NICU Flashcards
prematurity and the NICU
complex subspecialty of pediatric PT
knowledge beyond entry level- advanced education- fellowship programs
most fragile patients that PT will treat!
CA=
chronological age
AA=
age adjusted
viability=
23-24 weeks
SGA=
small for gestational age
AGA=
average for gestational age
LGA=
larger for gestational age
gestational diabetes
LBW=
low body weight
1501-2500 g= 3.5-5.5 lbs
VLBW=
very? low body weight
1001-1500 g= 2.2-3.5 lbs
ELBW=
extreme? low body weight
<2.2 lbs
micropremies=
<800g
what is average baby weight?
~7 lbs (3.25 kg)
500g=
- 5 kg
1. 1 lb
1000g=
- 0 kg
2. 2 lbs
1500g=
- 5kg
3. 5 lbs
2500g=
- 5 kg
5. 5 lbs
what are the 5 components of APGAR scores?
heart rate resp rate muscle tone reflex irritability color
what are the APGAR scores for heart rate?
0= absent 1= 100
what are the APGAR scores for resp rate?
0= absent 1= slow and irregular 2= good, crying
what are the APGAR scores for muscle tone?
0= limp 1= some flexion and ext 2= active movement
what are the APGAR scores for reflex irritability?
0= no response 1= grimace 2= cough or sneeze
what are the APGAR scores for color?
0= blue 1= pink, blue extremities 2= pink
neonatal care began in..
1880 in France with development of the incubator
increase in survival 1988-2002 for VLBW and ELBW due to antenatal steroids, aggressive resuscitation, surfactant therapy
what are the main principles of neonatal care?
support body temp
control infection
minimal handling
special care nursing
what are the nursery levels?
level 1: basic care
level 2: specialty care
level 3: subspecialty care
what is nursery level 1?
Basic care
35-37 weeks GA
stabilize infants less than 35 weeks until transfer
what is nursery level 2?
Specialty care (moderately ill)
2a: >32 weeks
2b: mechanical ventilation for brief period
what is nursery level 3?
Subspecialty care
3a: >28 weeks, minor procedures
3b: <28 weeks, high frequency ventilation/ pedi surgical specialists
3c: ECMO and complex cardiac surgery; cardiopulm bypass
what are the 6 environmental changes from in utero to NICU?
visual auditory gravity tactile proprioception thermo-reg
what is the environmental change from utero to NICU for visual?
in utero: dim red glow
NICU: bright lights
what is the environmental change from utero to NICU for auditory?
in utero: rhythmic heart beats, respiratory sounds, muted voices
NICU: constant offensive noise-equipment alarms, voices, etc
drugs commonly used in the NICU increase risk for hearing loss
what is the environmental change from utero to NICU for gravity?
in utero: amniotic fluid= gravity eliminated, random movements
NICU: gravity makes movement into flexion difficult for hypotonic neonate
what is the environmental change from utero to NICU for tactile?
in utero: N/A
NICU: adverse tactile input from necessary medical interventions
causes sustained arousal causing a physiological toll on the child. In utero- sleeps 80% of the time vs. being on avg disturbed 23x in 24 hours– begins to respond negatively to touch b/c unable to discern medical necessity
what is the environmental change from utero to NICU for proprioception?
in utero: deep proprio input by uterine wall as moves
NICU: decreased proprio feedback
what is the environmental change from utero to NICU for thermo-reg?
in utero: well controlled
NICU: at risk for problems
premie vs. full term:
hypotonia
extremities: ext and ABD
decreased midline and flexor activity
decreased spontaneous movements
reflexes: absent, decreased or variable
medical concerns:
- respiratory issues
- cardiopulm issues
- feeding problems
- temp regulation
- BP instability
what are other medical categories associated with motor risk?
neurological
IVH: intraventricular hemorrhage
respiratory
metabolic
congenital heart disease
viral/infection
substance exposure
other
orthopedic
neurological conditions:
HIE: hypoxic ischemic encephalopathy
PVL: periventricular leukomalacia
PVHI: hemorrhagic infarct necrosis
what is HIE?
hypoxic ischemic encephalopathy: episode of asphyxia on neonate’s brain (can occur concurrently or serially)
- cerebral ischemia
- hypoxemia
interference with umbilical BF (ischemia) resultant systemic hypotension and decreased cardiac output.
and poor gas exchange (hypoxemia) from the mother’s circulation through the placenta to the fetus, recurrent apnea, or severe respiratory disease. Hypoxemia also decreases myocardium causing bradycardia and hypotension which leads to further ischemia.
