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South Australian Perinatal Practice Guideline 

Hypoxic Ischaemic 
Encephalopathy  

(including Neonatal Hypothermic 
Neuroprotection)  

  Department for Health and Wellbeing, Government of South Australia. All rights reserved. 

 

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Note:

This guideline provides advice of a general nature.  This statewide guideline has been prepared to promote and facilitate 
standardisation and consistency of practice, using a multidisciplinary approach.  The guideline is based on a review of published 
evidence and expert opinion.  

Information in this statewide guideline is current at the time of publication.  

SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site and does not 
sponsor, approve or endorse materials on such links. 

Health practitioners in the South Australian public health sector are expected to review specific details of each patient and 
professionally assess the applicability of the relevant guideline to that clinical situation. 

If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must document in the patient s 
medical record, the decision made, by whom, and detailed reasons for the departure from the guideline. 

This statewide guideline does not address all the elements of clinical practice and assumes that the individual clinicians are 
responsible for discussing care with consumers in an environment that is culturally appropriate and which enables respectful 
confidential discussion. This includes: 
  The use of interpreter services where necessary, 
  Advising consumers of their choice and ensuring informed consent is obtained, 
  Providing care within scope of practice, meeting all legislative requirements and maintaining standards of professional 
conduct, and  
  Documenting all care in accordance with mandatory and local requirements 

 

Explanation of the Aboriginal artwork: 
The Aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst famil ies and the Aboriginal culture. The horse shoe shape design 
shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts a pregnant women. The smaller horse shoe shape in this instance represents 
the unborn child. The artwork shown before the specific statements within the document symbolises a footprint and demonstrates the need to move forward together in unison. 

 

     

 

 

 

 

 

Purpose and Scope of PPG 

The purpose of this guideline is to provide clinicians with information on recognising those infants 
with hypoxic ischaemic encephalopathy (HIE) who would benefit from therapeutic cooling, 
including assessment, monitoring, consultation and referral. Specific detail for referral sites on 
commencing active or passive cooling in consultation with a neonatologist is included. Clinical 
management in Neonatal Intensive Care sites using a Tecotherm device is detailed. 

Australian Aboriginal Culture is the oldest living culture in the world yet 

Aboriginal people continue to experience the poorest health outcomes when 

compared to non-Aboriginal Australians. In South Australia, Aboriginal women are 

2-5 times more likely to die in childbirth and their babies are 2-3 times more likely to 

be of low birth weight.  The accumulative effects of stress, low socio economic 

status, exposure to violence, historical trauma, culturally unsafe and discriminatory 

health services and health systems are all major contributors to the disparities in 

Aboriginal maternal and birthing outcomes. Despite these unacceptable statistics 

the birth of an Aboriginal baby is a celebration of life and an important cultural 

event bringing family together in celebration, obligation and responsibility. The 

diversity between Aboriginal cultures, language and practices differ greatly and so 

it is imperative that perinatal services prepare to respectively manage Aboriginal 

protocol and provide a culturally positive health care experience for Aboriginal 

people to ensure the best maternal, neonatal and child health outcomes. 

 



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Flowchart 1: Initial Management of HIE in Referral Sites 

 

 

 

Note: Babies that do not immediately meet the eligibility criteria, but had an APGAR &lt; 6 at 

5 minutes require hourly observations for 4-6 hours (including neurological examination) 



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Flowchart 2: Management of HIE in Level 6 Neonatal Units

 



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Table of Contents 
 

Purpose and Scope of PPG ............................................................................................................ 1 

Flowchart 1: Initial Management of HIE in Referral Sites ................................................................ 2 

Flowchart 2: Management of HIE in Level 6 Neonatal Units ........................................................... 3 

Abbreviations ................................................................................................................................... 5 

Definition .......................................................................................................................................... 5 

Background...................................................................................................................................... 6 

Clinical Presentation ........................................................................................................................ 6 

Principles of Medical Management ................................................................................................. 6 

Clinical management for referring centres ...................................................................................... 6 

1. Resuscitation ........................................................................................................................... 6 

