Should Your Hospital’s NICU Have Cooling for Brain Injuries?

Medically induced cooling of the brain can help treat damage. This relatively new procedure — the FDA approved it a little over 10 years ago —  provides the opportunity to treat babies who are suffering from hypoxic brain damage as a result of perinatal asphyxia.

We don’t totally understand exactly why brain cooling works although there are many theories that make perfect sense that are floating around out there.  But, ultimately, who cares why it works.  It appears to work on not only the brain but other vital organs that have been harmed from oxygen deprivation.

At this point, I don’t know why any hospital with a NICU would not have the ability to use cooling to protect an infant from brain damage.

What is hypoxic-ischemic brain damage, and how is it related to birth-related injuries?

Hypoxic brain damage occurs when the brain is not getting enough oxygen. The term hypoxia means a deficiency in the amount of oxygen reaching the issues. It contrasts with anoxic brain damage, which means there no supply of oxygen to the brain.

Hypoxia at birth is known as hypoxic-ischemic encephalopathy (HIE). It is also known as perinatal asphyxia. HIE can be caused by different factors. They include trauma to the infant in utero, placental problems, an umbilical cord prolapse, preeclampsia, eclampsia, overmedication of the mother, or shoulder dystocia. It usually occurs around the time of birth and can result in death in about 25 to 50 percent of severe cases.

What is brain cooling and how does it work?

baby-in-womb-300x160Therapeutic hypothermia, also known as brain cooling, is a process where the body temperature is reduced to a norm.

How does head cooling work for a brain injury?  Head cooling drops the metabolic rate of the brain. This alters the release of cytokines.

What are cytokines?  Cytokines are chemical mediators of inflammation.  The research is clear that pro-inflammatory mediators of the cytokine family are highly associated and lead to brain injury following infection.

Brain cooling also relieves pressure in the brain that is caused by cerebral edema. Cooling therapy is thought to reduce energy depletion and decrease transmitter activity in the brain.  Cooling therapy can also reduce ion flux alterations.  Whatever the mechanism, and we don’t fully understand it completely yet — it seems clear that postnatal cooling of the brain has a beneficial effect on the outcome.

Cooling therapy uses a purpose-made cap, a special blanket, or a mattress to cool the newborn in at a controlled temperature. It can be used to cool either the baby’s head or their entire body.

Medical professionals apply cooling therapy according to the severity of the infant’s injuries. More severe injuries need longer durations of cooling therapy. Cooling therapy can last for two to three days.

What happens after cooling therapy?

HIE brain coolingAfter cooling therapy, doctors provide assessments and monitoring to make sure they can function healthily. Professionals will provide further tests such as MRIs, EEGs, and heart monitors. This is done to detect possible abnormal brain, electrical, or heart activity.

University of Edinburgh study

Researchers from the University of Edinburgh conducted a study on medical induced cooling effects on brain and head-related injuries. Engineers and medical experts at the university collaborated to create a 3D model of the brain. This model considered simultaneous flow, heat transfer, and metabolism between arteries, veins, and brain tissue in three dimensions throughout the brain.

Through computer simulations, researchers discovered that cooling newborn babies’ heads to 10°C (50°F) would allow their core brain temperature to fall from 37°C to 36°C (98.6°F to 96.8°F). This temperature is low enough to help recovery. Researchers say that this could help babies at risk of long-term damage from birth complications.

Oxford University and Imperial College study

An Oxford University and Imperial College London study looked at how brain cooling can treat perinatal hypoxia. It was named the Total Body Hypothermia for Neonatal Encephalopathy Trial (TOBY). The TOBY clinical trial involved 325 newborn babies who experienced hypoxia at birth. They were randomly assigned into two groups within six hours of delivery. One group was treated with standard care. The other group received both standard care and brain cooling. This group had their body temperature reduced to 33.5°C (92.3°F) for 72 hours. After 72 hours, they would be slowly returned to a normal body temperature of 37°C (98.6°F).

Researchers found that 51.7% of oxygen-deprived babies who were treated with brain cooling survived to age six to seven years with a normal IQ.  Only 39.4% of babies who received standard care did the same. Brain cooling reduced the risk of cerebral palsy and other disabilities in children. However, there was no difference in mortality rate between standard care and brain cooling-treated groups. The mortality rate was at about 30% for both groups.

Are there any risks associated with brain cooling?

Research suggests there are few risks associated with cooling therapy if done correctly. Trials seem to suggest there are more positive than negative benefits. The most common side effect that appears to be a risk is sinus bradycardia, known as a slowed heart rate. However, it is not a life-threatening condition. It can also be treated depending on its cause and severity.

The biggest risk of cooling therapy, it would seem, is either not doing it at all or not doing it correctly.

What are the criteria for brain cooling treatment?

There are several things that qualify a baby for brain cooling. They must have an Apgar score of less than 5 after 10 minutes of birth. The Apgar score is a test that determines a newborn child’s health in relation to infant mortality. It checks skin color, pulse rate, reflex irritability grimace, activity, and respiratory effort. Other criteria are if the child needs resuscitation and oxygen after ten minutes of birth. A third is if the child was born within 36 weeks of gestation or more. The fourth criteria are infants who have moderate to severe encephalopathy.

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