From the Guidelines
Neonatal encephalopathy workup should begin with a thorough clinical assessment, including a detailed history of pregnancy, labor, and delivery, followed by a comprehensive neurological examination, and neuroimaging with MRI (preferred over CT) within the first 24-96 hours of life to identify patterns of injury, as recommended by the most recent study 1. The initial investigations should include blood glucose, complete blood count, electrolytes, blood gas analysis, liver and renal function tests, and coagulation studies.
- Key aspects of the workup include:
- Continuous amplitude-integrated EEG monitoring to detect seizures and assess background activity, with conventional EEG performed if abnormalities are detected
- Lumbar puncture if infection is suspected
- Additional tests such as metabolic screening (ammonia, lactate, pyruvate), genetic testing, and placental pathology
- Therapeutic hypothermia (cooling to 33-34°C for 72 hours) should be initiated within 6 hours of birth for moderate to severe encephalopathy if criteria are met, as supported by studies 1, which reduces mortality and neurodevelopmental disability. Supportive care includes maintaining normal ventilation, avoiding hyperthermia, treating seizures (phenobarbital as first-line at 20mg/kg loading dose), and careful fluid management to prevent cerebral edema while ensuring adequate perfusion. The use of MRI-compatible incubators and small footprint MRI scanners can help with safer transportation and imaging of the patient, as noted in the study 1. It is essential to carefully monitor for known adverse effects of cooling, such as thrombocytopenia and hypotension, and to follow up all treated infants longitudinally.
From the Research
Neonatal Encephalopathy Workups
- Neonatal encephalopathy (NE) is associated with high mortality and morbidity, and its etiology can be antenatal, perinatal, or a combination of both 2.
- Factors predisposing to NE include antenatal maternal factors, familial factors, genetic predisposition, hypoxic ischemic encephalopathy, infections, placental abnormalities, thrombophilia, coagulation defects, and metabolic disorders 2.
- Recognizing the etiology of NE is crucial in guiding investigations such as metabolic and sepsis workups to ensure optimal management 2.
- A combination of careful history, examination, and judicious use of investigations can help determine the cause of NE 3.
Diagnostic Approaches
- Advances in neuroimaging, brain monitoring techniques, and tissue biomarkers have improved the ability to diagnose, monitor, and care for newborn infants with NE 4.
- Therapeutic hypothermia is the most promising neuroprotective intervention to date for infants with moderate to severe NE after perinatal asphyxia 4.
- However, only 1 in 6 babies with encephalopathy will benefit from hypothermia therapy, and many infants still develop significant adverse outcomes 4.
- Specific diagnostic predictors are needed to identify patients likely to benefit from hypothermia treatment 4.
Beyond Hypoxic-Ischemic Encephalopathy
- NE encompasses a broad spectrum of symptoms and severity, and its differential diagnosis includes conditions with infectious, vascular, epileptic, genetic/congenital, metabolic, and toxic causes 5.
- Haematological dysfunction is relatively common in neonates with NE treated with hypothermia, and includes anaemia, thrombocytopenia, monocyte and neutrophil activation, hypofibrinogenemia, and coagulopathy 6.
- Derangements in hematological values are also associated with neurodevelopmental outcomes, and a framework for management is needed 6.