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Star-Gazing:
Medical and
Therapy Issues Huntsville Hospital Health System
Kimberly Limbo, MD
Stephanie Gyorok, PT and Mary Cofer, PT
Denise McNichol, OTR and Ginger Mason SLP
Disclosures
Dr. Limbo has no disclosures
Stephanie Gyorok, PT has no disclosures
Mary Cofer, PT has no disclosures
Denise McNichol, OT has no disclosures
Ginger Mason SLP has no disclosures
Overview of Medical Conditions
followed by Pediatric Neurology
Infants who underwent induced hypothermia
In utero stroke
Congenital CMV
Brachial Plexus Injury
Plagiocephaly
Brain malformations
Preterm infant
Intraventricular Hemorrhage (IVH) of newborn
Induced Hypothermia
Which infants qualify
36 week or older gestational age
Initiation within 6 hours of life
Severe acidosis within 1st hour life
Perinatal complications
Resuscitation at birth – APGAR less than 5 at 10minutes or
need continued ventilation at birth for at least 10 minutes
afterward
Induced Hypothermia
Goal of induced hypothermia is to reduce risk of death
or disability in infants with moderate to severe hypoxic
encephalopathy
Aim to decreased body temperature between 33.5*C to
34.5*C fro 72 hours
Rewarm gradually at 0.5*C per hour until desired range
(36.5*- 37*C)
Induced Hypothermia
What occurs during cooling
Decreased heart rate
Decreased metabolic rate and shivering
Induced Hypothermia
Outcome
Goal to diminish neurological impairment related to initial
brain injury
Followed in clinic for first 12 to 18months
- Monitor head circumference
- Monitor development
- Monitor for seizures
In Utero Stroke
Neonates differ from Adults
• Etiology is not well understood
• May not be identified until infant is older
• Perinatal can present with seizures and perinatal distress
in term infant
• Often identified on MRI Brain
• Coagulation testing not indicated
• Risk of recurrence is low at later time in life
In Utero Stroke
Most affect the Middle Cerebral Artery
Outcome affects more motor issues with sequela of
cerebral palsy
Monitor of use of affected side for weakness and
spasticity
Possible development delay
Seizure not common after neonatal period
In Utero Stroke
Treatment goal is to minimize deficit of affected side
Constraint induced therapy can be useful
Congenital CMV
Clinical findings and imaging
Change in therapy
Change in developmental outcome
Hearing Concerns
CMV symptoms at birth
Small size for gestational age (39 to 50 percent)
Microcephaly (36 to 53 percent)
Sensorineural hearing loss (SNHL, present at birth in 34
percent)
Lethargy and/or hypotonia (27 percent)
Poor suck (19 percent)
Seizures (4 to 11 percent)
CMV – imaging findings
• Periventricular calcifications
• Periventricular leukomalacia
• Ventriculomegaly
• Vasculitis
• Polymicrogyria
CMV treatment
10 years ago – no treatment
Ganciclovir – IV treatment twice a day for 6 weeks
Valganciclovir – oral treatment twice a day for 6 months
Followed by Pediatric ID/CMV clinic in Birmingham at
Childrens Hospital
CMV outcome
Prior to treatment – significant development delays and
hearing loss
Post anti-viral treatment – diminished development
delays and hearing loss
Hearing loss is sensorineural –hearing evaluation every 6
months for 1st 3 years of life and then yearly til 6 years
old
Hearing loss -fluctuate severity & age of onset
Brachial Plexus Injury
Stretch injury
Outcome
Goals of therapy
Surgical Intervention
Brachial Plexus Clinic at Children’s Clinic in
Birmingham
Plagiocephaly
Cosmetic issue
Window of time to intervene – positioning and use of
Tortle
Helmet use issue – limitations as insurance often not
cover and length of use and adjustments
Craniofacial Clinic at Children Hospital in Birmingham
Brain Malformations
Hydranencephaly
Holoprosencephaly
Schizencephaly
Polymicrogria
Agenesis of Corpus Callosum
Most brain malformations are associated with seizures
Hydranencephaly
Occurs in second trimester
Exact cause remains undetermined in most cases, the most likely general cause is by vascular insult such as stroke or injury, intrauterine infections, or traumaticdisorders after the first trimester of pregnancy
Brain's cerebral hemispheres are absent and replaced by sacs filled with cerebrospinal fluid
An infant with hydranencephaly may appear normal at birth.
Associated with: development delay, seizures, spasticity, visual and hearing deficits, endocrine issues, and macrocephaly
Holoprosencephaly
Occurs in early - prior to 5th week of gestation
Brain doesn't properly divide into the right and left hemispheres.
