TheStruggleisReal:IdentifyingtheDevelopmentalNeedsof
FragileInfants
ErikaClemensMSOTR/LSWCCLECUCSanDiegoHealth
Objectives:
• Identify3differentaspectsofDevelopmentalCarethatOccupationalTherapistsaddressintheNICU.• Differentiatebetweenstresssignalsandsoothingbehaviorsinfragileinfants• BeabletodiscussthepotentialeffectsoninfantskillacquisitionwithoutdevelopmentalinterventionwithintheNICU.
OTPromotesDevelopmentalCareintheNICU
DevelopmentalSkills…
• Neurobehavioralorganization/Toleranceforhandling
• Oral/Motorfunction• Sensorydevelopment&processing
• Social-emotional
…achievedthroughvariousactivities• Positioning• Splinting• OralPlay/Feeding• GradedSensoryInput• TherapeuticExercises• DevelopmentallyFacilitativePlay• Parent/StaffEducation
Whattodofirst?
• Age-Appropriate• BasedonAssessments,Observations,and
ReportsfromFamily&Staff• Allareasareinter-related&dynamic• Babyguidestheway• Timevariance• Bedsideinstructions
Positioning
Prematuritywillincludealtered/incomplete:• MuscleTissuedevelopment• ArticularStructures• ExtremityMal-Alignment• SpinalCurvatures• HeadMolding
MuscleTissue
• Differentiateintotwotypesby20weeksPCA• Slowtwitch/highoxidative(typeI):lowpower/highendurance• Fasttwitch/lowoxidative(typeII):highpower/lowendurance
• Notconsideredcompleteuntil40weeksPCA• DuringtimeinNICU,typeIlowerinratiototypeII• Thus,↑respiratoryfatigueanddecreasedposturalintegrity
LETone:33-35weeksPCAUETone:35-37weeksPCA
ArticularStructures
• Mechanoreceptorsrecordsstatic&dynamicpositions• Fetalmovement→ jointshaping• Developmentofproprioceptionthroughoutinfancyandchildhood• Withavariety ofpositions→mechanoreceptordevelopment• Restrictivebodypostures→chronicjointcompression,potentiallybringingonskeletaldeformation,muscleshortening,anddecreasedROM.
ExtremityMal-AlignmentinSupine:UpperBody
• Scapularadductionwithshoulderelevationandshoulderretraction
DevelopmentalDelay:• Midlinearmmovement• Reaching• Weightbearingin
prone/shoulderstability• Rolling
ExtremityMal-AlignmentinSupine:LowerBody
• Excessiveabductionandexternalrotation• “Froglegs”• Shortenedhipabductor
muscles• Iliotibial bandshortening• Increasedexternaltibial torsion
DevelopmentalDelay:• Transitionsoutofprone&sitting• Crawling• Heel-toegaitpattern• Causingwide-basedgaitwithout-toeing
SpinalCurvatures
• ExaggeratedCervicalLordosis• Neckhyperextensionpostures• Exacerbatedbyendotrachealtubing
• Overstretchedandweakenedanteriorneckmuscles
DevelopmentalDelay:• Headcentering• Downwardvisualgaze• Handcoordinationtomidline/mouth
SpinalCurvaturescontd.
• Secondarydevelopmentofcervicalandlumbarlordosis&thoracicandcoccygealkyphosishappeninlaterinfancy
SpinalCurvatures(contd.)DevelopmentalDelay:• LumbarLordosis• TummyTime/Proneat4monthsofage• Independentsittingat6monthsofage
HeadMolding/Torticollis
• NewMorbiditycorrelatedwith“SafeSleepGuidelines”• Usuallyidentifiedby2monthsofage• Torticollis• Positional/Muscular
DevelopmentalDelay:• VisionDevelopment• RightingReactions• Unilateralneglect/disuse• Asymmetricalpostures/mobility
TreatmentmustbemorethanZflo &Swaddles…• Kinesiotaping• SoftSplinting• JointCompression• ROM/stretch• Massage• PositiveTouch
GradedSensoryInput
• ContainmentHolds• StaticProprioceptiveInput• PositiveTouch• JointCompression• Massage• Rocking/Movement• TummyTime• TherapyBallExercises
SixBehavioralStatesSleep States Transitional
StateDrowsy
Awake StatesAwake – Alert
Irritable or Fussy Crying
Deep SleepLight Sleep
HowIshowthatIamstressed…•Mottling/ColorChanges•Changesinmyvitalsigns•Gagging•Hiccups•PassingGas•Vomiting•Sneezing•Yawning•Glassy-eyed•GazeAversion•Staring
•LookofPanic•Irritability•GeneralizedHypotonia•Frantic,Flailingmovements•Finger/ToeSplay•HandSalute•Hyperextensionofarms,legs,back•DiffuseSleepStates(twitching,grimacing,restlessness)•Tremor•Shutdown•InabilitytoIntegrateStimulation
HowITryToSelf-Soothe
• Bringinghandstomouth• Grasping• Sucking• Visuallocking• HandClasping• Face/Hand/FootBracing• Coveringmyeyes• ChangeinPosition• Closingeyes
Whatcanwedo?
