Intracranial hemorrhage (ICH) refers to the acute disease characterized by the bleeding inside the skull or brain and represents a life-threatening emergency. The overall incidence of spontaneous ICH globally is 24.6 per 100,000 person-years, with around 40,000 to 67,000 cases per year in the United States only (Caceres & Goldstein, 2013). The 30-day mortality rate from the disease ranges between 35% and 52%, with only around 20% of survivors expected to complete full functional recovery throughout a six-month period (Caceres & Goldstein, 2013). ICH represents a healthcare challenge because around half of mortality from the disease occurs in the first 24 hours from the onset, which points to the critical importance of emergency and effective treatment. For neonates, ICH is an uncommon but notable cause of mortality and morbidity and should be diagnosed with the help of the latest neuroimaging technologies (Hong & Lee, 2018). While the effective methods of prevention remain at the development stage, it is essential to discuss the already available models and interventions for ICH that rely on evidence-based practice.
In newborns that are born when expected, ICH is relatively uncommon and has different etiology compared to adult cases. In term neonates, the disease can be subdural, intraventricular, parenchymal, or epidural in location, which means that careful monitoring of fetuses and infants when they are born to identify potential risk factors (Bano, Chaudhary, Garga, Yadav, & Singh, 2014). The hemorrhage of both subdural and subarachnoid nature in neonates is linked to birth trauma “either from forceps delivery or unassisted vaginal delivery” (Bano et al., 2014, para. 2). It is essential to consider the risk factors for newborns having ICH. For example, maternal risk factors that cause the disease in children include the usage of drugs, pregnancy-associated hypertension, placental abruption, as well as autoimmune disorders (Bano et al., 2014). Important perinatal risk factors include birth trauma, resuscitation occurring at birth, vitamin K deficiency during breastfeeding, unassisted vaginal delivery, suction cup use, and sometimes cesarean-section (Bano et al., 2014). While there is no unified way of ensuring that ICH does not occur in newborns,
Subdural hemorrhage is the most widespread type of ICH in term infants, as mentioned in the research conducted by Hong and Lee (2018). The combination with supratentorial and infratentorial hemorrhage was more widespread compared to isolated infratentorial in infants. The structure of infants’ brains may explain the increased risk of the disease’s occurrence. One of the significant features of the immature brain is associated with the potential of the occurrence of severe blood flow changes that can disrupt endothelium and lead to ICH (Bada, 2020). ICH is identified in more than 90% of cases by 4 or 5 days of age, although 30% to 50% of cases are present within 12 hours of age, and it has been estimated that 40% of ICH occur as early as during the first hour of age (Bada, 2020). The current preventive measures differ for early and later-onset of ICH in neonates (Bada, 2020). It is expected that antenatal interventions will affect the initial occurrence of the disease while postnatal measures will impact the later-onset of the ICH. Since the earlier onset of the disease is more likely to become more severe, its prevention is expected to result in an overall decrease in the incidence of ICH.
Evidence-based antenatal prevention strategies range from the careful surveillance of a fetus to the prevention of preterm births. For example, to prevent the delivery of infants before their term, evidence-based practitioners suggested the use of tocolytics as the main for the management of labor (Bada, 2020). The use of tocolytics has shown to be associated with the lower occurrence of the disease since the successful prevention or a delay in the preterm delivery of infants showed to reduce the risks of the respiratory distress syndrome, which is a known risk factor for ICH development. Tocolytic agents, which include indomethacin, magnesium sulfate, and beta sympathomimetics, all of which are targeted at controlling the progress of labor, including its delay or initiation.
Beyond the use of tocolytics, optimal fetal surveillance, and the immediate treatment of fetal distress represents a method for addressing any issues that may lead to the occurrence of ICH in neonates. Fetal distress is necessary to eliminate because the prevention ensures that the delivery of neonates takes place in an optimal environment. Besides monitoring fetal distress, it is also recommended to look for symptoms of acidosis and vaginal bleeding, which are the facts reported to be associated with severe hemorrhages that may extend into the parenchyma. Therefore, antenatal management should be associated with the treatment of the mentioned stress factors to prevent the occurrence of ICH in neonates.
