Idea Transcript
Surviving the NICU: The Role of Occupation in the NICU and Beyond Holly Schifsky, OTR/L, NTMTC, CBIS, CNT November 11, 2017
Disclosure Statement
Holly M. Schifsky has documented that she has no relevant financial relationships to disclose or Conflict of Interests (COIs) to resolve. She has documented that her presentations will be free of unapproved or off-label, experimental, or investigational use.
Understand
Objectives
Understand the theoretical concept of Developmental Care and its integration in the NICU
Identify
Identify medical co-morbidities associated with prematurity and the affects on age appropriate occupations
Discuss
Discuss medical management for the term newborn with congenital birth defects
Identify
Identify treatment interventions utilized within the NICU by occupational therapists to maximize feeding and motor development
Discuss
Discuss the importance of early intervention with high-risk newborns
Newborn Intensive Care Unit Level 1: Normal Newborn Nursery Level 2: Special Care Nursery Level 3: Newborn Intensive Care
Respiratory Neonatal surgery Special diagnostics Very preterm infants
Level 4: Newborn Intensive Care Cardiac Surgery
NICU
Infants admitted to Intensive Care
Multiple diagnosis
Prematurity
Respiratory Distress
Surgical (GI, cardiac, renal)
Neurological problems
Congenital anomalies
Infection
Metabolic
22-26 Weeks: Very preterm infant Definition by Gestational Age
27-33 Weeks: Moderately preterm infant 34-36 Weeks: Late preterm infant
Extremely Low Birth Weight Infant
> 2500 grams: Normal Birth Weight Definition by Birth Weight
1500-2500 grams: Low Birth Weight 1000-1500 grams: Very Low Birth Weight < 1000 grams: Extremely Low Birth Weight
Size for Dates Appropriate for gestational age Small for gestational age Large for gestational age
Intrauterine Growth Restriction Term Infants: National Collaborative Perinatal Data Base 6.9 point IQ deficit at 7 years of age
Preterm Infants: with and without postnatal nutrition 8 point deficit on one year MDI if > 2weeks postnatal malnutrition
In the US in 2012:
- 11.5% of infants were born premature - 2% were very preterm - 10% were moderately preterm
Incidence of Prematurity
Source: March of Dimes, www.marchofdimes.com/peristats.
American Occupational Therapy Association created a special interest section within Pediatrics for NICU practitioners
Creation of “NICU Knowledge and Skills Paper” in 2000 with modifications in 2004, 2006, 2010
Provides a Framework for competency, skills, requirements to successfully work with three areas in the NICU:
Infant
Family
AOTA and NICU clinicians
Environment
Occupation based care in the NICU
Infant (consultative or direct assessment/intervention)
neurobehavioral organization sensory development and processing motor function pain daily activity (feeding, dressing, diaper changes, transfers, transitional states, sleep) social–emotional development
Occupation Based Care in the NICU
Family
Family systems Adult Learning styles Cultural parenting expectations Parent-Infant Interactions Role of the parent during hospitalization Family Centered Care Trauma Informed Care
The transition of the infant from hospital to home
Occupation based care in the NICU: Environment
• Sensory environment • Tactile: Timing, intensity, texture, handling for medical and nursing procedures, parent interaction • Proprioceptive-vestibular: Timing, intensity, handling for medical and nursing procedures, parent interaction • Olfactory and gustatory experiences specific to the NICU (timing, quality, intensity) • Auditory: Intensity, duration, timing, animate versus inanimate • Visual: Timing, ambient and focal light intensity, contents of visual field • Social environment • Parents and infant • Extended family members and infant • Staff members and infant • Parents and staff members • Occupational therapist, parents, staff, and infant
Physical Environment •Medical equipment and procedures •Frequency, timing, duration, quality, and intensity of sensory input from medical equipment and procedures •Sensory input from equipment, procedures, and staff activities that is disruptive to the infant’s neurobehavioral organization
Occupation based care: Environment
NICU culture
•The NICU’s specific philosophy of care, including its particular orientation toward acute and chronic care of infants •The team members’ roles, functions, attitudes, and positions in the organizational structure of the individual NICU •The influence of NICU stressors (e.g., census changes and subsequent staffing patterns) •Communication patterns and structure, both formal and informal, among staff members and between family and staff members •Spoken and unspoken rules of behavior •The effect of the physical and social environments on staff performance and morale •Hospital administrative policies (e.g., confidentiality)
National Association of Neonatal Therapists (NANT) http://neonataltherapists.com/ The National Association of Neonatal Therapists (NANT) is an organization that serves neonatal occupational therapists, physical therapists, and speech-language pathologists. NANT provides multiple ways for neonatal therapists to connect, learn, mentor and inspire while advancing this focused field of therapy on a national level.
