Neonatal Brain Damage & Long-Term Outcomes
Reiter & Walsh, P.C. | Trusted Infant Brain Injury Lawyers
Infant brain injuries are brain injuries that a child sustains during birth and delivery or in the neonatal period. Neonatal brain damage is often due to medical negligence or malpractice, as many infant brain injuries occur when a doctor deviates from accepted “standards of care.” These usually result in some form of disability (ranging from mild to severe), because brain injuries in developing children disrupt the proper formation of brain structures. This can have a global, long-term impact on a child’s ability to perform the Activities of Daily Living (ADLs).
Anatomy and Function of a Baby’s Brain
The outer part of the brain is made up of rounded ridges called gyri. Each individual gyrus is separated by grooves called fissures or sulci. Some of the sulci are very pronounced and serve as boundaries between the 4 lobes of the brain.
The 3 major parts of the brain include:
The cerebellum is a continuous thin layer of tissue that is tightly folded. It also sits on top of a lot of white matter. Within the cerebellum’s thin layers are many different types of neurons that form a complex network that have massive signal-producing capability. The cerebellum plays a major role in motor control (muscle control). This part of the brain does not initiate movement, but it greatly contributes to coordination of muscle movement, balance, timing and precision. The cerebellum controls a child’s sense of position, called proprioconception. A serious injury to the cerebellum can greatly affect a child’s ability to know where her arms and legs are in space. In addition, damage to this part of the brain can affect a child’s ability to walk, run, and have balance and normal muscle tone, as well as the ability to use fine motor function, such as holding a piece of cereal. The cerebellum is also involved in some cognitive functions, such as language and attention.
This is the largest part the brain. The cerebrum’s nerve centers control movement, cognition, reasoning, memory, perception, judgment and decision-making. The surface of the cerebrum is called the cerebral cortex. The cerebral cortex consists of 6 layers of neurons. Neurons are very important brain cells that process and transmit information via electrical and chemical signals, and they connect to each other and form the core of the nervous system. The layers of neurons sit on top of a large amount of the brain’s white matter. White matter helps transmit messages throughout the largest parts of the brain.
The brainstem plays a major role in regulating essential bodily functions, such as breathing, heart rate and blood pressure. It is also involved in relaying information from the cerebrum and cerebellum to the rest of the body through the spinal cord.
The 2 parts of the cerebrum are known as cerebral hemispheres. The corpus callosum connects these hemispheres so the left and right sides of the brain can communicate.
Major Lobes of the Brain in the Cerebrum
The Cerebrum: Frontal Lobe
The lobe of the brain that is the furthest forward is called the frontal lobe. This lobe is very important because it is responsible for voluntary movement and planning and researchers think it is the most important lobe for intelligence and personality. Some specific functions associated with the frontal lobe are coordinated movement, abstract thought, problem-solving, creative thought, judgment and emotion.
The motor cortex controls motor function and is located in the frontal lobe. The lowest portions of the motor cortex control the muscles of the face and mouth. The parts of the motor cortex near the top of the head control the legs and feet.
The Cerebrum: Parietal Lobe
This lobe is behind the frontal lobe and contains the somatosensory cortex. The parietal lobe is responsible for feeling touch on certain parts of the body. For example, the part of the parietal lobe closest to the temples is responsible for feeling touch on the mouth and face and the part of the lobe closest to the top of the head is responsible for feeling touch on the legs and feet. Specific functions associated with the parietal lobe include comprehension of pain, pressure, heat, cold and touch, as well as an appreciation of form.
The Cerebrum: Temporal Lobe
The lobe of the brain at the side of the head is called the temporal lobe. An important part of this lobe is the auditory cortex, which is connected with the ears and plays a major role in hearing. Specific functions associated with the temporal lobe include hearing, memories, and fear, as well as some speech and language behavior.
