1. Supporting Development of the Premature Infant after Discharge from the NICU
November 6, 2009
Susan M. Bickel, OTR/L
Denise Doorlag, OTR/L
Bronson Methodist Hospital
Rehabilitation Department
My experience as an OT
10 years at Bronson
describe mentoring in the nicu
preface that this Lecture is about Bronson's NICU

2. Objectives
Able to state the progression of normal development of the preterm infant
Able to identify the red flags of development and potential problems of the preterm infant
Able to select appropriate developmental activities for the preterm infant

3. The Neonatal Intensive Care Unit at Bronson Methodist Hospital
Bronson is a Level III NICU
45 bed unit – all private rooms
33 beds are intensive care
12 beds are intermediate care

4. Our NICU Team Neonatologists Nursing Social Worker Case Managers
Dietitian
Respiratory Therapists
Developmental Specialist (OT)
Pharmacist
Chaplain
Music Therapist
Child Life Specialist
Lactation Consultant
Meet the NICU team...need to get to know all these people on the unit so you can communicate and work closely with them all

5. The Role of the OT in the NICU
Developmental assessment and treatment
Feeding assessment and treatment
Education to nursing and family

6. Definitions NICU – Neonatal intensive care unit
Neonate – newborn infant-typically from birth through day 28 of life
Gestational Age – the length of time the infant was in utero
Post Conceptual Age – the age the infant is in weeks from conception and as he ages
Adjusted/Corrected Age or Conceptual age – same as post conceptual age
Chronological Age – the age of the infant calculated from day of birth
These are some terms specific to the NICU
It's important to know how to correct for a babies age
Ex: infant born at 28 wks is actually 12 wks or 3 months early
so when infant is 6 mo old..actually acting like 3 months

7. Definitions Term – infant born 37 – 42 weeks
Post Term – infant born over 42 weeks
Preterm – infant born 28 – less than 37 weeks
Extremely Preterm – infant born under 28 weeks
How to categorize a neonate

8. Definitions
Appropriate for Gestational Age (AGA) – infant’s weight falls between a normal range of the 10th and 90th percentile for that gestational age
Small for Gestational Age (SGS) – infant’s weight is less than the 10th percentile for that gestational age
Large for Gestational Age (LGA) – infant’s weight is above the 90th percentile for that gestational age
Intrauterine Growth Retardation (IUGR) – the infant’s weight and length are low for age

9.
21 weeks and six days on Oct. 24, Weighing less than ten ounces and measuring only 9.5 inches in length

10.
1 pound 6 ounces. 24 weeks

11. Medical Conditions Respiratory complications
Respiratory Distress Syndrome (RDS) – when tiny air sacs in the infant’s lungs do not stay open due to lack of surfactant
Chronic Lung Disease – complications of the lungs that persist after 36 weeks of age requiring supplemental oxygen
Bronchopulmonary Dysplasia (BPD) – abnormal growth of the infants airways and lungs due to high doses of oxygen and prolonged ventilator use
typical resp diseases all related to being premature

12. Medical Conditions Cardiac Complications
Patent Ductus Arteriosus (PDA) – a small blood vessel that connects the pulmonary artery to the descending aorta that should close on its own after birth; if it does not close, it may require medical or surgical management
Pulmonary Hypertension – increased pressure in the pulmonary blood flow
Atrial Septal Defect – a heart defect where there is an opening in the atria
Ventricular Septal Defect – a hole in the septum between the ventricles in the heart
Infants with cardiac complications may be weaker and fatigue quicker with eating

13. Medical Conditions Neurological Complications
Intraventricular Hemorrhage (IVH) – bleeding in the brain, often around the ventricles; very low birth weight infants are at high risk
Hydrocephalus – an increase in cerebrospinal fluid in the brain
Periventricular Leukomalacia (PVL) – decreased blood supply to the brain causing hollow spaces in the brain
OT will often assess premies with any neurological insults to help assess tone and feeding skills
ex: how a low tone infant may have difficulty feeding
relationship between low tone and feeding

14. Medical Conditions Neurological Complications
Hypoxic-ischemic Encephalopathy – injury to the brain due to decreased oxygen to the infant
Myelomeningocele – a protruding portion of the spinal cord and membranes
Infants with Myelom will often need ROM exercise for lower extremity
Give parents a home exer program

