Occupational Therapy in NICU

1 Š Nandgaonkar Hemant

• A neonatal intensive care unit (NICU) can be a confusing place with lots of complicated-looking electronics, dials, wires, tubes, strange noises, beeps, alarms, buzzers, flashing lights, pressure hoses, and bubbling cannisters that are confusing to visitors and parents.

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Radiant warmers • are used when a baby is very unstable or extremely premature. Small babies have a large surface area compared to their volume, and little body fat, and cannot maintain their own temperature. The overhead arm contains electric heating elements that are directed down toward the infant. A thermostat is hooked up to a sensor on the baby's abdomen and adjusts the power of the warmer up and down dynamically so that it delivers whatever heat is necessary to keep the baby at the perfect temperature. The shelves attached to the warmer allow monitors and other equipment to be placed conveniently near to the baby, the glass side walls prevent the baby from being chilled by drafts, and the open nature of the radiant warmer allows physicians and nurses to have easy access to the baby from all sides during the most critical periods.

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The scale • is one of the most humble yet one of the most important pieces of equipment in the NICU. Every feeding, IV solution, and medication is calculated and based on the baby's weight, and it's critically important that the weight be accurate, up-to-date, and readily available at all times. It's part of the morning ritual in every NICU to weigh each baby at the same time and in the same way each day, and then chart the weight on the baby's flow sheet. The weight is carefully corrected for the weight of the diaper and any equipment that is attached to the baby, as well as the clean piece of paper that the baby lies on during the weighing. It is typically recorded in grams and is accurate to within 5 grams. Note that one pound = 454 grams.

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A physiologic/ cardiorespiratory monitor • is attached to sensors on the baby and provides a constant read-out of the baby's heart rate and rhythm, breathing rate, arterial or central venous pressure, and other useful information. Alarms can be configured to provide an alert when any of the vital signs being monitored goes above or below a certain limit. Monitors come in a huge variety of shapes, sizes, configurations, and the most recent models contain embedded computer systems that are capable of filtering out false alarms, recording and reviewing data for extended periods, performing some degree of trend analysis, and many other sophisticated functions.

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The pulse oximeter, or "pulse ox," • monitors the oxygen saturation of the baby's blood. It does this by shining light through the baby's skin and measuring the color of the light that is transmitted. Most of you are familiar with the concept that red blood is arterial and blue blood is venous; this is another way of saying that blood which is being pumped by the heart from the lungs to the body and has a lot of oxygen in it is red, whereas blood that is returning to the heart through the veins after oxygen has been removed by the body's tissues is blue. By measuring the transmitted light at certain colors very precisely, the pulse oximeter can provide an estimate of how much oxygen is in the blood. The pulse oximeter can be fooled, however, when the flow of blood to the hands and feet is poor, such as when the baby is cold, or when the baby's blood pressure is low.

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• The "Dinamap" takes the baby's blood pressure at programmed intervals. It inflates a plastic cuff around the baby's arm or leg, exactly like a nurse or doctor taking a baby's blood pressure manually.

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An "oscillator," or "high frequency oscillatory ventilator" (HFOV) • is a new type of ventilator that came into use in the 1990's.

The equipment shown here is the Sensor-Medics 1000A, a popular brand. Unlike traditional ventilators, which essentially inflate and deflate the baby's lungs like a set of billows, the oscillator keeps the lungs open with a constant positive end-expiratiory pressure ("PEEP") and vibrates the air at a very high rate (up to 600 times per second). The vibration helps gases to quickly diffuse in and out of the baby's airways without the need for the "bellows" action which may damage delicate lung structures. Although oscillators are not appropriate for every disorder and situation, there is no doubt that because of their incredible power, oscillators have made it easier to care for the very sickest babies with certain types of lung problems.

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• A "blender" mixes pure oxygen and air (or other gases) in precise ratios and delivers the resulting mixture to the baby. The mixture is adjusted based on the level of oxygen in the baby's blood, measured by pulse oximeter or blood gas machine. Blenders are typically attached directly to ventilators, but may also be used in a stand-alone configuration -- as shown here -- when a baby is receiving oxygen during a resuscitation or by face mask or is in an oxygen "hood." The orange box and water cannister attached about half-way down the pole heat and humidify the gas mixture before it is delivered to the baby.

