Malcolm Battin Neonatologist ACH, Chair NE Working Group, PMMRC

“ That it will ever come into general use, notwithstanding its value, is extremely doubtful; because its beneficial application requires much time and gives a good bit of trouble both to the patient and the practitioner; because its hue and character are foreign and opposed to all our habits and associations ” London Times 1834

Reduction in death or disability in hypothermia trials at m CoolingControlP valueRelative Risk (95% CI) CoolCap59/10873/ (0.67, 1.02) TOBY74/16386/ (0.68, 1.07) NICHD45/10264/ (0.54, 0.93) Eicher14/2721/ (0.41, 0.92) China28/8835/ (0.43, 0.92) ICE55/10767/ ( ) NeoNet28/5546/ (0.49, 0.81)

P Shah. Seminars In Fetal and Neonatal Medicine 2010

Shankaran S et al. N Engl J Med 2012;366:

WeeFIM ratings were completed at 7–8 y of age on 62 (32 cooled; 30 std) of 135 surviving children with neuro- developmental assessment at 18 mo Guillet R et al. Pediatric Research 2012

 Only intervention that modifies outcome  Standard of care  Available in all level 3 units  Most effective < 6 hrs after insult

Potential issues with access: Cooling did not take place in 27/82 cases (33%). Ongoing plan to review potentially eligible cases  Delay  Geographical  Smaller units & primary birthing centres  Service provision  Poor uptake by a tertiary centre  Inadequate guidelines and protocols

 NE Working Group Data  Equity in availability but variable mode ▪ informal survey NZ 3 o centres  Formal collection on timing + clinical data  ANZNN  Cooling is an entry criteria  Delayed reporting

 Complete capture  Accurate information  LMC input  Timely  Protected  Web based  1 st year of data in PMMRC report 2012 NZPSU 1/12 Paediatricians PMMRC NEWG LMC Website Baby form Mother form Local data Coordinator

 Potential issues with access  Potential issues with transport

Passive Cooling in Transport : Risk Of Over Cooling 37 / 42 babies satisfactory WRT target range 5 excessive cooling with no monitoring Passive cooling resulted in 1.8 h earlier initiation Kendall et al. Arch. Dis. Child. Fetal Neonatal Ed. 2010

 Potential issues with access  Potential issues with transport  Problems with temperature control in NICU

Rapid induction ~ min. Potential overshoot acceptable if < 1 °C. Maintenance phase for 72 hrs minimal fluctuations servo-controlled most stable Rewarming slow and controlled rates of 0.2–0.5 °C/hr V. minimal overshoot Ongoing temperature monitoring ensure no fever Robertson Fetal and Neonatal Medicine 2010

Infant Rectal Temp During Cooling Using SHC, WBC And WBC Servo Hoque N et al. Pediatrics 2010 ©2010 by American Academy of Pediatrics

 Potential issues with access  Potential issues with transport  Problems with temperature control in NICU  Potential cooling complications

A form of panniculitis Involves back, scalp, arms 12 / 1239 cases in TOBY register of WBC Moderate-to-severe hypercalcemia in 8 / 10 with calcium measurement Skin lesions appeared after completion of cooling run Moderate hypothermia is a risk factor for SCFN Need to be aware of SCFN Monitor blood calcium

P Shah. Seminars In Fetal and Neonatal Medicine 2010

Recommendations  Guidelines for cooling should ensure timely availability and access for all  Evidence gap analysis by NZ guidelines group March 2012  Local centre guidelines to inform transfer of babies  The key to safe transfer is core temperature monitoring  Long term follow-up data vital  NE working group data collection  ANZNN