What is neonatology?

It is a branch of pediatrics that assists the fetus and newborn and is dedicated to clinical research. With the advancement of knowledge and the emergence of new techniques, this specialty has grown a lot in recent years, which is why newborns who often progress to death today survive, but some have severe neurological sequelae.

What is a neurological neonatal ICU?

PBSF’s neurological neonatal ICU model proposes innovation, quality of care, diagnostic safety, respect for human beings and the pursuit of quality of life for high-risk newborns.

Based on the methodologies of the best centers in the world, with adaptation to the Brazilian reality, PBSF implements the most advanced techniques for neurological assessment, in real time, aiming at early diagnosis and neuroprotection.

By creating an environment capable of promoting more precise and detailed care for newborns with a high-risk of brain injury, the company significantly reduces the number of babies that will develop neurological sequels SEQUELAE, which increases quality of life of little patients.

The neonatologist accompanying the baby will indicate the need for such monitoring. It is worth remembering that not all newborns referred to the neonatal ICU need a more detailed neurological follow-up.

Among the most common causes that require full-time monitoring are newborns who have: 

• Suspected or previous convulsive crisis;
• Perinatal asphyxia;
• Extreme prematurity;
• Postoperative complex heart surgery;
• Patient with severe hemodynamic or ventilatory instability;
• Patient with severe sepsis associated with symptomatic meningitis or other central nervous system infections;
• Patient with brain malformation.

How does monitoring with aEEG and NIRS work?

From the moment the newborn is in a neurological neonatal ICU, he will be monitored by several devices, including the Integrated Amplitude Electroencephalogram (aEEG) and Near Infrared Spectroscopy (NIRS).

Amplitude Integrated Electroencephalogram (aEEG)

It is a method of continuous brain monitoring at the bedside, in real time, and non-invasive. To perform this test, wires are placed on the newborn’s head to assess brain function. This equipment can detect seizures and changes in patterns of brain activity. Generally, the aEEG remains for more than 24 hours following the electrical activity of the newborn’s brain. This control offers several important data for the best handling of the case by the multidisciplinary team.

Near Infrared Spectroscopy (NIRS)

A small sensor, similar to an oximeter, is placed in the newborn’s cephalic region, which provides great information to the care team. NIRS helps with cerebral hemodynamics, by assessing blood flow and brain oxygenation, and also by producing data to assist the neonatologist in decision-making regarding neurological prognosis.

PERINATAL ASPHIXIA

Perinatal asphyxia, also known as hypoxia-ischemia, is the lack of oxygen and/or blood flow reaching the baby through the placenta during the child-birth.

This condition can affect all the organs: lungs, liver, heart, kidneys, and especially the brain. After resuscitation in the birth room, the baby may be hyperalert, irritable, eye rolling, have abnormal movements (seizures), or may have a reduced level of consciousness. Together, these symptoms are known as hypoxic-ischemic encephalopathy (HIE).

It is not always possible to know what causes HIE, but we do know that lack of oxygen can lead to injuries in babies. Such injuries can be mild, moderate or severe and, in certain situations, some babies may not even survive. Many survive but may develop disabilities, which can be mild, moderate or severe, while others recover fully.

Treatment Options

Treatment options vary depending on the symptoms the baby has. Doctors classify the condition into three categories: mild, moderate or severe HIE, because this will determine the treatment that will be recommended for the baby.

Most babies with mild HIE recover quickly and fully. With this condition, the doctors will monitor him THEM to ensure that he does THEY DO not need any further treatment after the initial lack of oxygen.

If a baby is diagnosed with moderate to severe HIE, they will likely be referred to a neonatal intensive care unit for intensive care, including a treatment known as mild hypothermia or cooling. This approach involves bringing the baby’s temperature down to 92°F from the normal temperature of 98.6°F.

Until recently, there was no specific treatment for HIE other than intensive care support. However, if a baby is referred for cooling, he or she will need to be treated in a hospital that has a NICU and has adequate cooling and highly trained staff.

Neonatal ICU and intensive care

The lack of oxygen during childbirth can affect all of the baby’s organs. Thus, various supportive treatments may be required. The baby’s blood pressure, for example, may be low and medication (inotropic) may be prescribed to increase it. To ensure that the baby is not in pain, painkillers and sedatives may be given. Careful monitoring includes regular blood tests to ensure the best treatment is given.