2. Measure cord gases ................................................................................................................ 6 

3. Monitoring ................................................................................................................................ 7 

4. Assess eligibility criteria for therapeutic hypothermia ............................................................. 7 

5. Consultation ............................................................................................................................. 7 

6. If no cooling machine available and cooling is required at referring sites ............................... 7 

Clinical management for Neonatal Intensive Care Units ................................................................. 8 

1. Resuscitation ........................................................................................................................... 8 

2. Hypothermia Therapy / Cooling in Neonatal Intensive Care Units .......................................... 8 

Eligibility Criteria ...................................................................................................................... 8 

Exclusion Criteria: .................................................................................................................... 8 

3. Respiratory support ................................................................................................................. 8 

4. Circulatory support .................................................................................................................. 8 

5. Metabolic ................................................................................................................................. 9 

6. Renal support and fluid management ..................................................................................... 9 

7. Neurological ........................................................................................................................... 10 

Table 1: Modified Sarnat Classification ................................................................................. 10 

8. Haematology ......................................................................................................................... 10 

9. Infection ................................................................................................................................. 11 

Investigations: ................................................................................................................................ 11 

Imaging ...................................................................................................................................... 11 

aEEG and a formal EEG ........................................................................................................... 11 

Metabolic studies ....................................................................................................................... 11 

In cases were death is imminent / palliation is about to occur .................................................. 11 

Hypothermia treatment .................................................................................................................. 12 

Tecotherm Device ..................................................................................................................... 12 

Nursing care during hypothermia therapy ................................................................................. 12 

Rewarming ................................................................................................................................. 12 

References .................................................................................................................................... 14 

Follow-Up                                      15 

  



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Summary of Practice Recommendations  

All infants requiring more than simple resuscitation should be admitted to a NICU for 
observations. 

Commencement of hypothermic neuroprotection should occur within 6 hours of birth if 
indicated. 

It can be difficult to assess the presence or absence of HIE. Have a low threshold for 
consultation with an on-call Neonatologist. 

HIE is a condition that evolves with time. Clinicians need to think about HIE as a delayed 
consequence of asphyxia and be alert to careful observations and serial neurological 
assessment. 

Abbreviations   

% Percent 

aEEG Amplitude integrated EEG 

aPPT Activated partial thromboplastin time  

 C Degrees Celsius 

bpm Beats per minute 

BE Base Excess 

BGL Blood glucose level 

BP Blood pressure 

cm Centimetre 

CSF Cerebrospinal fluid 

ECG Electrocardiograph 

EEG Electroencephalograph 

FFP Fresh frozen plasma 

g/L Grams per litre 

HIE Hypoxic ischaemic encephalopathy 

INR International normalized ratio 

MAS Meconium aspiration syndrome 

mg Milligrams 

microg Micrograms 

min Minute(s) 

mmHg Millimetres of mercury 

mmol/L Millimole(s) per litre 

MRI Magnetic resonance imaging 

NICU Neonatal Intensive Care Unit 

NSAT Neonatal skin assessment tool 

PAL Perinatal advice line 

pCO2 Partial pressure of carbon dioxide 

PPG Perinatal Practice Guideline 

PT Prothrombin time 

SaO2 Saturation of oxygen 

sec Second(s) 

TPN Total parenteral nutrition 

 

Definition 

Hypoxic Ischaemic 
Encephalopathy 

Lack of sufficient oxygen and blood perfusion to the brain, 
resulting in brain injury 

  



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Background 

Following a hypoxic ischaemic insult, neuronal death occurs in two phases: 

1. Primary neuronal death: This is related to cellular hypoxia leading to primary energy 
failure and cellular depolarisation. 

2. Secondary phase: After a latent phase (6-100 hours) neuronal death may be initiated by 
a cascade of pathologic processes and is associated with marked encephalopathy. This 
involves cytotoxic oedema, mitochondrial failure, accumulation of excito-toxins, active 
cell death, nitric oxide synthesis and cytotoxic actions of activated microglia. Seizure 
activity is increased during this phase. 

