Development of Infant Born Prematurely Flashcards
What is the age of viability?
23-24 weeks
Children born <37 weeks gestational age with VLVW are 30% more likely to develop what 6 disorders?
CP, ID, RDS, BPD, ROP, and HI
What is there a growing concern over in children who were born premature? Who is at greater risk? (Males or females)
high percentage of children who demonstrate minor impairments in cognitive, social, and motor functioning once they enter kindergarten
Prevalence of perceptual motor problems reported as high as 48%
*Males are at greater risk
Environmental factors
What are the recommended tests for children who were born premature?
- Movement Assessment Battery for Children (MABC)
- Visual Motor Test (VMI)
What is considered full term, postterm, and preterm?
- Full term: 37-41 weeks
- Postterm: >42 weeks
- Preterm: <37 weeks
How do you determine gestational age, post conceptual age, and corrected/adjusted age?
- Gestational age (GA): age of infant based on mom’s last menstrual period
- Post conceptual age: gestational age plus the number of weeks since the infant’s birth
Corrected age/adjusted age/post term corrected age: gestational age plus weeks since birth minus 40 weeks
What are the weights in grams for extremely low birth weights, very low birthweight, and low birth weight?
- Extremely low birth weight (ELBW): <1000g (2.2 lbs)
- Very low birth weight (VLBW): <1501g (3.3 lbs)
- Low birth weight (LBW): 1501-2500g (3.3-5.5 lbs)
What do these abbreviations mean?
AGA
SGA
LGA
IUGR
- AGA: appropriate for gestational age
- SGA: small for gestational age (<10th percentile)
- LGA: large for gestational age (>90th percentile)
- IUGR: intrauterine growth retardation
Determined via size of the infant at birth (based on length, head circumference and weight)
What are characteristics of a premature infant?
- Hypotonia
-
Decreased ratio of type I to type II
- Results in muscular fatigue (especially respiratory muscles)
-
Incomplete ossification of bones, ligamentous laxity
- Result in greater effects of positioning and gravity
- More reactive to sensory stimuli
-
Response to pain
- Term and preterm babies respond differently to pain
- Preterm babies are less robust in expressing pain through crying or moving
What are the NICU levels?
Level 1: Well baby nursery
Level II: Special Care Nursery
- Babies born <32 weeks and weighing <1500g
- Mechanical ventilation for a brief period
Level III: NICU
- Sustained life support
- Full range of medical specialties
- Advanced imaging
Level IV: Regional NICU
- Surgery for complex conditions
What is the APGAR?
- Scores given at 1, 5, and 10 minutes after birth
- A: activity, postural tone
- P: pulse
- G: grimace response to stimulation
- A: appearance/color
- R: respiratory rate
What are vital sign norms?
- HR: 120-180 BPM
- RR: 30-60 breaths / min
- Blood pressure
- Systolic: 76-87 mmHg
- Diastolic: 45-68 mmHg
What are the reasons a full term infant might be in the NICU? (6)
- Substance abuse
- Genetic disorders
- Congenital abnormalities
- Sepsis
- Feeding difficulties
- Breathing difficulties
What should PT’s in the NICU understand?
- Third trimester development
- Medical technology associated with care
- Medical conditions associated with prematurity
- Do no harm
- Interning and shadowing strongly recommended
What is the role of a PT in the NICU?
- Addresses functional and structural integrity of body parts and systems
- Promotes the development of postural and motor activities
- Promotes appropriate interaction between the infant and the environment
- Promotes interaction with the family, NICU staff, and consultants
What does a NICU PT eval include?
- Minimize excessive handling and overstimulation
- Cluster care
- Minimizes handling and stress
- Consider the state of the infant
- Brazelton States of Arousal (six states defined)
- During an assessment, observe
- Range of behavior
- Variety of behavior
- Duration of state
- Includes: observation, consultation, conversation, coordination
- Careful review of history
Tests and measures specific to premature infants (4)
- Assessment of Preterm Infant Behavior
- Neurologic Assessment of the Preterm and Full Term Infant
- Neonatal Individualized Developmental Care and Assessment Program
- Test of Infant Motor Performance
PT Intervention: Taping
- Allows easy inspection of the skin and vascular integrity
- Risk for intolerance → careful monitoring required
- Assess integumentary status and perform a patch test to determine any sensitivity to the tape
- Provide the nursing staff and family careful instructions in terms of signs of intolerance and how to safely remove the tape
Who is taping not recommended for in the NICU?
