Azzopardi et al (1) report the experience of introducing total body cooling as a standard form of therapy for infants with moderate or severe perinatal asphyxia. It is notable that this publication includes only one level 2 neonatal intensive care unit of the 25 units providing data for the TOBY register (Royal Cornwall Hospital, Truro). The Royal Devon and Exeter Hospital (also a level 2 unit) has since joined the TOBY register having participated in the TOBY trial. Part of the success in recruitment to the TOBY trial was due to the trial being rolled out to many more units in the second phase of the trial (2). The Peninsula Neonatal Network level 3 unit at Derriford Hospital in Plymouth participated in this trial as did the two level 2 units in Exeter and Truro. All the units were very well supported by training days set up at the units by the TOBY trial investigators.

In the Peninsula Neonatal Network this system of care has continued and total body cooling is provided at the three units that participated in the TOBY trial. Since the trial 6 babies have been cooled in Exeter and 9 babies in Truro. The two level 2 units inform the level 3 unit of infants that are being cooled. We believe that there are significant advantages providing total body cooling on a locality basis when the skills are there and the training is continually updated as long as the infant is stable without evidence of multi-system problems. There is close liaison on these issues with the level 3 centre. Early treatment is important and this is best done as soon as possible in the unit in which the infant is born. There are real benefits to not transferring the infant out to another unit particularly when the delivery has been traumatic and there may be a number of questions from parents and vital issues of communication about obstetric management. These can be addressed quickly and locally in these high risk situations. Providing thermal control for infants is part of the everyday management of neonatal units and the level 2 units have had no difficulty in the technical aspects of providing body cooling. This is likely to be made easier with the advent of servo controlled cooling. We all contribute to the TOBY register which provides feedback on our temperature control and all those providing cooling in the units have attended and presented at regional and national meetings on total body cooling.

We believe that there is a strong case to be made for level 2 units who have experience of cooling to continue to provide this. It is important to remember that one of the central tenets of the NHS is to provide appropriate care as close to home as possible for the family. The case for cooling to be provided in level 2 units rests on the support structures and a rigorous approach to case review and quality control/audit both through the TOBY register and by local oversight. The network approach establishes this by ensuring treatment is supported as a network provision, not as a unit provision.

Yours sincerely

Dr Michael Quinn Consultant Neonatal Paediatrician, Neonatal Unit, Royal Devon and Exeter Hospital, Barrack Rd, Exeter EX2 5DW

Dr Paul Munyard Consultant Neonatal Paediatrician, Neonatal Unit, Royal Cornwall Hospital, Treliske, Truro TR1 3LJ.

Correspondence to Dr Michael Quinn.

Competing Interests: None

REFERENCES

1. Azzopardi D, Strohm B, Edwards AD, Halliday H, Juszczak E, Levene M, Thoresen M, Whitelaw A, Brocklehurst P on behalf of the Steering Group and TOBY Cooling Register participants. Treatment of asphyxiated newborns with moderate hypothermia in routine clinical practice: how cooling is managed in the UK outside a clinical trial. Arch Dis Child (Fetal and Neonatal Edition) 2009; 94 (4):F260-F264 2. Azzopardi D, Strohm B, Edwards AD, Dyet L, Halliday H, Juszczak E, Kapellou O, Levene M, Marlow N, Porter E, Thoresen M, Whitelaw A, Brocklehurst P for the TOBY Study Group. Moderate hypothermia to treat perinatal asphyxial encephalopathy. N Eng J Med 2009; 361 (14): 1349-1358