Hypoxic Ischemic Encephalopathy (HIE): Causes, Symptoms, and Prognosis

Hypoxic ischemic encephalopathy (HIE) is a serious type of brain injury that occurs when a newborn’s brain doesn’t receive enough oxygen and blood flow during or near the time of birth. This condition can lead to permanent neurological damage, developmental delays, cerebral palsy, or even death. Learning that your baby has suffered from HIE is devastating, and many families struggle to understand how this happened and whether it could have been prevented. Understanding what happened during your child’s birth is the first step toward getting answers—and getting your family the support you deserve.

If you believe medical negligence during labor and delivery caused your baby’s HIE birth injury, you may have legal options. A birth injury attorney can review your case at no cost and help you understand whether malpractice occurred during the birthing process. Because statute of limitations deadlines apply in every state, it’s important to get answers sooner rather than later. Contact a birth injury lawyer today for a free, confidential case evaluation.

On this page:

• What is hypoxic ischemic encephalopathy
• How HIE affects the brain
• Signs and symptoms in newborns
• HIE severity levels
• Primary causes of HIE
• Risk factors during pregnancy
• When HIE is medical malpractice
• Diagnosing HIE in newborns
• Cooling therapy and treatment options
• Long-term prognosis and outcomes
• Life expectancy with HIE
• Filing an HIE lawsuit
• Finding a birth injury attorney
• Frequently asked questions

What Is Hypoxic Ischemic Encephalopathy?

Hypoxic ischemic encephalopathy is a brain injury caused by oxygen deprivation (hypoxia) and reduced blood flow (ischemia) to an infant’s brain around the time of delivery. The term “encephalopathy” refers to a disease or disorder that affects brain function. When these three conditions occur together—lack of oxygen, reduced blood flow, and resulting brain dysfunction—doctors diagnose HIE.

This birth injury typically develops during labor and delivery, though it can occur immediately before or shortly after birth. The developing brain requires a constant supply of oxygen-rich blood to function properly. When that supply is interrupted for even a few minutes, brain cells begin to die. The severity of the injury depends on how long the oxygen deprivation lasted and which areas of the brain were affected.

According to research published in pediatric neurology journals, HIE affects approximately 3 out of every 1,000 full-term births in the United States. While this may seem like a small percentage, it represents thousands of babies each year who suffer this preventable brain injury. The condition accounts for a significant portion of newborn deaths and contributes to nearly one-quarter of all cases of cerebral palsy in children.

Medical professionals sometimes use different terms to describe this condition, including birth asphyxia, perinatal asphyxia, or neonatal encephalopathy. While these terms are related, HIE specifically refers to the brain injury that results from oxygen deprivation and reduced blood flow during the perinatal period.

How HIE Affects the Developing Brain

The brain requires approximately 20% of the body’s oxygen supply, despite representing only 2% of body weight. In newborns, the brain is particularly vulnerable to oxygen deprivation because it’s still developing and has high metabolic demands. When oxygen levels drop, the brain cannot produce enough energy to maintain normal cell function.

Within minutes of oxygen deprivation, brain cells begin to malfunction. If the lack of oxygen continues, these cells start to die through a process called necrosis. Even after oxygen flow is restored, a second wave of brain injury can occur over the following hours and days through a process called reperfusion injury. This secondary injury involves inflammation, chemical imbalances, and additional cell death.

The extent of brain damage depends on several factors: the severity of oxygen deprivation, how long it lasted, which areas of the brain were affected, and how quickly treatment began. The basal ganglia, hippocampus, and watershed zones between major blood vessels are particularly susceptible to injury from oxygen deprivation.

Different patterns of brain injury can result from HIE. Some babies experience injury primarily to the brain’s gray matter, while others have white matter damage. The location and extent of injury help doctors predict which functions may be affected as the child grows. Motor control, cognitive abilities, vision, hearing, and speech can all be impacted depending on which brain regions sustained damage.

If you suspect your baby’s brain injury resulted from preventable medical errors, a birth injury attorney specializing in HIE birth injury cases can review your medical records and help determine whether negligence occurred.

Signs and Symptoms of HIE in Newborns

Recognizing HIE immediately after birth is critical because treatment must begin within hours to be effective. Healthcare providers watch for specific warning signs that indicate a baby may have experienced oxygen deprivation during delivery.

Immediate Signs at Birth

One of the first indicators of HIE is a low Apgar score. The Apgar test, performed at one minute and five minutes after birth, evaluates a newborn’s appearance, pulse, grimace response, activity, and respiration. Babies with HIE typically have Apgar scores below 5 at five minutes and often below 3 at ten minutes. These low scores indicate the baby is not transitioning well to life outside the womb.

Newborns with HIE often require immediate resuscitation after delivery. If your baby needed help breathing, required intubation, or needed chest compressions at birth, these interventions suggest possible oxygen deprivation during labor or delivery. The need for extensive resuscitation efforts is a red flag that the medical team should investigate for HIE.

Abnormal muscle tone is another early sign. Babies with HIE may appear either extremely floppy (hypotonic) or abnormally stiff (hypertonic). They may have weak or absent reflexes, including the Moro reflex, sucking reflex, and grasp reflex that are normally present in healthy newborns.

Symptoms in the First Days

As hours pass after birth, additional symptoms may emerge. Seizures are one of the most concerning signs of HIE, typically occurring within the first 24 to 48 hours after birth. These seizures may be obvious—with visible shaking or jerking movements—or subtle, manifesting as unusual eye movements, cycling motions of the legs, or brief pauses in breathing.

