Cerebral edema in a newborn

A cerebral edema in a newborn is a process caused by excessive accumulation of fluid in the cells and interstitial space of the brain in a child. This is a kind of protective reaction in response to damage to the brain tissue of any etiology. In small children, the disease has very serious consequences, so it is necessary to diagnose the process at the initial stages.

[1], [2], [3]

Causes of the cerebral edema in the newborn

The causes of cerebral edema in newborns stem from pathogenesis and can be completely different. Sometimes the process develops so quickly that there is no way to establish the true cause.

Localized edema occurs in a small area of the brain and its cause can be a tumor of the cerebral hemispheres or meninges. Such a tumor can press on the neighboring structures of the brain and disrupt the blood circulation in the vessels, and then the process develops by the mechanism of increasing pressure and penetration of liquid into the cells. In newborn babies, tumors can be a consequence of the intrauterine effect of environmental factors or can develop and grow after birth.

Trauma of the brain is one of the most common causes of cerebral edema in newborns. The skull of the child at birth is very malleable due to the fact that the seams between the bones are not tightly fused and there are fontanelles. On the one hand, it helps the child at birth to better pass through the birth canal, but on the other hand, this is a very serious risk factor for developing damage to the brain tissue. At birth, birth trauma is very common. They can be caused by pathology on the part of the mother, when the process of birth is unphysiological with rapid labor. There may also be interventions from doctors, in which birth trauma happens often. In any case, birth trauma can lead to hemorrhage or hematoma, and this is a compression of the brain tissue with the risk of developing a local edema.

The cause of development of generalized edema is often ischemic damage to brain tissue. If there is a pathology of pregnancy that disrupts blood circulation in the umbilical veins, then this leads to a prolonged ischemia of all the fetal tissues, including the brain. Premature aging of the placenta can lead to a lack of oxygen supply to brain cells, which in turn affects blood pressure. All these are additional risk factors for edema development.

Another reason for the development of generalized brain edema is the toxic effect on cells of medicinal and toxic substances. In utero, a child may be affected by an excess of alcohol, which inhibits the development of the brain. If before the birth the mother is in a state of intoxication, then the child is born with an alcoholic syndrome. This concept is that the child's brain is very sensitive to the toxic effects of alcohol. Therefore, the systematic influence of a large amount of alcohol disrupts the glucose ratio in the brain cells and can cause edema. After the birth of a child, toxic effects on the brain tissue can be caused by overdose of drugs, more often due to excessive infusion therapy. Liquid overload in newborns develops very quickly, given their body weight. Therefore, one must be very careful about infusion therapy in these children. Overdose with certain medications: sedatives, antiepileptic drugs can also cause swelling.

Inflammatory processes of the brain, such as encephalitis or meningitis, have a direct impact on the development of edema. This is because any inflammation is accompanied by swelling of the tissue, and inflammation of the brain tissue is accompanied by an increase in volume, that is, edema.

Arterio-venous malformations are one of the forms of the congenital pathology of the structure of the vessels, in which the vessels disrupt their normal blood flow. This leads to the formation of aneurysms and the accumulation of blood in them. If such malformation is located at the brainstem, then at considerable sizes it can cause edema.

[4], [5],

Risk factors

Given the many causes of cerebral edema in newborns, it is advisable to identify risk factors:

1. birth trauma is one of the most common and direct risk factors;
2. tumors of the brain and meninges;
3. abuse of alcohol or medicines of a pregnant woman throughout pregnancy or before giving birth directly;
4. violation of uteroplacental circulation with development of chronic or acute fetal hypoxia;
5. infectious pathologies - brain abscess, encephalitis, meningitis;
6. congenital abnormalities of the cerebral vessels, which are accompanied by volumetric processes with a violation of the outflow of fluid and the risk of hyperhydration of the space between the cells.

Many reasons for the development of cerebral edema in newborns suggest that it is important to diagnose the edema itself in time to start treatment, and the cause can be found already in parallel with treatment activities.

