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Birth injury attorney Scott Weidenfeller discusses treatments for HIE / neonatal encephalopathy.

When a baby experiences oxygen deprivation during or near the time of delivery, she may be diagnosed with hypoxic ischemic encephalopathy (HIE).  HIE, also known as neonatal encephalopathy, is a condition that occurs when a baby’s brain does not receive enough oxygen for a significant period of time.  Hypoxemia refers to a lack of oxygen in the baby’s blood, hypoxia refers to a lack of oxygen in the baby’s tissues, and ischemia refers to a lack of blood flow.  Ischemia in the baby’s brain can be caused by a number of conditions, but hypoxia can also cause ischemia.  Encephalopathy is a term that means any disorder or disease of the brain.

Babies who receive diagnoses of HIE may fully recover, without any permanent brain injury – especially if they receive brain cooling treatment / therapy in a timely manner and are given proper supportive care.

If there is any suspicion that a baby was significantly deprived of oxygen, the healthcare team must promptly evaluate the baby to determine if she meets the criteria for hypothermic brain cooling therapy.  The reason the team has to act fast is because hypothermia treatment is most effective if given within six hours of the time the baby’s brain experienced the oxygen-depriving insult, although there is evidence that hypothermia treatment can be beneficial if given within twenty-four hours of the oxygen-depriving insult.


Guidelines for hypothermic brain cooling therapy / treatment are continuously evolving, and exact criteria are usually different from hospital to hospital.  Below are some typical guidelines and recommendations that many hospitals utilize.

Evidence shows that the babies who benefit from hypothermia treatment are term and late preterm infants who are ≥36 weeks gestational age with HIE and who are ≤6 hours old and who meet either treatment criteria A or treatment criteria B, and also meet criteria C:

A. Arterial cord blood gas (ABG cord) pH ≤7.0, or ABG cord base deficit ≥ −16, OR

ABG cord pH 7.01 − 7.15, OR base deficit −10 to −15.9 on an ABG cord OR on an ABG within 1 hour of birth AND

  1. History of an acute perinatal event (such as a cord prolapse, placental abruption, or uterine rupture) AND
  2. An Apgar score ≤5 at 10 minutes, or at least 10 minutes of positive-pressure ventilation (PPV)

C. Evidence of moderate-to-severe encephalopathy, demonstrated by the presence of seizures OR at least one sign in three or more of the six categories shown below.

Category Moderate encephalopathy Severe encephalopathy
1. Level of consciousness Lethargy Stupor/coma
2. Spontaneous activity Decreased activity No activity
3. Posture Distal flexion, full extension Decerebrate (arms extended and internally rotated, legs extended with feet in forced plantar flexion)
4. Tone Hypotonia (focal, general) Flaccid
5. Primitive reflexes






6. Autonomic System

Heart rate (HR)




Periodic breathing

Skew deviation / dilated / nonreactive to light

Variable HR


All babies who are depressed at birth should be assessed to determine whether they meet criteria A or B.  Newborns that fulfill criteria A or B should then undergo a careful neurological examination to determine whether they meet criteria C.  Babies who meet criteria A and C or B and C should be offered hypothermia treatment.  Some cases may be difficult to categorize and thus require discussion with a specialized neonatologist at a larger hospital.

Indeed, research shows that when hypothermia treatment is timely given after an oxygen-depriving insult, the incidence of death and cerebral palsy is significantly reduced.  Hypothermia treatment is therefore the standard of care when a diagnosis of HIE has been made.  It is crucial for physicians to make an HIE diagnosis soon after the hypoxic/ischemic event occurred so that babies can receive hypothermia treatment as soon as possible.  The sooner the baby receives the treatment, the better.  It is negligence if a baby is a candidate for hypothermia treatment / therapy but the healthcare team fails to timely give her the therapy.


When babies are diagnosed with HIE, it is also imperative that they be given proper supportive care to help maximize oxygenation and blood flow in the brain, to help prevent any further insult to the brain, and to help the brain heal.  The following measures should be included in the care plan of a baby with HIE:

  1. Blood sugar levels should be closely monitored to make sure the baby doesn’t become hypoglycemic. Low blood sugar in newborns (neonatal hypoglycemia) is the most common preventable cause of brain damage in infancy.  Glucose is critical to a baby’s brain development since it is one of the only sources of energy the brain can use.
  2. The medical team should make sure that the baby is properly oxygenating and ventilating, and this means that a baby may need to receive what’s called CPAP (continuous positive airway pressure), BiPAP (bilevel positive airway pressure), NIPPV (non-invasive positive pressure ventilation). These treatments are usually used with a face mask or nasal prongs.  Sometimes, however, a baby must have a breathing tube placed in her upper airway (intubated) and be placed on a breathing machine (ventilator).
  3. The medical team should also ensure that the baby is not experiencing significant apneic / bradycardic periods (periods whereby the baby stops breathing and her heart rate slows down). Often, when a baby is having apneic / bradycardic periods, she will be treated with CPAP or BiPAP and a breathing machine, but sometimes a baby may need to be intubated.
  4. The baby’s metabolic rate should not be allowed to be too high. In other words, the baby’s oxygen demand / energy expenditure should not be unnecessarily high.  This means that that baby should not be working hard to breathe and that the baby should be kept warm.  If a baby is working hard to breathe, she may need to be intubated.
  5. Many babies with HIE also have seizures. The medical team must promptly diagnose seizure activity and give appropriate medication to help prevent seizures from occurring.


If you think your baby experienced a traumatic birth, oxygen deprivation, a brain bleed, delayed delivery, or delayed emergency C-section, or if your baby’s care was mismanaged after birth in the NICU, please contact our team of experienced Michigan birth injury attorneys.  The medical malpractice team at Grewal Law is comprised of attorneys and healthcare professionals, including an on-site physician, registered nurse, pharmacist, paramedic, and respiratory therapist.  We also work with the best consultants from around the country.  Our attorneys are licensed in Michigan and Florida, and we help victims of medical malpractice and birth trauma throughout Michigan and Florida.

If your baby was diagnosed with hypoxic ischemic encephalopathy (HIE), seizures, cerebral palsy, motor disorders, periventricular leukomalacia (PVL), hydrocephalus, intellectual disabilities, or developmental delays, or if you experienced problems during delivery or shortly before or after birth, please call us.  Our birth injury attorneys and medical staff are available to speak with you 24/7.

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