after severe HIE, stupor or coma requiring mechanical vent. 12-14 hours- seizures and apnea, then out of stupor/coma and increased seizure activity. May re-enter stupor/coma state at 24-72 hours of life. moderate HIE may improve arousal level in 2-3 days and are at much less risk for mortality and longterm neuo problems than severe. Mild-asphyxia immediately before birth and usually recover well requiring minimal resuscitation. Initially lethargic then hyper alertness, irritability, exaggerated moro and DTR.
what is PVL?
periventricular leukomalacia
- symmetrical, non-hemorrhagic, bilateral lesion
- spastic diplegia
- most common
ischemic lesion to the brain of the premature infant
motor tracts involving the LEs are closest to the ventricles.
may be transient or may reduce to cystic cavities that are highly correlated with CP. SDI-because of proximity of the ventricular system of descending motor fibers that innervate the LEs (if more lateral can involve UEs also)
what is PVHI?
periventricular hemorrhagic infarct necrosis
spastic/hemi/asymmetrical quad
key: prevent fluctuating BP
what is IVH?
intraventricular hemorrhage
most common brain lesion in <32 weeks
occurs in approximately 40% of premies
there is an inverse relationship b/w gestational age and incidence of IVH
most occur w/in the first 2 postnatal days, 90% by 72 hours
subependymal germinal matrix which is a gelatinous area that contains a rich vascular network. the matrix is prominent from 26-34 weeks of gestation and is usually gone by term.
what are the grades for IVH?
I: isolated germinal matrix
II: IVH w/ normal vent. size
III: IVH w/ vent dilation
IV: IVH w/ parenchymal hemorrhage (into the periventricular white matter)
I & II: minimal risk for LT neuro deficit
III & IV: sign higher incidence- hydrocephalus, CP and MR, cystic formations
respiratory conditions:
RDS: respiratory distress syndrome
BPD: bronchopulmonary dysplasia
MA: meconium aspiration
what is RDS?
respiratory distress syndrome
characterized by: chest wall retraction, cyanosis, expiratory grunt, nasal flaring and tachypnea
<37 weeks
leading cause of death in premature neonates which has reduced lately
due to pulmonary immaturity and a decrease of surfactant associated with RDS and thus introduction of exogenous surfactant has sign decreased morbidity and mortality. Steroids to increase lung development also prior to the preterm birth
what is BPD?
bronchopulmonary dysplasia:
chronic lung disease of infancy
believed due to iatrogenic factors (caused by Dr.)
trauma with mechanical vent, elevated concentrations of administered O2, endotracheal integration. Ciliary destruction followed by necrosis of respiratory cells. Recovery from damage >= 1 year. Chronic lack of O2 impairs neuromotor development
what is mechanical aspiration?
aspirates meconium with initial breath
causes airway obstruction that can cause respiratory distress
FT or post term at greater risk with 5-15% of live births
endotracheal suctioning required. MAS is defined as resp distress in an infant through meconium stained amniotic fluid whose symptoms can’t be otherwise explained
what are metabolic conditions?
metabolic acidosis
hyperbilirubinemia
what is metabolic acidosis?
reduced body pH
increase hydrogen forming acid or increase loss of basic material
increased production or inadequate excretion of hydrogen or loss of bicarbonate ions in the urine or stools- causes reduction in pH of the body
what is hyperbilirubinemia?
accumulation of bilirubin in the blood
blood incompatibility, physiological jaundice, reabsorption of blood and infection
kernicterus- yellow staining of the brain -high incidence of mortality and LT neurological sequelae
what are congenital heart disease conditions?
PDA: patent ductus arteriosus
ASD: atrial septal defect
VSD: ventricular septal defect
tetralogy of fallot
what is PDA?
shunts blood from pulmonary artery to the descending aorta
normal in utero, closes shortly after birth
thus shunts blood away from lungs which do not participate in gas exchange during fetal life. Typically closes shortly after birth but failure to close can vary from large (congestive heart failure with pulmonary vascular obstructive disease) to small insignificant PDA
what is ASD?
left to right shunting of blood
majority close spontaneously in first 3 years
lead to pulmonary vascular obstructive disease and associated pulmonary HTN.
if does not close, surgical closing at 4-5 years with suturing or insertion of a patch
what is VSD?
ventricular septal defect
most common structural cardiac defect
left to right shunting of the ventricles
range from small to large w/ pulmonary HTN and R ventricular hypertrophy. If this hypertrophy becomes great, shunting can reverse as R vent pressure overcomes the L.
In R to L- see cyanosis.
can close spontaneously but if large and symptomatic, will close surgically
what is tetralogy of fallot?
