-title>Hum Cell</secondary-title></titles><periodical><full-title>Hum Cell</full-title></periodical><pages>35-40</pages><volume>23</volume><number>2</number><edition>2010/08/18</edition><dates><pub-dates><date>May</date></pub-dates></dates><isbn>1749-0774 (Electronic)&#xD;0914-7470 (Linking)</isbn><accession-num>20712706</accession-num><urls><related-urls><url> [pii]&#xD;10.1111/j.1749-0774.2010.00083.x</electronic-resource-num><language>eng</language></record></Cite></EndNote>[3]. Recommendations:1. Feed with breast milk if available and no contraindications exist (AAP policy).2. May use formula if breast milk is not available.3. May use donor breast milk if available.4. If the neonates is not a candidate for feeding during hypothermia, consider oral care with maternal colostrum. Level of Evidence: IV- Case Series and Expert opinion based on current review of the literature.II. When should feeds be started and at what volume?Recent studies have demonstrated NEC to occur from 9-15 days of age in term neonates with HIE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MYW1iZXJ0PC9BdXRob3I+PFllYXI+MjAwNzwvWWVhcj48

UmVjTnVtPjE1MDI8L1JlY051bT48RGlzcGxheVRleHQ+WzQsIDVdPC9EaXNwbGF5VGV4dD48cmVj

b3JkPjxyZWMtbnVtYmVyPjE1MDI8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0i

RU4iIGRiLWlkPSIwdnd3dzJ2dGpmMmRmMWV4ZXBhdng1NXRzZjJkd2V4dmV2emQiIHRpbWVzdGFt

cD0iMCI+MTUwMjwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFy

dGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+TGFtYmVy

dCwgRC4gSy48L2F1dGhvcj48YXV0aG9yPkNocmlzdGVuc2VuLCBSLiBELjwvYXV0aG9yPjxhdXRo

b3I+SGVucnksIEUuPC9hdXRob3I+PGF1dGhvcj5CZXNuZXIsIEcuIEUuPC9hdXRob3I+PGF1dGhv

cj5CYWVyLCBWLiBMLjwvYXV0aG9yPjxhdXRob3I+V2llZG1laWVyLCBTLiBFLjwvYXV0aG9yPjxh

dXRob3I+U3RvZGRhcmQsIFIuIEEuPC9hdXRob3I+PGF1dGhvcj5NaW5lciwgQy4gQS48L2F1dGhv

cj48YXV0aG9yPkJ1cm5ldHQsIEouPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjxh

dXRoLWFkZHJlc3M+SW50ZXJtb3VudGFpbiBIZWFsdGggQ2FyZSwgT2dkZW4sIFVUIDg0NDAzLCBV

U0EuIHJkY2hyaXM0QGloYy5jb208L2F1dGgtYWRkcmVzcz48dGl0bGVzPjx0aXRsZT5OZWNyb3Rp

emluZyBlbnRlcm9jb2xpdGlzIGluIHRlcm0gbmVvbmF0ZXM6IGRhdGEgZnJvbSBhIG11bHRpaG9z

cGl0YWwgaGVhbHRoLWNhcmUgc3lzdGVtPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPkogUGVyaW5h

dG9sPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+SiBQ

ZXJpbmF0b2w8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz40MzctNDM8L3BhZ2VzPjx2

b2x1bWU+Mjc8L3ZvbHVtZT48bnVtYmVyPjc8L251bWJlcj48ZWRpdGlvbj4yMDA3LzAzLzMwPC9l

ZGl0aW9uPjxrZXl3b3Jkcz48a2V5d29yZD5EYXRhYmFzZXMsIEZhY3R1YWw8L2tleXdvcmQ+PGtl

eXdvcmQ+RW50ZXJvY29saXRpcywgTmVjcm90aXppbmcvKmVwaWRlbWlvbG9neS9ldGlvbG9neS9w

cmV2ZW50aW9uICZhbXA7IGNvbnRyb2w8L2tleXdvcmQ+PGtleXdvcmQ+SGVhbHRoIE1haW50ZW5h

bmNlIE9yZ2FuaXphdGlvbnM8L2tleXdvcmQ+PGtleXdvcmQ+SHVtYW5zPC9rZXl3b3JkPjxrZXl3

b3JkPkluZmFudCBOdXRyaXRpb25hbCBQaHlzaW9sb2dpY2FsIFBoZW5vbWVuYTwva2V5d29yZD48

a2V5d29yZD5JbmZhbnQsIE5ld2Jvcm48L2tleXdvcmQ+PGtleXdvcmQ+SW50ZW5zaXZlIENhcmUg

VW5pdHMsIE5lb25hdGFsPC9rZXl3b3JkPjxrZXl3b3JkPk1lZGljYWwgUmVjb3Jkczwva2V5d29y

ZD48a2V5d29yZD4qTWlsaywgSHVtYW48L2tleXdvcmQ+PGtleXdvcmQ+UmV0cm9zcGVjdGl2ZSBT

dHVkaWVzPC9rZXl3b3JkPjxrZXl3b3JkPlV0YWgvZXBpZGVtaW9sb2d5PC9rZXl3b3JkPjwva2V5

d29yZHM+PGRhdGVzPjx5ZWFyPjIwMDc8L3llYXI+PHB1Yi1kYXRlcz48ZGF0ZT5KdWw8L2RhdGU+

PC9wdWItZGF0ZXM+PC9kYXRlcz48aXNibj4wNzQzLTgzNDYgKFByaW50KSYjeEQ7MDc0My04MzQ2

IChMaW5raW5nKTwvaXNibj48YWNjZXNzaW9uLW51bT4xNzM5MjgzNzwvYWNjZXNzaW9uLW51bT48

dXJscz48cmVsYXRlZC11cmxzPjx1cmw+aHR0cDovL3d3dy5uY2JpLm5sbS5uaWguZ292L2VudHJl

ei9xdWVyeS5mY2dpP2NtZD1SZXRyaWV2ZSZhbXA7ZGI9UHViTWVkJmFtcDtkb3B0PUNpdGF0aW9u

JmFtcDtsaXN0X3VpZHM9MTczOTI4Mzc8L3VybD48L3JlbGF0ZWQtdXJscz48L3VybHM+PGVsZWN0

cm9uaWMtcmVzb3VyY2UtbnVtPjcyMTE3MzggW3BpaV0mI3hEOzEwLjEwMzgvc2ouanAuNzIxMTcz

ODwvZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+PGxhbmd1YWdlPmVuZzwvbGFuZ3VhZ2U+PC9yZWNv

cmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+TWFheWFuLU1ldHpnZXI8L0F1dGhvcj48WWVhcj4yMDA0

PC9ZZWFyPjxSZWNOdW0+MTUwMzwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+MTUwMzwvcmVj

LW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjB2d3d3MnZ0amYyZGYx

ZXhlcGF2eDU1dHNmMmR3ZXh2ZXZ6ZCIgdGltZXN0YW1wPSIwIj4xNTAzPC9rZXk+PC9mb3JlaWdu

LWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250

cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5NYWF5YW4tTWV0emdlciwgQS48L2F1dGhvcj48YXV0

aG9yPkl0emNoYWssIEEuPC9hdXRob3I+PGF1dGhvcj5NYXprZXJldGgsIFIuPC9hdXRob3I+PGF1

dGhvcj5LdWludCwgSi48L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PGF1dGgtYWRk

cmVzcz5EZXBhcnRtZW50IG9mIE5lb25hdG9sb2d5LCBFZG1vbmQgYW5kIExpbHkgU2FmcmEgQ2hp

bGRyZW4mYXBvcztzIEhvc3BpdGFsLCBTaGViYSBNZWRpY2FsIENlbnRlciwgVGVsLUhhc2hvbWVy

IGFuZCBUaGUgU2Fja2xlciBTY2hvb2wgb2YgTWVkaWNpbmUsIFRlbC1Bdml2IFVuaXZlcnNpdHks

IFRlbC1IYXNob21lciwgSXNyYWVsLjwvYXV0aC1hZGRyZXNzPjx0aXRsZXM+PHRpdGxlPk5lY3Jv

dGl6aW5nIGVudGVyb2NvbGl0aXMgaW4gZnVsbC10ZXJtIGluZmFudHM6IGNhc2UtY29udHJvbCBz

dHVkeSBhbmQgcmV2aWV3IG9mIHRoZSBsaXRlcmF0dXJlPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxl

PkogUGVyaW5hdG9sPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwt

dGl0bGU+SiBQZXJpbmF0b2w8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz40OTQtOTwv

cGFnZXM+PHZvbHVtZT4yNDwvdm9sdW1lPjxudW1iZXI+ODwvbnVtYmVyPjxlZGl0aW9uPjIwMDQv

MDcvMDI8L2VkaXRpb24+PGtleXdvcmRzPjxrZXl3b3JkPkNhc2UtQ29udHJvbCBTdHVkaWVzPC9r

ZXl3b3JkPjxrZXl3b3JkPkVudGVyb2NvbGl0aXMsIE5lY3JvdGl6aW5nLyplcGlkZW1pb2xvZ3kv

ZXRpb2xvZ3kvcHJldmVudGlvbiAmYW1wOyBjb250cm9sPC9rZXl3b3JkPjxrZXl3b3JkPkZlbWFs

ZTwva2V5d29yZD48a2V5d29yZD5IdW1hbnM8L2tleXdvcmQ+PGtleXdvcmQ+SW5jaWRlbmNlPC9r

ZXl3b3JkPjxrZXl3b3JkPkluZmFudCwgTmV3Ym9ybjwva2V5d29yZD48a2V5d29yZD5Jc3JhZWwv

ZXBpZGVtaW9sb2d5PC9rZXl3b3JkPjxrZXl3b3JkPk1hbGU8L2tleXdvcmQ+PGtleXdvcmQ+TWVk

aWNhbCBSZWNvcmRzPC9rZXl3b3JkPjxrZXl3b3JkPlJldHJvc3BlY3RpdmUgU3R1ZGllczwva2V5

d29yZD48a2V5d29yZD5SaXNrIEZhY3RvcnM8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHll

YXI+MjAwNDwveWVhcj48cHViLWRhdGVzPjxkYXRlPkF1ZzwvZGF0ZT48L3B1Yi1kYXRlcz48L2Rh

dGVzPjxpc2JuPjA3NDMtODM0NiAoUHJpbnQpJiN4RDswNzQzLTgzNDYgKExpbmtpbmcpPC9pc2Ju

PjxhY2Nlc3Npb24tbnVtPjE1MjI5NjIwPC9hY2Nlc3Npb24tbnVtPjx1cmxzPjxyZWxhdGVkLXVy

bHM+PHVybD5odHRwOi8vd3d3Lm5jYmkubmxtLm5paC5nb3YvZW50cmV6L3F1ZXJ5LmZjZ2k/Y21k

PVJldHJpZXZlJmFtcDtkYj1QdWJNZWQmYW1wO2RvcHQ9Q2l0YXRpb24mYW1wO2xpc3RfdWlkcz0x

NTIyOTYyMDwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48ZWxlY3Ryb25pYy1yZXNvdXJjZS1u

dW0+MTAuMTAzOC9zai5qcC43MjExMTM1JiN4RDs3MjExMTM1IFtwaWldPC9lbGVjdHJvbmljLXJl

c291cmNlLW51bT48bGFuZ3VhZ2U+ZW5nPC9sYW5ndWFnZT48L3JlY29yZD48L0NpdGU+PC9FbmRO

b3RlPn==

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MYW1iZXJ0PC9BdXRob3I+PFllYXI+MjAwNzwvWWVhcj48

UmVjTnVtPjE1MDI8L1JlY051bT48RGlzcGxheVRleHQ+WzQsIDVdPC9EaXNwbGF5VGV4dD48cmVj

b3JkPjxyZWMtbnVtYmVyPjE1MDI8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0i

RU4iIGRiLWlkPSIwdnd3dzJ2dGpmMmRmMWV4ZXBhdng1NXRzZjJkd2V4dmV2emQiIHRpbWVzdGFt

cD0iMCI+MTUwMjwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFy

dGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+TGFtYmVy

dCwgRC4gSy48L2F1dGhvcj48YXV0aG9yPkNocmlzdGVuc2VuLCBSLiBELjwvYXV0aG9yPjxhdXRo

b3I+SGVucnksIEUuPC9hdXRob3I+PGF1dGhvcj5CZXNuZXIsIEcuIEUuPC9hdXRob3I+PGF1dGhv

cj5CYWVyLCBWLiBMLjwvYXV0aG9yPjxhdXRob3I+V2llZG1laWVyLCBTLiBFLjwvYXV0aG9yPjxh

dXRob3I+U3RvZGRhcmQsIFIuIEEuPC9hdXRob3I+PGF1dGhvcj5NaW5lciwgQy4gQS48L2F1dGhv

cj48YXV0aG9yPkJ1cm5ldHQsIEouPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjxh

dXRoLWFkZHJlc3M+SW50ZXJtb3VudGFpbiBIZWFsdGggQ2FyZSwgT2dkZW4sIFVUIDg0NDAzLCBV

U0EuIHJkY2hyaXM0QGloYy5jb208L2F1dGgtYWRkcmVzcz48dGl0bGVzPjx0aXRsZT5OZWNyb3Rp

emluZyBlbnRlcm9jb2xpdGlzIGluIHRlcm0gbmVvbmF0ZXM6IGRhdGEgZnJvbSBhIG11bHRpaG9z

cGl0YWwgaGVhbHRoLWNhcmUgc3lzdGVtPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPkogUGVyaW5h

dG9sPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+SiBQ

ZXJpbmF0b2w8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz40MzctNDM8L3BhZ2VzPjx2

b2x1bWU+Mjc8L3ZvbHVtZT48bnVtYmVyPjc8L251bWJlcj48ZWRpdGlvbj4yMDA3LzAzLzMwPC9l

ZGl0aW9uPjxrZXl3b3Jkcz48a2V5d29yZD5EYXRhYmFzZXMsIEZhY3R1YWw8L2tleXdvcmQ+PGtl

eXdvcmQ+RW50ZXJvY29saXRpcywgTmVjcm90aXppbmcvKmVwaWRlbWlvbG9neS9ldGlvbG9neS9w

cmV2ZW50aW9uICZhbXA7IGNvbnRyb2w8L2tleXdvcmQ+PGtleXdvcmQ+SGVhbHRoIE1haW50ZW5h

bmNlIE9yZ2FuaXphdGlvbnM8L2tleXdvcmQ+PGtleXdvcmQ+SHVtYW5zPC9rZXl3b3JkPjxrZXl3

b3JkPkluZmFudCBOdXRyaXRpb25hbCBQaHlzaW9sb2dpY2FsIFBoZW5vbWVuYTwva2V5d29yZD48

a2V5d29yZD5JbmZhbnQsIE5ld2Jvcm48L2tleXdvcmQ+PGtleXdvcmQ+SW50ZW5zaXZlIENhcmUg

VW5pdHMsIE5lb25hdGFsPC9rZXl3b3JkPjxrZXl3b3JkPk1lZGljYWwgUmVjb3Jkczwva2V5d29y

ZD48a2V5d29yZD4qTWlsaywgSHVtYW48L2tleXdvcmQ+PGtleXdvcmQ+UmV0cm9zcGVjdGl2ZSBT

dHVkaWVzPC9rZXl3b3JkPjxrZXl3b3JkPlV0YWgvZXBpZGVtaW9sb2d5PC9rZXl3b3JkPjwva2V5

d29yZHM+PGRhdGVzPjx5ZWFyPjIwMDc8L3llYXI+PHB1Yi1kYXRlcz48ZGF0ZT5KdWw8L2RhdGU+

PC9wdWItZGF0ZXM+PC9kYXRlcz48aXNibj4wNzQzLTgzNDYgKFByaW50KSYjeEQ7MDc0My04MzQ2

IChMaW5raW5nKTwvaXNibj48YWNjZXNzaW9uLW51bT4xNzM5MjgzNzwvYWNjZXNzaW9uLW51bT48

dXJscz48cmVsYXRlZC11cmxzPjx1cmw+aHR0cDovL3d3dy5uY2JpLm5sbS5uaWguZ292L2VudHJl

ei9xdWVyeS5mY2dpP2NtZD1SZXRyaWV2ZSZhbXA7ZGI9UHViTWVkJmFtcDtkb3B0PUNpdGF0aW9u

JmFtcDtsaXN0X3VpZHM9MTczOTI4Mzc8L3VybD48L3JlbGF0ZWQtdXJscz48L3VybHM+PGVsZWN0

cm9uaWMtcmVzb3VyY2UtbnVtPjcyMTE3MzggW3BpaV0mI3hEOzEwLjEwMzgvc2ouanAuNzIxMTcz

ODwvZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+PGxhbmd1YWdlPmVuZzwvbGFuZ3VhZ2U+PC9yZWNv

cmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+TWFheWFuLU1ldHpnZXI8L0F1dGhvcj48WWVhcj4yMDA0

PC9ZZWFyPjxSZWNOdW0+MTUwMzwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+MTUwMzwvcmVj

LW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjB2d3d3MnZ0amYyZGYx

ZXhlcGF2eDU1dHNmMmR3ZXh2ZXZ6ZCIgdGltZXN0YW1wPSIwIj4xNTAzPC9rZXk+PC9mb3JlaWdu

LWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250

cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5NYWF5YW4tTWV0emdlciwgQS48L2F1dGhvcj48YXV0

aG9yPkl0emNoYWssIEEuPC9hdXRob3I+PGF1dGhvcj5NYXprZXJldGgsIFIuPC9hdXRob3I+PGF1

dGhvcj5LdWludCwgSi48L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PGF1dGgtYWRk

cmVzcz5EZXBhcnRtZW50IG9mIE5lb25hdG9sb2d5LCBFZG1vbmQgYW5kIExpbHkgU2FmcmEgQ2hp

bGRyZW4mYXBvcztzIEhvc3BpdGFsLCBTaGViYSBNZWRpY2FsIENlbnRlciwgVGVsLUhhc2hvbWVy

IGFuZCBUaGUgU2Fja2xlciBTY2hvb2wgb2YgTWVkaWNpbmUsIFRlbC1Bdml2IFVuaXZlcnNpdHks

IFRlbC1IYXNob21lciwgSXNyYWVsLjwvYXV0aC1hZGRyZXNzPjx0aXRsZXM+PHRpdGxlPk5lY3Jv

dGl6aW5nIGVudGVyb2NvbGl0aXMgaW4gZnVsbC10ZXJtIGluZmFudHM6IGNhc2UtY29udHJvbCBz

dHVkeSBhbmQgcmV2aWV3IG9mIHRoZSBsaXRlcmF0dXJlPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxl

PkogUGVyaW5hdG9sPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwt

dGl0bGU+SiBQZXJpbmF0b2w8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz40OTQtOTwv

cGFnZXM+PHZvbHVtZT4yNDwvdm9sdW1lPjxudW1iZXI+ODwvbnVtYmVyPjxlZGl0aW9uPjIwMDQv

MDcvMDI8L2VkaXRpb24+PGtleXdvcmRzPjxrZXl3b3JkPkNhc2UtQ29udHJvbCBTdHVkaWVzPC9r

ZXl3b3JkPjxrZXl3b3JkPkVudGVyb2NvbGl0aXMsIE5lY3JvdGl6aW5nLyplcGlkZW1pb2xvZ3kv

ZXRpb2xvZ3kvcHJldmVudGlvbiAmYW1wOyBjb250cm9sPC9rZXl3b3JkPjxrZXl3b3JkPkZlbWFs

ZTwva2V5d29yZD48a2V5d29yZD5IdW1hbnM8L2tleXdvcmQ+PGtleXdvcmQ+SW5jaWRlbmNlPC9r

ZXl3b3JkPjxrZXl3b3JkPkluZmFudCwgTmV3Ym9ybjwva2V5d29yZD48a2V5d29yZD5Jc3JhZWwv

ZXBpZGVtaW9sb2d5PC9rZXl3b3JkPjxrZXl3b3JkPk1hbGU8L2tleXdvcmQ+PGtleXdvcmQ+TWVk

aWNhbCBSZWNvcmRzPC9rZXl3b3JkPjxrZXl3b3JkPlJldHJvc3BlY3RpdmUgU3R1ZGllczwva2V5

d29yZD48a2V5d29yZD5SaXNrIEZhY3RvcnM8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHll

YXI+MjAwNDwveWVhcj48cHViLWRhdGVzPjxkYXRlPkF1ZzwvZGF0ZT48L3B1Yi1kYXRlcz48L2Rh

dGVzPjxpc2JuPjA3NDMtODM0NiAoUHJpbnQpJiN4RDswNzQzLTgzNDYgKExpbmtpbmcpPC9pc2Ju

PjxhY2Nlc3Npb24tbnVtPjE1MjI5NjIwPC9hY2Nlc3Npb24tbnVtPjx1cmxzPjxyZWxhdGVkLXVy

bHM+PHVybD5odHRwOi8vd3d3Lm5jYmkubmxtLm5paC5nb3YvZW50cmV6L3F1ZXJ5LmZjZ2k/Y21k

PVJldHJpZXZlJmFtcDtkYj1QdWJNZWQmYW1wO2RvcHQ9Q2l0YXRpb24mYW1wO2xpc3RfdWlkcz0x

NTIyOTYyMDwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48ZWxlY3Ryb25pYy1yZXNvdXJjZS1u