[6], [7], [8], [9], [10]

Pathogenesis

Before talking about the causes of edema, you need to understand the pathogenesis of this process. If the liquid accumulates inside the cell, then it is just about the swelling, but if the liquid accumulates in the interstitial fluid, then it is more correct to say about the swelling of the brain. In pathogenesis there are no special differences between these two conditions, but for therapeutic tactics this is very important.

Under normal conditions, the brain vessels pass between the cells and supply them with oxygen. This occurs against a background of stable pressure in the arteries, due to which oxygen penetrates into the interstitial space and cells. But in certain cases, the pressure in the arteries of the brain may increase, which leads to increased pressure in the interstitium. According to the laws of physics, all elements move towards higher pressure, so proteins from the blood plasma and fluid from the vessels penetrate through its wall into the interstitium. Thus, in the space between the cells is more protein, which increases the oncotic pressure. This leads to fluid movement toward increased oncotic pressure and hyperhydration of brain cells occurs. In the wall of the cell the ratio of sodium and potassium ions is violated in such a way that the sodium in the cell becomes larger. This leads to even greater changes in the accumulation of water in the cells. This process takes place very quickly and new cells are involved in pathological changes very quickly. This closes the circle and further increases the pressure and, accordingly, increases swelling.

There are different types of edema on the clinic and the flow. If the process is limited in a small area of the brain, then it is a localized edema. Generalized edema is more dangerous and is characterized by a diffuse accumulation of fluid involving both hemispheres. The main principle for distinguishing between these two concepts is time, because very quickly a localized process can pass into a generalized process.

Symptoms of the cerebral edema in the newborn

Statistics show that cerebral edema in newborns occurs no more than 4% of children. Of the causative factors in the first place is the birth trauma, as one of the most common causes of edema. A lethal outcome in children with brain edema occurs in 67%, which indicates the seriousness of the problem.

Given that the newborn baby all the symptoms have their own peculiarities of the flow, then immediately suspect the presence of cerebral edema is a bit difficult. But if there were complicated births or pregnancy, or there are other risk factors in the form of birth trauma in the child, then it is under the close supervision of doctors. After all, the first signs of cerebral edema can begin three days after the injury, while healthy children are already discharged home. Therefore, not only the doctor should observe the child, but the mother should pay attention to all the symptoms.

With swelling, each cell increases in volume very quickly, so there is an increase in intracranial pressure, even though the cranium of the newborn has fontanels. All the symptoms of edema are associated with increased pressure. There may be systemic manifestations and local signs. Systemic symptoms include nausea, vomiting, headache. But these symptoms in the newborn have their own characteristics. So nausea in a young child immediately causes vomiting, and this vomiting is food that was eaten a few hours ago. It is very difficult to steal such vomiting and it is difficult to correct, since it arises because the membranes of the brain are irritated at elevated pressure. Headache in a newborn can manifest as a so-called "brain cry", in which the baby is very much crying and has a characteristic pose of throwing the head back. If the cerebral edema develops against the background of an infectious process in the form of encephalitis or meningitis, then systemic manifestations also include an increase in body temperature, as a reaction to the infectious process. But the peculiarity of newborn babies is also that the temperature may not rise, but this does not exclude the infectious process.

The edema of the parenchyma of the brain in newborns is also accompanied by local symptoms. These symptoms appear when compression occurs in certain areas of the cerebral cortex. More often it is manifested by paresis or paralysis of a specific part of the body, or in newborns there are often convulsions. Seizures can begin with a simple chin jerk and in a few seconds can spread to the entire body. Often there is a small-amplitude tremor, short-term breath retardation, visual disturbances with horizontal nystagmus. There are also focal and generalized convulsions. One of the specific symptoms in newborns, which indicate the beginning of the process of damage to the cortex, is the rolling of the eyes.

Also characteristic of edema, which is increasing gradually, the emergence of a group of symptoms, such as increased excitability. The syndrome of increased nervous reflex excitability is manifested by increased spontaneous motor activity, restless surface sleep, frequent unmotivated crying, revival of unconditioned and tendon reflexes, muscular dystonia, tremor of limbs and chin, emotional lability.