Premature Infant Care and the Environment
Pioneer of Developmental Care: Dr. Heidelise Als
Research based discovery that the premature infants extrauterine sensory experience was damaging to the neurological structure of the immature brain.
History
Created a new approach to care in the NICU called “Developmental Care”
Newborn Individualized Developmental Care and Assessment Program (NIDCAP)
The NIDCAP Model
Focuses on enhancing the caregiver’s understanding of the infant’s self regulatory capacities View behavior of the infant as communication in itself Focuses on individual infant’s competencies and strengths Focuses on subsystem integration and modulation Supports all the infant’s caregivers-parents and professionals (Als, 1997; 2007)
Synactive Theory of Development (Als 1982)
Early Brain Development The environment affects not only the number of brain cells and connections among them, but the way connections are “wired” There is evidence of the negative impact of stress on early brain function: neurotransmitters released
The NICU environment and the developing brain
A preterm infant is developing in an unusual environment and has had less time for neurodevelopment in a controlled setting Preterm infants are vulnerable to ongoing exposure sensory stimuli they are not neurological ready to integrate: Sensory overload
Gilkerson,1997: Als,1999: Smith and Als,2008
Intrauterine environment
Intrauterine environment Supportive 1. defined boundaries 2. aquatic 3. fetus can move freely but supported back into physiological flexion
Controlled 1. temperature 2. lights/sounds 3. pain free 4. vestibular input
In-utero positioning
The Original “Closed Chain Activity”
The Original “Closed Chain Activity”
Cranium Broad bone structure: may have skull anomalies due to prolonged time in birth canal Slightly recessed mandible 15 degrees neck flexion Dome shape palette Flattened nasal bridge
Thorax Spinal flexion of cervical, thoracic, lumbar spine Ribcage 1/3 and abdominal cavity 2/3 of anterior thorax region
Pelvis Posterior pelvic tilt Neutral pelvic lift Upper Extremities Scapular elevation Internal rotation and adduction of shoulders Elbow flexion, wrist flexion, finger flexion, forearm pronation Lower Extremities Hip external rotation and flexion Knee flexion Neutral ankle, slight inversion Alignment of forefoot, midfoot, hindfoot May have slight forefoot adduction: assess for Metatarsus Adductus
Medical Advances for NICU
Offering medical interventions for the 22 week infant
Common medical lines for premature infant
Term infant
Term Infant: Neonatal Encephalopathy
CoMorbidities associated with prematurity: Systems approach
Neurological: IVH, PVL, hydrocephalus
Pulmonary: BPD, CLD
Integumentary: poor skin development, wounds
Renal: high blood pressure, bladder reflux of urine to kidneys
Musculoskeletal: osteopenia of prematurity, Ricketts, poor muscle tone development
Urology: high risk for UTI (especially boys)
Ophthalmology: ROP
Gastrointestinal: slow GI motility, NEC, cholestasis
Circulatory: increased PPHN, hyperbilirubinemia
Cardiac: PFO, PDA, congenital heart defect
Immune: environment stress leads to cortisol release, poor lymphatic movement
Grade 1:Isolated germinal matrix bleed
Intraventricular Hemorrhage
Grade 2: Blood in the lateral ventricles Grade 3:IVH with acute ventricular dilation Grade 4: Hemorrhage into the periventricular white matter
No Hemorrhage: 2mm cysts at 1 month are 95% predictive of CP if lesions extend from anterior to posterior Most common CP is spastic diplegia
Infant born at 34-36 weeks gestation
Account for majority of premature births
Late Preterm Infant
Known short-term increase respiratory distress, feeding difficulties, hyperbilirubenemia, sepsis, hypothermia, rehospitalization Increasing focus on higher incidence of difficulties at school age.
Respiratory Distress Syndrome Oxygen Assisted Ventilation Exogenous Surfactant
Respiratory Distress
Transient Tachypena of the Newborn (TTN) Supplemental Oxygen
Meconium Aspiration Oxygen Assisted ventilation ECMO
Retinopathy of Prematurity At risk infants require eye exams at 4-6 weeks of age until retinal mature