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• IV pumps, or infusion pumps, are a crucial item of equipment in an NICU. Most sick babies have one or more intravenous (IV) or arterial lines, and the fluid that is delivered through those lines must be very carefully regulated, all the way down to the amount of 0.1 cc per hour (about 1/30 of a teaspoon per hour). There are many brands, sizes, and shapes of IV pumps; the pump shown here is called an IVAC

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Phototherapy lights/ bili lights • Are used when babies are jaundiced (yellow). Some degree of jaundice, which is caused by the presence of a molecule called bilirubin in the blood, is common and even normal in newborns. However, in sick infants, jaundice can result from a variety of problems, and when jaundice is extreme it can cause brain damage. During the 1970's, it was discovered that certain wavelengths of light (in the blue part of the spectrum) can cause a chemical reaction that converts bilirubin into a harmless form as blood passes through the skin. It's important to note that bili lights do not deliver any ultraviolet light, so the babies are not in any danger of sunburn or other toxic effects. However, as a safety measure, the babies' eyes are usually shielded with a cloth covering when they are under bili lights.

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• A drainage pump may be hooked up to a nasogastric (NG) tube or to other tubes in order to keep secretions from accumulating in the stomach or to drain other areas when the infant is very sick. These pumps can be adjusted to provide constant or intermittent suction.

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A blood gas machine • Analyzes a sample of the baby's blood, usually obtained from an arterial catheter or from a "heelstick," and reports the pH and the level of oxygen and carbon dioxide. It also calculates values for the bicarbonate level, oxygen saturation, base deficit, and so on. These values are then used by the neonatologist, nurse practitioner, or respiratory therapist to adjust the setting of the ventilator and the oxygen blender. It was not practical to do blood gas tests on babies until the 1970's, when simple techniques for umbilical arterial catheterization were developed and blood gas machines appeared that could perform tests on "micro-samples."

Today's blood gas machines can perform a complete analysis on less then 0.2 cc of blood (less than 1/10 of a teaspoon).

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Lightbox • The "lightbox" is the traditional tool for viewing X-rays. Essentially, it's just a big metal frame with backlights and a translucent plastic face. Xrays are clipped onto the front of the lightbox and can then be viewed and interpreted by transmitted light.

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• In the modern, digital era, films are read on-line and the images can be manipulated through software to aid interpretation -- the contrast and brightness can be manipulated, the image can be flipped or rotated, edges can be enhanced, areas of interest can be enlarged, old images can be retrieved from disk storage and compared with the new images, etc.

Most importantly, an image can be viewed in more than one place at a time, the neonatologist does not need to wait for film to be "developed," and each image is stored and backed up electronically so it cannot be misplaced in the radiology file room or borrowed and lost.

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A transport incubator • is used when a sick or premature baby is moved from one hospital to another -- for example, from a community hospital to a larger medical center that has a neonatal intensive care unit. In fact, a transport incubator is like a little self-contained intensive care unit on wheels. It usually has a miniature ventilator (respirator), cardio-respiratory monitor, IV pump, pulse oximeter, and oxygen supply built right into its frame. A specially-trained physician, nurse, and respiratory therapist typically accompany the baby throughout the trip.

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• A defibrillator is used to "shock" the heart from an abnormal rhythm pattern back into a normal rhythm. Every neonatal ICU has one of these devices, but they are rarely used there.

Abnormal heart rhythms are quite unusual in babies, even those babies with several cardiac abnormalities -- arrhythmias are more typical of aged patients with damaged heart muscle or conduction pathways.

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Medical Complications of Preterm & High Risk Infants • Congenital cardiac defects ▫ Acyanotic congenital heart defects ▫ Cyanotic congenital heart defects

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Common respiratory complications ▫ Transient respiratory distress of the newborn (TRDN) ▫ Respiratory distress syndrome (RDS) ▫ Pulmonary insufficiency of the preterm (PIP) ▫ Meconium aspiration syndrome (MAS) ▫ Persistent pulmonary hypertension (PPHN) ▫ Broncho pulmonary dysplasia (BPD) ▫ Chronic lung disease (CLD) ▫ Apnea ▫ Pneumonia

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Common neurologic complications • • • • • • •