The syndrome of vegetative dysfunction also occurs with edema. Manifests the marbling of the skin, transient cyanosis, a violation of the rhythm of breathing and cardiac activity, thermoregulation disorders and dysfunction of the gastrointestinal tract with pylorospasm, constant regurgitation, increased peristalsis, constipation, vomiting, persistent hypotrophy. These symptoms can be isolated and may be the first to manifest, then it's hard to think about swelling.

Cerebral edema in a newborn during labor often occurs with accompanying birth trauma. Then the first signs can begin after birth, when the child can not breathe or it starts to convulsions. This is a direct indication for resuscitation.

Speaking about the spread of edema, it should be noted several types of this pathology, which differ clinically.

Moderate cerebral edema in newborns is when the process is not spreading so quickly and is easily amenable to correction. Morphological changes in the brain at a given degree in the future do not lead to a pronounced organic neurologic deficit.

At the same time there are arriving violations of hemolytic dinamics with a slight hypertensive syndrome, diapedic subarachnoid hemorrhages, local zones of cerebral edema. Clinical manifestations can also be minimal.

Periventricular cerebral edema in newborns is an edema in the area around the ventricles. More often such edema is observed with ischemic brain damage due to acute or chronic hypoxia of the child in utero or already in childbirth. This type of edema with timely diagnosis does not have a rapid spread with the risk of brain wedging. But there may be other complications.

The edema of the brain's ventricles in the newborn often occurs as a result of an intra-gastric hemorrhage. This leads to an increase in their volume, which presses the parenchyma around the ventricles and causes swelling. Then the clinic of such edema develops against the background of symptoms of impaired child's consciousness.

[11], [12]

Complications and consequences

The consequences and complications of brain edema in a newborn can be very serious, and there can be immediate and delayed consequences. Lethal outcome is the most terrible consequence of brain edema. With untimely tactics of treatment or in the presence of other pathologies, cerebral edema leads to the dislocation of the middle structures and brainstem. This is characterized by the penetration of the medulla oblongata into the large occipital foramen of the skull, in which the center of respiration and the cardiovascular system are located. Therefore, death in this case can be instantaneous.

Complications of edema can be distant and they can manifest lifelong impairment of motor activity, the phenomena of infantile cerebral palsy, convulsions. In the presence of periventricular edema, cysts can be formed in these places, which in the future can lead to persistent disturbances in the child's motor activity. If there was edema involving the ventricular system of the brain, then there may be hydrocephalus. This is a violation of the outflow of cerebral fluid, which leads to an increase in the size of the head.

Thus, the consequences of pathology are very serious and they prove the need for thorough diagnosis and timely treatment.

[13], [14], [15], [16]

Diagnostics of the cerebral edema in the newborn

In the diagnosis of such a pathology, anamnesis plays an important role in the first place. After all, if a child has a birth trauma or symptoms of meningitis, then the appearance of any symptoms from the central nervous system should be regarded as a phenomenon of swelling and immediately begin to act. Confirmation of the diagnosis can be carried out already in parallel with medical measures.

Symptoms that should lead to the thought of CNS involvement are a strong cry of the child, indomitable vomiting, convulsions, agitation or depression of the child, pathological reflexes. When examining, you need to pay attention to the position of the child, muscle tone, nystagmus, pathological reflexes. The position of the child with a head thrown back is a symptom of possible meningitis, including swelling. In newborns, one of the mandatory symptoms of brain damage is a positive sign of Lessuga. For this, the child needs to be lifted by the armpits and he will pull up the legs to the trunk, then the symptom is positive. If any of these symptoms appear, you should immediately begin additional diagnosis.

Analyzes that need to be carried out by a child with cerebral edema should be with minimal interference, but at the same time informative. Therefore, a general blood test is considered mandatory, which will allow to determine infectious changes or hemorrhagic processes.

When cerebral symptoms appear, it is mandatory to perform lumbar puncture. This allows you to differentiate meningitis, hemorrhage and reduce hydrocephalic syndrome. If there is blood in the cerebrospinal fluid, you can talk about intragastric hemorrhage, and further research can establish the presence of an inflammatory process and confirm or exclude meningitis. But it should be noted that with the slightest suspicion of swelling, the puncture is contraindicated. Therefore, priority is given to non-invasive diagnostic methods.

