November 6, 2009November 6, 2009

Susan M. Bickel, OTR/LDenise Doorlag, OTR/LBronson Methodist HospitalRehabilitation Department

Susan M. Bickel, OTR/LDenise Doorlag, OTR/LBronson Methodist HospitalRehabilitation Department

Supporting Development of the Premature Infant

after Discharge from the NICU

Objectives

• Able to state the progression of normal development of the preterm infant

• Able to identify the red flags of development and potential problems of the preterm infant

• Able to select appropriate developmental activities for the preterm infant

The Neonatal Intensive Care Unit at Bronson Methodist Hospital

•Bronson is a Level III NICU

•45 bed unit – all private rooms

•33 beds are intensive care

•12 beds are intermediate care

Our NICU Team

• Neonatologists• Nursing• Social Worker• Case Managers• Dietitian• Respiratory Therapists

• Developmental Specialist (OT)

• Pharmacist• Chaplain• Music Therapist• Child Life Specialist• Lactation Consultant

• Developmental assessment and treatment

• Feeding assessment and treatment

• Education to nursing and family

The Role of the OT in the NICU

Definitions

• NICU – Neonatal intensive care unit• Neonate – newborn infant-typically from birth through

day 28 of life• Gestational Age – the length of time the infant was

in utero• Post Conceptual Age – the age the infant is in

weeks from conception and as he ages• Adjusted/Corrected Age or Conceptual age –

same as post conceptual age• Chronological Age – the age of the infant calculated

from day of birth

Definitions

• Term – infant born 37 – 42 weeks• Post Term – infant born over 42

weeks• Preterm – infant born 28 – less than

37 weeks• Extremely Preterm – infant born

under 28 weeks

Definitions

• Appropriate for Gestational Age (AGA) – infant’s weight falls between a normal range of the 10th and 90th percentile for that gestational age

• Small for Gestational Age (SGS) – infant’s weight is less than the 10th percentile for that gestational age

• Large for Gestational Age (LGA) – infant’s weight is above the 90th percentile for that gestational age

• Intrauterine Growth Retardation (IUGR) – the infant’s weight and length are low for age

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Medical Conditions

• Respiratory complications• Respiratory Distress Syndrome (RDS) –

when tiny air sacs in the infant’s lungs do not stay open due to lack of surfactant

• Chronic Lung Disease – complications of the lungs that persist after 36 weeks of age requiring supplemental oxygen

• Bronchopulmonary Dysplasia (BPD) – abnormal growth of the infants airways and lungs due to high doses of oxygen and prolonged ventilator use

Medical Conditions

• Cardiac Complications• Patent Ductus Arteriosus (PDA) – a small

blood vessel that connects the pulmonary artery to the descending aorta that should close on its own after birth; if it does not close, it may require medical or surgical management

• Pulmonary Hypertension – increased pressure in the pulmonary blood flow

• Atrial Septal Defect – a heart defect where there is an opening in the atria

• Ventricular Septal Defect – a hole in the septum between the ventricles in the heart

Medical Conditions

• Neurological Complications• Intraventricular Hemorrhage (IVH) –

bleeding in the brain, often around the ventricles; very low birth weight infants are at high risk

• Hydrocephalus – an increase in cerebrospinal fluid in the brain

• Periventricular Leukomalacia (PVL) – decreased blood supply to the brain causing hollow spaces in the brain

Medical Conditions

• Neurological Complications• Hypoxic-ischemic Encephalopathy

– injury to the brain due to decreased oxygen to the infant

• Myelomeningocele – a protruding portion of the spinal cord and membranes

Medical Conditions

• Nutritional and GI complications• Necrotizing Entercolitis (NEC) – inflammation

of part of the intestine that may result in the death of that tissue; may allow bacteria to leak into the abdomen and cause infection

• Short – Gut Syndrome – infant is missing some intestine or too much has been removed

• Gastroesophageal Reflux Disease – contents in the stomach flow back up into the esophagus

Medical Conditions

• Nutritional and GI complications• Gastroschisis – a hole in the abdominal wall

resulting in some of the intestines developing outside the body

• Hirschsprung’s Disease – an extremely dilated colon requiring surgical removal of the affected area; lack of ganglia needed for peristalsis