Brachial plexus injuries Erb’s Palsy Erb’s Duchenne Klumpke’s Palsy Klumpke’s Palsy Intraventricular hemorrhage (IVH) Periventricular leukomalacia (PVL) Hydrocephalus ▫ Posthemorrhagic hydrocephalus ▫ Congenital obstructive hydrocephalus

• Hypoxic ischemic encephalopathy

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Hemolytic & infectious complications • • • •

Anemia Disseminated intravascular coagulation (DIC) Hyperbilurubinemia Sepsis

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Vision & hearing • Retinopathy of prematurity (ROP) • Hearing loss

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Nutritional or gastrointestinal complications • Rickets of prematurity (osteopenia) • Necrotizing entercolitis (NEC) • Gastroschisis

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References • www.neonatology.org • Pinelli J, Symington AJ. Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD001071.© 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Nursery classification & regionalization of care NICU Outcome indicators  Mortality  Morbidity

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Sensory deprivation versus stimulation

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 Preterm: < 37 weeks GA  Late preterm: 34 – 37 weeks GA  Very preterm: < 32 weeks GA  Extremely preterm: < 25 weeks GA  LBW: < 2500 grams  VLBW: < 1500 grams  ELBW: < 1000 grams  Corrected age: chronological age - # weeks born

premature  PMA (post-menstrual age): GA + chronological age © Nandgaonkar Hemant

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Gestational age (GA) – total number of weeks that the infant was in utero before birth. Last menstrual period (LMP), USG

Postconceptional age (PCA) – infant’s age in relation to when conception occurred & thus continually changes over time. Add weeks to GA  Chronologic age – actual age since birth  Corrected age – how old the infant would be if born at term rather than prematurely 

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An infant born before 37-38 weeks – preterm An infant born after 42 weeks is post term Once infant is born, the GA remains the same © Nandgaonkar Hemant

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BW b/w the 10th & 90th percentile on a standardized growth chart is AGA Below 10th percentile – SGA…PIH, IUGR Above 10th percentile is LGA….Diabetes Same for preterm, term and post term

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System

Intrauterine

Extra uterine

Tactile

Constant Proprioceptive input; smooth, wet usually safe & comfortable

Often painful & invasive; dry, cool air; predominance of medical touching versus social touching

Vestibula Maternal movements, diurnal r cycles, amniotic fluid creates gently oscillating environment, flexed posture

Horizontal, flat postures; Influence of gravity, restraints, and equipment

Auditory

Maternal biologic sounds, muffled environmental sounds

Extremely loud, harsh, mechanical, & constant noise

Visual

Dark; may occasionally have very dim red spectrum light

Bright fluorescent lights Often NO diurnal rhythms

Thermal

Constant warmth, consistent temperature

Environmental temperature variations, high risk of neonatal heat loss

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Issue â&#x20AC;˘ The preterm infant experiences a hostile environment in the intensive care (NICU) setting as compared to the womb. This altered sensory experience can have a negative impact on an infantâ&#x20AC;&#x2122;s brain development. While the history of neonatology has been characterized by monumental improvements in medical care, only recently has there been a focus on the environmental and interpersonal experiences of the preterm infant in the NICU.

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Background â&#x20AC;˘ The in-utero environment of a developing fetus is characterized by generalized extremity flexion and containment, limited light and noise exposure, sleep cycle preservation, and unrestricted access to mom via somatosensory, auditory, and chemosensory pathways. This environment is conducive to positive sensory input which is crucial for normal fetal brain development. A newborn preterm infant is deprived of these basic developmental needs upon transition from the womb to the environment of the newborn intensive care unit. This environment is typically characterized by painful procedures, excessive light and noise exposure, interrupted and inadequate sleep, and separation from mom. Negative replaces positive sensory input into the developing fetal brain which, as research shows, can permanently alter normal brain development.