Seizures often occur in infants who have had HIE. Sometimes, when observing the newborn, the medical or nursing staff detects a seizure; at other times, it can be difficult to identify. Doctors, therefore, (VIRGULAS) monitor the baby’s brain activity through the Brain Function Monitor, the aEEG (Amplitude Integrated Electroencephalogram), which can pick up these seizures.

If the little patient is having seizures, he can be treated with medication. Seizures associated with HIE usually resolve after three or four days; however, the baby may remain on the medication for some time afterwards.
In addition to what has been exposed, if the newborn needs extra help to breathe, a respirator will be used, equipment that delivers oxygen and pressure to the lungs through a tube that passes through the mouth or nose. For babies who still need assistance with breathing but do not require a ventilator, a different type of device called Continuous Positive Pressure (CPAP) can be used.

CPAP helps a newborn breathe through air flowing through two thin tubes or through a mask placed over the nostrils, which slightly increases the pressure in the lungs and helps keep them inflated.
Vascular catheters will be needed to administer medications and serum to the patient.

What is hypothermia or cooling treatment?

If it is identified that the baby needs cooling treatment, the process will start as soon as possible – it is best to start before six hours of life. The desired hypothermia can be achieved by undressing the baby and using other simple measures such as an ice pack, which is known as passive cooling.

The baby’s temperature and condition will be closely monitored throughout this time. Although hospitals can initiate cooling of a newborn, if the tiny patient is not already in a Neonatal ICU, transfer will be required as ongoing care needs to be provided in a specialist centre.

During transport or upon arrival at the NICU, the baby will be placed on a special cooling mat (a technique known as active cooling). This treatment will be in addition to the standard intensive care support the child may need. The mattress is filled with a liquid that can be cooled or heated according to the baby’s needs. His temperature will be closely monitored to ensure it remains at 92 °F. It will be held at this level for 72 hours (three days) before the gradual rewarming process takes place.

The team caring for the newborn will take steps to ensure that the newborn is comfortable, which may include reducing light and sound levels in the environment where the newborn is or giving pain relievers if necessary.

During the cooling treatment, the baby will:

• Have temperature, heart rate and blood pressure monitored continuously;
• Receive intravenous fluids until rewarmed;
• Take standard blood tests;
• Having your brain activity monitored through the Brain Function Monitor (aEEG);
• Having cerebral oxygenation controlled by NIRS (Proximal Infrared Spectroscopy);
• Receive medicine for pain, seizures and to keep blood pressure balanced;
• Have blood samples taken for other laboratory tests;
• Have the support of a breathing machine;
• Do magnetic resonance imaging (MRI).

Are there side effects?

The medical team responsible for the care of the hospitalized baby will be able to talk with the caregivers about the possible side effects related to the cooling treatment. This therapy can occasionally cause heart rhythm problems and change the number of platelets in the newborn. Another possible side effect of cooling is subcutaneous fat necrosis, a rare skin condition that can arise during treatment and can raise the patient’s calcium levels. If the baby develops this condition, he is likely to be monitored regularly until his condition returns to normal.

Doctors and nurses who care for newborns admitted to an ICU with HIE are aware of the possible side effects of the treatment and will always monitor them closely. You should also be aware that HIE is a serious illness and many of these complications can occur even without cooling.

Testes e procedimentos

Para que médicos e a enfermagem obtenham mais informações sobre a saúde do recém-nascido, ele pode ser submetido a várias investigações. Os profissionais médicos decidirão quais exames são mais úteis. 

Algumas das verificações adicionais podem incluir:

aEEG

Este é um monitor especial (aEEG) que registra a atividade cerebral. Vários fios finos (eletrodos) são colocados na região da cabeça do bebê para gravar a atividade do cérebro, o que permite que a equipe médica monitore as ondas elétricas e veja como o paciente está respondendo ao tratamento e a qualquer medicamento que tenha recebido. Esse exame pode ser feito no berço ou na incubadora.

NIRS

A Espectroscopia de Infravermelho Proximal fornece dados valiosos e em tempo real sobre a oxigenação e a perfusão sanguínea cerebral.

