HIE Treatment: Cooling Therapy and Other Critical Interventions
When your newborn is diagnosed with hypoxic-ischemic encephalopathy (HIE), immediate medical intervention becomes critical. HIE treatment centers on therapeutic hypothermia—commonly called cooling therapy—a time-sensitive protocol that must begin within six hours of birth to protect your baby’s brain from further injury. Beyond cooling therapy, HIE intervention includes respiratory support, seizure management, and comprehensive monitoring to stabilize your child and minimize long-term complications.
If your baby developed HIE and you suspect delayed treatment or medical errors contributed to the severity of the injury, you may have legal options. A birth injury attorney can review your case at no cost and help you understand whether malpractice occurred. Because statute of limitations deadlines apply, 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 HIE treatment
- Therapeutic hypothermia (cooling therapy)
- The six-hour treatment window
- HIE cooling protocol steps
- Supportive care and monitoring
- Treatment for HIE complications
- Recovery and rewarming process
- When delayed treatment is malpractice
- Long-term therapies and rehabilitation
- Finding a birth injury lawyer
- Frequently asked questions
What Is HIE Treatment?

Unlike the initial oxygen deprivation, which typically occurs during labor and delivery, secondary brain injury results from a cascade of harmful biological processes. These include inflammation, cell death, seizures, and metabolic dysfunction that continue damaging brain tissue even after oxygen flow is restored.
The most effective HIE treatment is therapeutic hypothermia, which cools the baby’s body or brain to slow these destructive processes. According to research published in the New England Journal of Medicine, cooling therapy significantly reduces death and disability when administered promptly to infants with moderate to severe hypoxic-ischemic encephalopathy.
Treatment decisions depend on the severity of HIE. Babies with mild HIE may require only close monitoring and supportive care, while those with moderate or severe HIE need immediate cooling therapy along with aggressive management of complications.
Therapeutic Hypothermia: The Gold Standard for HIE Treatment
Therapeutic hypothermia has become the standard of care for newborns with moderate to severe HIE. This cooling therapy HIE protocol involves carefully lowering your baby’s body temperature to approximately 33.5 degrees Celsius (92.3 degrees Fahrenheit) for 72 hours.
The treatment works by slowing the metabolic rate of brain cells, reducing inflammation, and preventing the biochemical cascade that causes secondary brain injury. Studies show that therapeutic hypothermia newborn treatment reduces the risk of death or major disability by approximately 25 percent when properly administered.
Two main approaches exist for delivering cooling therapy:
Selective head cooling uses a specialized cap filled with circulating cold water to cool the brain while maintaining a slightly warmer core body temperature. This method targets the brain directly while minimizing effects on other organs.
Whole-body cooling uses a cooling blanket or mat placed under the baby to lower the entire body temperature uniformly. This approach is more commonly used in the United States and is generally considered easier to implement and monitor.
Both methods have shown similar effectiveness in clinical trials. The choice between them often depends on available equipment and hospital protocols.
Your baby will be cared for in the neonatal intensive care unit (NICU) throughout the cooling process. Continuous monitoring tracks temperature, heart rate, blood pressure, oxygen levels, and brain activity to ensure the treatment remains safe and effective.
The Critical Six-Hour Treatment Window
The most important factor in HIE treatment effectiveness is time. Therapeutic hypothermia must begin within six hours of birth to provide maximum benefit. This narrow window exists because the secondary brain injury cascade begins immediately after the initial hypoxic event and accelerates rapidly in the first few hours of life.
Research demonstrates that cooling therapy started within the first three hours after birth provides the greatest protection. Effectiveness decreases as time passes, and treatment initiated after the six-hour window offers substantially reduced benefits.
This time constraint means medical teams must act quickly when HIE birth injury is suspected. Warning signs that should prompt immediate evaluation include:
Low Apgar scores at five and ten minutes after birth indicate ongoing difficulties with breathing, heart rate, or neurological function. A score below seven suggests possible HIE.
Need for extensive resuscitation signals that your baby experienced significant oxygen deprivation. Prolonged resuscitation efforts correlate with higher HIE risk.
Abnormal muscle tone—either too floppy (hypotonia) or too stiff (hypertonia)—suggests neurological injury. Medical staff should recognize this as a potential HIE symptom requiring urgent assessment.
Seizures in the first hours after birth are a serious sign of brain injury. Any seizure activity in a newborn warrants immediate investigation for HIE.
Altered consciousness or difficulty staying awake can indicate brain dysfunction. A baby who is abnormally lethargic or difficult to rouse needs emergency evaluation.
