BRAIN Protocol Reduces Brain Bleeds in Very Preterm Babies

Dr. Vivek Shukla is a neonatologist at Children’s of Alabama.

After implementing new measures to protect the brain health of preterm babies, a multidisciplinary team at Children’s of Alabama at the University of Alabama at Birmingham (UAB) saw promising results that suggest a new protocol could prevent brain bleeds in preterm neonates.

More and more infants born before 29 weeks, 6 days are surviving, bringing greater attention to their long-term outcomes, particularly their neurological health. In their first few weeks of life outside the womb, these babies have a high risk of intraventricular hemorrhage (IVH), a type of bleeding in the brain. To reduce the risk of IVH and other brain bleeds, Children’s of Alabama neonatologists Vivek Shukla, M.D., and Maran Ramani, M.D., led a multidisciplinary team from the level IV regional neonatal intensive care unit (NICU) at the University of Alabama at Birmingham (UAB) in the development of a quality-improvement and management program for infants at high risk of IVH or other neurological complications. The team implemented the program, called BRAIN, in April 2018 with the goal of improving long-term neurological outcomes for these babies.

The interventions begin at birth and continue through the first week of life, which is considered the highest-risk period for IVH and other brain bleeds. Components of BRAIN include:

  • Using more sophisticated monitoring such as near-infrared spectroscopy
  • Protocolizing routine medication use within six hours of birth for most of babies—such as initiating IV indomethacin prophylaxis, which can reduce the risk of IVH—and limiting the use of saline boluses and bicarbonate
  • Reducing noise levels by carefully handling equipment and the incubator, minimizing incubator

door opening, reducing the intensity of alarms and promptly responding to them, avoiding conversations at the bedside as much as possible and using a soft voice if needed.

  • Standardizing infant positioning with an elevated head of the bed, avoiding putting the baby flat on the bed and getting help when turning the baby to ensure a neutral head position.

Of 127 babies tracked after implementing the neuroprotective protocol, none experienced a brain bleed or early death in the first week of life compared to 11 out of 99 (11%) prior to the intervention. The results were published in the Journal of Perinatology in July 2022. The work isn’t finished, however, with several additional approaches planned, including using machine learning and artificial intelligence to identify features that predict worse outcomes.

“All the congratulations go to my wonderful team, my wonderful mentors and my excellent colleagues here,” Shukla said. “This is not a single-person show. A lot needs to be done to ensure that preterm infants reach their best potential development.”

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