NICU

Question 1

What is OTs role in NICU?

Answer 1

• Area of advanced practice for OT: requires further certification/ speech overlaps a lot/ medical care is primary/
• Changing Role for OT: History: nurses are very protective
• Nursery Classifications:
• Level I- basic community hospital/ non complicated prego
• Level II- mild complicated pregnancys
• Level III- nursing that has is all/ has all equipment/ special nurses

Question 2

NICU Terminology

Answer 2

• Full Term:(according to WHO)37 - 41 weeks
• Pre-Term: born before 37 weeks
• Post-Term: born after 41- 42 weeks/ placenta starts to break down/ baby may not get enough O2
• GA-gestational age
• CA-chronological
• AA- adjusted age
• Average birth weight for a term newborn = 5.5 pounds or 2500 grams
• SGA Small for GA: below 10th percentile
• LGA: (metabolic challenges) above 90th percentile
• Low birth weight:1500 - 2500g
• Very low birth weight: 1000 - 1500g
• Extremely low birth weight: under 1000g

Question 3

What is the common equipment?

Answer 3

• Thermoregulation: Incubator or Radiant warmer
• Oxygen Therapy:
  
  • Bag & mask ventilation
  • Hood oxygen
  • Nasal Cannula- nose prong thingy
  • Continuous Positive Airway Pressure (CPAP)
  • Mechanical ventilation- kid can’t breath on own
  • ECMO (extracorporeal membrane oxygenation) baby with so much challenge/ lungs underdeveloped/ machine actually pumps blood into body
• Pulse oximeter- O2 saturation
• Cardiorespiratory monitor (apnea monitor) breathing and heartrate monitor

Question 4

What is the comparison of Intrauterine & Extrauterine (NICU) Environments

Answer 4

Intrauterine:

• Tactile-deep pressure/ wet
• Vestibular- light/ buoyant/ weightless/ lessened feeling of gravity/ relaxing
• Auditory- heartbeat/ muffled voices/ calming
• Visual- move toward light?
• Thermal- warm

Extrauterine:

• Tactile- intense
• Vestibular- gravity
• Auditory-loud/ noxious
• Visual-bright lights
• Thermal- cold

Question 5

Neurobehavioral Organization Theories

Answer 5

• Heidi Als, Neonatologist
• “Synactive Model of Infant behavioral Organization”-
• 5 Behavioral subsystems:
  
  • (Bottom) Physiological or autonomic – body functions
  • Motor-
  • State- level of consciousness (asleep- wake)
  • Attentional- quiet alert stage
  • (top) Self-regulation- ability to control and modulate other states

Specialized Behavioral Assessments for the NICU

All require special training and certification

• Naturalistic Observations of Newborn Behavior (NONB) (for term or pre-term infants too fragile for handling): Heidi Als, PhD
• Assessment of Pre-term Infant Behavior (APIB)(For stable pre-term above 30 weeks or term infant): Heidi Als, PhD
• Neonatal Behavioral Assessment Scale (NBAS) (For term infants: 36 - 44 weeks): J. Kevin Nugent, PhD

Question 6

Infant Behavioral Cues:
Signs of stress or signs of stability

Answer 6

Infants display behaviors to respond to exposure to sensory input:

• May interpret stimulus as non-stressful (self-regulation “approach” signals)
• May interpret stimulus as stressful but can respond by using calming behaviors (self-regulation “coping” signals)
• May interpret stimulus as stressful and is unable to remain in calm state (stress & avoidance signals)

Question 7

Common Medical Disorders of the premature child (review)

and Intervention

Answer 7

• Respiratory disorders:
• Hyaline membrane disease (less than 34 weeks)
• BPD- broncho pulmon disphasia
• Perinatal asphyxia- lack of O2
• Cardiac disorders: PDA Patent ductus artiolus
• CNS disorders:
• IVH (grade I - IV) Interventricular hemorrage 4 most extreme ( high risk CP)
• PVL- periventricular leukomalacia
• Visual disorders: ROP (stage 1 - IV) Retinopathy of prematurity

Intervention in the NICU: OT Role

• Hypotonia is present & normal for pre-term infants: at risk for positional deformities
• Shoulder external rotation & retraction
• LE hip abduction, external rotation, knee flexion, ankle eversion
• Decreased depth of rib cage
• Dolicephaly (head flattening)
• Grooved palate
• Therapeutic Positioning: minimize deformities, maintain a calm state
• Work with nursing
• NICU definition of “Intervention” (anything you do with that child/ any time interacting with child to do task ie change diaper/ blood draw/ meds)

Question 8

What are the Therapeutic Positioning Guidelines?