If severe = can also affect development of the head and face
Linkes to mutations in at least 14 different genes, chromosome abnormalities; maternal diabetes, alcohol and retinoic acid
Based on severity associated with: seizures, hydrocephalus, endocrine issues, feeding difficulties, and instability of temperature, heart rate, and respiration, developmental delay
Schizencephaly
Abnormality in formation of cerebral hemisphere
Majority are sporadic
Has been linked to mutation in 4 genes: EMX2, SIX3, SHH, and COL4A1
Can be associated with:
Development delay
Seizures
Microcephaly
Intellectual disability
Hemiparesis
Polymicrogyria
Occurs late in pregnancy
Is result when surface of the brain develops too many folds which are unusually small.
Signs and symptoms associated with the condition vary based on how much of the brain and which areas of the brain are affected
Linked to some genetic and chromosomal abnormalities and infection such as CMV
Associated with:
Seizures, development delay and weakness
Agenesis of the
Corpus Callosum
(ACC)
Corpus callosum connects right and left brain
Occurs between 8th to 20th week of pregnancy
No single cause – 95% sporadic in occurrence, some related to genetic abnormality
Component in >100 syndromes
ACC has variable prognosis
Can be associated with other brain anomalies
Associated with:
Delays with motor, language and/or cognitive milestones
Seizures
Endocrine issues
Intraventricular Hemorrahage
(IVH)
Risk factors
Grade of IVH
Possible sequela
Monitoring in NICU and once home
Risk Factors of IVH
infants <750 grams
assisted conception
intrapartum factors (emergency cesarean section, low Apgar scores)
early neonatal complications (patent ductus arteriosus, pneumothorax, pulmonary hemorrhage)
blood gas disturbances, and need for pressor, volume infusion, and respiratory support
Grades of IVH
grade I restricted to
subependymal
region/germinal matrix grade II extension into normal sized ventricles and typically
filling less than 50% of the volume of the ventricle
grade III extension into dilated ventricles
grade IV grade III with
parenchymal haemorrhage
Possible Sequela of IVH
• Grade 1 & 2 with good prognosis
• Grade 3 & 4 more likely to have deficit
• Spasticity with sequela of cerebral palsy
• Hydrocephalus
• Developmental and learning delays
Medication options for
Spasticity
Botox
Baclofen
Botox
Derived from Botulimun Toxin
Off-label for children under 12 yo
Indications
Typical age when done
Who does it – Rehab, orthopedics, neurology
Duration and goals
Baclofen
Indications
Oral
Intrathecal Pump
Who is candidate
How does it work
Refill and Duration
Red Flags for Referral to
Neurology
Regression of Milestones attained
Asymmetric Use of Extremities
Abnormal Tone
Increased
Decreased
MRI brain normal as newborn
• Misnomer if neurological concerns
• When to repeat MRI brain
Resources for Family &
Providers
Specific Websites
https://rarediseases.info.nih.gov/diseases
https://www.ninds.nih.gov/
https://espanol.ninds.nih.gov/
Children Hospital of Birmingham Clinics
Craniofacial Clinic
Spasticity Clinic
Brachial Plexus Clinic
THERAPUTIC MANAGEMENT OF THE
PRETERM INFANT
TIMES ARE CHANGING
11.7% of neonates are born preterm annually
Over 40,000 infants born each year in US are extremely
preterm less than 28 weeks = approximately 1% of live
births
Incidence of feeding problems in 19-80% of extremely
preterm infants
TIMES ARE CHANGING
There is now an increase in survival rates of extremely preterm infants secondary to advances in medical care
With improved survival rates there are increased risks for nutritional, growth, motor and sensory problems
Delay of acquiring feeding skills is the most frequent cause of prolonged hospitalization in the NICU
Delay of acquiring feeding skills negatively affects family relationships
Do we impact brain
development?
NEUROPROTECTION
Neuroprotection = interventions that promote brain
development and prevent neuronal injury in the
developing premature neonate related to stress and/or
pain.
Interventions that promote neuronal connectivity are
essential to protect the developing brain.
ALL EARLY experiences affect the developing brain
Repeated stressful experiences during feeding are
believed to establish altered pathways in the infants
developing brain that guide the infant away from
feeding, lead to maladaptive behaviors, and adversely
affect the ability and desire to feed both in the NICU
and well into childhood.
Shaker, 2017
NEUROPROTECTION
5-15% of very preterm infants have neurobehavioral
disabilities (ex. CP) and severe neurosensory impairment
50-70% VLBW (≤ 1500g) have later dysfunction that impedes
school progress
Preterm birth is associated with high rates of both poor
neurobehavioral organization and cognitive function
Typical NICU environment is stressful for infants leading to
maladaptive physiological processes and predisposition to
disease and poorer developmental outcomes.
