NICU Flashcards
What are some special considerations of PT practice in the NICU?
- Child misses out on physiologic flexion
- lungs are underdeveloped
- more sensitive neurologically
- less body fat, smaller
- difficulty regulating temp and HR
- to be removed from NICU, must maintain core temp and gain weight
What are the educational requirements for a PT to work in the NICU?
- Not entry-level
- Sub-specialty area within pediatrics
- Potential for causing harm (physiologic jeopardy); Not for the PT or OT assistant
What is the role of the PT in the NICU?
- Screen infants to determine need for PT based on established referral criteria
- develop and implement a risk management plan to prevent neurobehavioral organization and secondary complications, to max neurodevelopment function
- design, implement, and evaluate intervention plans and strategies in collaboration with family and team
- consult and collaborate with internal and external players
What is the role of the SPT in the NICU
- non handling observations in the NICU: Varying ages, diagnoses and acuity levels; Infant caregiver interaction; Handling and interaction by all team members; Communication with team members
- Handling, examination, intervention on the pediatric unit and PICU
- Interaction, examination, intervention in NICU follow-up clinic
A high-risk infant is defined as High probability of demonstrating developmental delay as a result of exposure to medical factors. What is this classified based on?
- birth weight (under 5lb 8oz)
- gestational age
- pathophysiologic problems
What are the differences btwn NICU babies and “normal” babies?
- Less body fat
- Less muscle tone
- Smaller
- Can’t regulate body states: Temperature, Rhythm of breathing, Swallowing & sucking, Remembering to breathe, Jaundice
What does the posture look like in premature infants?
- Hyperextended neck
- Elevated shoulders with adducted scapulae
- Decreased midline arm movements
- Excessively extended trunk
- Immobile pelvis
- Infrequent antigravity movement of legs
- problems in prone, sitting, breathing, reaching
Neonates and premature neonates can feel pain. what are their physiologic and behavioral responses?
- increased heart reate
- blood pressure, and respirations
- decreased O2 sats
- pallor, flushing, diaphoresis, palmar sweating
- increased muscle tone
- dilated pupils
- crying, grimaces, furrowed brow, limb withdrawal, fist clenching, finger splaying
- changes in state
- Causes: Insufficient Surfactant; Pulmonary immaturity
- Risk factors: Prematurity, LBW, Low Apgar at 1 and 5, Maternal age over 35
- Treatment: Steroids to Mother, Administration of surfactant to infants, Prophylactically in infants <30wga, Positive pressure ventilation
Respiratory distress syndrome (Hyaline membrane disease)
- 32 weeks produce surfactant, prior to 30 wks, definitely not there
What are the respiratory conditions that can be seen in the NICU
- Respiratory distress syndrom
- Apneay and bradycardia - need apnea monitor
- bronchopulmonary dysplasia
- Chronic lung disease
- Damage to immature lung tissue from artificial ventilation
- Diagnostic Criteria: 28 days (born at >/=32 wga) and require supplemental O2; Abnormal physical exam (wheezes, tacypnea, retraction); Abnormal chest X-ray
Bronchopulmonary dysplasia
- thickened and hyperreactive airways, decreased lung compliance, increased airway resistance, impaired gas exchange with ventilation-perfusion mismatch, air trapping
- 36 wga and requires supplemental O2; same as BPD but at 36 wks or older
chronic lung disease
- clinical manifestations = irritability, restlessness, postural abnormalities, fatigue
What is the long term sequelae from respiratory problems?
- Repeated infections
- Requirement of supplemental oxygen
- Pulmonary hypertension
- Cardiac hypertrophy
- Transient hypertonicity
- Asthma - Especially with BPD
What is the cardiac condition seen in NICU?
Patent ductus arteriosus
- or persistent fetal circulation
- rx: indomethacin or sx
What are the causes of intraventricular hemorrhage (IVH)?
