Hypoxic-ischemic encephalopathy (HIE) is a serious type of newborn brain injury caused by reduced oxygen and/or blood flow to the brain before, during, or shortly after birth. When a newborn’s brain is deprived of oxygen, brain cells can become injured or die, potentially leading to permanent neurological damage.
Moderate to severe HIE carries a high risk of death or long-term disability. Even with treatment, medical research shows that approximately 30–50% of affected infants may either not survive or develop significant neurological impairments, including cerebral palsy, epilepsy, cognitive delays, or learning disabilities. Early diagnosis and timely medical intervention are critical to improving outcomes.
What Causes HIE?
HIE occurs when a baby’s brain does not receive sufficient oxygenated blood during labor or delivery. While some cases arise from sudden and unavoidable medical emergencies, many instances of HIE are linked to preventable errors in obstetric care, including a failure by healthcare providers to recognize, communicate, or respond appropriately to signs of fetal distress. When doctors, nurses, or hospital staff do not meet accepted medical standards of care, the risk of oxygen deprivation and resulting brain injury increases significantly.
Common causes and contributing factors associated with HIE and potential medical malpractice include:
- Umbilical cord complications, such as compression, entanglement, or prolapse, that are not promptly identified or addressed.
- Placental abruption, placental insufficiency, or reduced fetal blood flow without timely intervention.
- Delayed, mismanaged, or improperly performed emergency Cesarean section.
- Failure to properly monitor fetal heart rate tracings or respond to abnormal results.
- Prolonged or obstructed labor without appropriate escalation of care.
- Uterine rupture or other obstetric emergencies that are not treated immediately.
- Breakdowns in communication among labor and delivery staff.
- Improper use or dosing of anesthesia or labor-inducing medications.
- Failure to identify, monitor, or manage maternal infections or known pregnancy risk factors.
HIE is a medical emergency requiring immediate recognition and intervention. When treatment is delayed or appropriate steps—such as timely therapeutic hypothermia—are not initiated, the resulting brain injury may be more severe and, in some cases, preventable.
What Is Total Body Cooling for HIE?
Total body cooling, also known as therapeutic hypothermia, is a medical treatment designed to reduce brain damage following oxygen deprivation. The infant’s body temperature is carefully lowered to slow brain metabolism, reduce inflammation, and limit secondary brain cell death.
Therapeutic hypothermia is now widely recognized as the standard of care for eligible newborns with moderate to severe HIE when initiated promptly after birth. Extensive medical research over the past two decades has established cooling therapy as one of the most significant advances in neonatal neuroprotection.
Landmark studies supporting its use include the NICHD Whole-Body Cooling Trial, the TOBY Trial in the United Kingdom, and a major Cochrane systematic review analyzing more than 1,500 infants. These studies consistently demonstrate reduced death and disability when cooling is initiated within the appropriate clinical window.
How Does Cooling Treatment Work?
Total body cooling involves lowering a newborn’s core body temperature to approximately 91–93°F using a cooling blanket or specialized NICU equipment. Treatment typically lasts 72 hours, followed by a slow, carefully monitored rewarming process.
During cooling, the baby’s heart rate, breathing, oxygen levels, brain activity, and organ function are continuously monitored in a neonatal intensive care unit (NICU). The goal is to interrupt the secondary phase of brain injury, which occurs hours after the initial oxygen deprivation and is responsible for much of the long-term damage.
Many NICUs prefer total body cooling over selective head cooling because it is easier to maintain, provides uniform cooling, and protects deeper brain structures—such as the basal ganglia and thalamus—that are commonly affected in HIE. Some studies suggest total body cooling may result in fewer abnormal MRI findings compared to head-only cooling.
How Effective Is Total Body Cooling?
Therapeutic hypothermia is most effective when specific clinical criteria are met. To provide benefit, cooling must:
- Begin within 6 hours of birth.
- Reach and maintain a target temperature of 91.4–93.2°F.
- Continue for 72 hours, followed by controlled rewarming.
Clinical trials show that cooling therapy can:
- Reduce mortality by approximately 10–25%.
- Lower the risk of severe neurodevelopmental disability by about 30–40%.
