11/6/2018

Neonatal Intracranial Hemorrhage

Tanya Hatfield, RNC-NIC, MSN

UCSF BCH Outreach Program
November 2018

Objectives

Upon completion of this course, the learner will be able to:

▪ Identify the primary stages of neurodevelopment
▪ Discuss the use of diagnostic imaging in the neonate
▪ Differentiate between the different types of intracranial
hemorrhages
▪ Describe the nursing interventions to reduce the incidence of
intracranial hemorrhage in the preterm infant
▪ Use evidence based practice to influence care of the infant at risk
for intraventricular hemorrhage

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Neurodevelopment – Embryonic Review

▪ Primary neurulation (3 to 4 weeks gestation)

▪ Prosencephalic development (8 to 12 weeks gestation)
▪ Neuronal proliferation (12 to 16 weeks gestation)
▪ Neuronal migration (12 to 20 weeks gestation)
▪ Organization (20 weeks gestation to years postnatal)
▪ Myelination (24 weeks to adulthood)

Brain Development

(Giedd, 1999)

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http://diagramreview.com/brain-anatomy-and-diagram/brain-anatomy-diagram-detail/
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Let’s review circulation in the brain

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Let’s review circulation in the brain

What is Intracranial Hemorrhage?

• ICH is bleeding inside the skull

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Consequences of ICH

• Blood
accumulates
either within the
brain tissue or on
the surface of the
brain tissue
causing
compression and
cell damage or
death.

Types of Intracranial Hemorrhage

EXTRA-AXIAL
• Subarachnoid
• Subdural
• Epidural
INTRA-AXIAL
• Cerebellar
• Intraparenchymal/Intracerebral
• Intraventricular

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Types of ICH
Type of Preterm vs. Term Frequency Clinical Gravity
Hemorrhage
Subdural More common in Uncommon Serious
term
Subarachnoid More common in Common Benign
preterm
Cerebellar More common in Uncommon Serious
preterm
Intraventricular More common in Common Serious
preterm
Intraparenchymal/ More common in Uncommon Variable
Stroke term

Volpe JJ. Intracranial hemorrhage:Subdural, Primary Subarachnoid, Cerebellar, Intraventicular (Term

Infant), and Miscellaneous. In: Neurology of the Newborn, Fifth Ed. Philidelphia: WB Saunders, 2008:
484

Causes of Intracranial Hemorrhage

Maternal
Drug usage; including aspirin and illicit drugs
Pre-eclampsia
Placental abruption
Placental alloimmunization
Autoimmune disorders

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Causes of Intracranial Hemorrhage

Term Preterm
Mechanical Trauma Hemodynamic Instability
Birth ashpyxia; secondary to Vascular and Anatomic
ischemia-reperfusion injury immaturity

Infection Possibly inflammatory factors

Coagulation abnormality Possibly genetic factors
Vascular abnormality
Cardiac diagnosis that results
in increased cerebral venous
pressure
Thrombocytopenia

Symptoms of ICH
Will vary according to size and location of
hemorrhage. Will also vary by term vs. preterm
infant. Unfortunately, symptoms are non-specific to
ICH.
• Cardiorespiratory symptoms: apnea,
bradycardia, hypo/hypertension
• Unexplained drop in Hct
• Seizures
• Bulging fontanelles
• Encephalopathic; altered level of consciousness,
absent or weak reflexes, hyper/hypotonia

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True of ALL ICHs

• True incidence of ICH is unknown.
• For all types of ICH, incidence is estimated at 4 per
1,000 live births. The incidence increases for
instrumented births (forceps, vacuum).
• Many of the symptoms of ICH are similar and it will
be very difficult to distinguish between the types of
ICH without imaging.
• Sequelae from ICH will vary depending on the size
and location of the bleed in all types.
• Unless hydrocephalus develops, ICH is not
identifiable by assessment of the skull.
• It is common for hemorrhages to occur in multiple
sites both intra and extra cranial.

