Brain cooling: a simple intervention to save newborns

The pioneering treatment, lasting up to 96 hours, can also prevent permanent damage

Prof Geraldine Boylan, who is based in UCC, conducts research into the neonatal brain.

Prof Geraldine Boylan, who is based in UCC, conducts research into the neonatal brain.

 

When baby Tara Lee Harte was born at Cork University Maternity Hospital last summer after a difficult delivery, things were not looking good for her. Despite being delivered at full term after an uncomplicated pregnancy, she was born “flat”, with no cardiac activity.

Her parents watched in shock as medical staff tried frantically tried to save the infant’s life for more than half an hour before she began to stabilise and take breaths for herself. She also had to be given blood transfusions due to a massive scalp bleed.

Forty minutes after her birth, the baby was transferred to the Neonatal Intensive Care Unit at the hospital, where she underwent a treatment known as “cooling”. It was this intervention that her parents, Jonas and Norma, and her medical team believe saved Tara Lee’s life and prevented severe brain injury. Ten years ago, prior to the advent of therapeutic cooling, Tara Lee’s medical team would have had no option but to just observe her with no way of knowing whether she would survive or how badly her brain would be injured.

One in 20 newborn babies experience asphyxia at birth and may go on to develop brain injury and seizures. Today, thanks to new frontiers being pushed back in the young but exciting field of neonatal brain research, there is not only an effective treatment to prevent severe brain injury in infants deprived of oxygen at birth, but a new technique for monitoring seizures has been developed in Cork and is being trialled around the world.

The simple and relatively inexpensive cooling treatment, which involves placing newborns on a special mat and being cooled at 33 degrees, has become the standard of care across the world.

Tara Lee’s father, Jonas, says nobody who saw her in the first few days of her life would have expected her to develop into the healthy 14-month-old that she is today, meeting all of her developmental milestones and about to take her first steps.

“We believe the cooling probably saved Tara Lee’s life.

“Her brain activity was being monitored by EEG [electroencephalogram], which showed suppressed brain activity, so the indicators were not good at that stage. It was a matter of survival for her over the first couple of days and once they were confident she was going to survive, it was all about her quality of life,” he says.

Side effects

While there are very few side effects to cooling, the hardest part for new parents is not being able to hold their tiny baby for up to 96 hours: 72 hours while they are cooling and 24 while they are warmed up slowly.

The Hartes were prepared for the fact that Tara Lee could have mild to severe cerebral palsy – an incurable disorder that affects muscle tone, movement and motor skills – but an MRI two days after her cooling treatment detected no brain damage.

“From that point on, we could get positive about the good signs she was showing. She started sucking pretty quickly and we were able to bring her home a week later. Looking back at the photos now, she had black eyes from the blood loss, and it was obvious she had been through the wars, but she has thrived since,” says Jonas.

Tara Lee’s parents can’t speak highly enough about the outstanding level of care and support they and their baby received from the nursing and medical staff at the NICU at CUMH, where she was part of the Irish Centre for Fetal and Neonatal Translational Research (Infant) project.

Infant is based at CUMH and its mission is to improve healthcare outcomes for pregnant women and their babies. Prof Geraldine Boylan, professor of neonatal physiology at University College Cork, is at the cutting edge of international research into the neonatal brain.

She and consultant obstetrician/ gynaecologist Prof Louise Kenny are the directors of Infant and are joint recipients of the Science Foundation Ireland Researcher of the Year Award 2015, which was announced last week.

Boylan recently hosted the ninth International Conference on Brain Monitoring and Neuroprotection in the Newborn in Cork, which was attended by the top researchers in this field, including the man responsible for the first cooling trials in lambs, Prof Alistair Gunn from the University of Auckland.

Boylan explains that cooling doesn’t work for every baby. “It works very well for babies who have moderate disruption to oxygen during delivery, but not so well for babies who are severely deprived. However, we do still cool babies graded as severe because even if it only works for one of these babies, it’s a huge result for that family.”

The Infant centre is currently heading up an international trial on the use of a seizure-recognition computer algorithm that Boylan hopes could become the next major advance in neonatal brain care.

The Algorithm for Neonatal Seizure Recognition (ANSeR) project has been funded by the Wellcome Trust in hospitals across Europe. Boylan has been monitoring the brainwaves of newborns in the neonatal unit in Cork by EEG for many years and ANSeR is the result of work by a multidisciplinary team of scientists, clinicians and engineers. This new technique means that the brainwaves of tiny infants can be monitored by EEG 24/7, helping to detect and treat the usually silent seizures of the newborn.

“It’s so exciting to be in the right place at the right time, with the right technology and tools all coming together. When I started monitoring newborn brains, we didn’t have the equipment we have now; we didn’t have therapeutic cooling. Now we have created an algorithm that means we can intervene earlier and treat faster. We had drugs to treat seizures, but we did not know when to give these drugs. Now we can give the drugs in line with the EEG results,” says Boylan.

Saving lives

Terrie Inder, professor of paediatrics at Harvard Medical School and department chair at Brigham and Women’s Hospital in Boston, describes the cooling of babies as one of the most important medical therapies outside antibiotics for saving lives.

“You need to treat hundreds of patients with heart disease and high blood pressure to save one. You need to treat only four babies with cooling to prevent death or permanent injury resulting in cerebral palsy or epilepsy, in one baby. There are very few treatments in medicine, even antibiotics, that have this success rate.”

In terms of the new research, Inder points out that it’s about both survival and ensuring that they live without any or minimal challenges.

“We are trying to advance MRI as standard for babies born very prematurely or who had a difficult birth. MRI has been used in adults for a long time but it’s not as accessible or available for babies.”

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