- Author: Santina A Zanelli, MD; Chief Editor: Ted Rosenkrantz, MD more...
Perinatal asphyxia, more appropriately known as hypoxic-ischemic encephalopathy (HIE), is characterized by clinical and laboratory evidence of acute or subacute brain injury due to asphyxia. The primary causes of this condition are systemic hypoxemia and/or reduced cerebral blood flow (CBF) (see the image below). Birth asphyxia causes 840,000 or 23% of all neonatal deaths worldwide.[1, 2, 3]
Signs and symptoms
Mild hypoxic-ischemic encephalopathy
Muscle tone may be slightly increased and deep tendon reflexes may be brisk during the first few days
Transient behavioral abnormalities, such as poor feeding, irritability, or excessive crying or sleepiness (typically in an alternating pattern), may be observed
Typically resolves in 24h
Moderately severe hypoxic-ischemic encephalopathy
The infant is lethargic, with significant hypotonia and diminished deep tendon reflexes
The grasping, Moro, and sucking reflexes may be sluggish or absent
The infant may experience occasional periods of apnea
Seizures typically occur early within the first 24 hours after birth
Full recovery within 1-2 weeks is possible and is associated with a better long-term outcome
Severe hypoxic-ischemic encephalopathy
Seizures can be delayed and severe and may be initially resistant to conventional treatments. The seizures are usually generalized, and their frequency may increase during the 24-48 hours after onset, correlating with the phase of reperfusion injury.
As the injury progresses, seizures subside and the electroencephalogram becomes isoelectric or shows a burst suppression pattern. At that time, wakefulness may deteriorate further, and the fontanelle may bulge, suggesting increasing cerebral edema. Other symptoms include the following:
Stupor or coma is typical; the infant may not respond to any physical stimulus except the most noxious.
Breathing may be irregular, and the infant often requires ventilatory support
Generalized hypotonia and depressed deep tendon reflexes are common
Neonatal reflexes (eg, sucking, swallowing, grasping, Moro) are absent
Disturbances of ocular motion, such as a skewed deviation of the eyes, nystagmus, bobbing, and loss of "doll's eye" (ie, conjugate) movements may be revealed by cranial nerve examination
Pupils may be dilated, fixed, or poorly reactive to light
Irregularities of heart rate and blood pressure are common during the period of reperfusion injury, as is death from cardiorespiratory failure
An initial period of well-being or mild hypoxic-ischemic encephalopathy may be followed by sudden deterioration, suggesting ongoing brain cell dysfunction, injury, and death; during this period, seizure intensity may increase.
See Clinical Presentation for more detail.
Guidelines from the American Academy of Pediatrics (AAP) and the American College of Obstetrics and Gynecology (ACOG) for hypoxic-ischemic encephalopathy indicate that all of the following must be present for the designation of perinatal asphyxia severe enough to result in acute neurologic injury:
Profound metabolic or mixed acidemia (pH < 7) in an umbilical artery blood sample, if obtained
Persistence of an Apgar score of 0-3 for longer than 5 minutes
Neonatal neurologic sequelae (eg, seizures, coma, hypotonia)
Multiple organ involvement (eg, kidney, lungs, liver, heart, intestines)
Serum electrolyte levels
Renal function studies
Cardiac and liver enzymes - These values are an adjunct to assess the degree of hypoxic-ischemic injury to the heart and liver
Coagulation system - Includes prothrombin time, partial thromboplastin time, and fibrinogen levels
Arterial blood gas - Blood gas monitoring is used to assess acid-base status and to avoid hyperoxia and hypoxia, as well as hypercapnia and hypocapnia
Magnetic resonance imaging (MRI) of the brain
Electroencephalography (EEG) - Standard and amplitude-integrated EEG
Hearing test - An increased incidence of deafness has been found among infants with hypoxic-ischemic encephalopathy who require assisted ventilation
Retinal and ophthalmic examination
See Workup for more detail.
Following initial resuscitation and stabilization, treatment of hypoxic-ischemic encephalopathy is largely supportive and should focus on the following[4, 5] :
Perfusion and blood pressure management - Studies indicate that a mean blood pressure (BP) above 35-40 mm Hg is necessary to avoid decreased cerebral perfusion
Careful fluid management
Avoidance of hypoglycemia and hyperglycemia
Avoidance of hyperthermia - Hyperthermia has been shown to be associated with increased risk of adverse outcomes in neonates with moderate to severe hypoxic-ischemic encephalopathy 
Treatment of seizures
Hypothermia therapy (33-33.5C for 72h) followed by slow and controlled rewarming for infants with moderate to severe HIE
Despite major advances in monitoring technology and knowledge of fetal and neonatal pathologies, perinatal asphyxia or, more appropriately, hypoxic-ischemic encephalopathy (HIE), remains a serious condition that causes significant mortality and long-term morbidity.
Hypoxic-ischemic encephalopathy is characterized by clinical and laboratory evidence of acute or subacute brain injury due to asphyxia (ie, hypoxia, acidosis). Most often, the exact timing and underlying cause remain unknown.
