Controlled cooling or therapeutic hypothermia for newborn babies with brain injury

When a baby is born with brain injury after suffering from lack of oxygen at birth, the severity of their injury (e.g. moderate to severe hypoxic ischaemic encephalopathy or HIE) and their chances of survival will determine whether they must be treated with ‘cooling’.

A relatively new treatment, with potentially remarkable benefits in reducing severe disability to babies following brain injury, cooling has been accepted as safe when administered correctly in specialist neonatal units since 2010. In some cases, failure to offer cooling may even be regarded as negligent, yet its success is not necessarily the end of the story for victims of avoidable brain injury.

We asked specialist cerebral palsy and birth injury lawyer, Susan Brown, to tell us more about therapeutic hypothermia or controlled cooling.

What is cooling?

Therapeutic or controlled cooling is a proven (and in some cases mandatory) treatment for newborn babies with brain injury caused by lack of oxygen around the time of birth. The medical name for the procedure is ‘therapeutic hypothermia with intracorporeal temperature monitoring for hypoxic perinatal brain injury’ but for most purposes it is simply known as cooling.

Shortage of oxygen at or around the time of birth can cause brain injury to the newborn baby. This type of injury, known as HIE (hypoxic ischaemic encephalopathy) or asphyxial brain damage, can cause permanent disability or the death of the baby. There is no treatment or cure for this type of injury – at best the disability that it causes is ‘managed’ and living with the condition is eased by regular therapies, specialist equipment and care. Babies who are born with hypoxic brain damage are initially nursed according to their needs in a neonatal intensive care unit (NICU), sometimes also known as special care baby unit (SCBU).

Newborn babies with moderate to severe HIE receive cooling treatment, starting as soon as possible after their oxygen deprivation, to lower their brain temperature to a level which slows down the damage that occurs to the brain after a prolonged or acute shortage of oxygen. In medical trials, timely cooling treatment has been found to significantly reduce the permanent disability experienced by babies who have suffered a hypoxic brain injury at or around the time of birth. The lifelong potential benefits of this treatment in reducing severe disability are so important for babies who have suffered from oxygen deprivation that The National Institute for Health and Clinical Excellence (NICE), which sets national healthcare guidelines for the Department of Health and Social Care and the NHS, recommends therapeutic cooling for eligible newborn babies with HIE when carried out in accordance with recognised safety criteria.

When should cooling take place?

NICE guidelines say that cooling can be offered for carefully selected newborn babies with brain injury provided:

• the parents understand what is involved and agree to the treatment;
• the results of the treatment are monitored;
• it is carried out in units that are experienced in the care of very ill, newborn babies by healthcare professionals with special training in cooling treatments.

What happens when a baby has cooling?

The exact procedure can vary slightly from hospital to hospital but generally speaking, the following steps must take place.

If the neonatal care team think that therapeutic cooling treatment is suitable for a newborn baby, they must explain the benefits and risks to the parents before asking them to agree to it.

To maximise the benefits of cooling to the baby, the treatment must be started as soon as possible after the baby’s birth, usually within six hours, and will continue for about three days.

The baby’s body temperature is carefully lowered from normal temperature of 37°C to between 33°C and 35°C soon after birth. This is achieved by placing the baby on a special mattress filled with cooled fluid. Sometimes just the head is cooled using a special cap.

Before, during and after the treatment the baby’s condition must be carefully monitored. This can include blood tests to check blood gas and glucose levels, checking for infections, EEG monitoring to check for seizures, giving sedation and providing respiratory and cardiovascular support. The baby’s body temperature is monitored by a rectal thermometer.

After the end of the cooling period, the baby is gradually warmed up to normal temperature. This is known as rewarming.

What are the effects of cooling?

Cooling brings the baby’s body and brain temperature down. This allows the brain to recover from a period of oxygen deprivation.

In medical research studies, therapeutic cooling has been found to reduce the brain damage and permanent disability/cerebral palsy suffered by babies who have been deprived of oxygen around the time of birth.

What are the risks of cooling?

As with any treatment, cooling is not without its risks. However, the risks and benefits should be discussed with parents before the treatment so that they can make an informed decision. The reason the treatment is carried out in specialist units and must be very carefully monitored and managed is to avoid metabolic (the body’s chemical processes) problems, seizures and reperfusion injury (further damage caused to the brain by blood returning to the brain too quickly after rewarming).

Autism and learning difficulties after HIE and cooling

Boyes Turner’s birth injury and cerebral palsy specialists have been helping children with cerebral palsy and serious neurological injury caused by oxygen deprivation from negligent healthcare for decades. Sadly, despite the high numbers of claims from these injuries and initiatives by the RCOG and the Department of Health to help the NHS learn from these mistakes, avoidable hypoxic birth injuries are still occurring.

For some children, the injury will lead to a lifetime of severe physical and cognitive disability. Their cerebral palsy will impair their mobility, their ability to communicate, live independently, care for themselves or work.

For others, particularly in recent years, therapeutic cooling has been successful in slowing the progression of the brain injury, such that despite MRI scan evidence of a hypoxic ischaemic injury to their brain, they retain their motor coordination, mobility and communication – the most obvious impairments, often labelled as cerebral palsy, which arise from this type of injury.

Therapeutic cooling appears in many cases to have reduced the severity and impact of the physical disability but for many the retained ability to walk and talk is far from the end of the story. Increasingly, our legal team and our medical experts are being called upon to help children with difficulties such as autism and learning disability. Whilst these children may be less physically disabled, their injuries still have a life-long impact on the child and their family, their ability to live independently, learn and engage in the workplace and community.

At Boyes Turner, we recognise and welcome the benefits of properly managed therapeutic cooling in reducing the extent of harm caused by avoidable perinatal brain injury. Meanwhile, we remain committed to securing full compensation for babies who have suffered avoidable brain injury (in whatever form) as a result of negligence at, during or immediately after their birth.

If you are caring for a child or young person with cerebral palsy or other neurological disability caused by medical negligence and would like to find out more about making a claim, contact us by email at cerebralpalsy@boyesturner.com.