Developmental Therapy in the NICU – Flashcards
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Newborn Intensive Care Unit
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Level 1: Normal Newborn Nursery Level 2: Special Care Nursery Level 3: Newborn Intensive Care: Respiratory, Neonatal surgery, Special diagnostics, Very preterm infants Level 4: Newborn Intensive Care: Cardiac Surgery
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Diagnoses to admit to NICU
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Prematurity Respiratory Distress Surgical (GI, cardiac, renal) Neurological problems (lots of CVAs) Congenital anomalies Infection Metabolic
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Definition by Gestational Age
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23-26 Weeks: Very preterm infant 27-33 Weeks: Moderately preterm infant 34-36 Weeks: Late preterm infant 37-42 Weeks: Term infant
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Definition by Birth Weight
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> 2500 grams: Normal Birth Weight 1500-2500 grams: Low Birth Weight (LBW) 1000-1500 grams: Very Low Birth Weight (VLBW) < 1000 grams: Extremely Low Birth Weight (ELBW) any child <1500g in MN automatically qualifies for early intervention-- 500g is 1lb
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Size for Dates
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Appropriate for GA/Small for GA/ Large for GA (AGA, SGA, LGA) *Intrauterine Growth Restriction* Term Infants: National Collaborative: Perinatal Data Base 6.9 point IQ deficit at 7 years of age Preterm Infants: with and without postnatal nutrition 8 pt deficit on 1 year MDI if > 2wks postnatal malnutrition
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IUGR
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placenta couldn't give the baby nutrition for growth in utero lots of them develop ADD/ADHD motor delays due to decreased nutrition
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Common Diagnosis of the Preterm Infant
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Respiratory Distress Syndrome Chronic Lung Disease or Bronchopulmonary Dysplasia Sepsis Necrotizing enterocolitis Retinopathy of Prematurity Intraventricular hemorrhage
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Respiratory Distress Syndrome
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the baby's lungs aren't ready to be born, they should still be in an aquatic environment ventilator causes scarring muscles not ready to work against gravity younger = more severe RDS give surfactant to help alveoli grow steroids to mom pre-delivery and child post if lungs can't keep up with growth: BPD (bronchopulmonary dysplasia) or CLD (chronic lung disease)
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Sepsis
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skin is not strong enough to ward off the germs in the environment UTI can make them very ill and could cause death
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Necrotizing enterocolitis (NEC): very bad thing that is too common
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babies born before 30-32 weeks have very immature stomach, small int and large int Don't have flora in the int to help you digest food- won't gain weight Fluid feed with IV when they're born Once the baby is stable on fluids they slowly introduce enteric feedings: 1mL of breast milk over 4 hours (need human breast milk to establish a good GI tract Too much milk can cause too much bacteria and sm int can get inflammed, rupture, and sepsis. Ostomy bag placed.
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Retinopathy of Prematurity
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Will get exposed to O2 because of poor lung function- really bad for the eyes and will change how the vessels in the eye develop Can develop scarring in the back of the eye- pull the retina off and cause the baby to become blind
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Intraventricular Hemorrhage
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Brains are so fragile- germinal matrix inside the ventricles of the brain: very critical for the development of the brain Grade 1:Isolated germinal matrix bleed Grade 2: Blood in the lateral ventricles Grade 3:IVH with acute ventricular dilation Grade 4: Hemorrhage into the periventricular white matter Grade 3 & 4 are very high risk of significant dev delays and may need neuro surgery (shunt) 1 & 2 will have cognitive delays but not so much motor delays (ADD/ADHD/LD)
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Incidence of Prematurity
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In the US in 2012: - 11.5% of infants were born premature - 2% were very preterm - 10% were moderately preterm
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Incidence of Major Handicap for infants <1500 g
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No Hemorrhage: <10% Grade I or II IVH: 12% Grade III IVH: 36% Grade IV IVH: 75% (spastic diplegia CP usually) use Bayley to grade cognition, language, gross motor skills Major handicap: gross/fine motor related
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Periventricular Leukomalicia
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Hypoxic-ischemic etiology Periventricular echodensities are common on early ultrasound and are not prognostic >2mm cysts at 1 month are 95% predictive of CP if lesions extend from anterior to posterior Most common CP is spastic diplegia The development of cysts due to blood in the ventricles Cysts are fluid filled and will eventually decrease in size and cause scarring in the ventricular area PVL should not be seen until 3-4mo GA PVL they will probably have a poor neurological outcome