Classically….
• Reducestimulation• ↓Talking• ↓Movement• ↓Touching/stroking• ↓Facilitatinglatch
• Providecontainment• Bundletocalm• Burp
ButWait…
BabiesMAYrespondto:• Talking/Singing• GentleJiggling/Rocking• Massage• Latchachieved• Unswaddling• PositionChange
ReadytoEat!
• QuietAlertState• Activatingarms,handstomouth• Rootingsidetoside• Eagertolatchonpacifier,sustains• Grabbingontopacifiertopullinfurther
WeeReads!
• FreeBookBag• LibraryofBooks• Supportedbydonations/grants• Staff/Volunteersmodelreading• Encourageparents• 2016:MagnetBestPractice• 2016:AcceptedintoTJCLeadingPracticeLibrary
WhyWeeReads?
• Studiesintermchildrenages2monthsto36monthshaveshownthatthemoreparentstalktotheirchildren,thefastertheirvocabulariesgrowandthehigherthechildren'sIQtestscoresatage3.• ThenumberofwordsaparentsaystotheirchildperhourismorestronglyrelatedtoIQscore/vocabularygrowththananyotherfactor,includingSES/parents’educationlevel.• Preterminfantsvocalizemorewhentheirparentsarevisiting,withincreasesinthenumberofvocalizationsbyasmuchas129%whenaparentispresent,whichwasparticularlyevidentat32weeks.
Unfortunately…
• DepressionNICUparentslingerafterdischarge,20%reportingeffects9monthslater.
• Itisrecognizedthatonceanegativetrajectoryofparent-childinteractionisinitiatedintheNICU,changesarehardertofacilitateandevenmoredifficulttosustain.
• Veryfewparentsofhighriskchildrenplantoreadtochildrenbefore1yearofage.
HasSharedReadingbeenstudied?
• Moststudieshavebeendoneinvolvingchildren2yearsandolder.• AnticipatoryGuidance(e.g.ReachOut&Read):Clinicsandhomevisits
• Meta-analysisfindsthebenefitsofsharedreadingmorepositivetheearlierstartedandeffectsgrowmorepositivethelateroutcomemeasurementsaretested.• InthefewstudiesexaminingsharedreadingintheNICUnoted:
• Improvedparentbonding• Improvedreadingfrequency
NICUMusicTherapyGuidelines
• Startat28weeks• LiveSingingPreferred• 20-30minmaximum/1.5hoursin24hourperiod• Digitalmusicshouldhavethefollowingcomponents:• Voiceonlyorvoiceaccompaniedby1instrument• Constantvolume• Femaleorchildvocalists• Highrangemelodies• Light,constantrhythmwithnoalerting/surprisingfeatures• Decibellevel≤65(TypicalauditoryleveltolistentoTV/radio)• MusicalToys/MobileMusicshouldbeavoided
NICUMusicTherapyGuidelines
• SongsofKin• Discretionwhenusingprior/duringstressfulprocedure/inconsolability• Contraindicatedforhypersensitiveinfants--OTconsultindicated• Donotpropsmartphones/Ipads incribs• SuggestedApps:• BabySleep—handselectsimplelullabies• SleepHero—recordyourownlullabies• MagicSleep—soundsinsidewomb• BabyShusher—shusheswhenbabycries
VisualStimulation
• Modalitiesforinfants40weeksadjustedorolder• Prior,onlyambientandcyclicallight• Intermittent/OneSide• Mobilesafter40weeks• FootofCrib
• Monitorinfantcues
DevelopmentalActivities:0-2Months
• Talk,Sing,Read!• Bicycle• Supportedheadcontrolexercises• HOHtomouth• Skintoskin• Moveyourselfsidetosidetoallowinfantto“find”you• Havebabylookatselfinmirror• Placerattleinhandtofacilitategrasp• Providevarioussensoryexperiences• Tummytime(modification:Elevated/Upright)• Side-lying
DevelopmentalActivities:3-4Months
• Continuesharedreading,talkingwithconversationalturns• Sing&Dance!• Side-Lying/Rolling• Reaching• TummyTime(Flatsurface)• SupportedSitting• Therapyballexercises• ManipulationofToys(HOH)• Sensory/NovelToys• Supportedstanding
OtherInterventions…
• ShellsforTummyTime• HealingTouch• CollaboratingwithMusicTherapists• NeonatalHydrotherapy
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