The American Academy of Pediatrics (AAP) and American College of Obstetrics and Gynecology (ACOG) published guidelines to assist in the diagnosis of severe hypoxic-ischemic encephalopathy (see History).[7, 8]
Brain hypoxia and ischemia due to systemic hypoxemia, reduced cerebral blood flow (CBF), or both are the primary physiological processes that lead to hypoxic-ischemic encephalopathy.[1, 2, 3]
The initial compensatory adjustment to an asphyxial event is an increase in CBF due to hypoxia and hypercapnia. This is accompanied by a redistribution of cardiac output to essential organs, including the brain, heart, and adrenal glands. A blood pressure (BP) increase due to increased release of epinephrine further enhances this compensatory response. See the image below.
In adults, CBF is maintained at a constant level despite a wide range in systemic BP. This phenomenon is known as the cerebral autoregulation, which helps maintain cerebral perfusion. The physiological aspects of CBF autoregulation has been well studied in perinatal and adult experimental animals. In human adults, the BP range at which CBF is maintained is 60-100 mm Hg.
Limited data in the human fetus and the newborn infant suggest that CBF is stable over much narrower range of BPs.[9, 10] Some experts have postulated that, in the healthy term newborn, the BP range at which the CBF autoregulation is maintained may be only between 10-20 mm Hg (compared with the 40 mm Hg range in adults noted above). In addition, the autoregulatory zone may also be set at a lower level, about the midpoint of the normal BP range for the fetus and newborn. However, the precise upper and lower limits of the BP values above and below which the CBF autoregulation is lost remain unknown for the human newborn.
In the fetus and newborn suffering from acute asphyxia, after the early compensatory adjustments fail, the CBF can become pressure-passive, at which time brain perfusion depends on systemic BP. As BP falls, CBF falls below critical levels, and the brain injury secondary to diminished blood supply and a lack of sufficient oxygen occurs. This leads to intracellular energy failure. During the early phases of brain injury, brain temperature drops, and local release of neurotransmitters, such as gamma-aminobutyric acid transaminase (GABA), increase. These changes reduce cerebral oxygen demand, transiently minimizing the impact of asphyxia.
At the cellular level, neuronal injury in hypoxic-ischemic encephalopathy is an evolving process. The magnitude of the final neuronal damage depends on duration and severity of the initial insult combined to the effects of reperfusion injury, and apoptosis. At the biochemical level, a large cascade of events follow hypoxic-ischemic encephalopathy injury.
Excitatory amino acid (EAA) receptor overactivation plays a critical role in the pathogenesis of neonatal hypoxia-ischemia. During cerebral hypoxia-ischemia, the uptake of glutamate the major excitatory neurotransmitter of the mammalian brain is impaired. This results in high synaptic levels of glutamate and EAA receptor overactivation, including N-methyl-D-aspartate (NMDA), amino-3-hydroxy-5-methyl-4 isoxazole propionate (AMPA), and kainate receptors. NMDA receptors are permeable to Ca++ and Na+, whereas AMPA and kainate receptors are permeable to Na+. Accumulation of Na+ coupled with the failure of energy dependent enzymes such as Na+/ K+ -ATPase leads to rapid cytotoxic edema and necrotic cell death. Activation of NMDA receptor leads to intracellular Ca++ accumulation and further pathologic cascades activation.
EAAs accumulation also contributes to increasing the pace and extent of programmed cell death through secondary Ca++ intake into the nucleus. The pattern of injury seen after hypoxia-ischemia demonstrate regional susceptibility that can be largely explained by the excitatory circuity at this age (putamen, thalamus, perirolandic cerebral cortex). Finally, developing oligodendroglia is uniquely susceptible to hypoxia-ischemia, specifically excitotoxicity and free radical damage. This white matter injury may be the basis for the disruption of long-term learning and memory faculties in infants with hypoxic-ischemic encephalopathy.
Intracellular Ca++ concentration increases following hypoxia-ischemia as a result of (1) NMDA receptor activation, (2) release of Ca++ from intracellular stores (mitochondria and endoplasmic reticulum [ER]), and (3) failure of Ca++ efflux mechanisms. Consequences of increases intracellular Ca++ concentration include activation of phospholipases, endonucleases, proteases, and, in select neurons, nitric oxide synthase (NOS). Activation of phospholipase A2 leads to release of Ca++ from the ER via activation of phospholipase C. Activation of proteases and endonucleases results in cytoskeletal and DNA damage.
During the reperfusion period, free radical production increases due to activation of enzymes such as cyclooxygenase, xanthine oxidase, and lipoxygenase. Free radical damage is further exacerbated in the neonate because of immature antioxidant defenses. Free radicals can lead to lipid peroxidation as well as DNA and protein damage and can trigger apoptosis. Finally, free radicals can combine with nitric oxide (NO) to form peroxynitrite a highly toxic oxidant.
NMDA receptor activation results in activation of neuronal NOS vias PSD-95 and results in the early and transient rise in NO concentration observed in the initial phase of hypoxia. Inducible NOS is expressed in response to the marked inflammation secondary to cerebral ischemia and results in a second wave of NO overproduction that can be prolonged for up to 4-7 days after the insult.
This excessive NO production plays an important role in the pathophysiology of perinatal hypoxic-ischemic brain injury. NO neurotoxicity depends in large part on rapid reaction with superoxide to form peroxynitrite. This, in turn, leads to peroxynitrite-induced neurotoxicity, including lipid peroxidation, protein nitration and oxidation, mitochondrial damage and remodeling, depletion of antioxidant reserve, and DNA damage.