Difficulty feeding is common in babies with HIE. Your infant may have trouble coordinating sucking and swallowing, may tire easily during feeds, or may be too lethargic to feed effectively. Some babies cannot maintain their body temperature and require warming devices even when other factors are normal.

Changes in consciousness level provide important clues about HIE severity. Affected babies may be unusually sleepy, difficult to wake, or unresponsive to stimulation. Some alternate between lethargy and irritability. Their cry may be weak or high-pitched, different from the strong cry of a healthy newborn.

Respiratory problems frequently accompany HIE. Your baby may breathe too rapidly, too slowly, or irregularly. Some infants require supplemental oxygen or ventilator support to maintain adequate oxygen levels even after the initial resuscitation.

Don’t wait to explore your legal options if your child showed these warning signs and you suspect medical negligence played a role. Statute of limitations deadlines apply to HIE lawsuits, making it important to consult with an experienced attorney promptly.

HIE Severity Levels: Mild, Moderate, and Severe

Doctors classify HIE into three categories based on the severity of symptoms. This grading system helps predict outcomes and guides treatment decisions. The classification system most commonly used is the Sarnat staging system, which evaluates level of consciousness, muscle tone, reflexes, and presence of seizures.

Mild HIE (Sarnat Stage 1)

Babies with mild HIE show subtle symptoms that typically resolve within 24 hours. These infants may be irritable or hyperalert initially but maintain relatively normal muscle tone and reflexes. They generally do not have seizures. While mild HIE carries the best prognosis, these babies still require close monitoring and follow-up care. Most children with mild HIE recover without long-term neurological problems, though some may experience minor learning differences or attention challenges later in childhood.

Moderate HIE (Sarnat Stage 2)

Moderate HIE involves more pronounced symptoms that persist beyond the first day of life. These babies appear lethargic and have decreased muscle tone. Their reflexes are weak or abnormal. Seizures occur in many cases of moderate HIE, typically beginning within the first 24 hours. These infants often have difficulty feeding and may require tube feeding initially.

The outcome for moderate HIE varies considerably. Some children recover with minimal long-term effects, while others develop significant disabilities. Cooling therapy, if administered promptly, can significantly improve outcomes for babies with moderate HIE. Approximately 40-50% of infants with moderate HIE who do not receive cooling therapy will develop permanent neurological damage, but this percentage decreases substantially with proper treatment.

Severe HIE (Sarnat Stage 3)

Severe HIE presents with the most concerning symptoms. These babies are stuporous or comatose, showing minimal response to stimulation. Muscle tone is severely abnormal—either extremely floppy or rigid. Reflexes are absent or significantly impaired. Seizures are common and may be difficult to control with medication.

Babies with severe HIE often require intensive respiratory support and may have unstable heart rate and blood pressure. The pupils may respond poorly to light, and the baby may show abnormal eye movements. Unfortunately, severe HIE carries a high risk of death or severe permanent neurological impairment. According to studies in neonatal medicine, approximately 50% of infants with severe HIE die in the newborn period, and most survivors develop significant disabilities including cerebral palsy, intellectual disabilities, and epilepsy.

What Causes HIE During Birth?

Understanding the causes of hypoxic ischemic encephalopathy helps families determine whether medical negligence contributed to their child’s injury. HIE results from events that interrupt oxygen delivery or blood flow to the baby’s brain during the perinatal period—the time immediately before, during, and shortly after birth.

Umbilical Cord Complications

The umbilical cord serves as the baby’s lifeline in the womb, delivering oxygen-rich blood from the placenta to the developing fetus. Umbilical cord complications are among the most common causes of HIE. These complications include:

Umbilical cord prolapse occurs when the cord slips through the cervix before the baby during delivery. The baby’s head can compress the cord against the birth canal, cutting off blood flow. This is a medical emergency requiring immediate cesarean delivery.

Nuchal cord describes the situation where the cord wraps around the baby’s neck. While nuchal cords are relatively common and often harmless, tight or multiple loops can restrict blood flow. A true knot in the umbilical cord creates similar risks.

Cord compression can happen when the cord is pressed between the baby and the uterine wall, particularly during contractions. Prolonged or severe compression reduces oxygen delivery to the baby’s brain.

Placental Problems

The placenta is responsible for transferring oxygen from the mother’s blood to the baby’s blood. When the placenta malfunctions or separates prematurely, the baby’s oxygen supply is compromised.

Placental abruption is the premature separation of the placenta from the uterine wall before delivery. This separation cuts off the baby’s oxygen supply and can cause severe bleeding. The condition requires emergency delivery to prevent HIE and other complications.

Placental insufficiency occurs when the placenta doesn’t function properly, failing to deliver adequate oxygen and nutrients to the baby throughout pregnancy. This chronic condition can make the baby more vulnerable to oxygen deprivation during labor’s stresses.

Placenta previa, where the placenta partially or completely covers the cervix, can cause bleeding and may necessitate cesarean delivery to prevent oxygen deprivation during birth.

Uterine Rupture

Uterine rupture is a rare but catastrophic event where the uterine wall tears during labor. This is more likely to occur in women who have had previous cesarean deliveries, particularly if labor is induced with medications like Pitocin. When the uterus ruptures, the baby can be expelled into the mother’s abdominal cavity, immediately cutting off oxygen supply. Emergency surgery is required to prevent HIE, maternal hemorrhage, and death.