dW0+MTAuMTAzOC9zai5qcC43MjExMTM1JiN4RDs3MjExMTM1IFtwaWldPC9lbGVjdHJvbmljLXJl

c291cmNlLW51bT48bGFuZ3VhZ2U+ZW5nPC9sYW5ndWFnZT48L3JlY29yZD48L0NpdGU+PC9FbmRO

b3RlPn==

ADDIN EN.CITE.DATA [4, 5]. Many of the risk factors present in term neonates for developing NEC, such as hypotension, may be present in neonates with HIE after the initial insult ADDIN EN.CITE <EndNote><Cite><Author>Lambert</Author><Year>2007</Year><RecNum>1502</RecNum><DisplayText>[4]</DisplayText><record><rec-number>1502</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd" timestamp="0">1502</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lambert, D. K.</author><author>Christensen, R. D.</author><author>Henry, E.</author><author>Besner, G. E.</author><author>Baer, V. L.</author><author>Wiedmeier, S. E.</author><author>Stoddard, R. A.</author><author>Miner, C. A.</author><author>Burnett, J.</author></authors></contributors><auth-address>Intermountain Health Care, Ogden, UT 84403, USA. rdchris4@</auth-address><titles><title>Necrotizing enterocolitis in term neonates: data from a multihospital health-care system</title><secondary-title>J Perinatol</secondary-title></titles><periodical><full-title>J Perinatol</full-title></periodical><pages>437-43</pages><volume>27</volume><number>7</number><edition>2007/03/30</edition><keywords><keyword>Databases, Factual</keyword><keyword>Enterocolitis, Necrotizing/*epidemiology/etiology/prevention &amp; control</keyword><keyword>Health Maintenance Organizations</keyword><keyword>Humans</keyword><keyword>Infant Nutritional Physiological Phenomena</keyword><keyword>Infant, Newborn</keyword><keyword>Intensive Care Units, Neonatal</keyword><keyword>Medical Records</keyword><keyword>*Milk, Human</keyword><keyword>Retrospective Studies</keyword><keyword>Utah/epidemiology</keyword></keywords><dates><year>2007</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>0743-8346 (Print)&#xD;0743-8346 (Linking)</isbn><accession-num>17392837</accession-num><urls><related-urls><url> [pii]&#xD;10.1038/sj.jp.7211738</electronic-resource-num><language>eng</language></record></Cite></EndNote>[4]. Further, the effect of hypothermia on feeding tolerance in this population is currently unknown. In addition, studies have illustrated that intestinal motility in neonates with HIE is abnormal at 7 days post insult ADDIN EN.CITE <EndNote><Cite><Author>Berseth</Author><Year>1992</Year><RecNum>1504</RecNum><DisplayText>[6]</DisplayText><record><rec-number>1504</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd" timestamp="0">1504</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Berseth, C. L.</author><author>McCoy, H. H.</author></authors></contributors><auth-address>Department of Pediatrics, Mayo Clinic, Rochester, MN.</auth-address><titles><title>Birth asphyxia alters neonatal intestinal motility in term neonates</title><secondary-title>Pediatrics</secondary-title></titles><periodical><full-title>Pediatrics</full-title></periodical><pages>669-73</pages><volume>90</volume><number>5</number><edition>1992/11/01</edition><keywords><keyword>Asphyxia Neonatorum/*physiopathology</keyword><keyword>*Enteral Nutrition</keyword><keyword>*Gastrointestinal Motility</keyword><keyword>Humans</keyword><keyword>Infant, Newborn/*physiology</keyword><keyword>Manometry</keyword></keywords><dates><year>1992</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0031-4005 (Print)&#xD;0031-4005 (Linking)</isbn><accession-num>1408536</accession-num><urls><related-urls><url>;[6]. Recently, reports have demonstrated the safety of minimal enteral feeds in neonates undergoing hypothermia ADDIN EN.CITE <EndNote><Cite><Author>Thyagarajan</Author><Year>2015</Year><RecNum>1841</RecNum><DisplayText>[7]</DisplayText><record><rec-number>1841</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd" timestamp="1439310616">1841</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Thyagarajan, B.</author><author>Tillqvist, E.</author><author>Baral, V.</author><author>Hallberg, B.</author><author>Vollmer, B.</author><author>Blennow, M.</author></authors></contributors><auth-address>Neonatal Unit, Princess Anne Hospital, Southampton, UK.</auth-address><titles><title>Minimal enteral nutrition during neonatal hypothermia treatment for perinatal hypoxic-ischaemic encephalopathy is safe and feasible</title><secondary-title>Acta Paediatr</secondary-title><alt-title>Acta paediatrica</alt-title></titles><periodical><full-title>Acta Paediatr</full-title></periodical><alt-periodical><full-title>Acta Paediatr Suppl</full-title><abbr-1>Acta paediatrica</abbr-1></alt-periodical><pages>146-51</pages><volume>104</volume><number>2</number><dates><year>2015</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>1651-2227 (Electronic)&#xD;0803-5253 (Linking)</isbn><accession-num>25348803</accession-num><urls><related-urls><url>;[7]. Recommendations: Feeding may be started as early as deemed appropriate by the clinical team. This may be with small amounts during hypothermia in neonates without hypotension or the need for pressor support. The clinician may also examine LFTs and creatinine when making decisions about feeding initiation and volumes since these may represent other end-organ damage which may indirectly suggest gut injury. Level of Evidence: IV- Case Series and Expert opinion based on current review of the literature.III. How quickly should feeds be advanced?There is no evidence for term neonates who have suffered from HIE to guide the advancement of feeds. Therefore, one may extrapolate the experience and rationale used for preterm neonates ADDIN EN.CITE <EndNote><Cite><Author>Tyson</Author><Year>2007</Year><RecNum>1505</RecNum><DisplayText>[8]</DisplayText><record><rec-number>1505</rec-number><foreign-keys><key app="EN" db-id="0vwww2vtjf2df1exepavx55tsf2dwexvevzd" timestamp="0">1505</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tyson, J. E.</author><author>Kennedy, K. A.</author><author>Lucke, J. F.</author><author>Pedroza, C.</author></authors></contributors><auth-address>The University of Texas Medical School at Houston, Houston, TX 77030, USA. jon.e.tyson@uth.tmc.edu</auth-address><titles><title>Dilemmas initiating enteral feedings in high risk infants: how can they be resolved?</title><secondary-title>Semin Perinatol</secondary-title></titles><periodical><full-title>Semin Perinatol</full-title></periodical><pages>61-73</pages><volume>31</volume><number>2</number><edition>2007/04/28</edition><keywords><keyword>Bayes Theorem</keyword><keyword>Enteral Nutrition/*adverse effects</keyword><keyword>Enterocolitis, Necrotizing/prevention &amp; control</keyword><keyword>Humans</keyword><keyword>Infant Nutritional Physiological Phenomena/*physiology</keyword><keyword>Infant, Newborn</keyword><keyword>Infant, Very Low Birth Weight/*growth &amp; development/physiology</keyword><keyword>*Randomized Controlled Trials as Topic/methods</keyword><keyword>Risk Factors</keyword><keyword>Safety</keyword><keyword>Sample Size</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2007</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>0146-0005 (Print)&#xD;0146-0005 (Linking)</isbn><accession-num>17462490</accession-num><urls><related-urls><url>(07)00030-4 [pii]&#xD;10.1053/j.semperi.2007.02.008</electronic-resource-num><language>eng</language></record></Cite></EndNote>[8]. Route of feeding and type of feed may also be considered in the advancement of feeds. Recommendations: Feeds may be advanced as rapidly as appropriate based on clinical condition and route of feeding with a maximum volume of 20 mL/k/day. Due to the increased demands of PO feeding, all feeds should be administered via NG tube during hypothermia. Level of Evidence: V- Expert opinion based on current review of the literature.IV. References ADDIN EN.REFLIST 1.Kramer, M.S., "Breast is best": The evidence. Early Hum Dev. 86(11): p. 729-32.2.Le Huerou-Luron, I., S. Blat, and G. Boudry, Breast- v. formula-feeding: impacts on the digestive tract and immediate and long-term health effects. Nutr Res Rev. 23(1): p. 23-36.3.Patki, S., et al., Human breast milk is a rich source of multipotent mesenchymal stem cells. Hum Cell. 23(2): p. 35-40.4.Lambert, D.K., et al., Necrotizing enterocolitis in term neonates: data from a multihospital health-care system. J Perinatol, 2007. 27(7): p. 437-43.5.Maayan-Metzger, A., et al., Necrotizing enterocolitis in full-term infants: case-control study and review of the literature. J Perinatol, 2004. 24(8): p. 494-9.6.Berseth, C.L. and H.H. McCoy, Birth asphyxia alters neonatal intestinal motility in term neonates. Pediatrics, 1992. 90(5): p. 669-73.7.Thyagarajan, B., et al., Minimal enteral nutrition during neonatal hypothermia treatment for perinatal hypoxic-ischaemic encephalopathy is safe and feasible. Acta Paediatr, 2015. 104(2): p. 146-51.8.Tyson, J.E., et al., Dilemmas initiating enteral feedings in high risk infants: how can they be resolved? Semin Perinatol, 2007. 31(2): p. 61-73.III. Respiratory and Ventilator ManagementSection ContentsWhat are the goal values for PaCO2 and PaO2 on ABGs?What parameters are recommended for FiO2 and oxygen saturations?What defines a patient who may be a candidate for ECMO?How should temperature correction factor into the interpretation of blood gases?Should patients be extubated during the cooling or rewarming process?What are the recommendations regarding ventilator management?VII. What are the recommendations regarding the use of nitric oxide (iNO)?VIII. References I. What are the goal values for PaCO2 and PaO2 on ABGs?With regard to CO2, the goal may be values within the normal range (40-55 mmHg Note: although higher PaCO2 may be appropriate for certain infants with significant ventilator requirements). Infants who have suffered a hypoxic-ischemic insult will have resultant changes in metabolism that lead to less CO2 production. Also, CO2 may be low secondary to respiratory compensation for the initial metabolic acidosis. Hypothermia may reduce CO2 production as well (1). These factors combined lead to less ventilator support needed to obtain a desirable CO2. Hypocapnia has also been shown to be harmful in this population. Low CO2 leads to decreased cerebral perfusion and decreased oxygen release from hemoglobin. Current research has also determined it to be associated with death and poor neurodevelopmental outcome in infants with HIE (2). Hyperoxia has also been shown to have a detrimental effect on these infants. Hyperoxia leads to increased oxidative stress and increased free radical production. It can be especially toxic in the setting of reperfusion and attenuate brain injury (3). Further, hyperoxia has been associated with death and poor long-term outcomes post asphyxia (2). We therefore recommend goal PaO2 values of 50-100 mmHg. Infants who suffer from birth depression and resultant HIE often undergo vigorous resuscitation at birth. As a result, they may have hyperoxia and hypocapnia from birth. After initial asphyxia the cardiopulmonary function often improves rapidly necessitating less support. We recommend obtaining a post resuscitation ABG, and using a conservative ventilator strategy. Recommendations:Keep PaCO2 in the range of 40-55 mmHg (Note: these are suggested ranges and may need to be modified for individual patient care based on the bedside clinicians exam and the patient’s underlying pathophysiology). If the neonate is self hyperventilating to a lower level, assure that mechanical ventilation is not contributing to further decreases in CO2 by lowering support as much as clinically indicated.Keep PaO2 in the range of 50-80 mmHg to prevent hyperoxic injury. Avoid over ventilation by starting with a conservative initial ventilator rate (For example 30 breaths per minute. This suggestion should be modified based on the clinical presentation.)ABG post resuscitation, manage ventilator to obtain goal PaO2 and PaCO2 Level of Evidence: IV- Case Series and Expert opinion based on current review of the literature.II. What parameters are recommended for FiO2 and oxygen saturations?As outlined above, hyperoxia is particularly harmful in this population. Current guidelines recommend the use of room air for the initial resuscitation of term infants. Infants resuscitated with room air have higher Apgar scores at 5 minutes, higher heart rates at 90 seconds of age, and took their first breath 30 seconds earlier than those who received 100% oxygen (4).Recommendations:Initiate resuscitation with room air (follow the Neonatal Resuscitation ProgramTM guidelines 6th edition for delivery room management)When oxygen is required, use the least amount of FiO2 needed to maintain saturations > 92%Level of Evidence: IB- RCT and Expert opinion based on current review of literature.III. What defines a patient who may be a candidate for ECMO?Infants who suffer from severe HIE often meet ECMO support criteria secondary to pulmonary hypertension with or without meconium aspiration and/or hypoxic respiratory failure. Recent literature has examined the practice of continuing hypothermia therapy while undergoing ECMO with good results (5). One practice management that may be initiated as ECMO becomes likely is nitric oxide (NO). The use of NO, even at low dosing (5 ppm), can decrease the use of ECMO by as much as 35% when the oxygen index is > 25 (3). However, despite the use of NO, ECMO is often still the required therapy in this population. A recent survey to the directors of ECMO programs showed that there is significant variability in how neonates are selected for ECMO once severity of illness criteria has been met. In this survey, 48% of the responders stated they would not offer ECMO to infant’s with severe HIE (7). Recommendations:In the experience of the network sites, hypothermia may be continued safely during ECMO. Early discussion of the ECMO criteria for infants with severe HIE should be established. The discussion should include multiple disciplines (neonatology, pediatric surgery, ethics committee).May consider rewarming slowly by 0.20C to see if the pulmonary vascular resistance relaxes with mild increases in the temperature. The clinician may consider proceeding straight to ECMO if the baby is very early in the hypothermia course or rewarming to a target range which is still considered neuroprotective, 350C. Conversely, the clinician may consider rewarming fully if the neonate is close to the end of the 72 hour cooling period in an attempt to avoid ECMO. Level of Evidence: IV- Case Series and Expert opinion based on current review of the literature.IV. How should temperature correction factor into the interpretation of blood gases?Hypothermia affects blood gas parameters such as pH and CO2; at lower temperatures pH increases and CO2 decreases (6). Most blood gas instruments contain a temperature-controlled sample chamber specified to be 37oC, referred to as α-stat method. In the α-stat method, uncorrected values are used to keep the pH and CO2 close to the 37oC reference value. Alternatively, in the pH-stat method, the measured pH is corrected to the actual body temperature of the patient. For example, during hypothermia (core temperature 33°C), pH will rise to 7.5 and PCO2 will decrease 34 mm Hg (6). At this point it is unclear whether the α-stat or pH-stat method should be used for the ventilator management of the asphyxiated neonate undergoing hypothermia (6). Recommendation:Recognition that blood gas values will vary depending on the method used in calibration; the clinician may consider alternative ventilator strategies to obtain goal blood gas values. Level of Evidence: V- Expert opinion based on current review of literature.V. Should patients be extubated during the cooling or rewarming process?Recommendation:Based on case reports it appears to be a safe practice if the infant meets all the parameters needed for safe extubation. These infants represent a unique population and awareness of their high-risk status must be considered: airway protection (if diminished gag reflex), seizure activity, and apnea associated with the cooling and/or rewarming processLevel of Evidence: V- Expert opinion based on current review of literature.VI. What are the recommendations regarding ventilator management?As discussed previously, initial ventilator settings should be conservative, with moderate pressures and respiratory rate.? Initial PEEP should also be conservative.? Overdistension of the lung may increase PVR and reduce venous return, therefore impairing peripheral and cerebral perfusion.? Finding the optimal balance between sufficient MAP to allow lung recruitment and its potential negative effects on circulation may often require multiple chest radiographs and echocardiography (3).?? Level of Evidence: V- Expert opinion based on current review of literature.VII. What are the recommendations regarding the use of nitric oxide (iNO)?As discussed in the section on ECMO, iNO can effectively improve oxygenation in the asphyxiated newborn, with or without evidence of PPHN.? It may also be used, even at smaller doses, to aid in the weaning of FiO2 if the patient is on high settings.? In previous studies, oxygen used has diminished after the initiation of iNO therapy.? If infants are on high FiO2 and ventilator settings consideration should be given to starting NO therapy (8). Level of Evidence: V- Expert opinion based on current review of literature.VIII. ReferencesPappas A, et al. Hypocarbia and adverse outcome in neonatal hypoxic-ischemic encephalopathy. J Pediatr 2010; 158(5):752-758.Klinger G, Beyene J, Shah P, Perlman M. Do hyperoxaemia and hypocapnia add to the risk of brain injury after intrapartum asphyxia? Arch Dis Child Fetal Neonatal Ed 2005;90:49-52.Lapointe A, and Barrington KJ. Pulmonary hypertension and the asphyxiated newborn. J Pediatr 2011; 158(2):e19-e23. Saugstad OD. Resuscitation of newborn infants: from oxygen to room air. Lancet 2010; 376:1970-1971.Massaro A, et al. Therapeutic hypothermia for neonatal encephalopathy and extracorporeal membrane oxygenation. J Pediatr 2010; 157(3):499-502.Groenendaal F, De Voogt K, van Bel F. Blood gas values during hypothermia in asphyxiated term neonates. Pediatrics 2009; 123(1):170-171.Chapman R. Patient selection for neonatal extracorporeal membrane oxygenation: beyond severity of illness. Journal of Perinatology 2009; 29: 606-611. Wessel et al. Persistent Pulmonary Hypertension of the Newborn Improved Oxygenation in a Randomized Trial of Inhaled Nitric Oxide. Pediatrics 1997. IV. Cardiovascular Support and HIESection ContentsWhat is the goal Mean Arterial Blood Pressure (MAP) for infants with HIE?What is the optimal method to manage hypotension with HIE?How does hypothermia affect hemodynamic status post asphyxia?When should an echocardiogram be obtain for infants with HIE?Should serum markers of cardiac injury be obtained in infants with HIE, whatmarkers, and when should they be obtained?How should bradycardia associated with hypothermia be managed?VII. References I. What is the goal Mean Arterial Blood Pressure (MAP) for infants with HIE?Blood pressure must remain in a safe range post HIE with the goals of avoiding hypotensive associate cerebral ischemia while ensuring the infant is not hypertensive with subsequent intra-cerebral hemorrhage. The ideal MAP for term infants with HIE has not been established. Since infants operate over a narrow blood pressure range, and hypoxic-ischemia impairs cerebral autoregulation, it is recommended to maintain MAP within the critical margin of 40mmHg to 60mmHg ADDIN EN.CITE <EndNote><Cite><Author>Volpe</Author><Year>2008</Year><RecNum>102</RecNum><record><rec-number>102</rec-number><foreign-keys><key app="EN" db-id="0e5wpxtvj2v5x4ewattvp2z4ww05zzez0svv">102</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Volpe, JJ</author></authors><secondary-authors><author>Volpe, JJ</author></secondary-authors></contributors><titles><title>Neurology of the Newborn</title></titles><edition>Fifth</edition><section>400-480</section><dates><year>2008</year></dates><pub-location>Philadelphia</pub-location><publisher>Saunders</publisher><urls></urls></record></Cite></EndNote>(1) unless the hemodynamics suggest a more optimal MAP.Recommendations: Attempt to maintain MAP between 40mmHg and 60mmHg. Cerebral oximetry may be used to identify the optimal blood pressure for the patient. 2. Infants with pulmonary hypertension may require a MAP on the -higher end of this scale3. Attempt to avoid acute fluctuations in blood pressure Level of Evidence: V- Expert opinion based on current review of literature.II. What is the optimal method to manage hypotension with HIE?There is minimal documentation regarding the ideal method to augment MAP for infants with HIE. If there is clinical or historical evidence of hypovolemia (i.e. severe anemia, placenta abruption, cord compression) than volume may be indicated. The unwarranted use of fluids may exacerbate cerebral edema ADDIN EN.CITE <EndNote><Cite><Author>Kimelberg</Author><Year>1995</Year><RecNum>160</RecNum><record><rec-number>160</rec-number><foreign-keys><key app="EN" db-id="0e5wpxtvj2v5x4ewattvp2z4ww05zzez0svv">160</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kimelberg, H. K.</author></authors></contributors><auth-address>Division of Neurosurgery, Albany Medical College, New York, USA.</auth-address><titles><title>Current concepts of brain edema. Review of laboratory investigations</title><secondary-title>J Neurosurg</secondary-title></titles><periodical><full-title>J Neurosurg</full-title></periodical><pages>1051-9</pages><volume>83</volume><number>6</number><edition>1995/12/01</edition><keywords><keyword>Amino Acids/metabolism</keyword><keyword>Animals</keyword><keyword>Astrocytes/metabolism</keyword><keyword>Brain Edema/*physiopathology</keyword><keyword>Cells/metabolism</keyword><keyword>Electrolytes/metabolism</keyword><keyword>Extracellular Space/metabolism</keyword><keyword>Neurons/metabolism</keyword></keywords><dates><year>1995</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>0022-3085 (Print)&#xD;0022-3085 (Linking)</isbn><accession-num>7490620</accession-num><urls><related-urls><url>;(2). A 2002 Cochrane systemic review evaluating Dopamine for the prevention of morbidity and mortality with HIE was found to be inconclusive ADDIN EN.CITE <EndNote><Cite><Author>Hunt</Author><Year>2002</Year><RecNum>161</RecNum><record><rec-number>161</rec-number><foreign-keys><key app="EN" db-id="0e5wpxtvj2v5x4ewattvp2z4ww05zzez0svv">161</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hunt, R.</author><author>Osborn, D.</author></authors></contributors><auth-address>Neonatal Neurology, Royal Women&apos;s and Royal Children&apos;s Hospitals, Melbourne, Level 2, Royal Children&apos;s Hospital, Flemington Road, Parkville, VIC, Australia, 3052. huntr@cryptic.rch.unimelb.edu.au</auth-address><titles><title>Dopamine for prevention of morbidity and mortality in term newborn infants with suspected perinatal asphyxia</title><secondary-title>Cochrane Database Syst Rev</secondary-title></titles><periodical><full-title>Cochrane Database Syst Rev</full-title></periodical><pages>CD003484</pages><number>3</number><edition>2002/07/26</edition><keywords><keyword>Asphyxia Neonatorum/*prevention &amp; control</keyword><keyword>Cardiotonic Agents/*therapeutic use</keyword><keyword>Dopamine/*therapeutic use</keyword><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>Randomized Controlled Trials as Topic</keyword></keywords><dates><year>2002</year></dates><isbn>1469-493X (Electronic)&#xD;1361-6137 (Linking)</isbn><accession-num>12137696</accession-num><urls><related-urls><url> [pii]&#xD;10.1002/14651858.CD003484</electronic-resource-num><language>eng</language></record></Cite></EndNote>(3). Further, Dopamine may not be the ideal first line agent for infants with evidence of pulmonary hypertension (PPHN) and HIE because it increases both systemic (SVR) and pulmonary vascular resistance (PVR) ADDIN EN.CITE <EndNote><Cite><Author>Cheung</Author><Year>2001</Year><RecNum>162</RecNum><record><rec-number>162</rec-number><foreign-keys><key app="EN" db-id="0e5wpxtvj2v5x4ewattvp2z4ww05zzez0svv">162</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cheung, P. Y.</author><author>Barrington, K. J.</author></authors></contributors><auth-address>McGill University, Montreal, Quebec, Canada.</auth-address><titles><title>The effects of dopamine and epinephrine on hemodynamics and oxygen metabolism in hypoxic anesthetized piglets</title><secondary-title>Crit Care</secondary-title></titles><periodical><full-title>Crit Care</full-title></periodical><pages>158-66</pages><volume>5</volume><number>3</number><edition>2001/05/17</edition><keywords><keyword>Animals</keyword><keyword>Animals, Newborn</keyword><keyword>Anoxia/chemically induced/*drug therapy/physiopathology</keyword><keyword>Cardiotonic Agents/administration &amp; dosage/*pharmacology/therapeutic use</keyword><keyword>Disease Models, Animal</keyword><keyword>Dopamine/administration &amp; dosage/*pharmacology/therapeutic use</keyword><keyword>Dose-Response Relationship, Drug</keyword><keyword>Epinephrine/administration &amp; dosage/*pharmacology/therapeutic use</keyword><keyword>Fentanyl/diagnostic use</keyword><keyword>Hemodynamics/*drug effects</keyword><keyword>Liver Circulation/drug effects</keyword><keyword>Oxygen/*blood</keyword><keyword>Oxygen Consumption/drug effects</keyword><keyword>Pulmonary Circulation/drug effects</keyword><keyword>Random Allocation</keyword><keyword>Splanchnic Circulation/drug effects</keyword><keyword>Swine</keyword></keywords><dates><year>2001</year></dates><isbn>1364-8535 (Print)&#xD;1364-8535 (Linking)</isbn><accession-num>11353933</accession-num><urls><related-urls><url>;(4). Dobutamine, at high doses, can also increase pulmonary artery pressure while reducing afterload and therefore would not be an ideal agent for infants with HIE and PPHN ADDIN EN.CITE <EndNote><Cite><Author>Cheung</Author><Year>1999</Year><RecNum>163</RecNum><record><rec-number>163</rec-number><foreign-keys><key app="EN" db-id="0e5wpxtvj2v5x4ewattvp2z4ww05zzez0svv">163</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cheung, P. Y.</author><author>Barrington, K. J.</author><author>Bigam, D.</author></authors></contributors><auth-address>Department of Pediatrics, University of Alberta, Edmonton, Canada.</auth-address><titles><title>The hemodynamic effects of dobutamine infusion in the chronically instrumented newborn piglet</title><secondary-title>Crit Care Med</secondary-title></titles><periodical><full-title>Crit Care Med</full-title></periodical><pages>558-64</pages><volume>27</volume><number>3</number><edition>1999/04/13</edition><keywords><keyword>Analysis of Variance</keyword><keyword>Animals</keyword><keyword>Animals, Newborn</keyword><keyword>Cardiotonic Agents/administration &amp; dosage/*pharmacology</keyword><keyword>Dobutamine/administration &amp; dosage/*pharmacology</keyword><keyword>Dose-Response Relationship, Drug</keyword><keyword>Hemodynamics/*drug effects</keyword><keyword>Infusions, Intravenous</keyword><keyword>Random Allocation</keyword><keyword>Renal Circulation/drug effects</keyword><keyword>Swine</keyword><keyword>Thermodilution</keyword></keywords><dates><year>1999</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0090-3493 (Print)&#xD;0090-3493 (Linking)</isbn><accession-num>10199537</accession-num><urls><related-urls><url>;(5).Epinephrine, at low to moderate dosing, will increase SVR with little effect on PVR. In addition, epinephrine can improve myocardial perfusion and dysfunction. Infants with HIE and PPHN, epinephrine may be the optimal choice for blood pressure augmentation ADDIN EN.CITE <EndNote><Cite><Author>Cheung</Author><Year>2001</Year><RecNum>162</RecNum><record><rec-number>162</rec-number><foreign-keys><key app="EN" db-id="0e5wpxtvj2v5x4ewattvp2z4ww05zzez0svv">162</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cheung, P. Y.</author><author>Barrington, K. J.</author></authors></contributors><auth-address>McGill University, Montreal, Quebec, Canada.</auth-address><titles><title>The effects of dopamine and epinephrine on hemodynamics and oxygen metabolism in hypoxic anesthetized piglets</title><secondary-title>Crit Care</secondary-title></titles><periodical><full-title>Crit Care</full-title></periodical><pages>158-66</pages><volume>5</volume><number>3</number><edition>2001/05/17</edition><keywords><keyword>Animals</keyword><keyword>Animals, Newborn</keyword><keyword>Anoxia/chemically induced/*drug therapy/physiopathology</keyword><keyword>Cardiotonic Agents/administration &amp; dosage/*pharmacology/therapeutic use</keyword><keyword>Disease Models, Animal</keyword><keyword>Dopamine/administration &amp; dosage/*pharmacology/therapeutic use</keyword><keyword>Dose-Response Relationship, Drug</keyword><keyword>Epinephrine/administration &amp; dosage/*pharmacology/therapeutic use</keyword><keyword>Fentanyl/diagnostic use</keyword><keyword>Hemodynamics/*drug effects</keyword><keyword>Liver Circulation/drug effects</keyword><keyword>Oxygen/*blood</keyword><keyword>Oxygen Consumption/drug effects</keyword><keyword>Pulmonary Circulation/drug effects</keyword><keyword>Random Allocation</keyword><keyword>Splanchnic Circulation/drug effects</keyword><keyword>Swine</keyword></keywords><dates><year>2001</year></dates><isbn>1364-8535 (Print)&#xD;1364-8535 (Linking)</isbn><accession-num>11353933</accession-num><urls><related-urls><url>;(4). Milrinone increases myocardial contractility and acts as a vasodilator (systemic and pulmonary). Infants with myocardial dysfunction, Milrinone may be a superior agent to improve contractility ensuring MAP is within target range prior to its initiation PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NY05hbWFyYTwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+