Inflammatory mediators (cytokines and chemokines) have been implicated in the pathogenesis of hypoxic-ischemic encephalopathy and may represent a final common pathway of brain injury. Animal studies suggest that cytokines, particularly interleukin (IL)-1b contributes to hypoxic-ischemic damage. The exact mechanisms and which inflammatory mediators are involved in this process remains unclear.
Following the initial phase of energy failure from the asphyxial injury, cerebral metabolism may recover following reperfusion, only to deteriorate in a secondary energy failure phase. This new phase of neuronal damage, starting at about 6-24 hours after the initial injury, is characterized by mitochondrial dysfunction, and initiation of the apoptotic cascade. This phase has been called the "delayed phase of neuronal injury."
The duration of the delayed phase is not precisely known in the human fetus and newborn but appears to increase over the first 24-48 hours and then start to resolve thereafter. In the human infant, the duration of this phase is correlated with adverse neurodevelopmental outcomes at 1 year and 4 years after insult. See the image below.
Additional factors that influence outcome include the nutritional status of the brain, severe intrauterine growth restriction, preexisting brain pathology or developmental defects of the brain, and the frequency and severity of seizure disorder that manifests at an early postnatal age (within hours of birth).[13, 14, 15, 16, 17, 18]
In the United States and in most technologically advanced countries, the incidence of hypoxic-ischemic encephalopathy is 1-4 cases per 1000 births.
The incidence of hypoxic-ischemic encephalopathy is reportedly high in countries with limited resources; however, precise figures are not available. Birth asphyxia is the cause of 23% of all neonatal deaths worldwide. It is one of the top 20 leading causes of burden of disease in all age groups (in terms of disability life adjusted years) by the World Health Organization and is the fifth largest cause of death of children younger than 5 years (8%). Although data are limited, birth asphyxia is estimated to account for 920,000 neonatal deaths every year and is associated with another 1.1 million intrapartum stillbirths. More than a million children who survive birth asphyxia develop problems such as cerebral palsy, mental retardation, learning difficulties, and other disabilities.[19, 20]
Accurate prediction of the severity of long-term complications is difficult, although clinical, laboratory, and imaging criteria have been used. The following criteria have been shown to be the most helpful in outlining likely outcomes:
Lack of spontaneous respiratory effort within 20-30 minutes of birth is almost always associated with death.
The presence of seizures is an ominous sign. The risk of poor neurological outcome is distinctly greater in such infants, particularly if seizures occur frequently and are difficult to control.
Abnormal clinical neurological findings persisting beyond the first 7-10 days of life usually indicate poor prognosis. Among these, abnormalities of muscle tone and posture (hypotonia, rigidity, weakness) should be carefully noted.
EEG at about 7 days that reveals normal background activity is a good prognostic sign.
Persistent feeding difficulties, which generally are due to abnormal tone of the muscles of sucking and swallowing, also suggest significant CNS damage.
Poor head growth during the postnatal period and the first year of life is a sensitive finding predicting higher frequency of neurologic deficits.
Of note, the use of hypothermia therapy changes the prognostic value of clinical evaluation in infants with hypoxic-ischemic encephalopathy and its impact on predicting outcomes is still under evaluation.
Other early predictors of long-term neurodevelopmental outcomes are being actively investigated. Early evidence indicates that biomarkers such as serum S100B and neuron-specific enolase may be helpful in identifying infants with severe brain injury who may be candidates for novel neuroprotective or neuroregenerative therapies.
In severe hypoxic-ischemic encephalopathy, the mortality rate is reportedly 25-50%. Most deaths occur in the first week of life due to multiple organ failure or redirection of care. Some infants with severe neurologic disabilities die in their infancy from aspiration pneumonia or systemic infections.
The incidence of long-term complications depends on the severity of hypoxic-ischemic encephalopathy. As many as 80% of infants who survive severe hypoxic-ischemic encephalopathy develop serious complications, 10-20% develop moderately serious disabilities, and as many as 10% are healthy. Among the infants who survive moderately severe hypoxic-ischemic encephalopathy, 30-50% may have serious long-term complications, and 10-20% have minor neurological morbidities. Infants with mild hypoxic-ischemic encephalopathy tend to be free from serious CNS complications.
Two recent hypothermia trials provided updated information on mortality and the incidence of abnormal neurodevelopmental outcomes infants with moderate to severe hypoxic-ischemic encephalopathy.[24, 25] In these trials, 23-27% of infants died prior to discharge from the neonatal ICU (NICU), whereas the mortality rate at follow-up 18-22 months later was 37-38%. In these trials, neurodevelopmental outcomes at 18 months were as follows:
Mental development index (MDI): Scores of 85 or higher, 40%; 70-84, 21%; less than 70, 39%
Psychomotor development index (PDI): Scores of 85 or higher, 55%; 70-84, 10%; less than 70, 35-41%
Disabling cerebral palsy - 30%
Epilepsy - 16%
Blindness - 14-17%
Severe hearing impairment - 6%
Data from a randomized controlled trial was evaluated to determine the relationship between hypocarbia and the outcome for neonatal patients with hypoxic-ischemic encephalopathy. The results found that a poor outcome (death/disability at 18-22 mo) was associated with a minimum partial pressure of carbon dioxide (PCO2) and cumulative PCO2 of less than 35 mm Hg; death and disability increased with greater exposure to PCO2 of less than 35 mm Hg.
