Understanding cooling therapy, your baby's care, and what happens next.
When Birth Doesn't Go as Planned
You've probably spent months imagining the moment you would finally meet your baby. Holding them close, hearing their first cry, and beginning your life together. But sometimes, birth doesn't go as expected.
Instead of those first moments together, you may find yourself surrounded by medical professionals, hearing unfamiliar terminology, and wondering what happened.
If your baby has been diagnosed with hypoxic-ischemic encephalopathy (HIE), you may be feeling frightened, overwhelmed, or uncertain about the future.
At Bright Sprout, we believe that understanding your baby's medical care can help you feel more confident and involved during an incredibly difficult time.
You don't have to learn everything today. We're here to help you understand, one step at a time.
What Is Hypoxic-Ischemic Encephalopathy (HIE)?
Hypoxic-ischemic encephalopathy, commonly called HIE, is a type of brain injury that can occur when a baby's brain does not receive enough oxygen and blood flow around the time of birth.
Let's break down the medical terminology:
Hypoxic: Not enough oxygen.
Ischemic: Reduced blood flow.
Encephalopathy: A condition affecting how the brain functions.
The brain needs a continuous supply of oxygen and blood to function properly. When that supply is significantly interrupted, brain cells can become injured.
HIE can range from mild to severe. Some babies recover without significant long-term difficulties, while others may experience developmental or neurological challenges.
Although HIE is most commonly recognized in babies born at or near full term, hypoxic-ischemic brain injury can also affect premature infants.
Why Does HIE Happen?
HIE may develop when something interferes with oxygen delivery or blood flow to the baby's brain before, during, or shortly after birth.
Possible contributing events include:
Problems with the placenta, such as placental abruption.
Umbilical cord complications that significantly affect blood flow.
Uterine rupture.
Severe changes in the baby's heart rate during labor.
Significant maternal bleeding or low blood pressure.
Other serious complications that interfere with oxygen delivery.
Sometimes, even after reviewing the pregnancy, labor, delivery, and medical records, the exact cause cannot be determined.
It's important to understand that HIE is not always predictable or preventable. Having an HIE diagnosis does not automatically mean that someone made a mistake.
Your medical team can help explain what is known about your baby's individual circumstances.
How Is HIE Diagnosed?
Your baby's NICU team uses several pieces of information to determine whether HIE may be present.
These may include:
Your baby's condition at birth: Some babies require assistance with breathing or more extensive resuscitation immediately after delivery.
Apgar scores: These scores describe how a baby is doing shortly after birth. Low scores may raise concern, but an Apgar score alone does not diagnose HIE.
Blood tests: Blood gases can help determine whether your baby experienced significant acid buildup, which may occur when tissues do not receive enough oxygen.
Neurological examinations: Providers assess your baby's alertness, muscle tone, movements, reflexes, and responses.
Brain monitoring: An electroencephalogram (EEG) may be used to evaluate electrical activity in the brain and identify seizures.
The team considers these findings together when deciding whether treatment is needed.
What Is Therapeutic Hypothermia (Cooling Therapy)?
Therapeutic hypothermia, commonly called cooling therapy, is a specialized treatment that can help protect the brain following a significant oxygen and blood-flow interruption.
After the initial injury, additional changes can occur within brain cells over the following hours and days. Cooling slows some of these processes and can reduce additional brain injury.
Cooling therapy has been shown to improve outcomes for appropriately selected babies with moderate to severe HIE.
Which babies qualify for cooling?
Cooling is generally recommended for babies who:
Were born at 36 weeks of pregnancy or later.
Have findings consistent with moderate to severe HIE.
Meet additional clinical and laboratory criteria.
Treatment is ideally started within the first six hours after birth. In certain circumstances, specialists may consider treatment later or at 35 weeks after discussing the potential risks and benefits.
Not every baby with suspected HIE requires cooling.
What happens during cooling?
Your baby will be placed on a specialized cooling blanket or mattress that carefully lowers their body temperature to approximately 92.3°F (33.5°C).
This temperature is maintained for 72 hours.
Throughout treatment, the NICU team closely monitors your baby's temperature, heart rate, breathing, blood pressure, and neurological activity.
Your baby may have:
An IV or umbilical catheter for fluids and medications.
A breathing tube or other respiratory support.
