- Email: [email protected]
Neonatal Stroke
In Practice
A Primer for Nurses on Perinatal/Neonatal Stroke were good, 9 and 9, and she and Katie did well in the early postpartum period. From my standpoint, everything that had happened during labor was pretty routine with expected outcomes. It was too bad that Katie had a cesarean, but then, more than 30 percent of births are via cesarean (Martin, Hamilton, Osterman, Curtin, & Matthews, 2013), so it wasn’t too surprising. Because mom and baby were doing so well, I encouraged them to leave the hospital for the comforts of home with the offer of private duty baby nurse for the first night (me) even though
Abstract Perinatal or neonatal stroke is not uncommon, but diagnosis is often missed. Perinatal nurses are often the first health professionals in the position to observe the most typical symptom of stroke in a newborn, which is focal seizure. Etiology, symptoms and outcomes are reviewed and discussed through the context of the author’s personal story. DOI: 10.1111/1751-486X.12221 Keywords neonatal stroke | neurodevelopmental outcomes | newborn | perinatal stroke
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© 2015, AWHONN
http://nwh.awhonn.org
Photo © iStock Collection / thinkstockphotos.com
O
On her fourth day of life, my granddaughter, Charlotte, had a stroke. It was unexpected. As a perinatal nurse, I knew of nothing out of the ordinary that would have contributed to this condition. My daughter-in-law, Katie, a pediatric nurse, was a primigravida who had been induced for post dates and low amniotic fluid. In the last weeks of pregnancy, she had mild hypertension, but her condition was not considered pre-eclamptic. A decision to proceed with a primary cesarean surgical birth was made after a prolonged second stage with a non-reassuring fetal heart tracing. Charlotte’s APGAR scores
JILL S. BECKER
What Is Stroke in the Newborn? A neonatal or perinatal stroke is defined by Rutherford, Ramenghi, and Cowan (2011) as “an area of damaged cerebral tissue resulting either disruption to blood flow in a major cerebral artery from thrombosis or embolism or from thrombosis in a major cerebral vein which occurs between 20 weeks of fetal life to the 28th
August | September 2015
postnatal day …” (p. F377). The terms neonatal stroke and perinatal stroke are used interchangeably. Stroke occurs most frequently in term or late-term infants. Estimates of the prevalence of perinatal stroke vary and are derived from retrospective studies. van der Aa, Benders, Groenendaal, and de Vries (2014) have provided the most recent statistics, stating that a perinatal arterial ischemic stroke (PAIS) is more common. It occurs in between 1 in 1,600 and 1 in 5,000 births. Cerebral sinus venous thrombosis (CVST) is rarer, with an incidence of approximately 12 in 100,000 live births. Both types of stroke can result in long-term neurologic sequelae. Motor, cognitive and learning deficiencies can occur. Stroke in infants is more common than brain tumors, and by some estimates, as frequent as strokes in the elderly (Nelson & Lynch, 2004).
In Practice
they were entitled to one last night in the hospital. Everyone agreed, so I arrived at their home ready to manage feedings through the night. Charlotte was latching onto the breast well, but seemed hungry after feeding; Katie’s milk wasn’t yet in. Of note, Katie had previously had a surgical breast reduction; a lactation consultant had suggested a breast pump, which was producing just drops of colostrum. I suggested a bit of formula supplementation, which Katie agreed to. At 10 p.m., Charlotte took 1oz of formula and then slept for about 2 hours. When she woke up, I prepared another bottle. At this feeding, Charlotte seemed to demonstrate a disorganized suck but did take about 20 mL of formula. After the feeding, I held her and observed a rhythmic twitching of her right arm, which persisted for 3 to 5 minutes and then stopped. She fell asleep. I considered what I had observed. It wasn’t the jitteriness we associate with hypoglycemia; she seemed fine now; was I being an overly anxious nurse/grandmother? When Charlotte awoke later that night, the twitching of her right arm started anew. I woke up Katie and we both watched the baby for several minutes. Uncertain about what we had observed, we convinced ourselves that we were being hyperobservant because of our nursing backgrounds. Katie went back to bed and I rocked Charlotte. I felt her entire body start to jerk. I got Katie, we called the pediatrician’s emergency number and after discussing our observations with the on-call pediatrician, my son and daughter-in-law took Charlotte to the emergency department at the large teaching hospital where Katie worked. Charlotte had seizure activity on admission and was quickly diagnosed as having experienced a cerebral venous sinus thrombosis, a type of neonatal stroke, with seven separate clots by magnetic resonance imaging (MRI). She was admitted to the pediatric intensive care unit, where she spent the next 10 days.