Clinical Presentation 

Infants with HIE present with neurological symptoms, whose severity is classified based on the 
modified Sarnat staging (see Modified Sarnat Classification Table).

1
 There may be evidence of 

other end-organ damage such as coagulopathy, raised liver enzymes, acute renal failure, 
hypotension, pulmonary hypertension and/or respiratory failure. 

Principles of Medical Management  

Evidence from high quality randomised controlled trials indicates that cooling of neonates with 
moderate to severe HIE is safe and reduces the risk of death or disability at 18 to 22 months of 
age.

2 
Hence, infants with moderate or severe HIE should receive therapeutic hypothermia to 

maintain core temperature at 33-34 C. In order to be effective, cooling should commence as 
soon as possible.

3
   There is strong evidence that cooling initiated before 6 hours of age is 

effective. The evidence for the benefit of cooling initiated later than 6 hours is weaker. Few 
relevant studies have been conducted.

4,5
 

Therapeutic hypothermia should be continued for 72 hours. 

If evidence or concern for hypoxic injury, cease overhead heater for passive cooling and obtain a 
blood gas.  

It may be difficult to assess the presence or absence of HIE. In all cases resuscitation and early 
stabilisation are the priority.  

Any neonate recognised to be at high risk of HIE, or where HIE is considered to be a possible 
diagnosis, must be considered for therapeutic hypothermia and transferred to a Level 6 neonatal 
unit. 

Early consultation with a Neonatologist is recommended. Management discussions and transfer 
can be facilitated by calling the Perinatal Advice Line on 137827. 

Clinical management for referring centres (see Flowchart 1) 

1. Resuscitation  

Resuscitation as per the SA Health Newborn Life Support Algorithm (available at 
www.sahealth.sa.gov.au/perinatal), and local neonatal resuscitation and escalation guidelines. 

The priority in a situation where therapeutic hypothermia is being considered is to ensure 
appropriate resuscitation of the infant.  

2. Measure cord gases  

Ensure a capillary, venous or arterial gas is taken within the first hour following birth. 

  




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3. Assess eligibility criteria for therapeutic hypothermia  

Newborn is ?35 weeks and &lt; 6 hours of age and any 2 of the following: 

? Acute perinatal event that may result in HIE (e.g. placental abruption, cord prolapse etc.) 

? Apgar score &lt;6  at 10 minutes OR ongoing need for resuscitation at 10 minutes 

? Arterial cord pH &lt; 7.0 and/or base excess &lt; -12 mmol/L OR postnatal arterial gas within 
1 hour of birth pH &lt; 7.0 and/or base excess &lt; -12 mmol/L 

 

Note: Babies who do not immediately meet the eligibility criteria but have required resuscitation 

with an APGAR &lt; 6 at 5 minutes require closer monitoring as HIE can be a delayed consequence 
of asphyxia. The following observations should be undertaken regularly for the first 4-6 hours of 
life: 

? temperature, heart rate, respiratory rate and effort (as per RADAR charts) 

? neurological assessment using the Modified Sarnat Classification 

Observation should occur in an appropriate area; for example, in an incubator or nursery and not 
on the mother s chest.  

4. Monitoring 

Unwell infants require continuous monitoring and observation as their condition may change 
rapidly. 

1. Monitor temperature to avoid hyperthermia (Temp &gt;37.5
o
C) 

2. Prevent and treat hypoglycaemia (see Neonatal Hypoglycaemia PPG available at 
www.sahealth.sa.gov.au/perinatal)  

3. Treat suspected sepsis (see Early Onset Neonatal Sepsis PPG available at 
www.sahealth.sa.gov.au/perinatal)  

5. Consultation  

It can be difficult to assess the presence or absence of HIE. Have a low threshold for early 
consultation with a Neonatologist. 

Call the Perinatal Advice Line (phone: 137827) to discuss suitability for therapeutic hypothermia 

and to arrange retrieval/transfer to a level 6 neonatal unit if indicated. 

Following discussion with a Neonatologist through the PAL, there may be a recommendation to 
commence passive cooling prior to retrieval/transfer to a level 6 neonatal unit. 

