Brain Injuries at Birth
Cerebral Palsy and Perinatal Asphyxia
This is a short lens about the types of serious problems that can arise at birth covering Cerebral Palsy, Perinatal Asphyxia and how to spot the early signs and symptoms of other complications that can affect your baby.
Spotting the signs of a brain injury at birth - Quick reactions and prompt treatment are essential
When a baby is born there is almost always a certain amount of anxiety about the health and well-being of mother and child, so, when the labour is over and mum and dad have their brand-new baby in their arms, the relief is immense.
However, for some parents, those nagging feelings that something is wrong just won't go away no matter how many times a paediatrician, midwife or health visitor tells you that those little issues will sort themselves out. The prognosis for any child who has suffered a brain injury at birth can depend on how quickly they receive an accurate diagnosis and appropriate treatment so it is extremely worthwhile being vigilant, but, of course, no one wants to worry unnecessarily.
Sadly, in many cases, when a child suffers perinatal brain damage the results will be irreversible, but the sooner a correct diagnosis is made, the sooner parents can move forward and take the most appropriate course of action for themselves and their child – this may involve seeking a brain injury solicitor to help them make a claim for medical negligence compensation to help them cope with the financial aspect of caring for a child with disabilities and developmental problems.
When a child is born, parents are often prepared for many difficult situations, such as their baby having a touch of jaundice, or crying a lot. They will be warned that some babies have difficulty feeding and that some babies are just "small" babies who aren't going to gain weight quickly. Parents may be told not to worry, to just persevere with feeding and that a baby won't cry through the night forever. However for some infants, and their parents, these are the first signs that the child has suffered a brain injury and all such symptoms should be well monitored.
Even a baby with a good apgar score – the test performed on newborns at one and five minutes after birth to determine how the birthing process was tolerated – can have suffered a brain injury and it can take many months, even years, for the full extent of any brain injury to become apparent.
So, what are the major signs of brain injury in a baby? If a birth has been difficult or traumatic, or a paediatrician feels that the baby is showing abnormal symptoms, he or she will order an MRI or CT scan to check for brain injury. However, these may not always be conclusive as a newborn baby's brain is still extremely small. In many instances the symptoms will only show up as the child grows and starts to develop.
Parents should look out for and monitor any of the following symptoms:
Jaundice – hyperbilirubinaemia brain damage occurs when there is too much bilirubin in the blood and causes the baby's skin, and whites of eyes, to appear yellow. Jaundice in newborns is fairly common – however, in rare cases it can cause brain damage (kernicterus).
Abnormal formation of the skull – there are a number of factors, both environmental and congenital, which may cause a baby's skull to not form properly, including damage sustained during the birthing process – regardless of the cause, the result can be increased intracranial pressure which may cause brain damage, such as hydrocephalus.
Sporadic movements – most babies appear to jerk and their movements are seemingly uncontrolled, however all babies should react naturally to certain stimuli and their reflexes can easily be checked. Sporadic movements will gradually disappear over the first three to six months after birth. If any abnormality of movement is picked up during early health checks these should be followed up by a doctor or paediatrician .
Eye divergence – many parents are concerned when their baby's eyes appear to cross, but, like other developmental issues in newborns, eyesight and focussing will be monitored closely and appropriate milestones noted. Strabismus, where both eyes do not point in the same direction, occurs in around 2-5% of all children and will not cause any further problems, however strabismus can be a symptom of brain injury such as cerebral palsy and hydrocephalus. If eyes have not straightened after four to six months the baby should be closely examined to rule out any underlying brain damage or presence of a tumour.
Excessive crying – most babies will cry from time to time and many parents will feel their child is crying too much, especially if they themselves are tired and feeling stressful. However, most instances of a baby crying are benign and attributable to causes, such as hunger, wetness, tiredness or having wind. Some babies naturally cry more than others and there are a number of ways to sooth a fussing baby, while parents should try (although this is not always easy) to stay calm. If a baby continues to cry excessively, underlying causes such as brain injury, infection, or intussusception (intestinal complications) should be investigated.