15. Medical Conditions Nutritional and GI complications
Necrotizing Entercolitis (NEC) – inflammation of part of the intestine that may result in the death of that tissue; may allow bacteria to leak into the abdomen and cause infection
Short – Gut Syndrome – infant is missing some intestine or too much has been removed
Gastroesophageal Reflux Disease – contents in the stomach flow back up into the esophagus
Many premies are prone to getting NEC..often can be medically managed...at times req surgery....then may have gut problems
GERD- can be common in NICU and Peds...OT can help make feeding recs and suggest formula changes

16. Medical Conditions Nutritional and GI complications
Gastroschisis – a hole in the abdominal wall resulting in some of the intestines developing outside the body
Hirschsprung’s Disease – an extremely dilated colon requiring surgical removal of the affected area; lack of ganglia needed for peristalsis
Omphalocele – a congenital hernia of the umbilicus
Gastroschisis will require surgery-most feed normally once fixed

17. Medical Conditions Malformations
Club feet – where one or both feet turn into adduction and supination
Cleft palate – a separation of the hard or soft palate
Cleft lip – a separation of the upper lip and often the upper dental ridge
OT works closely with all three of these malform
splinting club feet with fragile skin
give example
teaching family feeding tech...cleft palate bottle

18. Bilateral Cleft Unilateral Cleft

19. Club Foot

20. Medical Conditions Blood Complications
Anemia – low hemoglobin in the blood
Hyperbilirubemia – jaundice due to an excess of bilirubin in the blood
Sepsis – infection in the blood
Visual Complications
Retinopathy of Prematurity (ROP) – an abnormal amount of blood vessels in the retina
often caused by increased oxygen use in infants
severe cases may result in retinal detachment and blindness
Infant who is Jaundice will need bili lights or blanket

21. Medical Conditions Other Complications
Brachial Plexus Injury – damage to the brachial plexus during a difficult birth that may result in paralysis or weakness of the arm
IDM – infant of a diabetic mother
Down’s Syndrome/Trisomy 21 – most common syndrome characterized by one additional chromosome 21
OT goes in and teaches family handling tech and ROM exer for brachial plexus
OT is often involved in therapy early on with Down's syndrome feeding and exer

22. Down’s Syndrome

23. A Typical Stay in the NICU
Nursing Care
One nurse may have 3-4 babies to care for
Infant is put on a 3 hour care schedule
Diaper changed, meds given, clothes changed, blood pressure and temperature taken, heel stick/blood draw, suctioning, CPAP/vent changes and adjustments, feeding given through tube or by bottle, baths, feeding tube checked, position changed
Infant is then able to have a calm/quiet sleep period until the next care time
Often interrupted by other care such as physician, x-ray, therapy, respiratory care, eye exams, ECHOs, ultrasounds, and other medical care

25. A Typical Stay in the NICU
Family Visitation
Families are allowed to visit whenever they want to be there
Family is limited to mom/dad, grandma/grandpa and siblings
Mom and dad can bring other visitors with them
Families are not allowed to sleep at the bedside
Barriers to family visits
Families that live far away often have transportation problems
Families that need to work
Families have other children at home

26. A Typical Stay in the NICU
Ups and Downs of Medical Status
Extremely premature infants have multiple system problems
Each day early on in life can bring a new problem
The need for emergent surgery may arise
An infant may go through several surgeries throughout their stay
Changes in respiratory status happen daily
Even infants who are doing well, can unexpectedly take a turn for the worse

27. Shows CPAP, feeding tube, monitor leads
Shows CPAP, feeding tube, monitor leads

28. Development of the Premature Infant
The infant at 31 weeks and under:
Behavior
Primarily in a sleep state
Brief periods of alertness when closer to 31 weeks
Able to consistently respond positively and negatively to stimulation
Easily startled and agitated
Motor
The extreme premature infants are generally hypotonic until about 29 weeks
Oral Motor
The sucking reflex is beginning but is weak and not very coordinated

29. Development of the Premature Infant
The infant at 32 – 36 weeks:
Behavior
Able to demonstrate brief alert periods
Beginning to open eyes in response to stimulation
Attempts to calm self (hands to mouth)
Motor
At 32 weeks developing more consistent hip flexion
Towards 36 weeks, demonstrating more consistent upper extremity flexion
Oral Motor
Demonstrating the rooting reflex and beginning to work on oral feedings

30. Development of the Premature Infant
The infant at 37 – 40 weeks:
Behavior
Infant awakens on his own
Tolerates longer alert periods with greater tolerance to stimulation
Beginning to track and focus with eyes
Motor
Flexor tone dominates throughout all four extremities
More spontaneous and controlled movements
Oral Motor
Consistent rooting reflex
Organized suck, swallow, breathe coordination

31. How to Correct for Gestational Age
It is recommended that a child’s age is corrected up to 2 years of age.
Subtract the number of weeks or months that the infant was early from the current age of the infant
Example: if the infant was born at 28 weeks gestation, he was born 3 months early. When he is 6 months old, his corrected age is 3 months. He then should be expected to do 3 month old skills.
The infant’s head, weight, and length measurements should be based on his corrected age.
Remind parents how to correct for their infant’s age and also have the parent remind the doctor what the infant’s corrected age is.