6. If no cooling machine available and cooling is required at referring sites 

Cooling should only be commenced at referring sites following consultation with a neonatologist. 

Use an oscillating fan and cold wet cloths. If further measures are required, use cold packs from 
the fridge. 

NEVER use ice packs from the freezer as frozen packs because of cold burns due to intense 
local vasoconstriction. 

Wrap the cool packs in a cloth nappy and place around the head, neck and shoulders, axillae 
and groins. 

Remove the cold packs when the rectal temperature reaches 33 C as this prevents excessive 
cooling.

6
 

Do not reduce the temperature of humidified gases. Reduction of inspired gas temperature 
reduces humidification and may lead to endotracheal tube obstruction.  

Document when and where the packs are placed, and when they are removed. 

Document skin integrity and report any discoloration or concerns using neonatal skin assessment 
tool (NSAT) form. 





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Clinical management for Neonatal Intensive Care Units 

1. Resuscitation  

Resuscitation as per the SA Health Newborn Life Support Algorithm (available at 
www.sahealth.sa.gov.au/perinatal), and local neonatal resuscitation guidelines. 

2. Hypothermia Therapy / Cooling in Neonatal Intensive Care Units 

The decision to cool a neonate with HIE is made by the on call Neonatologist.  

Eligibility Criteria 

Active cooling is commenced if the following eligibility criteria met: 

1. Newborn is ?35 weeks and &lt; 6 hours of age and any 2 of the following: 

? Acute perinatal event that may result in HIE (e.g. placental abruption, cord prolapsed 
etc.) 

? Apgar score &lt;6  at 10 minutes OR Ongoing need for resuscitation at 10 minutes 

? Arterial pH &lt; 7.0 OR BE &lt; -12 mmol/L or lower (from cord OR baby arterial gas &lt; 60 
minutes of age) 
 

2. Moderate to severe encephalopathy (modified Sarnat) +/- abnormal aEEG 

? lower margin &lt; 5uV or discontinuous trace OR  

? burst suppression/continuous low voltage/flat trace OR 

? evidence of seizures 

Note: Therapeutic hypothermia may be considered in infants between 6 and 10 hours of age. 

Exclusion Criteria: 

1. Major congenital abnormalities likely to render therapeutic hypothermia ineffective or unsafe 
2. Uncontrolled severe clinical coagulopathy not responding to appropriate therapy  
3. Infant not expected to survive 

3. Respiratory support 

Intubation and ventilation are frequently required due to altered conscious state (infant obtunded, 
ineffective spontaneous breathing or seizures).  

Meconium aspiration syndrome (MAS) is a typical co-morbidity 

Due to the evolving nature of HIE, where a baby is not intubated, careful monitoring and a low 
threshold for endotracheal intubation should be maintained for the purpose of airway protection. 

An arterial blood gas obtained within 1 hour of birth is useful to assess the degree of postnatal 
hypoxia. 

Initial frequency of arterial blood gas analysis should be 4-6 hourly until acidosis is corrected and 
low normocarbia is achieved (pCO2 35-45 mmHg). Subsequent frequency may be dictated by 
blood glucose and electrolyte management.  

Maintain preductal oxygen saturations (SaO2) above 93%. Persistent hypoxia can be due to 
pulmonary hypertension. Rarely, hypothermia treatment needs to be discontinued or modified 
because of severe hypoxaemia due to pulmonary hypertension.  

4. Circulatory support 

Obtain umbilical or peripheral arterial access for blood pressure monitoring and blood sampling.  

Insert a dual lumen umbilical venous catheter.  

For hypotension: 

Volume replacement - administration of blood products (fresh frozen plasma [FFP], 
cryoprecipitate, platelet transfusion and packed red cell transfusions). Targeted approach 
required, e.g. cryoprecipitate for low fibrinogen. 

 




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Inotropic support  

Aim for mean invasive blood pressure of 45-55mmHg. 

If pulmonary hypertension is suspected or confirmed (on echocardiogram), optimise pCO2, BP 
and pH. 