(Pickler 2013)
NEUROPROTECTION
Even infants without neurologic injury may develop
cognitive dysfunction with decreased attention,
memory, and reasoning skills
The human brain is functionally altered through
experience, and all experience is filtered by the senses
(touch, taste, smell, sound, and sight)
EI strategies seek to take advantage of neuroplasticity
which is most sensitive 2-3 months -15-18 months after
term age, congruent with a goal of neuroprotection.
(Pickler 2013)
WHERE DO WE START?
MULTI-DISCIPLINARY
EVALUATION OF INFANTS
Case History Intake
Age of infant
Pregnancy History
Delivery history
NICU History
Detailed medical history
Feeding history- Feeding problems/recommendations/positions
Hearing History- Newborn Hearing Screen (NBHS)-Diagnosis/meds related to hearing loss
Family/social history
MULTI-DISCIPLINARY
EVALUATION OF INFANTS
Musculoskeletal screen
Neuro screen
Integumentary screen
Cardio respiratory screen
Infant/Child state, movement patterns
MULTI-DISCIPLINARY
EVALUATION OF INFANTS
Age at initial visit
• CGA (current gestational age) : actual days since
birth
• Corrected age : Chronological age – number of
weeks born before 40 weeks of gestation
• Gestational age : Time from the first day of the last
menstrual period and day of delivery
• PMA (post menstrual age) : Gestational age +
chronological age
MULTI-DISCIPLINARY
EVALUATION OF INFANTS
Pregnancy history
Drug use
Gestational diabetes
Pre-eclampsia
PIH – pregnancy induced hypertension
NPC – No prenatal care
MULTI-DISCIPLINARY
EVALUATION OF INFANTS
Delivery history
Birth presentation
Use of assistance during delivery (forceps, vacuum
suction)
What complications led to preterm delivery
PROM – premature rupture of membranes
Placenta abruption
NRFS - Non-reassuring fetal status
MULTI-DISCIPLINARY EVALUATION OF
INFANTS
NICU Diagnoses
Time spent in NICU
NICU interventions and diagnoses
Ventilator
O2 dependent
ROP – retinopathy of prematurity
Feeding / swallowing problems
including special positioning needed for feeding
MULTI-DISCIPLINARY
EVALUATION OF INFANTS
NICU Diagnoses
Prematurity
Extremely Pre-Term- under 28 weeks
Extremely low birth weight – under 1000 grams
RDS- Respiratory Distress Syndrome
BPD- Bronchopulmonary Dysplasia
NEC- Necrotizing Enterocolitis
NAS- Neonatal Abstinence Syndrome
GBS – Group B Strep or other infections
CMV – Cytomegalovirus
MULTI-DISCIPLINARY
EVALUATION OF INFANTS
Neurological Impairment
IVH-Intraventricular Hemorrhage
PVL-Periventricular Leukomalacia
Hypoxic Ischemic Encephalopathy
Kernicterus- high bilirubin levels
MULTI-DISCIPLINARY
EVALUATION OF INFANTS
• Cardiac Disorders
• Patent Ductus Arteriosus (PDA)
• Atrial Septal Defect (ASD)
• Ventricular Septal Defect (VSD)
• Digestive Tract Disorders
• GER/GERD
• Pyloric Stenosis
• Motility Disorders
• NEC
• Short Gut
• Eosinophilic Esophagitis
• Hirschsprung’s Disease
MULTI-DISCIPLINARY
EVALUATION OF INFANTS
Failure to Thrive/Poor Weight Gain
Respiratory
Respiratory Distress Syndrome (RDS)/Chronic Lung Disease (CLD)
Bronchopulmonary Dysplasia (BPD)
Tracheal Stenosis
Laryngomalacia/tracheomalacia
Craniofacial Anomalies
Clefts
Pierre Robin Sequence
Goldenhar
Treacher Collins Syndrome
MULTI-DISCIPLINARY
EVALUATION OF INFANTS
Musculoskeletal Screen
o Symmetrical shape of the face, skull, and spine
o Rib cage symmetry
o Hip dysplasia
o Symmetrical neck ROM
o Palpation for sternocleidomastoid (SCM) masses or
restricted movement
o Congenital limb defects
o Orthopedic conditions, such as club feet
MULTI-DISCIPLINARY
EVALUATION OF INFANTS
Neurological Screen
o Abnormal or asymmetrical tone
o Reflexes
o Cranial nerve integrity
o Temperament (irritability, alertness)
o Developmental milestones
o Visual screen (symmetrical eye tracking, visual field
defects, nystagmus)
MULTI-DISCIPLINARY
EVALUATION OF INFANTS
Integumentary Screen
o Skin fold symmetry of hips and cervical region
o Color and condition of the skin
MULTI-DISCIPLINARY
EVALUATION OF INFANTS
Cardiorespiratory Screen
o Symmetrical coloration
o Rib cage expansion
o Clavicle movement
o Cyanosis- bluish discoloration of the skin
o Tachypnea- rapid respiratory rate
o Stridor- high pitched “crowing” sound
o Increased work of breathing (WOB)
MULTI-DISCIPLINARY
EVALUATION OF INFANTS
Gastrointestinal history
o History of reflux or constipation
o Prefers to feed from one side
MULTI-DISCIPLINARY
EVALUATION OF INFANTS
State of Infant- How does the infant respond to stimulus
in their environment- sounds, sights and movement.