Prolonged or Difficult Labor

Labor that lasts too long or progresses abnormally can lead to fetal oxygen deprivation. Each contraction temporarily reduces blood flow to the placenta. While babies normally tolerate this well, prolonged labor with extended periods of strong contractions can cause cumulative oxygen deprivation.

Shoulder dystocia occurs when the baby’s shoulder becomes stuck behind the mother’s pubic bone during delivery. This complication can cause brachial plexus injury to the baby’s nerves, but it can also lead to HIE if the baby’s chest is compressed for an extended period, preventing breathing while the head is already delivered.

Cephalopelvic disproportion—when the baby’s head is too large to safely pass through the mother’s pelvis—can result in prolonged pushing and fetal distress if not recognized and managed with cesarean delivery.

Maternal Blood Pressure Problems

The baby’s oxygen supply depends on adequate maternal blood pressure to perfuse the placenta. Both extremely high and extremely low maternal blood pressure can compromise oxygen delivery.

Preeclampsia and eclampsia cause dangerously high blood pressure and can reduce placental blood flow. Eclamptic seizures during labor create particular risk for fetal oxygen deprivation.

Maternal hypotension (low blood pressure) can occur as a side effect of epidural anesthesia or from blood loss. When maternal blood pressure drops, less blood flows through the placenta to the baby.

Infections

Maternal infections can trigger inflammation that affects placental function and fetal well-being. Chorioamnionitis—infection of the amniotic fluid and membranes—increases the risk of fetal oxygen deprivation and brain injury. Group B streptococcus (GBS) infections can cause sepsis in newborns, potentially leading to breathing problems and reduced oxygen delivery to the brain.

If medical professionals failed to properly monitor your baby during labor, didn’t recognize warning signs of fetal distress, or delayed necessary interventions, you may have grounds for a medical malpractice claim. Contact a qualified attorney to discuss your situation.

Risk Factors for HIE

Certain maternal and fetal conditions increase the likelihood that HIE may occur during delivery. While having risk factors doesn’t guarantee HIE will develop, it does mean healthcare providers should monitor more carefully and be prepared to intervene quickly if complications arise.

Maternal Risk Factors

Mothers with certain health conditions or pregnancy complications face higher risks of delivering a baby who develops HIE. These risk factors include:

Diabetes, particularly when poorly controlled, increases the risk of macrosomia (large baby), which can lead to difficult delivery and shoulder dystocia. Diabetic mothers also have higher rates of placental problems.

Thyroid disorders can affect placental function and fetal development. Both hyperthyroidism and hypothyroidism require careful management during pregnancy.

Blood clotting disorders increase the risk of placental blood clots, which can reduce oxygen delivery to the baby. Women with thrombophilias need specialized monitoring during pregnancy and delivery.

High blood pressure, whether pre-existing or developing during pregnancy (gestational hypertension, preeclampsia), can compromise placental blood flow and increase the risk of placental abruption.

Advanced maternal age (35 and older) is associated with increased risks of placental problems and labor complications that can lead to HIE.

Substance abuse, including alcohol, illicit drugs, and smoking, increases the risk of placental problems, preterm birth, and poor fetal growth—all of which can contribute to oxygen deprivation during delivery.

Fetal and Pregnancy Risk Factors

Premature birth (before 37 weeks gestation) increases HIE risk because premature babies have less mature lungs and are more vulnerable to breathing problems after birth.

Post-term pregnancy (beyond 42 weeks) increases risks because the placenta may begin to deteriorate, reducing its ability to deliver oxygen. Post-term babies are also more likely to experience meconium aspiration.

Multiple gestations (twins, triplets, or more) carry increased risks of premature birth, umbilical cord complications, and placental problems.

Intrauterine growth restriction (IUGR) indicates the baby isn’t growing properly in the womb, often due to placental insufficiency. These babies have fewer reserves to handle the stress of labor.

Abnormal fetal presentation, such as breech position, can complicate delivery and increase the risk of umbilical cord compression or prolapse.

When Is HIE Caused by Medical Malpractice?

While not every case of hypoxic ischemic encephalopathy results from medical negligence, many instances of HIE are preventable when healthcare providers follow proper standards of care. Understanding when medical malpractice during birth may have occurred can help families determine whether they should pursue legal action.

Failure to Monitor Fetal Heart Rate

Continuous fetal heart rate monitoring during labor is the primary tool for detecting fetal distress. The fetal heart rate pattern provides real-time information about how well the baby is tolerating labor. Medical staff must be trained to recognize concerning patterns and respond appropriately.

Late decelerations—where the baby’s heart rate drops after a contraction peaks—indicate the baby isn’t getting enough oxygen. Repeated late decelerations are a warning sign that requires intervention.

Prolonged decelerations, where the heart rate remains low for more than two minutes, signal severe fetal distress. This pattern demands immediate action, often including emergency cesarean delivery.

Minimal or absent variability—when the baby’s heart rate shows little fluctuation—can indicate the baby’s brain isn’t receiving adequate oxygen. When healthcare providers fail to properly interpret these warning signs or delay taking action, the baby may suffer oxygen deprivation that leads to HIE.