PFJlY051bT4xNjU8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjE2NTwvcmVjLW51bWJlcj48

Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjBlNXdweHR2ajJ2NXg0ZXdhdHR2cDJ6

NHd3MDV6emV6MHN2diI+MTY1PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9Ikpv

dXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhv

cj5NY05hbWFyYSwgUC4gSi48L2F1dGhvcj48YXV0aG9yPkxhaXF1ZSwgRi48L2F1dGhvcj48YXV0

aG9yPk11YW5nLUluLCBTLjwvYXV0aG9yPjxhdXRob3I+V2h5dGUsIEguIEUuPC9hdXRob3I+PC9h

dXRob3JzPjwvY29udHJpYnV0b3JzPjxhdXRoLWFkZHJlc3M+RGl2aXNpb24gb2YgTmVvbmF0b2xv

Z3ksIERlcGFydG1lbnQgb2YgUGVkaWF0cmljcywgVW5pdmVyc2l0eSBvZiBUb3JvbnRvLCBIb3Nw

aXRhbCBmb3IgU2ljayBDaGlsZHJlbiwgVG9yb250bywgT250YXJpbywgQ2FuYWRhIE01RyAxWDgu

IHBhdHJpY2subWNuYW1hcmFAc2lja2tpZHMuY2E8L2F1dGgtYWRkcmVzcz48dGl0bGVzPjx0aXRs

ZT5NaWxyaW5vbmUgaW1wcm92ZXMgb3h5Z2VuYXRpb24gaW4gbmVvbmF0ZXMgd2l0aCBzZXZlcmUg

cGVyc2lzdGVudCBwdWxtb25hcnkgaHlwZXJ0ZW5zaW9uIG9mIHRoZSBuZXdib3JuPC90aXRsZT48

c2Vjb25kYXJ5LXRpdGxlPkogQ3JpdCBDYXJlPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBl

cmlvZGljYWw+PGZ1bGwtdGl0bGU+SiBDcml0IENhcmU8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2Fs

PjxwYWdlcz4yMTctMjI8L3BhZ2VzPjx2b2x1bWU+MjE8L3ZvbHVtZT48bnVtYmVyPjI8L251bWJl

cj48ZWRpdGlvbj4yMDA2LzA2LzE0PC9lZGl0aW9uPjxrZXl3b3Jkcz48a2V5d29yZD5DeWNsaWMg

QU1QL3BoeXNpb2xvZ3k8L2tleXdvcmQ+PGtleXdvcmQ+Q3ljbGljIEdNUC9waHlzaW9sb2d5PC9r

ZXl3b3JkPjxrZXl3b3JkPkh1bWFuczwva2V5d29yZD48a2V5d29yZD5IeXBlcnRlbnNpb24sIFB1

bG1vbmFyeS8qY29uZ2VuaXRhbC8qZHJ1ZyB0aGVyYXB5L3BoeXNpb3BhdGhvbG9neTwva2V5d29y

ZD48a2V5d29yZD5JbmZhbnQsIE5ld2Jvcm48L2tleXdvcmQ+PGtleXdvcmQ+TWlscmlub25lLyp0

aGVyYXBldXRpYyB1c2U8L2tleXdvcmQ+PGtleXdvcmQ+T3h5Z2VuLypibG9vZDwva2V5d29yZD48

a2V5d29yZD5QaG9zcGhvZGllc3RlcmFzZSBJbmhpYml0b3JzL3RoZXJhcGV1dGljIHVzZTwva2V5

d29yZD48a2V5d29yZD5TaWduYWwgVHJhbnNkdWN0aW9uPC9rZXl3b3JkPjxrZXl3b3JkPlZhc29k

aWxhdG9yIEFnZW50cy90aGVyYXBldXRpYyB1c2U8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+

PHllYXI+MjAwNjwveWVhcj48cHViLWRhdGVzPjxkYXRlPkp1bjwvZGF0ZT48L3B1Yi1kYXRlcz48

L2RhdGVzPjxpc2JuPjA4ODMtOTQ0MSAoUHJpbnQpJiN4RDswODgzLTk0NDEgKExpbmtpbmcpPC9p

c2JuPjxhY2Nlc3Npb24tbnVtPjE2NzY5NDcxPC9hY2Nlc3Npb24tbnVtPjx1cmxzPjxyZWxhdGVk

LXVybHM+PHVybD5odHRwOi8vd3d3Lm5jYmkubmxtLm5paC5nb3YvZW50cmV6L3F1ZXJ5LmZjZ2k/

Y21kPVJldHJpZXZlJmFtcDtkYj1QdWJNZWQmYW1wO2RvcHQ9Q2l0YXRpb24mYW1wO2xpc3RfdWlk

cz0xNjc2OTQ3MTwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48ZWxlY3Ryb25pYy1yZXNvdXJj

ZS1udW0+UzA4ODMtOTQ0MSgwNikwMDAwMy03IFtwaWldJiN4RDsxMC4xMDE2L2ouamNyYy4yMDA2

LjAxLjAwMTwvZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+PGxhbmd1YWdlPmVuZzwvbGFuZ3VhZ2U+

PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+QmFzc2xlcjwvQXV0aG9yPjxZZWFyPjIwMDY8

L1llYXI+PFJlY051bT4xNjQ8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjE2NDwvcmVjLW51

bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjBlNXdweHR2ajJ2NXg0ZXdh

dHR2cDJ6NHd3MDV6emV6MHN2diI+MTY0PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5h

bWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+

PGF1dGhvcj5CYXNzbGVyLCBELjwvYXV0aG9yPjxhdXRob3I+Q2hvb25nLCBLLjwvYXV0aG9yPjxh

dXRob3I+TWNOYW1hcmEsIFAuPC9hdXRob3I+PGF1dGhvcj5LaXJwYWxhbmksIEguPC9hdXRob3I+

PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjxhdXRoLWFkZHJlc3M+RGl2aXNpb24gb2YgTmVvbmF0

b2xvZ3ksIERlcGFydG1lbnQgb2YgUGFlZGlhdHJpY3MsIE1jTWFzdGVyIFVuaXZlcnNpdHkgTWVk

aWNhbCBDZW50cmUsIEhhbWlsdG9uLCBPbnQuLCBDYW5hZGEuPC9hdXRoLWFkZHJlc3M+PHRpdGxl

cz48dGl0bGU+TmVvbmF0YWwgcGVyc2lzdGVudCBwdWxtb25hcnkgaHlwZXJ0ZW5zaW9uIHRyZWF0

ZWQgd2l0aCBtaWxyaW5vbmU6IGZvdXIgY2FzZSByZXBvcnRzPC90aXRsZT48c2Vjb25kYXJ5LXRp

dGxlPkJpb2wgTmVvbmF0ZTwvc2Vjb25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxm

dWxsLXRpdGxlPkJpb2wgTmVvbmF0ZTwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjEt

NTwvcGFnZXM+PHZvbHVtZT44OTwvdm9sdW1lPjxudW1iZXI+MTwvbnVtYmVyPjxlZGl0aW9uPjIw

MDUvMDkvMTM8L2VkaXRpb24+PGtleXdvcmRzPjxrZXl3b3JkPkFkbWluaXN0cmF0aW9uLCBJbmhh

bGF0aW9uPC9rZXl3b3JkPjxrZXl3b3JkPkFuaW1hbHM8L2tleXdvcmQ+PGtleXdvcmQ+QW5veGlh

L2NvbXBsaWNhdGlvbnM8L2tleXdvcmQ+PGtleXdvcmQ+RmVtYWxlPC9rZXl3b3JkPjxrZXl3b3Jk

Pkdlc3RhdGlvbmFsIEFnZTwva2V5d29yZD48a2V5d29yZD5IdW1hbnM8L2tleXdvcmQ+PGtleXdv

cmQ+SW5mYW50LCBOZXdib3JuPC9rZXl3b3JkPjxrZXl3b3JkPkluZmFudCwgUHJlbWF0dXJlPC9r

ZXl3b3JkPjxrZXl3b3JkPk1hbGU8L2tleXdvcmQ+PGtleXdvcmQ+TWVjb25pdW0gQXNwaXJhdGlv

biBTeW5kcm9tZTwva2V5d29yZD48a2V5d29yZD5NaWxyaW5vbmUvKnRoZXJhcGV1dGljIHVzZTwv

a2V5d29yZD48a2V5d29yZD5OaXRyaWMgT3hpZGUvKmFkbWluaXN0cmF0aW9uICZhbXA7IGRvc2Fn

ZTwva2V5d29yZD48a2V5d29yZD5PbGlnb2h5ZHJhbW5pb3M8L2tleXdvcmQ+PGtleXdvcmQ+UGVy

c2lzdGVudCBGZXRhbCBDaXJjdWxhdGlvbiBTeW5kcm9tZS8qZHJ1ZyB0aGVyYXB5PC9rZXl3b3Jk

PjxrZXl3b3JkPlBob3NwaG9kaWVzdGVyYXNlIEluaGliaXRvcnMvKnRoZXJhcGV1dGljIHVzZTwv

a2V5d29yZD48a2V5d29yZD5QcmVnbmFuY3k8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHll

YXI+MjAwNjwveWVhcj48L2RhdGVzPjxpc2JuPjAwMDYtMzEyNiAoUHJpbnQpJiN4RDswMDA2LTMx

MjYgKExpbmtpbmcpPC9pc2JuPjxhY2Nlc3Npb24tbnVtPjE2MTU1MzgwPC9hY2Nlc3Npb24tbnVt

Pjx1cmxzPjxyZWxhdGVkLXVybHM+PHVybD5odHRwOi8vd3d3Lm5jYmkubmxtLm5paC5nb3YvZW50

cmV6L3F1ZXJ5LmZjZ2k/Y21kPVJldHJpZXZlJmFtcDtkYj1QdWJNZWQmYW1wO2RvcHQ9Q2l0YXRp

b24mYW1wO2xpc3RfdWlkcz0xNjE1NTM4MDwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48ZWxl

Y3Ryb25pYy1yZXNvdXJjZS1udW0+ODgxOTIgW3BpaV0mI3hEOzEwLjExNTkvMDAwMDg4MTkyPC9l

bGVjdHJvbmljLXJlc291cmNlLW51bT48bGFuZ3VhZ2U+ZW5nPC9sYW5ndWFnZT48L3JlY29yZD48

L0NpdGU+PC9FbmROb3RlPgAAQwBp

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NY05hbWFyYTwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+

PFJlY051bT4xNjU8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjE2NTwvcmVjLW51bWJlcj48

Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjBlNXdweHR2ajJ2NXg0ZXdhdHR2cDJ6

NHd3MDV6emV6MHN2diI+MTY1PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9Ikpv

dXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhv

cj5NY05hbWFyYSwgUC4gSi48L2F1dGhvcj48YXV0aG9yPkxhaXF1ZSwgRi48L2F1dGhvcj48YXV0

aG9yPk11YW5nLUluLCBTLjwvYXV0aG9yPjxhdXRob3I+V2h5dGUsIEguIEUuPC9hdXRob3I+PC9h

dXRob3JzPjwvY29udHJpYnV0b3JzPjxhdXRoLWFkZHJlc3M+RGl2aXNpb24gb2YgTmVvbmF0b2xv

Z3ksIERlcGFydG1lbnQgb2YgUGVkaWF0cmljcywgVW5pdmVyc2l0eSBvZiBUb3JvbnRvLCBIb3Nw

aXRhbCBmb3IgU2ljayBDaGlsZHJlbiwgVG9yb250bywgT250YXJpbywgQ2FuYWRhIE01RyAxWDgu

IHBhdHJpY2subWNuYW1hcmFAc2lja2tpZHMuY2E8L2F1dGgtYWRkcmVzcz48dGl0bGVzPjx0aXRs

ZT5NaWxyaW5vbmUgaW1wcm92ZXMgb3h5Z2VuYXRpb24gaW4gbmVvbmF0ZXMgd2l0aCBzZXZlcmUg

cGVyc2lzdGVudCBwdWxtb25hcnkgaHlwZXJ0ZW5zaW9uIG9mIHRoZSBuZXdib3JuPC90aXRsZT48

c2Vjb25kYXJ5LXRpdGxlPkogQ3JpdCBDYXJlPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBl

cmlvZGljYWw+PGZ1bGwtdGl0bGU+SiBDcml0IENhcmU8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2Fs

PjxwYWdlcz4yMTctMjI8L3BhZ2VzPjx2b2x1bWU+MjE8L3ZvbHVtZT48bnVtYmVyPjI8L251bWJl

cj48ZWRpdGlvbj4yMDA2LzA2LzE0PC9lZGl0aW9uPjxrZXl3b3Jkcz48a2V5d29yZD5DeWNsaWMg

QU1QL3BoeXNpb2xvZ3k8L2tleXdvcmQ+PGtleXdvcmQ+Q3ljbGljIEdNUC9waHlzaW9sb2d5PC9r

ZXl3b3JkPjxrZXl3b3JkPkh1bWFuczwva2V5d29yZD48a2V5d29yZD5IeXBlcnRlbnNpb24sIFB1

bG1vbmFyeS8qY29uZ2VuaXRhbC8qZHJ1ZyB0aGVyYXB5L3BoeXNpb3BhdGhvbG9neTwva2V5d29y

ZD48a2V5d29yZD5JbmZhbnQsIE5ld2Jvcm48L2tleXdvcmQ+PGtleXdvcmQ+TWlscmlub25lLyp0

aGVyYXBldXRpYyB1c2U8L2tleXdvcmQ+PGtleXdvcmQ+T3h5Z2VuLypibG9vZDwva2V5d29yZD48

a2V5d29yZD5QaG9zcGhvZGllc3RlcmFzZSBJbmhpYml0b3JzL3RoZXJhcGV1dGljIHVzZTwva2V5

d29yZD48a2V5d29yZD5TaWduYWwgVHJhbnNkdWN0aW9uPC9rZXl3b3JkPjxrZXl3b3JkPlZhc29k

aWxhdG9yIEFnZW50cy90aGVyYXBldXRpYyB1c2U8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+

PHllYXI+MjAwNjwveWVhcj48cHViLWRhdGVzPjxkYXRlPkp1bjwvZGF0ZT48L3B1Yi1kYXRlcz48

L2RhdGVzPjxpc2JuPjA4ODMtOTQ0MSAoUHJpbnQpJiN4RDswODgzLTk0NDEgKExpbmtpbmcpPC9p

c2JuPjxhY2Nlc3Npb24tbnVtPjE2NzY5NDcxPC9hY2Nlc3Npb24tbnVtPjx1cmxzPjxyZWxhdGVk

LXVybHM+PHVybD5odHRwOi8vd3d3Lm5jYmkubmxtLm5paC5nb3YvZW50cmV6L3F1ZXJ5LmZjZ2k/

Y21kPVJldHJpZXZlJmFtcDtkYj1QdWJNZWQmYW1wO2RvcHQ9Q2l0YXRpb24mYW1wO2xpc3RfdWlk

cz0xNjc2OTQ3MTwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48ZWxlY3Ryb25pYy1yZXNvdXJj

ZS1udW0+UzA4ODMtOTQ0MSgwNikwMDAwMy03IFtwaWldJiN4RDsxMC4xMDE2L2ouamNyYy4yMDA2

LjAxLjAwMTwvZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+PGxhbmd1YWdlPmVuZzwvbGFuZ3VhZ2U+

PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+QmFzc2xlcjwvQXV0aG9yPjxZZWFyPjIwMDY8

L1llYXI+PFJlY051bT4xNjQ8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjE2NDwvcmVjLW51

bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjBlNXdweHR2ajJ2NXg0ZXdh

dHR2cDJ6NHd3MDV6emV6MHN2diI+MTY0PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5h

bWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+

PGF1dGhvcj5CYXNzbGVyLCBELjwvYXV0aG9yPjxhdXRob3I+Q2hvb25nLCBLLjwvYXV0aG9yPjxh

dXRob3I+TWNOYW1hcmEsIFAuPC9hdXRob3I+PGF1dGhvcj5LaXJwYWxhbmksIEguPC9hdXRob3I+

PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjxhdXRoLWFkZHJlc3M+RGl2aXNpb24gb2YgTmVvbmF0

b2xvZ3ksIERlcGFydG1lbnQgb2YgUGFlZGlhdHJpY3MsIE1jTWFzdGVyIFVuaXZlcnNpdHkgTWVk

aWNhbCBDZW50cmUsIEhhbWlsdG9uLCBPbnQuLCBDYW5hZGEuPC9hdXRoLWFkZHJlc3M+PHRpdGxl

cz48dGl0bGU+TmVvbmF0YWwgcGVyc2lzdGVudCBwdWxtb25hcnkgaHlwZXJ0ZW5zaW9uIHRyZWF0

ZWQgd2l0aCBtaWxyaW5vbmU6IGZvdXIgY2FzZSByZXBvcnRzPC90aXRsZT48c2Vjb25kYXJ5LXRp

dGxlPkJpb2wgTmVvbmF0ZTwvc2Vjb25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxm

dWxsLXRpdGxlPkJpb2wgTmVvbmF0ZTwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjEt

NTwvcGFnZXM+PHZvbHVtZT44OTwvdm9sdW1lPjxudW1iZXI+MTwvbnVtYmVyPjxlZGl0aW9uPjIw

MDUvMDkvMTM8L2VkaXRpb24+PGtleXdvcmRzPjxrZXl3b3JkPkFkbWluaXN0cmF0aW9uLCBJbmhh

bGF0aW9uPC9rZXl3b3JkPjxrZXl3b3JkPkFuaW1hbHM8L2tleXdvcmQ+PGtleXdvcmQ+QW5veGlh

L2NvbXBsaWNhdGlvbnM8L2tleXdvcmQ+PGtleXdvcmQ+RmVtYWxlPC9rZXl3b3JkPjxrZXl3b3Jk

Pkdlc3RhdGlvbmFsIEFnZTwva2V5d29yZD48a2V5d29yZD5IdW1hbnM8L2tleXdvcmQ+PGtleXdv

cmQ+SW5mYW50LCBOZXdib3JuPC9rZXl3b3JkPjxrZXl3b3JkPkluZmFudCwgUHJlbWF0dXJlPC9r

ZXl3b3JkPjxrZXl3b3JkPk1hbGU8L2tleXdvcmQ+PGtleXdvcmQ+TWVjb25pdW0gQXNwaXJhdGlv

biBTeW5kcm9tZTwva2V5d29yZD48a2V5d29yZD5NaWxyaW5vbmUvKnRoZXJhcGV1dGljIHVzZTwv

a2V5d29yZD48a2V5d29yZD5OaXRyaWMgT3hpZGUvKmFkbWluaXN0cmF0aW9uICZhbXA7IGRvc2Fn

ZTwva2V5d29yZD48a2V5d29yZD5PbGlnb2h5ZHJhbW5pb3M8L2tleXdvcmQ+PGtleXdvcmQ+UGVy

c2lzdGVudCBGZXRhbCBDaXJjdWxhdGlvbiBTeW5kcm9tZS8qZHJ1ZyB0aGVyYXB5PC9rZXl3b3Jk

PjxrZXl3b3JkPlBob3NwaG9kaWVzdGVyYXNlIEluaGliaXRvcnMvKnRoZXJhcGV1dGljIHVzZTwv

a2V5d29yZD48a2V5d29yZD5QcmVnbmFuY3k8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHll

YXI+MjAwNjwveWVhcj48L2RhdGVzPjxpc2JuPjAwMDYtMzEyNiAoUHJpbnQpJiN4RDswMDA2LTMx

MjYgKExpbmtpbmcpPC9pc2JuPjxhY2Nlc3Npb24tbnVtPjE2MTU1MzgwPC9hY2Nlc3Npb24tbnVt

Pjx1cmxzPjxyZWxhdGVkLXVybHM+PHVybD5odHRwOi8vd3d3Lm5jYmkubmxtLm5paC5nb3YvZW50

cmV6L3F1ZXJ5LmZjZ2k/Y21kPVJldHJpZXZlJmFtcDtkYj1QdWJNZWQmYW1wO2RvcHQ9Q2l0YXRp

b24mYW1wO2xpc3RfdWlkcz0xNjE1NTM4MDwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48ZWxl

Y3Ryb25pYy1yZXNvdXJjZS1udW0+ODgxOTIgW3BpaV0mI3hEOzEwLjExNTkvMDAwMDg4MTkyPC9l

bGVjdHJvbmljLXJlc291cmNlLW51bT48bGFuZ3VhZ2U+ZW5nPC9sYW5ndWFnZT48L3JlY29yZD48

L0NpdGU+PC9FbmROb3RlPgAAbwB0

ADDIN EN.CITE.DATA (6, 7). Recommendations: 1. If infant is hypotensive, start treatment with a pressor which supports the clinical need of the neonate. 2. Obtain an Echocardiogram to assist in management. If myocardial dysfunction is evident on echocardiogram, consider the addition of epinephrine. 3. This is the recommended approach for hypotensive, encephalopathic infants with or without PPHN. Of note, the addition of Milrinone as a single agent may be beneficial in PPHN when normotensive or a combination of Milrinone with low dose epinephrine to prevent systemic hypotension with Milrinone infusion or if the patient had hypotension and PPHN PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NY05hbWFyYTwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+

PFJlY051bT4xNjU8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjE2NTwvcmVjLW51bWJlcj48

Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjBlNXdweHR2ajJ2NXg0ZXdhdHR2cDJ6

NHd3MDV6emV6MHN2diI+MTY1PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9Ikpv

dXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhv

cj5NY05hbWFyYSwgUC4gSi48L2F1dGhvcj48YXV0aG9yPkxhaXF1ZSwgRi48L2F1dGhvcj48YXV0

aG9yPk11YW5nLUluLCBTLjwvYXV0aG9yPjxhdXRob3I+V2h5dGUsIEguIEUuPC9hdXRob3I+PC9h

dXRob3JzPjwvY29udHJpYnV0b3JzPjxhdXRoLWFkZHJlc3M+RGl2aXNpb24gb2YgTmVvbmF0b2xv

Z3ksIERlcGFydG1lbnQgb2YgUGVkaWF0cmljcywgVW5pdmVyc2l0eSBvZiBUb3JvbnRvLCBIb3Nw

aXRhbCBmb3IgU2ljayBDaGlsZHJlbiwgVG9yb250bywgT250YXJpbywgQ2FuYWRhIE01RyAxWDgu

IHBhdHJpY2subWNuYW1hcmFAc2lja2tpZHMuY2E8L2F1dGgtYWRkcmVzcz48dGl0bGVzPjx0aXRs

ZT5NaWxyaW5vbmUgaW1wcm92ZXMgb3h5Z2VuYXRpb24gaW4gbmVvbmF0ZXMgd2l0aCBzZXZlcmUg

cGVyc2lzdGVudCBwdWxtb25hcnkgaHlwZXJ0ZW5zaW9uIG9mIHRoZSBuZXdib3JuPC90aXRsZT48

c2Vjb25kYXJ5LXRpdGxlPkogQ3JpdCBDYXJlPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBl

cmlvZGljYWw+PGZ1bGwtdGl0bGU+SiBDcml0IENhcmU8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2Fs