When these warning signs appear, healthcare providers should perform rapid diagnostic testing to confirm HIE and determine whether cooling therapy is appropriate. Delays in recognition, testing, or treatment initiation can constitute medical negligence.
If your medical team failed to identify HIE symptoms or delayed starting therapeutic hypothermia, your child may have experienced preventable worsening of brain injury. Contact a birth injury attorney to review whether substandard care contributed to your baby’s condition.
The HIE Cooling Protocol: Step-by-Step Process
The HIE cooling protocol follows a standardized process designed to maximize safety and effectiveness. Understanding these steps helps you know what to expect if your baby requires this treatment.
Initial Assessment and Stabilization (0-1 hours)
Medical staff first stabilize your baby’s vital functions. This includes establishing adequate breathing—often with mechanical ventilation—securing intravenous access for medications and fluids, and performing initial blood tests to assess organ function and blood gas levels.
During this phase, the medical team evaluates whether your baby meets criteria for cooling therapy. Generally, candidates must be at least 36 weeks gestational age, less than six hours old, and show evidence of moderate to severe HIE based on neurological examination and sometimes additional testing like amplitude-integrated electroencephalography (aEEG).
Cooling Initiation (1-6 hours)
Once the decision is made to proceed with therapeutic hypothermia, cooling begins as quickly as possible. The cooling device—either a head cap or body blanket—is applied, and your baby’s temperature is carefully lowered over approximately one to two hours.
Temperature reduction must occur gradually to avoid complications. Medical staff continuously monitor core body temperature using a rectal or esophageal probe to ensure precise temperature control.
Maintenance Phase (72 hours)
Your baby remains at the target temperature of 33.5 degrees Celsius for exactly 72 hours. Throughout this period, intensive monitoring continues around the clock.
The medical team watches for and manages potential complications of cooling therapy, including changes in heart rate and blood pressure, increased bleeding risk due to effects on blood clotting, and fluctuations in blood sugar levels.
Medications may be needed to keep your baby comfortable during cooling. Sedatives help prevent shivering, which would work against the cooling process and increase metabolic demand on the brain.
Rewarming Phase (6-12 hours)
After 72 hours of cooling, your baby is slowly warmed back to normal body temperature. This rewarming must occur very gradually—typically at a rate of 0.5 degrees Celsius per hour—to prevent sudden physiological changes that could harm your child.
Rapid rewarming can cause complications including seizures, blood pressure instability, and metabolic disturbances. The controlled rewarming process usually takes between six and twelve hours.
Post-Rewarming Care
Once your baby reaches normal temperature, intensive monitoring continues. The medical team assesses neurological status, watches for delayed seizures or other complications, and performs diagnostic imaging—usually MRI—to evaluate the extent of brain injury.
This information helps doctors provide you with a more accurate prognosis and plan appropriate follow-up care and early intervention services.
Supportive Care and Monitoring During HIE Treatment

Respiratory Support
Many infants with moderate to severe HIE require mechanical ventilation to maintain adequate oxygenation. The breathing tube and ventilator ensure your baby receives sufficient oxygen while the brain heals, preventing additional hypoxic injury.
Ventilator settings are carefully adjusted based on continuous monitoring of blood oxygen and carbon dioxide levels. Too much or too little of either can affect brain injury progression.
Seizure Management
Seizures occur in approximately 40-60 percent of babies with moderate to severe HIE. These seizures can worsen brain injury and must be treated promptly.
Continuous EEG monitoring—called amplitude-integrated electroencephalography (aEEG)—helps medical staff detect seizures quickly, including subclinical seizures that aren’t visible externally. Anti-seizure medications like phenobarbital are administered when seizure activity is detected.
Cardiovascular Support
HIE can affect heart function and blood pressure regulation. Some babies need medications to support blood pressure and maintain adequate blood flow to the brain and other organs.
Careful fluid management is necessary because both dehydration and fluid overload can complicate HIE recovery.
Blood Sugar Control
Abnormal blood glucose levels—both high and low—can worsen brain injury in babies with HIE. Medical staff monitor blood sugar closely and adjust intravenous fluids to maintain levels in the optimal range.
Organ Function Monitoring
HIE affects more than just the brain. Many babies with severe oxygen deprivation experience injury to other organs including the kidneys, liver, heart, and intestines. Blood tests track organ function throughout treatment, and interventions address any problems that develop.
