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Official reprint from UpToDate
www.uptodate.com 2014 UpToDate
Authors
Sidhartha Tan, MD
Yvonne Wu, MD, MPH
Section Editors
Douglas R Nordli, Jr, MD
Leonard E Weisman, MD
Deputy Editor
John F Dashe, MD, PhD
Etiology and pathogenesis of neonatal encephalopathy
Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2014. | This topic last updated: Jan 15, 2014.
INTRODUCTION Neonatal encephalopathy is a heterogeneous syndrome characterized by signs of central nervous
system dysfunction in newborn infants. Clinical suspicion of neonatal encephalopathy should be considered in any infant
exhibiting an abnormal level of consciousness, seizures, tone and reflex abnormalities, apnea, aspiration, feeding
difficulties [1,2], and an abnormal hearing screen.
This topic will review the etiology and pathogenesis of neonatal encephalopathy. Other clinical aspects of this syndrome
are discussed separately. (See "Clinical features, diagnosis, and treatment of neonatal encephalopathy".)
TERMINOLOGY "Neonatal encephalopathy" has emerged as the preferred term to describe central nervous system
dysfunction in the newborn period [2,3]. The terminology does not imply a specific underlying pathophysiology, which is
appropriate since the nature of brain injury causing neurologic impairment in a newborn is poorly understood. While
neonatal encephalopathy was once automatically ascribed to hypoxia-ischemia [4], it is now known that hypoxia-
ischemia is only one of many possible contributors to neonatal encephalopathy. Whether a particular newborn's
encephalopathy can be attributed to hypoxic-ischemic brain injury is often unclear.
Some investigators require stringent criteria for using the term neonatal encephalopathy, such as two or more symptoms
of encephalopathy lasting over 24 hours [5], while others require no more than a low five minute Apgar score [6].
However, the use of Apgar scores alone is problematic, as Apgar scores may be low due to maternal analgesia or
prematurity, or can be normal in the presence of acute hypoxia-ischemic injury.
Neonatal encephalopathy usually refers to central nervous system dysfunction in term and near term infants, but for the
purposes of this review, encephalopathy of the preterm infant has also been included.
When neonatal encephalopathy is indisputably due to hypoxic-ischemic (anoxic) brain injury, it is appropriate to use the
term hypoxic-ischemic encephalopathy (HIE) [7]. Since the precise cause and temporal onset of neonatal
encephalopathy is unknown in most cases, some experts advocate calling the condition presumed HIE or apparent
HIE when the clinical features and neonatal brain injury patterns on MRI suggest that HIE is the most likely mechanism
[8]. Others favor using the non-specific term neonatal encephalopathy whenever there is doubt as to the underlying
mechanism of injury [3]. It remains to be established whether neuroimaging or other testing can one day be used as a
gold standard for determining when prenatal hypoxia, birth asphyxia, or hypoxic-ischemic brain injury is responsible for
neonatal encephalopathy. (See "Clinical features, diagnosis, and treatment of neonatal encephalopathy".)
There is an increased risk of cerebral palsy associated with neonatal encephalopathy but it is not an inevitable
consequence. In most cases of cerebral palsy or later developmental deficits, the cause is unknown or is related to
conditions other than prior neonatal encephalopathy. (See "Epidemiology and etiology of cerebral palsy".)
Placental conditions, including severe preeclampsia, post-dates, and abnormal appearance of the placenta
Fetal problems, such as intrauterine growth restriction
Of these, intrauterine growth restriction is the strongest risk factor. (See 'Risk factors' above and 'Antepartum'
above.)
Intrapartum risk factors for neonatal encephalopathy include the following: !
Persistent occipitoposterior position
Shoulder dystocia
Emergency cesarean delivery, which may include failed vacuum
Operative vaginal delivery
Acute intrapartum events or sentinel events (eg, uterine rupture, placental abruption, cord prolapse, tight
nuchal cord, maternal shock/death)