PjxwYWdlcz4yMTctMjI8L3BhZ2VzPjx2b2x1bWU+MjE8L3ZvbHVtZT48bnVtYmVyPjI8L251bWJl

cj48ZWRpdGlvbj4yMDA2LzA2LzE0PC9lZGl0aW9uPjxrZXl3b3Jkcz48a2V5d29yZD5DeWNsaWMg

QU1QL3BoeXNpb2xvZ3k8L2tleXdvcmQ+PGtleXdvcmQ+Q3ljbGljIEdNUC9waHlzaW9sb2d5PC9r

ZXl3b3JkPjxrZXl3b3JkPkh1bWFuczwva2V5d29yZD48a2V5d29yZD5IeXBlcnRlbnNpb24sIFB1

bG1vbmFyeS8qY29uZ2VuaXRhbC8qZHJ1ZyB0aGVyYXB5L3BoeXNpb3BhdGhvbG9neTwva2V5d29y

ZD48a2V5d29yZD5JbmZhbnQsIE5ld2Jvcm48L2tleXdvcmQ+PGtleXdvcmQ+TWlscmlub25lLyp0

aGVyYXBldXRpYyB1c2U8L2tleXdvcmQ+PGtleXdvcmQ+T3h5Z2VuLypibG9vZDwva2V5d29yZD48

a2V5d29yZD5QaG9zcGhvZGllc3RlcmFzZSBJbmhpYml0b3JzL3RoZXJhcGV1dGljIHVzZTwva2V5

d29yZD48a2V5d29yZD5TaWduYWwgVHJhbnNkdWN0aW9uPC9rZXl3b3JkPjxrZXl3b3JkPlZhc29k

aWxhdG9yIEFnZW50cy90aGVyYXBldXRpYyB1c2U8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+

PHllYXI+MjAwNjwveWVhcj48cHViLWRhdGVzPjxkYXRlPkp1bjwvZGF0ZT48L3B1Yi1kYXRlcz48

L2RhdGVzPjxpc2JuPjA4ODMtOTQ0MSAoUHJpbnQpJiN4RDswODgzLTk0NDEgKExpbmtpbmcpPC9p

c2JuPjxhY2Nlc3Npb24tbnVtPjE2NzY5NDcxPC9hY2Nlc3Npb24tbnVtPjx1cmxzPjxyZWxhdGVk

LXVybHM+PHVybD5odHRwOi8vd3d3Lm5jYmkubmxtLm5paC5nb3YvZW50cmV6L3F1ZXJ5LmZjZ2k/

Y21kPVJldHJpZXZlJmFtcDtkYj1QdWJNZWQmYW1wO2RvcHQ9Q2l0YXRpb24mYW1wO2xpc3RfdWlk

cz0xNjc2OTQ3MTwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48ZWxlY3Ryb25pYy1yZXNvdXJj

ZS1udW0+UzA4ODMtOTQ0MSgwNikwMDAwMy03IFtwaWldJiN4RDsxMC4xMDE2L2ouamNyYy4yMDA2

LjAxLjAwMTwvZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+PGxhbmd1YWdlPmVuZzwvbGFuZ3VhZ2U+

PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+QmFzc2xlcjwvQXV0aG9yPjxZZWFyPjIwMDY8

L1llYXI+PFJlY051bT4xNjQ8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjE2NDwvcmVjLW51

bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjBlNXdweHR2ajJ2NXg0ZXdh

dHR2cDJ6NHd3MDV6emV6MHN2diI+MTY0PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5h

bWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+

PGF1dGhvcj5CYXNzbGVyLCBELjwvYXV0aG9yPjxhdXRob3I+Q2hvb25nLCBLLjwvYXV0aG9yPjxh

dXRob3I+TWNOYW1hcmEsIFAuPC9hdXRob3I+PGF1dGhvcj5LaXJwYWxhbmksIEguPC9hdXRob3I+

PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjxhdXRoLWFkZHJlc3M+RGl2aXNpb24gb2YgTmVvbmF0

b2xvZ3ksIERlcGFydG1lbnQgb2YgUGFlZGlhdHJpY3MsIE1jTWFzdGVyIFVuaXZlcnNpdHkgTWVk

aWNhbCBDZW50cmUsIEhhbWlsdG9uLCBPbnQuLCBDYW5hZGEuPC9hdXRoLWFkZHJlc3M+PHRpdGxl

cz48dGl0bGU+TmVvbmF0YWwgcGVyc2lzdGVudCBwdWxtb25hcnkgaHlwZXJ0ZW5zaW9uIHRyZWF0

ZWQgd2l0aCBtaWxyaW5vbmU6IGZvdXIgY2FzZSByZXBvcnRzPC90aXRsZT48c2Vjb25kYXJ5LXRp

dGxlPkJpb2wgTmVvbmF0ZTwvc2Vjb25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxm

dWxsLXRpdGxlPkJpb2wgTmVvbmF0ZTwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjEt

NTwvcGFnZXM+PHZvbHVtZT44OTwvdm9sdW1lPjxudW1iZXI+MTwvbnVtYmVyPjxlZGl0aW9uPjIw

MDUvMDkvMTM8L2VkaXRpb24+PGtleXdvcmRzPjxrZXl3b3JkPkFkbWluaXN0cmF0aW9uLCBJbmhh

bGF0aW9uPC9rZXl3b3JkPjxrZXl3b3JkPkFuaW1hbHM8L2tleXdvcmQ+PGtleXdvcmQ+QW5veGlh

L2NvbXBsaWNhdGlvbnM8L2tleXdvcmQ+PGtleXdvcmQ+RmVtYWxlPC9rZXl3b3JkPjxrZXl3b3Jk

Pkdlc3RhdGlvbmFsIEFnZTwva2V5d29yZD48a2V5d29yZD5IdW1hbnM8L2tleXdvcmQ+PGtleXdv

cmQ+SW5mYW50LCBOZXdib3JuPC9rZXl3b3JkPjxrZXl3b3JkPkluZmFudCwgUHJlbWF0dXJlPC9r

ZXl3b3JkPjxrZXl3b3JkPk1hbGU8L2tleXdvcmQ+PGtleXdvcmQ+TWVjb25pdW0gQXNwaXJhdGlv

biBTeW5kcm9tZTwva2V5d29yZD48a2V5d29yZD5NaWxyaW5vbmUvKnRoZXJhcGV1dGljIHVzZTwv

a2V5d29yZD48a2V5d29yZD5OaXRyaWMgT3hpZGUvKmFkbWluaXN0cmF0aW9uICZhbXA7IGRvc2Fn

ZTwva2V5d29yZD48a2V5d29yZD5PbGlnb2h5ZHJhbW5pb3M8L2tleXdvcmQ+PGtleXdvcmQ+UGVy

c2lzdGVudCBGZXRhbCBDaXJjdWxhdGlvbiBTeW5kcm9tZS8qZHJ1ZyB0aGVyYXB5PC9rZXl3b3Jk

PjxrZXl3b3JkPlBob3NwaG9kaWVzdGVyYXNlIEluaGliaXRvcnMvKnRoZXJhcGV1dGljIHVzZTwv

a2V5d29yZD48a2V5d29yZD5QcmVnbmFuY3k8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHll

YXI+MjAwNjwveWVhcj48L2RhdGVzPjxpc2JuPjAwMDYtMzEyNiAoUHJpbnQpJiN4RDswMDA2LTMx

MjYgKExpbmtpbmcpPC9pc2JuPjxhY2Nlc3Npb24tbnVtPjE2MTU1MzgwPC9hY2Nlc3Npb24tbnVt

Pjx1cmxzPjxyZWxhdGVkLXVybHM+PHVybD5odHRwOi8vd3d3Lm5jYmkubmxtLm5paC5nb3YvZW50

cmV6L3F1ZXJ5LmZjZ2k/Y21kPVJldHJpZXZlJmFtcDtkYj1QdWJNZWQmYW1wO2RvcHQ9Q2l0YXRp

b24mYW1wO2xpc3RfdWlkcz0xNjE1NTM4MDwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48ZWxl

Y3Ryb25pYy1yZXNvdXJjZS1udW0+ODgxOTIgW3BpaV0mI3hEOzEwLjExNTkvMDAwMDg4MTkyPC9l

bGVjdHJvbmljLXJlc291cmNlLW51bT48bGFuZ3VhZ2U+ZW5nPC9sYW5ndWFnZT48L3JlY29yZD48

L0NpdGU+PC9FbmROb3RlPgAAAAAA

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NY05hbWFyYTwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+

PFJlY051bT4xNjU8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjE2NTwvcmVjLW51bWJlcj48

Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjBlNXdweHR2ajJ2NXg0ZXdhdHR2cDJ6

NHd3MDV6emV6MHN2diI+MTY1PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9Ikpv

dXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhv

cj5NY05hbWFyYSwgUC4gSi48L2F1dGhvcj48YXV0aG9yPkxhaXF1ZSwgRi48L2F1dGhvcj48YXV0

aG9yPk11YW5nLUluLCBTLjwvYXV0aG9yPjxhdXRob3I+V2h5dGUsIEguIEUuPC9hdXRob3I+PC9h

dXRob3JzPjwvY29udHJpYnV0b3JzPjxhdXRoLWFkZHJlc3M+RGl2aXNpb24gb2YgTmVvbmF0b2xv

Z3ksIERlcGFydG1lbnQgb2YgUGVkaWF0cmljcywgVW5pdmVyc2l0eSBvZiBUb3JvbnRvLCBIb3Nw

aXRhbCBmb3IgU2ljayBDaGlsZHJlbiwgVG9yb250bywgT250YXJpbywgQ2FuYWRhIE01RyAxWDgu

IHBhdHJpY2subWNuYW1hcmFAc2lja2tpZHMuY2E8L2F1dGgtYWRkcmVzcz48dGl0bGVzPjx0aXRs

ZT5NaWxyaW5vbmUgaW1wcm92ZXMgb3h5Z2VuYXRpb24gaW4gbmVvbmF0ZXMgd2l0aCBzZXZlcmUg

cGVyc2lzdGVudCBwdWxtb25hcnkgaHlwZXJ0ZW5zaW9uIG9mIHRoZSBuZXdib3JuPC90aXRsZT48

c2Vjb25kYXJ5LXRpdGxlPkogQ3JpdCBDYXJlPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBl

cmlvZGljYWw+PGZ1bGwtdGl0bGU+SiBDcml0IENhcmU8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2Fs

PjxwYWdlcz4yMTctMjI8L3BhZ2VzPjx2b2x1bWU+MjE8L3ZvbHVtZT48bnVtYmVyPjI8L251bWJl

cj48ZWRpdGlvbj4yMDA2LzA2LzE0PC9lZGl0aW9uPjxrZXl3b3Jkcz48a2V5d29yZD5DeWNsaWMg

QU1QL3BoeXNpb2xvZ3k8L2tleXdvcmQ+PGtleXdvcmQ+Q3ljbGljIEdNUC9waHlzaW9sb2d5PC9r

ZXl3b3JkPjxrZXl3b3JkPkh1bWFuczwva2V5d29yZD48a2V5d29yZD5IeXBlcnRlbnNpb24sIFB1

bG1vbmFyeS8qY29uZ2VuaXRhbC8qZHJ1ZyB0aGVyYXB5L3BoeXNpb3BhdGhvbG9neTwva2V5d29y

ZD48a2V5d29yZD5JbmZhbnQsIE5ld2Jvcm48L2tleXdvcmQ+PGtleXdvcmQ+TWlscmlub25lLyp0

aGVyYXBldXRpYyB1c2U8L2tleXdvcmQ+PGtleXdvcmQ+T3h5Z2VuLypibG9vZDwva2V5d29yZD48

a2V5d29yZD5QaG9zcGhvZGllc3RlcmFzZSBJbmhpYml0b3JzL3RoZXJhcGV1dGljIHVzZTwva2V5

d29yZD48a2V5d29yZD5TaWduYWwgVHJhbnNkdWN0aW9uPC9rZXl3b3JkPjxrZXl3b3JkPlZhc29k

aWxhdG9yIEFnZW50cy90aGVyYXBldXRpYyB1c2U8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+

PHllYXI+MjAwNjwveWVhcj48cHViLWRhdGVzPjxkYXRlPkp1bjwvZGF0ZT48L3B1Yi1kYXRlcz48

L2RhdGVzPjxpc2JuPjA4ODMtOTQ0MSAoUHJpbnQpJiN4RDswODgzLTk0NDEgKExpbmtpbmcpPC9p

c2JuPjxhY2Nlc3Npb24tbnVtPjE2NzY5NDcxPC9hY2Nlc3Npb24tbnVtPjx1cmxzPjxyZWxhdGVk

LXVybHM+PHVybD5odHRwOi8vd3d3Lm5jYmkubmxtLm5paC5nb3YvZW50cmV6L3F1ZXJ5LmZjZ2k/

Y21kPVJldHJpZXZlJmFtcDtkYj1QdWJNZWQmYW1wO2RvcHQ9Q2l0YXRpb24mYW1wO2xpc3RfdWlk

cz0xNjc2OTQ3MTwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48ZWxlY3Ryb25pYy1yZXNvdXJj

ZS1udW0+UzA4ODMtOTQ0MSgwNikwMDAwMy03IFtwaWldJiN4RDsxMC4xMDE2L2ouamNyYy4yMDA2

LjAxLjAwMTwvZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+PGxhbmd1YWdlPmVuZzwvbGFuZ3VhZ2U+

PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+QmFzc2xlcjwvQXV0aG9yPjxZZWFyPjIwMDY8

L1llYXI+PFJlY051bT4xNjQ8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjE2NDwvcmVjLW51

bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjBlNXdweHR2ajJ2NXg0ZXdh

dHR2cDJ6NHd3MDV6emV6MHN2diI+MTY0PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5h

bWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+

PGF1dGhvcj5CYXNzbGVyLCBELjwvYXV0aG9yPjxhdXRob3I+Q2hvb25nLCBLLjwvYXV0aG9yPjxh

dXRob3I+TWNOYW1hcmEsIFAuPC9hdXRob3I+PGF1dGhvcj5LaXJwYWxhbmksIEguPC9hdXRob3I+

PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjxhdXRoLWFkZHJlc3M+RGl2aXNpb24gb2YgTmVvbmF0

b2xvZ3ksIERlcGFydG1lbnQgb2YgUGFlZGlhdHJpY3MsIE1jTWFzdGVyIFVuaXZlcnNpdHkgTWVk

aWNhbCBDZW50cmUsIEhhbWlsdG9uLCBPbnQuLCBDYW5hZGEuPC9hdXRoLWFkZHJlc3M+PHRpdGxl

cz48dGl0bGU+TmVvbmF0YWwgcGVyc2lzdGVudCBwdWxtb25hcnkgaHlwZXJ0ZW5zaW9uIHRyZWF0

ZWQgd2l0aCBtaWxyaW5vbmU6IGZvdXIgY2FzZSByZXBvcnRzPC90aXRsZT48c2Vjb25kYXJ5LXRp

dGxlPkJpb2wgTmVvbmF0ZTwvc2Vjb25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxm

dWxsLXRpdGxlPkJpb2wgTmVvbmF0ZTwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjEt

NTwvcGFnZXM+PHZvbHVtZT44OTwvdm9sdW1lPjxudW1iZXI+MTwvbnVtYmVyPjxlZGl0aW9uPjIw

MDUvMDkvMTM8L2VkaXRpb24+PGtleXdvcmRzPjxrZXl3b3JkPkFkbWluaXN0cmF0aW9uLCBJbmhh

bGF0aW9uPC9rZXl3b3JkPjxrZXl3b3JkPkFuaW1hbHM8L2tleXdvcmQ+PGtleXdvcmQ+QW5veGlh

L2NvbXBsaWNhdGlvbnM8L2tleXdvcmQ+PGtleXdvcmQ+RmVtYWxlPC9rZXl3b3JkPjxrZXl3b3Jk

Pkdlc3RhdGlvbmFsIEFnZTwva2V5d29yZD48a2V5d29yZD5IdW1hbnM8L2tleXdvcmQ+PGtleXdv

cmQ+SW5mYW50LCBOZXdib3JuPC9rZXl3b3JkPjxrZXl3b3JkPkluZmFudCwgUHJlbWF0dXJlPC9r

ZXl3b3JkPjxrZXl3b3JkPk1hbGU8L2tleXdvcmQ+PGtleXdvcmQ+TWVjb25pdW0gQXNwaXJhdGlv

biBTeW5kcm9tZTwva2V5d29yZD48a2V5d29yZD5NaWxyaW5vbmUvKnRoZXJhcGV1dGljIHVzZTwv

a2V5d29yZD48a2V5d29yZD5OaXRyaWMgT3hpZGUvKmFkbWluaXN0cmF0aW9uICZhbXA7IGRvc2Fn

ZTwva2V5d29yZD48a2V5d29yZD5PbGlnb2h5ZHJhbW5pb3M8L2tleXdvcmQ+PGtleXdvcmQ+UGVy

c2lzdGVudCBGZXRhbCBDaXJjdWxhdGlvbiBTeW5kcm9tZS8qZHJ1ZyB0aGVyYXB5PC9rZXl3b3Jk

PjxrZXl3b3JkPlBob3NwaG9kaWVzdGVyYXNlIEluaGliaXRvcnMvKnRoZXJhcGV1dGljIHVzZTwv

a2V5d29yZD48a2V5d29yZD5QcmVnbmFuY3k8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHll

YXI+MjAwNjwveWVhcj48L2RhdGVzPjxpc2JuPjAwMDYtMzEyNiAoUHJpbnQpJiN4RDswMDA2LTMx

MjYgKExpbmtpbmcpPC9pc2JuPjxhY2Nlc3Npb24tbnVtPjE2MTU1MzgwPC9hY2Nlc3Npb24tbnVt

Pjx1cmxzPjxyZWxhdGVkLXVybHM+PHVybD5odHRwOi8vd3d3Lm5jYmkubmxtLm5paC5nb3YvZW50

cmV6L3F1ZXJ5LmZjZ2k/Y21kPVJldHJpZXZlJmFtcDtkYj1QdWJNZWQmYW1wO2RvcHQ9Q2l0YXRp

b24mYW1wO2xpc3RfdWlkcz0xNjE1NTM4MDwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48ZWxl

Y3Ryb25pYy1yZXNvdXJjZS1udW0+ODgxOTIgW3BpaV0mI3hEOzEwLjExNTkvMDAwMDg4MTkyPC9l

bGVjdHJvbmljLXJlc291cmNlLW51bT48bGFuZ3VhZ2U+ZW5nPC9sYW5ndWFnZT48L3JlY29yZD48

L0NpdGU+PC9FbmROb3RlPgAAAAAA

ADDIN EN.CITE.DATA (6, 7).4. In the case of refractory hypotension to pressor support, consideration should be given to the addition of steroids with hydrocortisone the steroid of choice. Consider checking serum cortisol prior to starting hydrocortisone. 5. A majority of neonates with HIE do not have acute volume or blood loss. Unless there is a history of volume or blood loss, caution should be used in volume expansion for hypotension given the risk of cerebral edema and renal insufficiency due to hypoxic-ischemic injury. Level of Evidence: IV- Case Series and Expert opinion based on current review of the literature.III. How does hypothermia affect hemodynamic status post asphyxia?Mild systemic hypothermia in itself appears to have minimal clinical effects on hemodynamic status. The CoolCap Trial which utilized mild systemic hypothermia to a rectal temperature of 34.5°C did not demonstrate affects on arterial blood pressure or initial treatment with inotropes or volume in infants with moderate to severe HIE ADDIN EN.CITE <EndNote><Cite><Author>Battin</Author><Year>2009</Year><RecNum>166</RecNum><record><rec-number>166</rec-number><foreign-keys><key app="EN" db-id="0e5wpxtvj2v5x4ewattvp2z4ww05zzez0svv">166</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Battin, M. R.</author><author>Thoresen, M.</author><author>Robinson, E.</author><author>Polin, R. A.</author><author>Edwards, A. D.</author><author>Gunn, A. J.</author></authors></contributors><auth-address>Newborn Services, National Women&apos;s Health, Auckland City Hospital, Private Bag 92 024, Auckland, New Zealand. malcolmb@t.nz</auth-address><titles><title>Does head cooling with mild systemic hypothermia affect requirement for blood pressure support?</title><secondary-title>Pediatrics</secondary-title></titles><periodical><full-title>Pediatrics</full-title></periodical><pages>1031-6</pages><volume>123</volume><number>3</number><edition>2009/03/04</edition><keywords><keyword>Blood Pressure/*physiology</keyword><keyword>Electroencephalography</keyword><keyword>Female</keyword><keyword>Fluid Therapy</keyword><keyword>*Head</keyword><keyword>Heart Rate/*physiology</keyword><keyword>Homeostasis</keyword><keyword>Humans</keyword><keyword>Hypothermia, Induced/*methods</keyword><keyword>Hypoxia-Ischemia, Brain/physiopathology/*therapy</keyword><keyword>Infant, Newborn</keyword><keyword>Male</keyword><keyword>Monitoring, Physiologic</keyword><keyword>Rewarming</keyword></keywords><dates><year>2009</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1098-4275 (Electronic)&#xD;0031-4005 (Linking)</isbn><accession-num>19255036</accession-num><urls><related-urls><url> [pii]&#xD;10.1542/peds.2008-1610</electronic-resource-num><language>eng</language></record></Cite></EndNote>(8). In the NICHD whole body hypothermia trial, there were no differences in the incidence of pulmonary hypertension or cardiac arrhythmias between the treatment and controlled groups. However, there was a trend towards an increase use of inotropes in the hypothermia group PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGFua2FyYW48L0F1dGhvcj48WWVhcj4yMDA1PC9ZZWFy

PjxSZWNOdW0+NzwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+NzwvcmVjLW51bWJlcj48Zm9y

ZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjBlNXdweHR2ajJ2NXg0ZXdhdHR2cDJ6NHd3

