Head Scans for Premature Babies

It is routine, not a reaction

The sentence that frightens parents is "we're going to do a head scan", said casually by somebody walking past. In very preterm babies this is scheduled surveillance. Bliss states that babies born very prematurely have a head ultrasound scan within the first few days to look for bleeding, and that in many cases babies with a bleed show no signs at all — it is found on that routine scan.

So a head scan being booked does not mean somebody has noticed something. It means your baby's gestation puts them on the scanning schedule.

What the scan actually is

A cranial ultrasound uses sound waves through the fontanelle, the soft spot on top of the head, to build a picture of the brain. Bliss notes that ultrasound is commonly used to see whether there is bleeding or other problems in a baby's brain, and that you can stay with your baby during it. There is no radiation, no sedation and no needle. It takes a few minutes at the cot side, with warm gel, and most babies sleep through it.

What they are looking for

Bliss explains that in premature babies the brain and its blood vessels are still developing, that the brain contains fluid-filled spaces called ventricles, and that the new blood vessels near them are very fragile. Intraventricular haemorrhage is when blood from those fragile vessels leaks into the ventricles. Bliss adds that most babies who have an IVH were born before 32 weeks, that it usually happens in the first few days, and that it becomes much less likely after the first week unless a baby becomes unwell again.

Scans also look at the size of the ventricles over time, and at the brain tissue around them. Repeat scans exist to watch for change, which is why a second scan being booked is not in itself bad news.

The grades, and what they are not

Bliss states that when it is diagnosed, IVH is graded one to four depending on how severe the bleeding is, with grade one the least serious and grade four the most serious, and that babies who show outward signs are more likely to have a more serious bleed.

What a grade does not do is forecast a child. Grading systems were built so that clinicians could compare and decide, not so that parents could be given a probability. Two babies with the same grade can have very different lives. If a grade frightens you, the question that gets a useful answer is not "what does grade two mean" but "what does this change about what happens next for her".

What signs would prompt an unscheduled scan

Bliss lists the things that might make a team scan sooner: a baby who is floppier or less active than expected, less alert, having unusual movements or seizures, breathing less regularly, or with swelling of the fontanelles. Most babies with a bleed have none of these.

MRI, and why it is a different conversation

Some babies have an MRI later, often near term-corrected age. Bliss notes that MRI scanners are usually in a different part of the hospital or occasionally a different hospital, that a baby may have to wait until they are well enough to be moved, and that sedation is sometimes needed to keep them still. An MRI gives more detail than ultrasound and is usually done to inform follow-up rather than to change immediate treatment.

What a normal scan does and does not tell you

A normal cranial ultrasound is genuinely reassuring about the specific things it looks for. It is not a guarantee about development, and no imaging is. NICE guideline NG72, on developmental follow-up of children born preterm, exists precisely because imaging alone cannot answer that question — it sets out enhanced developmental surveillance for children at higher risk, using assessments over years rather than a picture taken in a week.

NG72 also leads with the fact that gets lost in these conversations: the majority of children and young people born preterm have a good developmental outcome and a good quality of life.

Questions worth asking about a scan result

Ask whether this was a scheduled scan or a response to something. Ask what changed since the last scan, if there was one. Ask when the next scan is and what they will be looking at. And ask what, if anything, changes in today's plan because of the result. If the answer to the last one is "nothing", that is a real answer and it is worth hearing out loud.

If a result is difficult, ask for the conversation to happen sitting down, in a private room, with both parents present if possible. NICE NG124 tells units to have private areas for difficult conversations and to be sensitive about the timing of them. You are entitled to that.

What can lower the risk in the first place

Bliss explains that bleeding happens when fragile vessels tear because of changes in blood flow through the brain after birth, and lists the things that raise the risk alongside very preterm birth: unstable blood pressure, breathing difficulties needing a ventilator, serious infection, problems with blood clotting, and other conditions such as respiratory distress syndrome or a patent ductus arteriosus.

That explains a great deal of what the unit does in the first 72 hours. Minimal handling, clustered cares, careful positioning of the head, avoiding sudden swings in blood pressure and getting breathing support right early are all, in part, about protecting the brain. So is the steroid injection given before birth and the magnesium sulfate offered for neuroprotection at earlier gestations. When it looks as though very little is being done on day two, quite a lot is being deliberately not done.

What happens if a bleed is found

Bliss notes that if IVH is diagnosed, doctors may do repeat head scans to follow progress, and that a further ultrasound or an MRI may be arranged. Most small bleeds need no treatment at all and are simply watched. Where a bleed causes fluid to build up, the team monitors head circumference and ventricle size, and there are treatments for that if it develops. None of this changes on the day it is found, which is why the plan for the next 24 hours often stays exactly the same.