Hyperbaric Oxygen Therapy (HBOT) for Infants
According to Dr. Harch, “HBOT for infants is no different than HBOT for adults except that infants can be exquisitely sensitive to oxygen and thus, require careful dosing.” In the early 1990s, Dr. Harch began an investigation of Hyperbaric Oxygen Therapy (HBOT) in pediatric brain injury. Beginning with the first cerebral palsy (CP) child, he applied HBOT and SPECT brain blood flow imaging (discussed below) to any child with a neurological diagnosis primarily involving the brain. What he found was that HBOT acted like a generic drug on a multitude of different brain disorders in children, including genetic disorders.
A Remarkable Case
In those seminal years, he found that children as young as six months could be treated safely. One case of a 6 month old girl that was a shaken baby was treated four months after her injury when she was finally stable enough to travel. She had seizures, was paralyzed, blind, and very fragile. By the end of the first two months of treatment she was more alert and aware, responding to her mother, developing vision, and free of seizures. Dr. Harch then took her off her seizure medications and she remained seizure free. Her case is published in the Textbook of Hyperbaric Medicine, edited by K.K. Jain, 3rd Edition, Chapter 18. Her remarkable and shocking brain scans can also be viewed in the congressional testimony that Dr. Harch gave to the House of Representatives in 2002. That testimony is featured on the International Hyperbaric Medical Association website. In addition, a book has been written about her case called I Am Still Standing, by Sue Ann Worsley (Publish America). In the book, the grandmother recounts the family’s courageous trek to New Orleans to be the first child in the world to be treated with Hyperbaric Oxygen Therapy for shaken baby syndrome. Their efforts were rewarded with a baby who regained vision, a relationship with her mother, and eventually movement in her legs.
What these early cases showed was that brain injury in infants could be successfully and safely treated. Since that time, Dr. Harch has treated hundreds of children with over 50 different neurological diagnoses. What is important, however, is that different brain injuries and diagnoses can require different doses of HBOT. Seizure disorders, for example, if treated at higher pressures and higher frequency of treatments can be aggravated by HBOT. Similarly, autistic patients can be very sensitive to HBOT and require individual dosing. Since the initial safe treatment of so many brain injured children at Dr. Harch’s clinic in New Orleans, Dr. Neubauer and other physicians have treated thousands and thousands of children in the U.S. and worldwide.
Infant Neurological Development
The beauty of Hyperbaric Oxygen Therapy in neurologically abnormal infants is that HBOT can have a tremendous impact on the child at a time when the brain injury is relatively new and the infant’s brain is rapidly growing. At birth, each brain cell in a baby’s brain makes connections with a small number of other brain cells. These connections reach out like tentacles from each brain cell to touch others. Electricity then flows through the connections to communicate with other cells and give us neurological function. Since there aren’t a lot of connections in infancy, there is not a lot of function. This is why a baby just eats, smiles, cries, moves, poops, and sleeps. The brain is immature and is only capable of primitive functions due to the sparse brain connectivity.
It takes a tremendous amount of oxygen for a brain cell to make and conduct electrical signals. Once injured, the brain cells stop generating electrical signals usually because of low oxygen. The low oxygen often results from low blood flow which also is responsible for the lack of delivery of fuel, sugar, to run the brain. When the cell and its tentacles are deprived of fuel and oxygen, electricity ceases. When electricity ceases so does neurological function. The lack of neurological function is manifest as spasticity (high tone), floppiness (low tone), lack of awareness and alertness, poor coordination, paralysis or weakness, problems with feeding, developmental delays, and all the neurological abnormalities we see in brain injured children. Just as importantly, however, once electricity ceases, the tentacles of the brain cells die back from their connections. The electricity is necessary for maintenance of the connections and health of the brain tissue. The best examples of this are when an arm or leg is in a cast, someone has polio, or someone has had a stroke that paralyzes one side of the body. When the muscles can’t move because of the cast (no electrical impulses to the muscles), or because the nerve tracts have died (polio), or because the nerve cells in the brain have died, the muscles shrink or atrophy. When electricity is reestablished, the muscles begin to increase in size again.
As Dr. Harch notes in his book The Oxygen Revolution, when Hyperbaric Oxygen Therapy is applied to infant brain injury, HBOT’s first effect is to repair the metabolic injury to the brain cell caused by low oxygen and blood flow. Once the metabolic machinery has been repaired, the cell is now capable of generating electrical signals again. The electrical activity causes the tentacles to grow and remake lost connections as well as establish new connections. At this point, the infant’s brain begins development anew. It is also the time when additional therapies are needed to enrich the diversity of the new connections. This is known as maturation. By the time the infant reaches adulthood, each brain cell will be touching millions of other brain cells. This gives us the diversity and richness of human existence and behavior. If HBOT can be applied soon after brain injury in infants, before all of the connections have died back, HBOT can have a profound impact on the injury and return of function. The longer one waits, however, the later the process of renewed development will begin with HBOT and the longer it can take to correct brain injury.
The Drawbacks of Infant HBOT
While the benefit of infant Hyperbaric Oxygen Therapy (HBOT) can be tremendous, there are some precautions that need to be noted.
