Neonatal Neurological System Susan L Hicks, RN Nurse Manager, NICU Madigan Healthcare System

Objectives n Discuss pathophys n Identify Neural Tube Defects and care n Discuss Seizures n Discuss Glucose Management n Discuss IVH’s n Discuss HIE

Central Nervous System n The most complex system in the human brain n Early recognition of infants at risk for neurological dysfunction is crucial for long term outcomes of these infants

Development of the CNS- n Neurolation –2-3 weeks gestation n Procencephalic--2-3 months n Neuronal proliferation 3-5 months n Organization 5 months gestation to 1 year after birth n Myelinization 8 months gestation to 1 year after birth

Spinal Defects n Occur during neurolation n 3-4 weeks gestation n Folic Acid supplementation is decreasing incidence

Anecephaly n Failure of neural tube to close in the cranial area n 1:1000 live births, decreasing with folic acid supplementation n 20% are alive at 1 week of age n Supportive care measures

Encephalocele n Failure of closure of the anterior neural tube n 1:2000 live births n Can occur over any region of the spine, 75% over occipital region n Contain very little or large amounts of neural tissue not related to the size of the defect n Surgical closure with possibility of VP shunt in the presence of hydrocephalus

Spina Bifida n Deformations in the closure of the neural tube in the spine or vertebrae n Open or closed defects n Clinically vary- can have minimal neuromuscular effects, to paraplegia or quadriplegia with loss of bowel and bladder control

Spina Bifida n 4 types –Closed Spina Bifida Occulta –Meningocele –Myelomeningocele –Myeloschesis

Closed Spina Bifida Occulta n pilonidal / sacral dimple or hair tuft n 10-30% of general population n Little or no clinical significance

Meningocele n Cystic sac with meninges, but spinal cord and nerve roots are in normal position n Excellent outcome following surgical repair

Myelomeningocele n Cystic sac containing meninges, spinal cord, and vertebral elements n Sac exposed on back and covered with epithelium or a thin membrane n 1:1000 births, decreasing with Folic Acid supplementation n Most frequently in the lumbar region of the spine

Myelominingocele n Treatment –stabilization –surgical correction –bowel and bladder care –range of motion/ flexed positioning n Outcome –These infants are usually otherwise healthy and outcome dependent on location and severity of disease

Myeloschesis n Spinal cord is open and exposed n Most of these infants are stillborn

Nursing Care and Prep for Transport n Keep infant off site (may cut donut) n Keep site with sterile drsg on n Monitor VS closely – especially temperature n Give IVF, monitor glucose n Observe for change in neuro status n Transport as soon as possible.

Seizures n The most common sign of neurological dysfunction in the neonatal period n A sign of underlying disease process resulting in acute disturbances of the brain n If left untreated can lead to permanent Central Nervous System Damage

Seizures n Neonatal seizures are usually acute and resolve within the first few weeks of life n.15 % of term and 22.7% of premature infants experience neonatal seizures n Seizures result from excessive simultaneous electrical discharge or depolarization of neurons

Risk Factors for Seizures n Asphyxia n Metabolic disturbances n Intraventricular Hemorrhage n Infection n Congenital Anomalies

Seizures- Clinical Presentation n Because of immature brain organization at birth, especially in premature infants, the is an inability to propagate and sustain generalized seizure activity n In neonates, especially premature infants, the symptoms are subtle

Seizures- Clinical Presentation n Abnormal movement or alteration of tone in the trunk and extremities –clonic, tonic, bicycling or swimming, general loss of tone n Facial, oral and tongue movements –sucking, grimacing, twitching, chewing, swallowing, yawning

Seizures- Clinical Presentation n Ocular Movements –eye deviation, blinking staring n Respiratory –apnea, usually accompanied by one of the other subtle movements –labored, irregular respirations

Seizures n Seizure type is difficult to differentiate in newborns n It often mimics activity seen in the active sleep state

Jitteriness or Seizures

Seizures- Management n Treat underlying cause n Anticonvulsant- Phenobarbital (most common) –also dilantin, diazepam, lorazepam n Careful monitoring of serum toxicology is crucial to prevent toxicity n Controversy exists in the literature over how long to use anticonvulsant medications in neonates

Seizures- Nursing Care n Assessment – time of the beginning and end of abnormal activity –description of movements and areas involved –respiratory status and color –state

Hypoglycemia n May be seen as jittery infants (which could just be immature neurological system) n Anticipate which infants identified as “at risk’ and will need close monitoring. –SGA, LGA, Potential for Sepsis, Mag moms, –Diabetic moms!