Sinus bradycardia is common during hypothermia treatment. Obtain 12-lead ECG if there are 
rhythm abnormalities. 

5. Metabolic 

Obtain plasma glucose level on admission. Correct hypoglycaemia; aim for blood glucose level 
(BGL) above 3.5 mmol/L.

7  

Provide 4-6mg/kg/min of glucose infusion rate and check BGL as per protocol 

Infusion of concentrated dextrose solution may be required 

Correct metabolic acidosis with targeted circulatory support and fluid volume where necessary. 
Routine use of sodium bicarbonate is NOT recommended: Use at consultant discretion only. 

Obtain liver function tests on admission. Persistent hypoglycaemia and /or metabolic acidosis 
should raise suspicion for inborn errors of metabolism where consultation with a Metabolic 
Specialist is advised.   

6. Renal support and fluid management 

Acute kidney injury is common. Strict fluid balance +/- fluid restriction may be necessary. 

Obtain formal electrolytes and creatinine on admission, then electrolytes as per local guidelines. 
Commence dextrose infusion initially at target volumes of 25-40ml/kg/day.  

? This can be increased through custom TPN  

? Once renal function is recovering Standard Term parenteral nutrition (12% glucose) can 
be considered.

8
 

Insert urinary catheter for assessment of fluid balance and prevention of urinary retention. 

 

Enteral Nutrition 

Enteral nutrition to a maximum of 20 mL/kg/day of breast milk may be commenced at 24 hours of 
age in the stable infant undergoing therapeutic hypothermia.

9 

  



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7. Neurological  

Perform a structured neurological examination on admission, using modified Sarnat staging 
system

1
 to determine eligibility for hypothermia treatment. 

The presence of moderate / severe encephalopathy, based on the modified Sarnat classification 
is defined as: Clinical seizures OR presence of signs in at least 3 of the following 6 categories: 

 

Table 1: Modified Sarnat Classification
1 

Variable Mild 
encephalopathy 
Stage I 

Moderate 
encephalopathy 
Stage II 

Severe 
encephalopathy 
Stage III 

Level of consciousness Alert Lethargic Comatose 

Muscle Tone Normal or hypertonic Hypotonic Flaccid 

Tendon reflexes Increased Increased Depressed or absent 

Myoclonus Present Present Absent 

Seizures Absent Frequent Frequent 

Complex 
reflexes 

Suck Active Weak  Absent 

Moro Exaggerated Incomplete Absent 

Grasp Normal-exaggerated Exaggerated Absent 

Oculocephalic 
(doll eye) 

Normal Overactive Reduced or absent 

Autonomic 
function 

Pupils Dilated, reactive Small, reactive Variable / fixed 

Heart Rate Normal or 
tachycardia 

Bradycardia Bradycardia 

Respiration Regular Periodic breathing Ataxic ,apnoeic 

EEG Normal Low voltage, periodic 
or paroxysmal 

Periodic or isoelectric 

 

Record assessment on Encephalopathy chart. 

Perform regular neurological examination (daily) and documentation thereafter until discharge.  

Commence continuous aEEG monitoring on admission, during cooling and rewarming phases.  

 

Seizures  

Treat all clinical seizures (and electrographic seizures).
10,11 

Phenobarbital is first line treatment (see Phenobarbital Neonatal Medication Guideline available 
at www.sahealth.sa.gov.au/neonatal).  

If seizures are refractory to treatment, discuss further management with consultant responsible. 
Consider alternative anti-convulsion agents (e.g. benzodiazepine, phenytoin, 
levetiracetam).

12,13,14
  

 

Analgesia 

Hypothermia appears to be uncomfortable, even painful.  

An infusion of morphine at 5-10microg/kg/min may be beneficial. 

8. Haematology 

Obtain full blood count and coagulation profile on admission. 

Obtain EDTA specimen for group and match. 

Ensure Vitamin K administered via intramuscular route (see Vitamin K Neonatal Medication 
Guideline available at www.sahealth.sa.gov.au/neonatal).  