Stroke occurs most frequently in term or late-term infants Stroke in the newborn is different from birth asphyxia. Zanelli, Stanley, and Kaufman (2014) state that perinatal asphyxia as the cause of hypoxic-ischemic encephalopathy (HIE). HIE is a result of hypoxemia during pregnancy, labor or birth, leading to diffuse neurologic injury in many infants. Rather than specific insult in one area of the brain, damage occurs due to acidemia and cerebral edema. Seizures are also the most frequent symptom observed, but unlike the recurrent focal seizures seen in neonatal stroke, these seizures are usually myoclonic or multifocal. Timing of the seizures is also different—often starting soon after birth or within 6 to 12 hours after birth and are followed by stupor, coma, absent neonatal reflexes (sucking, Moro) and irregularities of breathing, heart rate and blood pressure. In terms of outcome, infants experiencing HIE have a higher rate of mortality (25 percent to 50 percent) and morbidity (up to 80 percent of infants with HIE develop serious complications). These children experience longterm functional impairments, such as cerebral palsy and intellectual disability. Identifying the timing and type of seizure occurring in a neonate is among the greatest challenges of diagnosing infants with neurologic damage. Events of apnea and bradycardia
Jill S. Becker, DNP, RN, CNE, is curriculum coordinator and professor of nursing at Northern Essex Community College, in Lawrence, MA. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
Nursing for Women’s Health
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In Practice seizure occurring in a neonate is among the greatest challenges of diagnosing infants with neurologic damage can represent seizure activity in newborns and remain undiagnosed. Seizures might not be observed until close to discharge or at home. In 50 percent of newborns who experience stroke, the seizures begin after 24 hours of age, and in 25 percent more, within the first week of life, making the onset of seizures a very important aspect of diagnosis. Additional signs can include apnea, lethargy and feeding difficulties. Diagnosis is made by MRI. A diagnosis of presumed perinatal stroke may be made in an older infant who presents with focal hand weakness, premature development of handedness, hemiplegia and delayed milestones or seizure. Hemiplegia may not be diagnosed until age 2 (Lynch, 2009).
Treatment Treatment of newborns with neonatal stroke focuses on neuroprotection. Extension of the brain damage from the original insult can result in long-term seizures, and, in the case of deep vein and dural sinus thrombosis, extension of
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the clot. Intravenous (IV) fluids are used to prevent dehydration, which may help to improve blood flow to the affected area of the brain. Monitoring and maintenance of normal blood pressure, sodium, temperature and glucose as well as early antibiotic treatment in case of infection have improved outcomes in babies with perinatal stroke (Musolino, P., personal communication, November 24, 2014). To identify seizure activity, continuous EEG monitoring may be used and antiseizure medications, such as Phenobarbital, are administered. The use of thrombolytics is contraindicated given the high risk of bleeding (Musolino, P., personal communication, November 24, 2014) and careful use of anticoagulants, such as low molecular weight heparin, is sometimes considered for specific types of stroke (Roach et al., 2008).
Risk Factors Because symptoms of neonatal stroke are generally not observed at birth but may show up at 48 hours of age or even later, nurses and other clinicians need to know which infants may be at risk. Maternal conditions nurses observe in the antepartum and intrapartum periods may be contributors to both PAIS and cerebral sinovenous thrombosis (CSVT). Alert nurses can help to get infants into treatment more rapidly when
Volume 19
Issue 4
Photos © Photodisc / thinkstockphotos.com
Identifying the timing and type of
August | September 2015
At this time, there does not seem to be a clear link between a particular prothrombotic factor, but Factor V Leiden is one that is mentioned frequently in studies (Mecuri et al., 2001). Dehydration may also be a factor, accentuating the thickness of the neonate’s blood and increasing the potential for clots. Sepsis is recognized as a risk factor, but recent studies imply that even a minor infection may increase risk. Another factor identified in neonates is congenital cardiac anomalies, such as a patent foramen ovale. It’s clear that multiple risk factors may be at play.
In Practice
symptoms are observed, hopefully preventing long-term disability, such as cerebral palsy. Retrospective studies of infants with arterial and venous strokes have identified the following independent maternal risk factors: a history of infertility, primiparity in term infants, pre-eclampsia, history of coagulation disorders (e.g., thrombophilia, deep vein thrombosis, myocardial infarction, miscarriages), gestational diabetes and maternal cocaine abuse (Roach et al., 2008; van de Aa et al., 2014). The studies to determine how these factors come together to create the potential for neonatal stroke have been small in size and limited in number. These studies have looked at how the hypercoagulable state of pregnancy may predispose women with antepartum and intrapartum risk factors to develop thrombi in the placental veins that then enter the fetal arterial circulation via the foramen ovale and ductus arteriosus (Curry et al., 2007). Studies that examine placental pathology may provide answers to this question, but because symptoms don’t occur until day 2 or 3, often the placenta has been disposed of and is not available for study. Elbers, Viero, MacGregor, deVeber, and Moore (2011) analyzed placental pathology in a cohort of neonates who were diagnosed with arterial and venous stroke and found that 83 percent of the placentas had some sort of lesion, hypothesizing that emboli may be sent into fetal circulation or caused an “inflammatory, procoagulant environment in the placenta and fetus promoting diffuse thrombus formation” (p. e726). The good news is that descriptive studies have found that recurrence rates in later pregnancies are low. In the intrapartum period, chorioamnionitis and prolonged rupture of membranes have been linked to perinatal stroke. There may be evidence of fetal distress during labor, such as a non-reassuring fetal heart rate or meconiumstained fluid. Many of the stricken neonates were products of complicated births; Cheong and Cowan (2009) report that more than onethird of infants were born by instrument or via cesarean, with some studies reporting up to a 60 percent rate of cesarean birth (Musolino, P., personal communication, November 24, 2014). Recent research has identified possible neonatal risk factors for stroke. Rutherford et al. (2011) cited prothrombotic factors as a finding in more than 50 percent of neonates with PAIS.