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â&#x20AC;˘ Developmental Care in the NICU is defined by efforts in unit design, equipment selection, policies, care protocols, and staff training to maintain the basic physical, sensory, and interpersonal needs of the preterm infant while minimizing exposure to noxious and painful stimuli. â&#x20AC;˘ The history of developmental care is rooted in the fields of neonatal nursing and physical/occupational therapy. While early research focused on improved short-term physiological stability, evidence is mounting that a comprehensive program which addresses NICU design, unit policies and staff training can positively impact preterm infant brain development and long-term outcome. Š Nandgaonkar Hemant

These efforts include • the provision of individual rooms for each patient/family • offering unrestricted access of infants to parents • supporting kangaroo care • breastfeeding • noise abatement • restricting light exposure • pain protocols • training staff on appropriate infant handling • state recognition, and • sleep preservation © Nandgaonkar Hemant

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• A successful developmental care program is the product of a multidisciplinary team of parents, nurses, nurse practitioners, physicians, occupational/physical therapists, administrators, architects, engineers, and social workers. It requires a paradigm shift of attitudes regarding ownership of an infant’s care and the personhood of the preterm patient.

Minimal stimulation Sensory deprivation theory Sensory stimulation programs Sensory overload theory Environmental neonatology Individualized, relationship based, family centered developmental care Š Nandgaonkar Hemant

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Traditional OT State of the art OT:  Developmental Support

 Therapist Trust and acceptance in NICU  Competencies for Neonatal Therapist

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Abbreviations & Terminology Classification for age Classification of Birth Weight Thermoregulation Medical Conditions & Equipment

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“Mismatch” of Immature Infant in high tech environment Lights in the NICU  Environmental modification

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Sound in the NICU  Environmental modification

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Care giving in the NICU  Modification © Nandgaonkar Hemant

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Noise

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Playing only soft, soothing music  Talking quietly near infants and away from areas where infants are sleeping  Placing reminder signs near babies who are very sensitive to noise  Covering the top of the bed with a blanket to muffle the sound of anything placed on top of it  Closing incubator portholes and doors carefully and quietly  Placing earmuffs over your baby's ears to help decrease noise  Removing telephones or silencing the ringer in patient areas  Providing special "quiet rooms" or areas for babies 54 who are especially sensitive to noise 

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Families in crisis Identifying needs of NICU Families Collaboration with families Parent perspectives Families as equals Skin to skin holding (Kangaroo Care) Discharge Planning

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KMC is a special way of caring of low birth weight babies. It fosters their health and well being by promoting effective thermal control, breastfeeding, infection prevention and bonding. In KMC, the baby is continuously kept in skin-to-skin contact by the mother and breastfed exclusively to the utmost extent, KMC is initiated in the hospital and continued at home. Š Nandgaonkar Hemant

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The two components of KMC are:  Skin-to-skin contact: Early, continuous and prolonged skin-to-skin contact between the mother and her baby is the basic component of KMC. The infant is placed on her mother's chest between the breasts. 

Exclusive breastfeeding: The baby on KMC is breastfed exclusively. Skinto-skin contact promotes lactation and facilitates the feeding interaction. © Nandgaonkar Hemant

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Breastfeeding: Studies have revealed that KMC results in increased breastfeeding rates as well as increased duration of breastfeeding. Even when initiated late and for a limited time during day and night, KMC has been shown to exert a beneficial effect on breastfeeding.

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Thermal control: Prolonged skin-to-skin contact between the mother and her preterm/ LBW infant provides effective thermal control with a reduced risk of hypothermia. For stable babies, KMC is at least equivalent to conventional care with incubators in terms of safety and thermal protection.

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Early discharge: Studies have shown that KMC cared LBW infants could be discharged from the hospital earlier than the conventionally managed babies. The babies gained more weight on KMC than on conventional care. © Nandgaonkar Hemant

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Less morbidity: Babies receiving KMC have more regular breathing and less predisposition to apnea. KMC protects against nosocomial infections. Even after discharge from the hospital, the morbidity amongst babies managed by KMC is less. KMC is associated with reduced incidence of severe illness including pneumonia during infancy.

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Other effects: KMC helps both infants and parents. Mothers are less stressed during kangaroo care as compared with a baby kept in incubator. Mothers prefer skin-to-skin contact to conventional care. They report a stronger bonding with the baby, increased confidence, and a deep satisfaction that they were able to do something special for their babies. Fathers felt more relaxed, comfortable and better bonded while providing kangaroo care. Š Nandgaonkar Hemant

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http://www.kmcindia.org/ Š Nandgaonkar Hemant

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Evaluation Infant assessment in the NICU Golden Rule “Above all, do not harm!”

