Management of Birth Asphyxia

1. Initial Assessment at Birth (First 60 Seconds - "Golden Minute")

• Term gestation?
• Good muscle tone?
• Breathing or crying?

Neonatal Resuscitation Algorithm

2. Step-by-Step Resuscitation (NRP)

Step A - Airway & Initial Stabilization

• Warm the infant under a radiant warmer
• Dry and stimulate - rub the back vigorously
• Position the airway (slight neck extension/"sniffing position")
• Clear secretions only if obstructed (mouth first, then nose); avoid routine/deep suctioning (risk: vagal bradycardia, apnea)
• Meconium: Only suction trachea via ETT if meconium is present AND infant has poor tone/poor respiratory effort/bradycardia (HR <100/min)

Step B - Breathing (Positive Pressure Ventilation)

• Apnea or gasping, OR
• HR <100 beats/min

• Start with room air (21%) for term infants; titrate O₂ using SpO₂ (preductal - right hand/wrist)
• Rate: 40-60 breaths/min
• Pressure: 30 cm H₂O for term; 20-25 cm H₂O for preterm
• Good chest rise + HR increase within 5-10 breaths = effective ventilation

• M - Mask adjustment (better seal)
• R - Reposition head
• S - Suction mouth then nose
• O - Open mouth (jaw thrust)
• P - Pressure increase (max 40 cm H₂O)
• A - Airway - proceed to ETT intubation

Step C - Circulation (Chest Compressions)

• Technique: Thumb-encircling method, lower one-third of sternum
• Ratio: 3:1 compressions:ventilations (90 compressions + 30 ventilations/min)
• Intubate if not already done before starting compressions
• Switch oxygen to 100% O₂ when compressions are needed
• Establish emergency UVC (umbilical venous catheter) access; IO is an alternative

Step D - Drugs (Epinephrine + Volume Expansion)

3. APGAR Score - Assessment

• 7-10: Normal
• 4-6: Moderate depression
• 0-3: Severe depression - active resuscitation required

4. Post-Resuscitation: HIE Assessment (Sarnat Staging)

5. Therapeutic Hypothermia (Cooling Therapy) - KEY NEUROPROTECTION

• Gestational age ≥35-36 weeks
• Evidence of moderate-to-severe HIE (Sarnat stage 2 or 3)
• Must be initiated within 6 hours of birth

• Cord/first-hour blood gas: pH <7.0 OR base deficit >16
• For pH 7.01-7.15 or BD 10-15.9, PLUS any of:
  • 10-minute APGAR ≤5
  • Evidence of moderate-to-severe encephalopathy
  • Need for assisted ventilation for ≥10 minutes at birth

• Target temperature: 33-34°C (whole-body cooling) for 72 hours
• Passive cooling first: turn off the warmer immediately if cooling is being considered
• Monitor temperature continuously
• Obtain neonatologist/NICU consultation urgently

6. Supportive/Systemic Management (Multiorgan Injury)

7. Neuroimaging

• Cranial Ultrasound: bedside, day 1-3 - initial screening
• MRI with DWI (Diffusion-Weighted Imaging): gold standard for defining brain injury; detects signal changes within 24-48 hours of insult
• MR Spectroscopy: detects lactate, NAA, choline alterations in injured regions
• EEG/aEEG (amplitude-integrated): detect subclinical seizures that cause secondary brain injury

8. Discontinuing Resuscitation

• No signs of life after 10 minutes of continuous active resuscitation: virtually certain to suffer severe morbidity/mortality; cessation is justified
• After 15 minutes of asystole: resuscitation may be stopped
• Gestation <22 weeks or weight <400 g: not considered viable
• At 22 weeks: survival 10-50%; at 23 weeks: 35-60%; at 24 weeks: 60-80%

9. Recent Evidence (PubMed, 2023-2026)

• A 2024 systematic review (PMID 38639099) evaluated cerebral NIRS (near-infrared spectroscopy) monitoring during therapeutic hypothermia for HIE, supporting its role in continuous cerebral oxygenation surveillance.
• A 2024 meta-analysis (PMID 38468452) reviewed magnesium sulphate for neonatal neuroprotection, noting potential adjunctive benefit when combined with cooling.
• A 2026 Cochrane review (PMID 41925053) assessed melatonin for neonatal encephalopathy as an emerging adjunctive neuroprotective agent.