Even in the absence of obvious neurologic deficits in the newborn period, long-term functional impairments may be present. In a cohort of school-aged children with a history of moderately severe hypoxic-ischemic encephalopathy, 15-20% had significant learning difficulties, even in the absence of obvious signs of brain injury. Thus, all children who have moderate or severe hypoxic-ischemic encephalopathy should be monitored well into school age.[27, 28, 29]
No predilection is noted.
No predilection is observed.
By definition, this disease is seen in the newborn period. Preterm infants can also suffer from hypoxic-ischemic encephalopathy, but the pathology and clinical manifestations are different. Most often, the condition is noted in infants who are term at birth. The symptoms of moderate-to-severe hypoxic-ischemic encephalopathy are almost always manifested at birth or within a few hours after birth.
Ferriero DM. Neonatal brain injury. N Engl J Med. 2004 Nov 4. 351(19):1985-95. [Medline].
Perlman JM. Brain injury in the term infant. Semin Perinatol. 2004 Dec. 28(6):415-24. [Medline].
Grow J, Barks JD. Pathogenesis of hypoxic-ischemic cerebral injury in the term infant: current concepts. Clin Perinatol. 2002 Dec. 29(4):585-602, v. [Medline].
Shankaran S. The postnatal management of the asphyxiated term infant. Clin Perinatol. 2002 Dec. 29(4):675-92. [Medline].
Stola A, Perlman J. Post-resuscitation strategies to avoid ongoing injury following intrapartum hypoxia-ischemia. Semin Fetal Neonatal Med. 2008 Dec. 13(6):424-31. [Medline].
[Guideline] American Academy of Pediatrics. Relation between perinatal factors and neurological outcome. In: Guidelines for Perinatal Care. 3rd ed. Elk Grove Village, Ill: American Academy of Pediatrics; 1992:221-234.
[Guideline] Committee on fetus and newborn, American Academy of Pediatrics and Committee on obstetric practice, American College of Obstetrics and Gynecology. Use and abuse of the APGAR score. Pediatr. 1996. 98:141-142. [Medline].
Papile LA, Rudolph AM, Heymann MA. Autoregulation of cerebral blood flow in the preterm fetal lamb. Pediatr Res. 1985 Feb. 19(2):159-61. [Medline].
Rosenkrantz TS, Diana D, Munson J. Regulation of cerebral blood flow velocity in nonasphyxiated, very low birth weight infants with hyaline membrane disease. J Perinatol. 1988. 8(4):303-8. [Medline].
Pacher P, Beckman JS, Liaudet L. Nitric oxide and peroxynitrite in health and disease. Physiol Rev. 2007 Jan. 87(1):315-424. [Medline].
Roth SC, Baudin J, Cady E, Johal K, Townsend JP, Wyatt JS. Relation of deranged neonatal cerebral oxidative metabolism with neurodevelopmental outcome and head circumference at 4 years. Dev Med Child Neurol. 1997 Nov. 39(11):718-25. [Medline].
Berger R, Garnier Y. Pathophysiology of perinatal brain damage. Brain Res Brain Res Rev. 1999 Aug. 30(2):107-34. [Medline].
Rivkin MJ. Hypoxic-ischemic brain injury in the term newborn. Neuropathology, clinical aspects, and neuroimaging. Clin Perinatol. 1997 Sep. 24(3):607-25. [Medline].
Vannucci RC. Mechanisms of perinatal hypoxic-ischemic brain damage. Semin Perinatol. 1993 Oct. 17(5):330-7. [Medline].
Vannucci RC, Yager JY, Vannucci SJ. Cerebral glucose and energy utilization during the evolution of hypoxic-ischemic brain damage in the immature rat. J Cereb Blood Flow Metab. 1994 Mar. 14(2):279-88. [Medline].
de Haan HH, Hasaart TH. Neuronal death after perinatal asphyxia. Eur J Obstet Gynecol Reprod Biol. 1995 Aug. 61(2):123-7. [Medline].
McLean C, Ferriero D. Mechanisms of hypoxic-ischemic injury in the term infant. Semin Perinatol. 2004 Dec. 28(6):425-32. [Medline].
Bryce J, Boschi-Pinto C, Shibuya K, Black RE. WHO estimates of the causes of death in children. Lancet. 2005 Mar 26-Apr 1. 365(9465):1147-52. [Medline].
Lawn J, Shibuya K, Stein C. No cry at birth: global estimates of intrapartum stillbirths and intrapartum-related neonatal deaths. Bull World Health Organ. 2005 Jun. 83(6):409-17. [Medline]. [Full Text].
Patel J, Edwards AD. Prediction of outcome after perinatal asphyxia. Curr Opin Pediatr. 1997 Apr. 9(2):128-32. [Medline].
Gunn AJ, Wyatt JS, Whitelaw A, et al. Therapeutic hypothermia changes the prognostic value of clinical evaluation of neonatal encephalopathy. J Pediatr. 2008 Jan. 152(1):55-8, 58.e1. [Medline].
Massaro AN, Chang T, Kadom N, Tsuchida T, Scafidi J, Glass P, et al. Biomarkers of Brain Injury in Neonatal Encephalopathy Treated with Hypothermia. J Pediatr. 2012 Apr 10. [Medline].