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Neurobehavioral Organization  Synactive Theory of Development  Synaction refers to process by which stable

functioning or decompensation in one subsystem can affect the organization & integrity of other systems.

▪ Preterm neurobehavioral organization ▪ In turning – immature ▪ Coming out – fragile & vulnerable ▪ Reciprocity – is able to attend & interact © Nandgaonkar Hemant

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▪ States of arousal ▪ State refers to the infants degree of consciousness or arousal/ ▪ ▪ ▪ ▪ ▪ ▪

State 1 – deep sleep State 2 – light sleep State 3 – transitional state of dozing or drowsiness State 4 – quite & alert State 5 – active alert State 6 - crying

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Reflex development Muscle tone Preemie positional deformities Therapeutic Positioning ▪ General Guidelines ▪ Supine ▪ Prone ▪ Sideling

 ROM  Splinting © Nandgaonkar Hemant

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Benefits of nonnutritive sucking Nutritive Sucking Nutritive sucking patterns  Mature  Immature  Transitional

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Nutritive sucking & respiration Feeding readiness © Nandgaonkar Hemant

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NOMAS was originally developed to assess feedings in premature and medically compromised newborns. NOMAS is a nonnutritive sucking assessment done with examiner’s finger in the infant’s mouth.  The revised version has four parts that test normal & abnormal characteristics of the jaw and tongue.

The examiner assesses and rates the newborn for theses characteristics. The rating ranges from 0 to 16. (Created by Marjorie Meyer Palmer) 

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NORMAL

DISORGANIZATION

DYSFUNCTION

• consistent degree of jaw depression • rhythmical excursions • spontaneous jaw excursions occur upon tactile presentations of the nipple up to 30 minutes prior to feed • jaw movement occurs at the rate of approximately one per second (1/2 the rate of NNS) • sufficient closure on the nipple during the expression phase to express fluid from the nipple

• inconsistent degree of jaw depression • arrhythmical jaw movements • difficulty initiating movements • inability to latch on • small, tremor-like start-up movements noted • does not respond to initial cue of nipple until jiggled • persistance of immature suck • pattern beyond appropriate age • under 40 weeks PC (transitional suck)

• excessively wide excursions that interrupt the intra-oral seal on the nipple • minimal excursions; clenching • asymmetry; lateral jaw deviation • absence of movement (% of time) • lack of rate change between NNS and NS (NNS = 2/sec; NS = 1/sec)

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NORMAL

DISORGANIZATION

DYSFUNCTION

• cupped tongue configuration (tongue groove) maintained during sucking • extension-elevation retraction movements occur in anterior posterior direction • rhythmical movements • movements occur at the rate of one per second • liquid is sucked efficiently into the oro-pharynx for swallow

• excessive protrusion beyond labial border during extension phase of sucking without interruption sucking rhythm • arrhythmical movements • unable to sustain suckle pattern for two minutes due to • habituation • poor respiration • fatigue • in coordination of suck/swallow and respiration which results in nasal flaring, head turning, extraneous movements

• flaccid; flattened with absent tongue groove • retracted; humped and pulled back into oro-pharynx • asymmetry; lateral tongue deviation • excessive protrusion beyond labial border before/after nipple insertion with out/dow movement • absence of movement (%of time)

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NNS decreases length of hospital stay in preterm infants, and appears to facilitate the transition to full oral/bottle feeds and bottle feeding performance in general.

Infants receiving NNS exhibited less defensive behaviors during tube feedings, spent significantly less time in fussy and active states during and after tube feedings, and settled more quickly into sleep states. © Nandgaonkar Hemant

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An infant born prematurely may be fed through a tube into the stomach, so is often given a pacifier to suck on to improve nutrition. An infant needs coordinated sucking, swallowing and breathing to feed.  The ability to suck and to swallow is present by 28 weeks gestation, but infants are not fully coordinated until 32 to 34 weeks. 

