Cooling for newborn babies with HIE brain injury

When a baby is born with hypoxic ischaemic encephalopathy (HIE) brain injury from lack of oxygen before, during or immediately after birth, the severity of their injury and their chances of survival will determine whether they should be treated with cooling.

Cooling is a standard treatment with remarkable benefits in reducing disability for babies born with moderate or severe HIE.  As with many medical treatments, cooling treatment carries some risks, but if administered correctly in a specialist neonatal unit, cooling has been accepted as safe since 2010. Given its proven benefits in reducing physical disability after HIE birth injury, it is possible that, depending on the individual circumstances, failure to offer cooling to an eligible baby could be regarded as negligent.

What is cooling for HIE birth injury?

Cooling is a proven 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 around the time of birth can cause hypoxic brain injury (HIE) to the baby, leaving them with permanent severe disability, such as cerebral palsy. There is no treatment or cure for this type of injury, and the disability it causes results in a lifelong need for therapies, specialist equipment and care.  Babies who are born with HIE birth injury are initially nursed according to their needs in a neonatal intensive care unit (NICU) or special care baby unit (SCBU).

Newborn babies with moderate to severe (but not mild) HIE should begin their cooling treatment as soon as possible after their oxygen deprivation. It is recommended that for cooling to be effective, it should begin within six hours. During cooling, the baby’s brain temperature is lowered to a level which slows down rate of damage that occurs to the brain after a prolonged or acute shortage of oxygen.

Timely treatment with cooling significantly reduces the permanent disability experienced by babies who have suffered a hypoxic brain injury at birth. The lifelong potential benefits of this treatment in reducing severe disability are so important for babies who have suffered from hypoxic birth injury 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 with treatment 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 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 their baby undergoing the cooling treatment.

To maximise the benefits of cooling, the baby’s treatment must be started as soon as possible after their birth, usually within six hours, and should 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. This is achieved by placing the baby on a special mattress filled with cooled fluid or by cooling the baby’s head 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 lowers the baby’s body and brain temperature to a level which slows down the rate of damage to the brain after a prolonged or acute (sudden) shortage of oxygen. This reduces brain swelling, intracranial pressure, slows down brain cell metabolism, reduces the toxins that the brain cells release after a hypoxic event, and increases the repair of brain cells. Timely, correctly administered cooling significantly reduces the physical disability (cerebral palsy) that the baby experiences after their HIE birth injury.

What are the risks of cooling?

Cooling treatment must be administered in a specialist neonatal unit and must be very carefully monitored and managed to avoid metabolic problems (disruption of the body’s chemical processes), seizures, and further damage from reperfusion injury caused by blood returning to the brain too quickly during rewarming. Mistakes during cooling can worsen the injury to the newborn baby’s brain.

Where a baby is born with HIE and is eligible for cooling, the risks and benefits should be discussed with the parents before the treatment, so that they can make an informed decision. 

Autism and learning difficulties after HIE and cooling

Until relatively recently, HIE birth injury commonly resulted in a lifetime of cerebral palsy disability, which impaired the injured child’s mobility, their ability to communicate, live independently, care for themselves or work. In recent years, therapeutic cooling has been hugely successful in slowing the progression of the damage to the brain, so that, despite MRI brain scan evidence of hypoxic injury, children who have been cooled after HIE birth injury can still retain their motor coordination, mobility and communication, avoiding the severe physical disability caused by this type of brain injury.

Whilst cooling undoubtedly has a life-changing impact in reducing physical disability after HIE birth injury, it is important that parents of children who have been cooled successfully remain aware that retained ability to walk and talk does not guarantee that their child will avoid other subtle forms of disability.  Increasingly, our specialist birth injury lawyers and our medical experts are being called upon to help school-aged children with difficulties, such as autism and learning disability, which may arise from a former birth injury which appeared to have been treated successfully with cooling. Whilst these children may be less physically disabled, their injuries still have a lifelong impact on the child’s ability to learn at school, live independently and engage in the workplace and community.

If your child has cerebral palsy or neurological disability as a result of medical negligence, or you have been contacted by HSSIB/MNSI or NHS Resolution, you can talk to a solicitor, free and confidentially, for advice about how to respond or make a claim by contacting us.