Delayed Emergency Cesarean Section

When fetal monitoring shows clear signs of distress, an emergency cesarean section is often necessary to prevent brain injury. The standard of care generally requires that hospitals be able to perform an emergency C-section within 30 minutes of making the decision. Delayed C-section delivery when a baby is in distress can result in HIE that would have been prevented by timely surgical intervention.

Situations that may require emergency cesarean delivery include:

• Umbilical cord prolapse
• Placental abruption  
• Uterine rupture
• Severe, persistent fetal distress
• Failed operative vaginal delivery (vacuum or forceps)
• Shoulder dystocia that cannot be quickly resolved

When doctors delay the decision to perform a C-section, attempt prolonged conservative management despite clear fetal distress, or fail to have the necessary resources available to perform emergency surgery quickly, they may be liable for resulting HIE.

Improper Use of Delivery Instruments

Vacuum extraction injuries and forceps delivery injuries can contribute to HIE when instruments are used improperly. Excessive traction, too many attempts at operative delivery, or using instruments when contraindicated can cause trauma and oxygen deprivation.

Current guidelines recommend abandoning operative vaginal delivery after a certain number of unsuccessful attempts and proceeding to cesarean section. Continuing to pull with forceps or vacuum when the baby isn’t descending can compress the umbilical cord, cause skull injuries, and deprive the baby of oxygen.

Failure to Treat Maternal Conditions

Healthcare providers must properly manage maternal medical conditions that could compromise the baby’s oxygen supply. Failure to treat preeclampsia, failure to control maternal diabetes, or failure to recognize and respond to maternal infections can all contribute to HIE.

Doctors should also recognize when labor induction or augmentation with medications like Pitocin creates excessive uterine contractions (tachysystole) that prevent adequate placental blood flow between contractions. Labor induction complications can be prevented when medical staff properly monitors contraction patterns and reduces or stops Pitocin when contractions become too frequent or too strong.

Inadequate Resuscitation After Birth

Even when oxygen deprivation occurs during delivery, proper resuscitation can minimize brain injury. Medical staff should be trained in neonatal resuscitation and must have the necessary equipment immediately available. Delays in providing ventilation, delays in intubating a baby who isn’t breathing adequately, or failure to provide chest compressions when needed can worsen HIE or cause brain injury that would otherwise have been avoided.

A birth injury lawyer experienced in handling HIE cases can review your medical records, consult with medical experts, and help you understand whether negligence contributed to your child’s injury. Get answers about your child’s birth injury through a free, confidential case review today.

How HIE Is Diagnosed in Newborns

Diagnosing hypoxic ischemic encephalopathy requires a combination of clinical findings, laboratory tests, and brain imaging. Early and accurate diagnosis is critical because treatment must begin within six hours of birth to be most effective.

Clinical Assessment

Doctors first evaluate the baby’s clinical presentation, looking for the signs and symptoms described earlier. They assess the baby’s level of consciousness, muscle tone, reflexes, and presence of seizures. The medical team reviews what happened during labor and delivery, including:

• Duration of labor and any complications
• Fetal heart rate patterns during labor
• Whether the baby required resuscitation at birth
• Apgar scores at one, five, and ten minutes
• Whether meconium was present in the amniotic fluid

This clinical picture helps doctors determine whether HIE is likely and how severe it may be.

Umbilical Cord Blood Gas Analysis

One of the most important tests for diagnosing HIE is umbilical cord blood gas analysis. Immediately after delivery, doctors can draw blood from the umbilical cord to measure oxygen and carbon dioxide levels, as well as pH and base deficit.

A pH below 7.0 in umbilical artery blood indicates significant acidosis—acid buildup in the baby’s blood that occurs when oxygen levels are low. A base deficit greater than 12 mmol/L also indicates the baby experienced significant oxygen deprivation.

These objective measurements help confirm that oxygen deprivation occurred around the time of birth, supporting the HIE diagnosis. However, normal cord blood gases don’t completely rule out HIE, as some babies may have experienced intermittent oxygen deprivation or may develop encephalopathy from other causes.

Brain Imaging Studies

Magnetic resonance imaging (MRI) is the best imaging test for evaluating brain injury in babies with HIE. However, MRI findings may not be visible immediately after birth. The optimal time for MRI is typically between days 2 and 8 after birth, when injury patterns become most apparent.

MRI can show specific patterns of brain injury that are characteristic of HIE, helping doctors understand the extent and location of damage. These patterns help predict which functions may be affected long-term. Diffusion-weighted imaging (DWI), a special type of MRI, can detect brain injury even earlier than conventional MRI.

Computed tomography (CT) scans are sometimes used in the first hours after birth, though they’re less sensitive than MRI for detecting the type of brain injury that occurs with HIE. CT scans expose babies to radiation, so MRI is preferred when timing allows.

Cranial ultrasound can be performed at the bedside and doesn’t require sedation, making it useful for very sick babies who can’t safely be transported to the MRI scanner. However, ultrasound is less sensitive than MRI for detecting the patterns of injury typical of HIE.

Electroencephalogram (EEG)

An electroencephalogram measures electrical activity in the brain and can detect seizures, including subtle seizures that aren’t visible. Many babies with moderate or severe HIE undergo continuous EEG monitoring (called amplitude-integrated EEG or aEEG) to detect seizures and monitor brain function.

The background pattern on EEG also provides information about the severity of brain injury and can help predict outcomes. Severely abnormal EEG patterns, such as burst suppression or flat tracings, indicate more serious brain injury.

