Premature Infants and Infant behavior

Question 1

Role of OT in the NICU

Answer 1

• Work within the social and physical bounds of NICU environment
• Assist each family (“caregivers”) to foster optimal infant development
• Encourage developmentally appropriate occupations, sensorimotor processes, and neurobehavioral organization
* Consider the fragility of the infant (and “fragility of the family system”)
• Collaborate with others to achieve effective social and physical environment
• Implement programs within context of family and NICU environment

Question 2

full term vs premature gestation

Answer 2

37-40 weeks

< 37 weeks

Question 3

full term vs premature muscle tone

Answer 3

Full term - physiological flexion

premature - hypotonia

Question 4

full term vs premature resting posture

Answer 4

full term - extremities are flexed and adducted to body, physiological flexion

premature - extremities are extended and abducted, decreased flexion and poor midline orientation

Question 5

General features of a premature infant

Answer 5

• Inconsistent or reduced primitive reflexes
• Minimal spontaneous movement
• Flexor muscle tone increases at the premature infant grows closer to full term gestation. This occurs in a caudocephalic direction, but a preterm infant may not achieve the same degree of physiological flexion as a infant born full term
• Some premature infants may experience some developmental motor delays due to poor elongation of extensors and poor development of flexors (in comparison to an infant born full term).
• A premature infant is given a “corrected age” up to 2 years to allow for developmental discrepancies due to prematurity. (ie. A premature infant is born 8 weeks early (2 months) at 32 weeks gestational age. At 1 year of age (12 months) a therapist would expect they baby to demonstrate developmental skills of a 10-month old).

Question 6

PCA

Answer 6

Post-conceptual age (ie. the baby is 27 weeks post-conceptual age, 27 weeks gestational age)

Question 7

general preterm neuromotor development

Answer 7

• generalized hypotonia
• movement (random become more purposeful by 40 weeks)
• reflexes: primary reflexes become consistent and complete (tonic labyrinthine reflex)
• oral reflexes: swallowing of amniotic fluid at 11 weeks, sucking at 28
• vision: unable to focus until retina optic nerve are fully developed
• auditory: by 40 weeks, can discriminate mother’s voice

Question 8

“scarf” sign

Answer 8

while in supine, examiner can take the infant’s hand and move it across the chest to opposite shoulder

increased ROM in shoulder due to hypotonia and lack of flexion

Question 9

APGAR

Answer 9

Appearance (skin color)
Pulse (heart rate)
Grimace (irritability)
Activity (muscle tone)
Respiration (work of breathing)

Question 10

APGAR scores

Answer 10

A newborn is evaluated and given an APGAR score at 1, 5 minutes of life (and at 10, 15 minutes of life until an overall score of at least 8 is achieved). Each of 5 variables is assigned a score of 0, 1, or 2 and then the scores are totaled for the APGAR score. A total score of 8-10 within 5 minutes indicates an excellent chance for survival.

2 is the best, 0 is worst

Question 11

thermal regulation

Answer 11

• limited fat cells to help the body regulate temperature
• need regular turning to avoid irritation to skin
• may live in a temperature controlled isolette to help maintain the body temperature, conserve oxygen and calories

Question 12

Respiratory distress syndrome (RDS) and cause

Answer 12

• poorly developed lungs, unable to produce sufficient amounts of surfactant until ~35 weeks gestational age.
  RDS is the end result of a relative surfactant deficiency affecting a premature infant’s respiratory capacity.
• Surfactant deficiency: fatty substance that coats the alveoli (tiny air sacs in lungs) and prevents them from collapsing.

Question 13

Pulmonary Interstitial Emphysema (PIE)

Answer 13

• premature infant receiving mechanical ventilation
• pressure may occasionally cause air to leak
• when tiny air bubbles are forced out of the alveoli and in between lung layers, a PIE occurs

Question 14

Pneumothorax

Answer 14

• air leak syndromes which results from the rupture (burst) of alveolar sac
• a chest tube is inserted to displace the air between the lungs and the chest wall and help lungs to re-inflate

Question 15

Physiological or Autonomic Responses

Answer 15

Includes patterns of respiration, heart rate, thermoregulation, and digestion

Question 16

Motor responses

Answer 16

Includes posture, tone, and activity of the trunk, extremities, and face.