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This means that preterm infants less than 32 weeks gestation are usually not able to feed effectively from the breast or a bottle. They are fed by a small tube that is placed up the nose into the stomach (gavage feeding). Sucking on a pacifier (NNS) during gavage feeding may encourage the development of sucking behaviour and improve digestion of the feeding. NNS may also have a calming effect on infants, although it does have the potential to interfere with breastfeeding. © Nandgaonkar Hemant

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General considerations Oral motor factors Facilitating feeding in the NICU

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Benefits of breast feeding in the NICU Challenges to breast feeding success in the NICU Facilitating BF in the NICU       

Early education & pumping Nonnutritive nuzzing at the breast BF readiness Methods for introducing & sustaining BF Transition to cue based feeding schedules Alternative feeding methods Discharge planning © Nandgaonkar Hemant

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Philips Avent Twin Electronic Breast Pump

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Sensory system development Supplemental sensory stimulation  Infant massage

 Auditory stimulation  Visual stimulation  Traditional developmental stimulation

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Neurologic assessment of the preterm & full term newborn infant  (NAPFI)

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Neonatal neurobehavioral evaluation  (NNE)

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Neurobehavioral assessment for preterm infants  (NAPI)

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Neonatal neurological examination  (NEONEURO) © Nandgaonkar Hemant

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Neurobehavioral Subsystems, Signs of stress & Stability

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The autonomic system, which can be observed in the infant's breathing pattern, skin color fluctuations, temperature control, and visceral function

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The motor system which can be observed from the infant’s muscle tone & movements of the face, trunk and extremities, respectively, and in extensor & flexor posture

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The system for state regulation can be observed in an infant’s range of available states, their robustness and modulation, and in the pattern of transition from sleep to quite awake, to active awake and aroused, and to upset and crying © Nandgaonkar Hemant

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The system of attention and interaction can be observed when the infant is able to reach a calm alert state;

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And the self regulatory system observe in the context of infant’s effort at attaining stability through approach or avoidance behaviors.

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Respiratory

Pauses, tachypnea, gasping

Smooth, regular respiratory rate

Color

Changes to mottled, flushed, pale, dusky, cyanotic, gray or ashen

Pale, stable, color

Visceral

Hiccups, gagging, spiting, up, grunting, straining,(as if producing bowel movement)

Stable viscera with no hiccups, gags, emesis, or grunting

Motor

Tremors, startles, twiches, coughs, sneezes, yawns, sighs, has seizures

No sign of tremors, startles, twitches, coughs, sneezes, yawns, sighs or seizures

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Fluctuating tone, uncontrolled activity

Motor

Flaccidity

Gape face, low tone in trunk, LE & UE

Hyper tonicity

Leg extensions & sitting on air, UE salutes, finger splays, & fisting, trunk arching; tougue extensions

Trunk, LE, UE Hyperflexions

Frantic, diffuse activity extremities Š Nandgaonkar Hemant

Consistent tone, controlled activity Muscle tone consistent in trunk & extremities & appropriate for postconceptional age

Smooth controlled posture Smooth movements of extremities & head

Motor control can be used for self regulation (hand & foot clasp, leg & foot bracing, hand to mouth, grasping, tucking, sucking) 104

state

During sleep

Diffused or disorganized quality of states, including range & transition between states

Twitches, sounds, whimpers, jerky movements, irregular RR, fussy, grimaces

Clear states; good, calming, focused alertness

Clear, well defined sleep states Good self-quieting & consolability Robust crying

When awake

Eye floating, glassy eyed, starin, gaze aversion, worried/ dull look, hyper alert panic expression, weak cry, irritability Abrupt state changes © Nandgaonkar Hemant

Focused clear alertness with animated expressions (frowning, cheek softening, “ooh” face, cooing, smiling) Smooth transition between states 105

Autonomic

Motor

State

Irregular RR, color changes, visceral responses, coughs, yawns, sneezes, sighs, straining tremors, twitches

Responsivity to auditory & visual stimuli is clear & prolonged

Fluctuating tone, frantic diffuse activity

Activity seeks out auditory stimulus; able to shift attention smoothly from one stimulus to another

Eye floating, glassy eyed, staring, worried or dull look, hyper alert panicked expression, gaze aversion, weak cry, irritability Abrupt state changes Becomes stressed if > 1 type of stimulus is given simultaneously Š Nandgaonkar Hemant

Face demonstrates bright eyed purposeful interest varying between arousal and relaxation

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Through positioning recommendations, OTst can possibly facilitate an infantâ&#x20AC;&#x2122;s improved ability to selfregulate, thereby benefitting infants by promoting calm sleep states and conserving energy for growth .