US de cérebro

Os médicos examinarão a estrutura do cérebro, por meio de avaliação da moleira (fontanela) do bebê, região logo acima da testa. A pesquisa dessa região pode mostrar se houve sangramento, acidente vascular cerebral ou outros problemas que estão, ocasionalmente, associados à EHI.

Magnetic resonance imaging (MRI)

This scan helps assess the extent of any brain damage and provides information about how the brain is maturing. MRI produces detailed images of the baby’s brain.

The ideal time to obtain these images after HIE is between 4 and 12 days of the newborn’s life (although other tests may be done earlier, depending on the baby’s condition). The scanner is usually located far from the neonatal unit, so you will likely need to transport the baby to the MR scanner, which can happen even if the baby is on a ventilator.

Because MRI generates specialized scanned images, an expert is needed to read and interpret them, so it can take a few days to get results.

Each of the exams that the baby is submitted to, as well as the way he responds to the treatment, is fundamental for an overall analysis of his health. While no single “piece” tells the complete story, it is by putting all the information together that the medical and nursing staff will begin to create a better picture of what the baby’s future may hold.

CEREBRAL HEMORRHAGE IN THE PREMATURE

A full-term pregnancy lasts between 37 and 42 weeks, so babies born before 37 weeks are considered premature.

Peri-intraventricular hemorrhage (PIVH) is a neurological injury that particularly affects premature newborns, as they have a region in the brain – the subependymal germinal matrix – which is an immature tissue of the central nervous system that is richly vascularized, however, the WITH blood vessels they THAT have thin walls, which is why they are subject to injury from changes in cerebral blood flow.

Babies with the highest risk of PIVH are those younger than 34 weeks of gestation and weighing less than 1,500 grams at birth. The incidence of PIVH is inversely proportional to the weight and gestational age of the baby at birth, that is, the lower the gestational age and the lower the weight, the greater the risk of PIVH; in 90% of babies, (VIRGULA) it occurs by the third day of life.

Diagnosis and classification

IVPHI is an examination finding on ultrasonography of the brain of preterm infants, which is routinely performed initially shortly after the third day of life. When symptomatic, patients with PIVH may present clinical neurological and respiratory worsening; apnea; bulging fontanelle and hypoactivity.

Antenatal risk factors for the condition:

• Gestational age less than 32 weeks;
• No use of antenatal corticosteroids;
• Maternal bleeding during pregnancy;
• Chorioamnionitis (intrauterine infection);
• Natural childbirth.

Postnatal risk factors:

• Weight less than 1,500 grams;
• Early sepsis;
• Hypoxemia;
• Respiratory distress syndrome;
• Mechanical lung ventilation;
• Perinatal asphyxia;
• Convulsions and changes in the coagulation system, among others.
  The classification currently used to measure the severity of PIVH is based on ultrasound images of the brain performed by trained radiologists – images obtained from computed tomography or magnetic resonance imaging also serve. The intensity of the condition are as follows:
  • Grade I – hemorrhage in the germinal matrix;
  • Grade II – intraventricular hemorrhage without dilation of the ventricles;
  • Grade III – intraventricular hemorrhage with dilation of the ventricles;
  • Grade IV – hemorrhage with intraparenchymal hematoma.

Follow-up and treatment

Investigation and follow-up of PIVH is ARE performed using a minimally invasive, radiation-free ultrasound examination of the brain that can be repeated periodically to observe progression or regression of PIVH.

In premature infants, fortunately, Grade I and II hemorrhages are the most common and, in general, are conservatively managed, as they do not lead to major complications or sequels SEQUELAE. Grade III and IV hemorrhages, on the other hand, can cause chronic damage to the central nervous system (CNS), such as hydrocephalus (increased amount of cerebrospinal fluid – central nervous system fluid) and, consequently, increased head circumference (head circumference) of the baby; in these cases, there may be a need for neurosurgical intervention.

The future sequels SEQUELAE of PIVH cannot be confirmed in the neonatal period, as the baby’s brain is still being formed, thus gains and losses of function are not yet fixed at this age.

Prevention

The use of antenatal corticosteroids, which helps to mature the lungs, also has an effect on the maturity of the germinal matrix, reducing the incidence of HIPV, as well as minimal manipulation protocols in the first 72 hours of life.

