Clinical scenario

‘Sarah is a baby girl born by an emergency caesarean section following a period of observation for non-reassuring cardiotocographic recordings. She was initially ‘flat’ and received positive pressure ventilation for 3 min before establishing spontaneous breathing. Her Apgar scores were 1, 6 and 8 at 1, 5 and 10 min, respectively; cord pH was 7.08 and standard base excess (sBE) was −12.1. Sarah stayed with her mother as she was breathing normally and centrally pink despite being mildly hypotonic with minimal activity. At 10 hours of age, she started to develop recurrent seizures. Cerebral MRI showed extensive diffusion restriction patterns compatible with acute hypoxic–ischaemic insult.’

Sarah is a composite case, developed to include real events that we and others have observed. Unfortunately, many neonatal units receive similar cases every year and they often end up not offering therapeutic hypothermia, the only available treatment with proven safety and efficacy to this condition.1 The current guidelines are not inclusive and do not consider borderline cases.2 3

The simple question clinicians should ask themselves, is it unreasonable to treat a newborn with perinatal asphyxia and moderate encephalopathy? Babies, in a situation like Sarah, may lose the opportunity to be treated with therapeutic hypothermia because they miss a single criterion from the current cooling guidelines. The selection criteria in the initial randomised controlled trials of hypothermia were developed to identify the highest risk newborns who had been exposed to hypoxia–ischaemia. Newborns who had lower levels of risk were pragmatically excluded. Now that the evidence for benefit is well established,1 4 we propose that those entry points …