Neonatal Encephalopathy (Brain Injury in a Newborn)
Neonatal encephalopathy (NE) is a broad term for neurological dysfunction in an infant. Neonatal encephalopathy can stem from a wide variety of causes, including hypoxic-ischemic injury, infection, neonatal stroke, traumatic birth, and more. While the underlying mechanisms of injury may be different, neonatal encephalopathy can cause seizures after birth, respiratory depression, abnormal reflexes, and changes in consciousness. Oxygen deprivation at birth (birth asphyxia) is one of the most common causes of neonatal encephalopathy. Medical professionals may use the terms hypoxic-ischemic encephalopathy (HIE), perinatal asphyxia, intrapartum asphyxia, and birth asphyxia interchangeably with neonatal encephalopathy, even though they are slightly different conditions.
What is Neonatal Encephalopathy (NE)?
Neonatal encephalopathy is an umbrella term encompassing any form of central nervous system dysfunction caused by an insult to the brain. This occurs in babies born at or later than 35 weeks of gestation (babies who are either late-preterm or term). Neonatal encephalopathy can be caused by numerous factors, including:
- Birth asphyxia
- Meningoencephalitis (encephalitis with meningitis)
- Intracranial and extracranial hemorrhages (brain bleeds)
- Fetal stroke
Hypoxic-ischemic encephalopathy (HIE) is a subset of neonatal encephalopathy, and refers to situations where a baby had a brain injury due to oxygen deprivation at or around the time of delivery. HIE is the most common cause of neonatal encephalopathy.
Conditions Associated with Neonatal Encephalopathy
Babies with neonatal encephalopathy or hypoxic-ischemic encephalopathy may have other related diagnoses, including:
- Brain damage
- Cerebral palsy
- Seizure disorders
- Periventricular leukomalacia (PVL)
What Does a Diagnosis of Neonatal Encephalopathy Mean?
A neonatal encephalopathy diagnosis can mean many things. At its simplest, it means that the baby has some degree of brain dysfunction. Sometimes there is swelling inside the brain due to injury. 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) therapy. Not all types of encephalopathy are treated the same way, however. Encephalopathy caused by a bacteria or virus, for example, is treated by controlling the underlying infection.
Babies who have hypoxic-ischemic encephalopathy (HIE) are eligible for hypothermia therapy, but it must be started within 6 hours of the insult (ie, within the first 6 hours of life). In addition, if brain bleeds, infection and strokes are promptly recognized and appropriately managed, the babies’ permanent disabilities may be limited.
Unfortunately, there are some cases where neonatal encephalopathy isn’t identified until a child reaches 4 to 5 years of age and begins to miss major developmental milestones. This often occurs in cases where neonatal encephalopathy ends up causing cerebral palsy.
The long-term impacts of neonatal encephalopathy vary. Some children with neonatal encephalopathy have severe disabilities, while others with less severe involvement of the brain may have mild disabilities, especially if they receive hypothermia therapy. In many cases, parents are advised to monitor their child closely and enroll them in appropriate Early Intervention programs to maximize the child’s abilities.
Signs and Symptoms of Neonatal Encephalopathy
Signs and symptoms of encephalopathy may include the following:
- Low Apgar scores
- A weak or absent cry at birth/delivery
- An abnormal level of consciousness (hyperalert, irritable, lethargic, obtunded (not very alert)
- Tone and reflex abnormalities, such as hypotonia (limp or floppy limbs; baby is limp) and/or hypertonia (stiff or spastic muscles; baby is stiff or spastic)
- Apnea (periods in which the baby stops breathing for 20 seconds or more)
- Feeding difficulties
- Respiratory problems (on a breathing machine)
- Neck stiffness (in the case of meningitis or meningoencephalitis)If the baby has meningitis or meningoencephalitis, her neck may be stiff
- Organ failure
- Hyper- or hypoglycemia
Newborn seizures are one of the most common signs of neonatal encephalopathy. It is important to note that seizures in babies do not look the same as seizures in adults; signs of seizures in babies are typically more subtle. Some babies with seizures have repetitive twitching or cycling motions in their limbs, or they may appear to stare blankly into space. These episodes can impact the baby‘s consciousness. These seizures must be quickly diagnosed via EEG testing and treated to prevent brain damage from worsening.
Treatment for Neonatal Encephalopathy
Because there are many different underlying mechanisms that can cause neonatal encephalopathy, managing and treating the injury is highly individualized:
- Hypothermia Therapy (Cooling): Babies with hypoxic-ischemic encephalopathy undergo hypothermia therapy within 6 hours of birth, lasting for a total of 72 hours.
- Ventilation: Babies with encephalopathy due to respiratory issues may be placed on a ventilator to help regulate their breathing and ensure adequate oxygenation.
- Blood-Related Treatment: Babies with brain bleeds may be given blood products (such as packed red blood cells and fresh frozen plasma) or normal saline to correct blood pressure issues.