A birth injury attorney can help determine whether your child received appropriate supportive care alongside cooling therapy or if gaps in treatment contributed to complications.
Treatment for HIE Complications
Even with optimal HIE treatment, complications can develop that require additional intervention.
Persistent Pulmonary Hypertension
This serious condition involves elevated blood pressure in the lungs, making it difficult for your baby to get adequate oxygen. Treatment may include specialized ventilation strategies, inhaled nitric oxide to dilate blood vessels in the lungs, or in severe cases, ECMO (extracorporeal membrane oxygenation), which temporarily takes over heart and lung function.
Feeding Difficulties
Babies who have experienced birth asphyxia often struggle with feeding due to poor coordination of sucking and swallowing or intestinal complications. A feeding tube may be necessary initially, with gradual transition to oral feeding as your baby recovers.
Metabolic Disturbances
HIE can cause problems with electrolyte balance, calcium levels, and other metabolic processes. These require careful monitoring and correction through intravenous medications and adjusted nutrition.
Infection Risk
Babies with HIE have increased susceptibility to infections. Medical teams watch closely for signs of sepsis and may administer antibiotics if infection is suspected or confirmed.
Your medical team should anticipate these potential complications and respond promptly when they occur. Failure to recognize or treat HIE-related complications appropriately may constitute medical negligence.
Recovery and Rewarming Process
The rewarming phase marks a critical transition in HIE treatment. After 72 hours at reduced temperature, your baby must return to normal body temperature through a carefully controlled process.
As mentioned earlier, rewarming occurs slowly—typically 0.5 degrees Celsius every hour—until your baby reaches 36.5-37 degrees Celsius. This gradual approach prevents the physiological stress that rapid temperature changes would cause.
During rewarming, medical staff watch carefully for complications including seizure activity that may have been suppressed during cooling, blood pressure fluctuations as the cardiovascular system adjusts, and changes in metabolic status.
Some babies tolerate rewarming without difficulty, while others experience setbacks. The medical team must be prepared to manage any problems that arise during this vulnerable period.
Once your baby reaches normal temperature and remains stable, diagnostic testing helps assess the effectiveness of treatment and the extent of remaining brain injury. MRI imaging performed between days seven and ten after birth provides valuable information about prognosis and helps guide long-term care planning.
Understanding what happened during your child’s birth and treatment is the first step toward getting answers—and getting your family the support you deserve.
When Delayed HIE Treatment Constitutes Medical Malpractice
Not all cases of HIE result from medical negligence, but failures in recognizing symptoms or initiating treatment promptly can constitute malpractice.
Failure to Recognize Warning Signs
Healthcare providers must identify signs of possible HIE immediately after birth. When medical staff overlook symptoms like low Apgar scores, need for resuscitation, abnormal muscle tone, or early seizures, delayed diagnosis prevents timely treatment.
Delay in Starting Cooling Therapy
Even when HIE is recognized, delays in initiating therapeutic hypothermia can harm your baby. Every hour that passes reduces the effectiveness of cooling therapy. Delays may result from inadequate staffing, lack of equipment, failure to transfer your baby to an appropriate facility, or poor communication between medical team members.
Hospitals that deliver babies—particularly those with high-risk obstetric services—should have protocols in place for rapid HIE assessment and treatment initiation. Facilities without cooling capabilities must have transfer agreements with hospitals that can provide this specialized care.
Inadequate Monitoring During Treatment
Throughout the 72-hour cooling period and subsequent rewarming, continuous monitoring is necessary to ensure treatment safety and effectiveness. Failures in monitoring can lead to complications including temperature control problems, unrecognized seizures, or organ dysfunction that worsens outcomes.
Improper Cooling Protocol Implementation
Medical staff must follow established cooling protocols precisely. Errors like cooling too rapidly or slowly, maintaining incorrect target temperature, rewarming too quickly, or failing to manage complications appropriately can reduce treatment effectiveness or cause additional harm.
If you believe delayed treatment or improper implementation of the HIE cooling protocol contributed to your child’s injuries, consult with a birth injury attorney who can review your medical records. An experienced lawyer will work with medical experts to determine whether the care your baby received met accepted standards.
Many families don’t realize that medical malpractice during birth can occur not only during labor and delivery but also in the critical hours afterward when HIE treatment should begin. Legal action may be appropriate when healthcare providers failed to act quickly enough to protect your baby’s brain.
Long-Term Therapies and Rehabilitation After HIE
HIE treatment doesn’t end when your baby leaves the NICU. Children who experienced hypoxic-ischemic encephalopathy often need ongoing therapies and interventions to maximize their development and quality of life.