Postnatal interventions are also important for ICH prevention because they are associated with primarily preventing neonatal factors that are linked to the higher risk of having the condition. Such measures can include resuscitative interventions when needed, the maintenance of appropriate ventilation, oxygenation, and the acid-base balance (Bada, 2020). In addition, ICH prevention is also carried out with the help of minimizing abrupt hemodynamic alterations through stabilizing infants’ blood pressure, reducing handling to prevent the spikes of hypertension, decreasing volume infusion to address the challenge of hypotension, as well as using inotropic pressors or agents for maintaining stable blood pressure within an acceptable range. Finally, it is important to administer surfactants at the same time with monitoring associated systemic hemodynamic changes.
Evidence-based practice has also pointed to the benefit of supportive measures that go hand-in-hand with the preventive interventions. For instance, relevant preventive and supportive measures that should be implemented soon after infants’ birth, including the maintenance of oxygenation as well as the reaching of the optimum acid-base status. These measures call for consistency on the part of the healthcare team as there is a need to regularly monitor the availability of gas in blood as well as its pH levels (Bada, 2020). In case of unwanted deviations from the norm, corrective measures should be immediately implemented, including ventilator settings changes, adjusting positive and expiratory pressure and inspiratory time, as well as administering a buffer if necessary. Ventilatory support, which is one of the core maintenance efforts, should be provided at the lowest settings to reduce the occurrence of complications such as air leaks or pneumothorax. In cases when preterm delivery cannot be prevented with the help of pharmaceutical interventions or other measures associated with antenatal preventive care cannot be instituted, it is expected that an infant develops respiratory distress syndrome. To address this challenge, a surfactant is usually administered for treating surfactant deficiency (Bada, 2020). Overall, ICH presents a range of challenges associated with not only prevention but also monitoring of infants’ condition immediately after birth. Therefore, the risks of ICH development can be minimized not only through consistent and dedicated supervision of a fetus for possible defects and deciding on appropriate actions targeted at reducing the likelihood of the disease’s occurrence.
Discussion
Child neurology is often a late player in the management of ICH in infants in the first week after birth. However, it is imperative that child neurologists understand the potential risks associated with the development of the disease and undertake comprehensive evaluations targeted at investigating the etiology and management of the hemorrhage (Gupta, Kechli, & Kanamalla, 2009). Since ICH is mostly associated with premature newborns, monitoring and early management represent the main steps for early prevention. Neuroimaging is an essential tool that can help the healthcare team to monitor the condition of soon-to-be-born children and make subsequent decisions on which methods of prevention or emergency management should be implemented. Since the analysis showed that both pre- and post-term methods should be implemented to reduce the occurrence of ICH, further research is needed to determine the efficacy of specific interventions.
Overall, ICH is a complicated problem that has not been addressed by the current clinical research just yet. While there is an available system of procedures and methods that are being used for addressing the early onset of ICH or preventing its occurrence altogether, there is still no cohesive set of actions that could facilitate a positive trends in the minimization of the disease’s rate in infants. Nevertheless, a range of reasonable clinical practices have the potential of decreasing the risk of ICH in infants, and it is imperative to monitor the condition of a fetus to initiate emergency action if needed.
References
Bada, H. (2020). Prevention of intracranial hemorrhage. NeoReviews, 1(3), 48-52.
Bano, S., Chaudhary, V., Garga, U., Yadav, S., & Singh, S. (2014). Intracranial hemorrhage in the newborn.
Caceres, J. A., & Goldstein, J. N. (2012). Intracranial hemorrhage. Emergency Medicine Clinics of North America, 30(3), 771-794.
Gupta, S., Kechli, A., & Kanamalla, U. (2009). Intracranial hemorrhage in term newborns: Management and outcomes. Pediatric Neurology, 40(1), 1-12.
Hong, H. S., & Lee, J. Y. (2018). Intracranial hemorrhage in term neonates. Child’s nervous system: ChNS: Official Journal of the International Society for Pediatric Neurosurgery, 34(6), 1135-1143.