Using a full-body postural support for positioning may provide a means to reduce postural and orthopedic abnormalities for preterm infants or any infant that must be confined to their bed for a long time period.

Overall, these studies make significant cases for positioning infants in supine or lateral decubitus positions to increase psychomotor and neurobehavioral outcomes and in prone or lateral decubitus positions to improve self regulation. Š Nandgaonkar Hemant

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Infant Neurological International Battery (INFANIB) for the Assessment of Neurological Integrity in Infancy.“ Clinicians working with infants to use this method for a quantified evaluation of tone and posture.

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NEWBORN SCREENING 

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Recommendations : 3rd specimen at 4 – 6 weeks or just prior to hospital discharge (at 30 days PMA)

Other recommendations 

1st specimen PRIOR to transfusions, hyperalimentation, steroids, antibiotics

© Nandgaonkar Hemant

VLBW infants and those ≥ 3 weeks of hospitalization with congenital hypothyroidism may have a delayed rise in TSH

If transfused before 1st specimen -> 3rd specimen at 4 – 6 weeks post transfusion  If given steroids -> subsequent specimen at 7 – 10 days post therapy 

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HEARING SCREENING Increased risk for hearing loss (2% compared to 0.2%) including auditory neuropathy  Recommendations 

Hearing screening with ABR (auditory brainstem response) – on ALL newborns 

If they fail -> refer to audiologist

© Nandgaonkar Hemant

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HEARING SCREENING 

Recommendations (continued) 

NICU stay of > 5 days or with  ECMO therapy  Mechanical ventilation  Ototoxic drugs (aminoglycosides, loop diuretics)  Hyperbilirubinemia requiring exchange transfusion  TORCHES, meningitis  Craniofacial anomalies  Syndromes associated with hearing loss, neurodegenerative syndromes, sensory motor neuropathies

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Some argue for repeat screening at 6 months

© Nandgaonkar Hemant

Reassessment by 24 – 30 months of age for those at increased risk regardless of newborn screening

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VISION SCREENING Increased risk for long-term ophthalmologic problems  Retinopathy of prematurity (ROP) 

© Nandgaonkar Hemant

Developmental vascular proliferative retinal disorder that occurs in the retina of preterm infants with incomplete retinal vascularization  Presents at ~34 weeks PMA, advances irregularly until 40 - 45 weeks PMA  Resolves spontaneously in the majority of infants  However, is the second most common case of childhood blindness 

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VISION SCREENING 

Recommendations (AAP) Screening criteria (one of the following):  BW < 1500 grams  Born at ≤ 32 weeks GA  BW between 1500 – 2000 grams or > 32 weeks GA whose clinical course puts them at higher risk  Evaluation schedule  4 – 8 weeks after birth depending on GA  Additional examinations at intervals of 1 – 3 weeks per ophthalmology 

© Nandgaonkar Hemant

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Other common ophthalmologic abnormalities: reduced visual acuity, strabismus, myopia 

Referral to ophthalmology at 6 – 12 months

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NEURODEVELOPMENTAL SCREENING 

Impaired neurodevelopmental outcomes 

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45% of children with CP were premature 9 – 12% of ELBW and VLBW infants are diagnosed with CP

Sensory impairment (vision, hearing)  Behavioral and psychological problems 

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© Nandgaonkar Hemant

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Cognitive skills Motor deficits (fine and gross motor) and CP

ADHD, anxiety, depression

Rates of disabilities increases with decreasing BW and GA 114

NEURODEVELOPMENTAL SCREENING 

Neurologic exam 

Tone

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Reflexes

© Nandgaonkar Hemant

Lower extremity extensor tone  Head lag  Shoulder girdle  Truncal tone 

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NEURODEVELOPMENTAL SCREENING Developmental evaluation should be based on corrected age until at least 24 months  Refer to an early intervention program (EIP) if there are any concerns 

NICU grads are encouraged to get PT/OT evaluation by 6 months regardless

© Nandgaonkar Hemant

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FACTORS AFFECTING GROWTH & NUTRITION 

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© Nandgaonkar Hemant

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Preterm birth Prolonged/complicated NICU course Neurodevelopmental deficits Congenital structural GI: malabsorption, GERD, feeding difficulty Chronic lung disease of prematurity (BPD) Congenital Heart Disease Poor feeding technique Neglect / Abuse Genetics (size of parents)

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SETTING THE STAGE FOR OPTIMAL FEEDING PERFORMANCE

Feed the infant in the quietest setting possible.  Remove all distractions and aim for no interruptions.  Expect to give your full attention to the infant throughout the feeding. 