MDV6emV6MHN2diI+Nzwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFs

IEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+U2hh

bmthcmFuLCBTLjwvYXV0aG9yPjxhdXRob3I+TGFwdG9vaywgQS4gUi48L2F1dGhvcj48YXV0aG9y

PkVocmVua3JhbnosIFIuIEEuPC9hdXRob3I+PGF1dGhvcj5UeXNvbiwgSi4gRS48L2F1dGhvcj48

YXV0aG9yPk1jRG9uYWxkLCBTLiBBLjwvYXV0aG9yPjxhdXRob3I+RG9ub3ZhbiwgRS4gRi48L2F1

dGhvcj48YXV0aG9yPkZhbmFyb2ZmLCBBLiBBLjwvYXV0aG9yPjxhdXRob3I+UG9vbGUsIFcuIEsu

PC9hdXRob3I+PGF1dGhvcj5XcmlnaHQsIEwuIEwuPC9hdXRob3I+PGF1dGhvcj5IaWdnaW5zLCBS

LiBELjwvYXV0aG9yPjxhdXRob3I+RmluZXIsIE4uIE4uPC9hdXRob3I+PGF1dGhvcj5DYXJsbywg

Vy4gQS48L2F1dGhvcj48YXV0aG9yPkR1YXJhLCBTLjwvYXV0aG9yPjxhdXRob3I+T2gsIFcuPC9h

dXRob3I+PGF1dGhvcj5Db3R0ZW4sIEMuIE0uPC9hdXRob3I+PGF1dGhvcj5TdGV2ZW5zb24sIEQu

IEsuPC9hdXRob3I+PGF1dGhvcj5TdG9sbCwgQi4gSi48L2F1dGhvcj48YXV0aG9yPkxlbW9ucywg

Si4gQS48L2F1dGhvcj48YXV0aG9yPkd1aWxsZXQsIFIuPC9hdXRob3I+PGF1dGhvcj5Kb2JlLCBB

LiBILjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48YXV0aC1hZGRyZXNzPkRpdmlz

aW9uIG9mIE5lb25hdGFsLVBlcmluYXRhbCBNZWRpY2luZSwgV2F5bmUgU3RhdGUgVW5pdmVyc2l0

eSwgQ2hpbGRyZW4mYXBvcztzIEhvc3BpdGFsIG9mIE1pY2hpZ2FuLCBEZXRyb2l0LCBNSSA0ODIw

MSwgVVNBLiBzc2hhbmthckBtZWQud2F5bmUuZWR1PC9hdXRoLWFkZHJlc3M+PHRpdGxlcz48dGl0

bGU+V2hvbGUtYm9keSBoeXBvdGhlcm1pYSBmb3IgbmVvbmF0ZXMgd2l0aCBoeXBveGljLWlzY2hl

bWljIGVuY2VwaGFsb3BhdGh5PC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPk4gRW5nbCBKIE1lZDwv

c2Vjb25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPk4gRW5nbCBK

IE1lZDwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjE1NzQtODQ8L3BhZ2VzPjx2b2x1

bWU+MzUzPC92b2x1bWU+PG51bWJlcj4xNTwvbnVtYmVyPjxlZGl0aW9uPjIwMDUvMTAvMTQ8L2Vk

aXRpb24+PGtleXdvcmRzPjxrZXl3b3JkPkFjaWRvc2lzL2V0aW9sb2d5PC9rZXl3b3JkPjxrZXl3

b3JkPkFzcGh5eGlhIE5lb25hdG9ydW0vY29tcGxpY2F0aW9uczwva2V5d29yZD48a2V5d29yZD5C

bGluZG5lc3MvcHJldmVudGlvbiAmYW1wOyBjb250cm9sPC9rZXl3b3JkPjxrZXl3b3JkPkNlcmVi

cmFsIFBhbHN5LypwcmV2ZW50aW9uICZhbXA7IGNvbnRyb2w8L2tleXdvcmQ+PGtleXdvcmQ+RGV2

ZWxvcG1lbnRhbCBEaXNhYmlsaXRpZXMvKnByZXZlbnRpb24gJmFtcDsgY29udHJvbDwva2V5d29y

ZD48a2V5d29yZD5GZW1hbGU8L2tleXdvcmQ+PGtleXdvcmQ+Rm9sbG93LVVwIFN0dWRpZXM8L2tl

eXdvcmQ+PGtleXdvcmQ+SGVhcmluZyBMb3NzL3ByZXZlbnRpb24gJmFtcDsgY29udHJvbDwva2V5

d29yZD48a2V5d29yZD5IdW1hbnM8L2tleXdvcmQ+PGtleXdvcmQ+Kkh5cG90aGVybWlhLCBJbmR1

Y2VkL2FkdmVyc2UgZWZmZWN0czwva2V5d29yZD48a2V5d29yZD5IeXBveGlhLUlzY2hlbWlhLCBC

cmFpbi9jb21wbGljYXRpb25zL21vcnRhbGl0eS8qdGhlcmFweTwva2V5d29yZD48a2V5d29yZD5J

bmZhbnQsIE5ld2Jvcm48L2tleXdvcmQ+PGtleXdvcmQ+TWFsZTwva2V5d29yZD48a2V5d29yZD5P

YnN0ZXRyaWMgTGFib3IgQ29tcGxpY2F0aW9uczwva2V5d29yZD48a2V5d29yZD5QcmVnbmFuY3k8

L2tleXdvcmQ+PGtleXdvcmQ+UHJlZ25hbmN5IENvbXBsaWNhdGlvbnM8L2tleXdvcmQ+PC9rZXl3

b3Jkcz48ZGF0ZXM+PHllYXI+MjAwNTwveWVhcj48cHViLWRhdGVzPjxkYXRlPk9jdCAxMzwvZGF0

ZT48L3B1Yi1kYXRlcz48L2RhdGVzPjxpc2JuPjE1MzMtNDQwNiAoRWxlY3Ryb25pYyk8L2lzYm4+

PGFjY2Vzc2lvbi1udW0+MTYyMjE3ODA8L2FjY2Vzc2lvbi1udW0+PHVybHM+PHJlbGF0ZWQtdXJs

cz48dXJsPmh0dHA6Ly93d3cubmNiaS5ubG0ubmloLmdvdi9lbnRyZXovcXVlcnkuZmNnaT9jbWQ9

UmV0cmlldmUmYW1wO2RiPVB1Yk1lZCZhbXA7ZG9wdD1DaXRhdGlvbiZhbXA7bGlzdF91aWRzPTE2

MjIxNzgwPC91cmw+PC9yZWxhdGVkLXVybHM+PC91cmxzPjxlbGVjdHJvbmljLXJlc291cmNlLW51

bT4zNTMvMTUvMTU3NCBbcGlpXSYjeEQ7MTAuMTA1Ni9ORUpNY3BzMDUwOTI5PC9lbGVjdHJvbmlj

LXJlc291cmNlLW51bT48bGFuZ3VhZ2U+ZW5nPC9sYW5ndWFnZT48L3JlY29yZD48L0NpdGU+PC9F

bmROb3RlPgAAAAA=

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGFua2FyYW48L0F1dGhvcj48WWVhcj4yMDA1PC9ZZWFy

PjxSZWNOdW0+NzwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+NzwvcmVjLW51bWJlcj48Zm9y

ZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjBlNXdweHR2ajJ2NXg0ZXdhdHR2cDJ6NHd3

MDV6emV6MHN2diI+Nzwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFs

IEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+U2hh

bmthcmFuLCBTLjwvYXV0aG9yPjxhdXRob3I+TGFwdG9vaywgQS4gUi48L2F1dGhvcj48YXV0aG9y

PkVocmVua3JhbnosIFIuIEEuPC9hdXRob3I+PGF1dGhvcj5UeXNvbiwgSi4gRS48L2F1dGhvcj48

YXV0aG9yPk1jRG9uYWxkLCBTLiBBLjwvYXV0aG9yPjxhdXRob3I+RG9ub3ZhbiwgRS4gRi48L2F1

dGhvcj48YXV0aG9yPkZhbmFyb2ZmLCBBLiBBLjwvYXV0aG9yPjxhdXRob3I+UG9vbGUsIFcuIEsu

PC9hdXRob3I+PGF1dGhvcj5XcmlnaHQsIEwuIEwuPC9hdXRob3I+PGF1dGhvcj5IaWdnaW5zLCBS

LiBELjwvYXV0aG9yPjxhdXRob3I+RmluZXIsIE4uIE4uPC9hdXRob3I+PGF1dGhvcj5DYXJsbywg

Vy4gQS48L2F1dGhvcj48YXV0aG9yPkR1YXJhLCBTLjwvYXV0aG9yPjxhdXRob3I+T2gsIFcuPC9h

dXRob3I+PGF1dGhvcj5Db3R0ZW4sIEMuIE0uPC9hdXRob3I+PGF1dGhvcj5TdGV2ZW5zb24sIEQu

IEsuPC9hdXRob3I+PGF1dGhvcj5TdG9sbCwgQi4gSi48L2F1dGhvcj48YXV0aG9yPkxlbW9ucywg

Si4gQS48L2F1dGhvcj48YXV0aG9yPkd1aWxsZXQsIFIuPC9hdXRob3I+PGF1dGhvcj5Kb2JlLCBB

LiBILjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48YXV0aC1hZGRyZXNzPkRpdmlz

aW9uIG9mIE5lb25hdGFsLVBlcmluYXRhbCBNZWRpY2luZSwgV2F5bmUgU3RhdGUgVW5pdmVyc2l0

eSwgQ2hpbGRyZW4mYXBvcztzIEhvc3BpdGFsIG9mIE1pY2hpZ2FuLCBEZXRyb2l0LCBNSSA0ODIw

MSwgVVNBLiBzc2hhbmthckBtZWQud2F5bmUuZWR1PC9hdXRoLWFkZHJlc3M+PHRpdGxlcz48dGl0

bGU+V2hvbGUtYm9keSBoeXBvdGhlcm1pYSBmb3IgbmVvbmF0ZXMgd2l0aCBoeXBveGljLWlzY2hl

bWljIGVuY2VwaGFsb3BhdGh5PC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPk4gRW5nbCBKIE1lZDwv

c2Vjb25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPk4gRW5nbCBK

IE1lZDwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjE1NzQtODQ8L3BhZ2VzPjx2b2x1

bWU+MzUzPC92b2x1bWU+PG51bWJlcj4xNTwvbnVtYmVyPjxlZGl0aW9uPjIwMDUvMTAvMTQ8L2Vk

aXRpb24+PGtleXdvcmRzPjxrZXl3b3JkPkFjaWRvc2lzL2V0aW9sb2d5PC9rZXl3b3JkPjxrZXl3

b3JkPkFzcGh5eGlhIE5lb25hdG9ydW0vY29tcGxpY2F0aW9uczwva2V5d29yZD48a2V5d29yZD5C

bGluZG5lc3MvcHJldmVudGlvbiAmYW1wOyBjb250cm9sPC9rZXl3b3JkPjxrZXl3b3JkPkNlcmVi

cmFsIFBhbHN5LypwcmV2ZW50aW9uICZhbXA7IGNvbnRyb2w8L2tleXdvcmQ+PGtleXdvcmQ+RGV2

ZWxvcG1lbnRhbCBEaXNhYmlsaXRpZXMvKnByZXZlbnRpb24gJmFtcDsgY29udHJvbDwva2V5d29y

ZD48a2V5d29yZD5GZW1hbGU8L2tleXdvcmQ+PGtleXdvcmQ+Rm9sbG93LVVwIFN0dWRpZXM8L2tl

eXdvcmQ+PGtleXdvcmQ+SGVhcmluZyBMb3NzL3ByZXZlbnRpb24gJmFtcDsgY29udHJvbDwva2V5

d29yZD48a2V5d29yZD5IdW1hbnM8L2tleXdvcmQ+PGtleXdvcmQ+Kkh5cG90aGVybWlhLCBJbmR1

Y2VkL2FkdmVyc2UgZWZmZWN0czwva2V5d29yZD48a2V5d29yZD5IeXBveGlhLUlzY2hlbWlhLCBC

cmFpbi9jb21wbGljYXRpb25zL21vcnRhbGl0eS8qdGhlcmFweTwva2V5d29yZD48a2V5d29yZD5J

bmZhbnQsIE5ld2Jvcm48L2tleXdvcmQ+PGtleXdvcmQ+TWFsZTwva2V5d29yZD48a2V5d29yZD5P

YnN0ZXRyaWMgTGFib3IgQ29tcGxpY2F0aW9uczwva2V5d29yZD48a2V5d29yZD5QcmVnbmFuY3k8

L2tleXdvcmQ+PGtleXdvcmQ+UHJlZ25hbmN5IENvbXBsaWNhdGlvbnM8L2tleXdvcmQ+PC9rZXl3

b3Jkcz48ZGF0ZXM+PHllYXI+MjAwNTwveWVhcj48cHViLWRhdGVzPjxkYXRlPk9jdCAxMzwvZGF0

ZT48L3B1Yi1kYXRlcz48L2RhdGVzPjxpc2JuPjE1MzMtNDQwNiAoRWxlY3Ryb25pYyk8L2lzYm4+

PGFjY2Vzc2lvbi1udW0+MTYyMjE3ODA8L2FjY2Vzc2lvbi1udW0+PHVybHM+PHJlbGF0ZWQtdXJs

cz48dXJsPmh0dHA6Ly93d3cubmNiaS5ubG0ubmloLmdvdi9lbnRyZXovcXVlcnkuZmNnaT9jbWQ9

UmV0cmlldmUmYW1wO2RiPVB1Yk1lZCZhbXA7ZG9wdD1DaXRhdGlvbiZhbXA7bGlzdF91aWRzPTE2

MjIxNzgwPC91cmw+PC9yZWxhdGVkLXVybHM+PC91cmxzPjxlbGVjdHJvbmljLXJlc291cmNlLW51

bT4zNTMvMTUvMTU3NCBbcGlpXSYjeEQ7MTAuMTA1Ni9ORUpNY3BzMDUwOTI5PC9lbGVjdHJvbmlj

LXJlc291cmNlLW51bT48bGFuZ3VhZ2U+ZW5nPC9sYW5ndWFnZT48L3JlY29yZD48L0NpdGU+PC9F

bmROb3RlPgAAAAA=

ADDIN EN.CITE.DATA (9). In addition, the TOBY Trial did not find any significant difference in the incidence of hypotension, cardiac arrhythmias or pulmonary hypertension between hypothermic and normothermic infants PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BenpvcGFyZGk8L0F1dGhvcj48WWVhcj4yMDA5PC9ZZWFy

PjxSZWNOdW0+MTU5PC9SZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj4xNTk8L3JlYy1udW1iZXI+

PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSIwZTV3cHh0dmoydjV4NGV3YXR0dnAy

ejR3dzA1enplejBzdnYiPjE1OTwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJK

b3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRo

b3I+QXp6b3BhcmRpLCBELiBWLjwvYXV0aG9yPjxhdXRob3I+U3Ryb2htLCBCLjwvYXV0aG9yPjxh

dXRob3I+RWR3YXJkcywgQS4gRC48L2F1dGhvcj48YXV0aG9yPkR5ZXQsIEwuPC9hdXRob3I+PGF1

dGhvcj5IYWxsaWRheSwgSC4gTC48L2F1dGhvcj48YXV0aG9yPkp1c3pjemFrLCBFLjwvYXV0aG9y

PjxhdXRob3I+S2FwZWxsb3UsIE8uPC9hdXRob3I+PGF1dGhvcj5MZXZlbmUsIE0uPC9hdXRob3I+

PGF1dGhvcj5NYXJsb3csIE4uPC9hdXRob3I+PGF1dGhvcj5Qb3J0ZXIsIEUuPC9hdXRob3I+PGF1

dGhvcj5UaG9yZXNlbiwgTS48L2F1dGhvcj48YXV0aG9yPldoaXRlbGF3LCBBLjwvYXV0aG9yPjxh

dXRob3I+QnJvY2tsZWh1cnN0LCBQLjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48

YXV0aC1hZGRyZXNzPkRpdmlzaW9uIG9mIENsaW5pY2FsIFNjaWVuY2VzIGFuZCBNZWRpY2FsIFJl

c2VhcmNoIENvdW5jaWwgQ2xpbmljYWwgU2NpZW5jZXMgQ2VudHJlLCBIYW1tZXJzbWl0aCBIb3Nw

aXRhbCwgSW1wZXJpYWwgQ29sbGVnZSBMb25kb24sIExvbmRvbiwgVW5pdGVkIEtpbmdkb20uIGQu

YXp6b3BhcmRpQGltcGVyaWFsLmFjLnVrPC9hdXRoLWFkZHJlc3M+PHRpdGxlcz48dGl0bGU+TW9k

ZXJhdGUgaHlwb3RoZXJtaWEgdG8gdHJlYXQgcGVyaW5hdGFsIGFzcGh5eGlhbCBlbmNlcGhhbG9w

YXRoeTwvdGl0bGU+PHNlY29uZGFyeS10aXRsZT5OIEVuZ2wgSiBNZWQ8L3NlY29uZGFyeS10aXRs

ZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5OIEVuZ2wgSiBNZWQ8L2Z1bGwtdGl0

bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz4xMzQ5LTU4PC9wYWdlcz48dm9sdW1lPjM2MTwvdm9sdW1l

PjxudW1iZXI+MTQ8L251bWJlcj48ZWRpdGlvbj4yMDA5LzEwLzAzPC9lZGl0aW9uPjxrZXl3b3Jk

cz48a2V5d29yZD5Bc3BoeXhpYSBOZW9uYXRvcnVtLypjb21wbGljYXRpb25zPC9rZXl3b3JkPjxr

ZXl3b3JkPkRldmVsb3BtZW50YWwgRGlzYWJpbGl0aWVzL2V0aW9sb2d5LypwcmV2ZW50aW9uICZh

bXA7IGNvbnRyb2w8L2tleXdvcmQ+PGtleXdvcmQ+RmVtYWxlPC9rZXl3b3JkPjxrZXl3b3JkPkZv

bGxvdy1VcCBTdHVkaWVzPC9rZXl3b3JkPjxrZXl3b3JkPkdlc3RhdGlvbmFsIEFnZTwva2V5d29y

ZD48a2V5d29yZD5IdW1hbnM8L2tleXdvcmQ+PGtleXdvcmQ+SHlwb3RoZXJtaWEsIEluZHVjZWQv

YWR2ZXJzZSBlZmZlY3RzLyptZXRob2RzPC9rZXl3b3JkPjxrZXl3b3JkPkh5cG94aWEtSXNjaGVt

aWEsIEJyYWluL2V0aW9sb2d5L21vcnRhbGl0eS8qdGhlcmFweTwva2V5d29yZD48a2V5d29yZD5J

bmZhbnQ8L2tleXdvcmQ+PGtleXdvcmQ+SW5mYW50LCBOZXdib3JuPC9rZXl3b3JkPjxrZXl3b3Jk

PipJbnRlbnNpdmUgQ2FyZTwva2V5d29yZD48a2V5d29yZD5NYWxlPC9rZXl3b3JkPjxrZXl3b3Jk

Pk5lcnZvdXMgU3lzdGVtIERpc2Vhc2VzL2V0aW9sb2d5LypwcmV2ZW50aW9uICZhbXA7IGNvbnRy

b2w8L2tleXdvcmQ+PGtleXdvcmQ+Umlzazwva2V5d29yZD48L2tleXdvcmRzPjxkYXRlcz48eWVh

cj4yMDA5PC95ZWFyPjxwdWItZGF0ZXM+PGRhdGU+T2N0IDE8L2RhdGU+PC9wdWItZGF0ZXM+PC9k

YXRlcz48aXNibj4xNTMzLTQ0MDYgKEVsZWN0cm9uaWMpJiN4RDswMDI4LTQ3OTMgKExpbmtpbmcp

PC9pc2JuPjxhY2Nlc3Npb24tbnVtPjE5Nzk3MjgxPC9hY2Nlc3Npb24tbnVtPjx1cmxzPjxyZWxh

dGVkLXVybHM+PHVybD5odHRwOi8vd3d3Lm5jYmkubmxtLm5paC5nb3YvZW50cmV6L3F1ZXJ5LmZj

Z2k/Y21kPVJldHJpZXZlJmFtcDtkYj1QdWJNZWQmYW1wO2RvcHQ9Q2l0YXRpb24mYW1wO2xpc3Rf

dWlkcz0xOTc5NzI4MTwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48ZWxlY3Ryb25pYy1yZXNv

dXJjZS1udW0+MzYxLzE0LzEzNDkgW3BpaV0mI3hEOzEwLjEwNTYvTkVKTW9hMDkwMDg1NDwvZWxl

Y3Ryb25pYy1yZXNvdXJjZS1udW0+PGxhbmd1YWdlPmVuZzwvbGFuZ3VhZ2U+PC9yZWNvcmQ+PC9D

aXRlPjwvRW5kTm90ZT4AAAAA

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BenpvcGFyZGk8L0F1dGhvcj48WWVhcj4yMDA5PC9ZZWFy

PjxSZWNOdW0+MTU5PC9SZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj4xNTk8L3JlYy1udW1iZXI+

PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSIwZTV3cHh0dmoydjV4NGV3YXR0dnAy

ejR3dzA1enplejBzdnYiPjE1OTwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJK

b3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRo

b3I+QXp6b3BhcmRpLCBELiBWLjwvYXV0aG9yPjxhdXRob3I+U3Ryb2htLCBCLjwvYXV0aG9yPjxh

dXRob3I+RWR3YXJkcywgQS4gRC48L2F1dGhvcj48YXV0aG9yPkR5ZXQsIEwuPC9hdXRob3I+PGF1

dGhvcj5IYWxsaWRheSwgSC4gTC48L2F1dGhvcj48YXV0aG9yPkp1c3pjemFrLCBFLjwvYXV0aG9y

PjxhdXRob3I+S2FwZWxsb3UsIE8uPC9hdXRob3I+PGF1dGhvcj5MZXZlbmUsIE0uPC9hdXRob3I+

PGF1dGhvcj5NYXJsb3csIE4uPC9hdXRob3I+PGF1dGhvcj5Qb3J0ZXIsIEUuPC9hdXRob3I+PGF1

dGhvcj5UaG9yZXNlbiwgTS48L2F1dGhvcj48YXV0aG9yPldoaXRlbGF3LCBBLjwvYXV0aG9yPjxh

dXRob3I+QnJvY2tsZWh1cnN0LCBQLjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48

YXV0aC1hZGRyZXNzPkRpdmlzaW9uIG9mIENsaW5pY2FsIFNjaWVuY2VzIGFuZCBNZWRpY2FsIFJl

c2VhcmNoIENvdW5jaWwgQ2xpbmljYWwgU2NpZW5jZXMgQ2VudHJlLCBIYW1tZXJzbWl0aCBIb3Nw

aXRhbCwgSW1wZXJpYWwgQ29sbGVnZSBMb25kb24sIExvbmRvbiwgVW5pdGVkIEtpbmdkb20uIGQu

YXp6b3BhcmRpQGltcGVyaWFsLmFjLnVrPC9hdXRoLWFkZHJlc3M+PHRpdGxlcz48dGl0bGU+TW9k

ZXJhdGUgaHlwb3RoZXJtaWEgdG8gdHJlYXQgcGVyaW5hdGFsIGFzcGh5eGlhbCBlbmNlcGhhbG9w

YXRoeTwvdGl0bGU+PHNlY29uZGFyeS10aXRsZT5OIEVuZ2wgSiBNZWQ8L3NlY29uZGFyeS10aXRs

ZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5OIEVuZ2wgSiBNZWQ8L2Z1bGwtdGl0

bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz4xMzQ5LTU4PC9wYWdlcz48dm9sdW1lPjM2MTwvdm9sdW1l

PjxudW1iZXI+MTQ8L251bWJlcj48ZWRpdGlvbj4yMDA5LzEwLzAzPC9lZGl0aW9uPjxrZXl3b3Jk

cz48a2V5d29yZD5Bc3BoeXhpYSBOZW9uYXRvcnVtLypjb21wbGljYXRpb25zPC9rZXl3b3JkPjxr

ZXl3b3JkPkRldmVsb3BtZW50YWwgRGlzYWJpbGl0aWVzL2V0aW9sb2d5LypwcmV2ZW50aW9uICZh

bXA7IGNvbnRyb2w8L2tleXdvcmQ+PGtleXdvcmQ+RmVtYWxlPC9rZXl3b3JkPjxrZXl3b3JkPkZv

bGxvdy1VcCBTdHVkaWVzPC9rZXl3b3JkPjxrZXl3b3JkPkdlc3RhdGlvbmFsIEFnZTwva2V5d29y

ZD48a2V5d29yZD5IdW1hbnM8L2tleXdvcmQ+PGtleXdvcmQ+SHlwb3RoZXJtaWEsIEluZHVjZWQv

YWR2ZXJzZSBlZmZlY3RzLyptZXRob2RzPC9rZXl3b3JkPjxrZXl3b3JkPkh5cG94aWEtSXNjaGVt

aWEsIEJyYWluL2V0aW9sb2d5L21vcnRhbGl0eS8qdGhlcmFweTwva2V5d29yZD48a2V5d29yZD5J

bmZhbnQ8L2tleXdvcmQ+PGtleXdvcmQ+SW5mYW50LCBOZXdib3JuPC9rZXl3b3JkPjxrZXl3b3Jk

PipJbnRlbnNpdmUgQ2FyZTwva2V5d29yZD48a2V5d29yZD5NYWxlPC9rZXl3b3JkPjxrZXl3b3Jk

Pk5lcnZvdXMgU3lzdGVtIERpc2Vhc2VzL2V0aW9sb2d5LypwcmV2ZW50aW9uICZhbXA7IGNvbnRy

b2w8L2tleXdvcmQ+PGtleXdvcmQ+Umlzazwva2V5d29yZD48L2tleXdvcmRzPjxkYXRlcz48eWVh

cj4yMDA5PC95ZWFyPjxwdWItZGF0ZXM+PGRhdGU+T2N0IDE8L2RhdGU+PC9wdWItZGF0ZXM+PC9k

YXRlcz48aXNibj4xNTMzLTQ0MDYgKEVsZWN0cm9uaWMpJiN4RDswMDI4LTQ3OTMgKExpbmtpbmcp

PC9pc2JuPjxhY2Nlc3Npb24tbnVtPjE5Nzk3MjgxPC9hY2Nlc3Npb24tbnVtPjx1cmxzPjxyZWxh

dGVkLXVybHM+PHVybD5odHRwOi8vd3d3Lm5jYmkubmxtLm5paC5nb3YvZW50cmV6L3F1ZXJ5LmZj

Z2k/Y21kPVJldHJpZXZlJmFtcDtkYj1QdWJNZWQmYW1wO2RvcHQ9Q2l0YXRpb24mYW1wO2xpc3Rf

dWlkcz0xOTc5NzI4MTwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48ZWxlY3Ryb25pYy1yZXNv

dXJjZS1udW0+MzYxLzE0LzEzNDkgW3BpaV0mI3hEOzEwLjEwNTYvTkVKTW9hMDkwMDg1NDwvZWxl

Y3Ryb25pYy1yZXNvdXJjZS1udW0+PGxhbmd1YWdlPmVuZzwvbGFuZ3VhZ2U+PC9yZWNvcmQ+PC9D

aXRlPjwvRW5kTm90ZT4AAAAA

ADDIN EN.CITE.DATA (10).Level of Evidence: IA- Based on Randomized Controlled Trials. VI. When should an echocardiogram be obtain for infants with HIE?We recommend an Echocardiogram be performed in any infant with HIE. Echocardiogram may be repeated and used to guide therapy in the following clinical scenarios:1. Elevated cardiac enzymes if performed at your center2. Clinical evidence of cardiac dysfunction3. Clinical evidence of pulmonary hypertension4. Hypotension (MAP < 40mmHg)5. Requiring inotropic support Level of Evidence: V- Expert opinion based on current review of literature.V. Should serum markers of cardiac injury be obtained in infants with HIE, what markers, and when should they be obtained?Myocardial dysfunction is often the direct cause of perinatal brain injury. Myocardial damage may be clinically occult with mild HIE or manifest as a systemic hypoperfusion state in the cases of moderate to severe HIE. Serum cardiac markers may assist in injury detection and guide clinical management. Recent evidence suggests cardiac Troponins are superior to other markers of myocardial injury (LDH, CK, CK-MB) in detecting earlier, cardiac specific injury PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HdW5lczwvQXV0aG9yPjxZZWFyPjIwMDU8L1llYXI+PFJl

