What is hypoxic ischaemic encephalopathy (HIE) and what does it mean for my child?

Parents who are trying to come to terms with a newborn baby’s brain injury often feel frustrated at the lack of clear information. They know that something serious happened at birth. They may even have been contacted by NHS Resolution, the NHS defence organisation, seeking information and ‘early resolution’. Too often, however, the parents’ key questions remain unanswered.

Questions, such as, ‘why did this happen?’ or ‘how did this happen?’ may be uncomfortable for healthcare staff to answer when the parents of a newborn baby are upset, angry or devastated by a brain injury diagnosis. However uncomfortable, when a baby suffers HIE, the parents have a right to know, and to understand what is known about the cause, and their child’s right to compensation for the effects of this condition. 

What is HIE?

HIE is an abbreviation of hypoxic ischaemic encephalopathy. 

• Encephalopathy means disease or damage which affects the brain. 
• Ischaemia means there is not enough blood supply to the affected area of the body. 
• Hypoxia means deprivation of oxygen.

HIE or hypoxic ischaemic encephalopathy means brain damage caused by a lack of oxygen in the blood supply to the baby’s brain during labour and around the time of birth. Severe hypoxia is sometimes known as anoxia (without oxygen). Another phrase that is used to describe brain injury at birth from lack of oxygen is birth asphyxia. 

How is HIE diagnosed?

Umbilical cord blood gases

There are various ways in which HIE is diagnosed. The most reliable way of finding out whether a baby has suffered lack of oxygen (hypoxia) during labour and delivery, is by the umbilical cord blood test that is carried out immediately after birth. 

At birth, the maternity team test samples of blood from the blood vessels in the umbilical cord. The vein in the umbilical cord carries oxygenated blood from the mother to the fetus. The two arteries in the cord carry de-oxygenated blood (containing carbon dioxide, lactic acid etc) back from the fetus to the mother. When a baby has been deprived of oxygen in labour, the blood sample from the umbilical artery contains an abnormally high level of acid.

APGAR scores

The APGAR score is another method of checking a newborn baby’s condition. The maternity team rate the baby’s appearance, pulse, grimace, activity and respiration, at one minute, five minutes and ten minutes of age, giving each a score between zero and two. The combined score (out of ten) gives an overall impression of the baby’s health. This method depends on the midwife’s observation of the baby and is less reliable than the cord blood gas test, but low APGAR scores at five and ten minutes may indicate that a newborn baby has HIE.

MRI brain scan

An MRI scan can reveal the areas of the baby’s brain that have suffered damage. The timing, severity and cause of injury can often be diagnosed from the pattern of injury on the MRI scan of the baby’s brain. 

Symptoms and signs of HIE

Babies with HIE may have any of the following signs and symptoms in the days immediately after birth: 

• low APGAR scores;
• blue or pale skin colour;
• low heart rate;
• breathing (respiration) difficulties, grunting;
• fits (seizures);
• feeding difficulties; 
• hypotonia (floppiness, reduced muscle tone);
• organ failure; 
• abnormal response to light;
• abnormal level of consciousness. 

Babies with HIE usually need help with breathing and may be resuscitated immediately after birth. They may be transferred to the neonatal unit (SCBU, NNU or NICU) for intensive care, particularly if they need ventilation to help them breathe. Most newborn babies with moderate or severe HIE are now treated with therapeutic hypothermia or controlled cooling. 

What is cooling?

Cooling has been used in specialist neonatal units since 2010 to reduce the permanent disability suffered by babies who have suffered moderate or severe hypoxic ischaemic encephalopathy during labour and birth. Birth asphyxia causes severe brain damage and permanent disability, such as cerebral palsy, which cannot be cured. Cooling works by lowering the temperature of the baby’s brain to a temperature at which the damage to the brain from the lack of oxygen is slowed down. Trials have shown that, if correctly administered, controlled cooling reduces the damage to the brain and the resulting severe physical disability. In our experience, children who have been cooled are often less severely physically disabled, despite their severe brain damage. They may still be left with more subtle, neurological impairments which only become evident in teenage years and later life.

NICE guidance recommends that babies with moderate or severe HIE should be cooled, under strict safety conditions. These conditions include ensuring that parents understand what is involved and agree to the treatment, and that the treatment is carried out by neonatal specialists with careful monitoring. 

Why is a diagnosis of HIE important? 

Brain injury affects individuals in different ways. Understanding the severity, type and location of the damage within the baby’s brain helps the neonatal and paediatric doctors predict and prepare the child’s parents for the disability and difficulties that the child may suffer in the future. The precise impact of the brain injury on the child will only become apparent as the child grows and develops. 

Despite the uncertainty of the future implications for any individual child of a birth-related injury, parents have a right to be made aware of the diagnosis. HIE is one of the most common types of brain injury that is caused by maternity negligence during childbirth. However, the RCOG’s Each Baby Counts programme, which analyses every reported serious birth injury in England, recently found that in half of all cases the child’s parents were not included in the hospital’s investigation of the cause of the injury. 

RCOG’s Each Baby Counts programme aims to identify the failings in maternity care which are causing countless brain injuries, stillbirths and neonatal (newborn baby) deaths each year. Any birth injury resulting in diagnosis of grade 3 hypoxic-ischaemic encephalopathy (HIE) within the first seven days of life should be reported to the programme for analysis. Other reporting criteria include the baby needing cooling, being floppy, comatose and having seizures. Of the 980+ babies who suffered stillbirth, neonatal death or brain injury in Each Baby Counts’ most recent annual report, their panel experts thought 72% would have avoided their injury with better care. 

Likewise, NHS Resolution, the organisation which defends the NHS against compensation claims, requires NHS trusts to report all HIE birth injuries immediately. Early notification ensures that NHS Resolution can intervene and make contact with the parents. Our experience suggests that the parents of injured babies aren’t being properly advised by NHS Resolution about their right to seek independent legal advice from claimant (for the patient) cerebral palsy specialists in connection with a claim for compensation. When a baby suffers HIE as a result of maternity or neonatal mistakes around the time of birth, they may be entitled to substantial compensation. 

Claiming compensation for HIE brain injury and cerebral palsy

If maternity mistakes during pregnancy, labour, delivery or immediately after birth have caused your child to suffer hypoxic ischaemic encephalopathy (birth asphyxia/anoxia or HIE), your child may be entitled to an immediate, substantial interim payment and full compensation. 

Boyes Turner’s cerebral palsy and birth injury specialists have supported countless families affected by birth-related HIE recover compensation to help pay for care, adapted accommodation, therapies, specialist aids and equipment, special education and provide lifelong financial security for their child. 

If you would like to speak in complete confidence to one of our experienced lawyers about making a claim, you can contact us by email on cerebralpalsy@boyesturner.com.