Gluckman PD, Wyatt JS, Azzopardi D, et al. Selective head cooling with mild systemic hypothermia after neonatal encephalopathy: multicenter randomised trial. Lancet. 2005. 365:663-70. [Medline].
Shankaran S, Laptook AR, Ehrenkranz RA, et al. Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy. N Engl J Med. 2005 Oct 13. 353(15):1574-84. [Medline].
Pappas A, Shankaran S, Laptook AR, et al. Hypocarbia and adverse outcome in neonatal hypoxic-ischemic encephalopathy. J Pediatr. 2011 May. 158(5):752-758.e1. [Medline].
van Handel M, Swaab H, de Vries LS, Jongmans MJ. Long-term cognitive and behavioral consequences of neonatal encephalopathy following perinatal asphyxia: a review. Eur J Pediatr. 2007 Jul. 166(7):645-54. [Medline].
Pin TW, Eldridge B, Galea MP. A review of developmental outcomes of term infants with post-asphyxia neonatal encephalopathy. Eur J Paediatr Neurol. 2009 May. 13(3):224-34. [Medline].
Simon NP. Long-term neurodevelopmental outcome of asphyxiated newborns. Clin Perinatol. 1999 Sep. 26(3):767-78. [Medline].
Martin-Ancel A, Garcia-Alix A, Gaya F, Cabanas F, Burgueros M, Quero J. Multiple organ involvement in perinatal asphyxia. J Pediatr. 1995. 127:786-793. [Medline].
Shah P, Riphagen S, Beyene J, Perlman M. Multiorgan dysfunction in infants with post-asphyxial hypoxic-ischaemic encephalopathy. Arch Dis Child Fetal Neonatal Ed. 2004. 89:F152-F155. [Medline].
Mizrahi EM, Kellaway P. Characterization and classification of neonatal seizures. Neurology. 1987 Dec. 37(12):1837-44. [Medline].
Hahn JS, Olson DM. Etiology of Neonatal Seizures. NeoReviews. 2004. 5(8):e327.
Sarnat HB, Sarnat MS. Neonatal encephalopathy following fetal distress: A clinical and electroencphalographic study. Archives of Neur. 1976. 33:696-705.
Badawi N, Kurinczuk JJ, Keogh JM, et al. Antepartum risk factors for newborn encephalopathy: the Western Australian case-control study. British Medical Journal. 1998. 317:1549-1553. [Medline].
Graham EM, Ruis KA, Hartman AL, Northington FJ, Fox HE. A systematic review of the role of intrapartum hypoxia-ischemia in the causation of neonatal encephalopathy. Am J Obstet Gynecol. 2008 Dec. 199(6):587-95. [Medline].
Enns, GM. Inborn errors of metabolism masquerading as hypoxic-ischemic encephalopathy. Neoreviews. 2005. 6:e549-e558.
Hobson EE, Thomas S, Crofton PM, Murray AD, Dean JC, Lloyd D. Isolated sulphite oxidase deficiency mimics the features of hypoxic ischaemic encephalopathy. Eur J Pediatr. 2005 Nov. 164(11):655-9. [Medline].
Shastri AT, Samarasekara S, Muniraman H, Clarke P. Cardiac troponin I concentrations in neonates with hypoxic-ischaemic encephalopathy. Acta Paediatr. 2012 Jan. 101(1):26-9. [Medline].
Huang BY, Castillo M. Hypoxic-ischemic brain injury: imaging findings from birth to adulthood. Radiographics. 2008 Mar-Apr. 28(2):417-39; quiz 617. [Medline].
Latchaw RE, Truwit CE. Imaging of perinatal hypoxic-ischemic brain injury. Semin Pediatr Neurol. 1995 Mar. 2(1):72-89. [Medline].
Rutherford M, Pennock J, Schwieso J, Cowan F, Dubowitz L. Hypoxic-ischaemic encephalopathy: early and late magnetic resonance imaging findings in relation to outcome. Arch Dis Child Fetal Neonatal Ed. 1996. 75:F145-F151. [Medline].
Rutherford M, Biarge MM, Allsop J, Counsell S, Cowan F. MRI of perinatal brain injury. Pediatr Radiol. 2010. 40(6):819-33. [Medline].
Cowan FM, de Vries LS. The internal capsule in neonatal imaging. Semin Fetal Neonatal Med. 2005 Oct. 10(5):461-74. [Medline].
Kidokoro H, Anderson PJ, Doyle LW, Woodward LJ, Neil JJ, Inder TE. Brain injury and altered brain growth in preterm infants: predictors and prognosis. Pediatrics. 2014 Aug. 134(2):e444-53. [Medline].
Cheong JL, Coleman L, Hunt RW, Lee KJ, Doyle LW, Inder TE, et al. Prognostic utility of magnetic resonance imaging in neonatal hypoxic-ischemic encephalopathy: substudy of a randomized trial. Arch Pediatr Adolesc Med. 2012. 7:634-40. [Medline].
Brenner, D.J. Estimating cancer risks from pediatric CT: going from the qualitative to the quantitative. Pediatr. Radiol. 1996. 32:228-231. [Medline].
Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012. 380(9840):499-505. [Medline].
Brenner DJ, Hall EJ. Computed tomography an increasing source of radiation exposure. N Engl J Med. 2007. 357:2277-2284. [Medline].