“So many layers, so many hemorrhages…”

Fig. 9.5 The coverings of the brain. (Reproduced from ‘Vascular lesions of mature infants’
in Neonatal Cerebral Ultrasound by Janet Rennie, Cambridge University Press, 1997)
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http://www.mrineonatalbrain.com/ch04-09.php

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Diagnostic Imaging in the NICU

▪ Imaging provides a noninvasive means to diagnose, screen, and
monitor patients in the NICU
▪ Radiography (X-ray): differentiates densities (air, fat, water, bone,
metal)
▪ Ultrasonography (US): converts electrons into mechanical
vibrations to create high frequency sound waves within the body –
best to compare vibrations of bone and other structures as the
sound waves resonate in the body
▪ Computed Tomography (CT): a series of X-rays taken from multiple
positions around a single axis to create a composite image
▪ Magnetic Resonance Imaging (MRI): images hydrogen ions in the
body (your body is 98% water)

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Subarachnoid Hemorrhage

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Subarachnoid Hemorrhage
• Asymptomatic SAH is rarely identified
• Symptomatic SAH is usually the result of a medium or large
bleed; most common type of hemorrhage in infants with
symptoms.
• More strongly associated with forceps or vacuum-assisted
birth.
• Medium sized bleeds may cause seizures. However, 90% of
these babes go on to have normal neurodevelopmental
outcomes. Blood is reabsorbed, and symptoms resolve.
• Negative neurologic sequela from this type of bleed are very
rare.
• If bleed is large, babies appear very encephalopathic, have
seizures, apnea and/or bradycardia. They can deteriorate
quickly if bleed progresses without intervention.
• Large bleeds can impair flow of CSF, and baby can develop
hydrocephalus.

Subarachnoid Hemorrhage

▪ Clinical presentation:
• Most commonly asymptomatic
• Seizure activity on day 2 of life (term infant)
• Otherwise “well-appearing”
• Recurrent apnea (preterm infant)

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Subarachnoid Hemorrhage

▪ Diagnostic:
• CT scan leads to a diagnosis by exclusion
• LP with uniformly bloody CSF
▪ Outcome:
• 90% of term infants with seizure have normal follow up

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Subdural Hemorrhage

Subdural Hematoma https://www.youtube.com/watch?v=jl_0hgn3Y-

w
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Subdural Hemorrhage
• Most common form of ICH in term infants without symptoms
• Usually infants are asymptomatic and bleeds resolve without any
intervention
• 2.9% PER 10,000 NSVD vs. 8 – 10% NSVD with forceps or
vacuum
• Can be traumatic if lesion/tear is large; can result in brain stem
compression and death
• Large lesions within major vessels = baby very encephalopathic at
birth and quickly progresses downward
• Small but progressive lesions = Baby may be “fine” 24 hours up to 5
days. Will slowly show signs of neurological deterioration as bleed
evolves and/or clot forms; lethargy, irritability, apnea, bradycardia
• Treatment: close surveillance without neurologic signs or surgery
may be indicated in large lesions with rapidly increasing ICP
• 80% of infants with SDH have normal outcomes.

Subdural Hemorrhage
▪ Diagnostic:
• CT scan
• MRI if the hemorrhage is posterior
• X-ray to determine skull fracture
▪ Outcome:
• Major laceration will result in massive hemorrhage
• Mortality approximately 45%
• Survivors develop hydrocephalus
• Often worsened by close association with HIE

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Epidural Hemorrhage
• Very rare in term infants
• The artery that is the cause of bleeds in
this region is more pliable in neonates and
thus much less likely to rupture.

Cerebellar Hemorrhage
• More common in preterm infants,
esp. < 750 grams.
• Very difficult to ID; not visualized on
head US unless specifically searched
• In preterm, cause is similar to IVH. In
term, cause is usually trauma.
• Symptoms will be secondary to
brainstem compression; apnea,
bradycardia and/or full fontanelles
from blockage of flow of CSF.
• Outcome:
• More favorable in term than
preterm infants
• Probable neurologic deficits

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Cerebellar Hemorrhage

Intracerebellar Hemorrhage

▪ Hemorrhage within the cerebellum resulting from primary bleeding

or an extension of bleeding of intraventricular or subarachnoid
hemorrhage into the cerebellum
▪ Risk factors: respiratory distress, hypoxic events, prematurity,
traumatic delivery
▪ More common in preterm than term infants
▪ Incidence:
• present in 5 to 10% of all neonatal deaths on autopsy
• 15 to 25% of preterm infants < 32 weeks or less than 1500
grams