VSD, PAS, R vent hypertrophy AND an aorta that overrides the interventricular septum
what is PAS?
pulmonary artery stenosis
narrowing at or just below the pulmonary valve last- aorta being positioned over the ventricular septal defect instead of the L ventricle
what are viral/infection conditions?
toxoplasmosis
rubella
cytomeglaovirus
herpes
HIV
infection:
developing brain is highly susceptible to injury from infection in utero or neonatal period
what is toxoplasmosis?
carried by cat feces- avoid while pregnant
what is cytomeglaovirus?
herpes virus that usually acts as an opportunistic virus to AIDS
80% of children with HIV get it via?
via transplacental transmission
90% of children with HIV show signs of?
encephalopathy (static or progressive)
what are conditions of substance exposure?
FAS: fetal alcohol syndrome
- facial features
- motor coordination difficulties
- learning difficulties
Cocaine exposure
- LBW, IUGR, preemies
- withdrawal
narcotics
-withdrawal from heroine first 4 days; methadone slightly later
what is necrotizing enterocolitis?
first 6 weeks
<2000g w/ prenatal insults
intestinal ulcers and hemorrhage w/ possible intestinal perforation
what is ROP?
retinopathy of prematurity: lesion caused by an ischemic event that interfere w/ the development of retinal blood vessels.
high levels of O2 causes vascular proliferation towards the hypoxic area
main cause of childhood blindness w/ abnormal growth of blood vessels occurs in the immature part of the retina
first year- heal themselves; leave nearsightness/strabismus; or continue w/ abnormal growth
what are orthopedic conditions?
BPI: brachial plexus injury
Clubfoot
metatarsus varus
tibial torsion
CDH: congenital diaphragmatic hernia
what is BPI?
brachial plexus injury
contractures and atrophy
positioning and ROM
following breech or forceps delivery
spontaneous recovery seen in first few days/weeks. IF delayed contractors at shoulder and elbow, weakness in ER, /, ABD, elbow flex, supination, and wrist /. Positioning to prevent further damage to plexus- 2 week recovery prior to rehab
what is clubfoot?
plantarflexion, inversion and supination
hereditary
associated w/ other disorders
what is metatarsus varus?
adduction of the forefoot
flexible-PROM
rigid- serial casting
what is tibial torsion?
typically self corrects by 8y/o
tibial torsion night brace
medial torsion improves w/ time.
lateral torsion often worsens bc the natural progression is toward increasing external torsion (as seen w/ CP). May be due to lax ligaments at knee.
what is CDH?
congenital diaphragmatic hernia
dynamic splinting
surgically when discovered later
barlow: supine w/ hips and knees flexed to 90. grasp the thigh medially over the lesser trochanter w/ the other hand stabilizing the pelvis. Apply gentle downward pressure w/ abd hip. As fem head slips over ace tabular rim a subtle clunk is felt.
what are common NICU goals?
1- state regulation: autonomic, motor, state, attention, interactive
2- parent-infant interaction
3-increased self-regulation behavior through environmental modification
4- postural alignment- therapeutic handling/positioning
5- enhance oral-motor feeding
6- inc. visual & auditory reaction
7- prevent secondary muscle contracture
8-address orthopedic issues
9- developmental assessment
10- positive transition from NICU to home
11- parent education
what are goals of therapeutic handling/positioning?
facilitate midline orientation/symmetry
promote newborn flexion
enhance self-quieting skills and behavioral organization
encourage relaxation and improve digestion
prevent bony deformities and skin breakdown
increase awareness of body in space
facilitate visual and auditory skill development
facilitate development of head control
decrease hyperextension of neck and trunk
reduce elevation of the shoulders
decrease retraction of the scapula
reduce extension of the LEs
activation of flexor muscles
state regulation:
5 states to assess in the premie
FT: function smoothly w/ all supporting and enhancing one another
Premie: do not develop simultaneously and demonstrates signs of distress
what are 5 states to assess in the premie?
autonomic or physiological response
motor development
state control
attention and interaction behaviors
self-regulation
understanding signs:
what are signs of stress?
happy signs
self-regulatory behaviors
Signs of stress:
- physiological indicators
- motor indicators
- behavioral indicators/state
- attention/interaction
what are happy signs?
smooth respiration
pink, stable color
animated facial expressions
brightening of the eyes
“oh” face
cooing
smiling
well-regulated muscle tone
what are self-regulatory behaviors?
smooth body movements/postural changes
visual locking
hand to mouth activity
sucking
hand clasping
grasping
physiological indicators of stress:
change in vitals: resp rate/rhythm, HR, BP
color changes
cough, sneeze, yawn
visceral responses (vomiting, bowel movements, hiccups, gagging)
what are motor indicators of stress?
sudden change in muscle tone
flaccidity
stiffness
changes in quality of movement
what are behavioral/state indicators of stress?
irritability
staring/gaze aversion
hyper alertness/sleeplessness and restlessness
roving eye movements/ gazed eye appearance
what are attention/interaction signs of stress?
demonstrate physiological, motor and behavioral indicators
unable to integrate social interaction w/ other sensory input
what is congenital muscular torticollis?