Y051bT4xNjg8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjE2ODwvcmVjLW51bWJlcj48Zm9y

ZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjBlNXdweHR2ajJ2NXg0ZXdhdHR2cDJ6NHd3

MDV6emV6MHN2diI+MTY4PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJu

YWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5H

dW5lcywgVC48L2F1dGhvcj48YXV0aG9yPk96dHVyaywgTS4gQS48L2F1dGhvcj48YXV0aG9yPktv

a2x1LCBTLiBNLjwvYXV0aG9yPjxhdXRob3I+TmFyaW4sIE4uPC9hdXRob3I+PGF1dGhvcj5Lb2ts

dSwgRS48L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PGF1dGgtYWRkcmVzcz5EaXZp

c2lvbiBvZiBOZW9uYXRvbG9neSwgRGVwYXJ0bWVudCBvZiBQYWVkaWF0cmljcywgRmFjdWx0eSBv

ZiBNZWRpY2luZSwgRXJjaXllcyBVbml2ZXJzaXR5LCBLYXlzZXJpLCBUdXJrZXkuIHRyZ3VuZXNA

ZXJjaXRlcy5lZHUudHI8L2F1dGgtYWRkcmVzcz48dGl0bGVzPjx0aXRsZT5Ucm9wb25pbi1UIGxl

dmVscyBpbiBwZXJpbmF0YWxseSBhc3BoeXhpYXRlZCBpbmZhbnRzIGR1cmluZyB0aGUgZmlyc3Qg

MTUgZGF5cyBvZiBsaWZlPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPkFjdGEgUGFlZGlhdHI8L3Nl

Y29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5BY3RhIFBhZWRp

YXRyPC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+MTYzOC00MzwvcGFnZXM+PHZvbHVt

ZT45NDwvdm9sdW1lPjxudW1iZXI+MTE8L251bWJlcj48ZWRpdGlvbj4yMDA1LzExLzI0PC9lZGl0

aW9uPjxrZXl3b3Jkcz48a2V5d29yZD5BbmFseXNpcyBvZiBWYXJpYW5jZTwva2V5d29yZD48a2V5

d29yZD5Bc3BoeXhpYSBOZW9uYXRvcnVtLypibG9vZC9lbnp5bW9sb2d5PC9rZXl3b3JkPjxrZXl3

b3JkPkJpb2xvZ2ljYWwgTWFya2Vyczwva2V5d29yZD48a2V5d29yZD5DYXNlLUNvbnRyb2wgU3R1

ZGllczwva2V5d29yZD48a2V5d29yZD5IdW1hbnM8L2tleXdvcmQ+PGtleXdvcmQ+SW5mYW50LCBO

ZXdib3JuPC9rZXl3b3JkPjxrZXl3b3JkPk15b2NhcmRpYWwgSXNjaGVtaWEvKmJsb29kL2Vuenlt

b2xvZ3k8L2tleXdvcmQ+PGtleXdvcmQ+U2V2ZXJpdHkgb2YgSWxsbmVzcyBJbmRleDwva2V5d29y

ZD48a2V5d29yZD5Ucm9wb25pbiBULypibG9vZDwva2V5d29yZD48L2tleXdvcmRzPjxkYXRlcz48

eWVhcj4yMDA1PC95ZWFyPjxwdWItZGF0ZXM+PGRhdGU+Tm92PC9kYXRlPjwvcHViLWRhdGVzPjwv

ZGF0ZXM+PGlzYm4+MDgwMy01MjUzIChQcmludCkmI3hEOzA4MDMtNTI1MyAoTGlua2luZyk8L2lz

Ym4+PGFjY2Vzc2lvbi1udW0+MTYzMDM3MDM8L2FjY2Vzc2lvbi1udW0+PHVybHM+PHJlbGF0ZWQt

dXJscz48dXJsPmh0dHA6Ly93d3cubmNiaS5ubG0ubmloLmdvdi9lbnRyZXovcXVlcnkuZmNnaT9j

bWQ9UmV0cmlldmUmYW1wO2RiPVB1Yk1lZCZhbXA7ZG9wdD1DaXRhdGlvbiZhbXA7bGlzdF91aWRz

PTE2MzAzNzAzPC91cmw+PC9yZWxhdGVkLXVybHM+PC91cmxzPjxlbGVjdHJvbmljLXJlc291cmNl

LW51bT5QNDFLNzAzMDczMzY0OTMyIFtwaWldJiN4RDsxMC4xMDgwLzA4MDM1MjUwNTEwMDQxMjIy

PC9lbGVjdHJvbmljLXJlc291cmNlLW51bT48bGFuZ3VhZ2U+ZW5nPC9sYW5ndWFnZT48L3JlY29y

ZD48L0NpdGU+PENpdGU+PEF1dGhvcj5Cb288L0F1dGhvcj48WWVhcj4yMDA1PC9ZZWFyPjxSZWNO

dW0+MTY5PC9SZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj4xNjk8L3JlYy1udW1iZXI+PGZvcmVp

Z24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSIwZTV3cHh0dmoydjV4NGV3YXR0dnAyejR3dzA1

enplejBzdnYiPjE2OTwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFs

IEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+Qm9v

LCBOLiBZLjwvYXV0aG9yPjxhdXRob3I+SGFmaWR6LCBILjwvYXV0aG9yPjxhdXRob3I+TmF3YXdp

LCBILiBNLjwvYXV0aG9yPjxhdXRob3I+Q2hlYWgsIEYuIEMuPC9hdXRob3I+PGF1dGhvcj5GYWR6

aWwsIFkuIEouPC9hdXRob3I+PGF1dGhvcj5BYmR1bC1Beml6LCBCLiBCLjwvYXV0aG9yPjxhdXRo

b3I+SXNtYWlsLCBaLjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48YXV0aC1hZGRy

ZXNzPkRlcGFydG1lbnQgb2YgUGFlZGlhdHJpY3MsIEhvc3BpdGFsIFVuaXZlcnNpdGkgS2ViYW5n

c2FhbiBNYWxheXNpYSwgS3VhbGEgTHVtcHVyLCBNYWxheXNpYS4gbnlib29AbWFpbC5odWttLnVr

bS5teTwvYXV0aC1hZGRyZXNzPjx0aXRsZXM+PHRpdGxlPkNvbXBhcmlzb24gb2Ygc2VydW0gY2Fy

ZGlhYyB0cm9wb25pbiBUIGFuZCBjcmVhdGluZSBraW5hc2UgTUIgaXNvZW56eW1lIG1hc3MgY29u

Y2VudHJhdGlvbnMgaW4gYXNwaHl4aWF0ZWQgdGVybSBpbmZhbnRzIGR1cmluZyB0aGUgZmlyc3Qg

NDggaCBvZiBsaWZlPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPkogUGFlZGlhdHIgQ2hpbGQgSGVh

bHRoPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+SiBQ

YWVkaWF0ciBDaGlsZCBIZWFsdGg8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz4zMzEt

NzwvcGFnZXM+PHZvbHVtZT40MTwvdm9sdW1lPjxudW1iZXI+NzwvbnVtYmVyPjxlZGl0aW9uPjIw

MDUvMDcvMTU8L2VkaXRpb24+PGtleXdvcmRzPjxrZXl3b3JkPkFzcGh5eGlhIE5lb25hdG9ydW0v

KmJsb29kL2Vuenltb2xvZ3k8L2tleXdvcmQ+PGtleXdvcmQ+Q3JlYXRpbmUgS2luYXNlLypibG9v

ZDwva2V5d29yZD48a2V5d29yZD5DcmVhdGluZSBLaW5hc2UsIE1CIEZvcm08L2tleXdvcmQ+PGtl

eXdvcmQ+RmVtYWxlPC9rZXl3b3JkPjxrZXl3b3JkPkh1bWFuczwva2V5d29yZD48a2V5d29yZD5J

bmZhbnQsIE5ld2Jvcm48L2tleXdvcmQ+PGtleXdvcmQ+SXNvZW56eW1lcy9ibG9vZDwva2V5d29y

ZD48a2V5d29yZD5NYWxheXNpYTwva2V5d29yZD48a2V5d29yZD5NYWxlPC9rZXl3b3JkPjxrZXl3

b3JkPlByb3NwZWN0aXZlIFN0dWRpZXM8L2tleXdvcmQ+PGtleXdvcmQ+VHJvcG9uaW4gVC8qYmxv

b2Q8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHllYXI+MjAwNTwveWVhcj48cHViLWRhdGVz

PjxkYXRlPkp1bDwvZGF0ZT48L3B1Yi1kYXRlcz48L2RhdGVzPjxpc2JuPjEwMzQtNDgxMCAoUHJp

bnQpJiN4RDsxMDM0LTQ4MTAgKExpbmtpbmcpPC9pc2JuPjxhY2Nlc3Npb24tbnVtPjE2MDE0MTM2

PC9hY2Nlc3Npb24tbnVtPjx1cmxzPjxyZWxhdGVkLXVybHM+PHVybD5odHRwOi8vd3d3Lm5jYmku

bmxtLm5paC5nb3YvZW50cmV6L3F1ZXJ5LmZjZ2k/Y21kPVJldHJpZXZlJmFtcDtkYj1QdWJNZWQm

YW1wO2RvcHQ9Q2l0YXRpb24mYW1wO2xpc3RfdWlkcz0xNjAxNDEzNjwvdXJsPjwvcmVsYXRlZC11

cmxzPjwvdXJscz48ZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+SlBDNjI2IFtwaWldJiN4RDsxMC4x

MTExL2ouMTQ0MC0xNzU0LjIwMDUuMDA2MjYueDwvZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+PGxh

bmd1YWdlPmVuZzwvbGFuZ3VhZ2U+PC9yZWNvcmQ+PC9DaXRlPjwvRW5kTm90ZT4AAAAAAA==

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HdW5lczwvQXV0aG9yPjxZZWFyPjIwMDU8L1llYXI+PFJl

Y051bT4xNjg8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjE2ODwvcmVjLW51bWJlcj48Zm9y

ZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjBlNXdweHR2ajJ2NXg0ZXdhdHR2cDJ6NHd3

MDV6emV6MHN2diI+MTY4PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJu

YWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5H

dW5lcywgVC48L2F1dGhvcj48YXV0aG9yPk96dHVyaywgTS4gQS48L2F1dGhvcj48YXV0aG9yPktv

a2x1LCBTLiBNLjwvYXV0aG9yPjxhdXRob3I+TmFyaW4sIE4uPC9hdXRob3I+PGF1dGhvcj5Lb2ts

dSwgRS48L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PGF1dGgtYWRkcmVzcz5EaXZp

c2lvbiBvZiBOZW9uYXRvbG9neSwgRGVwYXJ0bWVudCBvZiBQYWVkaWF0cmljcywgRmFjdWx0eSBv

ZiBNZWRpY2luZSwgRXJjaXllcyBVbml2ZXJzaXR5LCBLYXlzZXJpLCBUdXJrZXkuIHRyZ3VuZXNA

ZXJjaXRlcy5lZHUudHI8L2F1dGgtYWRkcmVzcz48dGl0bGVzPjx0aXRsZT5Ucm9wb25pbi1UIGxl

dmVscyBpbiBwZXJpbmF0YWxseSBhc3BoeXhpYXRlZCBpbmZhbnRzIGR1cmluZyB0aGUgZmlyc3Qg

MTUgZGF5cyBvZiBsaWZlPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPkFjdGEgUGFlZGlhdHI8L3Nl

Y29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5BY3RhIFBhZWRp

YXRyPC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+MTYzOC00MzwvcGFnZXM+PHZvbHVt

ZT45NDwvdm9sdW1lPjxudW1iZXI+MTE8L251bWJlcj48ZWRpdGlvbj4yMDA1LzExLzI0PC9lZGl0

aW9uPjxrZXl3b3Jkcz48a2V5d29yZD5BbmFseXNpcyBvZiBWYXJpYW5jZTwva2V5d29yZD48a2V5

d29yZD5Bc3BoeXhpYSBOZW9uYXRvcnVtLypibG9vZC9lbnp5bW9sb2d5PC9rZXl3b3JkPjxrZXl3

b3JkPkJpb2xvZ2ljYWwgTWFya2Vyczwva2V5d29yZD48a2V5d29yZD5DYXNlLUNvbnRyb2wgU3R1

ZGllczwva2V5d29yZD48a2V5d29yZD5IdW1hbnM8L2tleXdvcmQ+PGtleXdvcmQ+SW5mYW50LCBO

ZXdib3JuPC9rZXl3b3JkPjxrZXl3b3JkPk15b2NhcmRpYWwgSXNjaGVtaWEvKmJsb29kL2Vuenlt

b2xvZ3k8L2tleXdvcmQ+PGtleXdvcmQ+U2V2ZXJpdHkgb2YgSWxsbmVzcyBJbmRleDwva2V5d29y

ZD48a2V5d29yZD5Ucm9wb25pbiBULypibG9vZDwva2V5d29yZD48L2tleXdvcmRzPjxkYXRlcz48

eWVhcj4yMDA1PC95ZWFyPjxwdWItZGF0ZXM+PGRhdGU+Tm92PC9kYXRlPjwvcHViLWRhdGVzPjwv

ZGF0ZXM+PGlzYm4+MDgwMy01MjUzIChQcmludCkmI3hEOzA4MDMtNTI1MyAoTGlua2luZyk8L2lz

Ym4+PGFjY2Vzc2lvbi1udW0+MTYzMDM3MDM8L2FjY2Vzc2lvbi1udW0+PHVybHM+PHJlbGF0ZWQt

dXJscz48dXJsPmh0dHA6Ly93d3cubmNiaS5ubG0ubmloLmdvdi9lbnRyZXovcXVlcnkuZmNnaT9j

bWQ9UmV0cmlldmUmYW1wO2RiPVB1Yk1lZCZhbXA7ZG9wdD1DaXRhdGlvbiZhbXA7bGlzdF91aWRz

PTE2MzAzNzAzPC91cmw+PC9yZWxhdGVkLXVybHM+PC91cmxzPjxlbGVjdHJvbmljLXJlc291cmNl

LW51bT5QNDFLNzAzMDczMzY0OTMyIFtwaWldJiN4RDsxMC4xMDgwLzA4MDM1MjUwNTEwMDQxMjIy

PC9lbGVjdHJvbmljLXJlc291cmNlLW51bT48bGFuZ3VhZ2U+ZW5nPC9sYW5ndWFnZT48L3JlY29y

ZD48L0NpdGU+PENpdGU+PEF1dGhvcj5Cb288L0F1dGhvcj48WWVhcj4yMDA1PC9ZZWFyPjxSZWNO

dW0+MTY5PC9SZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj4xNjk8L3JlYy1udW1iZXI+PGZvcmVp

Z24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSIwZTV3cHh0dmoydjV4NGV3YXR0dnAyejR3dzA1

enplejBzdnYiPjE2OTwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFs

IEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+Qm9v

LCBOLiBZLjwvYXV0aG9yPjxhdXRob3I+SGFmaWR6LCBILjwvYXV0aG9yPjxhdXRob3I+TmF3YXdp

LCBILiBNLjwvYXV0aG9yPjxhdXRob3I+Q2hlYWgsIEYuIEMuPC9hdXRob3I+PGF1dGhvcj5GYWR6

aWwsIFkuIEouPC9hdXRob3I+PGF1dGhvcj5BYmR1bC1Beml6LCBCLiBCLjwvYXV0aG9yPjxhdXRo

b3I+SXNtYWlsLCBaLjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48YXV0aC1hZGRy

ZXNzPkRlcGFydG1lbnQgb2YgUGFlZGlhdHJpY3MsIEhvc3BpdGFsIFVuaXZlcnNpdGkgS2ViYW5n

c2FhbiBNYWxheXNpYSwgS3VhbGEgTHVtcHVyLCBNYWxheXNpYS4gbnlib29AbWFpbC5odWttLnVr

bS5teTwvYXV0aC1hZGRyZXNzPjx0aXRsZXM+PHRpdGxlPkNvbXBhcmlzb24gb2Ygc2VydW0gY2Fy

ZGlhYyB0cm9wb25pbiBUIGFuZCBjcmVhdGluZSBraW5hc2UgTUIgaXNvZW56eW1lIG1hc3MgY29u

Y2VudHJhdGlvbnMgaW4gYXNwaHl4aWF0ZWQgdGVybSBpbmZhbnRzIGR1cmluZyB0aGUgZmlyc3Qg

NDggaCBvZiBsaWZlPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPkogUGFlZGlhdHIgQ2hpbGQgSGVh

bHRoPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+SiBQ

YWVkaWF0ciBDaGlsZCBIZWFsdGg8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz4zMzEt

NzwvcGFnZXM+PHZvbHVtZT40MTwvdm9sdW1lPjxudW1iZXI+NzwvbnVtYmVyPjxlZGl0aW9uPjIw

MDUvMDcvMTU8L2VkaXRpb24+PGtleXdvcmRzPjxrZXl3b3JkPkFzcGh5eGlhIE5lb25hdG9ydW0v

KmJsb29kL2Vuenltb2xvZ3k8L2tleXdvcmQ+PGtleXdvcmQ+Q3JlYXRpbmUgS2luYXNlLypibG9v

ZDwva2V5d29yZD48a2V5d29yZD5DcmVhdGluZSBLaW5hc2UsIE1CIEZvcm08L2tleXdvcmQ+PGtl

eXdvcmQ+RmVtYWxlPC9rZXl3b3JkPjxrZXl3b3JkPkh1bWFuczwva2V5d29yZD48a2V5d29yZD5J

bmZhbnQsIE5ld2Jvcm48L2tleXdvcmQ+PGtleXdvcmQ+SXNvZW56eW1lcy9ibG9vZDwva2V5d29y

ZD48a2V5d29yZD5NYWxheXNpYTwva2V5d29yZD48a2V5d29yZD5NYWxlPC9rZXl3b3JkPjxrZXl3

b3JkPlByb3NwZWN0aXZlIFN0dWRpZXM8L2tleXdvcmQ+PGtleXdvcmQ+VHJvcG9uaW4gVC8qYmxv

b2Q8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHllYXI+MjAwNTwveWVhcj48cHViLWRhdGVz

PjxkYXRlPkp1bDwvZGF0ZT48L3B1Yi1kYXRlcz48L2RhdGVzPjxpc2JuPjEwMzQtNDgxMCAoUHJp

bnQpJiN4RDsxMDM0LTQ4MTAgKExpbmtpbmcpPC9pc2JuPjxhY2Nlc3Npb24tbnVtPjE2MDE0MTM2

PC9hY2Nlc3Npb24tbnVtPjx1cmxzPjxyZWxhdGVkLXVybHM+PHVybD5odHRwOi8vd3d3Lm5jYmku

bmxtLm5paC5nb3YvZW50cmV6L3F1ZXJ5LmZjZ2k/Y21kPVJldHJpZXZlJmFtcDtkYj1QdWJNZWQm

YW1wO2RvcHQ9Q2l0YXRpb24mYW1wO2xpc3RfdWlkcz0xNjAxNDEzNjwvdXJsPjwvcmVsYXRlZC11

cmxzPjwvdXJscz48ZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+SlBDNjI2IFtwaWldJiN4RDsxMC4x

MTExL2ouMTQ0MC0xNzU0LjIwMDUuMDA2MjYueDwvZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+PGxh

bmd1YWdlPmVuZzwvbGFuZ3VhZ2U+PC9yZWNvcmQ+PC9DaXRlPjwvRW5kTm90ZT4AAAAAAA==

ADDIN EN.CITE.DATA (11, 12). Cardiac Troponin T (cTnT) and I (cTNI) are structural cytoplasmic proteins of myosites and the most cardiac specific of the troponins in the neonatal period ADDIN EN.CITE <EndNote><Cite><Author>El-Khuffash</Author><Year>2008</Year><RecNum>170</RecNum><record><rec-number>170</rec-number><foreign-keys><key app="EN" db-id="0e5wpxtvj2v5x4ewattvp2z4ww05zzez0svv">170</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>El-Khuffash, A. F.</author><author>Molloy, E. J.</author></authors></contributors><auth-address>Department of Neonatology, National Maternity Hospital, Dublin, Ireland. afif_faisal@</auth-address><titles><title>Serum troponin in neonatal intensive care</title><secondary-title>Neonatology</secondary-title></titles><periodical><full-title>Neonatology</full-title></periodical><pages>1-7</pages><volume>94</volume><number>1</number><edition>2007/12/22</edition><keywords><keyword>Asphyxia Neonatorum/blood/physiopathology</keyword><keyword>Biological Markers/blood</keyword><keyword>Cardiomyopathies/blood/*physiopathology</keyword><keyword>Echocardiography</keyword><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>*Intensive Care, Neonatal</keyword><keyword>Respiratory Distress Syndrome, Newborn/blood/physiopathology</keyword><keyword>Troponin/*blood</keyword></keywords><dates><year>2008</year></dates><isbn>1661-7819 (Electronic)&#xD;1661-7800 (Linking)</isbn><accession-num>18097151</accession-num><urls><related-urls><url> [pii]&#xD;10.1159/000112540</electronic-resource-num><language>eng</language></record></Cite></EndNote>(13). Further, there is only one commercially available assay for Troponin T making standardization between different studies and reference ranges relatively consistent. Although there is not an accepted normal range for cTnT in neonates, a value of ≥ 0.1 ng/ml in the setting of HIE has been considered as elevated in several studies and as a potential indicator of mortality in the neonatal period PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYXR0ZXI8L0F1dGhvcj48UmVjTnVtPjE3MTwvUmVjTnVt

PjxyZWNvcmQ+PHJlYy1udW1iZXI+MTcxPC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBh

cHA9IkVOIiBkYi1pZD0iMGU1d3B4dHZqMnY1eDRld2F0dHZwMno0d3cwNXp6ZXowc3Z2Ij4xNzE8

L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwv

cmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPk1hdHRlciwgTS48L2F1dGhv

cj48YXV0aG9yPkFiZGVsLUhhZHksIEguPC9hdXRob3I+PGF1dGhvcj5BdHRpYSwgRy48L2F1dGhv

cj48YXV0aG9yPkhhZmV6LCBNLjwvYXV0aG9yPjxhdXRob3I+U2VsaWVtLCBXLjwvYXV0aG9yPjxh

dXRob3I+QWwtQXJtYW4sIE0uPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjxhdXRo

LWFkZHJlc3M+UGVkaWF0cmljIENhcmRpb2xvZ3kgVW5pdCwgTWFuc291cmEgVW5pdmVyc2l0eSBD

aGlsZHJlbiZhcG9zO3MgSG9zcGl0YWwsIE1hbnNvdXJhLCBFZ3lwdC48L2F1dGgtYWRkcmVzcz48

dGl0bGVzPjx0aXRsZT5NeW9jYXJkaWFsIHBlcmZvcm1hbmNlIGluIGFzcGh5eGlhdGVkIGZ1bGwt

dGVybSBpbmZhbnRzIGFzc2Vzc2VkIGJ5IERvcHBsZXIgdGlzc3VlIGltYWdpbmc8L3RpdGxlPjxz

ZWNvbmRhcnktdGl0bGU+UGVkaWF0ciBDYXJkaW9sPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+

PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+UGVkaWF0ciBDYXJkaW9sPC9mdWxsLXRpdGxlPjwvcGVy

aW9kaWNhbD48cGFnZXM+NjM0LTQyPC9wYWdlcz48dm9sdW1lPjMxPC92b2x1bWU+PG51bWJlcj41

PC9udW1iZXI+PGVkaXRpb24+MjAxMC8wMi8xMDwvZWRpdGlvbj48a2V5d29yZHM+PGtleXdvcmQ+

QXNwaHl4aWEgTmVvbmF0b3J1bS8qY29tcGxpY2F0aW9uczwva2V5d29yZD48a2V5d29yZD5CaW9s

b2dpY2FsIE1hcmtlcnMvYmxvb2Q8L2tleXdvcmQ+PGtleXdvcmQ+Q2FzZS1Db250cm9sIFN0dWRp

ZXM8L2tleXdvcmQ+PGtleXdvcmQ+Q2hpLVNxdWFyZSBEaXN0cmlidXRpb248L2tleXdvcmQ+PGtl

eXdvcmQ+KkVjaG9jYXJkaW9ncmFwaHksIERvcHBsZXI8L2tleXdvcmQ+PGtleXdvcmQ+RmVtYWxl

PC9rZXl3b3JkPjxrZXl3b3JkPkh1bWFuczwva2V5d29yZD48a2V5d29yZD5JbmZhbnQsIE5ld2Jv

cm48L2tleXdvcmQ+PGtleXdvcmQ+TWFsZTwva2V5d29yZD48a2V5d29yZD5NeW9jYXJkaWFsIElz

Y2hlbWlhLypwaHlzaW9wYXRob2xvZ3kvKnVsdHJhc29ub2dyYXBoeTwva2V5d29yZD48a2V5d29y

ZD5Qcm9zcGVjdGl2ZSBTdHVkaWVzPC9rZXl3b3JkPjxrZXl3b3JkPlJPQyBDdXJ2ZTwva2V5d29y

ZD48a2V5d29yZD5SaXNrIEZhY3RvcnM8L2tleXdvcmQ+PGtleXdvcmQ+U3RhdGlzdGljcywgTm9u

cGFyYW1ldHJpYzwva2V5d29yZD48a2V5d29yZD5Ucm9wb25pbiBUL2Jsb29kPC9rZXl3b3JkPjwv

a2V5d29yZHM+PGRhdGVzPjxwdWItZGF0ZXM+PGRhdGU+SnVsPC9kYXRlPjwvcHViLWRhdGVzPjwv

ZGF0ZXM+PGlzYm4+MTQzMi0xOTcxIChFbGVjdHJvbmljKSYjeEQ7MDE3Mi0wNjQzIChMaW5raW5n

KTwvaXNibj48YWNjZXNzaW9uLW51bT4yMDE0MzA1NDwvYWNjZXNzaW9uLW51bT48dXJscz48cmVs

YXRlZC11cmxzPjx1cmw+aHR0cDovL3d3dy5uY2JpLm5sbS5uaWguZ292L2VudHJlei9xdWVyeS5m

Y2dpP2NtZD1SZXRyaWV2ZSZhbXA7ZGI9UHViTWVkJmFtcDtkb3B0PUNpdGF0aW9uJmFtcDtsaXN0

X3VpZHM9MjAxNDMwNTQ8L3VybD48L3JlbGF0ZWQtdXJscz48L3VybHM+PGVsZWN0cm9uaWMtcmVz

b3VyY2UtbnVtPjEwLjEwMDcvczAwMjQ2LTAxMC05NjYxLTU8L2VsZWN0cm9uaWMtcmVzb3VyY2Ut

bnVtPjxsYW5ndWFnZT5lbmc8L2xhbmd1YWdlPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9y

Pkd1bmVzPC9BdXRob3I+PFllYXI+MjAwNTwvWWVhcj48UmVjTnVtPjE2ODwvUmVjTnVtPjxyZWNv

cmQ+PHJlYy1udW1iZXI+MTY4PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVO

IiBkYi1pZD0iMGU1d3B4dHZqMnY1eDRld2F0dHZwMno0d3cwNXp6ZXowc3Z2Ij4xNjg8L2tleT48

L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5

cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPkd1bmVzLCBULjwvYXV0aG9yPjxhdXRo

b3I+T3p0dXJrLCBNLiBBLjwvYXV0aG9yPjxhdXRob3I+S29rbHUsIFMuIE0uPC9hdXRob3I+PGF1

dGhvcj5OYXJpbiwgTi48L2F1dGhvcj48YXV0aG9yPktva2x1LCBFLjwvYXV0aG9yPjwvYXV0aG9y

cz48L2NvbnRyaWJ1dG9ycz48YXV0aC1hZGRyZXNzPkRpdmlzaW9uIG9mIE5lb25hdG9sb2d5LCBE

ZXBhcnRtZW50IG9mIFBhZWRpYXRyaWNzLCBGYWN1bHR5IG9mIE1lZGljaW5lLCBFcmNpeWVzIFVu

aXZlcnNpdHksIEtheXNlcmksIFR1cmtleS4gdHJndW5lc0BlcmNpdGVzLmVkdS50cjwvYXV0aC1h

ZGRyZXNzPjx0aXRsZXM+PHRpdGxlPlRyb3BvbmluLVQgbGV2ZWxzIGluIHBlcmluYXRhbGx5IGFz

cGh5eGlhdGVkIGluZmFudHMgZHVyaW5nIHRoZSBmaXJzdCAxNSBkYXlzIG9mIGxpZmU8L3RpdGxl

PjxzZWNvbmRhcnktdGl0bGU+QWN0YSBQYWVkaWF0cjwvc2Vjb25kYXJ5LXRpdGxlPjwvdGl0bGVz

PjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPkFjdGEgUGFlZGlhdHI8L2Z1bGwtdGl0bGU+PC9wZXJp

b2RpY2FsPjxwYWdlcz4xNjM4LTQzPC9wYWdlcz48dm9sdW1lPjk0PC92b2x1bWU+PG51bWJlcj4x

MTwvbnVtYmVyPjxlZGl0aW9uPjIwMDUvMTEvMjQ8L2VkaXRpb24+PGtleXdvcmRzPjxrZXl3b3Jk

PkFuYWx5c2lzIG9mIFZhcmlhbmNlPC9rZXl3b3JkPjxrZXl3b3JkPkFzcGh5eGlhIE5lb25hdG9y

dW0vKmJsb29kL2Vuenltb2xvZ3k8L2tleXdvcmQ+PGtleXdvcmQ+QmlvbG9naWNhbCBNYXJrZXJz

PC9rZXl3b3JkPjxrZXl3b3JkPkNhc2UtQ29udHJvbCBTdHVkaWVzPC9rZXl3b3JkPjxrZXl3b3Jk

Pkh1bWFuczwva2V5d29yZD48a2V5d29yZD5JbmZhbnQsIE5ld2Jvcm48L2tleXdvcmQ+PGtleXdv

cmQ+TXlvY2FyZGlhbCBJc2NoZW1pYS8qYmxvb2QvZW56eW1vbG9neTwva2V5d29yZD48a2V5d29y

ZD5TZXZlcml0eSBvZiBJbGxuZXNzIEluZGV4PC9rZXl3b3JkPjxrZXl3b3JkPlRyb3BvbmluIFQv

KmJsb29kPC9rZXl3b3JkPjwva2V5d29yZHM+PGRhdGVzPjx5ZWFyPjIwMDU8L3llYXI+PHB1Yi1k

YXRlcz48ZGF0ZT5Ob3Y8L2RhdGU+PC9wdWItZGF0ZXM+PC9kYXRlcz48aXNibj4wODAzLTUyNTMg

KFByaW50KSYjeEQ7MDgwMy01MjUzIChMaW5raW5nKTwvaXNibj48YWNjZXNzaW9uLW51bT4xNjMw

MzcwMzwvYWNjZXNzaW9uLW51bT48dXJscz48cmVsYXRlZC11cmxzPjx1cmw+aHR0cDovL3d3dy5u

Y2JpLm5sbS5uaWguZ292L2VudHJlei9xdWVyeS5mY2dpP2NtZD1SZXRyaWV2ZSZhbXA7ZGI9UHVi

TWVkJmFtcDtkb3B0PUNpdGF0aW9uJmFtcDtsaXN0X3VpZHM9MTYzMDM3MDM8L3VybD48L3JlbGF0

ZWQtdXJscz48L3VybHM+PGVsZWN0cm9uaWMtcmVzb3VyY2UtbnVtPlA0MUs3MDMwNzMzNjQ5MzIg

W3BpaV0mI3hEOzEwLjEwODAvMDgwMzUyNTA1MTAwNDEyMjI8L2VsZWN0cm9uaWMtcmVzb3VyY2Ut

bnVtPjxsYW5ndWFnZT5lbmc8L2xhbmd1YWdlPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9y

PkVsLUtodWZmYXNoPC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48UmVjTnVtPjE3MDwvUmVjTnVt

PjxyZWNvcmQ+PHJlYy1udW1iZXI+MTcwPC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBh

cHA9IkVOIiBkYi1pZD0iMGU1d3B4dHZqMnY1eDRld2F0dHZwMno0d3cwNXp6ZXowc3Z2Ij4xNzA8

L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwv

cmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPkVsLUtodWZmYXNoLCBBLiBG

LjwvYXV0aG9yPjxhdXRob3I+TW9sbG95LCBFLiBKLjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRy

aWJ1dG9ycz48YXV0aC1hZGRyZXNzPkRlcGFydG1lbnQgb2YgTmVvbmF0b2xvZ3ksIE5hdGlvbmFs

IE1hdGVybml0eSBIb3NwaXRhbCwgRHVibGluLCBJcmVsYW5kLiBhZmlmX2ZhaXNhbEBob3RtYWls

LmNvbTwvYXV0aC1hZGRyZXNzPjx0aXRsZXM+PHRpdGxlPlNlcnVtIHRyb3BvbmluIGluIG5lb25h

dGFsIGludGVuc2l2ZSBjYXJlPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPk5lb25hdG9sb2d5PC9z

ZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+TmVvbmF0b2xv

Z3k8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz4xLTc8L3BhZ2VzPjx2b2x1bWU+OTQ8

L3ZvbHVtZT48bnVtYmVyPjE8L251bWJlcj48ZWRpdGlvbj4yMDA3LzEyLzIyPC9lZGl0aW9uPjxr

ZXl3b3Jkcz48a2V5d29yZD5Bc3BoeXhpYSBOZW9uYXRvcnVtL2Jsb29kL3BoeXNpb3BhdGhvbG9n

eTwva2V5d29yZD48a2V5d29yZD5CaW9sb2dpY2FsIE1hcmtlcnMvYmxvb2Q8L2tleXdvcmQ+PGtl

eXdvcmQ+Q2FyZGlvbXlvcGF0aGllcy9ibG9vZC8qcGh5c2lvcGF0aG9sb2d5PC9rZXl3b3JkPjxr

ZXl3b3JkPkVjaG9jYXJkaW9ncmFwaHk8L2tleXdvcmQ+PGtleXdvcmQ+SHVtYW5zPC9rZXl3b3Jk

PjxrZXl3b3JkPkluZmFudCwgTmV3Ym9ybjwva2V5d29yZD48a2V5d29yZD4qSW50ZW5zaXZlIENh

cmUsIE5lb25hdGFsPC9rZXl3b3JkPjxrZXl3b3JkPlJlc3BpcmF0b3J5IERpc3RyZXNzIFN5bmRy

b21lLCBOZXdib3JuL2Jsb29kL3BoeXNpb3BhdGhvbG9neTwva2V5d29yZD48a2V5d29yZD5Ucm9w

b25pbi8qYmxvb2Q8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHllYXI+MjAwODwveWVhcj48

L2RhdGVzPjxpc2JuPjE2NjEtNzgxOSAoRWxlY3Ryb25pYykmI3hEOzE2NjEtNzgwMCAoTGlua2lu

Zyk8L2lzYm4+PGFjY2Vzc2lvbi1udW0+MTgwOTcxNTE8L2FjY2Vzc2lvbi1udW0+PHVybHM+PHJl

bGF0ZWQtdXJscz48dXJsPmh0dHA6Ly93d3cubmNiaS5ubG0ubmloLmdvdi9lbnRyZXovcXVlcnku

ZmNnaT9jbWQ9UmV0cmlldmUmYW1wO2RiPVB1Yk1lZCZhbXA7ZG9wdD1DaXRhdGlvbiZhbXA7bGlz

dF91aWRzPTE4MDk3MTUxPC91cmw+PC9yZWxhdGVkLXVybHM+PC91cmxzPjxlbGVjdHJvbmljLXJl

c291cmNlLW51bT4wMDAxMTI1NDAgW3BpaV0mI3hEOzEwLjExNTkvMDAwMTEyNTQwPC9lbGVjdHJv

bmljLXJlc291cmNlLW51bT48bGFuZ3VhZ2U+ZW5nPC9sYW5ndWFnZT48L3JlY29yZD48L0NpdGU+

PENpdGU+PEF1dGhvcj5Cb288L0F1dGhvcj48WWVhcj4yMDA1PC9ZZWFyPjxSZWNOdW0+MTY5PC9S

ZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj4xNjk8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48

a2V5IGFwcD0iRU4iIGRiLWlkPSIwZTV3cHh0dmoydjV4NGV3YXR0dnAyejR3dzA1enplejBzdnYi

PjE2OTwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFydGljbGUi

PjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+Qm9vLCBOLiBZLjwv

YXV0aG9yPjxhdXRob3I+SGFmaWR6LCBILjwvYXV0aG9yPjxhdXRob3I+TmF3YXdpLCBILiBNLjwv

YXV0aG9yPjxhdXRob3I+Q2hlYWgsIEYuIEMuPC9hdXRob3I+PGF1dGhvcj5GYWR6aWwsIFkuIEou

PC9hdXRob3I+PGF1dGhvcj5BYmR1bC1Beml6LCBCLiBCLjwvYXV0aG9yPjxhdXRob3I+SXNtYWls

LCBaLjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48YXV0aC1hZGRyZXNzPkRlcGFy

dG1lbnQgb2YgUGFlZGlhdHJpY3MsIEhvc3BpdGFsIFVuaXZlcnNpdGkgS2ViYW5nc2FhbiBNYWxh

eXNpYSwgS3VhbGEgTHVtcHVyLCBNYWxheXNpYS4gbnlib29AbWFpbC5odWttLnVrbS5teTwvYXV0

aC1hZGRyZXNzPjx0aXRsZXM+PHRpdGxlPkNvbXBhcmlzb24gb2Ygc2VydW0gY2FyZGlhYyB0cm9w

b25pbiBUIGFuZCBjcmVhdGluZSBraW5hc2UgTUIgaXNvZW56eW1lIG1hc3MgY29uY2VudHJhdGlv

bnMgaW4gYXNwaHl4aWF0ZWQgdGVybSBpbmZhbnRzIGR1cmluZyB0aGUgZmlyc3QgNDggaCBvZiBs

aWZlPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPkogUGFlZGlhdHIgQ2hpbGQgSGVhbHRoPC9zZWNv

bmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+SiBQYWVkaWF0ciBD

aGlsZCBIZWFsdGg8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz4zMzEtNzwvcGFnZXM+

PHZvbHVtZT40MTwvdm9sdW1lPjxudW1iZXI+NzwvbnVtYmVyPjxlZGl0aW9uPjIwMDUvMDcvMTU8

L2VkaXRpb24+PGtleXdvcmRzPjxrZXl3b3JkPkFzcGh5eGlhIE5lb25hdG9ydW0vKmJsb29kL2Vu

enltb2xvZ3k8L2tleXdvcmQ+PGtleXdvcmQ+Q3JlYXRpbmUgS2luYXNlLypibG9vZDwva2V5d29y

ZD48a2V5d29yZD5DcmVhdGluZSBLaW5hc2UsIE1CIEZvcm08L2tleXdvcmQ+PGtleXdvcmQ+RmVt

YWxlPC9rZXl3b3JkPjxrZXl3b3JkPkh1bWFuczwva2V5d29yZD48a2V5d29yZD5JbmZhbnQsIE5l

d2Jvcm48L2tleXdvcmQ+PGtleXdvcmQ+SXNvZW56eW1lcy9ibG9vZDwva2V5d29yZD48a2V5d29y

ZD5NYWxheXNpYTwva2V5d29yZD48a2V5d29yZD5NYWxlPC9rZXl3b3JkPjxrZXl3b3JkPlByb3Nw

ZWN0aXZlIFN0dWRpZXM8L2tleXdvcmQ+PGtleXdvcmQ+VHJvcG9uaW4gVC8qYmxvb2Q8L2tleXdv

cmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHllYXI+MjAwNTwveWVhcj48cHViLWRhdGVzPjxkYXRlPkp1

bDwvZGF0ZT48L3B1Yi1kYXRlcz48L2RhdGVzPjxpc2JuPjEwMzQtNDgxMCAoUHJpbnQpJiN4RDsx

MDM0LTQ4MTAgKExpbmtpbmcpPC9pc2JuPjxhY2Nlc3Npb24tbnVtPjE2MDE0MTM2PC9hY2Nlc3Np

b24tbnVtPjx1cmxzPjxyZWxhdGVkLXVybHM+PHVybD5odHRwOi8vd3d3Lm5jYmkubmxtLm5paC5n

b3YvZW50cmV6L3F1ZXJ5LmZjZ2k/Y21kPVJldHJpZXZlJmFtcDtkYj1QdWJNZWQmYW1wO2RvcHQ9

Q2l0YXRpb24mYW1wO2xpc3RfdWlkcz0xNjAxNDEzNjwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJs

cz48ZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+SlBDNjI2IFtwaWldJiN4RDsxMC4xMTExL2ouMTQ0

MC0xNzU0LjIwMDUuMDA2MjYueDwvZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+PGxhbmd1YWdlPmVu

ZzwvbGFuZ3VhZ2U+PC9yZWNvcmQ+PC9DaXRlPjwvRW5kTm90ZT4AAAAA

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYXR0ZXI8L0F1dGhvcj48UmVjTnVtPjE3MTwvUmVjTnVt

PjxyZWNvcmQ+PHJlYy1udW1iZXI+MTcxPC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBh

cHA9IkVOIiBkYi1pZD0iMGU1d3B4dHZqMnY1eDRld2F0dHZwMno0d3cwNXp6ZXowc3Z2Ij4xNzE8

L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwv

cmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPk1hdHRlciwgTS48L2F1dGhv

cj48YXV0aG9yPkFiZGVsLUhhZHksIEguPC9hdXRob3I+PGF1dGhvcj5BdHRpYSwgRy48L2F1dGhv

cj48YXV0aG9yPkhhZmV6LCBNLjwvYXV0aG9yPjxhdXRob3I+U2VsaWVtLCBXLjwvYXV0aG9yPjxh

dXRob3I+QWwtQXJtYW4sIE0uPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjxhdXRo

LWFkZHJlc3M+UGVkaWF0cmljIENhcmRpb2xvZ3kgVW5pdCwgTWFuc291cmEgVW5pdmVyc2l0eSBD

aGlsZHJlbiZhcG9zO3MgSG9zcGl0YWwsIE1hbnNvdXJhLCBFZ3lwdC48L2F1dGgtYWRkcmVzcz48

dGl0bGVzPjx0aXRsZT5NeW9jYXJkaWFsIHBlcmZvcm1hbmNlIGluIGFzcGh5eGlhdGVkIGZ1bGwt

dGVybSBpbmZhbnRzIGFzc2Vzc2VkIGJ5IERvcHBsZXIgdGlzc3VlIGltYWdpbmc8L3RpdGxlPjxz

ZWNvbmRhcnktdGl0bGU+UGVkaWF0ciBDYXJkaW9sPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+

PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+UGVkaWF0ciBDYXJkaW9sPC9mdWxsLXRpdGxlPjwvcGVy

aW9kaWNhbD48cGFnZXM+NjM0LTQyPC9wYWdlcz48dm9sdW1lPjMxPC92b2x1bWU+PG51bWJlcj41

PC9udW1iZXI+PGVkaXRpb24+MjAxMC8wMi8xMDwvZWRpdGlvbj48a2V5d29yZHM+PGtleXdvcmQ+

QXNwaHl4aWEgTmVvbmF0b3J1bS8qY29tcGxpY2F0aW9uczwva2V5d29yZD48a2V5d29yZD5CaW9s

b2dpY2FsIE1hcmtlcnMvYmxvb2Q8L2tleXdvcmQ+PGtleXdvcmQ+Q2FzZS1Db250cm9sIFN0dWRp

ZXM8L2tleXdvcmQ+PGtleXdvcmQ+Q2hpLVNxdWFyZSBEaXN0cmlidXRpb248L2tleXdvcmQ+PGtl

eXdvcmQ+KkVjaG9jYXJkaW9ncmFwaHksIERvcHBsZXI8L2tleXdvcmQ+PGtleXdvcmQ+RmVtYWxl

PC9rZXl3b3JkPjxrZXl3b3JkPkh1bWFuczwva2V5d29yZD48a2V5d29yZD5JbmZhbnQsIE5ld2Jv

cm48L2tleXdvcmQ+PGtleXdvcmQ+TWFsZTwva2V5d29yZD48a2V5d29yZD5NeW9jYXJkaWFsIElz

Y2hlbWlhLypwaHlzaW9wYXRob2xvZ3kvKnVsdHJhc29ub2dyYXBoeTwva2V5d29yZD48a2V5d29y

ZD5Qcm9zcGVjdGl2ZSBTdHVkaWVzPC9rZXl3b3JkPjxrZXl3b3JkPlJPQyBDdXJ2ZTwva2V5d29y

ZD48a2V5d29yZD5SaXNrIEZhY3RvcnM8L2tleXdvcmQ+PGtleXdvcmQ+U3RhdGlzdGljcywgTm9u

cGFyYW1ldHJpYzwva2V5d29yZD48a2V5d29yZD5Ucm9wb25pbiBUL2Jsb29kPC9rZXl3b3JkPjwv

a2V5d29yZHM+PGRhdGVzPjxwdWItZGF0ZXM+PGRhdGU+SnVsPC9kYXRlPjwvcHViLWRhdGVzPjwv

ZGF0ZXM+PGlzYm4+MTQzMi0xOTcxIChFbGVjdHJvbmljKSYjeEQ7MDE3Mi0wNjQzIChMaW5raW5n

KTwvaXNibj48YWNjZXNzaW9uLW51bT4yMDE0MzA1NDwvYWNjZXNzaW9uLW51bT48dXJscz48cmVs

YXRlZC11cmxzPjx1cmw+aHR0cDovL3d3dy5uY2JpLm5sbS5uaWguZ292L2VudHJlei9xdWVyeS5m

Y2dpP2NtZD1SZXRyaWV2ZSZhbXA7ZGI9UHViTWVkJmFtcDtkb3B0PUNpdGF0aW9uJmFtcDtsaXN0

X3VpZHM9MjAxNDMwNTQ8L3VybD48L3JlbGF0ZWQtdXJscz48L3VybHM+PGVsZWN0cm9uaWMtcmVz

b3VyY2UtbnVtPjEwLjEwMDcvczAwMjQ2LTAxMC05NjYxLTU8L2VsZWN0cm9uaWMtcmVzb3VyY2Ut

bnVtPjxsYW5ndWFnZT5lbmc8L2xhbmd1YWdlPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9y