Sleep difficulties – newborn babies will take some time to sleep through the night and many newborn infants will require parents to rock them to sleep or swaddle them closely to help them fall into a deep sleep during the early months. However, if, after six or seven months a baby is not sleeping regularly for periods of more than a few hours or has difficulty sleeping horizontally this may signify a neurological birth injury.
Eating difficulties – many instances of brain injury at birth cause babies to suffer dysphagia, difficulty in swallowing, so, if a baby continues to refuse food or cannot swallow correctly after the first few months, a doctor should investigate.
Seizures and breathing difficulties – occasionally the causes of infant seizure and breathing difficulties are temporary and harmless, and will dissipate as the baby develops. However, prolonged and frequent episodes of convulsion, irritability, limb twitching and apnoea may be a sign of underlying brain injury and should be fully investigated.
Developmental delays – age-specific milestones such as sitting up, drinking from a cup and manipulation of small objects are a measure of a baby's full health and well-being, and it is sometimes the non-fulfilment of such developmental tasks which may be an indicator that a child is suffering from a neurological brain injury.
Of course, almost every parent worries at some time or other that their child is unwell, or perhaps not doing as well as other children, but for many these fears and anxieties will be unfounded. If a child has undergone a difficult or traumatic birth, the above are symptoms which may become apparent during early years development and should be monitored or investigated closely.
Cerebral palsy - Cerebral Palsy can be caused before, during or after birth
One of the major causes of cerebral palsy (CP) is brain injury at birth, however, CP can also be caused by any brain malformation which happens while the brain is still developing. Cerebral palsy usually severely affects mobility because muscle control is compromised, as is muscle co-ordination and muscle tone development. Reflex, posture, and balance are also likely to be affected in sufferers as well.
Many high-profile cases of medical negligence have been reported over the years regarding children and young adults who were injured at birth, and their cerebral palsy brain injury claims have made headlines largely due to the high-value settlements these cases are awarded. However, each case of CP is unique and there are a number of other reasons why a child may be born with, or develop, cerebral palsy.
Disturbance of brain cell migration during gestational development - A number of genetic and circumstantial factors can inhibit correct cell movement within the brain so that cells do not reach the right location.
Lack of myelination (insulation) on developing nerve cell fibres - Where there is a lack of myelin protection on nerve cells in the brain which aid transmission, brain function can be impaired.
Perinatal brain damage - circumstances during labour and birth which cause cell destruction, such as oxygen starvation and rupture blood vessels.
Postnatal complications - faulty synapse connections in the brain; plus trauma, infections and asphyxia, all of which can cause brain damage.
For many parents, knowing the cause of brain damage which has led to a diagnosis of cerebral palsy is an important step in their onward journey. Understanding the reasons why it has happened, can, in some cases, be extremely useful, especially if medical negligence at birth played a part in the child's suffering of brain damage. However, it is not always straightforward to determine a cause and this can be emotionally very difficult for parents.
These are some of the terms used to describe the type of brain damage which results in babies being diagnosed as suffering from cerebral palsy.
Periventricular Leukomalacia (PVL) - damage to white matter (periventricular) of the brain which then leaves voids. These spaces then become filled with fluid (leukomalacia) and this damage can result in spasticity and intellectual impairment. The underlying cause of PVL is believed by experts to be intrauterine infections, where toxins attack the membrane surrounding the foetus and pass into the amniotic fluid. These toxins may also cause early breaking of waters and premature birth.
Cerebral dysgenesis (abnormal brain development) - Cerebral palsy caused by abnormal brain development differs from others in that it did not take any form of brain injury to the developing foetus to arrest normal brain development and may have been a result of:
Incomplete brain division
Abnormal brain cell growth
Incomplete brain development
However, these factors can sometimes be attributable to a damaging event which happened to the mother, such as fever, trauma or drug misuse. A baby's brain begins developing almost immediately post-fertilisation of the ovum and brain malformation can occur at any time, but the brain is particularly susceptible to damage in the first 20 weeks of gestation. Cerebral dysgenesis can also occur as a result of genetic mutation.