Not recommended for an infant <30-32 weeks gestation
PT Interventions: Splinting
what is the indication for splinting?
What are the 4 major risks?
- Indication: infants in the NICU with documented or potential alignment and joint motion limitation concerns
- Risks for:
- Fracture
- Dislocation
- Joint effusion
- Skin breakdown
- Traction on joints and nerves can be a concern because of the weight of the splinting material
- Instructions and pictures are posted bedside
- Post d/c monitoring
- Casting may be done by orthopedics
NICU Transition to Home
when is d/c considered?
- D/C plan
- Considered when an infant begins to demonstrate more consistent physiologic stability
- Long term health care f/up
- The families require time to learn the infant’s care
- Families should be included in the d/c process as soon as possible
What does communicating goals to family and medical team accomplish regarding NICU to home transfer?
- Promote success of the infant and family at home
- Prevent delays in access to health care and to establish links to resources for health and development in the community
Transition to Home: Suggestions for the environment
- Suggestions on environment
- Positioning
- Appropriate sensory experiences
- Developmental activities
- Referrals should be made to community resources such as early intervention
Positioning and the NICU baby regarding transition to home
- The therapist can develop a plan to wean the infant of positioning supports and transition to back sleeping as necessary
- Positioning supports can be for play and activities while awake
- Infants should be positioned on their back for sleeping
- Sleeping environment should be free of soft or loose bedding materials and stuffed toys or animals
- Blanket rolls may be positioned behind the infant’s shoulder and along the thighs while he or she is seated
Neonatal follow up
- The AAP recommends follow up services for these developmental concerns, as well as for organized post discharge tracking and to provide information regarding outcomes for this population
- Neonatal Follow Up Programs monitor the outcomes for these high risk neonates and determine the effects of NICU interventions on outcomes
- Track information
list what these abbreviations mean:
CP
RDS
BPD
ROP
NEC
ID
HI
DCD
- CP: cerebral palsy
- RDS: respiratory distress syndrome
- BPD: bronchopulmonary dysplasia
- ROP: retinopathy of prematurity
- NEC: necrotizing enterocolitis
- ID: intellectual deficit
- HI: hearing impairment
- DCD: developmental coordination disorder
list the senses in order of development
touch
movement
smell and taste
hearing
vision
vestibular system
- Mature in the full term newborn
- Modifications with development due to synapses and dendrites
- Vestibular stimulation is known to enhance behavioral states
- Vestibular stimuli in the womb vs. the NICU
describe olfactory and gustatory development
- Olfactory Development
- Begins at 5 weeks gestation
- Ability to smell at 18 weeks
- Gustatory Development
- Taste buds begin to mature at 13 weeks
The fetus experiences a variety of tastes/smells in utero vs. in the NICU
describe auditory development
when is the auditory system developed by?
- Auditory System
- Cochlea and peripheral sensory end organs are developed by 24 weeks gestation but the pathways continue to mature
- The premie is exposed to NICU noise that may cause:
- Cochlear damage
- Sleep disturbances
- Disturbed growth and development
describe visual system development
what happens at 24 weeks, 34 weeks, 36 weeks, and what is vision at term?