EEG leads attached to the scalp to monitor brain activity.
A temperature probe (sometimes rectal) for continuous monitoring.
Medications to provide comfort or treat seizures if needed.
Your baby may look different from what you expected. There may be wires, tubes, and equipment surrounding them.
Although this can be difficult to see, each piece of equipment has a purpose in helping the team provide safe, specialized care.
What Happens During the 72 Hours of Cooling?
During these first three days, the NICU team will carefully watch how your baby responds to treatment.
Your baby may be sleepier than expected or move less frequently. Some of this may be related to HIE, medications, or the cooling process itself.
The team will monitor for complications, including changes in blood pressure, heart rhythm, blood clotting, and kidney function.
Why is my baby having an EEG?
An EEG records electrical activity in the brain.
Babies with HIE can experience seizures, and some neonatal seizures are not visible from the outside.
Continuous EEG monitoring helps the medical team identify seizures that might otherwise go unnoticed and determine whether treatment is necessary.
An EEG can also provide information about overall brain activity, although it cannot predict your baby's future by itself.
Can I hold my baby during cooling?
Holding your baby may be limited during cooling because maintaining a stable body temperature and monitoring equipment is extremely important.
However, you can still be involved.
Depending on your baby's condition and your NICU's practices, you may be able to:
Gently touch your baby's hand or foot.
Speak softly or read to your baby.
Participate in mouth care or other appropriate caregiving activities.
Provide expressed breast milk when possible.
Help comfort your baby in ways approved by the care team.
Even when you cannot hold your baby, your presence matters.
Ask your baby's nurse what types of touch and interaction are safest during treatment.
What Happens After Cooling?
After 72 hours, your baby's temperature will be gradually returned to normal. This process is called rewarming.
Rewarming is carefully controlled and monitored.
During this time, the medical team continues watching your baby's vital signs, neurological activity, and overall condition.
Some babies may experience seizures or other changes during rewarming, which is why close monitoring remains important.
Once rewarming is complete and your baby is stable, the team may begin making changes to respiratory support, medications, nutrition, and other aspects of care.
This is often when parents begin to see more opportunities for holding, feeding, and participating in everyday care.
Progress may happen gradually, and every baby follows a different course.
Why Does My Baby Need an MRI?
A magnetic resonance imaging (MRI) study creates detailed pictures of the brain.
For babies with HIE, an MRI is often performed after cooling and rewarming, commonly during the first week of life.
The MRI can help identify areas of brain injury and provide information that may be useful when discussing your baby's prognosis.
However, an MRI is only one part of the overall picture.
Your baby's neurological examinations, EEG findings, feeding abilities, and progress over time also provide important information.
An MRI cannot predict every aspect of your baby's future development.
What Does HIE Mean for My Baby's Future?
This may be one of the hardest questions parents ask.
The answer is not always immediately clear.
Some babies with HIE develop normally or experience relatively mild challenges. Others may develop difficulties involving movement, learning, feeding, hearing, vision, or seizures.
More significant injuries may be associated with conditions such as cerebral palsy or developmental disabilities.
Unfortunately, severe HIE can also be life-threatening.
The severity of the initial injury, response to treatment, neurological examinations, EEG findings, and MRI results all help the medical team understand your baby's condition.
Even with this information, predicting long-term outcomes can be difficult.
An HIE diagnosis does not automatically determine your baby's future.
Your baby's team will continue evaluating progress and helping your family understand what is known, what remains uncertain, and what support may be needed.
How Can I Help My Baby?
One of the most difficult parts of having a baby in the NICU is feeling that everything is outside your control.
But you remain an essential part of your baby's care team.
You can help by:
Being present whenever you are able.
Asking questions and participating in daily rounds.
Providing breast milk if you choose and are able.
Learning your baby's cues and responses.
Participating in holding, feeding, and care as your baby becomes stable.
Keeping track of information and questions.
Advocating for developmental follow-up and early intervention services when recommended.
You are also recovering from your own birth experience. Rest, emotional support, and medical care for yourself are important.
You do not have to be at the bedside every moment to be a loving, involved parent.
Questions to Ask Your NICU Team
How severe is my baby's HIE, and how was that determined?
Does my baby meet the criteria for cooling therapy?
What are you watching most closely during cooling and rewarming?
Has my baby had any seizures, including seizures seen only on EEG?