Laboratory Tests

Blood tests help evaluate organ function and identify complications of HIE. Babies with HIE may have abnormalities in liver function, kidney function, and blood clotting. Testing for infections is also important, as sepsis can cause symptoms similar to HIE or can occur alongside HIE.

Cooling Therapy: The Standard Treatment for HIE

Therapeutic hypothermia, commonly called cooling therapy or brain cooling, is the only proven treatment that can reduce brain damage from HIE. This treatment must be started within six hours of birth to be effective, making rapid diagnosis critical.

How Cooling Therapy Works

During cooling therapy, the baby’s body temperature is reduced from the normal 98.6°F (37°C) to approximately 92.3°F (33.5°C) for 72 hours. This cooling slows the baby’s metabolism and reduces the secondary brain injury that occurs in the hours and days after oxygen deprivation.

The therapy works by interrupting the cascade of cellular processes that lead to brain cell death after oxygen deprivation is restored. Cooling reduces inflammation, decreases harmful chemical reactions, and allows brain cells that might otherwise die to recover.

There are two methods of therapeutic hypothermia:

Selective head cooling uses a special cap placed on the baby’s head to cool the brain specifically, while the body temperature is maintained at slightly below normal.

Whole body cooling places the baby on a special cooling blanket that reduces the entire body temperature. This is the more commonly used method in the United States.

Criteria for Cooling Therapy

Not every baby with HIE is a candidate for cooling therapy. Doctors use specific criteria to determine which infants should receive treatment:

• Baby must be at least 36 weeks gestational age (late preterm or full-term)
• HIE must be moderate or severe (mild HIE doesn’t benefit from cooling)
• Baby must be less than 6 hours old when treatment starts
• Evidence of oxygen deprivation must be present (low Apgar scores, need for resuscitation, abnormal cord blood gases)
• Clinical signs of encephalopathy must be present

Babies who meet these criteria are transferred to a neonatal intensive care unit (NICU) equipped to provide cooling therapy. Throughout the 72-hour cooling period, medical staff carefully monitors the baby’s temperature, brain activity, heart rate, blood pressure, and organ function.

Effectiveness of Cooling Therapy

Research has demonstrated that therapeutic hypothermia significantly improves outcomes for babies with moderate to severe HIE. According to studies published in the New England Journal of Medicine and other peer-reviewed journals, cooling therapy reduces the risk of death or severe disability by approximately 25% compared to babies who don’t receive treatment.

Among survivors, cooling therapy increases the likelihood of normal neurological development and reduces the severity of disabilities in those who do develop impairments. The treatment improves outcomes for both moderate and severe HIE, though babies with severe HIE still face significant risks.

The benefits of cooling therapy continue to be apparent as children grow. Long-term follow-up studies show that cooled infants have better cognitive outcomes, motor function, and quality of life compared to similar babies who weren’t cooled.

What Happens After Cooling

After 72 hours of cooling, doctors slowly rewarm the baby over 6-12 hours. Rapid rewarming can cause complications, so the temperature increase is carefully controlled. Once the baby reaches normal temperature, intensive care continues with focus on:

• Controlling seizures with anti-epileptic medications if needed
• Supporting breathing and blood pressure
• Maintaining normal blood sugar levels
• Providing nutrition (often through IV initially, then transitioning to feeding)
• Monitoring for complications affecting organs other than the brain

Many babies remain in the NICU for several weeks as they recover and as doctors assess the extent of injury and prognosis.

When Cooling Therapy Isn’t Provided

Unfortunately, some hospitals don’t have the capability to provide therapeutic hypothermia, and some healthcare providers fail to recognize HIE quickly enough to initiate treatment within the six-hour window. When medical professionals fail to diagnose HIE, fail to transfer the baby to a facility capable of providing cooling therapy, or delay treatment beyond the critical six-hour window, they may be liable for medical malpractice.

If your baby had signs of HIE but didn’t receive cooling therapy, or if treatment was delayed, an attorney specializing in birth injury cases can help determine whether negligence occurred.

Other Treatments and Supportive Care for HIE

While cooling therapy is the primary treatment that can modify HIE outcomes, babies with this condition require comprehensive supportive care to manage symptoms and complications.

Seizure Management

Seizures occur in 50-60% of babies with moderate to severe HIE. Controlling seizures is important because ongoing seizure activity can worsen brain injury. Doctors use anti-epileptic medications such as phenobarbital as the first-line treatment. If seizures don’t respond to phenobarbital, other medications like fosphenytoin, levetiracetam, or lidocaine may be tried.

Continuous EEG monitoring helps doctors confirm that medications are controlling seizures, as many seizures in newborns are subtle and not visible to observers.

Respiratory Support

Many babies with HIE have difficulty breathing and require ventilator support. The medical team carefully manages oxygen levels—too little oxygen can worsen brain injury, but too much oxygen can also cause harm. Maintaining normal carbon dioxide levels is also important, as abnormal carbon dioxide affects blood flow to the brain.

Blood Pressure Management

Maintaining normal blood pressure ensures adequate blood flow to the brain and other organs. Some babies with HIE have low blood pressure that requires treatment with IV fluids or medications. Others may have high blood pressure that needs to be controlled.

Nutrition and Fluid Management

Babies with moderate or severe HIE often cannot feed by mouth initially. They receive IV fluids carefully calculated to provide adequate hydration and nutrition without causing fluid overload. As the baby’s condition improves, doctors introduce milk feedings—either breast milk or formula—typically through a tube initially, then transitioning to bottle or breastfeeding as the baby becomes able to coordinate sucking and swallowing.