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Hypoxic Ischemic Event/Etiology/Encephalopathy
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Term baby with a small momma that gets stuck and the baby lacks oxygen during the delivery process Requires cooling protocol post-birth Global injury (not just some small spots like IVH) Depending on how diffuse the injury and how deep the injury, child can have great-poor outcome: radiologist report is necessary to read in order to set goals
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Late Preterm Infant
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Infant born at 34-36 weeks gestation Account for majority of premature births Known short-term increase respiratory distress, feeding difficulties, hyperbilirubenemia, sepsis, hypothermia, re-hospitalization Increasing focus on higher incidence of difficulties at school age. Most of these are multiples (twins, triplets, quads) Initial RDS: need pulm support- will be poor oral feeders sensory/tactile defensiveness and trouble in school seen
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Major Morbidity of Prematurity
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Mental Retardation Cerebral Palsy Blindness Severe hearing loss
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Respiratory Distress
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*Respiratory Distress Syndrome : Oxygen, Assisted Ventilation, Exogenous Surfactant *Transient Tachypena of the Newborn (TTN): Supplemental Oxygen, Seen in child born by c-section due to lack of compression releasing the amniotic fluid *Meconium Aspiration: Oxygen, Assisted ventilation, ECMO (bypass), their GI system is fully developed and is full of meconium (thick poo). Can excrete the meconium and aspirate the stool into their lungs
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Signs of Infection
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Temperature instability Poor Feeding Respiratory distress Apnea
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Hypoxic Ischemic Encephalopathy
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Abnormal tone, state, posture, reflexes, seizures Stages of HIE a) Stage 1 (Mild): hyperalertness, hyper-reflexia, dilated pupils, tachycardia, absence of seizures. b) Stage 2 (Mod): lethargy, hyper-reflexia, miosis, bradycardia, seizures, hypotonia with weak suck & Moro. c) Stage 3 (Severe): stupor, flaccidity, small to midposition pupils which react poorly to light, decreased stretch reflexes, hypothermia and absent Moro. Relatively new therapy: Body or head cooling for 72 hours- prevent secondary brain injury
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Neonatal Seizures
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Many causes: Metabolic, Infection, Bleeding, HIE Signs: Abnormal movements, Apnea, Staring, Sucking, chewing, Need to differentiate from jitteriness Treatment: Determine and treat underlying cause, Anticonvulsants, Outcome, Often dependent on cause of seizures
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Retinopathy of Prematurity (more information)
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At risk infants require eye exams at 4-6 weeks of age until retinal mature: <1500 grams, <30 weeks gestation The youngest, smallest, sickest infants at greatest risk Retinal maturity described as zones as goes out from the optic nerve Outcomes: Need for glasses, Strabismus, Blindness stages 1-5: severity // zone 1-3: location
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Stages of ROP
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Stage 1 is a faint demarcation line. Stage 2 is an elevated ridge. Stage 3 is extraretinal fibrovascular tissue. Stage 4 is sub-total retinal detachment. Stage 5 is total retinal detachment. Treatment: Initial treatment laser surgery or injection of Avastin
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Criteria for Discharge
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Parental Education Completion of appropriate elements of primary care in the hospital Development of a management plan for unresolved medical problems Development of a comprehensive home care plan Identification and involvement of support services Determination and designation of follow-up care
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Discharge Planning ****
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Resolution of med and surgical problems that required hospitalization Adequate weight gain on oral feedings Thermal stability Education and comfort of parents Predischarge health maintenance Appropriate screenings Immunizations Medications and equipment Post discharge environment Support and follow-up Primary care provider NICU Follow-up Clinic Other Specialty Clinic appointments Community Resources (Early Intervention, Home Health Care)
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Factors Influencing Long Term Outcome of Premature Infants
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1. Degree of Prematurity 2. Size for Dates (SGA) 3. Intraventricular hemorrhage 4. (Periventricular) Leukomalacia 5. Socio-economic Status 6. Postnatal Nutrition
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Risk Factors
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- Extreme prematurity - Intraventricular hemorrhage - Periventricular Leukomalacia - Severe bronchopulmonary dysplasia - Intrauterine Growth Restriction