How do they respond to handling and care times. State
needs to be assessed throughout the evaluation and
each treatment session.
6 Levels of State
1. Deep Sleep
2. Light Sleep
3. Drowsy or Semi-Drowsy
4. Alert
5. Active
6. Crying
Diagnosis and Effects on
Therapy
• Cardiac and Respiratory Patients present with problems related to:
• Endurance
• Fatigue
• Tone
• State
• Limited oral intake
• Tachypnea/increased work of breathing
• Poor coordination of Suck Swallow Breathe Sequence for non-nutritive suck (NNS) and nutritive suck reflex (NS)
• Poor weight gain
• Aspiration
Diagnosis and Effects on
Therapy (cont.)
Neurological Patients present with problems related to:
State
Endurance
Fatigue
Tone
Movement/Organization
Aspiration
Coordination of suck swallow breathe sequence
for non-nutritive suck (NNS) and nutritive suck
(NS)
Diagnosis and Effects on
Therapy (cont.)
Patients with digestive tract disorders present with problems related to:
State
Tone
Movement/Organization
Endurance
Food Refusal
Extended feeding periods
Constipation
Vomiting
Aspiration
How do we recognize these
problems in infants?
Infant communication
Infant Communication
Signs of Stability
Typical behaviors:
Smooth, regular respirations
Hands actively near face, with good, consistent postural control throughout body
Organized, calm, and with optimal color
Focused, clear alertness- alert state
Smooth state transition
Good coordination of sucking, swallowing and breathing on a pacifier- Non Nutritive suck (NNS)
(Shaker, 1999)
Infant Communication:
Stress Cues
Signs of Stress Gaze Aversion
Furrowed Brow
Raised eye brows
Arms /legs in extension
Finger/toe splays
Arching
Increase in tone
“Shutting down”
Irregular respirations
Video
Preterm Infant –
What to Expect?
Preterm Infant
Typical Motor Characteristics
Decreased flexor muscle tone
Decreased typical flexion contractures/posture
Decreased anti-gravity movements
Decreased midline movements
Primitive reflexes, including Moro and palmar grasp
May be absent
May persist longer that the full-term infant
Preterm Infant
Typical Motor Characteristics
• Tone not developed- Lower extremity tone develops 33-35 weeks
- Upper extremity tone develops 35-37 weeks
- Influenced by cramped intrauterine environment
• Muscle fiber differentiation by 20 weeks- Higher ratio of fast-twitch fibers
• Prevention of nursery-acquired deformities
Preterm Infant
Typical Motor Characteristics
• Prevention of nursery-acquired deformities
General Progression/What to Expect?
Flexor Tone
Improves as preterm baby approaches 40 weeks gestation
Generally does not reach the full degree of flexor tone present
in a term infant
Predominance of extensor tone with tendency for neck
hyperextension
General Progression/What to Expect?
Isolated Delay or Single Abnormal Sign
Does not always indicate that a child has a significant problem
These infants tend to grow and develop at different rates
Should be closely monitored
Jittery Movement Quality
May improve or resolve with time
Should be closely monitored
General Progression/What to Expect?
Delays in Head and Trunk Control
May be due to lengthy immobilization due to medical
complications
Can also be due to compromised respiratory or cardiac status
May resolve as infants medical condition improves
Should be closely monitored
Test of infant motor performance (TIMP)o Identify infants with motor delay from 34 weeks PCA through 4 months GA or CA
o Self-instructional program available from IMPS, LLC
o www.thetimp.com
o Selective control
o Midline alignment
o Quality of movement (fidgety, ballistic, oscillating)
o Elicited items
o Postural control
Anti-gravity
Organized synergies
In functional context
Elicited by natural handling
Predict 12 month motor performance
90 day TIMP score most sensitive for predicting future performance with the PDMS-2
General Progression/What to Expect?
Video- Pathways.org (6 minutes)
https://pathways.org/watch/2-month-old-
baby-typical-and-atypical-development/
Other videos available up to 1 year old
Handouts and other information available
General Progression/What to Expect?
Red flags include
Consistent and persistent movement asymmetries
More than typical hypotonia without explanation
Hypertonia
Lack or very slow rate of progression
Guiding Principals of Treatment
Individualized support
Support the infant/child where they are
Support emerging skills
Carefully watch response to interventions to ensure tolerance
and a positive experience
Support the caregivers where they are
Are they ready for action, or just beginning to process their
child’s needs?