Outcomes It’s thought that the neonatal brain has “plasticity,” suggesting that in the young brain, different neural pathways can develop. In the American Heart Association Scientific Statement by Roach et al. (2008), outcomes of stroke survivors are discussed (p. 2647). At least 50 percent of perinatal stroke survivors experience long-term neurologic impairment, such as hemiparesis, language and learning difficulties. Some children go on to develop epilepsy. Early hand preference
At least 50 percent of perinatal stroke survivors experience long-term neurologic impairment, such as hemiparesis, language and learning difficulties and sensory impairment, such as visual field cuts, have been reported. Researchers are now suggesting that stroke may be a leading cause of cerebral palsy, especially in those infants with delayed presentation and diagnosis (Golomb, 2009; Golomb, Garg, Saha, Azzouz, & Williams, 2008). Death is rare and is often ascribed to comorbidities, such as sepsis or congenital heart disease. More research is needed to determine which therapies will best help children who experience stroke as neonates. Chen, Lo, and Heathcock (2013) compared a small cohort of infants who had a neonatal stroke with a group of infants with typical development. They found that the infants with stroke had poorer fine and gross motor skills and midline grasping behaviors. The authors concluded that early identification may aid in rehabilitative efforts for these children. The majority of stroke victims who develop epilepsy are well-controlled on medication or
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our term neonates who had reassuring APGAR scores at birth. But we need to increase our surveillance of these at-risk infants with surgical procedures. Since other deficits may not be immediately identified, Golomb (2009) suggests that all perinatal stroke survivors will benefit from rehabilitation starting with early intervention services, such as physical and occupational therapy and continued assessment and therapies as the children grow.
What Can Nurses Do? After Charlotte’s birth, I asked my nursing peers about their knowledge of perinatal stroke. In this admittedly unscientific study, I found only one perinatal nurse who was aware of assessing for focal seizures of the type seen in stroke. Most nurses had never heard of a newborn having a stroke. This finding is consistent with research findings. I searched the CINAHL and Medline databases and found few articles on neonatal stroke, and none by nurses at the
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time. As an educator of undergraduate nursing students, I checked the maternal-child textbook we used and others that I had access to. There was limited content about stroke, and nothing about neonatal stroke. I did find that many major pediatric medical centers, including in our hometown, have stroke clinics and that they have parent-oriented websites, but few resources for professionals. I began to wonder what knowledge maternalchild nurses need to increase awareness of this problem, and to assess motherbaby couplets who may be at risk. We don’t ordinarily expect to see seizures in our term neonates who had reassuring APGAR scores at birth. But we need to increase our surveillance of these at-risk infants. Jordan and Hillis (2011) state that “despite efforts to raise awareness regarding stroke in children, this condition is often overlooked
Volume 19
Issue 4
Photos © Soren Jessenn / thinkstockphotos.com
We don’t ordinarily expect to see seizures in
as a cause of symptoms by health care providers and families.” Why? Because providers often don’t consider stroke in their differential diagnosis. One study found that the median in-hospital delay from presentation to diagnosis was 12.7 hours. The median prehospital delay was 1.7 hours (Rafay et al., 2009). The authors of this study suggest that early identification of seizures may enhance the survival and outcomes of these infants. When presented with a postpartum couplet in which the woman has a history of pre-eclampsia or gestational diabetes or with a newborn who has experienced a stressful birth, our focus as nurses has been on assessing the risk of maternal complications from pre-eclampsia and monitoring the newborn for signs and symptoms of hypoglycemia as we support the attachment process of mother and infant. Maternal-child nurses need to be aware that the symptoms of neonatal stroke are subtle and nonspecific. Nurses need to assess for signs and symptoms of sepsis, dehydration and anemia, taking into account maternal conditions that can increase risk, as well as intrapartum events. Identification of seizure activity is paramount. Behaviors that can indicate seizure in a newborn include repetitive sucking motions, bicycling, lip smacking, eyelid fluttering, sustained gaze deviation, periods of apnea desaturations and occasionally focal clonic seizures (Panayiotopoulos, 2005). Clear differentiation between jittery behaviors related to hypoglycemia, hypocalcemia and seizure needs to be made. Since dehydration is considered to be a risk factor for the development of both arterial and venous strokes in the newborn, maternal-child nurses should educate lactating women about sources for ongoing information available from organizations, such as La Leche League and Breast Feeding After Breast and Nipple Surgeries (BFAR; see Box 1). These may be valuable
Conclusion
Behaviors that can indicate seizure in a newborn include repetitive sucking motions, bicycling, lip smacking, eyelid fluttering, sustained gaze deviation, periods of apnea desaturations and occasionally focal clonic seizures Obstetric nurses need to be aware of potential risk factors for perinatal stroke. Early detection and treatment of infants with stroke will improve the outcomes for these children. I hope that sharing what I’ve learned will increase awareness among nurses of neonatal stroke, and result in healthier outcomes for the families that we all care for every day. NWH
Photos © Photodisc / thinkstockphotos.com
We were lucky. It remains to be seen if Charlotte will have residual effects from her stroke. We will never know exactly what caused it, as testing for the common risk factors, such as sepsis or coagulation disorders, were negative. The neurology team that has been following her and
her pediatrician tells us that if they didn’t know about her history and MRI, they wouldn’t believe that she had had a stroke. She has minimal signs of impairment–a very slightly diminished muscle tone on one side and early hand preference. At 24 months of age, she is meeting all developmental milestones and is a typical toddler, heading into her “terrible twos.” I can’t help but watch her and think, “What if…?” I’m thankful for the great care she got from the entire health care team, including pediatric intensive care nurses, attending physicians and residents, pharmacists and therapists.
