Review Question - QID 105434

All premature infants are at risk of intraventricular hemorrhage (IVH). As the condition is often asymptomatic, screening for IVH via cranial (transfontanel) ultrasound should occur by day 7 of life.

IVH is most commonly found in premature infants and in low birth weight infants, with bleeding most often arising from the germinal matrix. Hemorrhage is thought to arise due to structural fragility of the germinal matrix as well as impaired autoregulation of cerebral blood flow. The hemorrhage is graded according to the severity and location of the bleed: Grade I (germinal matrix), Grade II (ventricle), Grade III (ventricle filled and dilated), Grade IV (cerebral tissue). Many IVH in infants presents asymptomatically. It is recommended that all infants born at < 32 weeks gestation undergo screening cranial ultrsound within the first week of life, often with follow up ultrasounds thereafter.

Langley et. al review the clinical manifestations, diagnosis, and management of IVH in premature infants. They discuss the high prevalence of asymptomatic disease, as well as common manifestations in symptomatic disease. They also discuss the importance of ultrasound screening in infants born at or before 32 weeks gestation, as well as follow up imaging for those with positive screening studies.

Incorrect answers:
Answer 1: Car seat tests are done prior to discharge from the NICU to make sure the infant can maintain appropriate heart rate and oxygenation while in a car seat. Given the patient's gestational age, cranial ultrasound should be performed prior to discharge preparation.

Answer 3: An echocardiogram would be useful if the infant showed signs or symptoms of congenital heart disease, such as cyanosis or a murmur on exam. This infant has no signs or symptoms suggestive of congenital heart disease. Therefore, cranial ultrasound is the more appropriate screening test.

Answer 4: Retinopathy of prematurity is a common complication of both prematurity as well as prolonged supplemental oxygen therapy in infancy. Retinal exams are not useful until several weeks after birth.

Answer 5: Sweat chloride test would be appropriate if cystic fibrosis (CF) was suspected. This would present with failure to pass meconium secondary to meconium ileus. This infant does not have signs or symptoms suggestive of CF.

Bullet Summary:
Due to the high prevalence of asymptomatic intraventricular hemorrhage in premature infants, screening cranial ultrasound should be performed within the first week of life for all infants born at or before 32 weeks gestation.