What can they do at this time and what are the obstacles?
What we wish every new parent knew
Infant cues
Plagiocephaly and Torticollis Prevention
Prone time benefits
Movement stimulation
Plagiocephaly and torticollis
prevention
• Plagiocephaly is a flattening of one side of the back of the head and
contralateral forehead
• Torticollis is tightness of the SCM on one side of the neck causing a tilt of
the head to one side and/or rotation of the head to the opposite side
• Can affect vision and motor skill development
• Many cases can be prevented with education
Increased incidence due to time spent on back for safe sleep
Premature infants at greater risk due to low tone and movement asymmetry
Positional plagiocephaly may increase risk for torticollis
Plagiocephaly and torticollis
prevention
Torticollis
Plagiocephaly and torticollis
prevention
Plagiocephaly and torticollis
prevention
Screen each infant
Early treatment improves outcomes
Torticollis and head shape in NICU
Prone positioning when extremely premature
Positioning due to medical interventions
Environmental factors (bed position, care side)
Feeding positions
**If patient is being seen by SLP for feeding, check with
SLP before making any feeding position
recommendations**
Reflux may lead to R rotation preference
Usually minimal loss of PROM
May have strong preference for AROM
Initially start with stretching and/or positioning program
If ROM and repositioning ineffective, may use Tortle
Tortle Midliner
Designed for premature babies
Adjustable, soft beanie, designed with two support rolls made of
polyurethane foam
Velcro front opening to minimize infant handling and help reduce
stress
Highly compatible with attachments, including: CPAP, nasal
cannulas, feeding tubes, and more
Head circumference from 24-38 cm
https://tortle.com/medical/tortle-midliner
Tortle Midliner
Tortle Midliner
Tortle Air
Lightweight beanie with a single support roll
The Tortle Air’s single support roll
Velcro front opening to minimize infant handling and help reduce stress,
as well as elastic side tabs to ensure a proper fit.
Positioning aid to assist with proper head repositioning, which helps to
prevent and manage cranial asymmetry and head preference issues.
Do not use during unsupervised sleep or in car
Used for infants up to 9 Kg
www.tortle.com
Tortle Air
https://www.tortle.com/pages/how-to-properly-wear-tortle
Plagiocephaly and torticollis
prevention
Back to sleep
Head at opposite end of the crib each night
Turn baby’s head to the opposite side each night
Alternate the arm you hold baby in for feeding
Carry baby on alternating sides
Play with your baby in the middle and then to each side, encouraging
head turning
Build tummy time in a variety of ways
Limit time in carriers and car seats
Plagiocephaly and torticollis
prevention
Excellent parent handout
Incorporates tummy time and prevention of
plagiocephaly and torticollis
https://www.choa.org/~/media/files/Childrens/medica
l-services/orthopaedics/orthotics-and-
prosthetics/tummy-time-tools-update-2014.pdf?la=en
Torticollis – Other Considerations
o Hip dysplasia
o Scoliosis
o Clavicle fx
o Brachial plexus injury
o Congenital and/or genetic conditions
o Skull and/or facial asymmetry
o Atypical presentations, such as tilt and turn to the same side
o Abnormal tone
o Late onset torticollis at 6 months or older
o Visual abnormalities
o History of acute onset (trauma or acute illness)
More of what we wish every
parent knew….
Movement and Development
Movement stimulation
Role of OT and PT in infant population
Therapists generally receive little training in the role of
the vestibular system- it may be overlooked
How does movement stimulation impact development?
How does movement stimulation
impact development?
All of the movement in utero and after birth facilitates
a baby’s development – physical, visual, intellectual.
A baby needs movement to learn in order to self soothe,
move, communicate, learn
We derive our physical abilities through all types of
movement. We have to know where we are in space in
order to know where everything else is.
We learn to identify and manipulate and change as well
as recall what we identified.
Take a moment
How many times do you move in a minute?
Our bodies need movement at any age to
Keep us awake
Be on guard
Physically fit
Aware of our surroundings
Mentally alert
As Mom moves
Baby moves in amniotic fluid
Movements are reflexive to build future skills
Enhances sensory system development
Prepares baby for birth
Facilitates development through early childhood
Reflexive movements build
future skills
Relation of reflexes and sensory development
Vestibular
Vision
Proprioception/body awareness
Reflexive movements build
future skills
Supported suspension in amniotic fluid
Rhythm – mom’s heartbeat, walking, talking
Sound – exposure through the womb
Visual orientation to changes in light intensity
Heavy work in utero builds muscle tone secondary
to decreased space
Participation in birth process
These exposures are limited in a baby who is
born prematurely
Primitive reflexes
• Help us to move
• Integration of reflexes develop quality of our
movements
• Our reflexes help us to roll over, crawl, creep –
constantly dependent upon baby’s head position in
space
• As reflexes integrate, they allow baby to function with
more mature movement patterns.