The Cerebrum: Occipital Lobe
This lobe is at the back of the head and it contains the visual cortex, which receives information from the eyes and controls vision. Specific functions associated with the occipital lobe include complex processing of vision, reading, and relating vision to other sensory experiences.
The brainstem is a very important part of the brain because the nerve connections of the motor and sensory systems in the main portion of the brain travel to the rest of the body through the brainstem. It has several critical functions. The brainstem regulates heart and lung functions, such as heart rate and breathing. It also controls the central nervous system and plays a major role maintaining consciousness and regulating the sleep cycle.
In the brainstem, there are many fiber tracts that carry nerve impulses from the brain to the spinal cord. In addition, there are numerous areas of nuclei, which are groups of brain cells that have specialized functions. The diencephalon, pons, midbrain and medulla oblongata make up the brainstem.
- Diencephalon: This part of the brainstem includes the thalamus, which relays sensory impulses from one part of the brain to another to be interpreted. Temperature, touch and pain sensation are affected by the thalamus and cortex. The hypothalamus is also located in the diencephalon, and it plays a crucial function in regulating blood pressure, heart rate, body temperature, fluid, sleep cycle and hormones. Optic nerves cross over in the thalamus, so injury here can cause a child to have vision problems.
- Pons: The pons connects the medulla oblongata and the thalamus. It transmits information between the cerebrum, medulla oblongata and cerebellum. The pons also plays a major role in the depth and frequency of respiration. An injury to the pons can affect a child’s breathing, ability to close the mouth and chew, vision, hearing, and ability to have coordinated motor function in the head, neck and face.
- Midbrain: The midbrain connects the spinal cord and brainstem to the cerebral cortex. It helps control posture, balance, hearing, visual reflexes, hearing, temperature, arousal (alertness), the sleep cycle, and coordinated movement of the head and eyes.
- Medulla oblongata: The medulla contains important nuclei that control essential body functions, and it is what connects the brainstem to the rest of the brain. Nerve impulses transmitted up and down the body go through the medulla. It has a cardiac center that controls how fast the heart beats, a respiratory center that helps control breathing and a vasomotor center that affects the dilation or constriction of blood vessel, thereby regulating blood pressure.
- Corticospinal tracts: These tracts connect the body to the motor cortex, conducting impulses from the brain to the spinal cord. The corticospinal tracts control the fine motor function of the limbs, such as precise movements of the fingers and toes.
Cellular Functions in the Brain
The brain is comprised of many different types of cells. Neurons carry out the numerous brain functions; these cells process and transmit information through electrical and chemical signals. Neurons connect to each other and are the core of the nervous system. They are also the cells that are the most vulnerable to injury.
Neurons receive information from cells through dendrites and they send information via axons. Dendrites are short fiber branches, while axons are much longer nerve fibers that are lined with myelin, which serve to insulate the fibers. The synapse is the region where electrical / chemical signals are communicated from one cell to another.
The information sent to the neurons from the dendrites is processed by the neuron body. Multiple dendrites can send information a neuron, but in general, there is only one axon per neuron to carry information away. Thus, a lot of information gets bundled when it is sent away via the axon. Sometimes, however, only one nerve impulse arrives, so it gets sent away in a straight shot. Whether there is a bundling or a straight shot of a nerve impulse depends on the function, location, and strength of the impulse as well as the size and shape of the neuron and several other factors.
The cell bodies of neurons are typically located in the gray matter portion of the brain. The axons are part of the white matter, which forms the deeper areas of the brain.
The nucleus is the control center of the cell because it maintains the integrity of the genes and controls the activity of the cell by regulating gene expression. Groups of nuclei usually appear as gray matter and are mixed within the white matter in the brainstem.
If a neuron is damaged so much that the cell dies, it will not regenerate. Injury of an axon may sometimes be repaired, depending on how much damage there is.