Question 17

state control

Answer 17

This includes the range of states available to the infant, the transitions from one state to another, and the clearness and differentiation of states.
- don’t want to interact with baby

Question 18

deep sleep

Answer 18

regular breathing, eye closed, non-eye movements, relaxed facial expression, no spontaneous activity
– don’t want to interact with baby

Question 19

light sleep

Answer 19

eyes closed, rapid eye movement, respirations irregular, disorganized movements, sucking and mouthing movements, whimpers, facial twitching

Question 20

drowsy

Answer 20

transitional state) – semi-dozing, eyes open or closed, diffuse movement, whimpers, facial grimacing
BEST state for infant feeding*

Question 21

awake/quiet

Answer 21

eyes open with bright shiny look, seems to focus attention, minimal motor activity
BEST state for infant handling and interaction

Question 22

awake/active

Answer 22

eyes open or closed, well defined motor activity, facial grimacing, fussing, HYPERALERT – eyes wide open giving impression of panic or fear

Question 23

agitated/crying

Answer 23

intense crying/upset, intense facial grimacing

Question 24

attention and interactional behaviors

Answer 24

This includes the infant’s ability to assume and maintain an alert state and take in and respond to environmental input (ie. handling from family, caregivers

Question 25

self regulation

Answer 25

The ability of the infant to maintain stability of the other systems and to initiate behaviors to promote his/her own stability. A premature infant will attempt to maintain organization/stability using these behaviors, they are protective in nature.

Question 26

approach cues

Answer 26

• hands to face
• postural change
• sucking
• visual “locking”
• grasping

Question 27

distress cues

Answer 27

Autonomic: changes in color, vital signs, visceral responses, tremors, startles, sneezing, yawning

Motor: sudden changes in muscle tone, frantic flailing movements, jitteriness, increased squirming, fingers splaying, back arching or hyperextension or trunk and extremities (“saluting”), facial grimacing, tongue extension

State: diffuse sleep state (twitching, grimacing), glassy-eyed, gaze aversion, paniced look (hyperalert), irritability (crying), hyper-alert (“staring” and “wide-eyed”)

Question 28

infant’s response to a stimulus can be affected by

Answer 28

• the level of medical support required (# of procedures/tests during the day)
• medications (morphine, ativan, nervous system depressants)
• time of the exam in relation to the feeding schedule

Question 29

potential indications for referral to OT in the NICU

Answer 29

1. abnormal muscle tone or posturing (asymmetries, arching of back, high or low muscle tone)
2. prolonged hospitalization
3. feeding or suck-swallow difficulties
4. congenital malformations
5. sensory impairments
6. disorganized behavior (ie. irritability, inability to self-quiet, excessive startle or hyper-excitability)

Question 30

common goals of developmental intervention in the NICU

Answer 30

1. to promote behavioral state organization (asleep/calm)
2. to promote parent-infant interaction and bonding
3. to enhance self-regulatory behavior through environmental modification
4. to promote postural alignment and more normal patterns of movement through therapeutic handling and positioning:
5. to enhance oral-motor skills and assist with oral feeding
6. to improve visual and auditory reactions
7. to prevent musculoskeletal abnormalities
8. to provide appropriate remediation or orthopedic complications
9. to provide consultation to team members, including the nursing and staff, parents
10. to help with transition to home by participation in discharge planning

Question 31

when does physiological flexion develop

Answer 31

• the last trimester of pregnancy:
  • in response to decreased inutero space
  • as an active process in neurological development

**Many premature infants are born before they have chance to develop physiological flexion. **

Question 32

overall goals of positioning

Answer 32

1. support the infant’s sensorimotor abilities and developing systems
2. counteract any emerging abnormal postures (ie. arching, full body extension)
3. provide positive input during the hours each day spent without direct physical contact.
4. cannot interfere with necessary medical intervention

Question 33

swaddling

Answer 33

a technique to provide physiological flexion using blanket and wrapping. It encourages flexion, assist in “motor inhibition” (limits excessive movement of arms and legs), aids in calming baby and normalizing tactile input.

• Infant’s hands are positioned in midline
• Legs are softly flexed towards the abdomen
• Blanket snuggly wraps like a cocoon around infant

Question 34

prone

Answer 34

• facilitates flexion
• may improve oxygenation due to the mechanical advantages of prone positioning on chest wall expansion
• infants tend to be calmer in prone, more organized
• research has documented that infants sleep more, spend less energy, have lower oxygen consumption, improve arterial oxygen pressure, lower intracranial pressure, and lower respiration rates in prone
• Principles: hips and knees are flexed with the knees under the hips. The arms should be flexed (elbow flexion) with the hands near the mouth. The head should be turned to one side.

