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Interview with Dr. Sonia Bonifacio: Preventing Brain Damage in Newborns

Sonia Bonifacio

Audio Interview

Hear a Patient Power interview with Dr. Sonia Bonifacio, a neonatologist who specializes in the treatment of critically ill and premature newborns, and Kelsey Dimitropoulos, whose son Luke was born without a heartbeat. Luke was revived and transferred to UCSF Benioff Children's Hospital where he received hypothermia treatment, using a cooling blanket, to bring down his core temperature and prevent brain damage.

Interview Transcript

Introduction

Andrew Schorr:

Babies who don't receive enough oxygen to their brain during and after birth can be at risk for brain damage, but a new technique to cool body temperatures can help reduce or prevent this damage. We'll hear more from an expert from UCSF Benioff Children's Hospital and a woman whose child benefitted from this procedure. It's all next on Patient Power.

Hello and welcome to Patient Power, sponsored by UCSF Medical Center. I'm Andrew Schorr. Well, I have three children and the birth is always exciting. For most of us, the birth goes quite normally, but there are times when it doesn't. One thing you really worry about is the oxygen supply to the baby. Is that baby struggling? And if they're born and they survive, there could be life-long disability. How can we try to minimize that? We're going to talk about that in this program.

I want to introduce you to a mom who faced that with her baby three years ago. That's Kelsey Dimitropoulos. She joins us from near Sacramento today. She's from Orangevale, California, about two hours east of San Francisco.

Kelsey, let's go back to that day, April 22, 2009. Your heart rate was going up. What was going on with the baby? Was the pregnancy normal up to this point?

Kelsey's Story

Kelsey Dimitropoulos:

His heart rate was dropping due to too much Pitocin and too many contractions, and he was losing oxygen.

Andrew Schorr:

And so you had an emergency C-section. When this baby, Luke, was born, was he breathing or seemed to be alive at all?

Kelsey Dimitropoulos:

No, he wasn't breathing. He didn't have a heart rate. They told us he was not alive at the time.

Andrew Schorr:

Now, fortunately, they were after many minutes able to revive him. Then before you knew it, he was sent off by ambulance to UCSF about two hours away. And he benefitted from what seemed like very high-tech procedure, where they put a cooling blanket around him. Now, when you finally caught up with him, I know you see your little baby there and you're just hoping this is going to work. Must have been very shocking for you, but at least something was being done. How were you feeling at this time?

Kelsey Dimitropoulos:

I think I was still kind of in shock. He had gained over the first few days quite a bit of weight because of all the fluids that were being pumped into him.

I think they determined he had got up to about 14 pounds within a couple days, so he didn't even look like a baby.

Andrew Schorr:

Wow.

Kelsey Dimitropoulos:

But he just laid there motionless. There was no brain activity. He had a breathing tube in. He couldn't open his eyes, and it was all kind of shocking, but at the same time we were hopeful because of the cooling process.

Andrew Schorr:

We're going to learn about that. Now, the good news is after he had three days of that and then started to recover, there was a point where he could squeeze your finger, right?

Kelsey Dimitropoulos:

He did. At some point when we put our fingers in his hand, he did squeeze it very gently, but it was very noticeable.

Andrew Schorr:

Now, we should jump ahead and say that Luke is now 3 years old. He's with you in the car today. How is Luke as best you can tell?

Kelsey Dimitropoulos:

He's perfect, does everything a kid his age should do and more.

He knows his colors and shapes, his numbers, his letters. He sings songs.

Andrew Schorr:

Well, do you think he'll say hi to me?

Kelsey Dimitropoulos:

I think he will. He would love to.

Andrew Schorr:

Let's give it a go.

Luke Dimitropoulos:

Hi.

Andrew Schorr:

Hi, Luke.

Understanding Hypothermia Treatment

Andrew Schorr:

Kelsey, it was a very specialized team at UCSF, the site of the nation's first Neurointensive Care Nursery. That's where all this went on. One of the doctors, and there were many I know, who was there by your side and helping play a key role in your care, is Dr. Sonja Bonifacio, who is a neonatologist at the children's hospital there, and she joins us.

Doctor, first of all, it must make you feel great that here's a 3 year old now who seems to be leading a normal life.

Dr. Sonia Bonifacio:

It's wonderful. Every time I see Kelsey and Luke I almost have tears in my eyes just thinking about the many things that he went through, and to watch him grow and develop over the last three years has been absolutely amazing.

