Neonatal Care Quiz

NICU Overview

• Neonatal intensive care units (NICUs) are specialized care settings for very young, small, and/or sick infants.
• Early 1900s to 1950s: NICU care focused on a "hands-off" policy to prevent unnecessary handling.
• 1958: Virginia Apgar emphasized the newborn's right to their own medical care.
• 1970s: Neonatology became a subspecialty in pediatrics, leading to specialized care.
• Advances in technology and medicine during the 1960s and 1970s led to improved infant survival in NICUs.
• Developmental care in a NICU provides a supportive environment for the infant's development.
• Optimal 20th-century NICU care is defined as developmentally supportive, family-focused, culturally sensitive, and evidence-based.

History of the NICU

• Early 1900s-1950s: Philosophy of care in first NICU units emphasised careful handling to protect babies.
• 1958: Virginia Apgar proposed newborn should have own doctor.
• 1970: American Academy of Pediatrics (AAP) added neonatology as a subspecialty.
• 1973: Brazelton's Neonatal Behavioral Assessment Scale.
• 1975: Committee on Perinatal Health published guidelines for regional perinatal centres.

History of the NICU (continued)

• Advances in 1960s and 1970s led to better survival rates.
• NICU stays can sometimes have detrimental effects on development.
• Ongoing research focuses on improving developmental outcomes within the NICU environment.

Levels of Neonatal Care

• Different levels of care exist within the NICU.
• Level I: basic care, stabilization and follow-up for healthy newborns or late preterm infants.
• Level II: care for infants requiring advanced procedures such as ventilation or more specialized support.
• Level III: comprehensive care for high-risk infants, including very low birth weight babies.
• Level IV: Most intensive, specialized, and complex care for extremely low birth weight babies and infants with the most critical conditions.

Role of Physical Therapists (PTs) in the NICU

• PTs in NICUs address functional and structural body integrity.
• PTs promote postural and motor development.
• PTs promote interaction between infants and the environment.
• PTs support interaction with families, NICU staff and consultants.

Theoretical Frameworks for NICU Therapy

• Dynamic Systems Theory
• Neuronal Group Selection Theory
• International Classification of Functioning, Disability, and Health
• Synactive Theory
• Developmental Care
• Family-Centered Care
• Als H. (1982). Synactive theory

Signs of Stability and Stress in Preterm Infants (Als H, 1982)

• Autonomic: Smooth breathing, stable color, controlled digestion. Distress: Respiratory pauses, pallor, cyanosis, etc.
• Motor: Smooth, controlled movements, Stable posture. Distress: Flaccid movements, hypertonic movements, etc.
• State: Well-defined sleep states. Distress: Diffuse activity, fussing, etc.

Newborn Individualized Developmental Care and Assessment Program (NIDCAP)

• NIDCAP observations occur every 7-10 days at a baseline.
• Observations are taken over 10-20 minutes before feeding.
• Observation of the environment and caregiver interactions are a key aspect.
• Assessment includes signs of stability and stress to identify needs.
• Recommendations for environmental modification, care giving and parental involvement are important.

Family-Centered Care in the NICU

• Recognize loss/difficulty parents experience during/after pregnancy.
• Encourage hope and positive outlook.
• Foster parent-infant bonding.

Preterm Infants

• Age of viability: 23-24 weeks.
• Perceived as small and unattractive.
• Less responsive and more difficult to calm.
• Cry elicits negative emotions in caregivers.

Mother/Child Relationships with Preterm Infants

• Less synchronous interactions.
• Fewer games and decreased interactions between both parties.
• Less gratification from infants and challenge to bonding.

Preterm vs. Term Infants

• Term infants exhibit better behavioral functioning, more coordinated systems, and higher EEG/Evoked responses.
• Potential developmental delays may be due to inappropriate sensory stimulation in NICU environment.

NICU Environment

• The NICU environment is designed to reduce risks; however it can disrupt normal sleep cycles, cause stress reactions in infants.
• Sound, light and medical procedures can disrupt sleep, cause stress responses, result in weight loss and/or adverse physiological effect.

Environmental Changes in the NICU

• Dimming lights, covering isolettes, and day/night cycling help support the infant's health needs.
• Clustering of medical care, kangaroo care, hammocks, putting twins together, minimize stress.
• Environmental cues such as music, smell and clothing can influence the infant's behaviour and response to stress.

High-Risk and Low Birth Weight Infants

• Classification based on weight: SGA (Small Gestational Age), LBW (low birth weight), VLBW (very low birth weight), ELBW (extremely low birth weight) - based on specific weight guidelines, gestational age, and pathology, factors that increase infants risk of future developmental issues.
• The Dubowitz method is frequently used to asses gestational age.