Brain haemorrhage (intracranial haemorrhage) - bleeding inside the brain which kills or damages areas of the brain used in motor function and crucial to brain development. The types and levels of impairment caused by a brain haemorrhage in an infant will greatly depend on where the bleed occurs and how much damage is wrought.
Intraventricular haemorrhage (IVH) is a common factor in cerebral palsy and is most commonly seen in premature babies born before 30 weeks of gestation. IVH occurs when blood enters the fluid-filled areas (ventricles) of the brain. Smaller babies are at significantly greater risk of suffering IVH as their blood vessels in the brain are fragile and not fully developed. IVH is unlikely to be present at birth and usually occurs within a few days of delivery.
There are four grades of IVH - Grades 1 and 2 are where the bleed is small and the resulting damage is unlikely to cause long-term problems for the child.
Grades 3 and 4 are where the bleeding has been more serious and has pressed onto or damaged the delicate brain tissues. If blood clots form they may block the passage of cerebrospinal fluid, which leads to a build up of fluid on the brain (hydrocephalus).
Epidural haematoma (localised collection of blood, usually clotted, in a tissue or organ) and subdural haematoma occur in head injuries and trauma - both can occur as result of birth accidents and are implicated in instances of cerebral palsy.
Subarachnoid haematoma is probably the most common type of brain haemorrhage which follows birth trauma. It occurs, usually, as a result of damage to the veins which cause bleeding between the two membranes which surround the brain.
Hypoxic-Ischemic Encephalopathy (HIE) or Intrapartum Asphyxia - lack of oxygen to the brain caused, in certain instances, as a result of medical negligence during labour and birth. If the unborn baby is oxygen depleted for too long it will suffer brain damage as the delicate brain tissue is easily destroyed.
Hypoxic-ischemic encephalopathy due to perinatal asphyxia is a major cause of cerebral palsy in infants and, in many cases, the full extent of impairment will not be known until the child reaches three to four years of age. This type of brain injury is most common in full term babies and can occur during a mismanaged labour.
There are three levels of HIE: mild, moderate and severe. When a diagnosis is made medical professionals must be careful to rule out a number of neurodegenerative and metabolic conditions which can mimic similar symptoms to cerebral palsy.
Whichever way cerebral palsy occurs it is important for parents, and their children, to get the best, most appropriate advice and care. When the condition has been caused by avoidable negligence it may be necessary, and financially essential, to seek the help of a solicitor with a proven track record in birth injury claims. The law in this instance is complex and cases can take many years to be finalised, so it is a really good idea, once parents and family members have come to terms with their circumstances, to seek out the best brain injury solicitor possible and they will be able to help family members fund the best treatments and therapeutic care for their child.
How traumatic brain injury at birth can affect a family's life - The emotional consequences
Brain injury at birth has profound and lasting consequences, not only on the affected child but also on his or her family and, later, on schools and communities. With this in mind, it is necessary to consider some of the issues which will affect these groups. This article will begin with a look at the emotional and psychological impact felt by the family.
Firstly, once they have been through the initial shock parents are inevitably going to experience a range of complex, conflicting, and traumatic emotions.
Among these is the "what if" question. "What if," wonder most parents, "I had done things differently? What if I had not drunk that glass of wine? What if I had paid for an independent midwife? What if I had chosen the maternity unit at the other hospital, the one I was recommended?"
The list of "what ifs" can go on and on and can extend to the even the most seemingly insignificant of minutiae. Guilt is almost inevitable in situations where a child suffers brain injury at birth, although the reality is that in most instances, excepting perhaps cases of serious drug or alcohol abuse or injury caused by parental violence during pregnancy, parents have nothing to feel guilty about.
Despite this, it is the psychological condition of parenthood that parents will continue to interrogate themselves and their actions before and during pregnancy, wondering if there was somehow more they could have done to protect the child.
However futile and self-flagellatory such interrogation might seem, it is something that needs to be worked through, usually with a trained counsellor, therapist, or mental health professional.
