TheStruggleisReal:IdentifyingtheDevelopmentalNeedsof

FragileInfants

ErikaClemensMSOTR/LSWCCLECUCSanDiegoHealth

Ihavenothingtodisclose….Ipromise.

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

EngageandEmpowerParentsEarly!

StaffMustBuyIn!

NICUcareisnotblackandwhite…

Tosock…ornottosock

Rockingtheoneglovelook…

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

HeadMoldingPlagiocephaly Brachycephaly Dolicho/

Scaphocephaly

TreatmentmustbemorethanZflo &Swaddles…• Kinesiotaping• SoftSplinting• JointCompression• ROM/stretch• Massage• PositiveTouch

GradedSensoryInput

• ContainmentHolds• StaticProprioceptiveInput• PositiveTouch• JointCompression• Massage• Rocking/Movement• TummyTime• TherapyBallExercises

ProgressingwithActivityBasedonInfantCues

HowFragileInfantsCommunicate

• Subtle• IndividualResponses• DynamicRelationship

ReadytoEat?

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

WhatIlooklikewhenIamstressed

HowITryToSelf-Soothe

• Bringinghandstomouth• Grasping• Sucking• Visuallocking• HandClasping• Face/Hand/FootBracing• Coveringmyeyes• ChangeinPosition• Closingeyes

WhatIlooklikewhenIamreadytointeractwithyou

Whatcanwedo?

Classically….

• Reducestimulation• ↓Talking• ↓Movement• ↓Touching/stroking• ↓Facilitatinglatch

• Providecontainment• Bundletocalm• Burp

ButWait…

BabiesMAYrespondto:• Talking/Singing• GentleJiggling/Rocking• Massage• Latchachieved• Unswaddling• PositionChange

Whenmore…notlessstimulationworks!

FacilitatingStateChange

CryingandStressed Calmbut…

ReadytoEat!

• QuietAlertState• Activatingarms,handstomouth• Rootingsidetoside• Eagertolatchonpacifier,sustains• Grabbingontopacifiertopullinfurther

WhatdoIwanttodo?

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

24weeksGA,5 Monthsadjusted,3monthsafterdischarge

AllPlayedOut…AnyQuestions?