• We continue to use the reflexive patterns throughout
life – i.e. pitch a ball,
• Reflexes help us to learn the motor movement and
coordinate the sequence of movements.
After birth• Exposure to movement through external means
• Picked up/carried by caregivers
• Infant swing, car rides, strollers, rocking to sleep
• This movement exposure is limited in a medical
setting
Medical stability and tolerance for handling
On monitors limiting distance from the bed
Nurse caring for multiple babies
Varying parent ability to spend time in NICU
Eventually hierarchy of movement begins with active
movements such as batting with arms, kicking with
legs, rolling, etc.
Movement
• During the first year of life, the baby
learns many motor skills through the
information provided by the tactile,
kinesthetic, and vestibular systems in
response to visual and auditory input
Movement types
Movement can be slow/rhythmical (stroller or swing) or
more unpredictable (hitting a bump while in the
stroller) – both benefit the baby through different
sensory systems in different ways
Movement can benefit development – each sensory
system has a dual function of perceiving and
interpreting sensory awareness and providing precise
discrete sense of detail
Movement system
• Tells infant which way is up and where infant is going
• Tells exactly where we are in space even with ever
changing environment
• Responds to changes at all times in all conditions
• Can impact self regulation, social emotion skills,
confidence and well being
• Internal GPS – inner ear receptors help us to maintain
orientation of head/body during movement and auditory
and visual systems for time/space
Organization of movement
In the NICU and early intervention setting, we focus a
great deal on organization of movement and midline
development
Organization of movement promotes
coordination, orientation to midline
visual attention/tracking of caregivers
sucking on pacifier/bottle
reaching, batting at objects
and then later…supporting self when sitting, using
arms/legs when rolling, list of skills is endless
Midline orientation helps coordinate use of arms
together or individually, encourages grasping, holding
bottle, shaking toys, bringing fingers to mouth
Movement begets movement
Improves ability to learn motor skills, perform accurate
movements, anticipation/timing of motor commands,
fine tuning muscle movements
Motivation to repeat movements that infant finds novel
or enjoyable from the vestibular/kinesthetic feedback
they get
Communication/social
emotional development
Movement helps thinking/communication and builds
confidence and competence
As the movements develop, social and communication
skills also develop
Lack of movement/Lack of
stimulation
Premature delivery
May have extensive hospitalization which limits
opportunities for typical exposure to movement
May be limited in strength, mobility in order to move
themselves, kick, bat at toys
May need more movement opportunities to help develop
these skills
How do we make up for lost
time?
Early treatment
Babies can be referred to OT while in the NICU –
movement programs are initiated
Some babies start with only 3-4 repetitions of movement
Tolerance to movement can be very low when movement is
initiated after
Once home from hospital, movement programs need to
be continued to facilitate development of all systems
(sensory and cognition/communication/perceptual)
Watch baby’s cues
20 minutes in a swing at a time is enough
Movement is good – holding/rocking, swinging
Continued therapy as needed – Early Intervention, Out
patient therapy
FEEDING AND THE
PRETERM INFANT
Feeding is a COMPLEX
DEVELOPMENTAL SKILL that has
to be LEARNED
There is no light bulb suddenly
turning on
PREMATURE INFANT
=
PREMATURE SKILL
Typical Feeding Reflexes
16-17 weeks- swallowing regulates amniotic fluid
25-26 weeks- rooting reflex emerging; sucking reflex
continues to improve
27-28 weeks- beginning of swallow reflex
32 weeks- improved coordination of swallowing; rooting
is complete; gag and non-nutritive suck present
34-35 weeks- coordination & strength to begin bottle
feeding, poor endurance
36 weeks- coordinated nutritive suck
37-38 weeks- suck-swallow reflex like full-term infant
(Miller, Sonies & Macedonia, 2003)
Challenges with
Feeding Bottle feeding is a physiologically challenging activity
for preterm infants
Due to immature brain development
Difficulty in regulating breathing, heart rate etc.
Difficulty in achieving behavioral state organization when presented with stimuli. (Pickler, 2004)
Infant Challenges With Feeding
Highest profile for feeding problems are extremely
preterm- under 28 weeks and extremely low birth
weight under 1000gm
The following diagnosis are at greater risk for feeding
difficulty:
Respiratory
Cardiac
Digestive
Neurological
Craniofacial
(Shaker, 2017)
Reading the infants cues is the first step in providing
developmentally supportive care
Effective feeding is achieved by responding contingently
to the stress signals related to swallowing and breathing
This supports the infant in maintaining or regaining
coordination, facilitates endurance, ensures adequate
intake and promotes safe feedings.