Key Priorities Summary

1. Immediate resuscitation using NRP within the first 60 seconds
2. Avoid hyperoxia - titrate O₂ to preductal SpO₂ targets
3. Start therapeutic hypothermia within 6 hours for eligible infants (≥35 wks, moderate-severe HIE)
4. Treat hypoglycemia aggressively - it worsens HIE outcome
5. Monitor and manage multiorgan dysfunction systematically
6. EEG monitoring for subclinical seizures

Neonatal Seizure Management

1. Why Neonatal Seizures Are Different

• Neonates do not have organized tonic-clonic seizures - their immature synaptic connections prevent generalised spread
• Up to two-thirds of EEG seizures have no visible clinical correlate (subclinical/electrographic-only seizures)
• Only one-third of clinically suspected seizures are confirmed on EEG
• This means: EEG can both miss and over-diagnose seizures when used without objective monitoring

2. Clinical Classification of Neonatal Seizures (Volpe)

• Jitteriness (exaggerated startle - suppressed by touch; stimulus-sensitive)
• Sleep myoclonus (suppressed by waking)
• Tetany from hypocalcemia (DiGeorge syndrome)

3. Common Causes (Underlying Aetiology Must Be Treated)

4. Diagnosis and Monitoring

Step 1 - Confirm Seizures with EEG

• Continuous EEG (cEEG) is gold standard - mandatory when seizures are suspected
• Amplitude-integrated EEG (aEEG) - simplified, bedside, single/dual channel; less sensitive but readily interpreted by NICU staff
• Per 2025 ACNS Guidelines (PMID 39752571): continuous EEG monitoring is indicated for all neonates at high risk (HIE, post-cardiac surgery, clinical seizure)

Step 2 - Check Correctable Causes Immediately

• Blood glucose (treat hypoglycemia first - 10% dextrose 2 mL/kg)
• Electrolytes: Na, Ca, Mg
• Blood gas, CBC, CRP (infection screen)
• Lumbar puncture if infection suspected

Step 3 - Neuroimaging

• Cranial ultrasound - bedside, IVH, major infarct
• MRI with DWI - gold standard for ischemic injury
• EEG - seizure localization, background activity (burst suppression = poor prognosis)

5. Anti-Seizure Medication (ASM) - Step-Up Algorithm

First-Line: Phenobarbital

• ILAE 2023 guidelines (PMID 37655702): Phenobarbital is the first-line ASM regardless of etiology (evidence-based recommendation)
• Exception: If channelopathy is likely (positive family history) - use phenytoin or carbamazepine (sodium channel blockers) instead

Second-Line Options (if seizures persist after max phenobarbital)

The 2023 Cochrane Review (PMID 37873971) found phenobarbital is probably more effective than levetiracetam as first-line (RR 2.32 for seizure control after first loading dose; moderate-certainty evidence)

For Refractory/Unknown Aetiology - Consider Vitamins

6. Special Considerations

Therapeutic Hypothermia

• Reduces seizure burden in HIE (evidence-based ILAE recommendation)
• Should be initiated within 6 hours of birth alongside seizure management

When to Treat Electrographic-Only (Subclinical) Seizures

• ILAE 2023: Treating electrographic-only seizures to achieve lower seizure burden may improve outcomes (expert agreement)
• Each NICU should have a standardized pathway

Duration of ASM Treatment

• For acute provoked seizures (e.g., HIE, transient metabolic) with no evidence of ongoing epilepsy:
  • Discontinue ASMs before hospital discharge - regardless of MRI or EEG findings (ILAE 2023 expert agreement)
  • Do NOT continue phenobarbital as outpatient maintenance in acute provoked cases

Channelopathies (Genetic Epilepsies)

• KCNQ2, KCNQ3, SCN2A mutations: respond to sodium channel blockers (phenytoin, carbamazepine)
• Benign familial neonatal epilepsy: autosomal dominant, often remits within the first year
• Ohtahara syndrome / Early myoclonic encephalopathy: severe, often refractory; burst suppression on EEG

7. Prognosis

• Etiology is the strongest predictor of outcome (not seizure type or burden alone)
• HIE-related seizures: outcome depends on Sarnat stage
• Benign familial neonatal seizures: generally favorable, remit in first year
• Early infantile epileptic encephalopathies (EIEE/Ohtahara): poor - may evolve to West or Lennox-Gastaut syndrome

Quick Reference Summary

Suspect → EEG/aEEG + check glucose/electrolytes
      ↓
Phenobarbital 20 mg/kg IV (first-line)
      ↓ (if persists)
Phenobarbital 10 mg/kg IV × 2 more doses
      ↓ (if persists)
Fosphenytoin 20 mg/kg IV   OR   Levetiracetam 60 mg/kg IV
      ↓ (if refractory)
Midazolam infusion 2→24 mcg/kg/min
      + Consider vitamin trial (PLP + folinic acid)
      + Cooling if HIE within 6 hours

• Persistent Pulmonary Hypertension of the Newborn (PPHN) - a major complication of birth asphyxia
• HIE staging and neuroimaging - MRI patterns, DWI findings, prognosis
• Neonatal hypoglycemia - management protocol and glucose targets
• Preterm complications - RDS, IVH, NEC, BPD
• Meconium Aspiration Syndrome (MAS) - management and overlap with PPHN