If evidence of coagulation abnormalities, consider FFP / cryoprecipitate / platelet transfusion. 

Aim for INR &lt;1.9; aPPT 40-60 sec; PT &lt;16s; fibrinogen ?1.5 g/L (Note: hypothermia in itself can 
prolong in vitro coagulation tests). 





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9. Infection 

If sepsis suspected, obtain blood culture on admission and commence antibiotics. 

Gentamicin level should be performed PRIOR to second dose. 

Cerebrospinal fluid (CSF) analysis should be performed if indicated when clinically stable (usually 
post hypothermia treatment). 

Investigations: 

Blood investigations  

? Full Blood Examination 

? Electrolytes 

? Liver function testing and Urinalysis 

? Coagulation profile: activated partial thromboplastin time (aPTT), INR (international 
normalized ratio), prothrombin time (PT), fibrinogen  

? Occasionally: cardiac troponin 

Imaging 

? Cranial ultrasound should be performed as soon as practical to exclude neurosurgical 
cause for HIE or structural brain abnormality. Cranial ultrasound lacks sensitivity in 
newborn babies for evaluating the nature and extent of the injury.  

? Arrange MRI on day 4-7 of life if HIE. MRI can be done earlier if needed to rule out 
alternative diagnosis (e.g. ischaemic/haemorrhagic stroke, cerebral malformation), or if 
imaging is critical for clinical decision making (e.g. redirection of care). 

aEEG and a formal EEG 

It is very important to apply the leads and start recording the amplitude integrated EEG as soon 
as possible after admission. This will assist in the diagnosis of HIE and identification of 
seizures.

15
 

? A formal EEG (via Neurophysiology Department) should be arranged in the first 1-2 
weeks for infants who have seizures. 

? Obtain neurology consult.  

? Frequent neurological examination. 

Metabolic studies  

Metabolic studies are not done on a routine basis but should be considered if the cause of HIE is 
unclear. 

? Urine amino and organic acids, serum ammonium levels, CSF  

? Amino acids and neurotransmitters if the cause of HIE is unclear. Rare metabolic 
conditions can mimic HIE. Specialist advice is recommended prior to obtaining these 
specimens 

In cases were death is imminent / palliation is about to occur 

Consider collecting metabolic studies and blood for chromosomal/microarray testing. Seizures 
can be a presentation of metabolic conditions or developmental brain anomalies associated with 
chromosomal/genetic defects. Contact the Metabolic consultant on call for advice. 

All deaths should be discussed with the Coroner.  

If directed, formally report the death to the coroner.  

In non-coronial cases an autopsy should be recommended to the parents. In most cases of 
presumed asphyxia a cause is not immediately apparent.  

  



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Hypothermia treatment  

Tecotherm Device 

Set-up with Tecotherm device: 

? Use an open Intensive Care Incubator. The infants are then easier to monitor and to 
regulate temperature 

? Cardio-respiratory monitor with an oesophageal or rectal temperature probe - provides 
accurate temperature measurement in the desired low temperature range 

? Apply skin probe and connect to the Cooling machine, place cooling mattress covered 
with blue sheet under baby. To commence cooling set machine to Servo control 
complete treatment mode. 

? Insert oesophageal probe. Insertion distances: 
o Nasal insertion depth = (Body length ( in cm) / 4) + 3 cm 
o Oral insertion depth =(Body length (in cm) / 4) + 2 cm 

 This places the tip of the thermistor at T7/T8, which is just behind the left atrium. 

? NB. If you have to use a rectal probe, insert temperature probe to 6-8 cm and secure with 
tape. Insert at this distance to accurately monitor the core temperature. 

? Attach to cooling machine. If no cooling machine available attach to Philips X2 module 

Check probe insertion distance hourly. 

Open Intensive Care Incubator is placed in manual mode. 

Monitor temperature continuously and document skin and oesophageal temperature hourly. 
Digital thermometers register from 32 C 

Temperature is monitored to maintain a core temperature between 33 C and 34 C.  

It is currently considered important to achieve this target temperature within 6 hours of birth and 
to maintain it for 72 hours for neuroprotection.  

