Sometimes when babies are born, there are signs of brain, heart or lung problems. Babies may have been born non-vigorous and limp, or had low Apgar scores, which can be a sign of many serious issues (including brain injury and hypoxic ischemic encephalopathy (HIE)). Babies born prematurely or who had a difficult labor/delivery may need resuscitation if they are not breathing, are struggling to breathe, have an abnormal heart rate or have periods of apnea (time periods where breathing stops). The NICU is the only unit that cares for babies who are intubated and on breathing machines (ventilators). TheNICU also treats premature babies with high bilirubin levels (jaundice) and low red blood cell counts (anemia). Birth injuries can also cause the need for a NICU stay due to asphyxia/hypoxia-ischemia. Even if hypoxic-ischemic conditions don’t cause a baby to a brain injury known as hypoxic ischemic encephalopathy (HIE), they can cause the newborn to have seizures, intracranial hemorrhages (brain bleeds), hypoglycemia, respiratory distress syndrome (RDS) and many other problems that require a stay in the NICU.
Conditions Treated with Neonatal Intensive Care
Neonatal Encephalopathy (Newborn Brain Injury)
A common reason for babies to be admitted to the NICU is that they show signs of brain injury soon after birth. Neonatal encephalopathy (NE) is a term used to describe disturbed brain function during the first few days of life. Babies who had a difficult labor and delivery and experienced a lack of oxygen to the brain (birth asphyxia) or head trauma may show signs of NE right away. Hypoxic ischemic encephalopathy (HIE), meningoencephalitis (encephalitis with meningitis), intracranial and extracranial hemorrhages (brain bleeds), stroke, and infection can all cause encephalopathy in a newborn, but HIE is by far the most common cause of NE. Neonatal encephalopathy can cause the baby to have cerebral palsy, a seizure disorder, hydrocephalus, microcephaly, intellectual disabilities, developmental delays and periventricular leukomalacia (PVL).
Seizures and a below normal level of consciousness are some of the earliest indications of encephalopathy.
Other signs of NE may include the following:
- The baby needed resuscitation at birth
- Low Apgar scores
- A weak or absent cry at birth
- An abnormal level of consciousness (hyperalert, irritable, lethargic)
- Tone and reflex abnormalities, such as being limp and floppy or stiff and spastic
- Apnea (periods in which the baby stops breathing for 20 seconds or more)
- Feeding difficulties
- Respiratory problems (on a breathing machine)
- Low blood pressure
- Organ failure
- Hyper or hypoglycemia (high or low blood sugar)
- Stiff neck (If the baby has meningitis)
How is Neonatal Encephalopathy Treated?
Encephalopathy means that the baby has signs of brain swelling caused by an insult to the brain. In many cases, the baby ends up with no permanent damage or long-term consequences, especially if the encephalopathy is the kind that can be treated with hypothermia (brain cooling) treatment. Babies who have hypoxic ischemic encephalopathy (HIE) are eligible for hypothermia treatment, but it must be started within 6 hours of the insult, which usually means within 6 hours after delivery. Hypothermia treatment has been shown to slow down almost every injurious process that occurs when a baby is oxygen deprived. The treatment can either prevent the baby from having cerebral palsy or it can cause the CP to be less severe.
If respiratory distress, brain bleeds, infection and strokes are promptly recognized and appropriately managed, the babies’ permanent disabilities may be limited. Sometimes brain damage in a baby is not recognized until the child is 4 or 5 years old when certain developmental milestones are missed. Parents can sometimes begin to suspect birth injury or HIE when they begin to notice signs of cerebral palsy (CP), seizures, developmental delays, or intellectual disabilities.
Hypoxic ischemic encephalopathy (HIE) is the most frequent cause of seizures in a newborn. Seizures occur when the brain is injured, causing abnormal continuous electrical discharges. A baby with seizures may have involuntary jerking movements that can last several seconds or a few minutes, though often there are no outward signs of seizures. Because of this, babies with HIE should be monitored with EEG (electroencephalography) to determine if seizures are occurring. Many NICUs now have the equipment to perform continuous EEG monitoring on newborns.
Seizures can cause permanent brain damage, so they must be promptly recognized and treated. After managing the baby’s airway, heart, blood pressure and circulation issues (and determining the underlying cause of the seizures), the physician will typically start antiepileptic drug (AED) therapy if the seizures continue. Common AEDs include phenobarbital, diazepam, lorazepam, and phenytoin.
Brain Bleeds (Intracranial and Extracranial Hemorrhages)
Intracranial hemorrhages are bleeds within the skull or brain. Bleeds can be caused by head trauma that occurs during delivery. Mismanagement of abnormal positions (such as breech and face presentation) and attempted vaginal delivery when shoulder dystocia or cephalopelvic disproportion (CPD) are present can also cause brain bleeds. Premature babies (who have underdeveloped, weak blood vessels) are susceptible to intraventricular hemorrhages (IVH), the most serious type of brain bleed. The best way to prevent IVH in a baby is to prevent premature birth.
Hypoxic ischemic encephalopathy (HIE) is another cause of intrancranial hemorrhages. HIE causes cell breakdown and death, which causes blood vessel walls to degrade, leading to bleeding.
Forceps and vacuum extractors are a common cause of brain bleeds in newborns. Vacuum extractors place a baby at a significant risk of suffering a type of brain bleed called a subgaleal hemorrhage due to the pressure of the suction cup applied to the baby’s head. A subgaleal bleed occurs when the vacuum ruptures a vein and then the vein bleeds into a space between the scalp and the skull. This condition is life-threatening because almost half of the baby’s blood volume can end up in the subgaleal space. In the NICU, the baby can be closely watched for this type of bleed, which starts during delivery if the cause is suction from a vacuum extractor.