When will the MRI be performed, and what can it tell us?
When might I be able to hold or feed my baby?
What signs of improvement are you seeing?
What concerns do you have about my baby's neurological development?
What follow-up appointments or developmental services will my baby need?
Who can help our family cope with the emotional impact of this experience?
You can write down these questions and bring them to rounds. It is always appropriate to ask for an explanation more than once.
When Birth Doesn't Go as Expected:
Caring for Yourself
Having a baby diagnosed with HIE can be an emotionally overwhelming experience.
You may be processing a difficult delivery while trying to understand your baby's condition and treatment.
You may feel frightened, angry, confused, exhausted, or emotionally numb.
You might also find yourself replaying the events surrounding your baby's birth, searching for an explanation.
These reactions can occur after a traumatic birth and unexpected NICU admission.
Consider asking your NICU team about social work, counseling, chaplaincy, peer support, or other resources available to your family.
If distressing memories, anxiety, or sadness become difficult to manage, your own healthcare provider can help you find appropriate support.
You deserve care and compassion, too.
A Final Thought From Bright Sprout
HIE can turn the first days of your baby's life into a time filled with medical decisions, uncertainty, and waiting.
There may be moments when you feel hopeful and moments when you feel afraid.
You don't have to have all the answers today.
Keep asking questions. Keep learning about your baby's care. Celebrate progress when it comes, even when it looks different from what you expected.
You are not a visitor in your baby's NICU journey. You are an essential member of the care team.
And your baby is so much more than a diagnosis.
For the NICU Nurse
Clinical Education Corner | Professional Education
Clinical reminder: This section is intended for professional education and does not replace institutional cooling protocols, provider orders, or neonatal neurology consultation.
Select a topic below to expand the clinical information.
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HIE is neonatal encephalopathy associated with impaired cerebral oxygen delivery and perfusion. Injury can evolve through primary energy failure, a latent period, and secondary energy failure involving excitotoxicity, inflammation, oxidative stress, and cellular injury.
Assessment and Severity
Neurological assessment may include modified Sarnat staging, evaluating:
Level of consciousness
Spontaneous activity
Muscle tone and posture
Primitive reflexes
Autonomic function
Seizure activity
Assessment findings must be interpreted alongside the infant's clinical history, laboratory findings, and neurological monitoring
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Standard evidence-based treatment for eligible infants includes:
Gestational age generally ≥36 weeks.
Moderate to severe encephalopathy with qualifying clinical and biochemical findings.
Initiation ideally within six hours of birth.
Target core temperature approximately 33.5°C.
Cooling duration of 72 hours.
Controlled rewarming according to institutional protocol.
The 2026 AAP clinical report also discusses selected circumstances involving infants at 35 weeks or initiation after six hours. These decisions require specialist assessment and shared decision-making.
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Maintain precise temperature monitoring and avoid unintended overcooling or rapid rewarming.
Monitor cardiorespiratory status, perfusion, and hemodynamic stability.
Support continuous EEG monitoring and timely recognition of electrographic seizures.
Monitor glucose, electrolytes, urine output, renal function, and coagulation findings.
Assess skin integrity and positioning.
Provide comfort and pain assessment appropriate to the infant's condition.
Support safe, developmentally appropriate family participation.
Communicate changes in neurological status and clinical stability promptly.
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Parents may hear complex medical explanations while processing an unexpected and potentially traumatic delivery.
Use understandable language, explain the purpose of equipment, reinforce information without unnecessary repetition of jargon, and avoid making premature predictions about neurological outcomes.
Encourage parents to participate in rounds and identify ways they can safely engage in their baby's care.
Medical References
American Academy of Pediatrics. Therapeutic Hypothermia for Neonatal Hypoxic-Ischemic Encephalopathy.Pediatrics, 2026.
American Heart Association and American Academy of Pediatrics. 2025 Guidelines for Neonatal Resuscitation.
American Academy of Pediatrics, HealthyChildren.org. AAP Guidance on Therapeutic Hypothermia Treatment for HIE Updated, 2026.
Medical information is educational and should not replace individualized advice from your baby's healthcare team.
Bright Sprout | Helping NICU Families Understand, Connect, and Grow
Draft reviewed against published guidance: November 2026. Clinical editorial review recommended before publication.