Treatment of Other Organ Dysfunction

HIE can affect organs beyond the brain. Healthcare providers monitor and support:

Kidney function – HIE can cause acute kidney injury requiring careful fluid management and occasionally dialysis

Liver function – Liver injury can affect blood clotting and require treatment with vitamin K or blood products

Heart function – Some babies develop heart muscle dysfunction that requires medication support

Blood sugar – Both low blood sugar (hypoglycemia) and high blood sugar (hyperglycemia) can worsen brain injury and require careful monitoring and management

Emerging and Experimental Treatments

Researchers are investigating additional treatments that might improve outcomes for HIE beyond cooling therapy. These experimental approaches include:

Erythropoietin (EPO) – This medication, usually used to treat anemia, may have neuroprotective properties. Clinical trials are studying whether EPO combined with cooling therapy improves outcomes.

Melatonin – This natural hormone has antioxidant properties and may reduce brain injury. Research is in early stages.

Stem cell therapy – Some centers are investigating whether umbilical cord blood stem cells or other stem cell treatments might help repair brain injury.

Xenon gas – This inert gas may have neuroprotective properties when combined with cooling therapy. Studies are ongoing.

Magnesium sulfate – While primarily studied for preventing cerebral palsy in premature infants, magnesium is being investigated for potential benefits in term infants with HIE.

These treatments are not yet standard of care and are only available through research protocols at specialized centers. Families interested in experimental treatments should discuss options with their neonatal care team.

Long-Term Prognosis and Outcomes After HIE

One of the first questions parents ask after their baby is diagnosed with HIE is: “What will my child’s future be like?” Prognosis varies considerably depending on the severity of HIE and the extent of brain injury.

Factors That Affect Prognosis

Several factors help doctors predict outcomes:

Severity of HIE – Babies with mild HIE have excellent prognosis, with most developing normally. Moderate HIE has variable outcomes—some children recover fully while others develop disabilities. Severe HIE carries the highest risk of death or severe impairment.

MRI findings – The pattern and extent of brain injury visible on MRI provides valuable prognostic information. Injury to the basal ganglia and thalamus typically indicates worse outcomes than isolated injury to the cortex. Extensive injury involving multiple brain regions predicts more severe disabilities.

EEG patterns – The background EEG pattern during the first days of life correlates with outcomes. Normal or mildly abnormal patterns predict better outcomes, while severely abnormal patterns indicate higher risk of disability or death.

Clinical course – How quickly the baby improves after birth provides clues about prognosis. Babies who show rapid improvement in the first week generally have better outcomes than those who remain critically ill for prolonged periods.

Response to cooling therapy – While all eligible babies should receive cooling therapy, those who show clinical improvement during treatment tend to have better long-term outcomes.

Outcomes for Mild HIE

Children with mild HIE typically develop normally. Most meet developmental milestones on time and attend regular school without special education services. Some studies suggest that even mild HIE may be associated with subtle learning differences, attention challenges, or executive function difficulties that become apparent in school-age children, but these are generally minor and don’t prevent children from leading normal, fulfilling lives.

Outcomes for Moderate HIE

Moderate HIE has the most variable prognosis. Among babies with moderate HIE who receive cooling therapy, approximately 40-50% develop normally without significant disabilities. The remaining 50-60% may experience a range of outcomes from mild learning disabilities to severe impairments.

Common long-term effects of moderate HIE include:

Motor impairments – Some children develop cerebral palsy affecting their ability to walk, use their hands, or control body movements. The severity ranges from mild clumsiness to inability to walk or care for oneself.

Cognitive impairments – Intellectual disabilities can range from mild learning challenges to severe cognitive impairment requiring lifelong support.

Epilepsy – Approximately 20-30% of children with moderate HIE develop seizure disorders requiring ongoing medication.

Vision and hearing problems – Brain injury can affect the parts of the brain that process visual and auditory information, even when the eyes and ears themselves are normal.

Speech and language delays – Many children with moderate HIE require speech therapy to develop communication skills.

Behavioral and emotional challenges – Some children experience ADHD, anxiety, autism spectrum features, or other behavioral differences.

Outcomes for Severe HIE

Severe HIE carries the worst prognosis. Approximately 50% of babies with severe HIE die in the newborn period. Among survivors, the majority develop significant disabilities. Most children who survive severe HIE have spastic cerebral palsy, often affecting all four limbs (spastic quadriplegia). Many cannot walk independently and require wheelchairs or other mobility devices.

Intellectual disability is common and often severe, affecting the child’s ability to communicate, learn self-care skills, and achieve independence. Many children with severe HIE require extensive support throughout their lives, including:

• Assistance with feeding, bathing, dressing, and toileting
• Specialized wheelchairs and positioning equipment
• Communication devices for those who cannot speak
• Medication for seizures, muscle spasticity, and other complications
• Gastrostomy tubes for nutrition if swallowing is unsafe
• Ongoing physical, occupational, and speech therapy

Importance of Early Intervention

Regardless of HIE severity, early intervention services can optimize each child’s potential. Starting therapies in infancy takes advantage of the brain’s plasticity—its ability to reorganize and form new connections. Early intervention programs provide:

• Physical therapy to improve motor skills and prevent contractures
• Occupational therapy to develop self-care abilities and hand function
• Speech therapy for communication and feeding skills
• Developmental therapy to encourage cognitive growth
• Family education and support

Children who receive early, intensive therapy often achieve better outcomes than those who don’t access these services. Even children with severe disabilities can make progress and improve their quality of life through appropriate interventions.