• Omphalocele – a congenital hernia of the umbilicus

Medical Conditions

• Malformations• Club feet – where one or both feet

turn into adduction and supination• Cleft palate – a separation of the hard

or soft palate• Cleft lip – a separation of the upper

lip and often the upper dental ridge

http://www.cleftline.org/photos/campbell/campbell1.jpg http://en.wikipedia.org/wiki/Cleft_lip_and_palate

Bilateral Cleft Unilateral Cleft

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Club Foot

Medical Conditions

• Blood Complications• Anemia – low hemoglobin in the blood• Hyperbilirubemia – jaundice due to an excess of

bilirubin in the blood• Sepsis – infection in the blood

• Visual Complications• Retinopathy of Prematurity (ROP) – an abnormal

amount of blood vessels in the retina– often caused by increased oxygen use in infants– severe cases may result in retinal detachment

and blindness

Medical Conditions

• Other Complications• Brachial Plexus Injury – damage to

the brachial plexus during a difficult birth that may result in paralysis or weakness of the arm

• IDM – infant of a diabetic mother• Down’s Syndrome/Trisomy 21 –

most common syndrome characterized by one additional chromosome 21

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Down’s Syndrome

A Typical Stay in the NICU

• Nursing Care– One nurse may have 3-4 babies to care for– Infant is put on a 3 hour care schedule

• Diaper changed, meds given, clothes changed, blood pressure and temperature taken, heel stick/blood draw, suctioning, CPAP/vent changes and adjustments, feeding given through tube or by bottle, baths, feeding tube checked, position changed

• Infant is then able to have a calm/quiet sleep period until the next care time

– Often interrupted by other care such as physician, x-ray, therapy, respiratory care, eye exams, ECHOs, ultrasounds, and other medical care

A Typical Stay in the NICU

• Family Visitation– Families are allowed to visit whenever they

want to be there• Family is limited to mom/dad,

grandma/grandpa and siblings• Mom and dad can bring other visitors

with them• Families are not allowed to sleep at the

bedside– Barriers to family visits

• Families that live far away often have transportation problems

• Families that need to work• Families have other children at home

A Typical Stay in the NICU

• Ups and Downs of Medical Status– Extremely premature infants have

multiple system problems• Each day early on in life can bring a

new problem– The need for emergent surgery may arise– An infant may go through several

surgeries throughout their stay– Changes in respiratory status happen

daily – Even infants who are doing well, can

unexpectedly take a turn for the worse

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Development of the Premature Infant• The infant at 31 weeks and under:

– Behavior• Primarily in a sleep state• Brief periods of alertness when closer to 31 weeks• Able to consistently respond positively and

negatively to stimulation• Easily startled and agitated

– Motor• The extreme premature infants are generally

hypotonic until about 29 weeks– Oral Motor

• The sucking reflex is beginning but is weak and not very coordinated

Development of the Premature Infant•The infant at 32 – 36 weeks:

–Behavior•Able to demonstrate brief alert periods•Beginning to open eyes in response to stimulation•Attempts to calm self (hands to mouth)

–Motor•At 32 weeks developing more consistent hip flexion•Towards 36 weeks, demonstrating more consistent upper extremity flexion

–Oral Motor•Demonstrating the rooting reflex and beginning to work on oral feedings

Development of the Premature Infant• The infant at 37 – 40 weeks:

– Behavior• Infant awakens on his own• Tolerates longer alert periods with greater

tolerance to stimulation• Beginning to track and focus with eyes

– Motor• Flexor tone dominates throughout all four

extremities• More spontaneous and controlled movements

– Oral Motor• Consistent rooting reflex• Organized suck, swallow, breathe coordination

How to Correct for Gestational Age

• It is recommended that a child’s age is corrected up to 2 years of age.

• Subtract the number of weeks or months that the infant was early from the current age of the infant– Example: if the infant was born at 28 weeks

gestation, he was born 3 months early. When he is 6 months old, his corrected age is 3 months. He then should be expected to do 3 month old skills.

• The infant’s head, weight, and length measurements should be based on his corrected age.