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Intracerebellar Hemorrhage

▪ Clinical presentation:
• Catastrophic deterioration with apnea, bradycardia, decreasing
Hct
• LP with bloody CSF
• Most common in the first 2 days of life up to 3 weeks of life

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Intracerebellar Hemorrhage

▪ Diagnostic:
• Cranial ultrasound
• CT to define the
hemorrhage
• MRI for definitive diagnosis
▪ Outcome:
• More favorable in term than
preterm infants
• Probable neurologic deficits

http://www.mrineonatalbrain.com/ch04-
09.php
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Intra-axial ICH : Intraparenchymal

• Usually co-exist with a hemorrhage

somewhere else in the brain.
• Can be focal or multi-focal

Intraparenchymal Hemorrhage - Stroke

• The term “stroke”, when referring to

intraparenchymal hemorrhage, really only
applies to term infants.
• Hemorrhagic stroke accounts for 50% of
childhood strokes
• However, there is not much literature on
hemorrhagic stroke in the infant population

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Stroke

• All intraparenchymal/intracranial hemorrhage

is stroke, but not all strokes are hemorrhagic.
• The definition of stroke encompasses not only
intracranial bleeding, but also non-traumatic
subarachnoid bleeds and isolated
intraventricular bleeds in the TERM infant.
• Prevalence of hemorrhagic stroke in the
perinatal population is 6.2/100,000, with the
vast majority intracranial.
• Most hemorrhagic strokes are idiopathic.

Definition
• Stroke
– Blockage (ischemic stroke) or breakage
(hemorrhagic stroke) of a blood vessel (artery
or vein) in the brain.

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Hemorrhagic vs. Ischemic

Hemorrhagic Stroke - Outcomes

• Neurodevelopmental outcomes for children with
hemorrhagic stroke are poorer than those with ischemic
stroke
• Because of limited data on this patient population,
statistics are wide-ranging. Mortality for hemorrhagic
stroke is estimated anywahere from 5% - 33%.
• Poor neurodevelopmental outcome is estimated at 25% -
52%.
• Outcomes are determined by
– The size of the stroke
– Presence of hydrocephalus
– Presence of herniation
– Location of the stroke

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Periventricular-Intraventricular Hemorrhage
(IVH)
▪ Occurs once germinal matrix hemorrhage extends into the lateral
ventricle
▪ Risk factors: prematurity (less than 34 weeks), respiratory failure,
increasing arterial blood pressure, perinatal asphyxia
▪ Incidence:
• 10 to 15% of infants with hemorrhages
• 30 to 40% of preterm infants <30 weeks or <1500 grams
• 3 times higher risk if <28 weeks
• 2 to 3% of term infants

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So why
are
preemies
at high
risk?!

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This is
what we
are
working
with…

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Intraventricular Hemorrhage - Term

• Very rare.
• Source of the bleed differs from that of
preterm infants.
• Coagulopathy and trauma play a bigger role
in the cause of IVH bleed in the term infant
vs. preterm infant.
• Seizures are a symptom in 50 – 65% of
cases.
• Approximately 50 % of infants have normal
neurologic outcomes.

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Pathogenesis

Thought to be caused by capillary bleeding.

▪ Major factors:
• Intra-vascular factors
‒ Loss of cerebral autoregulation
‒ Abrupt alterations in cerebral blood flow and pressure
• Vascular factors
‒ Germinal matrix-vulnerable to hypoxia
‒ Reperfusion injury
• Extravascular factors
‒ Poor vascular support in cerebral tissue
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IVH Risk Factors

Abrupt changes in cerebral circulation
▪ Rapid changes in PaCO2
▪ Rapid changes in aortic pressure
• Rapid infusion of volume expander
• Excessive increase in vasopressor
infusion
• Noxious procedures
‒ suctioning, PIV insertion, CT insertion,
loud noises, aggressive handling
▪ Large PDA with left-to-right shunt
▪ Elevated venous pressure from tension
pneumothorax or excessive ventilator
pressures

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IVH Timing and Progression

▪ May begin in utero, but usually begins after birth

▪ Hemorrhages may be small at first, then progress
to larger hemorrhages later
▪ Most large or progressive IVH’s begin in the first
week of life
Why is this important to the bedside
nurse?