Andrew Schorr:

Let's talk about this, this limiting of oxygen to a baby at a critical time. This has gone on forever, and we've had kids with cerebral palsy and many kids who have not survived, but we haven't really had treatments. So where are we now with this hypothermia approach? It sounds like it's quite a breakthrough.

Dr. Sonia Bonifacio:

It's an amazing breakthrough. It's really the first therapy that we've had available to us to try to prevent further brain injury and to save some babies who might not have been saved before. It's now being rapidly implemented in different centers.

There have been several trials over the last 10 years, which have shown significant improvement in the incidence, or decrease in the incidence of death or disability after this therapy has been done. So it's great to have something to be able to offer families and children.

Andrew Schorr:

And [when thinking] about preventing disability where otherwise a child may survive but have a life for themselves and their parents that was very different, this is a big deal.

Dr. Sonia Bonifacio:

Absolutely a huge deal. The reduction in the incidence of death or disability is about 11 percent from prior to being able to do hypothermia. But when you think about the life-long impact that having a significant disability might have, it's really a huge thing to be able to reduce the risk of that by even 11 percent. It's a big deal.

Andrew Schorr:

Now, I mentioned that this baby, Luke was in this cooling blanket for three days, sedated and fluids and other things you're doing to help the baby survive. What is actually going on? Where does cooling come into play [to help] minimize the damage due to the lack of oxygen that they've had?

Dr. Sonia Bonifacio:

The really basic concept is that you're slowing down all of the body's metabolic rates, and that specifically we're trying to lower the metabolic demands of the brain. We're trying to prevent what is called secondary energy failure after an insult. It's a very simple concept. You lower the body temperature, you keep the baby sedated and we do a lot of other things to help us understand what's going on with the brain during that time. Then we do some imaging after the hypothermia is done to look for areas of brain injury.

But the very simple concept is to lower the metabolic rate of the brain and to prevent any secondary effects from the initial insult.

Andrew Schorr:

So we understand that normal temperature is 98.6 [degrees]. What temperature are you cooling the baby to?

Dr. Sonia Bonifacio:

In Celsius, they go down to 33.5 [degrees], which is 3 degrees lower than the normal temperature of 36.5. It's not a huge drop in temperature, but it is something that is noticeable and can cause other physiologic changes that we need to monitor very closely.

Andrew Schorr:

Is the idea that you can reverse damage that was done or you can minimize further damage and maybe that the baby's brain can adapt to damage that has been done and get a second chance, if you will?

Dr. Sonia Bonifacio:

The idea is that we're minimizing any secondary effects. It's very difficult and no one really has a way yet to reverse damage that might have already occurred, but really to minimize the secondary effects of that initial insult.

The Hypothermia Cooling Process

Andrew Schorr:

Now, Kelsey and Luke were at an outlying hospital. For this to be effective, how quickly does the baby need to be cooled?

Dr. Sonia Bonifacio:

The most common process now is to start the cooling even before the baby gets to a specialized center. The way that it was studied in the randomized trials, and the information came from animal models, is that it needs to be initiated within six hours of birth. Again, the way that the injury cascade happens is that there are different phases of injury and we're trying to prevent getting to what's called the latent and secondary phases of injury. It's been shown in the animal models that you need to have the animals or in our case the baby cooled before they reach that phase.

Andrew Schorr:

Kelsey, I believe that they actually started the cooling process at the local hospital before Luke was at UCSF, right?

Kelsey Dimitropoulos:

They did. They had started it before they had transferred him up there.

Andrew Schorr:

Now, when you think of what care came into play for him in this special unit, do you feel they saved his life, Kelsey?

Kelsey Dimitropoulos:

I do. Absolutely.

Andrew Schorr:

Anything you want to say to Dr. Bonifacio publicly here?

Kelsey Dimitropoulos:

Oh, my gosh, anything I haven't already said. I know we owe his life to everyone in that hospital a hundred percent. They cared for him day in and day out. They didn't just care for him, they cared for our entire family. They were so nice. They've all become a family to us, and we are so grateful for everyone that did everything they could for him.

Andrew Schorr:

And you got to know them pretty well because he was there for about five and-a-half weeks, right?

Kelsey Dimitropoulos:

We got to know everyone very well. We still keep in contact with a lot of them.

Andrew Schorr:

And, doctor, you continue to monitor kids like Luke over time. From what I've been reading, let's face it, not everything is perfect always, but you all are very encouraged by the results you're seeing long term, aren't you?