© Nandgaonkar Hemant

1. Provide an appropriate setting for the observation

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SETTING THE STAGE FOR OPTIMAL FEEDING PERFORMANCE

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Ensure that the infant is hungry and in a quietawake state. Change the diaper, and bring the infant to an awake state before starting the feeding. Facilitate minimal expenditure of the infant's energy during the pre feeding period.

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If needed, offer nonnutritive sucking and/or visual, auditory, vestibular, and/or tactile stimulation to help the infant get organized and ready for feeding.

© Nandgaonkar Hemant

2. Select an optimal feeding:

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SETTING THE STAGE FOR OPTIMAL FEEDING PERFORMANCE 3. Assess the baseline condition of the infant 

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© Nandgaonkar Hemant

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During a calm, inactive period, when no demands are being placed on the infant and when he is not recovering from a recent change such as handling, assess the infant's baseline physiologic status: Baseline oxygen saturation Baseline respiratory rate and breathing effort Baseline heart rate Stability/variability of physiologic measures Pre feeding color Level of oxygen supplementation, if administered

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SETTING THE STAGE FOR OPTIMAL FEEDING PERFORMANCE 3. Assess the baseline condition of the infant 

    

© Nandgaonkar Hemant

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During a calm, inactive period, when no demands are being placed on the infant and when he is not recovering from a recent change such as handling, assess the infant's baseline physiologic status: Baseline oxygen saturation Baseline respiratory rate and breathing effort Baseline heart rate Stability/variability of physiologic measures Pre feeding color Level of oxygen supplementation, if administered

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4. PROVIDE DEVELOPMENTAL FEEDING SUPPORT Hold the infant either in your arms or semi upright in your lap with the upper body and head upright at a 45° angle to the buttocks; or feed with the infant side-lying, head higher than hips.  If side-lying, have the infant face you to enable you to see stress signals.  Facilitate neutral head-neck flexion (chin slightly tilted down, not with the head extended or with excessive flexion, which can compromise airway maintenance). 

© Nandgaonkar Hemant

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Keep the infant's head midline (not to one side).  Swaddle-support the infant with a blanket, elbows inside, to promote hands toward the midline/center of the body and to contain the infant.  Avoid tightly swaddling the arms away from the face. Avoid losing sight of the infant's upper arms and hands, which provide important information regarding the infant's experience and energy level during feeding. 

© Nandgaonkar Hemant

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CO REGULATE THE FEEDING Observe for stress signals and respond contingently in ways that promote self-regulation.  Begin feeding by eliciting the rooting response (i.e., by stroking the infant's lips at the corners or center). This promotes the infant's active engagement in feeding, which reflects his readiness to begin feeding with adequate breathing and vigor. Lack of rooting may indicate stress and typically signals non readiness to initiate sucking. If the infant does not open his mouth in response to a nipple touching his lips, re alert the infant, swaddle or re swaddle him to provide better support, and reassess his interest and capacity to engage in feeding. Place the nipple in the infant's mouth only in response to his cues of readiness (rooting, descending tongue). 

© Nandgaonkar Hemant

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Š Nandgaonkar Hemant

Do not urge the infant to feed. Respect his pauses in sucking, not only because they influence the infant's ability to self-regulate during feeding, but also because they influence swallowing coordination. The pause patterns that occur or do not occur reflect the infant's skill or lack of skill in coordinating sucking, swallowing, and breathing. Observe the infant's physiologic status during pauses to learn potential reason(s) for them. Do not attempt to prod the infant to continue sucking (through turning or twisting the bottle or by passively moving the infant's jaw). If the infant's breathing is calm and sleep or fatigue is suspected, do not encourage sucking, but rather provide a rest and re alerting period.

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