Don’t wait to get answers if you believe medical negligence caused your child’s HIE. A birth injury attorney can help you understand your legal rights and pursue compensation to pay for your child’s current and future care needs.

Life Expectancy with HIE

Parents understandably worry about their child’s life expectancy after an HIE diagnosis. The answer depends on the severity of injury and resulting disabilities.

Children with mild HIE who develop normally have typical life expectancies. Those with moderate HIE and mild to moderate disabilities also generally have normal or near-normal life spans, though some may face health challenges related to their condition.

Life expectancy is more significantly affected in children with severe HIE who develop profound disabilities. Factors that impact life expectancy include:

Severity of cerebral palsy – Children with mild cerebral palsy affecting primarily the legs generally have normal life expectancies. Those with severe spastic quadriplegia and profound intellectual disability face higher mortality risks, particularly in the first years of life.

Ability to swallow safely – Children who cannot swallow safely are at risk for aspiration pneumonia, one of the leading causes of death in people with severe cerebral palsy. Many require feeding tubes to provide nutrition while protecting their airways.

Seizure control – Poorly controlled epilepsy increases mortality risk. Status epilepticus (prolonged seizures) and sudden unexpected death in epilepsy (SUDEP) are concerns.

Respiratory function – Weakness of respiratory muscles, scoliosis affecting lung expansion, and recurrent pneumonia can shorten life expectancy.

Mobility level – Children who cannot move independently are at higher risk for respiratory complications, pressure sores, and other secondary conditions.

According to research published in developmental medicine journals, children with mild cerebral palsy have a life expectancy close to that of the general population. Those with moderate disabilities may have life expectancy reduced by 10-15 years on average. Children with the most severe impairments—unable to walk, talk, or feed themselves, with poorly controlled seizures—face the highest mortality risk, with some studies showing life expectancy into the teens or twenties, though many individuals exceed these estimates with good medical care.

It’s important to remember that these are population statistics and don’t predict any individual child’s outcome. Many children with even severe disabilities live longer than average with excellent medical care, loving support, and appropriate interventions. Medical advances continue to improve outcomes and extend life expectancy for people with disabilities.

Filing an HIE Birth Injury Lawsuit

If medical negligence caused your child’s hypoxic ischemic encephalopathy, you have the right to pursue legal action. A birth injury lawsuit can provide compensation to cover your child’s extensive medical needs and support your family through this difficult time.

When to Consider Legal Action

You should consult with a birth injury attorney if you have concerns that medical errors contributed to your child’s HIE. Warning signs that malpractice may have occurred include:

• Fetal heart rate monitors showed concerning patterns that were ignored or not recognized
• You or medical staff expressed concerns during labor that were dismissed
• Your baby required extensive resuscitation at birth
• Emergency cesarean delivery was delayed despite signs of fetal distress
• Your baby didn’t receive cooling therapy despite having HIE
• Medical records show disagreement among staff about how to manage your labor
• The medical team has been evasive about answering questions or has suggested the injury was unavoidable when you have doubts

How Birth Injury Cases Work

Birth injury lawsuits are a type of medical malpractice claim. To succeed, you must prove four elements:

Duty – The healthcare providers had a duty to provide care that met accepted medical standards

Breach – The providers failed to meet those standards (committed negligence)

Causation – The negligence directly caused your child’s HIE and resulting disabilities

Damages – Your family suffered actual harm as a result

Proving these elements requires extensive evidence, including detailed review of medical records, testimony from medical experts in obstetrics and neonatology, and documentation of your child’s injuries and needs.

The Legal Process

Filing a birth injury lawsuit typically involves these steps:

Free consultation – You meet with a birth injury lawyer to discuss what happened. The attorney evaluates whether your case has merit.

Investigation – If the attorney believes you have a case, they’ll request your medical records and have them reviewed by medical experts.

Expert review – Specialists in obstetrics, neonatal medicine, and neurology review the records to determine whether the standard of care was met and whether negligence caused the injury.

Filing the complaint – If experts confirm malpractice occurred, your attorney files a legal complaint in the appropriate court.

Discovery – Both sides exchange information. Your attorney deposes (formally questions) the doctors, nurses, and other healthcare providers involved in your care. Defense attorneys may depose you and request medical examinations of your child.

Settlement negotiations – Many birth injury cases settle before trial. Your attorney negotiates with the defense to reach a fair settlement amount.

Trial – If settlement isn’t reached, the case proceeds to trial where a jury decides whether malpractice occurred and what compensation you should receive.

The entire process typically takes 2-4 years, though some cases resolve more quickly through settlement while others take longer if they go to trial.

Statute of Limitations for HIE Cases

Every state has time limits—called statutes of limitations—for filing medical malpractice lawsuits. These deadlines vary by state and can be complex in birth injury cases.

Most states have special rules for injuries to children. While the standard statute of limitations might be two years from the date of injury for adults, many states extend this deadline for babies. Some states allow lawsuits to be filed until the child reaches a certain age, such as the child’s 18th birthday or a certain number of years after the injury was discovered.

However, some states impose absolute deadlines regardless of the child’s age, and many have specific procedural requirements that must be met before filing suit. Because these laws are complex and vary significantly by state, it’s important to consult with an attorney promptly after your child’s diagnosis rather than waiting.