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Symptoms of IVH
▪ Majority are asymptomatic
• Dx is cranial ultrasound
‒ 4th day 90% detected
‒ Serial ultrasounds

▪ Timing of onset:
• 50% by 24 hours of age
• 80% by 48 hours of age
• 90% by 72 hours of age
• 99.5% by 7 days of life
• 20 to 40% have progression of the hemorrhage over 3
44 to 5 days

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Acute/ Catastrophic Presentation

▪ Clinical signs include:

• Bulging anterior fontanelle/split sutures
• Decreasing hematocrit
• Bradycardia
• Hypotension (or reactive hypertension)
• Temperature instability
• Glucose intolerance or hypoglycemia
• Metabolic acidosis
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Surveillance for Intracranial Hemorrhage

▪ Stable neonate
• HUS at end of the first week of life
• If HUS normal repeat at 1 month of age
• Repeat HUS sooner if infant has a predisposing event
or deteriorates
‒ Weekly head circumference measurements

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Anatomy!!
▪ Ventricles
▪ Intraventricular
Foramen
▪ Cerebral aqueduct
▪ Choroid plexus
▪ Germinal matrix

Introductory sentence Arial – 21pt font

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Germinal Matrix
▪ Highly vascularized and poorly supported
• Involutes over time
‒ 23-24 weeks 2.5 mm width
‒ 32 weeks 1.4 mm width
‒ 36 weeks involute

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IVH
▪ Diagnostic:
• Cranial ultrasound (serial) – Papile Classification (1988):
‒ Grade I: Subependymal hemorrhage in the periventricular
germinal matrix.
‒ Grade II: Partial filling of the lateral ventricles without
ventricular dilation.
‒ Grade III: Intraventricular hemorrhage with dilation
‒ Grade IV (PHI): Intraventricular hemorrhage with parenchymal
involvement or extension of blood into the cerebral tissue
• LP to rule out septic shock or meningitis

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Anatomy!!

Introductory sentence Arial – 21pt font

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Grade I IVH

http://www.slideshare.net/PediatricHomeService/brain-injury-in-preterm-infants
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Grade II IVH

http://www.slideshare.net/PediatricHomeService/brain-injury-in-preterm-infants
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Grade II IVH

http://pediatriceducation.org/2005/03/14/

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Grade III IVH

http://www.slideshare.net/PediatricHomeService/brain-injury-in-preterm-infants
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Grade III IVH

http://pediatriceducation.org/2005/03/14/

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Grade IV IVH

http://www.slideshare.net/PediatricHomeService/brain-injury-in-preterm-infants
http://www.nrdaddy.com/lectures/ivh_pvl/ivhgrad_4a.htm
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http://www.slideshare.net/PediatricHomeService/brain-injury-in-preterm-infants
http://www.nrdaddy.com/lectures/ivh_pvl/ivhgrad_4a.htm
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Periventricular Leukomalacia

http://www.armobgyn.com/en/Neurosonography.htm

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Periventricular Leukomalacia

http://www.armobgyn.com/en/Neurosonography.htm

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Kidokoro, H., Anderson, P., Doyle, L., Woodward, L., Neil, J., & Inder, T. (2014). Brain Injury
60 and Altered Brain Growth in Preterm Infants: Predictors and Prognosis. PEDIATRICS, 134(2),
e444-e453. http://dx.doi.org/10.1542/peds.2013-2336

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IVH Outcomes
▪ Small (Grade I)
• Neurodevelopmental disability similar to premature infants
without IVH
▪ Moderate (Grade II-III)
• Neurodevelopmental disability in 40%
• Mortality 10%
• Progressive hydrocephalus in 20%
▪ Severe (Grade PVHI)
• Major neurodevelopmental disability in 80%
• Mortality rate 50-60%
• Hydrocephalus common in survivors
Introductory sentence Arial – 21pt font

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Periventricular Leukomalacia (PVL)

▪ Ischemic, necrotic periventricular white matter lesions of arterial

origin
▪ Risk factors: systemic hypotension, recurrent apnea with
bradycardia
▪ Incidence:
• Unknown

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PVL

▪ Clinical presentation:
• Acute phase: hypotension and lethargy
• 6 to 10 weeks later:
‒ Irritable
‒ Hypertonic
‒ Increased arm flexion and leg extension
‒ Frequent tremors
‒ Abnormal Moro reflex