(Shaker, 1999)
Cue based/Infant Driven
Feeding
Detailed medical history
State
Movement Patterns/Tone
Facial symmetry
Pre-Feeding observations- baseline
Respiration
Clear
Stridor
Labored breathing
Supplemental Oxygen
Secretion Management
Tracheostomy
Feeding
Oral motor assessment
Assess oral motor reflexes for root, gag, phasic
bite, tongue protrusion, transverse
tongue/sucking, swallowing
Non- nutritive suck (NNS)
Very high ratio or 6/8:1 (suck: swallow)
2 sucks per second
Stable pattern of bursts and pauses
(Wolf & Glass , 1992)
Feeding
Nutritive Suck Reflex (NS)
1:1 suck:swallow ratio in young infants
2/3:1 suck swallow ratio in older infant
One suck per second
Initial continuous suck bursts moving to shorter
bursts and longer pauses as feeding progresses (Wolf
& Glass, 1992)
Feeding Observations
Readiness to feed
Oral motor skill
Overall stability
Infant communication
Signs of Stability
When the preterm infant is coordinating sucking, swallowing, and breathing his behaviors reflect self-regulation.
Typical behaviors of an infant nippling well:
Smooth, regular respirations (minimal to no increase in respiratory effort beyond pre-feeding baseline)
Hands actively near face, with good, consistent postural control throughout body
Organized, calm, and with optimal color (little to no change in color from pre-feeding baseline)
Focused, clear alertness
Good coordination of sucking, swallowing and breathing
(Shaker, 1999)
Signs of Stability
Although an infant may reflect signs of self-regulation when he begins a nipple feeding, it is often difficult to maintain self-regulation with the ongoing effort required.
Careful attention to the infant’s behaviors can facilitate early recognition of emerging stress. The feeder can then promote and sustain stability and self-regulation, intervening whenever the infant shows, through his behaviors, that he is losing stability and can not self regulate.
(Shaker, 2013)
Signs of Stress
The following behaviors, which reflect disruption of
the suck-swallow-breathe synchrony are signs of
stress during nipple feeding:
Color change
Breathing
Swallowing
Change in state
Behavioral Stress Signs
(Shaker, 1999)
Signs of Stress-
Color Change
1. Color change
– earliest stress signal
– may be subtle
– indicates a decline in oxygen
– infant feeds too quickly and takes shallow breaths
– Sudden color change may be infant holding breath to
protect airway
– (Shaker, 1999)
Signs of Stress-
Breathing
2. Breathing
Respiratory fatigue
Tachypnea – rapid breathing
Nasal flaring and/or blanching
Chin tugging /head bobbing
Reliance on shallow “catch” breaths
High-pitched “crowing” sounds- Stridor
(Shaker, 1999)
Signs of stress
Swallowing
3. Swallowing Drooling – formula spilling out of the mouth
Gulping
Gurgling sounds in the pharynx- wet vocal
quality
Swallowing several times in succession
Coughing or choking
(Shaker, 1999)
Signs of Stress-
Change in State of Alertness
4. Change in state of alertness:
A quiet alert state is optimal for feeding- the infant is best able to focus on the feeding task and display vigor and rooting. As a result, the muscle movements required for feeding are more likely to be organized and timely.
A subtle change in state may be the first sign that the infant is losing control. Ex: A calm infant that starts to become fussy may be a fussy baby. However, increasing fussiness may be a sign of stress due to demands of feeding.
(Shaker, 1999)
Signs of Stress
Change in State of Alertness
An infant that gets drowsy and falls asleep may be exhibiting respiratory fatigue related to feeding too fast, inadequate oxygenation, or excessive respiratory effort.
An infant may be drowsy from demands made on him before the feeding such as bath, or waiting for his feeding
Drowsiness may also be his way of controlling the input he receives- this may be him “shutting down”
(Shaker, 1999)
Signs of Stress- Behavioral
Changes in facial expressions- Especially in the eyes
Raised Eye Brows
Furrowed Brow
Wide Eyes
Loss of tone/flexion
Pulling away
Pushing nipple out with tongue or hands
Extremities
Arms move away from midline
Fingers splay
Strategies
Do not feed past the infants “stop signs”:
Pushing the nipple out
No active rooting or sucking
Arching
Shutting down
Irritability
Feeding past the stop signs may cause
aspiration
lead to maladaptive behaviors
long term feeding refusals
Strategies
The following strategies relate directly to facilitating
coordination with bottle feeding and swallowing:
Supporting state regulation
Positioning
Imposed Breaks/Pacing
Bolus Size
Flow Rate
Chin and cheek support
Avoiding prodding
(Shaker, 1999)
Strategies
Supporting State/Regulation:
Patient must be in an optimal state of alertness for feeding. Drowsy/semi-dozing, quiet alert and active state.