Missing the statute of limitations deadline means you lose your right to pursue compensation, regardless of how clear the malpractice was. Don’t risk losing your legal rights—contact a birth injury lawyer to understand the deadlines that apply to your case. Learn more about time limits in different states at our birth injury statute of limitations page.

Compensation Available in HIE Cases

Birth injury lawsuits can provide compensation for both economic and non-economic damages.

Economic damages cover financial losses, including:

• Past and future medical expenses
• Costs of physical, occupational, and speech therapy
• Specialized equipment (wheelchairs, communication devices, home modifications)
• Medications and medical supplies
• Special education services
• Lost earning capacity (compensation for the child’s inability to work in adulthood)
• Parental lost wages for time spent caring for the child

Non-economic damages compensate for intangible losses such as:

• The child’s pain and suffering
• Loss of enjoyment of life
• Emotional distress
• Loss of normal childhood experiences

In cases involving particularly egregious negligence, some states allow punitive damages designed to punish the defendant and deter similar conduct in the future.

The value of HIE cases varies tremendously depending on the severity of injury, the strength of the malpractice evidence, and the child’s specific needs. Cases involving severe HIE with profound disabilities often result in multi-million dollar settlements or verdicts because the child will require expensive care for their entire life.

Working on Contingency Fee

Most birth injury attorneys work on a contingency fee basis, meaning you pay no upfront costs and the attorney only receives payment if you win your case. The attorney’s fee is a percentage of the recovery, typically 30-40%. This arrangement allows families to pursue justice without having to pay hourly legal fees that could easily exceed hundreds of thousands of dollars.

If you don’t recover compensation, you don’t owe attorney fees, though you may be responsible for case costs (expert witness fees, medical record fees, court filing fees) depending on your specific agreement. Many attorneys advance these costs during the case and only recoup them if you win.

To understand the potential value of HIE cases, visit our page on birth injury settlements.

Finding the Right Birth Injury Lawyer for Your HIE Case

Choosing an attorney to handle your child’s HIE case is one of the most important decisions you’ll make. Birth injury lawsuits are among the most complex medical malpractice cases, requiring attorneys with specific experience and resources.

What to Look for in a Birth Injury Attorney

Experience with HIE cases specifically – Birth injuries encompass many different conditions. Look for an attorney who has successfully handled HIE cases, not just general medical malpractice. They should understand the medical complexities of oxygen deprivation, brain injury, cooling therapy, and long-term effects.

Track record of results – Ask about the attorney’s history of settlements and verdicts in birth injury cases. While past results don’t guarantee future outcomes, they demonstrate the attorney’s ability to achieve substantial compensation for clients.

Resources to handle complex litigation – Birth injury cases require significant upfront investment in medical expert witnesses, often costing $50,000-$100,000 or more before trial. The law firm must have the financial resources to properly investigate and litigate your case.

Access to medical experts – The attorney should have relationships with respected experts in obstetrics, neonatal medicine, neurology, and life care planning who can testify about what went wrong and what your child will need throughout their life.

Clear communication – Your attorney should explain complex medical and legal concepts in language you understand and should keep you informed throughout the legal process. You should feel comfortable asking questions and confident that your concerns are heard.

Compassion and understanding – Dealing with a birth injury is emotionally devastating. Your attorney should demonstrate genuine empathy for your situation while also being a strong advocate for your rights.

Questions to Ask Potential Attorneys

When consulting with birth injury lawyers, ask:

• How many HIE cases have you handled?
• What were the outcomes in those cases?
• Who will actually work on my case? (Some large firms assign cases to junior attorneys after the initial consultation with a senior partner.)
• What medical experts will you consult for my case?
• How do you communicate with clients throughout the process?
• What is your contingency fee percentage and what costs will I be responsible for?
• What is the likely timeline for my case?
• What do you see as the strengths and challenges in my case?

Why You Need an Attorney Who Specializes in Birth Injuries

Some families consider hiring a general personal injury attorney to handle their birth injury case. While any licensed attorney can technically file a lawsuit, birth injury cases require specialized knowledge that general practitioners don’t have.

A birth injury lawyer must understand complex obstetrical care, fetal monitoring interpretation, neonatal resuscitation, brain injury mechanisms, and long-term neurological outcomes. They must know what questions to ask medical experts, which records are most important, and how to present medical evidence to a jury.

Defense attorneys for hospitals and doctors are highly specialized and work with the best medical experts money can buy. To level the playing field, you need an attorney who specializes in birth injury cases and has the experience and resources to take on these powerful defendants.

Free Case Evaluations

Most birth injury attorneys offer free, no-obligation case evaluations. You can discuss what happened during your child’s birth, share your concerns, and get an honest assessment of whether you have a case worth pursuing.

The consultation is confidential—everything you share is protected by attorney-client privilege even if you don’t ultimately hire that lawyer. There’s no risk in seeking this consultation and getting answers about what happened to your child.

If you believe medical negligence caused your baby’s HIE, contact an experienced birth injury attorney today. Time limits apply, and the sooner you begin investigating your case, the better preserved the evidence will be and the more time you’ll have to build a strong claim. Speak with a qualified lawyer specializing in HIE cases for a free, confidential evaluation of your legal options.

Frequently Asked Questions About Hypoxic Ischemic Encephalopathy (HIE)