- IV: Babies with strokes may be given IV fluids and medication to prevent blood clotting issues.
- Medication: Babies with encephalopathy due to infection may be given antiviral medication or antibiotics to control the infection (depending on infection type).
- EEG Monitoring: Babies with seizures due to encephalopathy may have regular or continuous EEG monitoring for the first 48 hours of life, along with anti-seizure medications (anti-epileptics such as phenobarbitol) to prevent worsening brain damage.
What Causes Neonatal Encephalopathy?
Encephalopathy can be caused by a wide variety of mechanisms. These mechanisms can cause cell damage and tissue inflammation in the brain, leading to a cascade effect outward from the injury site. These mechanisms are often very inter-related; one underlying condition can often be a risk factor for other conditions. These mechanisms can include:
Birth Asphyxia (Lack of Oxygen to the Brain)
In the womb, babies get oxygen from oxygen-rich blood that travels from the mother to the placenta to the umbilical cord. Anything that affects the oxygen going to the baby can cause the baby to be deprived of oxygen. If the mother’s blood supply is compromised (such as with major bleeding), the baby will also have a reduced oxygen supply. Problems with the umbilical cord, placenta or uterus can also cause hypoxic-ischemic encephalopathy (HIE). Often, these problems occur during or near the time of birth. There are many conditions that can cause limited oxygen flow to the baby’s brain, and many of these conditions are preventable. These conditions include:
|Conditions that can cause neonatal encephalopathy (NE) due to hypoxia-ischemia|
|Placental insufficiency||Preeclampsia||Placental abruption|
|Uterine rupture||Umbilical cord prolapse||Nuchal cord (cord wrapped around baby’s neck)|
|Short umbilical cord||Umbilical cord in a true knot||Placenta previa|
|Stroke||Premature rupture of the membranes (PROM)||Prolonged and arrested labor|
|Oligohydramnios (low amniotic fluid)||Failure to quickly deliver the baby when fetal distress is evident on the heart rate monitor||Hyperstimulation of the uterus caused by the labor induction drugs Pitocin, Cytotec and Cervidil|
|Brain bleeds||Traumatic delivery||The use of forceps and vacuum extractors|
|Nuchal cord||Vasa previa||Post-term pregnancy|
Underlying Maternal Health Conditions
Certain health conditions can make a pregnancy high-risk. These health conditions carry with them a higher risk of birth injury, necessitating closer monitoring and more frequent prenatal care appointments. These conditions include:
|Conditions that can cause neonatal encephalopathy (NE) due to underlying maternal health conditions|
|Gestational diabetes||Gestational diabetes → increased risk of preeclampsia → increased risk of placental abruption|
|Maternal high blood pressure (preeclampsia)||Preeclampsia impacts blood flow through the placenta → baby may have poor oxygen or nutrient supply → baby may have poor growth/IUGR, which makes them more susceptible to neonatal encephalopathyIncreased risk of placental abruption → placental abruption can compromise blood and oxygen supply to baby|
|Placental insufficiency||Can cause intrauterine growth restriction (IUGR) → baby can have potentially reduced oxygen reserves and cannot tolerate labor as well|
|Oligohydramnios||Can cause intrauterine growth restriction (IUGR) → baby can have potentially reduced oxygen reserves and cannot tolerate labor as well|
|Maternal Infections (such as Group B streptococcus (GBS), Chorioamnionitis, herpes simplex virus (HSV), E coli, Staphylococcus (staph))||Infections can be passed to the baby during labor/delivery → can spread to become pneumonia, meningitis, encephalitis, or sepsis, causing seizures and brain damage|
While encephalopathy can be caused by a number of conditions, it can often also be caused by a traumatic birth. It is very important that babies be delivered by experienced obstetricians, gynecologists or other medical staff who have proper knowledge of delivery techniques and procedures for difficult deliveries. If medical staff deliver the baby in a way that is not up to the standards of care, the baby can have a traumatic birth. The impact of a traumatic birth isn’t always immediately obvious – there may not be any external bleeding. Sometimes there will be internal bleeding (brain bleeds). Babies may show signs of neurological dysfunction immediately – in the form of seizures, for example – or – in some cases – the child will only show neurological dysfunction as they grow and begin missing major developmental milestones. Causes of traumatic birth can include:
|Causes of traumatic birth and brain bleeds|
|Misuse of vacuum extractors and forceps||Mismanaged delivery of a baby in breech position||Mismanaged delivery of a baby who is large for gestational age (macrosomic)|
|Mismanaged cephalopelvic disproportion (CPD)||Prolonged labor and uterine hyperstimulation||Trauma from abnormal changes in blood pressure|
Preventing Neonatal Encephalopathy (NE)
Many of the conditions that cause neonatal encephalopathy (NE) are conditions with risk factors that are known. This means that medical staff can prevent adverse outcomes by properly monitoring the mother’s and baby’s health and conducting interventions if necessary.