The state needs to be maintained throughout the feeding through re-alerting or calming
Repositioning
Burping
Reswaddling
(Shaker, 1999)
Strategies
Positioning-
Modified sidelying position is generally the preferred position for feeding premature infants.
mimics breastfeeding position
Sidelying position with a slightly upright tilt, head higher than feet
more control of the bolus/liquid and decreases risks of choking
Additional Positions
Cradle
Semi Upright in lap-upper body & head 45 degree angle to buttocks
(Shaker, 1999)
Side lying
https://babylink.scot.nhs.uk/FamilyCentredCare/CaringForYourBaby/BottleFeeding/
Pages/HowToBottleFeedYourBaby.aspx
Strategies
Positioning
With positions you want to facilitate a neutral head-neck flexion- chin slightly tilted down
You do not want the head extended or with excessive flexion as this can compromise the airway
Keep head at midline – not to one side
Swaddle and support the infant with a blanket, elbows inside, to promote hands toward midline/center of body and to contain infant
Avoid swaddling arms away from face and do not lose sight of arms and hands as they provide information regarding infants experience and energy level with feeding
(Shaker, 1999)
Strategies
Imposed breaks/pacing – Brief breaks that are offered to help the infant maintain or regain self regulation during nipple feeding.
Tilting the bottle down slightly or removing from mouth and allowing patient to show readiness to resume feeding
Imposed breaks/pacing may be used to provide:
Brief rest
Decrease fatigue
Pace energy expenditure
Provide time to reorganize breathing
Promote deep breathing
Provide time to clear the mouth or throat
Improve bolus control
Slow the infant down when he is gulping (Shaker, 1999)
Strategies
Imposed breaks/pacing-
Infants need to be paced based on cues such as:
Raising eyebrows- typically one of the first signs
that infant needs pacing
Eye widening
Pulling head backward
Abrupt/rapid change in muscle tone
(Shaker, 1999)
Strategies
Bolus size-
Bolus size can have a significant effect on breathing and
swallowing
Too large a bolus can lead to coughing or choking
Bolus size is determined by number of sucks infant
takes in a row
Fewer sucks smaller bolus
Observe number of sucks infant takes before showing
cues of stress then limit suck bursts
(Shaker, 1999)
Strategies
Flow rate
Respiration, feeding ability and swallowing safety are
all affected by flow rate.
High flow nipples may cause coughing or choking due to
loss of bolus control
Higher flow rate makes the coordination of sucking,
swallowing and breathing more challenging.
Ventilation decreases as the liquid flow rate increases-
more time is spent in swallowing and less time is
available for breathing
(Shaker, 1999)
Nipples
Preemie/slow flow
Infant controlled
Term/Regular flow
Less controlled
False- Most babies are ready for this
Remember preterm infant preterm skill
Babies need support to learn this complex skill
Strategies
Chin and cheek support
Used with caution and only when indicated – can increase flow rate
Feeding After Discharge
Coming home is a time of adjustment, learning and
stress for the infant and the family
Challenges /concerns expressed by parents after NICU
discharge
Safety during feeding
Adequate caloric intake
Advancing Feeding
(Thoyre, 2001)
Feeding After Discharge
Preterm infants discharged home frequently have not
achieved fully organized and mature eating skills
Feeding problems are prevalent and are reported by
parents immediately after discharge from the NICU
50% of parents report problematic feeding behaviors
from the toddler years into early childhood in their
former preemies
Growth is typically compromised by potential medical
problems as well as delay in attaining eating skills
(Ross, Browne 2013)
Strategies
CONSISTENCY IS KEY
Babies need similar approaches between caregivers
Parents need to be supported and taught
How to read their infants communication
How to support their baby as they learn to feed
How to progress feeding skills
Appropriate bottles/utensils
Calorie boosting
Positioning and seating devices
Successful Feeding
When following a cue based/ infant guided approach:
INTAKE WILL IMPROVE WITH DEVELOPMENT
Listen to the families and how they feel their baby is doing with feeding
Support the family and help them understand how to teach their babies to feed
Requires GOOD COMMUNICATION with team and families
Summary
Thorough medical history from birth and NICU
Understanding the plan from the NICU therapy team
All specialists they are scheduled to see after discharge
Establishing a team outside of the NICU to include those
specialists
Parent/caregiver
Primary Care Physician
Specialists – Neurology, Pulmonology, Cardiology,
Ophthalmology, ENT, GI, Orthopedic, Audiology, Therapy,
Dietician, Lactation Consultant, Case Manager, Counselors
Understanding developmental milestones for corrected
age
Summary
Understanding infant communication/cues
Supporting and educating families in the understanding
infant communication and cues
Supporting and educating families in developmental
milestones based on corrected age
Supporting the family wherever they are in their
journey
Resources
Websites
Pathways.org
thetimp.com
tortle.com
pediatricapta.org/fact-sheets
Feedingmatters.org
shaker4swallowingandfeeding.com
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