Hypoglycemia Management n Follow your hospital guidelines for d-stix protocol. n Know acceptable blood glucose values at your hospital –<40 usually feed, then recheck? –<20 automatically get IV ? –Continues with problem then continuous IVF?

Hypoglycemia n If treating with feeding, colostrum excellent. Use of formula should be last option. n If treating with D10: use 2ml/kg bolus dosing. n Always recheck Dstix according to your policies.

Intraventricular Hemorrhage n Capillary bed of the germinal matrix in premature infants is immature n Neurological Autoregulation –Maintains consistent cerebral blood flow despite changes in systemic blood flow –asphyxia and hypoxemia alter autoregulation n brain becomes a pressure passive system

Germinal Matrix

Intraventricular Hemorrhage n Risk of IVH –prematurity –PPV –Medications/ Volume expansion –hypercapnea –care giving events –suctioning –pain –high pressure ventilation

Intraventricular Hemorrhage n 90% of IVH within the first 72 hours of life n 50% within the first 24 hours

Intraventricular Hemorrhage n Clinical signs –unexplained drop in Hematocrit –Decrease in BP support despite pressor support –full fontanel –change in activity and state –decreased tone

Grades of IVH

Treatment of IVH n Indomethacin is used for IVH prophylaxis in premature infants n Treatment includes cardiopulmonary support, treatment of seizures, control of pain, and possibly ventriculo-peritoneal shunting or tapping n Outcome dependent of degree of IVH, unilateral or bilateral, and whether the bleed is resolved or develops PVL

Hypoxic/ Ischemic Encephalopathy n 2-4% of term infants n 60% of very low birth weight infants n 3 stages

Stage 1 HIE n Hyper-alert, hyperresponsive to stimulation n Dilation of pupils, reactive n Scarce secretions n EEG within normal limits

Stage II HIE n Lethargic, Hypotonic, weak suck n Seizure activity frequent n Pupils constrictive and reactive n Periodic variable respiration n Critical period- either improve or deteriorate

Stage III HIE n Unresponsive, comatose, seizures within 6-12 hours n Pupils unequal, variable reactivity n Absent or depressed reflexes n Mechanical ventilation is required n Survivors take days to months to improve n Feeding difficulties and neurological abnormalities frequently develop

HIE n Outcomes –20-50% die during newborn period –17-75% with significant sequelea –disappearance of abnormal neurologic signs by 2 weeks offers good prognosis

Subgaleal Hemorrhage n Occurs when emissary veins are damaged and blood accumulates in the potential space between the galea aponeurotica and the periosteum of the skull n Potentially life threatening injury

Subgaleal Hemorrhage n This space has no containing membranes or boundaries, the subgaleal hematoma may extend from orbital ridges to the nape of the neck n There is a large potential space for blood to accumulate, and the possibility of life threatening hemorrhage

Subgaleal Hemorrhage

n Clinical presentation –Diffuse swelling of the head –Signs of hypovolemic shock n pallor n hypotension n tachycardia n tachypnea n prolonged capillary refill time

Subgaleal Hemorrhage n Clinical presentation –The symptoms may be present at delivery, or may not become clinically apparent until several hours or up to a few days following delivery

Subgaleal Hemorrhage n Clinical presentation –The swelling is usually diffuse, and shifts depending on position, and indents easily upon palpation –In some cases, swelling is difficult to distinguish from edema of the scalp –Occasionally, the cranial findings are unremarkable, and hypotension and pallor are the dominant signs

Subgaleal Hemorrhage n Patient Care Management –Close documentation of vital signs per policy –Closely monitor any infant with signs of poor perfusion following vacuum delivery n blood pressure n capillary refill time n pulses n heart rate n respiratory rate and effort

Subgaleal Hemorrhage n Document any findings, interventions, and outcomes thoroughly n Follow hospital policy regarding physician notification n Outcome –Once infant has survived the acute phase, recovery will occur in 2-3 week