There are many different types of cells that help support neuron function, and these include oligodendrocytes, astrocytes, and microglia, which are all a type of glial cell. Glial cells support the function of neurons by supplying oxygen and nutrients, insulating neurons from each other, surrounding and holding neurons in place, destroying harmful agents and removing neurons that have died. In addition, glial cells play an important role in helping with signal transmission.
Long-Term Outlook and Side Effects of Neonatal Brain Injury
Knowing the location of a brain injury can give some information regarding what type of complications a child will face long-term. Of course, the outcome cannot be determined solely based on the assessment of the injury location. Important items to remember include the fact that brain injury is an evolving process. Clinicians recognize the fact that brain injury occurring during or near the time of birth is the most common cause of long-term neurological deficits in a child. When a brain injury is suspected, head imaging is typically performed within 12 – 24 hours of the brain insult. Brain imaging studies must be continuous because an injury can evolve over days, weeks and even months. Examining the evolution of injury as well as the final extent of the damage is very important.
Preventing HIE, Injury and Permanent Brain Damage with Hypothermia Therapy
There are many factors that contribute to how a brain injury will affect a child long-term. One factor is early intervention. Physical therapy can be started when a child is just a few months old. Another important treatment is called hypothermia (brain cooling) treatment. Hypothermia treatment has been shown to halt almost every cellular process involved in the progression of brain injury. Brain cooling must take place within 6 hours of the insult that caused the brain injury. Hospitals have criteria the physicians use to determine if a child qualifies for hypothermia treatment. If a child is diagnosed with hypoxic ischemic encephalopathy (HIE), she almost always qualifies for brain cooling therapy. A diagnosis of HIE can be made without brain imaging (although imaging must be performed as soon as possible).
Hypothermia treatment has been shown to reduce the likelihood that a child will develop cerebral palsy after a diagnosis of HIE. It also has been shown to reduce the severity of brain injury and resultant cerebral palsy. The more severe the brain insult, the sooner the brain cooling treatment should be initiated.
Hypothermia treatment is also a treatment for stroke. Research shows that stroke and hypoxic ischemic encephalopathy often occur together.
When children experience a brain injury, hypothermia treatment may prevent lifelong conditions such as cerebral palsy. If the child is diagnosed with cerebral palsy, there are many different types of treatments and therapies – including a groundbreaking surgery called selective dorsal rhizotomy (SDR) – that can greatly improve a child’s muscle function.
Disabilities Associated with Infant Brain Damage
When a child experiences a brain insult, she may later be diagnosed with one or more of the following:
- Hypoxic ischemic encephalopathy (HIE)
- Cerebral palsy
- A seizure disorder
- Periventricular leukomalacia (PVL)
- Intellectual disabilities and developmental delays
Children with brain injuries can have muscle function, intellectual, perceptual, emotional, attention and language problems. There are treatments and therapies for all of these types of problems. The key is early recognition and intervention.
How Can I Tell If My Baby Has a Brain Injury?
Seizures are a common sign that a baby has had a brain injury. Sometimes seizures aren’t recognized until an EEG is performed on the baby. Failure to perform frequent or continuous EEGs can result in a brain injury going undetected for a long time, especially since seizure activity is often the only sign of a brain injury. Listed below are some of the signs that a baby has suffered a brain injury.
Signs of brain injury in a baby include the following:
- Seizures within the first 24 – 48 hours of delivery
- Low Agar scores for more than 5 minutes. An Apgar score assesses the overall health of a newborn over the first few minutes of life. It assigns scores to factors such as the baby’s skin color / complexion, pulse rate, reflexes, muscle tone, and breathing.