In Practice
resources for parents to have after hospital discharge. As nurses caring for couplets, we routinely assess for signs of dehydration, but it bears reminding. Another aspect of the failure of a health care provider to consider neonatal stroke occurred that first night Charlotte was home when we contacted the on-call pediatrician after we identified her symptoms. We need to be certain that new parents feel comfortable contacting their pediatric provider with questions at any time, and to not feel intimidated during those conversations—even in the middle of the night. Our emergency phone consultation with the pediatrician on call left us feeling that we were too anxious and were “newbies,” even though we were experienced nurses. We were able to persist until we were certain that our concerns were heard. Imagine if we hadn’t had the ability—as many young parents don’t—to clearly state our concerns. We got Charlotte to the hospital and treatment started quickly, rather than waiting for that afternoon new baby visit.
August | September 2015
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In Practice
Box 1.
Selected Resources Breastfeeding After Breast and Nipple Surgeries
www.bfar.org La Leche League International
www.llli.org Children’s Hemiplegia and Stroke Association
www.chasa.org and www.pediatricstroke.org
Lynch, J. K. (2009). Epidemiology and classification of perinatal stroke. Seminars in Fetal & Neonatal Medicine, 14(5), 245–249. doi:10.1016/ j.siny.2009.07.001 Martin, J. A., Hamilton, B. E., Osterman, M. J. K., Curtin, S. C., & Matthews, T. J. (2013). Births: Final data for 2012. National Vital Statistics Reports, 62(9), 1–68. Mecuri, E., Cowan, F., Gupte, G., Manning, R., Laffan, M., Rutherford, M., … Roberts, I. (2001). Prothrombotic disorders and abnormal neurodevelopmental outcome in infants with neonatal cerebral infarction. Pediatrics, 107(6), 1400–1404. Nelson, K. B., & Lynch, J. K. (2004). Stroke in newborn infants. Lancet Neurology, 3(3), 150–158.
References Chen, C. Y., Lo, W. D., & Heathcock, J. C. (2013). Neonatal stroke causes poor midline motor behaviors and poor fine and gross motor skills during infancy. Research in Developmental Disabilities, 34(3), 1011–1017. doi:10.1016/ j.ridd.2012.11.028 Cheong, J. L., & Cowan, F. M. (2009). Neonatal arterial ischaemic stroke: Obstetric issues. Seminars in Fetal & Neonatal Medicine,14(5), 267–271. doi:10.1016/j.siny.2009.07.009 Curry, C. J., Bhullar, S., Holmes, J., Delozier, C. D., Roeder, E. R., &Hutchinson, H. T. (2007). Risk factors for perinatal arterial stroke: A study of 60 mother-child pairs. Pediatric Neurology, 37(2), 99–107. Elbers, J., Viero, S., MacGregor, D., DeVeber, G., & Moore, A. M. (2011). Placental pathology in neonatal stroke. Pediatrics, 127(3), e722–e729. doi:10.1542/peds.2010-1490 Golomb, M. R. (2009). Outcomes of perinatal arterial ischemic stroke and cerebral sinovenous thrombosis. Seminars in Fetal & Neonatal Medicine, 14(5), 318–322. doi:10.1016/ j.siny.2009.07.003
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Panayiotopoulos, C. P. (2005). Neonatal strokes and neonatal syndromes. In The epilepsies: Seizures, syndrome and management (pp. 87–116). Oxfordshire, U.K.: Bladon Medical Publishing. Rafay, M. F., Cortez, M. A., deVeber, G. A., Tan-Dy, C., Al-Futaisi, A., Yoon, W., … Moore, A. M. (2009). Predictive value of clinical and EEG features in the diagnosis of stroke and hypoxic ischemic encephalopathy in neonates with seizures. Stroke, 40(7), 2402–2407. doi:10.1161/ STROKEAHA.109.547281 Roach, E. S., Golomb, M. R., Adams, R., Biller, J., Daniels, S., deVeber, G., … Council on Cardiovascular Disease in the Young. (2008). Management of stroke in infants and children: A scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke, 39(9), 2644–2691. doi:10.1161/STROKEAHA.108.189696 Rutherford, M. A., Ramenghi, L. A., & Cowan, F. M. (2011). Neonatal stroke. Archives of Disease in Childhood: Fetal and Neonatal Edition, 97(5), F377–F384. doi:10.1136/ fetalneonatal-2010-196451
Golomb, M. R., Garg, B. P., Saha, C., Azzouz, F., & Williams, L. S. (2008). Cerebral palsy after perinatal arterial ischemic stroke. Journal of Child Neurology, 23(3), 279–286. doi:10.1177/0883073807309246
van der Aa, N. E., Benders, M. J., Groenendaal, F., & de Vries, L. S. (2014). Neonatal stroke: A review of the current evidence on epidemiology, pathogenesis, diagnostics and therapeutic options. Acta Paediatrica, 103(4), 356–354. doi:10.1111/apa.12555
Jordan, L. C., & Hillis, A. E. (2011). Challenges in the diagnosis and treatment of pediatric stroke. National Review of Neurology, 7(4), 199–208. doi:10.1038/nrneurol.2011.23
Zanelli, S. A., Stanley, D. P., & Kaufman, D. A. (2014). Hypoxic-ischemic encephalopathy. Retrieved from emedicine.medscape.com/ article/973501-overview
Nursing for Women’s Health
Volume 19
Issue 4