- Visual system
- Least mature at birth
- From 24 weeks to term: the retina and visual cortex undergo extensive maturation and differentiation
- 34 weeks: pupillary reflex present, may see brief eye opening and fixation on a high contrast form under low illumination
- 36 weeks: saccadic visual following horizontally and vertically
- At term: vision is 20/400
development of passive muscle tone chart
27-28 weeks posture, handling responses, and active movements
Posture:
- Generalized hypotonia
- Beginning of hip flexion
Handling responses
- Full passive ROM without resistance
- No attempt at arm recoil when the arms are extended parallel to the body and released
- No attempt to align head and body with pull to sit
- No attempt at toe grasp
Active Movement
- Movements are spasmodic and involve the total extremity
34 weeks posture, handling responses, active movement
Posture:
- Increase in hip flexion with frog like position
Handling Responses
- Able to grasp and maintain traction with UEs
- LE traction increasing
- Placing response demonstrated
- Some flexion in elbows/knees with effort to lift head in ventral suspension
- Moro reflex: extend and abd the arm followed by partial adduction, resists passive knee extension
Active Movement
- Kicks vigorously during more prolonged awake states
- Movements more purposeful
- Reciprocal and now involve trunk flexion
40 weeks posture, handling responses, and active movement
nP at term
Posture:
- All extremities held in flexion
- Flexor tone of a preterm infant who has reached full term is never as great as the flexor tone of an infant born at term
Handling responses
- Resists full extension of the knee, hip, and shoulder
- Arm recoil after release within 2-3 seconds
- Easily bear weight in supported standing
- May not reciprocally step like infant born at term
- Lacks the shoulder muscle tone of an infant born at term; may not be able to keep head alignment with pull to sit
Active Movement
- Smooth and purposeful
- Reflexes are consistent and complete
- Less predictable sleep wake cycles and feeding pattern than an infant born full term
- Less flexor hypertonicity resulting in greater ranges of movement compared to an infant born at term
What are the medical issues of prematurity? (9)
- Respiratory Distress Syndrome
- Bronchopulmonary dysplasia
- Patent Ductus Arteriosus
- Hyperbilirubinemia
- Retinopathy of Prematurity
- Necrotizing Enterocolitis
- Chorioamnionitis
- Meconium Aspiration Syndrome
- Osteopenia
What is the pathophys of RDS?
-
Pulmonary immaturity
- Poor alveolar capillary development
- Lack of type II alveolar cells
-
Inadequate pulmonary surfactant
- Surfactant: produced by type II alveolar cells and lines the alveoli and small bronchioles
- Increased surface tension
- Alveolar collapse
- Diffuse atelectasis
- Decreased lung compliance
-
Increased compliance of chest wall
- Cartilaginous composition of the ribs
- Decreased type I fatigue resistant muscles in the diaphragm and intercostal muscles
- Instability of neural control of breathing
What factors increase risk of RDS?
- Degree of prematurity (<34 weeks)
- Maternal diabetes
- Insulin interferes with surfactant production
- Thoracic malformations
prevention of RDS
- Antenatal steroids to accelerate lung maturity
- Controversial use: poor neurobehavioral outcomes
Clinical signs and symptoms of RDS
- Increased RR
- Expiratory grunting
- Sternal and intercostal retractions
- Nasal flaring
- Cyanosis
- Decreased air entry on auscultation
- Hypoxia
- Hypercarbia
RDS interventions
- Oxygen supplementation
- ECMO: extracorporeal membrane oxygenation
- CPAP: continuous positive airway pressure
- PEEP: positive end expiratory pressure
- Mechanical ventilation
- Surfactant administration prophylactically
complications of RDS
- Barotrauma: increased airway pressure
- Volutrauma: large gas volume
- Atelectotrauma: alveolar collapse
- Biotrauma: increased inflammation
Bronchopulmonary Dysplasia pathophys
- (multifactorial pathological process)
- Acute lung injury from combined effects of