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Criteria for NICU Follow-up Clinic
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Birth weight <1500 grams Gestational age 4 days on the ventilator or has persistent pulmonary problems (BPD) IUGR (> 2 S.D. below the mean in two growth parameters) ECMO patients Neonatal seizures, IVH (any grade), PVL, hydrocephalus, perinatal asphyxia, or other neurological abnormality Elevated bilirubin levels requiring an exchange transfusion IDM with symptomatic hypoglycemia Congenital or acquired infection (meningitis or positive blood cultures associated with pulmonary compromise, DIC, or shock)
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Goals of NICU Follow-up Clinic
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Identification of concerns related to health, growth and development Early identification of problems related to development Responding to parent concerns, remaining questions from NICU course Recommendations for care Appropriate referrals Reassurance
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At Each Follow-up Clinic Visit
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History and Physical Exam Growth and Nutrition Assessment Health Status Development and muscle tone Referrals if needed Summary of visit to primary care provider Anticipatory guidance
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Routine NICU Follow-up Visits
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4 months corrected age 12 months corrected age 24 months corrected age 4 years of age
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Additional Clinic Visits
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Infants with Chronic Lung Disease Management of oxygen and medications Infants with Feeding Problems Infants with Growth Concerns Assessment of growth Changes in feeding regimen Infants with Developmental Concerns Children return for interim assessment 8 months 18 months 3 years
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Concerns of Premature Infants
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Poor growth Motor Delays Cognitive Problems Hearing loss (Greater than 5 days NICU) Vision Problems Retinopathy of prematurity Higher incidence of re-hospitalization Increased health care costs the first year
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School Age
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Increase in special education services Higher incidence on ADHD, increase in attention problems Lower IQ scores, generally in normal range, but lower than term infants Learning disabiliItes Visual-motor problems Impaired executive function Increase autism spectrum disorder
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Moderating Factors
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Nutrition and Adequate Postnatal Growth Use of Breastmilk Home Environment Early Intervention
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History: Premature Infant Care and Interventions
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Pioneer of Developmental Care: Dr. Heidelise Als Research based discovery that the premature infants extrauterine sensory experience was damaging to the neurological structure of the immature brain. Created a new approach to care in the NICU called "Developmental Care" Newborn Individualized Developmental Care and Assessment Program (NIDCAP) must have a dev specialist in all NICUs
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Intrauterine Environment
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Need to replicate this environment for the baby Supportive: 1. Allows movement but isn't restrictive 2. Uterus is mm-- closed chain input (UE and LE movement patterns going back to physiological flexion) 3. Aquatic: no gravity Controlled: 1.Dark to allow eyes to develop without being oversensitive to light 2. Relatively quiet: quiet sounds 3. Same temp: fluid is the same temp as mom
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Extrauterine Environment
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New Exposure to: Light Smells Touch Sounds It can be TOO much for an immature CNS, so developmental intervention is critical for long-term outcomes
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Supportive Environment
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*Graded sensory input following the hierarchy of neuro-sensory dev of the brain *Hierarchy Tactile (begins development at conception) Vestibular (21 weeks gestation)- bedrest can slow this Gustatory and Olfactory (begins 11-15 weeks, developed at 26) Auditory (23-28 weeks gestation) Visual (30 weeks papillary response begins)
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Positioning Program
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baby repositioned every few hours to prevent contractures and pressure sores (they cannot move against gravity) Need them to be in prone, supine, and sidelying Keep in physiological flexion, have boundaries, and be careful of the head shape Prone: good because prone will help their pulmonary support Supine: frog leg position is no-no. (circumducted gait) *see slides for info on positioning aids*
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Team Approach to Care
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*Clustering Care Structuring the infant schedule to allow for minimal interruptions. NICU infant requires 20-22 hours of sleep per day compared to term infant requiring 17-20 hours of sleep per day Monitoring signs of stress and overstimulation for the infant
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Additional Treatment