Furthermore, in cases where medical or other third party negligence is behind the injury, the question of guilt can sometimes only be resolved by a claim for compensation and the receipt of a formal apology, whether from an NHS trust or another liable party.
Sadly, brain injury at birth can cause rifts between parents, occasionally permanently. In many cases this may be unjustified and be only a non-rational reaction to a very difficult and traumatic situation. In others, such as where it has been caused by reckless driving leading to a car accident or drug use leading to birth defect, it may be justified and hard, if not impossible, to ever properly gain closure on.
Anger can be debilitating in cases of hospital negligence, too. Although it is easy to understand why parents might be angry and unforgiving at the mistakes of maternity and obstetric professionals, it does not make such emotions any less unpleasant and damaging to hold. In extremis, this emotional baggage can become crippling and contaminate parents' dealings with all kinds of medical staff and authorities.
Post traumatic stress disorder (PTSD) is also very common in families who have experienced the trauma of having a child born with a brain injury. When what is meant to be a time of joy becomes one of sudden and unexpected trauma, it can be hard to find any kind of psychic equilibrium and the consequences can be profound.
This in turn may lead to depression, anxiety, and other psychological symptoms. Even in cases where PTSD is not symptomatic, these symptoms may develop, whether in the immediate aftermath of the brain injury's diagnosis or much later.
Of course, there is also the practical fallout of brain injury at birth. This is a huge and important topic which deserves to be addressed in another article. However, that said, it is important not to forget how factors such as a parent having to give up or cut down on work can impact a family both financially and emotionally – becoming a carer is a monumental life event and can transform a person's identity, lifestyle, and feelings of self-worth.
Another topic worthy of a separate discussion is the way having a brain injured brother or sister can affect siblings. They may feel the loss of the opportunity to have a "normal" sibling and grieve for this while simultaneously resenting or being hurt by the loss of attention they feel due to having a sibling who requires so much though, emotional investment, and specialist attention.
These and other factors can lead to all kinds of anger and anxiety, even where children appear to be adapting well. As such, it may be necessary for siblings to receive counselling and therapy in order safeguard their welfare.
Of course, every family is different and these are just a small sample of the types of issues which might affect families who experience the trauma of brain injury at birth.
For more information talk to your GP, local counselling service, or a support services such as Headway of the Child Brain Injury Trust.
Brain injury at birth | Cooling and perinatal asphyxia
Cooling and xenon gas, the future of brain injury treatment
Perinatal asphyxia (oxygen deprivation at birth) is a traumatic situation for everyone involved and can have profound lifetime consequences.
Until recent decades, aside from expediting delivery, whether by Caesarean Section or other means, there was little doctors could do to reduce the risk of brain injury following perinatal asphyxia.
Since then the use of assisted ventilation has become common practice, but despite this, there was little in the way of intervention that could make a material difference in long-term outcome.
However, recent years have seen the introduction of a landmark cooling treatment in 2009 and, as such, there has been increased hope for parents whose children suffer perinatal asphyxia.
Cooling treatment does just what it says on the tin - it cools babies' body temperatures by around four degrees centigrade for around 72 hours (three days) while all the time keeping careful observation of the baby, both visually and instrumentally.
Although the treatment is new, for about two decades it has been postulated that cooling might be an effective method of reducing brain damage following asphyxia.
It took scientists from Imperial College London and other institutions to really test the theory when, as part of a Medical Research Council funded Toby (Total Body Hypothermia for Neonatal Encephalopathy) project, they carried out a study of more than 300 babies across more than 33 hospitals in the United Kingdom, Ireland, Finland, Sweden, Hungary and Israel.
Published in the New England Journal of Medicine, the TOBY study detailed how bringing infants' temperatures down in a controlled way makes them 57 percent more likely to survive without suffering any form of brain injury.