CMT is defined as the shortening of the SCM causing the neck to laterally flex to the affected side and rotate to the opposite side.
CMT is the most common type of torticollic and the 3rd most common congenital MS anomaly.
CMT is estimated to occur in 1/300 live births.
what causes CMT?
damage to or shortening of the SCM
exact etiology is unknown
- in utero positioning
- lack of space in utero
- traumatic birth
- multiple birth
- increased incidence w/ breech presentation
- low amniotic fluid
what are clinical features of CMT?
PHYSICAL EXAM:
- restriction of neck ROM
- head tilted toward the shortened SCM and the chin rotated to the opp side
- characteristic mass palpable in the affected SCM (usually resolves spontaneously by 2-6 months of age)
- plagiocephaly
- facial asymmetry
during delivery, if the SCM muscle is stretched or pulled, it may tear, causing bleeding and bruising w/in the ms. the injured ms. develops fibrosis (scar tissue) which causes the ms. to shorten and tighten, pulling the infant’s head to 1 side. The fibrosis forms a mass or lump that sometimes can be felt on the side of the neck.
what are associated anomalies w/ CMT?
hip dysplasia
foot deformities
plagiocephaly
facial asymmetry
GERD
diagnosis of CMT:
typically made by the infant’s pediatrician based on physical exam and hx
ant-post and lat radiographs of the cervical spine
ultrasound of the affected SCM
differential diagnosis of CMT:
alternate diagnoses should be considered in infants in whom CMT is suspected but who lack of hx consistent w/ the typical presentation of CMT
- skeletal abnormalities
- Klippel-Feil syndrome
- benign paroxysmal torticollis
- ophthalmologic disorders
- brachial plexus palsy
- Sandifer’s syndrome/gastroesophageal reflux
what are red flags for CMT?
poor visual tracking
abnormal muscle tone
extramuscular masses
asymmetries inconsistent w/ CMT
remember medical red flags (vomiting, weight loss, etc)
acute or late onset
suspected hip dysplasia or scoliosis
what is positional torticollis?
back to sleep campaign
car seats and other baby equipment
little to no tummy time
PT eval/hx/intake for CMT:
standard intake form
birth history:
- age of onset of sx
- pregnancy hx
- presentation at delivery
- delivery (forceps, vacuum)
- head posture and preference
- tolerance to tummy time and time in “containment” devices
- milestones
objective tests for CMT:
posture
ROM (active and passive)
strength (righting reactions)
cranial measurements
pain
skin integrity and symmetry of skin folds
PT intervention for CMT:
neck PROM
neck and trunk AROM
development of symmetrical movement patterns
environmental adaptations
parent/caregiver education
how is torticollis treated?
first 12 months: conservative
- PROM to SCM, upper traps, hyoids
- positioning and handling
- AROM/strengthening
- neck righting reactions
- environmental adaptions
surgical intervention:
- > 12 months old; no response to PT
- referred >12 months w/ cervical rotation >30 degrees and facial asymmetries
untreated:
- facial/cranial asymmetries
- cervical scoliosis w/ compensatory T curve
- occular and vestibular impairment
stretching of the tight SCM
lateral flexion
cervical rotation
strengthening of the contralateral muscles;:
lateral neck flexion via head righting
- side carry
- ball exercises
positioning:
position infant w/ head in midline
prop head to discourage lateral neck flexion to side of tight SCM
encourage active rotation to non-preferred side
encourage supervised tummy time
what are additional methods used to treat CMT?
taping
cervical orthoses
- tubular orthosis for torticollis (TOT collar)
- torticollis orthosis (post-op)
massage
botox injections
surgery
craniosacral therapy
myofascial release
chiropractor
what is deformational plagiocephaly?
caused by external forces applied to the soft infant skull
common in babies w/ CMT since they almost always have the same area of their head in contact with the surface
what is plagiocephaly?
flattening on one side of the occiput
prominent forehead on same side
may see facial asymmetry w/ flattening on one side of the face and/or misaligned ear, eye or mouth
treatment for deformational plagiocephaly:
positioning
orthotics
- DOC band
- STAR band
what are factors influencing CMT outcomes?
compliance w/ home program
severity of torticollis
pt’s age at onset of tx
pt’s tolerance for handling
