The miracle machine

Sadiq was starved of oxygen at birth. Ordinarily, he would have been brain damaged, but he was given a pioneering treatment that offers a future to hundreds of babies every year. Jeremy Laurance reports

For Sufia Begum, the birth of her eighth child was a nightmare that will stay with her for the rest of her life. It had been a very difficult labour that ended with a Caesarean. When her son, Sadiq, was delivered, he had been starved of oxygen, there was a build-up of acid in his blood and he had a very slow heart-beat. The expectation was that, if he survived at all, he would be severely brain damaged.

For Sufia Begum, the birth of her eighth child was a nightmare that will stay with her for the rest of her life. It had been a very difficult labour that ended with a Caesarean. When her son, Sadiq, was delivered, he had been starved of oxygen, there was a build-up of acid in his blood and he had a very slow heart-beat. The expectation was that, if he survived at all, he would be severely brain damaged.

Today, Sadiq is a boisterous six-year-old, who delights in playing pranks on his three sisters and four brothers. He is going to school where he is holding his own and receiving no special help. He wears glasses and has had mild speech delay, but he is otherwise largely unaffected by the drama of his birth.

He was one of the first babies to receive an experimental treatment designed to prevent brain damage in the new-born. For the first three days after his birth, he wore a special plastic cap strapped to his head filled with water to cool his brain. Doctors believe that this cooling effect was enough to save him from brain damage.

His mother, Sufia, says: "I was so happy and so grateful. If they had not done the cooling technique, he might not have survived. Even if he had survived he might have had difficulty walking and talking. Now we expect him to lead a normal life."

Sufia, aged 48, and her husband, Jamal, run a shop selling saris in Bethnal Green, east London. They speak Bengali at home and Sadiq's English is limited, though he is learning. His older brother, Moyaz, 21, a student, says: "He is naughtier than the other kids. He never sits down for five minutes. He likes football and practical things like building with bricks. He is not interested in watching television. He likes to be doing something."

Brain damage caused by oxygen deprivation at birth affects 600 to 700 babies a year in the UK. As well as being a catastrophe for the family, it is a major burden on society. The lifelong costs of care for a severely brain-damaged baby can be as high as £5m. Often, there is no warning of a problem until the very last days of pregnancy, or during labour. The umbilical cord may become wrapped round the baby's head, or the womb may rupture down a previous Caesarean scar. Once the baby is born, the oxygen supply is restored - but by then it is too late. Any restriction of the blood flow to the brain causes damage within minutes.

Or so the orthodox view goes. It now looks as though this may be wrong, however. A study of the cooling cap in four countries - Canada, the US, New Zealand and the UK - published in The Lancet last month found that it saved one in six babies who suffered oxygen deprivation at birth from death or lifelong disability.

The idea for the cooling cap was sown a decade ago by research at University College Hospital, London, which suggested that there is a window of a few hours during which the effects of oxygen starvation are treatable. Professor John Wyatt, the consultant neonatologist who led the research, says: "In a completely normal, healthy labour, oxygen levels can fall incredibly low. A quarter of the blood in the brain changes with each contraction. It is like being throttled. The placenta only works between contractions, so if the contractions are coming very rapidly it can't keep up and the oxygen level keeps falling."

Fluctuations in the level of oxygen continue after birth, especially in premature babies whose lungs are underdeveloped. But early intervention to counter the effects is possible, the researchers found. "Instead of damage being instantaneous, we found that there was a delay of a number of hours and then a wave of cells started dying across the brain. That suggested there was a window of opportunity after the baby was born before the injury became permanent," says Professor Wyatt. "We tried to find an intervention that would help and the one that stood out was reduction of the brain's temperature. It seems to prevent the cascade of damaging reactions in a way that we don't understand."

He adds: "The temperature only needs to come down by a few degrees. We have found that the brain is exquisitely temperature-sensitive. Cooling the brain is much less likely to have catastrophic side effects than giving drugs. It is the most promising line of treatment we have."

For the trial, researchers in hospitals in the four countries selected 234 babies who were deprived of oxygen at birth and who had been shown to be at high risk of brain damage by tests of electrical activity in the brain. The cooling cap was fitted to the baby's head within a few hours of birth, lowering the temperature by 3-4 degrees. It was removed after 72 hours.

The treatment ran directly counter to orthodox care of the new-born, which dictates that they should be kept warm and that hypothermia is a real threat. "What we were doing was very counter-intuitive and we were concerned we might do harm. All the textbooks were filled with the dire hazards of our hypothesis. So we only included babies in the trial who had significant abnormalities," says Professor Wyatt.

When the babies were examined 18 months later, the results showed that the proportion who had suffered severe disability or death was reduced from 66 per cent in the group given conventional care to 55 per cent in those treated with the cooling cap. This was improved to 48 per cent, achieving statistical significance, when the one-fifth most severely affected babies, who had least chance of recovery, were excluded.

"It confirms what we would expect, that some babies are so severely affected that therapy can't help them. But what is encouraging is the larger, less severely affected, group, of whom one in six showed benefit," says Professor Wyatt. "For the last 40 years it has been paediatric orthodoxy that babies should be kept warm. We are not changing the advice to parents - it is very important that babies are kept warm - but this does turn conventional wisdom on its head."

The technique is being developed, and a new study is underway at Hammersmith Hospital, London, involving whole body cooling for babies starved of oxygen at birth. "There is reason to think the therapy could be improved further," says Professor Wyatt. "In the trial, there were delays with some babies before cooling could begin. If we started cooling sooner after birth we might get more of a therapeutic effect. We also don't know what the optimum temperature is - it is likely to be lower than we have tried so far. The technique we have used creates a temperature gradient across the brain in which the surface is cooler and the centre warmer. It may be that different parts of the brain do better at different temperatures."

Other researchers are cautiously optimistic. Professor Marianne Thoresen, who led the trial at Bristol University, where most of the English babies were treated, says: "This demonstrates for the first time that treatment may be possible for babies who suffer oxygen deprivation at birth." Professor Andrew Whitelaw, also from Bristol and another of the researchers, stresses the need for more detailed research: "We need to get further information on the timing and methods of cooling, as well as which babies are most suitable for treatment, before cooling becomes the standard care for oxygen-deprived babies."

Dr Denis Azzopardi, who is leading the total body hypothermia (Toby) trial at Hammersmith Hospital, which includes groups from Bristol University and Imperial College, London, says: "The Toby trial will determine whether this simpler form of cooling has a beneficial effect and could bring routine treatment a step closer."