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Tagin and Gunn suggest that the current criteria from randomised controlled trials of hypothermia for moderate or severe encephalopathy are limiting the application to infants with perinatal hypoxia-ischaemia.1 They propose that current criteria be expanded and simplified based on clinical judgement to maximise potential benefit. Extending hypothermia therapy based on clinical context alone will be difficult to implement without many potential downsides (cooling for the wrong diagnosis, overtreatment, iatrogenic problems from a therapy not needed and so on).
The criteria of the trials of hypothermia for moderate or severe encephalopathy used parameters which indicated that an impairment of gas exchange had occurred close to the time of birth and detailed the response to the impaired gas exchange [encephalopathy, abnormal amplitude integrated electroencephalogram (aEEG)].2 Acid base disturbances and elevations of lactate at birth or in the first postnatal hour provide objective measures to support critical events close to birth. The National Institute of Child Health and Human Development (NICHD) Neonatal Research Network (NRN) screening criteria for hypoxia-ischaemia included approaches when no blood gases were available or when there was less fetal acidemia; infants then had to have evidence of an acute perinatal sentinel event and either a 10 min Apgar score <5 or need for continued resuscitation at birth. Clinical context can easily lose sight of the rationale for the criteria and may result in cooling infants who are not encephalopathic or cooling for other potential causes of encephalopathy.
Drs Tagin and Gunn have provided valid justifications for not relying solely on either Apgar scores or blood gas values as criteria for screening infants for evaluation of encephalopathy. We concur that an abnormal EEG could be additional criteria for diagnosing encephalopathy; however, it may not be feasible to …
Contributors SS was the primary author and AL and ST contributed to the editorial.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.