SEIZURES IN THE NEWBORN

Causes

They most often occur as a result of an acute event in the brain, most often caused by lack of oxygen or bleeding, but they can also have other causes, such as infections, genetic syndromes, congenital heart defects, other malformations and metabolism disorders.

Features in the newborn

The newborn’s brain is still immature, so it is more susceptible to convulsive crises because of the greater excitation of neurons and the difficulty in inhibiting these stimuli. These seizures are a medical emergency as they reflect a serious neurological condition that needs to be treated as soon as possible to avoid sequelae. The investigation of the cause of the crises should include clinical analysis and, when necessary, collection of exams.

The great difficulty in the investigation is that 80% of seizures in newborns are subclinical, that is, they do not show visible signs such as tremors and hypertonia, which we usually see in older children and adults.

Como detectar

Os bebês podem não aparentar nenhuma alteração ao exame físico e à observação clínica e, mesmo assim, estar convulsionando. Por isso, casos considerados de risco para lesão cerebral aguda e, consequentemente, para convulsão devem ser monitorizados de forma contínua por videoeletroencefalograma convencional ou vídeo-aEEG (EEG de amplitude integrada) por, pelo menos, 24 horas.

Treatment

When the convulsive crisis is confirmed, drug treatment must be started immediately. After starting the medication, monitoring should continue to assess whether the seizures have actually ceased, as there are cases in which the phenomenon of electroclinical dissociation occurs, which is when the clinical manifestation of the seizures disappears, the baby does not have convulsive movements, but the seizures Electrographic changes (detected on the aEEG) continue.

But if the electrographic crisis does not generate any changes that can be seen in the baby at that moment, does it really need to be treated? Yes! Even if we cannot see that the newborn is convulsing, these seizures cause sequelae in neurodevelopment. Today, there is already clear evidence that the correct treatment of these subclinical seizures generates better neurological development.

Monitoring is not only important for diagnosing subclinical seizures, but also for confirming or excluding suspected seizures when the baby shows visible signs of seizures. That’s right: even when the patient has tremors and repetitive movements, most of the time, they are not seizures. Therefore, many suspected seizures medicated only after observation actually should not be approached in this way. It is important to remember that medications also have adverse effects and that, when used unnecessarily, they can cause neurological damage instead of preventing it.

NEONATAL MENINGITIS

What is it?

It is the disease that is characterized by the occurrence of an infectious process in the meninges (membranes that cover the brain and spinal cord). It is usually identified between birth and the 28th day of life.

What causes meningitis?

This infection is caused by viruses or, in the neonatal period, by bacteria in the bloodstream. The infection is usually a consequence of contamination by bacteria acquired in the birth canal, most commonly group B streptococci, Escherichia coli and Listeria monocytogenes.

Bacterial meningitis is more common in the first month of life than any other period and may result in little or no sequelae or have devastating consequences.

It is more common in newborns with:

• Low birth weight (< 2,500 g);
• Preterm infants (< 37 weeks of gestational age);
• Born in an inadequate environment with potential for infection;
• History of amniotic sac rupture long before childbirth;
• Maternal history of infection at the time of childbirth;
• Hypoxemia (lack of oxygen) at the time of childbirth.

What are the symptoms?

The newborn may have no symptoms or show nonspecific signs, such as temperature changes (hyper or hypothermia), vomiting, rapid and labored breathing, and apnea (breathing pause). Not always, neurological symptoms are present, but babies can show irritability, reduced spontaneous activity, decreased tone (muscle weakness) and even seizures.

How is the diagnosis confirmed?

To confirm the infection, the doctor needs to evaluate the results of blood tests and liquor, which is the liquid that is in contact with the meninges and can be collected through lumbar puncture.

Treatment

It is performed in a neonatal intensive care unit and consists of the administration of antibiotics. It can last between 14 and 21 days, depending on the causative agent and the newborn’s clinical condition. As these patients are at greater risk of developing seizures during the infectious period, monitoring the brain in real time with Integrated Amplitude Electroencephalogram (aEEG) helps the pediatrician to control brain functions and possible seizures, which are frequent, and allows that, when these are present, early treatment is instituted, thus reducing the chance of neurological that this complication can cause.

At the end of treatment, brain imaging tests (ultrasound, tomography or magnetic resonance imaging) are commonly performed in these newborns to assess whether there are any signs suggestive of complications or sequelae.