Nursing care during hypothermia therapy  

Abnormalities of the aEEG have prognostic significance. Medical staff and nursing staff are to 
document predominant aEEG background in medical records once per shift, including occurrence 
of seizures. Also mark events and clearly describe circumstances on the aEEG log. 

Continue usual NICU observations. 

Pending arterial line placement: 15-minutely Doppler blood pressure measurements must be 
recorded.  

Note: Sinus bradycardia (80 100bpm/min) is common with hypothermia; therefore adjust the low 
alarm limit to 80 beats per minute on Philips monitoring system. This needs to have medical 
approval. 

 

Skin integrity  

The sedated or obtunded infant is prone to problems with skin integrity / fat necrosis. 

Change infant position regularly as tolerated to reduce pressure. 

Perform assessment and document accordingly using neonatal skin assessment tool (NSAT) 

If cooling device not available make sure that no ice packs are used on infant`s skin and that the 
infant is not lying on wet sheets. 

Rewarming 

Commenced after 72 hours of hypothermia treatment. 

Continue to monitor core temperature. 

If no cooling device available and manual cooling utilised then follow rewarming steps. 

Secure the skin probe to the abdomen and set skin temperature probe to 35?C. Turn the 
intensive care cot temperature control to servo control. This is generally sufficient to re-warm the 
infant at an appropriate rate. 

 



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Maintain the oesophageal temperature probe and avoid warming faster than 0.5  C per hour over 
6 8 hours. 

Rapid warming may increase the metabolic rate and oxygen consumption of poorly perfused 
tissues and cause tissue hypoxia. 

To avoid rapid warming it may be necessary to re-initiate cooling techniques. 

Follow up 

All babies receiving cooling therapy are enrolled into the Neonatal Long Term Follow up 

program.  

 

  



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References   

1. Sarnat HB, Sarnat MS. Neonatal encephalopathy following fetal distress: a clinical and 
electroencephalographic study. Arch Neurol. 1976;33(10):696-705 

2. Jacobs S, Hunt R, Tarnow-Mordi W, Inder T, Davis P. Cooling for newborns with hypoxic 
ischaemic encephalopathy. The Cochrane Database of Systematic Reviews 2013 Jan 
31; (1) : CD003311 

3. Edwards AD and Azzopardi DV (2006). Therapeutic hypothermia following perinatal 
asphyxia. Archives of Disease in Childhood - Fetal and Neonatal Edition 2006;91:F127-
F131 

4. Laptook AR, Shankaran S, Tyson JE, et al. Effect of Therapeutic Hypothermia Initiated 
After 6 Hours of Age on Death or Disability Among Newborns With Hypoxic-Ischemic 
Encephalopathy: A Randomized Clinical Trial [published correction appears in JAMA. 
2018 Mar 13;319(10 ):1051. Khan AM [added]]. JAMA. 2017;318(16):1550 1560. 
doi:10.1001/jama.2017.14972 

5. Li T, Xu F, Cheng X, et al. Systemic hypothermia induced within 10 hours after birth 
improved neurological outcome in newborns with hypoxic-ischemic 
encephalopathy. Hosp Pract (1995). 2009;37(1):147 152. doi:10.3810/hp.2009.12.269 

6. Gardiner J, Wagh D, McMichael J, Hakeem M, Rao S. Outcomes of hypoxic ischaemic 
encephalopathy treated with therapeutic hypothermia using cool gel packs - experience 
from Western Australia. Eur J Paediatr Neurol. 2014 May;18(3):391-8 

7. Tan J, Minutillo C, McMichael J, Rao S. Impact of hypoglycaemia on 
neurodevelopmental outcomes in hypoxic ischaemic encephalopathy: a retrospective 
cohort study. BMJ Paediatr Open. 2017 Sep 18;1(1):e000175 

8. Kecskes Z, Healy G, Jensen A. Fluid restriction for term infants with hypoxic-ischaemic 
encephalopathy following perinatal asphyxia. The Cochrane Database of Systematic 
Reviews 2005, Issue 3 

