A Cool Miracle
By Greg Raver-Lampman
Cooling therapy helped counter effects of oxygen-deprivation at birth.
In the sonographic image, Rita Powell saw her unborn daughter far more clearly than she saw the extra lobe on her placenta.
Even as she watched her daughter’s fingers and toes take shape in subsequent ultrasounds, the lobe remained there, right where doctors pointed it out.
“It worried me the whole time,” Rita said. “I asked about it every single appointment.”
Though this extra lobe could pose problems at delivery, her doctors assured her the baby continued to do well.
But at 2:30 a.m., on November 30, 2006, two weeks before her due date, Rita awoke in pain, bleeding profusely. Her husband Jimmie called 911 and followed the ambulance that took her to Sentara Leigh Hospital. There, doctors called for an immediate delivery by cesarean section.
The extra lobe on the placenta had ruptured, siphoning vital blood from Rita’s baby. There was no time to lose.
During a rapid c-section, Jimmie remained in the operating room, trying to soothe Rita. When baby Nailah emerged, blue and limp, he recalls, “I sobbed and asked God to please let her be OK.”
But the clock was ticking. Their baby had suffered severe oxygen deprivation during the birth process, which could result in catastrophic brain damage or death. About two or three in 1,000 full-term newborns suffer oxygen deprivation during or before delivery, when the placenta separates before the baby is delivered or the umbilical cord is pinched shut. Many newborns with the condition die soon after birth.
Although infants may survive those early critical hours, individual brain cells may continue to die off for days. Doctors have struggled for decades to find effective treatments to staunch the death of additional brain cells, but with little success.
In cases as severe as Nailah’s, newborns may have a 50 percent chance of survival – and a slim chance of escaping without serious brain damage.
But fate in the form of neonatologist Thomas Bass from CHKD intervened.
Rita and Jimmie received a telephone call from CHKD soon after Nailah was born. Dr. Bass told them of a treatment that aims at slowing, or even stopping, progressive death of brain cells.
The treatment offered hope. Just what the Powells needed.
“Whatever needs to be done,” Jimmie responded. “Go ahead and do it.”
With that, the CHKD transport team rushed across town to bring Nailah Powell to the CHKD neonatal intensive care unit.
To many experienced with caring for sick and premature infants, Dr. Bass’s initial research ran against accepted norms. Historically, doctors swaddle infants in incubators that approximate the temperature of a mother’s womb. Dr. Bass’s technique involves keeping the newborn’s body cool. The effect of cooling explains well-publicized cases in which children emerge from icy water after as long as 40 minutes with no brain damage.
“Cooling the brain decreases its need for oxygen and can slow or stop continuing damage,” said Dr. Bass, co-investigator of a groundbreaking study on the subject published in Pediatric Neurology in 2005.
Just as importantly, cooling appears to disrupt a meticulously choreographed process that causes brain cells to destroy themselves.
With cooling therapy, the infants are placed on a specially designed pad filled with cool water. Keeping the body cool, Dr. Bass found, disrupts a biochemical process that results in brain cell death.
Initially, experienced caregivers had to adjust.
“It was difficult at first to get used to the change,” recalled NICU charge nurse MaryBeth Sanders. “The babies were cold to the touch.”
When Rita Powell arrived in the NICU, the first sight of her daughter shocked her.
“Nailah looked lifeless,” she recalls. “I thought, ‘That’s my baby, and she’s not responding.’ I could see her chest move with her breathing, but that was with the help of a respirator.”
In the first couple of days, tests that measure brain activity showed that Nailah sustained apparent brain damage. But it was too soon to tell what the outcome of the treatment would be.
Nailah remained on the cooling blanket for three full days at a steady body temperature of 91 degrees. On the fourth day, over the course of 24 hours, doctors slowly warmed the water in the blanket to increase Nailah’s temperature to a normal 98.6 degrees.
Even then, Rita and Jimmie couldn’t tell if the cooling therapy had worked. And Nailah’s body began to swell with retained fluid due to kidney failure.
“She was so swollen that when she tried to open her eyes, we could see her eyebrows lift, but her eyes stayed swollen shut,” Rita said.
The new parents remained hopeful and reveled in small improvements, like the first time Nailah moved her hand.
“Every day I would come and talk to Nailah,” Jimmie said. “I told her to continue to fight. I called her our little fighter, right from the get-go. I’d always say, ‘Please, God, show me a sign that she’s going to be okay.’”
Dr. Bass spoke to Rita and Jimmie twice a day. They learned enough to know that most children who’ve suffered severe oxygen deprivation sustain severe brain damage and often cerebral palsy. They were praying Nailah’s case would be different.
Nailah remained in the NICU under constant monitoring and undergoing repeated dialysis for kidney failure. After a full month in the NICU, the dialysis drained enough fluids that her weight dropped to below her birth weight.
“She had actually started acting normal,” said Jimmie.
After more than five weeks, Nailah’s medical condition stabilized. By January, Nailah no longer needed the intensive care of the NICU, but EEG tests showed that Nailah’s brain activity remained suppressed.
“We started talking about some of the long-term effects,” said Jimmie.
On Nailah’s last day at CHKD, January 9, Rita stood alone at her daughter’s bedside, waiting for the discharge papers, while Jimmie went to the parking lot to get the car seat. Nurse practitioner Julia Lomax approached Rita, clutching a sheaf of papers, beaming. She showed Rita the results of the latest EEGs.
As she read the results, Rita broke into tears.
“It was normal,” Rita recalls. “Julia gave me a big hug.”
Today, more than a year later, Nailah is a busy toddler, hitting all the normal milestones. Her kidneys have recovered to the point that she doesn’t require dialysis.
Dr. Bass’s study, conducted with neonatologists from seven other centers across the nation, showed such encouraging results that cooling therapy is gradually being accepted in other advanced-level NICUs. Community hospital NICUs, most unequipped to provide cooling therapy, increasingly transfer children to advanced centers like CHKD that have the equipment, specialists and expertise.
“For neonatologists, there’s nothing more gratifying than the feeling you’ve helped an infant through a difficult medical problem and increased the chance of a normal life,” Dr. Bass said. “Although the initial results of hypothermia therapy are encouraging, a lot of work still needs to be done to determine the optimal degree and duration of cooling and to determine which patients respond best to cooling.”
In order to help fine-tune the cooling therapy, Dr. Bass has launched another study to develop a small, non-invasive device to measure the precise temperature of an infant’s brain. Doctors currently measure the rectal temperature to determine the degree of cooling, and rectal temperature can be two to three degrees warmer or cooler than the brain’s temperature.
The new device, being developed with the help of a $750,000 grant from the National Institutes of Health, will allow doctors to use precise brain temperature measurements, improving therapy that’s already proven remarkably effective.
The Powells are proud that Nailah was able to participate in this groundbreaking effort.
“It thrills me,” Jimmie said, “that Nailah was part of something that will help other children out there.”
“I’m grateful that Dr. Bass was there when we needed a miracle,” Rita said.
Dr. Bass practices with Children’s Specialty Group PLLC at CHKD.
This story was featured in the first quarter 2008 issue of KidStuff, a publication of Children's Hospital of The King's Daughters.