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PVL

▪ Diagnostic:
• Cranial ultrasound
• CT
• MRI

• Initial presentation: PV
echodensities
• Later: PV cystic changes

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Periventricular Leukomalacia

http://www.armobgyn.com/en/Neurosonography.htm
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PVL

▪ Outcome:
• Based on location and extent of the injury
• Major motor deficits
• Significant upper arm involvement is associated with intellectual
deficits
• Visual impairment
• Lower limb weakness

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PVL Outcome

http://www.nrdaddy.com/lectures/ivh_pvl/prog4.htm
http://www.perinatal.nhs.uk/reviews/cp/cp_causes.ht
67
m

Posthemorrhagic Hydrocephalus

▪ Progressive dilation of the ventricles after IVH caused by injury to

the periventricular white matter; inhibition of CSF flow
▪ Two types:
• Acute
• Chronic (subacute)
▪ Incidence:
• Acute dilation in up to 50% of infants with IVH (generally
resolves)
• Slightly more than 50% of severe cases will result in progressive
ventricle dilation

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Post Hemorrhagic Hydrocephalus

▪ Frequent complication of GM-IVH
• Clot obstructing CSF flow at the level of the
aquaduct of Sylvius

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Hydrocephalus

▪ Clinical presentation:
• Rapid increase in head size
• Episodic apnea and bradycardia
• Lethargy
• Increased ICP
• Tense, bulging anterior fontanel
• Separated cranial sutures
• Ocular movement abnormalities

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Hydrocephalus

http://www.spinabifida.net/hydrocephalus-in-children-adults-facts-treatment-symptoms.html
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Hydrocephalus

▪ Diagnostic:
• Measure weekly OFC
• CT
• Cranial ultrasound
• MRI
▪ Outcome:
• Poor outcomes if decompression is not successful with shunt
placement
• Motor and cognitive deficits

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Post Hemorrhage Ventricle Device

External Ventricular Drain/Reservoir/Shunt/

▪ EVD
▪ Ommaya reservoir
▪ Ventriculoperitoneal
(VP) shunt

Willows Vision Appeal,. (2015). Willow's Story. Retrieved 10 November 2015, from http://www.willowsvisionappeal.com/willows-story.html
Mskcc.org,. (2015). About Your Ommaya Reservoir Placement Surgery for Pediatric Patients | Memorial Sloan Kettering Cancer Center. Retrieved 10
November 2015, from https://www.mskcc.org/cancer-care/patient-education/about-your-ommaya-reservoir-placement-surgery
73 Seattlechildrens.org,. (2015). Hydrocephalus Treatment | Seattle Children’s Hospital. Retrieved 10 November 2015, from
http://www.seattlechildrens.org/medical-conditions/brain-nervous-system-mental-conditions/hydrocephalus-treatment/

Patient Care and Management

▪ Prevent preterm birth

▪ Promote in utero transport
▪ Promote a no stressful intrapartum course
▪ Provide efficient resuscitation with expedient intubation
▪ Cluster care activities and promote appropriate handling
▪ Minimize noxious stimuli
▪ Avoid events associated with wide swings in arterial and venous
pressures (i.e.: seizures, apnea, etc.).
▪ Prevent blood pressure swings – slow volume replacement

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Patient Care and Management

▪ Avoid over ventilation leading to pneumothorax

▪ Use inline suctioning devices
▪ Use noninvasive monitoring devices
▪ Monitor and maintain normal pH
▪ Correct abnormal clotting
▪ Be alert to signs of hemorrhage (changes in LOC, etc.)
▪ Educate and support the parents

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Educate
and
support
the
parents

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Neuroprotection in the NICU

▪ Antenatal steroids and Magnesium Sulfate

▪ Delayed Cord Clamping
▪ The “Golden” Hour / CPQCC Delivery Room Toolkit
▪ Neutral head positioning
▪ NIDCAP
▪ Developmental care

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IVH Bundles

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Potentially Better Practices to

Prevent Brain Injury
1. Antenatal steroids & magnesium
2. Optimize management and delivery at center with a NICU
3. Early management by a Neonatologist/NNP
4. Minimize pain and stress
1. Avoid pain and stress
2. Developmental Care
5. Optimal positioning (midline)
6. Treat hypotension
7. Judicious indomethacin use
8. Optimize respiratory management
9. Limit sodium bicarbonate use
10. Use post-natal dexamethasone judiciously