Many of these events affect the baby during labor and delivery. Because of the risks associated with labor and delivery, the baby’s heart rate should be continuously monitored with a fetal heart rate monitor. This monitor will alert the medical team if the baby starts to become oxygen-deprived, which will show up as a non-reassuring heart tracing (fetal distress). When fetal distress occurs, the physician should deliver the baby right away, often by C-section (the fastest and safest way to deliver a baby in distress). Fetal distress can occur in a variety of situations, but is especially serious in the cases of placental abruption, umbilical cord problems and uterine rupture, because these conditions can cause a baby to be completely cut off from their oxygen supply.
One of the key things that is very important in preventing neonatal encephalopathy in babies is proper technique for using vacuum extractors or forceps if it becomes necessary. There should be no twisting of the head or neck, no excessive pulling, and no pulling for more than 10 to 15 minutes. If the vacuum extractor comes off 3 times during use, the physician should move on to a C-section. These instruments should only be used by physicians who follow standards of care, which includes being skilled.
If a baby has a brain bleed from a labor and delivery incident, the bleed must be promptly recognized and treated so that encephalitis and permanent conditions such as cerebral palsy can be avoided. This can include:
- Medications to help stop or slow the bleeding
- Medications to increase blood pressure and blood volume
- Ventilatory support for the baby (a breathing machine)
- Medications to decrease inflammation
- Close monitoring of intracranial blood pressure
In other cases, conditions that occur during pregnancy can cause oxygen deprivation over the long-term. These conditions include:
Pregnant women are supposed to have regular prenatal check-ups that assess both their health and their baby’s health. Prenatal tests include non-stress tests and biophysical profiles (BPPs). If the mother has a high risk pregnancy, the prenatal testing should be more frequent and she should be referred to a maternal-fetal specialist. These prenatal tests, when done properly, can detect underlying health conditions that can mean that a baby is at higher risk for having a birth injury.
During prenatal visits, physicians should pay close attention to test results, especially the baby’s heart tracings. These tracings, along with ultrasound results, will alert the medical team to health problems the baby may have, including if the baby is being deprived of oxygen. If this is occurring, the mother may be admitted to the hospital so the medical team can closely monitor the baby. Sometimes a baby may have to be delivered early to help prevent permanent brain damage from a lack of oxygen and/or nutrients.
Reiter & Walsh ABC Law Centers: Neonatal Encephalopathy Attorneys
If your child has neonatal encephalopathy, consider having a birth injury attorney review your case. Some children with neonatal encephalopathy need around-the-clock care, medical assistance, rehabilitation and therapy, and other services. A birth injury lawsuit can help cover the costs of your child’s care.
Contact the birth injury attorneys at Reiter & Walsh ABC Law Centers for a free, 100% confidential case evaluation. We focus only on birth injury, unlike other firms that say they focus only on birth injury, but have case lists full of dog bites, auto accidents, and medical device malfunctions.
Birth injury requires a deep knowledge of the medicine, legal issues, radiology concerns, and care planning surrounding childhood disability. The birth injury attorneys at ABC Law Centers have nearly 100 combined years of experience.
You wouldn’t trust a generalist doctor with delicate microsurgery. Why trust your birth injury case to a personal injury generalist?
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Video: Neonatal Encephalopathy Attorneys Discuss Hypoxic-Ischemic Encephalopathy (HIE)
- Executive summary: Neonatal encephalopathy and neurologic outcome, second edition. Report of the American College of Obstetricians and Gynecologists’ Task Force on Neonatal Encephalopathy. Obstet Gynecol 2014; 123:896.
- Wu YW, Backstrand KH, Zhao S, et al. Declining diagnosis of birth asphyxia in California: 1991-2000. Pediatrics 2004; 114:1584.
- Graham EM, Ruis KA, Hartman AL, et al. A systematic review of the role of intrapartum hypoxia-ischemia in the causation of neonatal encephalopathy. Am J Obstet Gynecol 2008; 199:587.
- Thornberg E, Thiringer K, Odeback A, Milsom I. Birth asphyxia: incidence, clinical course and outcome in a Swedish population. Acta Paediatr 1995; 84:927.
- Lee AC, Kozuki N, Blencowe H, et al. Intrapartum-related neonatal encephalopathy incidence and impairment at regional and global levels for 2010 with trends from 1990. Pediatr Res 2013; 74 Suppl 1:50.
- Chau V, Poskitt KJ, Miller SP. Advanced neuroimaging techniques for the term newborn with encephalopathy. Pediatr Neurol 2009; 40:181.
- Barnette AR, Horbar JD, Soll RF, et al. Neuroimaging in the evaluation of neonatal encephalopathy. Pediatrics 2014; 133:e1508.
- Redline RW. Severe fetal placental vascular lesions in term infants with neurologic impairment. Am J Obstet Gynecol 2005; 192:452.
- Ferriero DM. Neonatal brain injury. N Engl J Med 2004; 351:1985.