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Treatment reduces disability in premature babies

1st April 2013


A pioneering technique, a world first in Bristol, has been shown to reduce disability in premature babies with serious brain haemorrhage by washing the brain to remove toxic fluid.

The research, led by Andrew Whitelaw, Professor of Neonatal Medicine at the University of Bristol, and Ian Pople, paediatric neurosurgeon at North Bristol NHS Trust, has shown that, after a haemorrhage, the fluid inside the ventricles contains substances potentially toxic to the immature brain. In 1998, Professor Whitelaw and Ian Pople pioneered a technique by which the inside of the brain was "washed out" to remove the toxic substances.

The Bristol team report on this pioneering work in an article published online in Pediatrics, the journal of the American Academy of Pediatrics.

One of the most feared complications of being born very early is bleeding into the ventricles in the centre of the brain. A large haemorrhage usually injures the developing brain with consequent cerebral palsy and serious learning difficulties in several hundred children each year in the UK. In about half of the children, fluid builds up inside the brain causing the brain and head to expand excessively. This condition is called ‘hydrocephalus'. Until now, no treatment in these premature babies has been shown to reduce disability, or improve any aspect of health. The standard approach has been to repeatedly insert needles into the spine or head to remove fluid until, after several months, a permanent surgical "shunt" drains fluid from the brain to the abdomen.

Professor Whitelaw said: "Premature babies are particularly at risk of bleeding because in the middle of pregnancy, the fetus has many fragile blood vessels in the centre of the brain. These blood vessels shrink by full term and bleeding is rare in babies born at 40 weeks."

Professor Whitelaw and Ian Pople have researched the mechanisms and treatment of the condition called ‘hydrocephalus' over the last 20 years.

If a premature baby was shown by repeated ultrasound scans to have had a large haemorrhage and then expanded ventricles, the baby was anaesthetised and two tubes were inserted into the ventricles in the brain. One tube was used to continuously drain out the cola-coloured fluid while the other tube was used to let clear fluid flow in. The pressure in the brain was measured continuously and more fluid was drained out than flowed in so the brain slowly decompressed. When the fluid draining out cleared, the two tubes were removed. This took on average three days. After four years work on the feasibility and practicality of the technique, a randomised trial, funded by grants from Cerebra and the James and Grace Anderson Trust, was started.

From 2003 to 2006, 77 premature babies with large brain haemorrhages in Bristol, Glasgow, Katowice (Poland) and Bergen (Norway) were recruited. Thirty-nine babies had the ventricles washed out using the Drainage, Irrigation and Fibrinolytic Therapy (DRIFT) and 38 had standard treatment.

When they were two years old, independent assessors examined all the survivors. Of 39 infants assigned to being washed out, 21 (54 per cent) died or were severely disabled versus 27 of 38 (71 per cent) in the standard group. Amongst the survivors, 11 of 35 (31 per cent) in the DRIFT group had severe cognitive disability versus 19 of 32 (59 percent) in the standard group. Median Mental Development Index was 68 (out of 100) in the washout group, and below 50 with standard care. These results are statistically and clinically significant.
Ian Pople said: "This is the first time that any treatment anywhere in the world has been shown to benefit these very vulnerable babies. Initially known as "Drainage, Irrigation and Fibrinolytic Therapy (DRIFT)" this treatment is now called "ventricular lavage" and it is hoped that in the very near future it will be set up as a service at Southmead Hospital in Bristol."





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