Brain bleeds put a baby at a high risk of suffering from seizures. Brain bleeds must be diagnosed very quickly and EEG monitoring for seizures must take place. Treatment for brain bleeds includes making sure the baby’s blood pressure is normal and providing breathing assistance if needed. Medical staff should perform frequent measurements of red blood cell counts, and in most cases, measurements of head size. Head imaging and blood clotting studies are also essential.
Treatment for blood loss includes giving the baby blood and other therapies to increase blood volume and blood pressure. This includes packed red blood cells, fresh frozen plasma, and normal saline administration.
In cases of a subdural hematoma, surgery to remove excess fluid and blood may need to be performed to decrease pressure inside the brain. Emergency surgery is needed when there is brain stem compression caused by bleeds in parts of the brain that don’t have as much plasticity (ability to move) as other parts.
A common reason babies need to be admitted to the NICU is so they can get help breathing. Brain injury caused by a lack of oxygen to the brain (birth asphyxia) can cause respiratory depression and difficulty breathing. Breathing problems include a decreased drive to breathe, apnea, secretions caused by meconium inhalation, and respiratory distress syndrome (RDS). Sometimes babies have heart and pulmonary vessel problems which also require them to be on a breathing machine (ventilator).
RDS is associated with a difficult delivery and birth asphyxia. RDS is also common in premature babies and is usually caused by a deficiency of surfactant (an important lipoprotein that helps lungs be more flexible) in the baby’s lungs due to premature birth. When a baby has insufficient surfactant, the lungs will be stiff and there can be a lot of collapsed airways. This can make it very difficult for the baby to breathe, even if on a ventilator. Stiff lungs can become seriously injured in the process of ventilation. In addition, babies with stiff lungs and respiratory distress are prone to getting lung infections and pneumonia. Stiff lungs, collapsed airways and infection can cause the baby to suffer from oxygen deprivation, which can cause hypoxic ischemic encephalopathy (HIE), periventricular leukomalacia (PVL) and cerebral palsy. Thus, surfactant is very important for the baby. If the baby is born before 35 weeks – and especially if the baby is born before 30 weeks – surfactant therapy will likely be needed.
If the ventilator settings are not properly managed, the baby may receive breaths that are too large and fast, which can cause overventilation injuries such as hypocarbia and a pneumothorax (a hole in the lungs). Overventilation injuries can cause the baby to have PVL, cerebral palsy and hypoxic ischemic encephalopathy (HIE).
When a baby is on the ventilator, the medical team must carefully monitor the device’s settings and the baby’s response to them. The baby will be slowly weaned off the ventilator to allow independent breathing.
Neonatal hypoglycemia (NH) occurs when the baby’s blood sugar (glucose) falls to unsafe levels in the first few days after birth. Babies need glucose for energy and brain function. Severe NH is one of the leading causes of brain injury. Neonatal hypoglycemia is not difficult to diagnose in a newborn, and it is usually very easily treated. Untreated NH, however, can have serious consequences for the baby because glucose is the major component for energy in all organs, and in the brain, glucose is used almost exclusively for energy. If the amount of glucose supplied by the blood falls, the brain is one of the first organs affected. When brain cells receive insufficient glucose, they start to die. This can cause cerebral palsy and seizures.
Hypoglycemia is a common effect of birth asphyxia. All babies should have their glucose levels monitored, but if a baby experienced a lack of oxygen to the brain during birth, the medical team should be on alert that the baby may have NH.
Jaundice is the yellowing of the baby’s skin and eyes caused by too much bilirubin in the blood. It is one of the most common problems in both premature and term babies. Bilirubin is a product of red blood cell breakdown. All babies experience a period of rapid red blood cell breakdown after birth and may look a little yellow. Most babies are able to easily process the bilirubin. In some babies, however, red blood cells break down faster than normal and the body can’t easily metabolize the bilirubin. When this happens, bilirubin builds up to dangerous levels in the blood. This can lead to bilirubin entering the brain tissue. It is toxic to the brain and can cause a form of brain damage called kernicterus. Kernicterus often leads to cerebral palsy.
High bilirubin levels are easy to diagnose and treat. Most of the time, treatment simply requires the baby to be placed under lights or on a fiberoptic blanket in a process called phototherapy. Other times, the baby may need a blood exchange transfusion. There is no excuse for not properly treating a baby with abnormally high bilirubin. If a baby with jaundice requires testing, the lights should be transported with the infant to provide uninterrupted treatment.
Michigan Cerebral Palsy Lawyers & Neonatal ICU Attorneys Helping Children Nationwide Who Have Birth Injuries
If your child was diagnosed with a permanent disability, such as cerebral palsy, periventricular leukomalacia (PVL), a seizure disorder or hypoxic ischemic encephalopathy (HIE), the award-winning lawyers at ABC Law Centers can help. We have helped children throughout the country obtain compensation for lifelong treatment, therapy and a secure future, and we give personal attention to each child and family we represent. Our nationally recognized firm has numerous multi-million dollar verdicts and settlements that attest to our success and no fees are ever paid to our firm until we win your case. Email or call Reiter & Walsh ABC Law Centers at 888-419-2229 for a free case evaluation. Our award-winning birth injury lawyers are available 24/7 to speak with you.
Free Case Review | Available 24/7 | No Fee Until We Win