• Remind parents how to correct for their infant’s age and also have the parent remind the doctor what the infant’s corrected age is.

Premature Infant vs. Term Infant

– Flexor tone of the preterm infant at term age is not as great as the infant born at term

– The preterm infant at term age will have less head control than the infant born at term

– The preterm infant at term age will have less predictable sleep-wake cycles and feeding patterns than the infant born at term

– Breastfeeding skills are not as mature in the preterm infant at term age

– The preterm infant at term age has decreased ability to tolerate multiple types of stimulation

Why Does the Premature Infant Develop Differently?

– Lack of the uterine environment• Inability to develop physiological

flexion• Decreased exposure to

movement and joint compression

• Early exposure to sound, light and other stimuli

– Poor positioning• Prolonged positioning in the

supine position resulting in poor head shape and weakened flexor muscles

Why Does the Premature Infant Develop Differently?

– Respiratory complications and medical instability• Abnormal tightness in muscles• Delay of initiation of feeding• Increase in noxious stimulus associated with

care• Early fatigue and decreased endurance with all

activity• Infants being sedated or on prolonged

ventilation may develop extending postures making it difficult to move normally and to self-organize (article: “Enhancing Occupational Performance in Infants in the NICU”)

Why Does the Premature Infant Develop Differently?

– Increased noxious stimuli and decreased pleasing interactions

• “Research shows that highly stimulating physical environments such as the NICU are stressful to infants and may affect their self-regulation and ability to engage in activities.” (article: “Enhancing Occupational performance in Infants in the NICU”)

• Due to high amounts of unpleasing stimuli in the NICU, infants have a hard time exploring the caregiver’s face and visually following the caregiver in poor social play (article: “Enhancing Occupational performance in Infants in the NICU”)

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Potential Problems of the Premature Infant

• Muscle tightness• Muscle weakness• Poor endurance• Visual problems• Feeding problems• Behavioral and Sensory problems

Red Flags of Preterm Development

• Muscle tightness– Infant prefers to turn head to one side– Flat spots on back/side of head– Arching– Difficulty bringing hands to the middle– Standing on toes– Delayed rolling– Difficulty changing diaper/changing clothes

How We Can Help

• Frequent position changes• Tummy time• Range of motion exercises/stretching• Eliminate walkers, exersaucers, and jumpers• Helmet use for severe plagiocephaly • Possible referral to physician for medication• Referral to physical therapy and occupational therapy• Educating parents on proper progression of

developmental milestones• Teach parents appropriate play activities to work on

midline, rolling, and tracking

Red Flags of Preterm Development

• Muscle weakness– Poor head control– Floppy baby– Delayed sitting– Delayed rolling– Delayed crawling– Decreased active arm and leg movements– Tires easily with activity

How We Can Help

• Practice supported upright sit• Range of motion exercises• Tummy time to help strengthen trunk muscles• Keep newborn swaddled when sleeping• Use mobiles, play gyms, and wrist rattles to

encourage movement• Pull to sit activities• Help facilitate muscle tone• Eliminate walkers, exersaucers and jumpers• Position infant so he can easily get hands to mouth• Possible referral to PT/OT, if developmental

milestones are not being met

Red Flags of Preterm Development

• Poor endurance– Sleepy baby– Unable to take whole feeding– Tires easily with activity

How We Can Help

• Help parents create a schedule for baby• Allow infant to have full, restful sleep in crib, away

from disturbances• Help parents understand why baby is fatiguing

Red Flags of Preterm Development

• Visual Problems– Infant does not make eye contact with caregiver– Infant does not track toy or face– Infant’s eyes are averted to the left or right– Infant prefers to look to the right or the left only

How We Can Help

• Provide a variety of toys that offer visual stimulation

• Educating parents on appropriate amount of visual stimulation

• Education on retinopathy of prematurity and how it may affect the baby

• Facilitating infant to look to the direction he favors the least

• Identify whether there is tightness in the neck, in which case, range of motion will be needed

• Infants respond best to visual stimulation that has depth such as parent’s face