Instrumental diagnosis of edema involves the use of ultrasound diagnosis. Use ultrasonography of the brain through the fontanelle, which allows you to establish changes in the parenchyma and ventricular system.

Another method of instrumental diagnosis is used - this is Dopplerencephalography. This is one of the most modern methods that allows you to study the blood flow in the arteries of the brain. In the presence of local edema, there may be changes in the form of a decrease in the perfusion of the blood of a particular artery.

[17], [18]

Differential diagnosis

Differential diagnosis should be carried out with hypoxic-ischemic injury of the central nervous system, congenital malformations of the brain, primary hydrocephalus, intrauterine infections with damage to the nervous system. The difficulty of differentiation is that these pathologies can be accompanied by symptoms of local edema or edema of the parenchyma of the brain already during decompensation. Therefore, careful differential diagnosis is carried out after the relief of acute conditions.

Treatment of the cerebral edema in the newborn

Edema of the brain in the period of newborns is a very serious diagnosis, which can have complications in the future. Therefore, treatment can be divided into two conditional stages: emergency care and restorative treatment.

The main element in the treatment of edema is active dehydration therapy. This allows you to reduce the concentration of fluid in the brain cells and reduce swelling. The drugs that are used for rehydration with edema are osmotic diuretics. These include mannitol, as well as saluretic lasics.

1. Manitol  is an osmotic diuretic, which acts by increasing the outflow of fluid from the tissues, enhancing filtration in the glomeruli, and the liquid is not reabsorbed in the tubules. Thus, the drug raises the osmotic pressure in the vessels of the brain and causes fluid to move from the brain cells to the vessels. Due to this action, the rheological properties of the blood improve and oxygen passes better into the cortical cells. This action of the drug lasts four to six hours, until its concentration is greater in the vascular bed than in the tissues. Therefore, the repeated administration of the drug must be carried out after such a time. Dosage of the drug is 0.5 grams per kilogram of the body weight of the child 20% solution. Side effects - headache, nausea, vomiting, with prolonged use - dehydration and hypernatremia. Precautions - with congenital heart disease use with great caution.
2. Furosemide  is a loop diuretic, which acts in the proximal tubules, has a rapid diuretic effect. It reduces the absorption of sodium in the kidneys, but also has a direct effect on the edema of the brain by reducing the synthesis of cerebrospinal fluid. And the effect of reducing intracranial pressure is equal to the rate of removal of fluid from the body, which makes it possible to quickly reduce the risk of complications in edema. The method of application of the drug can be intravenous and intramuscular. The dose is 0.5 to 1 milligram per kilogram of the child's body weight. Side effects - hypovolemia, hypokalemia, metabolic alkalosis, impaired glucose tolerance, arterial hypertension, cardiac arrhythmias, acute tubulo-interstitial nephritis, vomiting, diarrhea, aplastic anemia.
3. Glucocorticoids  occupy a significant place in the treatment of cerebral edema due to a wide range of their properties. They reduce the permeability of the wall of brain neurons for sodium and water and reduce the synthesis of cerebrospinal fluid. If the edema is of infectious origin or there is a suspicion of meningitis or encephalitis, then they reduce the inflammation focus and normalize the function of the cerebral vessels. You can use any drug, with calculation for dexamethasone: the dosage can be 0,3 -0,6- 0,9 mg per kilogram single dose. Repeat reception should be every four to six hours. Precautions - to avoid removal of the drug, you must maintain the interval between hormones and diuretics for at least 15 minutes. Adverse effects - hypofunction of the adrenal glands, septic complications, thromboembolic complications, osteoporosis, muscle atrophy, hypokalemia, sodium retention, leukocytosis, thrombocytosis, intercurrent diseases. To prevent the occurrence of side effects of SCS, they should be prescribed in accordance with the circadian rhythm after the first day of admission, gradually reducing the dose to 4-6 days of treatment (for the prevention of withdrawal and atrophy of the adrenal glands), while prescribing potassium, calcium, vitamin D.
4. A child with brain edema is treated only in the intensive care unit, so he is immediately transferred to artificial lung ventilation. Ventilator has a therapeutic effect by reducing the pressure of CO2 in the vessels. This, in turn, causes a spasm of the vessels that are not damaged and are normally regulated and causes additional blood flow to the damaged areas. The use of ventilation in the mode of hyperventilation in short courses can reduce intracranial pressure in as early as 2 hours.
5. In addition to the main drugs, infusion of isotonic solutions in the zero water balance regime is also used. Maintain acid-base balance of blood through control and infusion of bicarbonate. It is also necessary to control the rheological properties of the blood, because it is easy to lead to hypercoagulability.

