Bleeding in the Brains of Very Early Babies: What Raises the Risk, Whether We Can Predict It, and How Hospitals Can Help

Ghaderi 2025, Zhan 2026 and Variane 2026: three new studies on intraventricular hemorrhage in premature babies

Intraventricular hemorrhage, or IVH, is bleeding inside the brain's fluid-filled spaces that can happen in babies born very early. Three new studies looked at what makes it more likely, whether doctors can predict it, and how hospitals might prevent it. They suggest that steroids before birth and gentle, coordinated care in the first days matter, while prediction tools are not yet ready for bedside use.

When a baby is born many weeks early, the blood vessels deep in the brain are still very delicate. Sometimes one of them leaks, and blood spills into the small fluid-filled chambers called ventricles. Doctors call this intraventricular hemorrhage (IVH). Bleeds range from mild to severe, and the larger ones can lead to serious problems, which is why neonatal intensive care units (NICUs) work so hard to lower the chances. For families, the most important thing to know is that this is a recognized risk of being born early, and researchers are working hard to reduce it.

How doctors came to understand brain bleeds in early babies

The three new studies discussed here come from Dr. Ghaderi's group [1], Dr. Zhan's group [2] and Dr. Variane's group [3], and they build on a long history. In 1978, a team led by Dr. Papile described a way of sorting these bleeds into grades by how large they are, studying babies who weighed less than 1,500 grams at birth [4]. Grades one and two are mild; grades three and four are severe. That scheme is still used. Over the following decades, hospitals became able to save smaller and smaller babies, so more babies were at risk of the problem. Researchers learned that most bleeds happen early. One of the new papers notes that about half occur within the first day of life and about 90 percent within three days [2]. A large combined analysis of 9633 babies, described in one of the new studies, found bleeding of any grade in 31 percent of babies born at 32 weeks or less, and severe bleeding in 11 percent [5].

Earlier studies pointed to a few things that seemed to matter. A California study of 44,028 premature babies found that steroid medicine given to the mother before birth was the one factor linked to fewer severe bleeds [6], which other work in very small babies also supported [7]. Other studies linked repeated attempts to place a breathing tube [8], early use of blood-pressure medicines [9] and getting too cold after birth [10] to a higher chance of brain bleeding or injury. Hospital teams then began combining safer practices into "care bundles", and a Canadian bundle was reported to coincide with a 69 percent drop in bleeding rates [11]. Other hospitals followed with their own improvement projects [12][13][14], and researchers have since reviewed these efforts [15], as well as the biology of how and why the bleeds happen [16]. Still, what we knew was scattered across many separate studies.

Three studies each asked a different question

The first study, led by Dr. Ghaderi, asked what goes along with IVH. The team gathered 30 earlier studies and combined their results, a method called a meta-analysis [1]. The second, led by Dr. Zhan, asked whether doctors can predict severe IVH. The team reviewed 16 "risk calculators" that other researchers had built from the records of 75,499 premature babies [2]. The third, led by Dr. Variane, looked at real life. It followed 268 babies born before 32 weeks, or weighing under 1,500 grams, in four neonatal intensive care units in Brazil over one year [3]. Each study adds a different piece to the puzzle. Together they move from "what raises the chance" to "can we predict it" to "what are hospitals actually doing, and what could they do together to prevent it."

Bleeding was more common in smaller and sicker babies

The combined analysis found that bleeding was more common in babies who were smaller at birth, had low scores on the first newborn checks (called Apgar scores), had lung trouble at birth, or had an open ductus arteriosus, a small blood vessel that normally closes after birth. Babies who needed a breathing machine, or medicines to support their blood pressure, also had more bleeding. In numbers, babies on a ventilator had about three times the chance of bleeding compared with babies who were not. Steroids given to the mother before birth went the other way, with about a 20 percent lower chance.

It is important to understand what this does not mean. A ventilator does not cause a brain bleed; babies who are the sickest need the ventilator, and are also the most likely to bleed. The researchers said as much about some of the medicines they studied: the link probably reflects how sick the baby already was. These studies show patterns, not causes.