Dr. Sonia Bonifacio:

Most definitely. I think Luke is one of our miracles . . . we like to say when we think about Luke. He's very, very lucky that the doctors at the referring hospital noticed and remembered that this therapy was available and that he would qualify for it.

It is still really important to continue to follow Luke and the other children who receive this therapy because there are some things that don't show up until later on in life. What we usually tell families is that babies, they don't need to do a lot. They need to wake up and eat and sleep and look around, but there aren't a lot of things required of them.

So we watch them very closely, and we follow them in our specialized follow-up clinic. We have developmental assessments at different time intervals so we can really be on it in terms of if we start to notice a problem so that they might receive therapies earlier on if they were to need them.

Team Approach to Neonatal Care

Andrew Schorr:

I want to help people understand what devotion you have at the children's hospital at UCSF. So you're a neonatologist and you have pediatric neurologists working hand-in-hand with you. There's a whole team that's come together to help your center stand out. Is that right?

Dr. Sonia Bonifacio:

Yes, that is correct. We definitely have a team approach. We, the neonatologists, work very closely with the neurologists. We discuss these acute patients on a daily basis.

Our nurses have been specially trained. So we have a core group of nurses. We always have an educated nurse, a nurse who is educated in our Neurointensive Care Nursery procedures and processes. There is always a nurse present all the time, so if a patient comes in things can be initiated rapidly, and the people with the appropriate training are present to take care of the patient and recognize things like seizures if they were to occur.

We have a multidisciplinary approach, and we're very comprehensive in the services that we provide.

Andrew Schorr:

Well, I know Kelsey, all of us listening, are so grateful that you have this center and that kids like Luke can benefit from it, not just in the short term but hopefully for a long, healthy very cognitively sharp life.

Advice for Other Families

Andrew Schorr:

Kelsey, what do you think the lesson is for women going through pregnancy? Is it to keep in the back of your mind that, "Is there a specialized center that may be called upon?" What would you say if some friend of yours said, "Well, gee, what should I be thinking about? I'm going to have a baby." Usually it's going to go fine, but I guess you've got to keep in the back of your mind that you may need specialized care if things aren't going fine.

Kelsey Dimitropoulos:

I think my best advice to give to anybody would be to ask questions. If you're not sure what's going on, if you're questioning what's happening when you're in the delivery room, ask questions. If you don't know or you really don't trust what's happening, just ask questions. Ask everyone to double-check things. You know, [ask], "Can you check his heart rate, make sure it's okay? Can you continue to monitor it? Can you tell me how it's going, just communicate, please." There wasn't a lot of communication between me and the nurses in Mercy in Folsom when I was there, and I didn't think I needed to ask questions. I figured they're professionals, they're doing their jobs, they know what they're doing, but they're human. They make mistakes.

Andrew Schorr:

This program is called Patient Power so we certainly believe in that. Kelsey and Luke, we want to wish you all the best for just having fun with each other, and hopefully you see a wonderful young man develop who goes on for a full life. Kelsey, I want to thank you so much for being with us with Luke.

Kelsey Dimitropoulos:

Thank you for having us.

Andrew Schorr:

Give him a pat on the back for being such a good, well-behaved boy while we did this.

Kelsey Dimitropoulos:

I will.

Andrew Schorr:

Dr. Sonja Bonifacio, thank you so much for being with us and for what you do at UCSF in your Neurointensive Care Nursery, a one-of-a-kind place. I know it makes a difference to so many people.

Dr. Sonia Bonifacio:

Thank you. It was a pleasure to be here for this.

Andrew Schorr:

Thank you so much for joining us all on Patient Power, where we can connect you with a leading specialist like Dr. Bonifacio and someone who is really inspiring, Kelsey and little Luke. They've benefitted from state-of-the-art medical care.

I'm Andrew Schorr. Remember, knowledge can be the best medicine of all.

Recorded January 2012

Photo by Tom Seawell

 

Reviewed by health care specialists at UCSF Benioff Children's Hospital.

This information is for educational purposes only and is not intended to replace the advice of your doctor or health care provider. We encourage you to discuss with your doctor any questions or concerns you may have.

Related Information

UCSF Clinics & Centers

Pediatric Brain Center

Critical Care

Neurointensive Care Nursery
505 Parnassus Ave., 15th floor
San Francisco, CA 94143
Phone: (415) 353-1565
Fax: (415) 353-1202