Question 35

sidelying

Answer 35

• Used to facilitate flexion towards midline
• Encourages hand to mouth activity
• May reduce “arching” by providing boundaries that support flexion of the spine (C-shaped curve)
• Principles: the hips and knees are flexed, arms flexed forward with hands positioned near the body. Rotate side to side to prevent skull flattening and scoliosis

Question 36

supine

Answer 36

• Allows for easy viewing of medically unstable infants
• Found to be disruptive and disorganizing for newborns. Promotes arms and legs extension and abduction away from midline of the body (pull of gravity on limbs).
• Research has documented that supine positioning promotes extensor patterns, increases energy expenditure, increases intracranial pressure, predisposes infants to upper airway obstruction, and constantly exposes the infant’s eyes to ceiling lights.
• Principles: the knees and hips should be flexed towards the abdomen, the shoulders flexed forward with the hand on the chest or near the face. The arms and legs should be symmetrical with the head in midline or turned to one side. Provide “nesting” with blanket rolls to provide boundaries and facilitate self-regulation. Prolonged supine positioning may contribute to a premature infant’s extended posture

Question 37

managing stress and organizing behavior - modifying the environment

Answer 37

• Decrease the lighting – dim/dark for calming
• Decrease overall sound levels
• Silence monitor alarms as soon as they are located
• Divert any conversations with medical personal away from baby’s bedside
• Avoid musical toys
• Close isolette portholes very gently (sound amplifies inside isolette)

Question 38

managing stress and organizing behavior - decrease handling

Answer 38

• Contain the infant’s limbs and limit excessive movement
• Use slow, gentle movements when repositioning, hold extremities in flexion close to body until calm
• Avoid the “premie flip” (quickly turning baby over from prone to supine)
• A first positive touch is the grasp reflex, very organizing for baby

Question 39

managing stress and organizing behavior - provide optimal positioning

Answer 39

• Avoid the “W” configuration or “frogged-legged” positioning
• Encourage positions that allow baby’s hands near face

Question 40

managing stress and organizing behavior - cluster care

Answer 40

• Allow for longer periods of quiet and growth
• Try to establish regular patterns for therapeutic caregiving
• Only offer 1 mode of stimuli at a time if possible (ie. avoid moving, looking, touching, and talking to baby at the same time)
• Provide momentary “time-out” from incoming stimuli when baby is showing stress signs. This is called stress cue intervention.

Question 41

infant massage

Answer 41

Infant massage is a type of complementary and alternative treatment approach that uses massage therapy for infants. There is strong evidence to support the effectiveness of massage-based interventions in addressing parental stress, maternal depression, and social engagement.

Question 42

feeding issues in premature infants

Answer 42

Successful oral feeding experiences are dependent on many variables. The suck-swallow reflex emerges around 28-30 weeks but is weak and poorly coordinated and lacks rhythm. A gag reflex may not be present until 32 weeks gestational age. Generally, oral feeding is initiated at 31-34 weeks (dependent on hospital protocol, MUSC is 31 weeks for medically stable premature infant). Coordination of suck/swallow/breathing may not be fully developed until 37-40 weeks due to myelination of the medulla controlling speed and coordination of motor responses.

Question 43

neonatal sucking

Answer 43

combine the use of positive pressure (expression) with negative pressure (suction). Infants may pause between sucking bursts to rest, re-group, socialize, and process the information.

Question 44

research on neonatal sucking

Answer 44

1. assists in infant state regulation
2. prolongs periods of quiet, calm state
3. reduces energy expenditures
4. improves oxygenation (especially if continued 5-10 min. post-feeding)
5. improves GI functioning by increasing gastric mobility
6. promotes advancement to oral feeding
7. may help establish a positive association between sucking and relief from hunger during tube feedings (when oral stimulation provided at tube feeding times)
8. helps increase weight gain (by increasing GI function and promoting sleep patterns)
9. promotion of earlier hospital discharge (by helping with all of the above)

Question 45

assessing readiness for prior oral feeding

Answer 45

• reflexes – are reflexes easily elicited?
(rooting, suck/swallow, gag)
• medical history
• evaluation of behavioral state for feeding
- DROWSY ALERT is best state for oral feeding (reduce environmental stimuli)
- does the baby demonstrate “hunger” behaviors? (ie. cries at feeding time, spontaneous rooting, spontaneous hand to mouth activity)
•evaluation of muscle tone
- hyper or hypotonic infants have special positioning considerations
- feeding skills of premature infants can be adversely affected by limited overall endurance
• evaluation of oral-motor skills, non-nutritive sucking pattern
- feeding skills of premature infants can be adversely affected by decreased buccal fat pads and limited tongue mobility
• evaluation of medical stability
- can the infant handle re-positioning and handling without signs of stress?
- does the infant require supplemental oxygen or increased liter flow during + oral stimulation activities?