The encephalopathic neonate: choosing the proper imaging technique. AJNR Am J Neuroradiol. 1997. 18(10):1816-20. [Medline].
de Vries LS, Toet MC. Amplitude integrated electroencephalography in the full-term newborn. Clin Perinatol. 2006. 33:619-632. [Medline].
Hellstrom-Westas L, Rosen I. Continuous brain-function monitoring: state of the art in clinical practice. Semin Fetal Neonatal Med. 2006. 11:503-511. [Medline].
van Rooij LGM, Toet MC, Osredkar D, van Huffelen AC, Groenendaal F, de Vries LS. Recovery of amplitude integrated electroencephalographic background patterns within 24 hours of perinatal asphyxia. Arch. Dis. Child. Fetal Neonatal Ed. 2005. 90:F245-F251. [Medline].
Jacobs S, Hunt R, Tarnow-Mordi W, Inder T, Davis P. Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database Syst Rev. 2007. 4:CD003311. [Medline].
Spitzmiller RE, Phillips T, Meinzen-Derr J, Hoath SB. Amplitude-integrated EEG is useful in predicting neurodevelopmental outcome in full-term infants with hypoxic-ischemic encephalopathy: a meta-analysis. Journal of Child Neurology. 2007. 22:1069-1078. [Medline].
Pressler RM, Boylan GB, Morton M, Binnie CD, Rennie JM. Early serial EEG in hypoxic ischaemic encephalopathy. Clinical neurophysiology. 2001. 112:31-37. [Medline].
Rowe JC, Holmes GL, Hafford J, et al. Prognostic value of the electroencephalogram in term and preterm infants following neonatal seizures. Electroencephalogr Clin Neurophysiol. 1985 Mar. 60(3):183-96. [Medline].
Volpe JJ. Hypoxic-ischemic encephalopathy. Neurology of the Newborn. 5th ed. Philadelphia, PA: Saunders-Elsevier; 2008. Volume 899: chapter 9.
Murray DM, Boylan GB, Ryan CA, Connolly S. Early EEG Findings in Hypoxic-Ischemic Encephalopathy Predict Outcomes at 2 Years. Pediatrics. 2009 Aug 24. [Medline].
Sinclair DB, Campbell M, Byrne P, Prasertsom W, Robertson CMT. EEG and long-term outcome of term infants with neonatal hypoxic-ischemic encephalopathy. Clinical neurophysiology. 1999. 110:655-659. [Medline].
Tong AY, El-Dairi M, Maldonado RS, et al. Evaluation of optic nerve development in preterm and term infants using handheld spectral-domain optical coherence tomography. Ophthalmology. 2014 Sep. 121(9):1818-26. [Medline]. [Full Text].
Perlman JM. Intervention strategies for neonatal hypoxic-ischemic cerebral injury. Clin Ther. 2006 Sep. 28(9):1353-65. [Medline].
[Guideline] Biban P, Filipovic-Grcic B, Biarent D, Manzoni P; International Liaison Committee on Resuscitation (ILCOR); European Resuscitation Council (ERC); American Heart Association (AHA); American Academy of Pediatrics (AAP). New cardiopulmonary resuscitation guidelines 2010: managing the newly born in delivery room. Early Hum Dev. 2011. 87 (suppl 1):S9-11. [Medline].
[Guideline] Kattwinkel J, Perlman JM, Aziz K, Colby C, Fairchild K, Gallagher J, et al. Neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2010. 126(5):400-413. [Medline].
Sabir H, Jary S, Tooley J, Liu X, Thoresen M. Increased Inspired Oxygen in the First Hours of Life is Associated with Adverse Outcome in Newborns Treated for Perinatal Asphyxia with Therapeutic Hypothermia. J Pediatr. 2012 Apr 18. [Medline].
[Guideline] American Academy of Pediatrics. Committee on Fetus and Newborn. Use of inhaled nitric oxide. Pediatrics. 2000 Aug. 106(2 Pt 1):344-5. [Medline].
Kecskes Z, Healy G, Jensen A. Fluid restriction for term infants with hypoxic-ischaemic encephalopathy following perinatal asphyxia. Cochrane Database Syst Rev. 2005 Jul 20. CD004337. [Medline].
Bakr AF. Prophylactic theophylline to prevent renal dysfunction in newborns exposed to perinatal asphyxia--a study in a developing country. Pediatr. Nephrol. 2005. 20:1249-1252. [Medline].
Bhat MA, Shah ZA, Makhdoomi MS, Mufti MH. Theophylline for renal function in term neonates with perinatal asphyxia: a randomized, placebo-controlled trial. J. Pediatr. 2006. 149:180-184. [Medline].
Jenik AG, Ceriani Cernadas JM, Gorenstein A, et al. A randomized, double-blind, placebo-controlled trial of the effects of prophylactic theophylline on renal function in term neonates with perinatal asphyxia. Pediatrics. 2000. 105:E45. [Medline].
Salhab WA, Wyckoff MH, Laptook AR, Perlman JM. Initial hypoglycemia and neonatal brain injury in term infants with severe fetal acidemia. Pediatrics. 2004 Aug. 114(2):361-6. [Medline].
Miller SP, Weiss J, Barnwell A, et al. Seizure-associated brain injury in term newborns with perinatal asphyxia. Neurology. 2002 Feb 26. 58(4):542-8. [Medline].