- Oxygen toxicity
- Barotrauma
- Volutrauma
- May go on to develop chronic lung disease
- Interrupted alveolar development
- Destruction of the parenchyma
- Acute lung injury from combined effects of
Complications of Bronchopulmonary dysplasia
- Systemic HTN
- Metabolic imbalance
- Hearing loss
- ROP
- Nephrocalcinosis (too much Ca2+ in kidneys)
- Osteoporosis
- GER
- Early growth failure
- Neurodevelopmental delays
patent ductus arteriosus
- The ductus arteriosus typically closes within 10-15 hours after birth
- Consequences in the premature infant
- Hypotension
- Poor perfusion
- CHF
- Metabolic acidosis
Hyperbilirubinemia
-definition and common premies due to what 3 things
- Definition: accumulation of excessive bilirubin in the blood
- Common in premies due to:
- Immature hepatic function
- Increased hemolysis of RBC from birth injuries
- Possible polycythemia
Retinopathy of prematurity
-definition, onset, incidence
- Definition: abnormal development of blood vessels; may lead to scarring and detached retina and may result in blindness
- Onset: peaks at 34-40 weeks
- Note: There should be regular monitoring by ophthalmology
- Incidence
- Leading cause of visual impairment in prematurely born children
Retinopathy of prematurity pathophys/contributing factors
- Increased concentrations of oxygen
- Hypoxia / anoxia
- Hypocapnia
- Acidosis
- IVH
- Fluctuations in blood gas tensions
- Sepsis
- RDS/BPD
- Dexamethasone exposure
- PDA (patent ductus arteriosus)
- Vitamin E deficiency
- Precocious exposure to light
levels of retinopathy of prematurity
- 1-5
- Level 5 = complete detachment of the retina
Necrotizing enterocolitis definition
the intestinal tissue becomes damaged (typically due to infection) and begins to die
Necrotizing Enterocolitis signs and symptoms
- Bloating/swelling in the abdomen
- Distension
- Gastric retention (residual milk in the stomach before a feeding)
- Tenderness
- Vomiting
- Diarrhea
- Rectal bleeding (hematochezia)
- Bilious drainage from enteral feeding tubes
Chorioamnionitis
- bacterial infection, most common cause of preterm labor
- Risk associated
- In babies where there is a fetal inflammatory response → risk for BPD, NEC, and NI
Meconium Aspiration Syndrome
- Definition: early onset of respiratory distress in term or near term infants born through meconium stained amniotic fluid
- Outcomes
- Approximately 20% demonstrate delays at 3 y/o
Osteopenia background, onset, outcomes
when is majority of bone produced?
What is there an increased risk of? (2 things)
- Background
- Approximately 80% of bone is produced between 24-40 weeks gestation
- Mechanical loading occurs due to increasing muscle mass and decreased uterine space
- Onset
- Risk increases with decreasing gestational age and birth weight
- Outcomes
- Increased risk for fx and positional deformities (such as dolichocephaly)
Osteopenia contributing factors (6)
- Chronic illness
- Prolonged hyperalimentation
- BPD
- NEC
- Use of steroids
- Diuretics
Neurologic Complications of Prematurity
- Periventricular leukomalacia
- Germinal matrix: intraventricular hemorrhage and periventricular hemorrhage
- Hypoxic Ischemic Encephalopathy
- Placenta previa
- Placenta Insufficiency
- Oligohydramnios
- Polyhydramnios
Periventricular Leukomalacia (definition, onset, etiology)
- Definition: symmetric, nonhemorrhagic, ischemic lesion to the brain of a premature infant
- Onset: incidence of white matter damage increases with decreases in gestational age
- Etiology: reduction in cerebral blood flow in the highly vulnerable periventricular region
Periventricular Leukomalacia diagnosis
- Serial ultrasonography
- White matter echodensities
- Echolucencies associated with CP
- CT
- MRI
- PET
Periventricular Leukomalacia medical management
- Prevention of intrauterine asphyxia
- Maintenance of adequate ventilation and perfusion
- Avoidance of systemic hypotension
- Control of seizures
Germinal Matrix – Intraventricular Hemorrhage and Periventricular Hemorrhage
(incidence, age of onset, risk, diagnosis, pathogenesis)