9. Chang L, L, Wynn J, L, Pacella M, J, Rossignol C, C, Banadera F, Alviedo N, Vargas A, 
Bennett J, Huene M, Copenhaver N, Sura L, Barnette K, Solomon J, Bliznyuk N, A, Neu 
J, Weiss M, D: Enteral Feeding as an Adjunct to Hypothermia in Neonates with Hypoxic-
Ischemic Encephalopathy. Neonatology 2018;113:347-352. doi: 10.1159/000487848 

10. Srinivasakumar P, Zempel J, Trivedi S, Wallendorf M, Rao R, Smith B, et al. Treating 
EEG seizures in hypoxic ischemic encephalopathy: a randomized controlled trial. 
Pediatrics 2015;136(5):e1302-e9. 

11. Weeke LC, Boylan GB, Pressler RM, Hallberg B, Blennow M, Toet MC, et al. Role of 
EEG background activity, seizure burden and MRI in predicting neurodevelopmental 
outcome in full-term infants with hypoxic-ischaemic encephalopathy in the era of 
therapeutic hypothermia. European Journal of Paediatric Neurology 2016;20(6):855-64. 

12. Kharoshankaya L, Stevenson N, Livingstone V, Murray DM, Murphy B, Ahearne C, 
Boylan G. Seizure burden and neurodevelopmental outcome in neonates with hypoxic-
ischemic encephalopathy. Dev Med Child Neurol. 2016 Dec; 58(12):1242-1248. 

13. van Rooij LG, van den Broek MP, Rademaker CM, de Vries LS. Clinical management of 
seizures in newborns : diagnosis and treatment. Paediatr Drugs. 2013 Feb; 15(1):9-18. 

14. El-Dib M, Soul JS. The use of phenobarbital and other anti-seizure drugs in newborns. 
Semin Fetal Neonatal Med. 2017 Oct; 22(5):321-327. 

15. Del R o et al. Amplitude Integrated Electroencephalogram as a Prognostic Tool in 
Neonates with Hypoxic-Ischemic Encephalopathy: A Systematic Review. PLoS One. 
2016 Nov 1; 11(11):e0165744. 

 

 

 

 

 

 

 



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Acknowledgements 

The South Australian Perinatal Practice Guidelines gratefully acknowledge the contribution of 
clinicians and other stakeholders who participated throughout the guideline development process 
particularly:  

 

Write Group Lead 
Dr Vanessa Ellison  
 

Write Group Member 
Dr Marcus Brecht  
Dr Michael Hewson 
Dr Bevan Headley 
Nichola Johnson  
Dr Nigel Stewart 
Dr Alvin Tan  
Dr Jojy Varghese 
 

SAPPG Management Group Members 
Sonia Angus 
Lyn Bastian 
Dr Elizabeth Beare 
Elizabeth Bennett 
Dr Feisal Chenia 
John Coomblas 
Dr Vanessa Ellison 
Jackie Kitschke 
Dr Kritesh Kumar 
Catherine Leggett 
Dr Anupam Parange 
Rebecca Smith 
A/Prof Chris Wilkinson 

  



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Document Ownership &amp; History 

Developed by:  SA Maternal, Neonatal &amp; Gynaecology Community of Practice 
Contact:  HealthCYWHSPerinatalProtocol@sa.gov.au 
Endorsed by:    Commissioning and Performance, SA Health 
Next review due:  17/08/2025  
ISBN number:   978-1-76083-278-0 
PDS reference:  CG118 
Policy history:  Is this a new policy (V1)?  N 
   Does this policy amend or update and existing policy?   Y  
   If so, which version? V1.0 
   Does this policy replace another policy with a different title?  N 
   If so, which policy (title)? 
 

 
 

Date of 
approval 

Version Approving body Reason for change 

17/08/2020 2.0 
Lynne Cowan, Deputy CE, Commissioning 
and Performance Division, SA Department 
for Health and Wellbeing 

Complete review 

29/03/2013 1.0 
SA Health Quality and Safety Strategic 
Governance Committee 

Original approved version 



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