Transition from Hospital to Home

Cindy Redd, M.EdAnn Marie Elmore, P.T

Passage: the act of passing from one state or place to the next

Conversion: an event that results in a transformation

Change from one place or state or subject or stage to another

Cause to convert or undergo a transition

wordnet.princeton.edu

Needs, priorities, concerns, strengths, resources etc. are changing

Strategies for support and intervention must be assessed and adjusted frequently

Stress and anxiety may increase due to change even when change is positive.

Beginning and end of transition can be unclear.

View transition as “bridge” from one place/state to the next.

Reflect and recognize progress and movement Celebrate the baby steps of progress Expect and support grief for what’s left behind

Needs of Premature Infants Needs of Families Services Needed

Feeding Sleep Self-Regulation Social Interactions Motor Development Infection Control

Taking everything by mouth (full po feeds) is a newly acquired skill, two or three days, therefore feeding is not well established and can be stressful for parents

Chokes Wants to Eat all the Time Takes a Long Time to Eat Sucks Frantically Frequently Spits Up

Difficulty coordinating suck, swallow, breathing.

Slow flow nipple Side lying to feed Assist baby with pacing and timing by

tilting the bottle

Babies sucking to feed and to self-regulate

Only sleeps if being held Sleeps all day, stays awake during the

night Catnaps throughout the day Does not sleep thought the night when it’s

age appropriate.

Holding provides the supports babies need to sleep ◦ containment◦ incline ◦ ventral support◦ warmth

Mother’s body is “home” to baby◦ Rhythms of breathing & heart beat familiar◦ Mother’s smell is comforting

It’s easier for premature baby to be awake when it is dark and quiet.

The “stress” of daytime activities can cause premature baby to “shut down.”

Strategies should support baby’s efforts to stay awake or asleep at the appropriate times.

Place light and/or radio near the baby’s bassinet at night

Avoid social interactions and “invitation to play”

Dark quiet environment is optimal environment for being awake/alert

Even dim natural light and buffered sounds can cause stress reaction.

Dim lights and close blinds, especially those in baby’s face

Minimize noise and social activity Communicate “invitation to play” when

baby wakes up during the day

“My baby does no want to look at me”

Fussy◦ Maybe self-regulation or reflux related

Baby does not want to look at parents Fussiness

Decrease environmental stimulation Read and respond to subtilities of infant

cues

Dispel myth – “baby just wants to be held” Support infant’s effort to self-regulate

◦ Suck◦ Hands together◦ Hands to mouth◦ Feet together

Give infant time to respond to support Avoid constant repositioning Vestibular Movement with containment

Decrease stimulation Understand how different environments

and fatigue effects self-regulation

Premature infants have strong extensor muscles◦ If extension activities are encouraged then baby

will develop extensor dominance ◦ Encourage flexion

Hyper-extended Neck Retracted Shoulders Decreased Trunk/Pelvic Mobility Frog Legged Toe Walking

Facilitate Flexion Trunk/Pelvic Mobility Weight Shifting

Shoulders Forward Hips Tucked and Together

Activates Neck Flexors Facilitates Shoulder Forward

Hand to Feet Play Pivoting on Stomach

Lap Standing Exersaucers Johnny Jump Ups Be sure heel cords are not tight

With “back to sleep” infants spend more time on their backs, in infant carriers, car seats & swings and much less awake/play tummy time

Prior to 2 months (corrected age), babies will turn their head to the side when lying on their back

85% of newborns have right head preference

Baby’s heads are very moldable Increase in abnormal head shapes

Monitor head position Alter sleep, carrying, and play positions Head in midline in carriers, car seats,

swings Range of motion exercises- preferably

active Increase awake stomach time and sitting

play

Head tilted to the side and rotated to the opposite side

Torticollis can be obvious or subtle

Head position can lead to flat head

Immature immune system BPD and Cardiac conditions RSV Child care

Emotional responses and support networks

Shift of trust from hospital to community providers

Compensatory Parenting

Parent may “fall apart” after discharge even though baby is okay

Post-traumatic reactions to smells & sounds in the community that may trigger memory of NICU

FSN, March of Dimes, Hospital Reunions

Neonatologist Pediatrician NICU specialists EI/CSC providers NICU nurse daily caregivers

Tend to try to compensate for perceived loss Parenting should be based on developmental

info & family values Parenting should not be based on fear and

guilt

Consultation & Anticipatory Guidance Observation & Monitoring Initial Home Visits Coordination of Services

Relationship begins with parent/caregiver and evolves toward infant

Parent brings expertise from NICU experience Routine assessment of “how things are

going?” Partners in problem solving not solutions Prepare family for “what to expect next”

Looking for subtle qualitative differences not measurable delays

Should monitor over time since some differences may appear at various developmental stages.

Encourage families to stay enrolled in services at least until18 mos. when motor & language can be assessed.

May need to be more frequent due to baby’s rapid growth & development

May take longer due to amount of concerns and mother’s need to “tell her story”

May be difficult to schedule due to other appointments, stress of having visitor and desire to “lay claim” on their baby.

Services may include medical, developmental, legal, social and support.

Important to be sensitive to # of service providers involved with family

Communication& collaboration between providers is critical and challenging