- Improve long-term cognitive and motor outcomes, including higher rates of normal IQ at school age.
Cooling is most effective for infants with moderate HIE. While it is also used for severe HIE, outcomes are less predictable because the initial brain injury may already be extensive. For mild HIE, the benefit of cooling remains under investigation, and it is not yet universally recommended.
Importantly, studies such as the HELIX Trial highlight that cooling therapy is most effective when delivered in advanced NICU settings with comprehensive monitoring and supportive care, emphasizing the importance of proper implementation and timely intervention.
How Doctors Determine Eligibility for Cooling Therapy (Sarnat Staging)
Doctors use the Sarnat Staging System to assess the severity of neonatal encephalopathy and determine whether an infant qualifies for therapeutic hypothermia. This neurological examination is typically performed within the first few hours after birth.
- Stage 1 (Mild HIE): The infant may be hyper-alert or irritable, with normal muscle tone and no seizures. These infants generally do not meet the criteria for cooling therapy.
- Stage 2 (Moderate HIE): Characterized by lethargy, low muscle tone, weak reflexes, and seizures. This is the primary group targeted for cooling, as untreated infants face a substantial risk of long-term disability.
- Stage 3 (Severe HIE): Marked by coma, flaccid muscle tone, absent reflexes, and severely abnormal neurological findings. Cooling is initiated urgently, though outcomes are often less predictable.
Sarnat staging is frequently paired with abnormal EEG or amplitude-integrated EEG (aEEG) findings to confirm eligibility and guide treatment decisions.
Intensive Supportive Care During Cooling
While cooling therapy protects the brain, comprehensive supportive care is essential to manage the effects of oxygen deprivation on other organs. Standard NICU care often includes:
- Mechanical ventilation or supplemental oxygen.
- Seizure monitoring and treatment, typically with phenobarbital.
- Blood pressure support using IV fluids or medications such as dopamine or dobutamine.
- Frequent monitoring of blood glucose, electrolytes, and acid-base balance.
- Sedation to prevent shivering and reduce metabolic demand.
This level of care is critical to maximizing the effectiveness of therapeutic hypothermia.
What Are the Risks and Complications of Cooling Therapy?
Therapeutic hypothermia is generally safe when properly administered, but potential risks include:
- Heart rhythm abnormalities
- Breathing difficulties
- Blood clotting or bleeding issues
- Electrolyte imbalances
- Temporary kidney or liver dysfunction
- Increased susceptibility to infection
NICU teams closely monitor infants throughout treatment to manage these risks and ensure stability.
What Happens After Cooling Therapy?
After rewarming, infants typically remain in the NICU for continued monitoring. Doctors may order brain MRIs (usually 4–10 days after birth), EEGs, and developmental evaluations to assess the extent of injury.
Early intervention services—such as physical, occupational, and speech therapy—often begin shortly after discharge. Some children require long-term medical or developmental support, while others experience milder or minimal complications.
How Can the Law Offices of Dr. Michael M. Wilson, M.D., J.D. & Associates Help?
Although cooling therapy can reduce harm, the need for therapeutic hypothermia may indicate that preventable errors occurred earlier in labor or delivery. Missed warning signs, delayed intervention, improper monitoring, or failure to respond to fetal distress can all result in avoidable oxygen deprivation.
At the Law Offices of Dr. Michael M. Wilson, M.D., J.D. & Associates, clients work with a lawyer who is also a licensed physician. Dr. Wilson’s dual medical and legal background allows the firm to evaluate medical records with exceptional insight, determine whether standards of care were followed, and pursue accountability when preventable mistakes lead to lifelong injury.
Contact Our Washington, D.C. HIE Lawyers at the Law Offices of Dr. Michael M. Wilson, M.D., J.D. & Associates Today
Our Washington, D.C. HIE lawyers at the Law Offices of Dr. Michael M. Wilson, M.D., J.D. & Associates are available to review your case and discuss your legal options. Call 202-223-4488 or contact us online to schedule a free consultation. Located in Washington, D.C., we serve clients throughout the surrounding areas, including Northern Virginia and Maryland.