Early Intervention Services
Most states offer early intervention programs for infants and toddlers with developmental delays or disabilities. These services typically include physical therapy to improve motor skills and muscle control, occupational therapy to develop fine motor skills and daily living abilities, and speech therapy to support communication and feeding skills.
Starting these therapies early—often in the first months of life—takes advantage of brain plasticity during critical developmental periods and can significantly improve outcomes.
Treatment for Cerebral Palsy
Many children with moderate to severe HIE develop cerebral palsy, a group of disorders affecting movement and posture. Treatment may include ongoing physical and occupational therapy, medications to manage muscle stiffness or spasms, orthotic devices to support proper positioning and prevent contractures, and in some cases, surgical interventions to address muscle or bone problems.
Seizure Management
Children who develop epilepsy as a result of HIE require long-term treatment with anti-seizure medications. Some may need multiple medications or other interventions like special diets or even surgery if seizures prove difficult to control.
Educational Support
Depending on the severity of brain injury, your child may need special education services, classroom accommodations, or specialized learning programs. Early assessment and appropriate educational planning help your child reach their full potential.
Assistive Technology
Many children benefit from assistive devices including communication devices for those with speech difficulties, mobility aids like walkers or wheelchairs, adaptive equipment for daily activities, and computer-based learning tools.
The cost of these long-term therapies and interventions can be substantial. Families dealing with HIE often face hundreds of thousands or even millions of dollars in medical expenses over their child’s lifetime.
If medical negligence contributed to your child’s HIE or delayed treatment reduced the effectiveness of cooling therapy, you may be entitled to compensation that covers past and future medical costs, therapy and rehabilitation expenses, assistive devices and home modifications, special education needs, and lost parental income due to caregiving responsibilities.
Don’t wait to explore your legal options. Statute of limitations deadlines apply to birth injury cases, and waiting too long can prevent you from seeking compensation for your child’s injuries.
Finding a Birth Injury Lawyer

What to Look For in a Birth Injury Attorney
Choose a lawyer with specific experience handling HIE birth injury cases. These cases require understanding of complex medical concepts including fetal monitoring, oxygen deprivation mechanisms, cooling therapy protocols, and long-term neurological outcomes.
Look for an attorney who works with qualified medical experts who can review your records and provide opinions about whether care met accepted standards. Birth injury cases require expert testimony to establish that malpractice occurred.
Your lawyer should have the resources to handle expensive, complex litigation. Birth injury cases often involve substantial investigation, multiple expert witnesses, and lengthy court proceedings.
Questions to Ask During Your Consultation
How many HIE cases have you handled? Experience with this specific type of injury matters because HIE involves unique medical and legal issues.
What medical experts will review my case? The quality and qualifications of expert witnesses can make or break a birth injury lawsuit.
How long will my case take? Most birth injury cases take two to four years to resolve, though timelines vary based on case complexity and whether settlement is reached.
What expenses will I pay? Most birth injury attorneys work on contingency, meaning you pay no upfront costs and the lawyer receives payment only if you recover compensation. Understand what percentage of recovery the lawyer will receive and whether you’ll be responsible for case expenses if you don’t win.
Free Case Evaluation
Reputable birth injury law firms offer free, confidential case evaluations. During this consultation, an attorney reviews the basic facts of your case, discusses whether you may have grounds for legal action, and explains your options with no obligation to proceed.
This evaluation typically involves providing information about your pregnancy, labor, delivery, and your baby’s condition at birth, sharing medical records from your delivery and your baby’s NICU stay, and discussing the current status of your child’s health and development.
The attorney will assess whether evidence suggests medical negligence and whether your case falls within the statute of limitations for your state.
Your family may be entitled to significant compensation if substandard care caused or worsened your child’s brain injury. A birth injury lawyer can review your medical records and help determine whether healthcare providers failed to meet accepted standards of care. Contact an experienced attorney today for a free consultation.
Frequently Asked Questions About HIE Treatment
Therapeutic hypothermia, or cooling therapy, involves lowering a newborn’s body temperature to approximately 33.5 degrees Celsius for 72 hours after birth. This treatment slows the metabolic processes that cause secondary brain injury following oxygen deprivation. Research shows cooling therapy reduces the risk of death or major disability by approximately 25 percent when started within six hours of birth. The treatment must be administered in a neonatal intensive care unit with continuous monitoring throughout the cooling and rewarming phases.