- Failure to breathe immediately after delivery / the baby needed to be resuscitated
- The baby’s blood is acidic / has a low pH (acidosis)
- Difficulty feeding, including inability to latch, suck or swallow
- Abnormal limpness
- Poor head position
- Multiple organ problems (e.g., involvement of the lungs, liver, heart, intestines)
- No brainstem reflexes (e.g., breathing problems and an abnormal response to light, and only blood pressure and heart function reflexes are functioning)
- Hypotonia (low muscle tone)
When a pregnancy or birth was difficult or a baby experienced an event that could cause oxygen deprivation and / or brain bleeds, the medical team must be on the lookout for signs of a brain injury. When a brain injury is suspected, head imaging and other diagnostic tests can be done so the medical team can pinpoint the type of injury, the cause of the injury and any ongoing processes that can be treated. In addition, if HIE is even remotely suspected in a newborn, the medical team should promptly assess the baby for HIE so that crucial hypothermia treatment can be given, if indicated.
What Complications Cause Neonatal Brain Injury?
Conditions that occur close to or during the time of delivery that can cause oxygen deprivation and brain injury include the following:
- Placenta previa
- Ruptured uterus (womb)
- Preeclampsia / eclampsia
- Placental abruption
- Umbilical cord problems, such as a nuchal cord (cord wrapped around the baby’s neck), umbilical cord prolapse, short cord, cord in a true knot
- Premature rupture of the membranes (PROM) / premature birth
- Failure to quickly deliver a baby when fetal distress is evident on the fetal heart rate monitor (delayed emergency C-section)
- Oligohydramnios (low amniotic fluid)
- Anesthesia mistakes, which can cause blood pressure problems in the mother, including a hypotensive crisis
- Prolonged and arrested labor
- Stroke in the baby
- Intracranial hemorrhages (brain bleeds), which can be caused by a traumatic delivery. Forceps and vacuum extractors can cause brain bleeds. Mismanagement of cephalopelvic disproportion (CPD), abnormal presentations (face or breech presentation), and shoulder dystocia also put a child at risk of having a brain bleed.
- Hyperstimulation caused by Pitocin and Cytotec
There are many other injuries that can damage a baby’s brain and cause conditions such as cerebral palsy. This includes:
- Improperly treated high bilirubin levels (jaundice) that cause a form of brain damage called kernicterus.
- Improperly treated neonatal hypoglycemia (low blood sugar).
- Brain infection such as meningitis, which can be caused by infections in the mother that travel to the baby at birth. These maternal infections include the following: Group B Strep (GBS), herpes simplex virus (HSV), urinary tract infection (UTI), bacterial vaginosis (BV) and chorioamnionitis.
Legal Help for Neonatal Brain Damage, Cerebral Palsy and Birth Injuries
Michigan-Based Birth Injury Attorneys with a National Presence
When a loved one is diagnosed with permanent brain damage from a preventable birth injury, it can feel overwhelming to grasp the medical and legal aspects of the situation. Parents, loved ones, friends and family are often left wondering how they can support their birth-injured loved one. At Reiter & Walsh, these concerns are at the core of our firm’s mission.
Reiter & Walsh ABC Law Centers was founded specifically to handle birth trauma, pregnancy and neonatal injury cases. Cerebral palsy and hypoxic ischemic encephalopathy (HIE) are difficult areas of law to pursue due to the complex nature of the disorders and the medical records that support them. The award-winning lawyers at ABC Law Centers have decades of experience with cerebral palsy and HIE cases. Our team has Michigan roots and a national presence, handling cases all over the country. We’ve helped families in Ohio, Michigan, Pennsylvania, Texas, Arkansas, Mississippi, Washington, D.C., Wisconsin, Tennessee and other parts of the United States. Additionally, our team has the ability and experience to handle cases involving the Federal Tort Claims Act (FTCA), which implicates cases involving military medical malpractice and birth injury in federally funded clinics.
To begin your free case review with our team, please reach out to us in any of the following ways:
Free Case Review | Available 24/7 | No Fee Until We Win
Birth Injury Video: Michigan Infant Brain Injury Lawyers Discuss Birth Injuries and Brain Damage in a Baby
Watch a video of Michigan infant brain injury lawyers Jesse Reiter & Rebecca Walsh discussing the causes of brain damage in a baby.
- 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.