79 McLendon et al. Pediatrics, 2003; Carteaux, et al, Pediatrics, 2003

Delayed Cord Clamping (DCC)

• ACOG Committee Opinion, Number 684, January 2017
• DCC in vigorous term and preterm infants for at
least 30-60 seconds after birth
• DCC increases hemoglobin levels at birth and improves
iron stores
• Improves transitional circulation
• Decreases need for pRBC transfusion
• Lowers incidence of NEC and IVH
• Does not increase risk of postpartum hemorrhage
• What is done in your center?

http://www.acog.org/Resources-And-Publications/Committee-
80
Opinions/Committee-on-Obstetric-Practice/Timing-of-Umbilical-Cord-Clamping-
After-Birth

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The “Golden” Hour (Delivery Room

Toolkit)
▪ Based on principles from cardiovascular and emergency medicine
▪ First hour of life is a time of critical transition and adaptation
▪ Management has been show to impact long term outcomes
▪ Structured focus on thermoregulation, minimizing energy
consumption, and respiratory support
▪ Measurable data points include: time to admission, admission
temperature, admission glucose, initiation of IV fluids with glucose
and amino acids
▪ What does your “Golden” hour look like?

Castrodale, V. and Rinehart, S. (2014). The Golden Hour: improving the stabilization of the very low birth-weight infant.
Advances in Neonatal Care, 14(1):9-14.
81

Neutral Head Positioning

▪ First studied in adults in the 1980s
▪ Infants less than 32 weeks are positioned
in neutral midline position with the head of
the bed tilted upward for 72 hours
▪ Goal: to reduce alterations in cerebral
blood flow associated with turning of the
head from side to side in efforts to reduce
the incidence of IVH
▪ Thoughts?
▪ Key stakeholders? Equipment needs?
▪ How is this audited?

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Cerebral blood flow

▪ELBWs have impaired cerebral autoregulation
▪Everyday ICN tasks that affect Cerebral Blood Flow (CBF)
•Diaper changes
•Suctioning
•Blood sampling
▪Can we prevent harm to our patients?

Schulz, G., Keller, E., Haensse, D., Arlettaz, R., Bucher, H., &
Fauchere, J. (2003). Slow Blood Sampling From an Umbilical
Artery Catheter Prevents a Decrease in Cerebral Oxygenation in
83 the Preterm Newborn. PEDIATRICS, 111(1), e73-e76.
http://dx.doi.org/10.1542/peds.111.1.e73

Blood Sampling
▪Evidence has shown blood sampling
techniques from UACs affect cerebral
blood flow and oxygenation
▪20 second vs. 40 second push-pull

Schulz, G., Keller, E., Haensse, D., Arlettaz, R., Bucher, H., & Fauchere, J. (2003). Slow Blood Sampling From
84 an Umbilical Artery Catheter Prevents a Decrease in Cerebral Oxygenation in the Preterm Newborn.
PEDIATRICS, 111(1), e73-e76. http://dx.doi.org/10.1542/peds.111.1.e73

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Permissive hypotension

▪ Current practice

▪ Preterm infants with a MAP<GA often have no

clinical signs of shock

• Presumably have adequate tissue oxygen

delivery

• May not need treatment.

Ahn, S., Kim, E., Kim, J., Shin, J., Sung, S., & Jung, J. et al. (2012). Permissive Hypotension in Extremely Low Birth
Weight Infants (≤1000 gm). Yonsei Medical Journal, 53(4), 765. http://dx.doi.org/10.3349/ymj.2012.53.4.765
85

Permissive hypotension
▪ Numerical blood pressure value lower than gestational
age should not be used as the only indicator for
treating early period hypotension

▪ Hemodynamic status should be included in

assessment

• unstable vital signs, impaired perfusion, skin color,

capillary refill rate, urine output, blood lactate level,
and acidosis

86

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Treatment for hypotension

▪ Treat the cause!