Scher MS. Neonatal seizures and brain damage. Pediatr Neurol. 2003 Nov. 29(5):381-90. [Medline].
Holmes GL. Effects of seizures on brain development: lessons from the laboratory. Pediatr Neurol. 2005 Jul. 33(1):1-11. [Medline].
Boylan GB, Rennie JM, Chorley G, et al. Second-line anticonvulsant treatment of neonatal seizures: a video-EEG monitoring study. Neurology. 2004 Feb 10. 62(3):486-8. [Medline].
Boylan GB, Rennie JM, Pressler RM, Wilson G, Morton M, Binnie CD. Phenobarbitone, neonatal seizures, and video-EEG. Arch Dis Child Fetal Neonatal Ed. 2002 May. 86(3):F165-70. [Medline].
Painter MJ, Scher MS, Stein AD, Armatti S, Wang Z, Gardiner JC, et al. Phenobarbital compared with phenytoin for the treatment of neonatal seizures. N Engl J Med. 1999 Aug 12. 341(7):485-9. [Medline].
Castro Conde JR, Hernandez Borges AA, et al. Midazolam in neonatal seizures with no response to phenobarbital. Neurology. 2005 Mar 8. 64(5):876-9. [Medline].
Maytal J, Novak GP, King KC. Lorazepam in the treatment of refractory neonatal seizures. J Child Neurol. 1991 Oct. 6(4):319-23. [Medline].
Gunn AJ, Gunn TR. The 'pharmacology' of neuronal rescue with cerebral hypothermia. Early Hum Dev. 1998 Nov. 53(1):19-35. [Medline].
Gunn AJ. Cerebral hypothermia for prevention of brain injury following perinatal asphyxia. Curr Opin Pediatr. 2000. 12(2):111-115. [Medline].
Eicher DJ, Wagner CL, Katikaneni LP, et al. Moderate hypothermia in neonatal encephalopathy: safety outcomes. Pediatr Neurol. 2005. 32 (1):18-24. [Medline].
Eicher DJ, Wagner CL, Katikaneni LP, et al. Moderate hypothermia in neonatal encephalopathy: efficacy outcomes. Pediatr Neurol. 2006. 34(2):169. [Medline].
Jacobs SE, Morley CJ, Inder TE, et al. Whole-Body Hypothermia for Term and Near-Term Newborns With Hypoxic-Ischemic Encephalopathy: A Randomized Controlled Trial. Arch Pediatr Adolesc Med. 2011 Aug. 165(8):692-700. [Medline].
Zhou WH, Cheng GQ, Shao XM, et al. Selective head cooling with mild systemic hypothermia after neonatal hypoxic-ischemic encephalopathy: a multicenter randomized controlled trial in China. J Pediatr. 2010 Sep. 157(3):367-72, 372.e1-3. [Medline].
Simbruner G, Mittal RA, Rohlmann F, Muche R. Systemic hypothermia after neonatal encephalopathy: outcomes of neo.nEURO.network RCT. Pediatrics. 2010 Oct. 126(4):e771-8. [Medline].
Azzopardi DV, Strohm B, Edwards AD, et al. Moderate hypothermia to treat perinatal asphyxial encephalopathy. N Engl J Med. 2009 Oct 1. 361(14):1349-58. [Medline].
Shankaran S, Pappas A, Laptook AR, et al. Outcomes of safety and effectiveness in a multicenter randomized, controlled trial of whole-body hypothermia for neonatal hypoxic-ischemic encephalopathy. Pediatrics. 2008 Oct. 122(4):e791-8. [Medline]. [Full Text].
Shankaran S, Pappas A, McDonald SA, Vohr BR, Hintz SR, Yolton K, et al. Childhood outcomes after hypothermia for neonatal encephalopathy. N Engl J Med. 2012 May 31. 366(22):2085-92. [Medline].
Azzopardi D, Strohm B, Marlow N,et al, for the TOBY Study Group. Effects of hypothermia for perinatal asphyxia on childhood outcomes. N Engl J Med. 2014 Jul 10. 371(2):140-9. [Medline].
Laptook AR. Use of therapeutic hypothermia for term infants with hypoxic-ischemic encephalopathy. Pediatr Clin North Am. 2009 Jun. 56(3):601-16, Table of Contents. [Medline].
Fairchild K, Sokora D, Scott J, Zanelli S. Therapeutic hypothermia on neonatal transport: 4-year experience in a single NICU. Journal of Perinatology. 2009. In press:
Zanelli SA, Naylor M, Dobbins N, et al. Implementation of a 'Hypothermia for HIE' program: 2-year experience in a single NICU. J Perinatol. 2008. 28(3):171-175. [Medline].
Vannucci RC, Perlman JM. Interventions for perinatal hypoxic-ischemic encephalopathy. Pediatrics. 1997 Dec. 100(6):1004-14. [Medline].
Hall RT, Hall FK, Daily DK. High-dose phenobarbital therapy in term newborn infants with severe perinatal asphyxia: a randomized, prospective study with three-year follow-up. J Pediatr. 1998 Feb. 132(2):345-8. [Medline].
Goldberg RN, Moscoso P, Bauer CR, et al. Use of barbiturate therapy in severe perinatal asphyxia: a randomized controlled trial. J Pediatr. 1986 Nov. 109(5):851-6. [Medline].