A Primer for Nurses on Perinatal/Neonatal Stroke were good, 9 and 9, and she and Katie did well in the early postpartum period. From my standpoint, everything that had happened during labor was pretty routine with expected outcomes. It was too bad that Katie had a cesarean, but then, more than 30 percent of births are via cesarean (Martin, Hamilton, Osterman, Curtin, & Matthews, 2013), so it wasn’t too surprising. Because mom and baby were doing so well, I encouraged them to leave the hospital for the comforts of home with the offer of private duty baby nurse for the first night (me) even though
Abstract Perinatal or neonatal stroke is not uncommon, but diagnosis is often missed. Perinatal nurses are often the first health professionals in the position to observe the most typical symptom of stroke in a newborn, which is focal seizure. Etiology, symptoms and outcomes are reviewed and discussed through the context of the author’s personal story. DOI: 10.1111/1751-486X.12221 Keywords neonatal stroke | neurodevelopmental outcomes | newborn | perinatal stroke
350
© 2015, AWHONN
http://nwh.awhonn.org
Photo © iStock Collection / thinkstockphotos.com
O
On her fourth day of life, my granddaughter, Charlotte, had a stroke. It was unexpected. As a perinatal nurse, I knew of nothing out of the ordinary that would have contributed to this condition. My daughter-in-law, Katie, a pediatric nurse, was a primigravida who had been induced for post dates and low amniotic fluid. In the last weeks of pregnancy, she had mild hypertension, but her condition was not considered pre-eclamptic. A decision to proceed with a primary cesarean surgical birth was made after a prolonged second stage with a non-reassuring fetal heart tracing. Charlotte’s APGAR scores
JILL S. BECKER
What Is Stroke in the Newborn? A neonatal or perinatal stroke is defined by Rutherford, Ramenghi, and Cowan (2011) as “an area of damaged cerebral tissue resulting either disruption to blood flow in a major cerebral artery from thrombosis or embolism or from thrombosis in a major cerebral vein which occurs between 20 weeks of fetal life to the 28th
August | September 2015
postnatal day …” (p. F377). The terms neonatal stroke and perinatal stroke are used interchangeably. Stroke occurs most frequently in term or late-term infants. Estimates of the prevalence of perinatal stroke vary and are derived from retrospective studies. van der Aa, Benders, Groenendaal, and de Vries (2014) have provided the most recent statistics, stating that a perinatal arterial ischemic stroke (PAIS) is more common. It occurs in between 1 in 1,600 and 1 in 5,000 births. Cerebral sinus venous thrombosis (CVST) is rarer, with an incidence of approximately 12 in 100,000 live births. Both types of stroke can result in long-term neurologic sequelae. Motor, cognitive and learning deficiencies can occur. Stroke in infants is more common than brain tumors, and by some estimates, as frequent as strokes in the elderly (Nelson & Lynch, 2004).
In Practice
they were entitled to one last night in the hospital. Everyone agreed, so I arrived at their home ready to manage feedings through the night. Charlotte was latching onto the breast well, but seemed hungry after feeding; Katie’s milk wasn’t yet in. Of note, Katie had previously had a surgical breast reduction; a lactation consultant had suggested a breast pump, which was producing just drops of colostrum. I suggested a bit of formula supplementation, which Katie agreed to. At 10 p.m., Charlotte took 1oz of formula and then slept for about 2 hours. When she woke up, I prepared another bottle. At this feeding, Charlotte seemed to demonstrate a disorganized suck but did take about 20 mL of formula. After the feeding, I held her and observed a rhythmic twitching of her right arm, which persisted for 3 to 5 minutes and then stopped. She fell asleep. I considered what I had observed. It wasn’t the jitteriness we associate with hypoglycemia; she seemed fine now; was I being an overly anxious nurse/grandmother? When Charlotte awoke later that night, the twitching of her right arm started anew. I woke up Katie and we both watched the baby for several minutes. Uncertain about what we had observed, we convinced ourselves that we were being hyperobservant because of our nursing backgrounds. Katie went back to bed and I rocked Charlotte. I felt her entire body start to jerk. I got Katie, we called the pediatrician’s emergency number and after discussing our observations with the on-call pediatrician, my son and daughter-in-law took Charlotte to the emergency department at the large teaching hospital where Katie worked. Charlotte had seizure activity on admission and was quickly diagnosed as having experienced a cerebral venous sinus thrombosis, a type of neonatal stroke, with seven separate clots by magnetic resonance imaging (MRI). She was admitted to the pediatric intensive care unit, where she spent the next 10 days.