• Normal Saline

• PRBCs

▪ Medications

• Dopamine

• Hydrocortisone

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Reperfusion injury
▪ Tissue damage caused when
blood supply returns to the tissue
after a period of ischemia or lack
of oxygen

▪ Absence of oxygen and nutrients

from lack of blood supply during
ischemic insult

▪ Restoration of circulation results

in inflammation and oxidative
damage rather than restoring
Carden, DL; Granger, DN (Feb 2000). "Pathophysiology of
normal function ischaemia-reperfusion injury.". The Journal of Pathology 190 (3):
255–66. doi:10.1002/(SICI)1096-9896(200002)190:3<255::AID-
PATH526>3.0.CO;2-6. PMID 10685060.
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Premature Infants-
Developmental Consequences
Evolution of developmental delay is evident by term equivalents:
Compared to full term infants:
• Poor orientation (p<.001)
• Poor tolerance of handling (p<.001)
• Poor self regulation (p<.001)
• More sub-optimal reflexes (p<.001)
• More stress (p<.001)
• More hypertonicity (p<.001)
• More hypotonia (p<.001)
• More excitability (p=.007)

Pineda, Bobbi. "Neurobehavioral Assessment Of High-Risk Infants In The NICU". (2016): n. pag. Web.
89

Emotional and Behavioral Problems of Preterm

and Full-Term Children at School Entry

Hornman et al, 2016

▪ 401 early preterm (25–31 weeks’ gestational age)
▪ 653 moderately preterm (32–35 weeks’ gestational age)
▪ 389 term

“Compared with term children… all preterm children

are at risk for persistent and changing EB-problems at
school entry”

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Psychiatric Disorders and General Functioning in

Low Birth Weight Adults: A Longitudinal Study
(Lærum et al. 2016)

▪ Term SGA group increase in the estimated probability

of psychiatric disorders from 9% to 39%
▪ At 26 y/o, preterm VLBW and term SGA had
increased psychiatric disorders (36%, 38% vs 14%)
▪ Both low birth weight groups had lower educational
level and functioning scores than controls and a
higher frequency of unemployment and disability
benefit.

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Neuro-developmental Care
▪ Efforts focused on promoting positive neuronal organization
and myelination
• Cluster care
• Reduce environmental stimuli
• Positive touch
• Early skin to skin
• Procedural support
▪ Nutrition
▪ Neuro-protection
▪ What else are you doing in your unit?

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93

Minimize pain, stress & noxious stimuli

Important aspect of care for the ELBW

Pain, stress & noxious stimuli can all lead to

physiologic instability

ALL handling and care of the ELBW infant and

their experiences affect BRAIN DEVELOPMENT

“What fires together, wires together”

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Neuro-developmental Care

95

NISS scores

Smith, G., Gutovich, J., Smyser, C., Pineda, R., Newnham, C., & Tjoeng, T. et al. (2011).
96 Neonatal intensive care unit stress is associated with brain development in preterm
infants. Annals Of Neurology, 70(4), 541-549. http://dx.doi.org/10.1002/ana.22545

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Offsetting stress with POSITIVE experiences

▪ Stressful experiences in NICU are inevitable
▪ How do we provide positive experiences?
• Tactile
• Vestibular
• Gustatory
• Olfactory
• Auditory
• Visual
▪ How do we document this?

97

Sleep Preservation
▪ Touch times should allow for ample sleep Sleep
• Promote & protect sleep cycles disruptions
reported as many
• Never wake a baby in REM sleep as 234 times
▪ Sleep deprivation or disruption leads to: within a 24 hour
period
• Disordered sensory system
• Decreased learning and memory capabilities
• Smaller adult brain
• Irritability

Graven, S., & Browne, J. (2008). Visual Development in the Human Fetus, Infant,
and Young Child. Newborn And Infant Nursing Reviews, 8(4), 194-201.
98 http://dx.doi.org/10.1053/j.nainr.2008.10.011 11/22/2016

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QUESTIONS??

References

▪ ACOG (2012). Timing of umbilical cord clamping. Committee

Opinion, number 543.
▪ Castrodale, V. and Rinehart, S. (2014). The golden hour: improving
stabilization of the very low birth-weight infant. Advances in
Neonatal Care, 14(1): 9-14.
▪ Gardner, et al. (2011). Handbook of Neonatal Intensive Care, 7th
Edition.
▪ Malusky, S and Donze, A. (2011). Neutral head positioning in
premature infants for intraventricular hemorrhage prevention: an
evidence-based review. Neonatal Network 30(6): 381-396.
▪ Verklan, M. T. and Walden, M. (2010). Core Curriculum for
Neonatal Intensive Care Nursing, 4th Edition.

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Take care of this brain

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