| Clinical features |
- Disturbed neurologic function in the earliest days of life in an infant born at ≥35 weeks gestation, manifested by:
- Abnormal state of consciousness (hyperalert, irritable, lethargic, or obtunded)
- Diminished spontaneous movements
- Weak or absent cry
- Respiratory or feeding difficulty
- Poor tone
- Abnormal posturing
- Abnormal primitive reflexes
- Seizures
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| Evaluation |
- Cord blood: Umbilical arterial and venous pH and base deficit
- Placenta: Examine for vascular lesion, infection/inflammation, or umbilical cord thrombosis
- Laboratories: Arterial blood gas, CBC with differential, electrolytes, creatinine, calcium, magnesium, liver enzymes, blood cultures, coagulation tests; consider ammonia, lactate, pyruvate, serum amino acids, urine organic acids, genetic testing
- Lumbar puncture: If concern for intracranial infection
- Cranial ultrasound: If concern for hemorrhage or hydrocephalus
- EEG on first day of life
- Brain MRI at 4 to 7 days of age
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| Indications for therapeutic hypothermia |
- All of the following:
- Gestational age ≥36 weeks and ≤6 hours of age*
- Any of the following:
- Metabolic or mixed acidosis with a pH of ≤7.0 or a base deficit ≥16 mmol/L in an umbilical cord blood sample or any blood obtained within first hour after birth
- 10-minute Apgar score of ≤5
- Ongoing resuscitation (eg, assisted ventilation, chest compressions, or cardiac medications) initiated at birth and continued for ≥10 minutes
- Moderate to severe encephalopathy on clinical examination
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| Treatment |
- Start therapeutic hypothermia within 6 hours of age for infants meeting above criteria
- Maintain adequate ventilation and avoid hypoxemia and hyperoxia
- Maintain sufficient brain and organ perfusion (avoid systemic hypotension and hypertension; avoid hyperviscosity)
- Maintain normal metabolic status (normoglycemia, normal pH, adequate nutrition)
- Treat seizures with phenobarbital, lorazepam, fosphenytoin, or levetiracetam
- For persistent pulmonary hypertension, use high frequency ventilation, nitric oxide, or extracorporeal membrane oxygenation to maintain oxygenation
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