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Objective: To determine the relationship between the results of cerebral proton magnetic resonance spectroscopy (1H-MRS) and neuromotor development in neonates with hypoxia., Design: Descriptive., Setting: Wilhelmina Childrens' Hospital and University Hospital, Utrecht, The Netherlands., Methods: 32 infants with hypoxic-ischaemic encephalopathy (Sarnat grade I (mild; n = 5), grade II (moderate; 20), grade III (severe; 7)) were examined at a mean of 8 days following the hypoxic event (range 2-22). 1H-MRS of the periventricular white matter and part of the basal ganglia was performed in a 1.5 T field: TR/TE: 2000/272 ms. Peak-to-peak NAA/Cho ratios were calculated. The presence of a lactate resonance was considered abnormal. Assessment of neuromotor development of the survivors was performed at 6, 9 and 18 months of age., Results: 6 patients died (all grade III), 10 survived with handicaps (I grade III, 9 grade II). Handicaps consisted of spastic quadriplegia (n = 7), hemiplegia and mental retardation (n = 1), and global developmental delay (n = 2). The other 16 survivors were normal at 18 months. 1H-MRS showed NAA/Cho ratios of 0.97 (SD:0.13) in the patients with a normal outcome and 0.74 (0.17) in the patients with an adverse outcome (handicaps or death); p < 0.0001 (t-test). Lactate was demonstrated in all 7 grade III neonates, but not in any of the other infants., Conclusion: Cerebral 1H-MRS was related to neurodevelopmental outcome of neonates with HIE. A low NAA/Cho ratio and presence of a lactate resonance predicted an adverse outcome.