32. Premature Infant vs. Term Infant
Flexor tone of the preterm infant at term age is not as great as the infant born at term
The preterm infant at term age will have less head control than the infant born at term
The preterm infant at term age will have less predictable sleep-wake cycles and feeding patterns than the infant born at term
Breastfeeding skills are not as mature in the preterm infant at term age
The preterm infant at term age has decreased ability to tolerate multiple types of stimulation

33. Why Does the Premature Infant Develop Differently?
Lack of the uterine environment
Inability to develop physiological flexion
Decreased exposure to movement and joint compression
Early exposure to sound, light and other stimuli
Poor positioning
Prolonged positioning in the supine position resulting in poor head shape and weakened flexor muscles

34. Why Does the Premature Infant Develop Differently?
Respiratory complications and medical instability
Abnormal tightness in muscles
Delay of initiation of feeding
Increase in noxious stimulus associated with care
Early fatigue and decreased endurance with all activity
Infants being sedated or on prolonged ventilation may develop extending postures making it difficult to move normally and to self-organize (article: “Enhancing Occupational Performance in Infants in the NICU”)

36. Why Does the Premature Infant Develop Differently?
Increased noxious stimuli and decreased pleasing interactions
“Research shows that highly stimulating physical environments such as the NICU are stressful to infants and may affect their self-regulation and ability to engage in activities.” (article: “Enhancing Occupational performance in Infants in the NICU”)
Due to high amounts of unpleasing stimuli in the NICU, infants have a hard time exploring the caregiver’s face and visually following the caregiver in poor social play (article: “Enhancing Occupational performance in Infants in the NICU”)

37.
common CPAP...cont post airway pressure...keeping lungs open to help baby breathe better

38. Potential Problems of the Premature Infant
Muscle tightness
Muscle weakness
Poor endurance
Visual problems
Feeding problems
Behavioral and Sensory problems

39. Red Flags of Preterm Development
Muscle tightness
Infant prefers to turn head to one side
Flat spots on back/side of head
Arching
Difficulty bringing hands to the middle
Standing on toes
Delayed rolling
Difficulty changing diaper/changing clothes

40. How We Can Help Frequent position changes Tummy time
Range of motion exercises/stretching
Eliminate walkers, exersaucers, and jumpers
Helmet use for severe plagiocephaly
Possible referral to physician for medication
Referral to physical therapy and occupational therapy
Educating parents on proper progression of developmental milestones
Teach parents appropriate play activities to work on midline, rolling, and tracking

41. Red Flags of Preterm Development
Muscle weakness
Poor head control
Floppy baby
Delayed sitting
Delayed rolling
Delayed crawling
Decreased active arm and leg movements
Tires easily with activity
An OT in acute care needs to have a plan for the day - but yet needs to be flexible because things are always changing

42. How We Can Help Practice supported upright sit
Range of motion exercises
Tummy time to help strengthen trunk muscles
Keep newborn swaddled when sleeping
Use mobiles, play gyms, and wrist rattles to encourage movement
Pull to sit activities
Help facilitate muscle tone
Eliminate walkers, exersaucers and jumpers
Position infant so he can easily get hands to mouth
Possible referral to PT/OT, if developmental milestones are not being met

44. Red Flags of Preterm Development
Poor endurance
Sleepy baby
Unable to take whole feeding
Tires easily with activity

45. How We Can Help Help parents create a schedule for baby
Allow infant to have full, restful sleep in crib, away from disturbances
Help parents understand why baby is fatiguing

46. Red Flags of Preterm Development
Visual Problems
Infant does not make eye contact with caregiver
Infant does not track toy or face
Infant’s eyes are averted to the left or right
Infant prefers to look to the right or the left only
demonstrate program on doll