Doctors cannot yet reliably predict which baby will bleed

Prediction tools are attractive because they could, in theory, tell a team which babies need the closest watch. The review found that, on average, the best-documented calculators did a fairly good job at telling babies apart, with a score of 0.805 on a scale where 0.5 is a coin flip and 1.0 is perfect [2]. But all 16 studies had weaknesses that made the researchers worry about their reliability, such as using hospital records collected after the fact and handling missing information poorly. Most of the calculators leaned on things doctors already know: how early the baby was born, how much the baby weighed and whether the mother had steroids. The authors concluded that these tools are not ready to guide care on their own. For families, this means that no score can tell you the future of your own baby, and the bedside team will be watching closely anyway.

The Brazilian units showed room for improvement

The Brazilian study gives a picture of everyday neonatal care [3]. Of the 268 babies, 246 had a head ultrasound, and 22 died before they could be scanned. Of the 246 scanned, about six in ten had a normal scan, about two in ten (22.4 percent) had a mild bleed and about one in ten (11.4 percent) had a severe one. Counting babies with a severe bleed together with those who died before a scan, the figure was 20 percent, or one baby in five.

Several things stood out. Only about half the mothers (47 percent) had received a full course of steroids before delivery. Many babies were cold on arrival to the NICU, and about two in three had a low temperature at admission. Babies who ended up with severe bleeding or death had been born earlier and smaller, were far more likely to need a breathing tube in the delivery room, and were more likely to need blood-pressure medicine in the first days. The authors called for a standard "prevention bundle" that combines steroids before birth, keeping babies warm, gentle handling during resuscitation and careful decisions about blood-pressure support.

Families can take several practical points from these studies

If your baby is born early, the team will usually perform head ultrasounds in the first days to weeks to look for bleeding. In the Brazilian units the first scan was typically done around day five. The Canadian and American pediatric societies mentioned in the prediction review suggest scans at roughly four to seven days or seven to ten days, depending on the guideline [2]. Mild bleeds were the more common type, while a severe bleed means more monitoring and sometimes longer hospital stays. In the Brazilian study, survivors with severe bleeding stayed a median of 95 days.

There are things that help. If you are at risk of delivering early, asking whether you should receive steroids and how soon is reasonable; our article on antenatal steroid timing goes into the details. Warmth matters, too, and our piece on the newborn hypothermia bundle explains how teams keep babies at a safe temperature. And you can often help directly: in the Brazilian units, parental touch was reported in 84 percent of babies and minimal handling in 77 percent.

Researchers have several next steps in mind

Across the three studies, the authors point to several next steps. They want clearer, shared definitions of IVH so that studies can be compared. They want research that follows babies over time to see how bleeding relates to later development. They want better-designed prediction studies that follow babies forward in time, report how well predictions match reality and test the tools in new hospitals. And they want hospitals to adopt and carefully evaluate prevention bundles, so that we learn which parts truly help.

Conclusion

In short, brain bleeds in very early babies are more common in the smallest and sickest babies, steroids before birth appear to help, and prediction scores are not yet dependable enough for bedside decisions. A Brazilian study found room for improvement in steroids, warmth and gentle care, and called for bundles of prevention steps. These studies show patterns, not proof of cause, but they point in a hopeful direction.

References

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  2. Zhan Z, Zhang J, Rong H, Shen F, Chong Q. Predictive model for severe intraventricular hemorrhage risk in preterm infants: a systematic review and meta-analysis. Front Pediatr. 2026;14:1785442. doi:10.3389/fped.2026.1785442 ↩
  3. Variane GFT, Leandro DMK, de Azevedo SS, et al. Intraventricular hemorrhage in preterm newborns: a multicenter study in four Brazilian hospitals. J Pediatr (Rio J). 2026;102(5):101574. doi:10.1016/j.jped.2026.101574 ↩
  4. Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J Pediatr. 1978;92(4):529–534. doi:10.1016/s0022-3476(78)80282-080282-0) ↩
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