Stroke occurs most frequently in term or late-term infants Stroke in the newborn is different from birth asphyxia. Zanelli, Stanley, and Kaufman (2014) state that perinatal asphyxia as the cause of hypoxic-ischemic encephalopathy (HIE). HIE is a result of hypoxemia during pregnancy, labor or birth, leading to diffuse neurologic injury in many infants. Rather than specific insult in one area of the brain, damage occurs due to acidemia and cerebral edema. Seizures are also the most frequent symptom observed, but unlike the recurrent focal seizures seen in neonatal stroke, these seizures are usually myoclonic or multifocal. Timing of the seizures is also different—often starting soon after birth or within 6 to 12 hours after birth and are followed by stupor, coma, absent neonatal reflexes (sucking, Moro) and irregularities of breathing, heart rate and blood pressure. In terms of outcome, infants experiencing HIE have a higher rate of mortality (25 percent to 50 percent) and morbidity (up to 80 percent of infants with HIE develop serious complications). These children experience longterm functional impairments, such as cerebral palsy and intellectual disability. Identifying the timing and type of seizure occurring in a neonate is among the greatest challenges of diagnosing infants with neurologic damage. Events of apnea and bradycardia
Jill S. Becker, DNP, RN, CNE, is curriculum coordinator and professor of nursing at Northern Essex Community College, in Lawrence, MA. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
Nursing for Women’s Health
351
In Practice seizure occurring in a neonate is among the greatest challenges of diagnosing infants with neurologic damage can represent seizure activity in newborns and remain undiagnosed. Seizures might not be observed until close to discharge or at home. In 50 percent of newborns who experience stroke, the seizures begin after 24 hours of age, and in 25 percent more, within the first week of life, making the onset of seizures a very important aspect of diagnosis. Additional signs can include apnea, lethargy and feeding difficulties. Diagnosis is made by MRI. A diagnosis of presumed perinatal stroke may be made in an older infant who presents with focal hand weakness, premature development of handedness, hemiplegia and delayed milestones or seizure. Hemiplegia may not be diagnosed until age 2 (Lynch, 2009).
Treatment Treatment of newborns with neonatal stroke focuses on neuroprotection. Extension of the brain damage from the original insult can result in long-term seizures, and, in the case of deep vein and dural sinus thrombosis, extension of
352
Nursing for Women’s Health
the clot. Intravenous (IV) fluids are used to prevent dehydration, which may help to improve blood flow to the affected area of the brain. Monitoring and maintenance of normal blood pressure, sodium, temperature and glucose as well as early antibiotic treatment in case of infection have improved outcomes in babies with perinatal stroke (Musolino, P., personal communication, November 24, 2014). To identify seizure activity, continuous EEG monitoring may be used and antiseizure medications, such as Phenobarbital, are administered. The use of thrombolytics is contraindicated given the high risk of bleeding (Musolino, P., personal communication, November 24, 2014) and careful use of anticoagulants, such as low molecular weight heparin, is sometimes considered for specific types of stroke (Roach et al., 2008).
Risk Factors Because symptoms of neonatal stroke are generally not observed at birth but may show up at 48 hours of age or even later, nurses and other clinicians need to know which infants may be at risk. Maternal conditions nurses observe in the antepartum and intrapartum periods may be contributors to both PAIS and cerebral sinovenous thrombosis (CSVT). Alert nurses can help to get infants into treatment more rapidly when
Volume 19
Issue 4
Photos © Photodisc / thinkstockphotos.com
Identifying the timing and type of
August | September 2015
At this time, there does not seem to be a clear link between a particular prothrombotic factor, but Factor V Leiden is one that is mentioned frequently in studies (Mecuri et al., 2001). Dehydration may also be a factor, accentuating the thickness of the neonate’s blood and increasing the potential for clots. Sepsis is recognized as a risk factor, but recent studies imply that even a minor infection may increase risk. Another factor identified in neonates is congenital cardiac anomalies, such as a patent foramen ovale. It’s clear that multiple risk factors may be at play.
In Practice
symptoms are observed, hopefully preventing long-term disability, such as cerebral palsy. Retrospective studies of infants with arterial and venous strokes have identified the following independent maternal risk factors: a history of infertility, primiparity in term infants, pre-eclampsia, history of coagulation disorders (e.g., thrombophilia, deep vein thrombosis, myocardial infarction, miscarriages), gestational diabetes and maternal cocaine abuse (Roach et al., 2008; van de Aa et al., 2014). The studies to determine how these factors come together to create the potential for neonatal stroke have been small in size and limited in number. These studies have looked at how the hypercoagulable state of pregnancy may predispose women with antepartum and intrapartum risk factors to develop thrombi in the placental veins that then enter the fetal arterial circulation via the foramen ovale and ductus arteriosus (Curry et al., 2007). Studies that examine placental pathology may provide answers to this question, but because symptoms don’t occur until day 2 or 3, often the placenta has been disposed of and is not available for study. Elbers, Viero, MacGregor, deVeber, and Moore (2011) analyzed placental pathology in a cohort of neonates who were diagnosed with arterial and venous stroke and found that 83 percent of the placentas had some sort of lesion, hypothesizing that emboli may be sent into fetal circulation or caused an “inflammatory, procoagulant environment in the placenta and fetus promoting diffuse thrombus formation” (p. e726). The good news is that descriptive studies have found that recurrence rates in later pregnancies are low. In the intrapartum period, chorioamnionitis and prolonged rupture of membranes have been linked to perinatal stroke. There may be evidence of fetal distress during labor, such as a non-reassuring fetal heart rate or meconiumstained fluid. Many of the stricken neonates were products of complicated births; Cheong and Cowan (2009) report that more than onethird of infants were born by instrument or via cesarean, with some studies reporting up to a 60 percent rate of cesarean birth (Musolino, P., personal communication, November 24, 2014). Recent research has identified possible neonatal risk factors for stroke. Rutherford et al. (2011) cited prothrombotic factors as a finding in more than 50 percent of neonates with PAIS.