Red Flags of Preterm Development

• Feeding Problems– Infant is not gaining weight– Infant falls asleep during feeding– Infant is irritable during feeding– Gagging or difficulty progressing to solids– Infant chokes or coughs during feeding– Infant changes color during feeding– Infant has increase in vomiting/spitting up

How We Can Help

• If infant is not gaining weight, refer to the physician• Help parents create a feeding schedule• Help parents understand how much food the infant

should be eating• Educate parents on why infant fatigues when eating• Consider need to try a different flow rate/nipple• Educate parents on symptoms and

recommendations of reflux• Educate on signs of aspiration• Consider referral to OT or speech for feeding therapy• Support the breastfeeding mom by referring to a

lactation specialist, if needed

Red Flags of Preterm Development

• Behavioral and Sensory Problems– Increased crying or irritability– Difficulty tolerating movement/position changes– Sleeping an unusual amount or difficulty waking– Delayed smiling or laughing– Inconsolable– Frequent and abrupt state changes– Infant not able to stay in a nice alert state for long– Not tolerating bath time– Frantic movements when unswaddled– Aversive to certain foods or stimulation around

mouth

How We Can Help

• Keep infant swaddled• Provide slow, gentle movement• Help parents create a schedule• Teach consoling techniques• Teach how to give proprioceptive input• Decrease or modify stimulation to a tolerable level• Support alert state with calm, positive interactions• Offer age appropriate social play

• Never, Never, Never Shake A Baby!

Assessing Behavior

1 = Deep sleep –infant is very still and difficult to wake up

2 = Light sleep – infant moves arms and legs to change position but usually goes back to sleep

3 = Drowsy – infant is just starting to wake up; eyes may be half closed; infant looks very tired

4 = Quiet Alert – infant’s eyes are wide open and bright; infant is quiet but looks very interested; good attention

5 = Active Alert – infant is awake but is becoming more active and may become fussy

6 = Crying – may mean infant is hungry, tired, wet, or needs help to calm down

Why We Need YOU!

• Some developmental problems may not be detected until after discharged home

• Parents need frequent reeducation on development• Sometimes parents need to be taught how to PLAY• Young parents need more support• Pediatricians are not always able to offer the time to

discuss developmental problems• Developmental delays may get missed at well child

visits• Due to an increased survival of very low birth weight

infants, there is an increase in prevalence of lifelong motor, cognitive and behavioral dysfunction.(article: “Positive Screening for Autism in Ex-preterm Infants: prevalence and Risk Factors”).

References• Limberopoulos C, et al. Positive Screening for Autism in

Ex-preterm Infants: Prevalence and Risk Factors. Pediatrics.2008;121(4): 758-765.

• Maddalena P, Gibbons S. Cerebellar Hemorrhage in Extremely Low Birth Weight Infants: Incidence, Risk Factors, and Impact on Long-Term Outcomes, Neonatal Network. 2008; 27(6): 387-396.

• Vergara E. Enhancing Occupational Performance in Infants in the NICU. OT Practice. 2002; July 8: 8-13.

• Van Haastert IC, etal. Early Gross Motor Development of Preterm Infants According to the Alberta Infant Motor Scale. The Journal of Pediatrics. 2006; Nov; 617-621.

• Wilson-Costello D, et al. Improved Neurodevelopmental Outcomes for Extremely Low Birth Weight Infants in 2000-2002. Pediatrics. 2007; 119(1): 37-45.

References• Da Costa SP, et al. Sucking and Swallowing in Infants and

Diagnostic Tools. Journal of Perinatology. 2008; 28: 247-257.

• Limperopoulos C, et al. Does Cerebellar Injury in Premature Infants Contribute to the High Prevalence of Long-term Cognitive, Learning, and Behavioral Disability in Survivors. Pediatrics. 2007; 120(3): 584-593.

• Vandenberg K. Assessing Behavior Organization in Infants. Physical Assessment of the Newborn: A Comprehensive Approach to the Art of the Physical. 329-339.

• Vergara E, Bigsby R. Developmental & Therapeutic Interventions in the NICU. 2004. Paul H Brookes Publishing Co.

• Staff of The Children’s Hospital Denver, Colorado, Cregar P (editor). Developmental Interventions for Preterm and High-Risk Infants. 1995. Therapy Skill Builders.