Treatment of cerebral edema is a very difficult task that requires a lot of knowledge and practical skills. Positive dynamics is observed after the first day and in two to three weeks the child can already be discharged. But the consequences can be serious and physiotherapy and alternative means are already at home at the recovery stages.

Physiotherapy treatment of children with motor impairment after the transferred brain edema is one of the main methods in rehabilitation. To this end, you can use different methods - massage, physiotherapy, physiotherapy, reflexology. The main type of massage depends on many factors: the presence of hypertonic or hypotonic muscles in the child, impaired motor activity, and the state of cognitive functions. Classical massage includes stroking, shaking, felting, kneading, rubbing, fretting, shading. Along with this, segmental, circular, acupressure massage (combining inhibition and stimulating action) is used. Also, with increased muscle tone, special exercises are recommended for all muscle groups with alternate involvement of the upper and lower extremities.

Vitamins can be used in the syndrome of child depression. Encefabol is recommended for this. It is a derivative of the molecule of pyridoxine (vitamin B6) and has a complex trophic effect at the level of neurons and glial elements. The drug activates the exchange of glucose in the brain tissues, easily passes through the blood-brain barrier, has antioxidant properties and stabilizes the processes of inter-neuronal transmission. Encephabol has a positive effect on the microcirculation of the brain, improves the plasticity of erythrocytes and increases the level of ATP in them. The drug is presented in two forms: a 100 mg tablet No. 50 and a suspension in 200 ml bottles (100 mg in 5 ml). Schemes of prescription for children of the first months of life - 1 ml of suspension (20 mg) every morning for a month, for children up to a year the daily dose is gradually increased to 5 ml (100 mg).

Actovegin is a vitamin preparation containing amino acids, oligopeptides, nucleosides, microelements, electrolytes, intermediate products of lipid metabolism. The drug completely lacks proteins, antibodies and pyrogens. Due to its low molecular weight, it passes well through the blood-brain barrier. Actovegin increases the efficiency of energy processes at the cell level by increasing the accumulation of glucose and oxygen. Increasing the transport of glucose and oxygen and increasing intracellular utilization accelerates the metabolism of ATP, which in turn increases the energy resources of the cell. The use of fatty acids and amino acids stimulates intracellular protein synthesis and the exchange of nucleic acids. Along with this, there is an activation of cholinergic processes and accelerated elimination of toxic metabolic products. Therefore, the use of this drug in the recovery period accelerates the recovery and recovery after the transferred brain edema. The drug is used in the early recovery period parenterally (intravenously and intramuscularly), not more than 20 mg / day. For 15-20 days, then orally in a dose of 50 mg 2-3 times daily for 1.5-2 months.

Alternative treatment of cerebral edema

Alternative methods of treatment of brain edema in newborns are used closer to the first year of life, when one can see those or other changes that are subject to correction.

1. Clay is known for its healing properties for children with spastic muscle manifestations or with hyperkinetic disorders. For treatment, you can take the infusion of clay inside. For this, the blue clay is best suited. A glass of boiled water should be mixed with a teaspoon of clay and take on a tablespoon of this solution three times a day. Massages with blue clay are very useful. To do this, you need to spread clay on the limbs or spasmodic muscles and massage with light movements.
2. Baths with medicinal herbs - this is a very good method for treating the nervous system and restoring the function of excitation or inhibition. If the child after the transferred edema has increased excitability and hypertonic muscles, then you need to take 1-2 times a week a bath of oats. To do this, dry grass oats need to be insisted in a liter of water and add to a warm bath. If, on the contrary, the hypotonus in the child is dominated by a decreased motor activity, then in this case the bath must be taken with needles.
3. Special gymnastics at home with rubbing the muscles with balls. Use this medication every day. The best thing is for the mother to learn this from the doctor-masseur and be able to do it herself, taking into account the peculiarities of the child's violations.
4. Grass wormwood must be poured a hundred grams of olive oil and insist for three days in a dark place. After this, you need to rub the muscles with an oil solution and gently massage.