"The study builds on a 20-year body of research but gives, for the first time, irrefutable proof that cooling can be effective in reducing brain damage after birth asphyxia," one of the researchers told the journal.1 (Medical Research Council online 01-10-09)
"Although unfortunately it doesn't work in every case, our study showed the proportion of babies that survived without signs of brain damage went from 28% to 44% with cooling treatments - that's a 57% increase." (ibid)
The study has also been assessed by the National Institute for Health and Clinical Excellence (NICE). NICE actually considered the evidence of cooling from a total of eight studies and, after consulting specialist clinical advisers, concluded that cooling should be adopted as a routine treatment for babies at risk of brain injury as a result of perinatal asphyxia.
The process of cooling is actually relatively easy to describe. Babies are placed on special fluid-filled cooling mattresses which help regulate temperature. They have a small probe inserted into the rectum in order to accurately measure core temperature.
Temperature is then stabilized at around 33.5C for around 72 hours before temperature is gradually returned to normal. Although not all babies benefit from this process, the benefits are significant enough for the treatment to have received NICE recommendation.
Of course, just as with most sensitive medical procedures, there is the risk of some side effects. Although the treatment is still relatively new, meaning the full side effects may not yet be known, it is thought that it may lead to some clotting, blood pressure and heart irregularities. The possibility of blood and blood-sugar imbalances has also been reported.
The reason the cooling method is so effective is that although oxygen deprivation is the trigger for brain injury, it merely precipitates the process – the actual injury does not occur immediately.
"We had always thought that there is not much you can do after brain damage, but a recent study showed that brain cells took 24 to 48 hours to die so there is a window during which brain damage can be stopped," Dr Topun Austin, a neonatologist at Addenbrooke's Hospital in Cambridge, told the BBC.2 (BBC, 03-03-11)
And, although the treatment is far from perfect, it so far represents the best chance for children who are at risk of perinatal asphyxia-related brain injury.
The treatment has by no means reached the peak of its evolution either. In 2010 doctors at a hospital in Bristol administered cooling in conjunction with xenon gas.
According to Marianne Thoreson, professor of neonatal neuroscience at the University of Bristol, xenon gas increases the efficacy of cooling by 100 percent.
"Over the past eight years, we have shown in the laboratory that xenon doubles the protective effect of cooling on the brain," 3 (BBC, 09-04-10) Professor Thoreson told the BBC.
"However, we faced the challenge of how to safely and effectively deliver this rare and extremely expensive gas to newborn babies," (ibid) she said.
Xenon gas is most familiar to us for its use in street lamps, in IMAX cinemas and as an ion thruster for space travel exploration. However, it is its properties as a neuroprotective agent, as evidenced by Professor Thoreson's work, which make it such an exciting prospect and, potentially, a real brain injury saver.
Perinatal asphyxia brain injury
Issues involved in an at-birth brain injury
Oxygen starvation at birth is the major cause of brain injury in newborn babies and every year leads to unimaginable hurt and distress for around 1,400 families in Britain, with some incidents proving fatal. In fact, every one in 500 newborn babies dies or suffers serious injury as a result of oxygen deprivation at birth, while the World Health Organisation ranks oxygen deprivation as the fifth biggest cause of death in children under the age of five.
However, in cases of both death and injury, this is not hurt and distress which passes. For those, who lose a child, the tragedy will remain with them until they die, while where children survive the practical reality of caring for a brain injured child throughout its childhood, adolescence and adult life will have profound emotional and financial consequences.
Even a small amount of oxygen deprivation at birth may cause developmental problems and impact upon a child's IQ, cognitive function and eventual intellect. Birth may be the most exciting life event of all, but it is also the most crucial, and it is during this time that the human brain is placed in considerable peril.
"If a baby develops birth asphyxia during childbirth, then his or her life is in immediate danger," Dr Daqing Ma from Imperial College London told Action Medical Research.1 (Action Medical Research online10-05-12)
"Sadly, many babies are stillborn or die soon after birth. Babies who survive can develop life-long disabilities, such as cerebral palsy, learning disabilities, deafness and epilepsy, which can severely affect quality of life for these babies and their families." (ibid)
The technical term for oxygen deprivation at birth is perinatal asphyxia. Until recently there has been little in the way of treatment or intervention to try to prevent or reduce the possibility of brain injury caused by perinatal asphyxia, and parents of children who have the condition have typically had to adopt a "wait and see" approach in order to determine the extent of injury.
