# Balance of Antioxidants vs. Oxidants in Perinatal Asphyxia
## 6 Clinical Assessment of Neonates with Encephalopathy  
Several scoring methods can be used to evaluate NE and predict the outcomes with clinical examination. There is a clear correlation between neuro-developmental outcomes and the Sarnat staging of encephalopathy at less than six hours of life [95]. However, a multicenter prospective analysis of newborns with hypothermia and NE revealed that a clinical neurological exam performed before six hours of life and showing moderate to severe encephalopathy was insufficient to predict unfavorable outcomes [96]. Studies on hypoxemic/ischemic newborns treated with hypothermia have also demonstrated that the Thompson score is a useful prognostic tool for predicting outcomes at 4 to 5 years of age [97]. To appropriately predict outcomes in infants with NE, clinical indicators alone are not sufficient unless clinical examination is combined with multiorgan dysfunction and Apgar score. Regarding laboratory findings, it has been previously demonstrated that poor outcomes were linked to low initial newborn arterial pH (umbilical or arterial, within the first hour after birth). According to a meta-analysis, poor newborn outcomes were significantly correlated with low initial arterial pH in encephalopathic neonates prior to the hypothermia era [98]. Also, a lower initial pH was linked to more severe brain injury on MRI in a cohort of hypoxic/ischemic infants treated with therapeutic hypothermia [99]. Moreover, in a follow-up to the NICHD randomized trial of therapeutic hypothermia, early hypocarbia was linked to death or worse outcomes at 18 to 22 months of age [100]. Also, it was shown that worse 2-year outcomes were related to substantial variability in PCO\({}_{2}\) during hypothermia [101]. Additionally, a longer time for serum lactate to normalize was correlated with the severity of encephalopathy and the manifestation of seizures in neonates with NE [102]. Finally, hypo- and hyperglycemia in the early postnatal period have also been correlated with neurologic adverse outcomes [103]. Neuroimaging remains the cornerstone in the evaluation of asphyxiated newborns. In at-risk groups, electroencephalography (EEG) and amplitude-integrated EEG (aEEG) enable real-time evaluation of brain development and function in addition to seizure detection. The predictive accuracy of aEEG is time-dependent, such that a burst-suppression pattern persisting beyond 36 to 48 h suggests a significant risk of an aberrant neurodevelopmentaloutcome [104]. Also, suppressed aEEG tracings longer than 48 h increase the likelihood of severe impairments in survivors, albeit they are not a valid early single predictor in hypothermic neonates [105]. When combined with an aberrant early MRI, a persistently abnormal 48 h EEG background pattern was highly indicative of an unfavorable prognosis [106]. Evoked potentials, including visual, brain-stem auditory, and somatosensory, are electrical reactions to sensory input. In term newborns with NE, delayed or absent responses on the somatosensory-evoked potentials during the first few weeks of life were associated with poorer neurological outcomes at 18 to 24 months of age [107]. Although evoked potentials are effective supplemental prognostic tools in severe cases, the lack of rigorous studies and consensus regarding their prognostic efficacy has limited their utilization in clinical practice. Near-infrared spectroscopy can be utilized for the noninvasive assessment and continuous bedside monitoring of cerebral hemodynamics and oxygenation. Previous evidence has shown that at six and twenty-four hours postpartum, cerebral blood volume and cerebral oxygenation levels were higher in neonates with aberrant MRI findings [108]. Also, persistent higher levels of cerebral oxygenation in hypothermic neonates with NE were correlated with poor neurological outcomes [109]. Finally, brain MRI is a standard procedure used for the diagnosis and prognosis of newborns with NE. MRI is also becoming a common procedure for assessing the type and extent of brain damage in newborns with NE.