Middle Ear Barotrauma
All humans have a small pocket of air behind the eardrum called the middle ear space. The hearing bones sit in this space. It is the space that fills with fluid and pus when infant ear infections occur. This space is connected by a tube or small passage (the Eustachian Tube) to an opening in the back of the throat behind the nose. (Everyone has felt this tube and the middle ear space inflate with air when we sneeze and accidentally hold our nose so that the sneeze goes up into our ears). As people are compressed in a hyperbaric chamber, the air in the middle ear space is also compressed and gets smaller. Unless the little opening at the end of the Eustachian Tube is opened to allow the middle ear space to have the same pressure as the air in the mouth and rest of the hyperbaric chamber (“clear or pop your ears”), a vacuum is created in the middle ear space such that the walls of the middle ear space are sucked in to fill the contracting middle ear space. If the pressure in the chamber continues to increase, fluid and blood can seep into this space from the moist tissue lining the space. This results in middle ear barotrauma.
Babies, unlike adults who can consciously “clear their ears” to equalize pressure, often cannot clear their ears. The best example of this occurs on commercial airlines when the cabin pressure is recompressed to landing pressure as the plane begins its descent. All the babies on the plane start crying because the middle ear space is compressed, they can’t clear their ears, and pain results. If babies are compressed too rapidly in a hyperbaric chamber, middle ear barotrauma occurs. Usually this can be avoided by slow compression of the chamber and a variety of techniques that prevent barotrauma until the baby learns to automatically clear his/her ears.
Oxygen toxicity seizures have always been a risk with Hyperbaric Oxygen Therapy. Any human being, if given enough oxygen, will seize. People with existing seizure disorders will seize with less oxygen exposure. It wasn’t until Dr. Harch treated a group of near-drowning children with seizures between 1989 and 1993 that it was realized seizure disorders were responsive to HBOT. Dr. Machado in Brazil similarly noted in 1989 that his cerebral palsy children with seizures had a lessening of seizures after HBOT. Since that time, dozens and dozens of children with seizure disorders have been successfully treated with HBOT in New Orleans and elsewhere. The problem, however, is that too high a pressure and too much HBOT can worsen seizures. Dosing and careful observation of the infant or child with seizures is essential. Complications, including death, have been reported with over-treatment with HBOT is some children. This is why it is important to obtain HBOT for seizure disorders under the direction of a physician who can adjust anticonvulsant medication or the dose of HBOT.
The Youngest Infants
Hyperbaric Oxygen Therapy treatment of the youngest infants, less than 4-6 months, is often a problem because of the low level of neurological function at this age, especially in a brain-injured child. The effectiveness of HBOT for neurological injury has always been judged by Drs. Harch, Neubauer, and others based on the clinical response of a patient. SPECT brain blood flow imaging and other tests have been used to document changes in brain function, but ultimately it is the patient’s neurological, cognitive, and behavioral changes that are most important. In infants, neonates, less than 4-6 months of age there is very little neurological function to follow. Milestones can take weeks or months to achieve. In brain injured children at this age, neurological function is even less apparent and difficult to follow clinically. In such cases, the infants can be treated expectantly, but the parents must realize that improvements can be more difficult to follow.
Tracheostomies, Copious Secretions, Respiratory Problems, and Reflux
These can be the most challenging infants to treat and the group with the highest complication rates. An infant with an airway problem in a hyperbaric chamber can be a catastrophe. As a result, these higher risk infants should be treated with physicians in attendance. Proper positioning, in chamber suction with a handheld mechanical device, and accompaniment by an attendant are important. When done with these and other precautions, the results can be extremely rewarding. These children, actually, are the ones most in need of HBOT.
Can My Baby Go Blind From HBOT?
There is no evidence of babies becoming blind due to Hyperbaric Oxygen Therapy. Fifty years ago, babies developed retrolental fibroplasia, the fancy term for blindness purportedly from high oxygen concentrations, after exposure to high oxygen concentrations right after birth. Since that time, all high oxygen exposures are presumed to produce blindness in babies until proven otherwise. According to Dr. Harch, in the last 10 years Dr. Philip James of the University of Dundee, Scotland discovered medical literature that strongly suggests that the blindness was not from the high oxygen exposure itself, but rather from the abrupt withdrawal of the oxygen. Once the baby’s eye has become accustomed to elevated levels of oxygen, rapid withdrawal caused spasm and eventually breakdown of the blood vessels with bleeding. It is the bleeding that caused scarring of the retina and blindness. When the oxygen was slowly withdrawn, there were no retrolental fibroplasias. Unfortunately, this has not been appreciated in the medical profession to this day. More recently, animal experiments in which neonatal rats were exposed to hyperbaric oxygen revealed no damage at all to the retinas. In Dr. Harch’s 19 years of HBOT for pediatric brain injury, Dr. Neubauer’s 11 years of HBOT for pediatric brain injury, and the experience of now numerous physicians worldwide, only restoration of vision has been reported. Again, only restoration or improvement of vision have been reported, particularly in cortical blindness or vision impairment.