Brain Cooling: New Hope for the Sickest Newborns
Over his 30-year career, Siva Subramanian, MD, chief of Neonatology, has witnessed tremendous advances in medicine’s ability to save the lives of critically ill newborns. But until recently, he could only stand by and watch when one of the infants in his care suffered asphyxia, or lack of oxygen to the brain. There was simply no treatment available, anywhere in the world, to stop the damage.
Now a new technique is giving these babies another chance at living a more normal life: brain cooling. And, in keeping with its history of innovation, Georgetown University Hospital is one of the first in the region to offer the procedure.
“Reducing body temperature has been effective in protecting the brains in animals, and is already used in adults in certain neurological and heart procedures,” says the expert neonatologist, known simply as Dr. Siva. “Now, two new international studies have demonstrated the value of cooling the brain in newborns suffering with moderate or severe asphyxia, as well.”
Technically called hypoxic-ischemic encephalopathy, or HIE, the condition evolves over several hours. The initial oxygen and/or lack of blood supply to the brain kicks off a series of other events, as the body tries to repair itself. This natural approach is effective when HIE is mild. But in moderate or severe cases, the body’s desperate attempts could cause more brain damage.
Dr. Siva Subramanian, Chief, Division of Neonatology, Department of Pediatrics
All too often, the result is long-term developmental, physical and mental delays. Many infants with HIE will face life-long struggles with cerebral palsy, mental retardation, learning disabilities and vision or hearing impairments. Up to 60 percent of all newborns with severe HIE die.
The cooling technique is designed to minimize such outcomes. Using specialized equipment adapted for newborns, neonatologists reduce the baby’s core body temperature over a period of 72 hours. Studies report a 16 to 27 percent drop in the number of deaths or severe disability.
Because it is so new, the effect of brain cooling on improving the long-term developmental outlook for infants with HIE will not be known for several years. However, the process itself carries no risks and is currently the only alternative to doing nothing.
Timing, however, is critical.
“To work, brain cooling must be initiated within six hours of delivery in infants with asphyxia,” Dr. Siva says. Asphyxia occurs both before and during birth. “Any baby who is at risk of, or suspected of, suffering moderate or severe asphyxia should be considered for transfer to the Georgetown University Hospital NICU immediately for evaluation,” adds Dr. Siva.
HIE is an uncommon occurrence, but not rare. Approximately two to four of every 1,000 newborns are affected, which translates to between 100 and 200 cases in the metropolitan Washington, D.C., area each year. Causes are diverse and may include a difficult delivery, maternal disease or maternal bleeding. Infants with severe HIE often suffer seizures or become comatose shortly after birth.
Georgetown has been offering this new technique for several months in its Neonatal Intensive Care Unit (NICU), one of the state-of-the-art NICUs in the country. With 44 incubators, the unit treats approximately 600 children from the area each year, of which about one-third transferred from other facilities.
Under Dr. Siva’s leadership and with the hard work of his faculty and nurses, the NICU has been the site of many clinical advances over the years, including the use of extracorporeal membrane oxygenation (ECMO) in near term and term infants, and high-frequency jet and oscillatory ventilation to improve respiration in sick newborns. He and his team were also instrumental in developing the mobile neonatal intensive care unit on wheels – a specially equipped incubator with high frequency ventilator and inhaled nitric oxide to help sick babies during transport.
The entire NICU team is excited about the prospects that brain cooling holds for the future of HIE care.
“It’s obviously not a miracle cure, but a procedure that can help reduce the most serious consequences – at least in some infants,” he says. “These are among the sickest babies we ever see. I’m glad we finally have something to offer them and their parents.”
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