Outcomes It’s thought that the neonatal brain has “plasticity,” suggesting that in the young brain, different neural pathways can develop. In the American Heart Association Scientific Statement by Roach et al. (2008), outcomes of stroke survivors are discussed (p. 2647). At least 50 percent of perinatal stroke survivors experience long-term neurologic impairment, such as hemiparesis, language and learning difficulties. Some children go on to develop epilepsy. Early hand preference
At least 50 percent of perinatal stroke survivors experience long-term neurologic impairment, such as hemiparesis, language and learning difficulties and sensory impairment, such as visual field cuts, have been reported. Researchers are now suggesting that stroke may be a leading cause of cerebral palsy, especially in those infants with delayed presentation and diagnosis (Golomb, 2009; Golomb, Garg, Saha, Azzouz, & Williams, 2008). Death is rare and is often ascribed to comorbidities, such as sepsis or congenital heart disease. More research is needed to determine which therapies will best help children who experience stroke as neonates. Chen, Lo, and Heathcock (2013) compared a small cohort of infants who had a neonatal stroke with a group of infants with typical development. They found that the infants with stroke had poorer fine and gross motor skills and midline grasping behaviors. The authors concluded that early identification may aid in rehabilitative efforts for these children. The majority of stroke victims who develop epilepsy are well-controlled on medication or
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our term neonates who had reassuring APGAR scores at birth. But we need to increase our surveillance of these at-risk infants with surgical procedures. Since other deficits may not be immediately identified, Golomb (2009) suggests that all perinatal stroke survivors will benefit from rehabilitation starting with early intervention services, such as physical and occupational therapy and continued assessment and therapies as the children grow.
What Can Nurses Do? After Charlotte’s birth, I asked my nursing peers about their knowledge of perinatal stroke. In this admittedly unscientific study, I found only one perinatal nurse who was aware of assessing for focal seizures of the type seen in stroke. Most nurses had never heard of a newborn having a stroke. This finding is consistent with research findings. I searched the CINAHL and Medline databases and found few articles on neonatal stroke, and none by nurses at the
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time. As an educator of undergraduate nursing students, I checked the maternal-child textbook we used and others that I had access to. There was limited content about stroke, and nothing about neonatal stroke. I did find that many major pediatric medical centers, including in our hometown, have stroke clinics and that they have parent-oriented websites, but few resources for professionals. I began to wonder what knowledge maternalchild nurses need to increase awareness of this problem, and to assess motherbaby couplets who may be at risk. We don’t ordinarily expect to see seizures in our term neonates who had reassuring APGAR scores at birth. But we need to increase our surveillance of these at-risk infants. Jordan and Hillis (2011) state that “despite efforts to raise awareness regarding stroke in children, this condition is often overlooked
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We don’t ordinarily expect to see seizures in
as a cause of symptoms by health care providers and families.” Why? Because providers often don’t consider stroke in their differential diagnosis. One study found that the median in-hospital delay from presentation to diagnosis was 12.7 hours. The median prehospital delay was 1.7 hours (Rafay et al., 2009). The authors of this study suggest that early identification of seizures may enhance the survival and outcomes of these infants. When presented with a postpartum couplet in which the woman has a history of pre-eclampsia or gestational diabetes or with a newborn who has experienced a stressful birth, our focus as nurses has been on assessing the risk of maternal complications from pre-eclampsia and monitoring the newborn for signs and symptoms of hypoglycemia as we support the attachment process of mother and infant. Maternal-child nurses need to be aware that the symptoms of neonatal stroke are subtle and nonspecific. Nurses need to assess for signs and symptoms of sepsis, dehydration and anemia, taking into account maternal conditions that can increase risk, as well as intrapartum events. Identification of seizure activity is paramount. Behaviors that can indicate seizure in a newborn include repetitive sucking motions, bicycling, lip smacking, eyelid fluttering, sustained gaze deviation, periods of apnea desaturations and occasionally focal clonic seizures (Panayiotopoulos, 2005). Clear differentiation between jittery behaviors related to hypoglycemia, hypocalcemia and seizure needs to be made. Since dehydration is considered to be a risk factor for the development of both arterial and venous strokes in the newborn, maternal-child nurses should educate lactating women about sources for ongoing information available from organizations, such as La Leche League and Breast Feeding After Breast and Nipple Surgeries (BFAR; see Box 1). These may be valuable
Conclusion
Behaviors that can indicate seizure in a newborn include repetitive sucking motions, bicycling, lip smacking, eyelid fluttering, sustained gaze deviation, periods of apnea desaturations and occasionally focal clonic seizures Obstetric nurses need to be aware of potential risk factors for perinatal stroke. Early detection and treatment of infants with stroke will improve the outcomes for these children. I hope that sharing what I’ve learned will increase awareness among nurses of neonatal stroke, and result in healthier outcomes for the families that we all care for every day. NWH
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We were lucky. It remains to be seen if Charlotte will have residual effects from her stroke. We will never know exactly what caused it, as testing for the common risk factors, such as sepsis or coagulation disorders, were negative. The neurology team that has been following her and
her pediatrician tells us that if they didn’t know about her history and MRI, they wouldn’t believe that she had had a stroke. She has minimal signs of impairment–a very slightly diminished muscle tone on one side and early hand preference. At 24 months of age, she is meeting all developmental milestones and is a typical toddler, heading into her “terrible twos.” I can’t help but watch her and think, “What if…?” I’m thankful for the great care she got from the entire health care team, including pediatric intensive care nurses, attending physicians and residents, pharmacists and therapists.