It is very important that you are part of the baby’s care. Talk to the baby care team about how to help. Some examples include:

• When visiting the baby, sit by the bed and talk to the baby, read or sing to the baby. Babies like to hear your voice;
• When the baby is being cooled, you can hold his hand or foot or touch him to let him know you are there;
• Many hospitals allow you to provide some basic care, such as changing diapers or helping to breastfeed the newborn;
• If you want to breastfeed, you will first need to express your milk. The unit’s nursing staff will be able to help you with this. Breast milk will be stored in the milk bank, in the refrigerator or freezer, until the baby is ready to be fed. It is important that you start pumping as soon as possible after giving birth. Doctors will decide when it is safe to give breast milk to the baby; initially, he will receive food through a tube placed through his nose or mouth that goes into his stomach. As he develops, you can breastfeed him;
• Ask as many questions as you need. It is important to understand your baby’s treatment and progress;
• Be sure to take care of yourself, attend postnatal checkups and talk about how you feel.

Nurses will help care for the newborn as much as possible, but being there is important. Likewise, sick babies need a lot of peace and quiet, and some hospitals try to promote some quiet times when no procedures are performed and the little patients are not disturbed.

When your baby is no longer being cooled, but is still connected to machines and tubes, the medical and nursing staff can help you hold your baby. Some parents like the Kangaroo Mother Care, a technique that encourages skin-to-skin contact with the baby, in order to help build a close bond between mother and baby and encourage breastfeeding.

During this difficult time, it’s important that you take care of yourself. Make sure you get the postnatal care you need to stay as healthy as possible. Having a baby in intensive or special care can be stressful for families. Talk about how you are feeling. Some people have family support and can tell what is happening with the baby and how they feel. Others prefer to only tell a select number of people about how their baby is doing. It’s important to do what’s right for you and your family.

This is one of the most important questions you will be asked, but it is often one of the hardest questions to answer with certainty.

After you go home with your baby, you’ll likely have an appointment with your pediatrician or neonatal consultant to monitor and discuss your baby’s progress. Some newborns with HIE recover fully and do not experience long-term difficulties, while others may develop sequelae that require help and support from health professionals, such as physiotherapists and speech therapists. Each child is unique and the care they receive will be tailored to their needs. The number and frequency of appointments will depend on the baby’s demands.

As EHI is a complex condition, it may take some time to figure out your child’s future and possible needs. The medical team caring for your baby will be able to gradually gather the results of the different investigations your baby has been subjected to in order to have a better understanding of what the future may bring. This, with information about how you perceive your baby’s development at home, will be vital for planning ahead.

A developmental assessment can be performed on an outpatient basis, between 18 months and 2 years; sometimes before that, depending on the protocols of the unit where your baby is being treated.

The health professional will carry out some activities with your child that will provide information about their physical, motor, sensory and cognitive development. This assessment can help give you a better understanding of how he is developing and may alleviate any concerns you may have.

In childhood, the child may have problems with learning, thinking, speaking (cognitive problems), and walking or moving (sometimes called cerebral palsy).

Palliative care and bereavement

For some babies severely affected by HIE, all available treatments may still not be enough to help them. Doctors and nurses can talk to you about palliative care, which is the care patients receive when they are recognized as having a life-limiting condition. Palliative care is aimed at keeping the baby comfortable and managing any symptoms.

Everyone’s experience is individual and every circumstance is different. Parents/caregivers whose child died said that the grief runs deeper and lasts much longer than many realize. Parents/caregivers can experience an unexpected mix of emotional and physical reactions after the death of a child.

Baby’s development

The time taken to reach developmental milestones (walking, first word…) in infants and toddlers varies enormously. Children who have suffered medical complications in the neonatal period may have a developmental delay, but they may also reach all of their milestones on time.

If you have concerns about your baby’s development, discuss them with the health care provider who is caring for your baby. He may not have all the answers for you, but he will be able to tell you how he’s progressing and what you can do to help him. If there is a need for additional support, such as physiotherapy, he can organize the appropriate treatment.

Clínica PBSF promotes a specialized follow-up for low and high-risk children, with a highly prepared team to provide excellent care.

Our little ones deserve the best!

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