- Incidence: most common type of neonatal intracranial hemorrhage
- Age of onset: characteristic of infant <32 weeks and weighing <1500g
- Risk: RDS
- Diagnosis: serial portable cranial sonography
- Pathogenesis
- Germinal matrix has primitive capillaries
- Fluctuating cerebral blood flow + increased cerebral blood pressure + platelet and coagulation disturbance
Germinal Matrix – Intraventricular Hemorrhage and Periventricular Hemorrhage neuropathic complications (4)
- Hydrocephalus
- Germinal matrix destruction
- Cyst formation
- Accompanying hypoxic-ischemic lesions
- PVL
- Pontine neural necrosis
Germinal Matrix – Intraventricular Hemorrhage and Periventricular Hemorrhage grading
- Grade I: isolated germinal matrix hemorrhage
- Grade II: hemorrhage ruptures into lateral ventricles but they are normal sized
- Grade III: hemorrhage into ventricles with dilation
- Grade IV: hemorrhage into the periventricular white matter
Hypoxic-Ischemic Encephalopathy (HIE) pathophys
- Pathophysiology
- Period of reperfusion is when many of the complications that affect metabolism, function, and structure of the brain occur
- Infants with HIE commonly have disturbances of pulmonary, cardiovascular, hepatic, and renal functions
- perinatal asphyxia -→ hypoexemia -→ ischemia
Hypoxic-Ischemic Encephalopathy signs and symptoms
- Seizures
- Abnormalities in state of consciousness
- Tone
- Posture
- Reflexes
- Suck
- Swallow
- Gag
- Tongue movements
- Respiratory pattern
- Autonomic function
Conditions associated with increased risk (antenatally) Hypoxic-Ischemic Encephalopathy
-
Altered placenta exchange
- Abruption
- Placenta previa
- Postmaturity
- Prolapsed umbilical cord
- Cord around neck
- Placental insufficiency
-
Reduced maternal blood flow to the placenta
- Maternal hypotension
-
Decreased maternal oxygen saturation
- Maternal hypoventilation
- Hypoxia
- Cardiopulmonary disease
- Conditions associated with increased risk (intrapartum period) Hypoxic-Ischemic Encephalopathy
- Traumatic delivery
- Prolonged labor
- Acute placental or cord problems
Neuropathologic classifications Hypoxic-Ischemic Encephalopathy (4)
- Selective neuronal necrosis
- PVL (periventricular leukomalacia)
- Parasagittal cerebral injury
- Focal ischemic brain necrosis
Selective neuronal necrosis Hypoxic-Ischemic Encephalopathy definition and clinical findings
- Definition: death of neurons in a widespread but characteristic pattern (major sites = hippocampus, parts of diencephalon, BG, pons, medulla, cerebellum, thalamus, brainstem, spinal cord)
- Clinical findings
- Seizures
- Hypotonia
- Oral motor problems
- ID
- Spastic quadriplegia
- Ataxia
- Bulbar and pseudobulbar palsy
- ADHD
Parasagittal cerebral injury definition and clinical signs and symptoms
Hypoxic-Ischemic Encephalopathy
- Definition: lesion of the cerebral cortex and subcortical white matter (usually bilateral and symmetric with the parietal-occipital regions most affected)
- Clinical S&S
- Spastic quadriplegia
- ID
Hypoxic-Ischemic Encephalopathy Focal Ischemic brain necrosis and cavitation definition
- Definition: large, localized areas of neuronal death in the distribution of a single or multiple major blood vessels in the cerebral cortex and subcortical white matter
- Most lesions are unilateral and involve the MCA
- Resolution of the necrosis results in the formation of cavities
Placenta Previa definition and effect
- Definition: baby’s placenta partially or totally covers the mother’s cervix
- Effect: can cause severe bleeding before or during delivery
Placenta Insufficiency definition and common causes
- Definition: placenta cannot bring enough oxygen and nutrients to the baby
- Common causes
- Diabetes
- High blood pressure
- Blood clotting conditions
- Smoking
Amniotic fluid
what is oligohydramnios? Polyhydramnios?
- Amniotic fluid: protects the baby, aids in the development of muscles, limbs, lungs, and the digestive system
- Oligohydramnios: deficiency of amniotic fluid
- Polyhydramnios: excessive accumulation of amniotic fluid