- perinatal asphyxia in premature brain with fragile vasculature (germinal matrix 26-34 weeks)
- Resuscitating infants (sudden inc in BP)
- Respiratory Distress Syndrome
- 28-32wga key time for neurologic damage due to vulnerability of the brain and developing glial cells
What are the 4 stage classifications of IVH?
- Grade I: hemorrhage in the germinal matrix only
- Grade II: bleeding within ventricles without distention
- Grade III: bleeding with ventricular distension
- Grade IV: bleeding extends into brain parenchyma with hydrocephalus (blood seeps into gray or wh matter)
What are the risk factors for the different stage classifications of IVH?
I and II are low risk for neuro impairments
III and IV have 25-60% chance of neuro complications
What are the key points of IVH?
- Incidence increased as Gestational Age decreases
- Multiple risk factors
- Occurs early postnatally (75% by 72 hours)
- Caused by hypoperfusion
- Corticosteroids antenatally decrease IVH
What are the neurological complications seen in the NICU?
- Intraventricular hemorrhage - bleed
- Hypoxic ischemic encephalopathy (HIE) - inadequate O2 in events surrounding birth
- Periventricular Leukomalacia - ischemia
- Occurs antepartum, intrapartum, or postnatal
- Mild to severe sequelae: normal neuro exam at 1 week=+ prognosis; Abnormal neuro exam at 3 weeks indicates risk for major sequelae (CP, intellectual disability, seizures, cortical blindness, hearing impairment, microcephaly)
Hypoxic ischemic encephalopathy (HIE)
- older infants - late preterm/ full term
- general, not focal
Ischemia in white matter around the ventricles; main sites of focal necrosis = trigone of lateral ventricles and border zones btwn the cerebral arteries
Periventricular leukomalacia
- motor tracts control leg movements closest to ventricles, resulting in spastic diplegia CP
- strongest and most independent risk factor for the development of CP
- can occur due to IVH
GI complication: acute inflammatory disease of the bowel; most frequently occurs in 1st 6 weeks of life in infants weighing less than 200 g
Necrotizing enterocolitis
Abnormal vascularization of the retina; Incidence is less than 1000 cases per year; Increases with lower gestational age, lower birth weight, and BPDF; Classification = 5 stages; Outcomes = Normal vision to blindness
Retinopathy of prematurity
- actually affects the eye, not cortical blindness
liver complication: Can’t secrete bilirubin due to immature liver; Can cause - Kernicterus (athetoid CP)-deposition of bilirubin in the brain, especially basal ganglia and hippocampus
RX: Phototherapy/blood transfusions
Hyperbilirubinemia
- AKA jaundice
- if undiagnosed, can causes damage to the brain
When infants are exposed to drugs in utero; manifests as withdrawal; Can cause temporary and permanent neurological issues
Neonatal abstinence syndrome
What are the discharge criteria for the NICU?
- Sustained pattern of weight gain
- Maintenance of normal body temperature in an open environment
- Successful mode of feeding
- No episodes of apnea and bradycardia for 3 days
- Car Seat Test – 2 hrs
What babies should have a follow up?
- anyone who has a diagnosed condition
- other clinic established criteria (i.e., clinic may require follow ups for anyone born under 32 weeks or under 4 lbs)
- 4 mos adjusted age
- infants d/c with tech supports (ventilator, apnea monitor, etc)
- 10-30% of VLBW have major neuro impairments
- 40% of VLBW have minor
What is the developmental follow up schedule?
- Every 3 months the 1st year
- Every 6 months in the 2nd year
- Yearly until school age
What are the early manifestations of CP?
- Hypertonia in LE*
- Hypotonia in trunk** - Nothing in the head or trunk
- Poor feeding
- Neck hyperextension (predictive but majority of infants who exhibit this are okay)
- Primitive reflexes are LEAST predictive
- Fisting of hands [prolonged]
What is the difference btwn healthy premature and full term infants in terms of neuromotor behavior?
- Greater joint mobility
- Less antigravity movements in supine
- Primitive reflexes persist longer
- Balance reactions are immature
- Flexion control less mature