Cooling therapy must begin within six hours of birth to provide meaningful benefit. The treatment is most effective when started within the first three hours after birth, with effectiveness decreasing as time passes. After the six-hour window closes, therapeutic hypothermia offers substantially reduced benefits. This narrow timeframe means medical teams must recognize HIE symptoms immediately and initiate treatment without delay. Failure to start cooling therapy promptly can constitute medical negligence if it results in worse outcomes for your baby.
Not all infants are candidates for therapeutic hypothermia. Generally, babies must be at least 36 weeks gestational age, less than six hours old, and show evidence of moderate to severe HIE based on clinical examination and sometimes additional testing. Babies with mild HIE typically don’t receive cooling therapy because the risks may outweigh benefits for less severe injury. Very premature infants usually aren’t candidates because cooling can cause complications in babies born significantly early. The medical team evaluates each baby individually to determine whether cooling therapy is appropriate.
After 72 hours of cooling, your baby undergoes a careful rewarming process that typically takes six to twelve hours. Temperature is raised gradually at approximately 0.5 degrees Celsius per hour to prevent complications from rapid temperature changes. Once your baby reaches normal temperature, intensive monitoring continues to watch for delayed seizures or other problems. Diagnostic imaging—usually MRI performed around day seven to ten—helps assess the extent of brain injury and provides information about likely long-term outcomes. Your baby may remain in the NICU for additional days or weeks depending on medical needs.
Cooling therapy significantly improves outcomes but doesn’t guarantee complete recovery. Even with optimal treatment, some babies with moderate to severe HIE will develop long-term complications including cerebral palsy, developmental delays, learning disabilities, seizure disorders, or vision and hearing problems. The severity of the initial brain injury, how quickly treatment began, and individual factors all influence outcomes. Cooling therapy reduces the risk and severity of these complications but cannot always prevent them entirely. Your medical team will provide ongoing assessments to monitor your child’s development.
You may have grounds for a medical malpractice lawsuit if healthcare providers failed to recognize HIE symptoms, delayed starting cooling therapy beyond the six-hour treatment window, or didn’t transfer your baby to a facility capable of providing therapeutic hypothermia. Not every case of HIE involves negligence, but when medical errors or delays worsen your baby’s condition, legal action may be appropriate. An experienced birth injury attorney can review your medical records and work with medical experts to determine whether the care your baby received met accepted standards. Statute of limitations deadlines apply, so consult with a lawyer promptly.
While cooling therapy is generally safe when properly administered, potential complications include changes in heart rate and blood pressure, increased bleeding risk due to effects on blood clotting, metabolic disturbances affecting blood sugar and electrolytes, and rarely, skin irritation from cooling equipment. Medical staff monitor your baby continuously throughout treatment to detect and manage any complications quickly. Most babies tolerate cooling therapy well when protocols are followed correctly. The benefits of treatment typically far outweigh the risks for babies with moderate to severe HIE.
HIE treatment in the neonatal intensive care unit can cost tens of thousands to hundreds of thousands of dollars depending on the length of stay and complexity of care needed. Most health insurance plans cover medically necessary NICU care including therapeutic hypothermia. However, families often face significant out-of-pocket expenses through deductibles, co-insurance, and services that insurance doesn’t fully cover. If medical negligence caused or worsened your child’s HIE, a successful birth injury lawsuit can help recover compensation for medical expenses, ongoing therapy costs, and other damages related to your child’s injury.
Most children who experienced moderate to severe HIE benefit from ongoing therapies including physical therapy, occupational therapy, and speech therapy. Early intervention services—available in most states for infants and toddlers with developmental delays—provide these therapies starting in the first months of life. The specific therapies your child needs depend on the extent of brain injury and how it affects development. Some children require intensive therapy for years, while others need less extensive support. Your medical team will recommend appropriate services and help connect you with early intervention programs. Long-term therapy costs can be substantial, making it important to explore legal options if negligence contributed to your child’s injury.
Determining whether medical negligence caused HIE requires careful review of medical records by qualified experts. Warning signs that may indicate malpractice include failure to monitor fetal heart rate appropriately during labor, delayed response to signs of fetal distress, improper use of delivery instruments like forceps or vacuum extractors, unnecessary delay in performing an emergency cesarean section, or medication errors during labor and delivery. Additionally, failures after birth—such as not recognizing HIE symptoms or delaying cooling therapy—can constitute negligence. A birth injury attorney can coordinate expert review of your records to determine whether the care you and your baby received met accepted medical standards.