Medical Complications in the NICU

• RDS (Respiratory Distress Syndrome)
• BPD (Bronchopulmonary Displasia)
• PVL (Periventricular Leukomalacia)
• IVH (Intraventricular Hemorrhage)
• HIE (Hypoxic-Ischemic Encephalopathy)
• NEC (Necrotizing Enterocolitis)
• ROP (Retinopathy of Prematurity)
• Hyperbilirubinemia
• Neonatal Seizures
• Other complications like Fetal Alcohol Syndrome (FAS), Fetal Abstinence (Withdrawal), HIV-AIDS and Brachial Plexus Injuries

State Regulation in Babies

• Babies have distinct states of arousal and consciousness (e.g., deep sleep, light sleep, active awake, crying).
• Premature infants have difficulty regulating their states.

Brazelton States of Arousal

• Brazelton identified and characterized six states of arousal in newborns.
• Observations during an assessment note behaviors, the range and duration of those behaviors.

Examination/Assessment

• Developmental assessments in NICUs help identify impairments and needs.
• Adaptation of the the environment may aid in optimizing development.
• Observations should be taken over several visits due to the fluctuations in infant status.

Tests and Measures

• Tests and measures like Dubowitz, NIDCAP, NAPI, and TIMP support assessment of preterm infants.
• Tests and measures like Dubowitz, NBAS, Morgan, oral-motor assessment, and NOMAS and NCAFS support assessment of full-term infants.

Intervention in the NICU

• Evidence-based interventions can improve function, weight gain, and earlier discharge in NICUs.
• Interventions like environmental modification, positioning, handling, sensorimotor stimulation, taping/splinting, hydrotherapy, oral motor therapy, and parent education are vital.

Therapy Assessment

• Therapy assessments need to include medical chart information, nursing reports, parental history, prenatal history, birth history, and important episodes like apnea, bradycardia, and oxygen desaturation.
• Assessing the infant's need for nutrition, medication affects and tolerance/response to medical procedures is key.

Parent Education

• Educate parents about preterm baby behaviors, typical development, and expectations.
• Assist parents in developing supportive strategies for their child.

Kangaroo Care

• Kangaroo care involves skin-to-skin contact between parent and infant.
• Encourages infant stabilization and parent-infant attachment and interaction.
• Promotes positive outcomes in the NICU environment.

Positioning in Preterm Infants

• Avoid postures of extension to prevent discomfort and imbalance.
• Promote neutral head and neck positions
• Slight chin tuck and scapular protraction support upper extremity flexion and hand midline positioning.
• Blanket rolls and commercially available devices aid in supported position.

Prone Positioning

• Unsupported prone position promotes shoulder retraction, neck hyperextension, and truncal flattening, and hip abduction and external rotation.
• Place a thin roll under the chest to elevate the chest.
• Shoulder protraction and more neutral neck alignment need to be encouraged.

Side-Lying Positioning

• Decreased stress behaviors are noted than in supine position in infants.
• The infant's respiratory system has been improved and placement in midline.
• Reduced risk of gastro-esophageal reflux disorders (GERD).

Supine Positioning

• Maximal observation and access to the infant by caregivers.
• Forces of gravity lead to neck extension, trunk extension, scapular retraction, and an anterior pelvic tilt.
• Does not generally promote calming or self-regulation in infants.

Supported Supine Positioning

• Support needs to be provided as this position poses the most challenges to infants.
• Support rolls around the infant to assist with midline symmetrical flexion in head and trunk.
• Support with hands, legs, and posterior skull.

Observation

• Therapists assess infant competence and identify when to terminate or continue a procedure to prevent negative reactions from the infant.
• Collaboration with nursing to get understanding of baby's current medical status and any notable events.
• Infant evaluated before, during, and after as a part of the observation process.

Observation (continued)

• Repeated light and sound can assess the infant's stability as a part of the observation strategy.
• This can be a helpful tool to determine the infant's readiness before handling.

Collaboration in NICUs

• Collaborative relationships are a key element for optimal NICU experience.
• PT's need to engage with medical and nursing staff and parents to improve the outcomes for the infant.

Level of Expertise

• High level of therapist expertise is essential to understand physiological and behavioral changes in infants due to metabolic, neuromusculoskeletal, and cardiopulmonary complexities and risks.
• Ongoing assessment and adjustment of procedures are needed in response to these changes.

Level of Expertise (continued)

• Possible risks of routine care in NICU include hemodynamic complications, respiratory issues, cardiac, metabolic, orthopedic, integumentary concerns and risk of infection/inflammation.
• Therapists need to be assessed for their experience and training to manage the higher-risk infants with complex and rapid changes.

Preparation to work in the NICU

• The most appropriate preparation for working in a NICU should include practice observing healthy term infants and/or providing services in home or day care to provide familiarity with a normal environment for the infants and children.
• Hands-on experience in directly providing NICU services in a supervised practical setting under the support of an experienced staff person.