47. How We Can Help
Provide a variety of toys that offer visual stimulation
Educating parents on appropriate amount of visual stimulation
Education on retinopathy of prematurity and how it may affect the baby
Facilitating infant to look to the direction he favors the least
Identify whether there is tightness in the neck, in which case, range of motion will be needed
Infants respond best to visual stimulation that has depth such as parent’s face

48. Red Flags of Preterm Development
Feeding Problems
Infant is not gaining weight
Infant falls asleep during feeding
Infant is irritable during feeding
Gagging or difficulty progressing to solids
Infant chokes or coughs during feeding
Infant changes color during feeding
Infant has increase in vomiting/spitting up

49. How We Can Help
If infant is not gaining weight, refer to the physician
Help parents create a feeding schedule
Help parents understand how much food the infant should be eating
Educate parents on why infant fatigues when eating
Consider need to try a different flow rate/nipple
Educate parents on symptoms and recommendations of reflux
Educate on signs of aspiration
Consider referral to OT or speech for feeding therapy
Support the breastfeeding mom by referring to a lactation specialist, if needed

50. Red Flags of Preterm Development
Behavioral and Sensory Problems
Increased crying or irritability
Difficulty tolerating movement/position changes
Sleeping an unusual amount or difficulty waking
Delayed smiling or laughing
Inconsolable
Frequent and abrupt state changes
Infant not able to stay in a nice alert state for long
Not tolerating bath time
Frantic movements when unswaddled
Aversive to certain foods or stimulation around mouth

51. How We Can Help Never, Never, Never Shake A Baby! Keep infant swaddled
Provide slow, gentle movement
Help parents create a schedule
Teach consoling techniques
Teach how to give proprioceptive input
Decrease or modify stimulation to a tolerable level
Support alert state with calm, positive interactions
Offer age appropriate social play
Never, Never, Never Shake A Baby!

52. Assessing Behavior
1 = Deep sleep –infant is very still and difficult to wake up
2 = Light sleep – infant moves arms and legs to change position but usually goes back to sleep
3 = Drowsy – infant is just starting to wake up; eyes may be half closed; infant looks very tired
4 = Quiet Alert – infant’s eyes are wide open and bright; infant is quiet but looks very interested; good attention
5 = Active Alert – infant is awake but is becoming more active and may become fussy
6 = Crying – may mean infant is hungry, tired, wet, or needs help to calm down
This tool is used to describe the infants behavior throughout your assessment. Helps determine readiness to feed

53. Why We Need YOU!
Some developmental problems may not be detected until after discharged home
Parents need frequent reeducation on development
Sometimes parents need to be taught how to PLAY
Young parents need more support
Pediatricians are not always able to offer the time to discuss developmental problems
Developmental delays may get missed at well child visits
Due to an increased survival of very low birth weight infants, there is an increase in prevalence of lifelong motor, cognitive and behavioral dysfunction.(article: “Positive Screening for Autism in Ex-preterm Infants: prevalence and Risk Factors”).

54. References
Limberopoulos C, et al. Positive Screening for Autism in Ex-preterm Infants: Prevalence and Risk Factors. Pediatrics.2008;121(4):
Maddalena P, Gibbons S. Cerebellar Hemorrhage in Extremely Low Birth Weight Infants: Incidence, Risk Factors, and Impact on Long-Term Outcomes, Neonatal Network. 2008; 27(6):
Vergara E. Enhancing Occupational Performance in Infants in the NICU. OT Practice ; July 8:
Van Haastert IC, etal. Early Gross Motor Development of Preterm Infants According to the Alberta Infant Motor Scale. The Journal of Pediatrics. 2006; Nov;
Wilson-Costello D, et al. Improved Neurodevelopmental Outcomes for Extremely Low Birth Weight Infants in Pediatrics. 2007; 119(1):

55. References
Da Costa SP, et al. Sucking and Swallowing in Infants and Diagnostic Tools. Journal of Perinatology. 2008; 28:
Limperopoulos C, et al. Does Cerebellar Injury in Premature Infants Contribute to the High Prevalence of Long-term Cognitive, Learning, and Behavioral Disability in Survivors. Pediatrics. 2007; 120(3):
Vandenberg K. Assessing Behavior Organization in Infants. Physical Assessment of the Newborn: A Comprehensive Approach to the Art of the Physical
Vergara E, Bigsby R. Developmental & Therapeutic Interventions in the NICU Paul H Brookes Publishing Co.
Staff of The Children’s Hospital Denver, Colorado, Cregar P (editor). Developmental Interventions for Preterm and High-Risk Infants Therapy Skill Builders.