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Kangaroo Care Joint compression (Alkaline Phosphate) PROM to all extremities Increase handling tolerance Facilitate vestibular development Monitor potential movement disorders Oral motor development and feeding Cranial molding Musculoskeletal development support
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Oral motor development and feeding
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Basically teaching a baby how to suck Goal is for each infant to have a positive feeding experience and avoid oral aversion development Feeding a NICU baby is complex, challenging, and risky as the infant is learning to coordinate SSB and high probability for aspiration Requires advanced training: AOTA recommends minimal of 2 years pediatric experience before NICU placement
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Oral motor development
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Initial sucking and swallowing of amniotic fluid at 9 weeks gestation Coordination of SSB at 28 weeks gestation Fully maturation to allow for fluid introduction at 32-34 weeks (breast feed/bottle) Protective cough at 36 weeks: manual cough assist needed
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Oral motor progression
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NNS program at 28 weeks gestation Manual techniques on muscles of the face to help the baby get a good seal for sucking
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Feeding
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Discuss with family their preferred feeding plan for home discharge: Breastfeeding, Bottle feeding, Coordinated plan to reduce risk of over-fatigue of oral motor musculature, Breastfeeding starts around 32 weeks, bottle feeding at 34 weeks Bottle needed for most premies because of decreased respiratory support
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Bottle Feeding Considerations
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Anatomical: frenulum length, tone of tongue, hard/soft palate structure O2 needs Organization of suck pattern with NNS Historical considerations Flow rate
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Bottling Techniques
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Positioning infant Pacing infant Oral motor control Musculoskeletal support
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Aspiration Risk
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Common for infants with history of IVH, oral motor anatomical anomalies Video Fluoroscopy Swallow Study (VFSS) with radiologist to confirm swallow safety Alter liquid consistency for safe swallow or may need G-tube for home feeding
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Specialized Infant Feeding
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cleft palate: cannot generate negative intra-oral pressure (no seal) 6-9 months they will repair the lip, 12-18 months they will repair the hard palate (need both levels of the bone to descend first) Every time they suck you squeeze and the fluid squirts down the throat: squeeze when they suck
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Kinesiotaping in the NICU
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Neuro-motor facilitation Functional correction Edema management Orthopedic correction: club feet
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Splinting
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Soft splint: wrist/finger anomalies (thumbs especially) Thermoplastic splinting: clubfoot deformity, wrist flexion contracture Amniotic banding of extremities
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Manual Edema Management
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Critically ill infants will have fluid imbalance with significant acute/chronic edema. Immature lymphatic system that needs facilitation for maturation Manual Edema mobilization, kinesiotaping, clear/flow PROM program, weight bearing with joint compression
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Visceral Manipulation and Abdominal Strengthening
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Utilized with infants with significant reflux Rectus abdominus home program to increase GI motility, reduce constipation, and increase gastric emptying Visceral Manipulation: mobilization of abdominal viscera to support GI motility Sandafers syndrome: severe reflux that ends up causing torticollis and cranioplagia -- baby goes into extension and turns head away from stomach when they reflux
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Caregiver Education
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Joint compression, PROM Tummy Time Back to sleep Flexion swaddling Feeding techniques: including use of home bottles while in NICU Abdominal development Visual development Referral to Early Intervention KT/splinting education as needed Expected development
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Dev Education to parents of children with special needs
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Trisomy 21 Cardiac complications Genetic syndromes Orthopedic anomalies Referral to appropriates outpatient services: Rehabilitation, Specialized physician, VFSS, NICU follow-up clinic
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NICU Follow-up Clinic
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Corrected gestation age: corrected until 2 years of age, education to parents on developmental expectations Assess for development "red flags": cranioplagia, torticollis, asymmetry, cerebral palsy, etc At 12 month CGA completion of Bayley's Pediatric assessment