This is because although medical examinations may be able to yield some basic information about a child's health, it is not until a child is older and its progress can be plotted against the median scale of development, and its developmental landmarks observed, that the full extent of damage can be assessed. In many cases it may not be until the child has reached adulthood that an accurate assessment can be carried out.
Because of these factors, in cases where the oxygen deprivation has been caused by negligence, it can be very difficult for those affected to claim suitable sums of compensation until such point as personal injury lawyers and medical experts can accurately assess the extent of damage.
Of course, quantifying the nature of damage can be a very complex business. Those concerned with this question must ask themselves just what kind of loss of enjoyment and loss of opportunity has been caused by the injury.
One case that was notable for the clarity with which it answered this question was the March, 2012 compensation win of a young man from Leicestershire. Although his was not a birth-related claim, he had suffered a brain injury in 1998 car accident when he was eight, because he has a non-injured identical twin brother, personal injury lawyers had been able to use his brother's progress as an exact benchmark of the claimant's likely progress had he not suffered the accident.
Only once judges had been able to assess the differences in the two boys, including their relative career prospects, capacity for self-care, ability to live independently and specialist treatment, home and equipment requirements, was a suitable compensation settlement able to be determined – in the end, more than £2.5 million.
In fact, there have been a number of birth injury cases involving identical twins where only one has sustained a brain injury at birth. It is simply that these cases are difficult to report on because of their sensitive nature and so, are often settled out of court for undisclosed sums.
Even bringing a claim can be a risky business – no matter how justified the circumstances. For example in 1999 two parents from South West London were told that they could not receive compensation for the catastrophic brain injury sustained by their daughter during a bungled forceps deliver.
The parents believed that they had been the victims of a compensation lottery. "Why did we have to go through all this?" the girl's father asked The Independent.2 (Independent 15-12-99)
"Why is everything still such a battle to get anything done? The law is a lottery. The dice are loaded against the parents. It would be far, far better if the money spent on the case had been put into a compensation fund for children... Why can't we have a situation where health authorities can admit something went wrong, without conceding negligence, and pay compensation?" (ibid)
Indeed, at the time of the claim, the newspaper carried a story contrasting the experience of the above family with another whose 11-year legal battle ended with a record sum of birth brain injury compensation. The paper called the disparity in the two families' experiences a "gross inequality" and pointed out the family which won its case managed to do so only because it instructed a firm or "specialist medical negligence lawyers" – that, it said, was the only difference.
However, it is hoped that with the evolution of science and medical treatment there will be a reduction in the need for this type of claim – although there is a will and a drive to reduce the incidence of clinical negligence, it would be quixotic to believe that we are anyway near to eradicating human error by hospital staff.
Until relatively recently the only way to try to prevent injury has been to speed the process of delivery, whether by emergency Caesarean Section or other means, and then to provide the baby with the means of assisted breathing.
Fortunately though, the situation has changed recently with the advent of cooling and xenon gas treatments, both of which are discussed in another article in this section.
1 Action Medical Research online, accessed on 17-08-12
2 The Independent online, accessed on 17-08-12
More information about brain injury at birth - Useful websites
Click on the links below if you would like more information about brain injuries caused at birth
- Help for Brain Injury Sufferers in Scotland
The team of specialist brain injury solicitors at Thompsons can help you make a claim for damages if the incident which led to the head injury was caused by someone else's negligence.
Headway work to improve life after a head injury
An article about how a new type of 'gas and air' might relieve mothers' labour pains and save babies lives.
- Healys Brain Injury Compensation
A law firm which offers a nationwide legal service for those who have suffered a brain injury after an accident on the roads or at work
- The Medical Research Council
An article about how cooling treatments can reduce brain damage caused by birth asphyxia.
- The Independant
The Independent's article about the inequality iof the medical negligence system.