In Practice
resources for parents to have after hospital discharge. As nurses caring for couplets, we routinely assess for signs of dehydration, but it bears reminding. Another aspect of the failure of a health care provider to consider neonatal stroke occurred that first night Charlotte was home when we contacted the on-call pediatrician after we identified her symptoms. We need to be certain that new parents feel comfortable contacting their pediatric provider with questions at any time, and to not feel intimidated during those conversations—even in the middle of the night. Our emergency phone consultation with the pediatrician on call left us feeling that we were too anxious and were “newbies,” even though we were experienced nurses. We were able to persist until we were certain that our concerns were heard. Imagine if we hadn’t had the ability—as many young parents don’t—to clearly state our concerns. We got Charlotte to the hospital and treatment started quickly, rather than waiting for that afternoon new baby visit.
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In Practice
Box 1.
Selected Resources Breastfeeding After Breast and Nipple Surgeries
www.bfar.org La Leche League International
www.llli.org Children’s Hemiplegia and Stroke Association
www.chasa.org and www.pediatricstroke.org
Lynch, J. K. (2009). Epidemiology and classification of perinatal stroke. Seminars in Fetal & Neonatal Medicine, 14(5), 245–249. doi:10.1016/ j.siny.2009.07.001 Martin, J. A., Hamilton, B. E., Osterman, M. J. K., Curtin, S. C., & Matthews, T. J. (2013). Births: Final data for 2012. National Vital Statistics Reports, 62(9), 1–68. Mecuri, E., Cowan, F., Gupte, G., Manning, R., Laffan, M., Rutherford, M., … Roberts, I. (2001). Prothrombotic disorders and abnormal neurodevelopmental outcome in infants with neonatal cerebral infarction. Pediatrics, 107(6), 1400–1404. Nelson, K. B., & Lynch, J. K. (2004). Stroke in newborn infants. Lancet Neurology, 3(3), 150–158.
References Chen, C. Y., Lo, W. D., & Heathcock, J. C. (2013). Neonatal stroke causes poor midline motor behaviors and poor fine and gross motor skills during infancy. Research in Developmental Disabilities, 34(3), 1011–1017. doi:10.1016/ j.ridd.2012.11.028 Cheong, J. L., & Cowan, F. M. (2009). Neonatal arterial ischaemic stroke: Obstetric issues. Seminars in Fetal & Neonatal Medicine,14(5), 267–271. doi:10.1016/j.siny.2009.07.009 Curry, C. J., Bhullar, S., Holmes, J., Delozier, C. D., Roeder, E. R., &Hutchinson, H. T. (2007). Risk factors for perinatal arterial stroke: A study of 60 mother-child pairs. Pediatric Neurology, 37(2), 99–107. Elbers, J., Viero, S., MacGregor, D., DeVeber, G., & Moore, A. M. (2011). Placental pathology in neonatal stroke. Pediatrics, 127(3), e722–e729. doi:10.1542/peds.2010-1490 Golomb, M. R. (2009). Outcomes of perinatal arterial ischemic stroke and cerebral sinovenous thrombosis. Seminars in Fetal & Neonatal Medicine, 14(5), 318–322. doi:10.1016/ j.siny.2009.07.003
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Panayiotopoulos, C. P. (2005). Neonatal strokes and neonatal syndromes. In The epilepsies: Seizures, syndrome and management (pp. 87–116). Oxfordshire, U.K.: Bladon Medical Publishing. Rafay, M. F., Cortez, M. A., deVeber, G. A., Tan-Dy, C., Al-Futaisi, A., Yoon, W., … Moore, A. M. (2009). Predictive value of clinical and EEG features in the diagnosis of stroke and hypoxic ischemic encephalopathy in neonates with seizures. Stroke, 40(7), 2402–2407. doi:10.1161/ STROKEAHA.109.547281 Roach, E. S., Golomb, M. R., Adams, R., Biller, J., Daniels, S., deVeber, G., … Council on Cardiovascular Disease in the Young. (2008). Management of stroke in infants and children: A scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke, 39(9), 2644–2691. doi:10.1161/STROKEAHA.108.189696 Rutherford, M. A., Ramenghi, L. A., & Cowan, F. M. (2011). Neonatal stroke. Archives of Disease in Childhood: Fetal and Neonatal Edition, 97(5), F377–F384. doi:10.1136/ fetalneonatal-2010-196451
Golomb, M. R., Garg, B. P., Saha, C., Azzouz, F., & Williams, L. S. (2008). Cerebral palsy after perinatal arterial ischemic stroke. Journal of Child Neurology, 23(3), 279–286. doi:10.1177/0883073807309246
van der Aa, N. E., Benders, M. J., Groenendaal, F., & de Vries, L. S. (2014). Neonatal stroke: A review of the current evidence on epidemiology, pathogenesis, diagnostics and therapeutic options. Acta Paediatrica, 103(4), 356–354. doi:10.1111/apa.12555
Jordan, L. C., & Hillis, A. E. (2011). Challenges in the diagnosis and treatment of pediatric stroke. National Review of Neurology, 7(4), 199–208. doi:10.1038/nrneurol.2011.23
Zanelli, S. A., Stanley, D. P., & Kaufman, D. A. (2014). Hypoxic-ischemic encephalopathy. Retrieved from emedicine.medscape.com/ article/973501-overview
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Issue 4