Herbal treatment has many positive results, since herbs can affect muscles, nerve endings and, due to this, stimulate the work of the autonomic nervous system. If, after a cerebral edema, a child has a convulsive syndrome, then in addition to medication, it is very important to correct the work of the nervous system with the help of herbs.

1. Very good effect in the treatment of edema and its effects is tincture of herbs rue and a mordant. To do this, take 30 grams of herb rue and the same number of seeds, pour the boiled water and insist. It is necessary to give the child two drops three times a day. If your mother is breastfeeding, you can take such an infusion to your mother.
2. If, after swelling in the baby, there are disturbances in coordination of movements, then the periwinkle flowers are excellent in this. To make a tincture on a glass of hot water, take 50 grams of dry leaves. After insisting, you need to dilute this glass of water twice and give the child to drink a teaspoon at night.
3. Grapefruit herb can be used for convulsive syndrome. To do this, you need to prepare an aqueous solution of 20 grams of grass and 300 grams of water. You need to give three drops three times a day.

Homeopathy in the treatment of brain edema can also be used for a long time in the recovery period.

1. Cannabis indica is a means of homeopathic origin, which is used to improve nerve conduction with increased spastic muscle activity. Produced in the form of a mono drug in granules. Dosage of the drug for a child at the beginning of therapy - two pellets three times, and in more severe cases, the dose is doubled. There may be side effects in the form of pale skin and mucous baby, as well as involuntary twitching of the muscles that quickly passes.
2. Tarrantula sp. 30 is a remedy that improves muscle trophy and the state of brain eeyronons, improving the cognitive abilities of the baby. It is produced in granules and in such a dilution it is necessary to take one granule three times a day. Side effects can be in the form of abdominal cramps. Precautions - do not use for allergies to honey.
3. Sokale kornutum - used to correct the syndrome of hyperexcitability with pronounced vegetative disorders. The drug is used in granules - two granules four times a day. Side effects can be in the form of drowsiness or loss of appetite, then the dose should be reduced.
4. Nervochel is a combination drug that can be used in a convulsive syndrome. It includes potassium bromide, ignition, valerian, zinc. These drugs reduce increased excitability and convulsive alertness. For use by children from 1 year, you can use half the tablets three times a day, after three years you can use a whole tablet. The course of treatment is from two weeks to a month. Side effects can be in the form of allergic manifestations.

Alternative methods of treatment can be used only on the recommendation of a doctor and should not exclude the main drug therapy.

Surgical treatment of edema can be carried out with ineffectiveness of medications and in certain conditions. If the swelling is caused by a tumor, then during the neurosurgical treatment of this tumor, local edema is corrected. Sometimes there is a need to reduce intracranial pressure, then they can dissect the meninges through the fontanelles and perform decompression.

[19], [20], [21]

Prevention

Prevention of cerebral edema is nonspecific, and it consists in the strict adherence to all recommendations for healthy pregnancy and childbirth. It is very important to exclude factors that could lead to trauma to the child or an infectious disease after the birth. Proper care and prevention of injuries play a key role.

[22], [23], [24], [25]

Forecast

The prognosis of brain edema in newborns for recovery is not very favorable, as the process progresses rapidly. Often it is not possible to stop edema and a lethal forecast. But local swelling has a lighter flow. If the child has suffered cerebral edema, then there may be a violation of motor activity, cognitive functions and other disorders.

Edema of the brain in a newborn is an infrequent pathology, but given the high mortality and complications, it is important to know about it as much as possible. The cause may be a trauma or an infectious agent, which affects the clinic. Any violations on the part of the child associated with the central nervous system, should be regarded as a possible edema and immediately move to urgent measures.

[26], [27], [28]