Answer 8

• Soft surface (sheepskin, water mattress, gel mattress)
• Promote “nesting” using blanket rolls or commercially available rolls
• Sidelying:
  
  • Midline orientation
  • Chest shape & breathing improvement
  • Digestion better when placed on right side
  • Careful with very small & premature infants due to breathing issues
• Prone:
  
  • Improved oxygenation & ventilation
  • Better gastric emptying
  • If supported well, facilitates flexion
  • Less energy expenditure
  • Reduced possibility of aspiration secondary to reflux
• Supine:
  
  • Make sure infant is flexed, with head in midline since supine facilitates extension
  • Can increase sleep time; reduced risk of SIDS
  • Increased risk of reflux & aspiration
• Swaddling
• Adaptive equipment:
  
  • Blanket rolls
  • Hammock
• Adaptive Equipment: “Bendy Bumper”

Question 9

Intervention in the NICU: OT Role

Answer 9

• PROM: rarely needed unless neuromuscular limitation of movement
• Splinting: Rarely needed unless significant neuromuscular limitation of movement (fisting), use alternatives to thermoplastics due to skin sensitivity:
  
  • Towel rolls
  • Firm foam
• Feeding: Speech & Nursing involvement
  
  • Readiness: Is infant mature enough? Suck-swallow reflex present?
  • Encourage non-nutritive sucking on pacifier during non-oral feedings
  • Consider:
    
    • Medical issues
    • Behavioral alertness
    • Neuromuscular issues
    • Positioning
• Sensory stimulation issues: Watch behavioral cues! Consider the infant’s behavioral state!
• Consider what is “normal” baby handling
• Try to limit to one sensory input at a time
• Tactile: most developed
  
  • Holding
  • Infant massage
• Auditory: maternal heart beat sounds; soft human voice
• Visual: soft, simple forms or face; avoid high contrast patterns
• Vestibular: gentle rocking
• Working with Parents
  
  • Help educate parents about behavior of premature infants
  • Teach parents positioning, holding, stimulation, and feeding techniques that are appropriate for their child
  • Allow parents to do some of the care
  • Refer to parent support groups
  • Refer to support services & follow-up when ready for discharge

Question 10

Early Intervention: 0 - 3 years Major or Minor risk categories:

Answer 10

Major risk categories for developmental delays:

• <1250 grams at birth
• <28 weeks gestation
• ECMO
• High frequently ventilation
• BPD requiring home oxygen
• Abnormal neurological evaluation
• Seizures for other than metabolic reasons
• SGA
• Dysmorphic infants or with syndromes with known developmental delay or unknown neurological outcome
• Congenital viral infections (Herpes, CMV, AIDS)
• IVH
• PVL
• Hydrocephalus
• Meningitis
• Severe twin to twin transfusion syndrome

Minor Risks

• Minor Risk factors (2 or more increases risk)
• 28 - 32 weeks gestation
• Microcephaly
• ROP
• Confirmed hearing impairment
• APGAR < 4 at 5 minutes
• Severe meconium aspiration
• Severe pulmonary hypertension
• Symptomatic hypoglycemia
• Hypotension requiring presser support
• Hyperbilirubinemia requiring exchange transfusion
• Substance abuse in utero (cocaine, heroin, multiple drugs)
• Referral by hospital social worker for family/social concerns

Question 11

Early Intervention:
**Developmental “Red Flags”

Answer 11

Gross-Motor:

• Extreme high or low tone
• Tendency to use extensor patterns of arms or legs
• Poor or slow to develop head control
• Strong or persistent presence of primitive reflexes
• Poor or slow to develop postural control

Fine-Motor:

• Extreme high or low tone
• Persistence of grasp reflex beyond 3 months
• Use of one arm more than the other in children less than 18 months
• Persistent posturing of arms & hands away from midline
• Shaking or tremor of arms

Cognitive/Perceptual development & Self-regulation behaviors

• Constant irritability
• Family lack of awareness of infant “signals”
• Poor ability to selectively attend

Feeding:

• Infant tires easily & consistently does not finish meals
• Infant takes a long time to feed (30 minutes or more to feed 2 - 4 ounces)
• Frequent vomiting or reflux with increased irritability after feeding
• Frequent choking or gagging

Question 12

Early Intervention: OT Role

Answer 12

• Private funding for OT services: follow referring physician’s request
• Federal funding of OT services through Part C of IDEA:
• Determination of developmental delay through multidisciplinary assessment (eligibility based on State guidelines)
• Family priorities are identified and documented in an IFSP
• State “Lead” Agency; Service coordination
• Service delivery in “natural environments”
• Transition to preschool (Funding transfers to Department of Education)
• Follow timelines
• Facilitate change in child’s developmental function
• Interpret & re-define behavioral responses
• Compensate for or adapt to the effects of the disability
• Provide support for family members
• Coordinate with other professionals
• Development of Gross-Motor skills related to sensory exploration, & cognitive, social, self-help development
• Fine-Motor development and manipulative hand function = develop cognitive, social, self-help skills and sensory exploration
• Development of play skills
• Sensory skills and behavior
• Oral-motor function and feeding
• Adaptive equipment & positioning

Treatment Guidelines

• Understand process of normal development!
• Design OT program at the child’s level and challenge child to reach the next level of skill development.
• Understand the impact of muscle tone on development!
• Use positioning techniques during OT intervention!
• Apply knowledge of sensory systems to help with attention & focus & behavior
• Consider upright positions, especially if child is older than 12 months.
• Be sensitive to parent & caregiver needs; discuss what you are doing & why
• Coaching families
• Suggest ways that parents can apply what you are doing at home in the context of play, and everyday activities.

Question 13

Sample Activity: Prone prop, weight shift & reach

Answer 13

Question 14

Sample Activity: Sit, weight shift & reach

Answer 14