Evans DJ, Levene MI, Tsakmakis M. Anticonvulsants for preventing mortality and morbidity in full term newborns with perinatal asphyxia. Cochrane Database Syst Rev. 2007 Jul 18. CD001240. [Medline].
Zhu C, Kang W, Xu F, et al. Erythropoietin improved neurologic outcomes in newborns with hypoxic-ischemic encephalopathy. Pediatrics. 2009 Aug. 124(2):e218-26. [Medline].
Van Bel F, Shadid M, Moison RM, et al. Effect of allopurinol on postasphyxial free radical formation, cerebral hemodynamics, and electrical brain activity. Pediatrics. 1998 Feb. 101(2):185-93. [Medline]. [Full Text].
Depp R. Perinatal asphyxia: assessing its causal role and timing. Semin Pediatr Neurol. 1995 Mar. 2(1):3-36. [Medline].
Edwards AD, Azzopardi DV. Therapeutic hypothermia following perinatal asphyxia. Arch Dis Child Fetal Neonatal ed. 2006. 91:F127-F131. [Medline].
Guillet R, Edwards AD, Thoresen M, Ferriero DM, Gluckman PD, Whitelaw A, et al. Seven- to eight-year follow-up of the CoolCap trial of head cooling for neonatal encephalopathy. Pediatr Res. 2012. 2:205-9.
Guillet R, Edwards AD, Thoresen M, Ferriero DM, Gluckman PD, Whitelaw A, et al. Seven- to eight-year follow-up of the CoolCap trial of head cooling for neonatal encephalopathy. Pediatr Res. 2012. 2:205-9. [Medline].
Gunn AJ, Gunn TR, de Haan HH, Williams CE, Gluckman PD. Dramatic neuronal rescue with prolonged selective head cooling after ischemia in fetal lambs. 1: J Clin Invest. 1997. 99(2):248-256. [Medline].
Gunn AJ, Hoehn T, Hansmann G, et al. Hypothermia: an evolving treatment for neonatal hypoxic ischemic encephalopathy. Pediatrics. 2008. 121:648-649. [Medline].
Hull J, Dodd KL. Falling incidence of hypoxic-ischaemic encephalopathy in term infants. Br J Obstet Gynaecol. 1992. 5:386-91. [Medline].
Perlman M, Shah PS. Ethics of therapeutic hypothermia. Acta Paediatr. 2009 Feb. 98(2):211-3. [Medline].
Schulzke SM, Rao S, Patole SK. A systematic review of cooling for neuroprotection in neonates with hypoxic ischemic encephalopathy - are we there yet?. BMC Pediatrics. 2007. 7:30. [Medline].
Shah PS, Ohlsson A, Perlman M. Hypothermia to treat neonatal hypoxic ischemic encephalopathy: systematic review. Arch Pediatr Adolesc Med. 2007. 161:951-958. [Medline].
Shankaran S, Pappas A, McDonald SA, Vohr BR, Hintz SR, Yolton K, et al. Childhood outcomes after hypothermia for neonatal encephalopathy. N Engl J Med. 2012. 22:2085-92. [Medline].
Smith J, Wells L, Dodd K. The continuing fall in incidence of hypoxic-ischaemic encephalopathy in term infants. BJOG. 2000. 4:461-6. [Medline].
Srinivasakumar P, Zempel J, Wallendorf M, Lawrence R, Inder T, Mathur A. Therapeutic hypothermia in neonatal hypoxic ischemic encephalopathy: electrographic seizures and magnetic resonance imaging evidence of injury. J Pediatr. 2013 Aug. 163(2):465-70. [Medline].
[Guideline] Ten VS, Matsiukevich D. Room air or 100% oxygen for resuscitation of infants with perinatal depression. Curr Opin Pediatr. 2009 Apr. 21(2):188-93. [Medline].
Wilkinson DJ. Cool heads: ethical issues associated with therapeutic hypothermia for newborns. Acta Paediatr. 2009 Feb. 98(2):217-20. [Medline].
|Level of Consciousness||Alternating (hyperalert, lethargic,irritable)||Lethargic or obtunded||Stuporous|
|Posture||Normal||Decorticate (arms flexed/legs extended)||Intermittent decerebration (arms and legs extended)|
|Stretch reflexes||Normal or hyperactive||Hyperactive or decreased||Absent|
|Suck||Weak||Weak or absent||Absent|
|Moro||Strong; low threshold||Weak; incomplete; high threshold||Absent|
|Oculovestibular||Normal||Overactive||Weak or absent|
|Autonomic Function||Generalized sympathetic||Generalized parasympathetic||Both systems depressed|
|Pupils||Mydriasis||Miosis||Variable; often unequal; poor light reflex|
|Bronchial and Salivary Secretions||Sparse||Profuse||Variable|
|GI Motility||Normal or decreased||Increased; diarrhea||Variable|
|Seizures||None||Common; focal or multifocal||Delayed|
|EEG Findings||Normal (awake)||Early: low-voltage continuous delta and theta
Later: periodic pattern (awake)
Seizures: focal 1-to 1-Hz spike-and-wave
|Early: periodic pattern with Isopotential phases
Later: totally isopotential
Typically < 24h
|2-14 days||Hours to weeks|