Pkd1bmVzPC9BdXRob3I+PFllYXI+MjAwNTwvWWVhcj48UmVjTnVtPjE2ODwvUmVjTnVtPjxyZWNv

cmQ+PHJlYy1udW1iZXI+MTY4PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVO

IiBkYi1pZD0iMGU1d3B4dHZqMnY1eDRld2F0dHZwMno0d3cwNXp6ZXowc3Z2Ij4xNjg8L2tleT48

L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5

cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPkd1bmVzLCBULjwvYXV0aG9yPjxhdXRo

b3I+T3p0dXJrLCBNLiBBLjwvYXV0aG9yPjxhdXRob3I+S29rbHUsIFMuIE0uPC9hdXRob3I+PGF1

dGhvcj5OYXJpbiwgTi48L2F1dGhvcj48YXV0aG9yPktva2x1LCBFLjwvYXV0aG9yPjwvYXV0aG9y

cz48L2NvbnRyaWJ1dG9ycz48YXV0aC1hZGRyZXNzPkRpdmlzaW9uIG9mIE5lb25hdG9sb2d5LCBE

ZXBhcnRtZW50IG9mIFBhZWRpYXRyaWNzLCBGYWN1bHR5IG9mIE1lZGljaW5lLCBFcmNpeWVzIFVu

aXZlcnNpdHksIEtheXNlcmksIFR1cmtleS4gdHJndW5lc0BlcmNpdGVzLmVkdS50cjwvYXV0aC1h

ZGRyZXNzPjx0aXRsZXM+PHRpdGxlPlRyb3BvbmluLVQgbGV2ZWxzIGluIHBlcmluYXRhbGx5IGFz

cGh5eGlhdGVkIGluZmFudHMgZHVyaW5nIHRoZSBmaXJzdCAxNSBkYXlzIG9mIGxpZmU8L3RpdGxl

PjxzZWNvbmRhcnktdGl0bGU+QWN0YSBQYWVkaWF0cjwvc2Vjb25kYXJ5LXRpdGxlPjwvdGl0bGVz

PjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPkFjdGEgUGFlZGlhdHI8L2Z1bGwtdGl0bGU+PC9wZXJp

b2RpY2FsPjxwYWdlcz4xNjM4LTQzPC9wYWdlcz48dm9sdW1lPjk0PC92b2x1bWU+PG51bWJlcj4x

MTwvbnVtYmVyPjxlZGl0aW9uPjIwMDUvMTEvMjQ8L2VkaXRpb24+PGtleXdvcmRzPjxrZXl3b3Jk

PkFuYWx5c2lzIG9mIFZhcmlhbmNlPC9rZXl3b3JkPjxrZXl3b3JkPkFzcGh5eGlhIE5lb25hdG9y

dW0vKmJsb29kL2Vuenltb2xvZ3k8L2tleXdvcmQ+PGtleXdvcmQ+QmlvbG9naWNhbCBNYXJrZXJz

PC9rZXl3b3JkPjxrZXl3b3JkPkNhc2UtQ29udHJvbCBTdHVkaWVzPC9rZXl3b3JkPjxrZXl3b3Jk

Pkh1bWFuczwva2V5d29yZD48a2V5d29yZD5JbmZhbnQsIE5ld2Jvcm48L2tleXdvcmQ+PGtleXdv

cmQ+TXlvY2FyZGlhbCBJc2NoZW1pYS8qYmxvb2QvZW56eW1vbG9neTwva2V5d29yZD48a2V5d29y

ZD5TZXZlcml0eSBvZiBJbGxuZXNzIEluZGV4PC9rZXl3b3JkPjxrZXl3b3JkPlRyb3BvbmluIFQv

KmJsb29kPC9rZXl3b3JkPjwva2V5d29yZHM+PGRhdGVzPjx5ZWFyPjIwMDU8L3llYXI+PHB1Yi1k

YXRlcz48ZGF0ZT5Ob3Y8L2RhdGU+PC9wdWItZGF0ZXM+PC9kYXRlcz48aXNibj4wODAzLTUyNTMg

KFByaW50KSYjeEQ7MDgwMy01MjUzIChMaW5raW5nKTwvaXNibj48YWNjZXNzaW9uLW51bT4xNjMw

MzcwMzwvYWNjZXNzaW9uLW51bT48dXJscz48cmVsYXRlZC11cmxzPjx1cmw+aHR0cDovL3d3dy5u

Y2JpLm5sbS5uaWguZ292L2VudHJlei9xdWVyeS5mY2dpP2NtZD1SZXRyaWV2ZSZhbXA7ZGI9UHVi

TWVkJmFtcDtkb3B0PUNpdGF0aW9uJmFtcDtsaXN0X3VpZHM9MTYzMDM3MDM8L3VybD48L3JlbGF0

ZWQtdXJscz48L3VybHM+PGVsZWN0cm9uaWMtcmVzb3VyY2UtbnVtPlA0MUs3MDMwNzMzNjQ5MzIg

W3BpaV0mI3hEOzEwLjEwODAvMDgwMzUyNTA1MTAwNDEyMjI8L2VsZWN0cm9uaWMtcmVzb3VyY2Ut

bnVtPjxsYW5ndWFnZT5lbmc8L2xhbmd1YWdlPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9y

PkVsLUtodWZmYXNoPC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48UmVjTnVtPjE3MDwvUmVjTnVt

PjxyZWNvcmQ+PHJlYy1udW1iZXI+MTcwPC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBh

cHA9IkVOIiBkYi1pZD0iMGU1d3B4dHZqMnY1eDRld2F0dHZwMno0d3cwNXp6ZXowc3Z2Ij4xNzA8

L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwv

cmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPkVsLUtodWZmYXNoLCBBLiBG

LjwvYXV0aG9yPjxhdXRob3I+TW9sbG95LCBFLiBKLjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRy

aWJ1dG9ycz48YXV0aC1hZGRyZXNzPkRlcGFydG1lbnQgb2YgTmVvbmF0b2xvZ3ksIE5hdGlvbmFs

IE1hdGVybml0eSBIb3NwaXRhbCwgRHVibGluLCBJcmVsYW5kLiBhZmlmX2ZhaXNhbEBob3RtYWls

LmNvbTwvYXV0aC1hZGRyZXNzPjx0aXRsZXM+PHRpdGxlPlNlcnVtIHRyb3BvbmluIGluIG5lb25h

dGFsIGludGVuc2l2ZSBjYXJlPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPk5lb25hdG9sb2d5PC9z

ZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+TmVvbmF0b2xv

Z3k8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz4xLTc8L3BhZ2VzPjx2b2x1bWU+OTQ8

L3ZvbHVtZT48bnVtYmVyPjE8L251bWJlcj48ZWRpdGlvbj4yMDA3LzEyLzIyPC9lZGl0aW9uPjxr

ZXl3b3Jkcz48a2V5d29yZD5Bc3BoeXhpYSBOZW9uYXRvcnVtL2Jsb29kL3BoeXNpb3BhdGhvbG9n

eTwva2V5d29yZD48a2V5d29yZD5CaW9sb2dpY2FsIE1hcmtlcnMvYmxvb2Q8L2tleXdvcmQ+PGtl

eXdvcmQ+Q2FyZGlvbXlvcGF0aGllcy9ibG9vZC8qcGh5c2lvcGF0aG9sb2d5PC9rZXl3b3JkPjxr

ZXl3b3JkPkVjaG9jYXJkaW9ncmFwaHk8L2tleXdvcmQ+PGtleXdvcmQ+SHVtYW5zPC9rZXl3b3Jk

PjxrZXl3b3JkPkluZmFudCwgTmV3Ym9ybjwva2V5d29yZD48a2V5d29yZD4qSW50ZW5zaXZlIENh

cmUsIE5lb25hdGFsPC9rZXl3b3JkPjxrZXl3b3JkPlJlc3BpcmF0b3J5IERpc3RyZXNzIFN5bmRy

b21lLCBOZXdib3JuL2Jsb29kL3BoeXNpb3BhdGhvbG9neTwva2V5d29yZD48a2V5d29yZD5Ucm9w

b25pbi8qYmxvb2Q8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHllYXI+MjAwODwveWVhcj48

L2RhdGVzPjxpc2JuPjE2NjEtNzgxOSAoRWxlY3Ryb25pYykmI3hEOzE2NjEtNzgwMCAoTGlua2lu

Zyk8L2lzYm4+PGFjY2Vzc2lvbi1udW0+MTgwOTcxNTE8L2FjY2Vzc2lvbi1udW0+PHVybHM+PHJl

bGF0ZWQtdXJscz48dXJsPmh0dHA6Ly93d3cubmNiaS5ubG0ubmloLmdvdi9lbnRyZXovcXVlcnku

ZmNnaT9jbWQ9UmV0cmlldmUmYW1wO2RiPVB1Yk1lZCZhbXA7ZG9wdD1DaXRhdGlvbiZhbXA7bGlz

dF91aWRzPTE4MDk3MTUxPC91cmw+PC9yZWxhdGVkLXVybHM+PC91cmxzPjxlbGVjdHJvbmljLXJl

c291cmNlLW51bT4wMDAxMTI1NDAgW3BpaV0mI3hEOzEwLjExNTkvMDAwMTEyNTQwPC9lbGVjdHJv

bmljLXJlc291cmNlLW51bT48bGFuZ3VhZ2U+ZW5nPC9sYW5ndWFnZT48L3JlY29yZD48L0NpdGU+

PENpdGU+PEF1dGhvcj5Cb288L0F1dGhvcj48WWVhcj4yMDA1PC9ZZWFyPjxSZWNOdW0+MTY5PC9S

ZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj4xNjk8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48

a2V5IGFwcD0iRU4iIGRiLWlkPSIwZTV3cHh0dmoydjV4NGV3YXR0dnAyejR3dzA1enplejBzdnYi

PjE2OTwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFydGljbGUi

PjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+Qm9vLCBOLiBZLjwv

YXV0aG9yPjxhdXRob3I+SGFmaWR6LCBILjwvYXV0aG9yPjxhdXRob3I+TmF3YXdpLCBILiBNLjwv

YXV0aG9yPjxhdXRob3I+Q2hlYWgsIEYuIEMuPC9hdXRob3I+PGF1dGhvcj5GYWR6aWwsIFkuIEou

PC9hdXRob3I+PGF1dGhvcj5BYmR1bC1Beml6LCBCLiBCLjwvYXV0aG9yPjxhdXRob3I+SXNtYWls

LCBaLjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48YXV0aC1hZGRyZXNzPkRlcGFy

dG1lbnQgb2YgUGFlZGlhdHJpY3MsIEhvc3BpdGFsIFVuaXZlcnNpdGkgS2ViYW5nc2FhbiBNYWxh

eXNpYSwgS3VhbGEgTHVtcHVyLCBNYWxheXNpYS4gbnlib29AbWFpbC5odWttLnVrbS5teTwvYXV0

aC1hZGRyZXNzPjx0aXRsZXM+PHRpdGxlPkNvbXBhcmlzb24gb2Ygc2VydW0gY2FyZGlhYyB0cm9w

b25pbiBUIGFuZCBjcmVhdGluZSBraW5hc2UgTUIgaXNvZW56eW1lIG1hc3MgY29uY2VudHJhdGlv

bnMgaW4gYXNwaHl4aWF0ZWQgdGVybSBpbmZhbnRzIGR1cmluZyB0aGUgZmlyc3QgNDggaCBvZiBs

aWZlPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPkogUGFlZGlhdHIgQ2hpbGQgSGVhbHRoPC9zZWNv

bmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+SiBQYWVkaWF0ciBD

aGlsZCBIZWFsdGg8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz4zMzEtNzwvcGFnZXM+

PHZvbHVtZT40MTwvdm9sdW1lPjxudW1iZXI+NzwvbnVtYmVyPjxlZGl0aW9uPjIwMDUvMDcvMTU8

L2VkaXRpb24+PGtleXdvcmRzPjxrZXl3b3JkPkFzcGh5eGlhIE5lb25hdG9ydW0vKmJsb29kL2Vu

enltb2xvZ3k8L2tleXdvcmQ+PGtleXdvcmQ+Q3JlYXRpbmUgS2luYXNlLypibG9vZDwva2V5d29y

ZD48a2V5d29yZD5DcmVhdGluZSBLaW5hc2UsIE1CIEZvcm08L2tleXdvcmQ+PGtleXdvcmQ+RmVt

YWxlPC9rZXl3b3JkPjxrZXl3b3JkPkh1bWFuczwva2V5d29yZD48a2V5d29yZD5JbmZhbnQsIE5l

d2Jvcm48L2tleXdvcmQ+PGtleXdvcmQ+SXNvZW56eW1lcy9ibG9vZDwva2V5d29yZD48a2V5d29y

ZD5NYWxheXNpYTwva2V5d29yZD48a2V5d29yZD5NYWxlPC9rZXl3b3JkPjxrZXl3b3JkPlByb3Nw

ZWN0aXZlIFN0dWRpZXM8L2tleXdvcmQ+PGtleXdvcmQ+VHJvcG9uaW4gVC8qYmxvb2Q8L2tleXdv

cmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHllYXI+MjAwNTwveWVhcj48cHViLWRhdGVzPjxkYXRlPkp1

bDwvZGF0ZT48L3B1Yi1kYXRlcz48L2RhdGVzPjxpc2JuPjEwMzQtNDgxMCAoUHJpbnQpJiN4RDsx

MDM0LTQ4MTAgKExpbmtpbmcpPC9pc2JuPjxhY2Nlc3Npb24tbnVtPjE2MDE0MTM2PC9hY2Nlc3Np

b24tbnVtPjx1cmxzPjxyZWxhdGVkLXVybHM+PHVybD5odHRwOi8vd3d3Lm5jYmkubmxtLm5paC5n

b3YvZW50cmV6L3F1ZXJ5LmZjZ2k/Y21kPVJldHJpZXZlJmFtcDtkYj1QdWJNZWQmYW1wO2RvcHQ9

Q2l0YXRpb24mYW1wO2xpc3RfdWlkcz0xNjAxNDEzNjwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJs

cz48ZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+SlBDNjI2IFtwaWldJiN4RDsxMC4xMTExL2ouMTQ0

MC0xNzU0LjIwMDUuMDA2MjYueDwvZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+PGxhbmd1YWdlPmVu

ZzwvbGFuZ3VhZ2U+PC9yZWNvcmQ+PC9DaXRlPjwvRW5kTm90ZT4AAAAA

ADDIN EN.CITE.DATA (11-14). Recommendations:1. If performed at your center and clinically indicated, obtain an ECG and Echocardiogram if cTnT or cTNI is ≥ 0.1ng/ml to evaluate myocardial ischemia and cardiac function.As stated above, Cardiac Troponin T or Troponin I may also be predictive of outcome and may aid the bedside clinician with additional prognostic information. Level of Evidence: IIC- based on outcome data and case-controlled studies. VI. How should bradycardia associated with hypothermia be managed? Relative bradycardia (70-100 bpm) is not an uncommon occurrence in infants undergoing hypothermia. However, pathologic bradycardia can be a result of cardiac dysfunction, arrhythmias, deep hypothermia and increased intracranial pressure. Clinical intervention should be initiated when bradycardia is associated with evidence of decreased cardiac output, electrolyte abnormalities, elevated cardiac enzymes, and/or ECG abnormalities. Recommendations:1. If heart rate is <70bpm with evidence of reduced cardiac output (worsening metabolic acidosis, ↑lactic acid, prolonged capillary refill time, diminished pulses, low or borderline low MAP) obtain electrolytes including ionized calcium, ECG, echocardiogram, and ensure core temperature is appropriate.2. If heart rate is <70bpm but >60bpm without evidence of reduced cardiac output, normal electrolytes, normal ECG and echocardiogram then close clinical observation is a reasonable approach.3. The bedside clinician may consider decreasing sedation or rewarming by 0.50C to see if the HR increases if below 60 or below 70 with evidence of reduced cardiac output. Level of Evidence: V- Expert opinion based on current review of literature.VII. References: ADDIN EN.REFLIST 1. Volpe J. Neurology of the Newborn. Fifth ed. Philadelphia: Saunders; 2008.2. Kimelberg HK. Current concepts of brain edema. Review of laboratory investigations. J Neurosurg 1995;83(6):1051-9.3. Hunt R, Osborn D. Dopamine for prevention of morbidity and mortality in term newborn infants with suspected perinatal asphyxia. Cochrane Database Syst Rev 2002(3):CD003484.4. Cheung PY, Barrington KJ. The effects of dopamine and epinephrine on hemodynamics and oxygen metabolism in hypoxic anesthetized piglets. Crit Care 2001;5(3):158-66.5. Cheung PY, Barrington KJ, Bigam D. The hemodynamic effects of dobutamine infusion in the chronically instrumented newborn piglet. Crit Care Med 1999;27(3):558-64.6. McNamara PJ, Laique F, Muang-In S, Whyte HE. Milrinone improves oxygenation in neonates with severe persistent pulmonary hypertension of the newborn. J Crit Care 2006;21(2):217-22.7. Bassler D, Choong K, McNamara P, Kirpalani H. Neonatal persistent pulmonary hypertension treated with milrinone: four case reports. Biol Neonate 2006;89(1):1-5.8. Battin MR, Thoresen M, Robinson E, Polin RA, Edwards AD, Gunn AJ. Does head cooling with mild systemic hypothermia affect requirement for blood pressure support? Pediatrics 2009;123(3):1031-6.9. Shankaran S, Laptook AR, Ehrenkranz RA, Tyson JE, McDonald SA, Donovan EF, et al. Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy. N Engl J Med 2005;353(15):1574-84.10. Azzopardi DV, Strohm B, Edwards AD, Dyet L, Halliday HL, Juszczak E, et al. Moderate hypothermia to treat perinatal asphyxial encephalopathy. N Engl J Med 2009;361(14):1349-58.11. Gunes T, Ozturk MA, Koklu SM, Narin N, Koklu E. Troponin-T levels in perinatally asphyxiated infants during the first 15 days of life. Acta Paediatr 2005;94(11):1638-43.12. Boo NY, Hafidz H, Nawawi HM, Cheah FC, Fadzil YJ, Abdul-Aziz BB, et al. Comparison of serum cardiac troponin T and creatine kinase MB isoenzyme mass concentrations in asphyxiated term infants during the first 48 h of life. J Paediatr Child Health 2005;41(7):331-7.13. El-Khuffash AF, Molloy EJ. Serum troponin in neonatal intensive care. Neonatology 2008;94(1):1-7.14. Matter M, Abdel-Hady H, Attia G, Hafez M, Seliem W, Al-Arman M. Myocardial performance in asphyxiated full-term infants assessed by Doppler tissue imaging. Pediatr Cardiol;31(5):634-42.V. Neurologic and Seizure ManagementSection ContentsWhat medications should be used for analgesia during hypothermia?When and how should infants be monitored for seizures?How should seizures be managed in neonates with HIE?What is the optimal time for neuroimaging in neonates with HIE?ReferencesI. What medications should be used for analgesia during hypothermia?Though optimal therapy for sedation in neonates is a highly debated topic, neonates being cooled do demonstrate agitation and irritability in response to cooling. Studies of animal models of global hypoxic insults demonstrate that unsedated piglets subjected to hypothermia post hypoxic injury do not benefit from total body cooling and have grossly elevated cortisol levels, shivering, and generally increased motor activity that is postulated to diminish and even counteract the neuroprotective benefits of total body hypothermia (12). Due to known suppression of the cytochrome P450 pathway due to cooling as well as the risk for polypharmacy and drug interactions in acutely ill neonates, care must be taken in choosing a medication for analgesia (13).Recommendations:Begin an opiate or dexmedetomidine upon initiation of cooling. The recommended starting doses are: Morphine infusion of 5 mcg/kg/hr or an intermittent dose of 40 to 50 mcg/kg/dose IV every 6 hours, Fentanyl 0.5 mcg/k/hour and dexmedetomidine 0.3 mcg/k/hour [1].May consider titrating based on the neurologic exam and NPASS score with weaning if the neonate appears overly sedate. If any value is below 0, wean the sedation.If NPASS score is between 0-3, consider weaningIf the score is 3 or higher, increase the dose to decrease the scoresNPASS scores should be checked every 3 hoursStop unnecessary analgesia and sedation after warming has occurred. If opiate or dexmedetomidine at low dosages does not provide adequate analgesia, the dose can be gradually increased as well as having other medications may be added. The goal should be continuous and adequate analgesia and anxiolysis to prevent excessive irritability and agitation and not an attempt to maintain the infant on mechanical ventilation, unless clinically indicated.The clinician may consider obtaining a serum cortisol to assess the degree of stress. The cortisol along with the heart rate may aid the clinician with the management of sedation. Level of Evidence: V Expert opinion based on current review of the literature and animal models.II. When and how should infants be monitored for seizures?Multiple studies have shown the benefit of continuous EEG monitoring of neonates with HIE. Besides being a very useful early predictor of neurologic outcomes(1,2), studies have shown that aggressive treatment of seizures decreases neurologic sequlae (3). Due to the large amount of resources consumed by continuous EEG monitoring, amplitude integrated EEG has been used extensively for neonates with HIE for monitoring. The ease of application and interpretation of aEEG makes it especially useful in continuous monitoring.Recommendations:Upon admission to the NICU, neonates suspected of having HIE should have an aEEG placed (see #3).Monitoring duration via aEEG should optimally occur during the entire systemic hypothermia process, including warming.If video EEG is used for continuous monitoring instead of aEEG, someone at the bedside of the patient should be trained in interpretation of the EEG or the aEEG feature on the video EEG should be monitored by the bedside personnel.If aEEG demonstrates seizure activity and/or an abnormal background pattern, it is recommended to obtain formal EEG evaluation and continuously monitor for electrographic seizures until warming has occurred and seizures are under control (2).Level of Evidence: IIC based on outcome data and case control studiesIII. How should seizures be managed in neonates with HIE?HIE is the number one cause of neonatal seizures. Despite the high incidence of seizures in this population of neonates, a Cochrane review did not find benefit in morbidity and mortality with routine use of prophylactic anti-epileptic medications (4).Though there is no evidence to support routine prophylaxis, studies have shown a definite benefit to aggressive therapy of seizures: clinical or electrographic. FDA approved management for seizures in neonates is limited to Phenobarbital and Fosphenytoin. Studies have not demonstrated a benefit of Phenobarbital over Fosphenytoin (5). Recent randomized control studies have demonstrated that Keppra is a safe and effective therapy in neonatal seizures with vastly better pharmacokinetics and side effect profile than Phenobarbital and Fosphenytoin (6,7,8). Some studies have also demonstrated a potential neuroprotective benefit of Keppra and neurotoxic side effects associated with Phenobarbital and Fosphenytoin (9).Recommendations:Any electrographic or clinical evidence of seizures should be aggressively treated with appropriate anti-epileptic therapy and close monitoring for recurrence as over 50% of seizures from HIE will require more than one medication for treatment.Initial treatment may be with either an intravenous benzodiazepine or IV Phenobarbital at 20 mg/kg.Maintenance treatment may be started if neonates continue to have seizure activity. If maintenance is started, recheck in one week to reassess if AED can be discontinued.VI. What is the optimal time for neuroimaging in neonates with HIE?Appropriate neuroimaging is an important part of evaluating the etiology of HIE and predicting long term neurodevelopemental outcomes. Magnetic Resonance Imaging with diffusion weighted images and spectroscopy of the basal ganglia is the imaging study of choice (10). Elevated lactate peaks and low N-acetylaspartate levels in the basal ganglia are associated with poor neurodevelopemental outcomes (10, 11). Deep gray matter injuries including basal ganglia injuries and thalamic injury can indicate acute injury while injuries in the watershed areas can indicate prolonged partial hypoxia (5).Recommendations:Head ultrasound should be acquired on admission.MRI with diffusion weighted images and spectroscopy of the basal ganglia is the preferred study.Suggested MRI imaging can be performed at 4-5 days of life and again at 7-14 days. If only one MRI can be performed, it should occur during the 7-14 day period. These recommendations may need to be adjusted in critically ill neonates who will be compromised in obtaining the MRI.Level of Evidence: IA randomized control trials.V. References ADDIN EN.REFLIST 1.O'Mara, K. and M.D. Weiss, Dexmedetomidine for Sedation of Neonates with HIE Undergoing Therapeutic Hypothermia: A Single-Center Experience. AJP Rep, 2018. 8(3): p. e168-e173.2.Pressler, R.M., et al., Early serial EEG in hypoxic ischaemic encephalopathy. Clin Neurophysiol, 2001. 112(1): p. 31-7.3.de Vries, L.S. and M.C. Toet, Amplitude integrated electroencephalography in the full-term newborn. Clin Perinatol, 2006. 33(3): p. 619-32, vi.4.van Rooij, L.G., et al., Effect of treatment of subclinical neonatal seizures detected with aEEG: randomized, controlled trial. Pediatrics, 2010. 125(2): p. e358-66.5.Evans, D.J., M.I. Levene, and M. Tsakmakis, Anticonvulsants for preventing mortality and morbidity in full term newborns with perinatal asphyxia. Cochrane Database Syst Rev, 2007(3): p. CD001240.6.Glass, H.C. and D.M. Ferriero, Treatment of hypoxic-ischemic encephalopathy in newborns. Curr Treat Options Neurol, 2007. 9(6): p. 414-23.7.Abend, N.S., et al., Levetiracetam for treatment of neonatal seizures. J Child Neurol, 2011. 26(4): p. 465-70.8.Khan, O., et al., Use of intravenous levetiracetam for management of acute seizures in neonates. Pediatr Neurol, 2011. 44(4): p. 265-9.9.Ramantani, G., et al., Levetiracetam: safety and efficacy in neonatal seizures. Eur J Paediatr Neurol, 2011. 15(1): p. 1-7.10.Cilio, M.R. and D.M. Ferriero, Synergistic neuroprotective therapies with hypothermia. Semin Fetal Neonatal Med. 15(5): p. 293-8.11.Boichot, C., et al., Term neonate prognoses after perinatal asphyxia: contributions of MR imaging, MR spectroscopy, relaxation times, and apparent diffusion coefficients. Radiology, 2006. 239(3): p. 839-48.12.Barkovich, A.J., et al., MR imaging, MR spectroscopy, and diffusion tensor imaging of sequential studies in neonates with encephalopathy. AJNR Am J Neuroradiol, 2006. 27(3): p. 533-47. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download