PEDS - Preemies and NICU babies

What is the formal definition of prematurity?

Birth occurring before completion of 37 weeks gestation (in da oven)

When does late preterm occur?

Between 34 and 36 weeks gestation (approximately 74% of all preterm births!)

What is the leading cause of neonatal deaths (70%) and long-term neurologic disabilities (50%)?

prematurity

What is considered the normal range of birthweight for gestational age?

between the 10th and 90th percentiles for his/her age.

What is considered a low birthweight?

1501-2500g

5.5 lbs

What is considered a very low birthweight?

1000 - 1500g

3.3 lbs

What is considered an extremely low birthweight?

What are most premature births caused by?

spontaneous preterm labor secondary to membrane rupture

What lifestyle factors put you at a higher risk for a preterm birth?

- little to no prenatal care

- drugs, smoking, alcohol

- under 17 or over 35 y/o

- low socioeconomic status

- domestic violence/high stress environment

What medical factors increase the risk of pre-term births?

- infections (over 40%)

- hypertension

- diabetes

- underweight/obese

- injury/malformation of fetus

What age is just about the earliest you could expect a child to have a chance at surviving prematurity?

23 weeks has about a 40% chance of survival.

What are the roles and goals of the NICU?

- monitoring of well infants at risk for serious illness

- intensive treatment of acutely ill infants

- treatment of preemies

What is level 1 of a hospital perinatal care level?

Well-Baby Nursery

What is level 2 of a hospital perinatal care level?

Special Care Nursery

What is level 3 of a hospital perinatal care level?

NICU

What is level 4 of a hospital perinatal care level?

Regional NICU

What are the roles and responsibilities of a well-baby nursery?

- neonatal resuscitation at delivery

- postnatal care to stable term newborn

- Care for healthy preemies from 35-37wk gestation

- stabilize ill preemies

Where are well-baby nurseries located?

small community hospitals

What are the roles and responsibilities of a Special Care Nursery?

- care for infants over 32 weeks gestation with physiologic immaturity & resolving issues

- care for convalescing infants post intensive care

- mechanical vent./CPAP for brief duration (

Where are special care nurseries located?

regional or community hospitals

What are the roles and responsibilities of the NICU?

- provide and sustain life support

- take care of infants that are

Where are NICUs typically located?

@ specialized hospitals

What is the gist of the roles and responsibilities of Regional NICUs?

- has everything a NICU has, but has the ability to perform complex repair surgeries

- provides transport and outreach services

What are the requirements of a physical therapist in the Neonatal ICU?

MUST have an advanced level of pediatric practice (involves precepted clinical training)

What is the goal of NICU intervention?

- reduce morbidity/mortality

- provide intrauterine environment as much as possible

- provide optimal growth/developmental environment to support neurobehavioral functioning

What are the three theoretical frameworks guiding practice in the NICU?

- Family systems

- ICF

- Synactive Theory

What are the 5 subsystems within the synactive theory of development listed from BOTTOM to TOP?

1. Autonomic (physiologic stability) *we look at this FIRST*

2. Motor

3. Behavioral State

4. Attention/Interaction

5. Self-Regulation

Within the synactive theory of development, stability of the ___________ subsystems is needed for maturation and expression of the ___________ subsystems.

lower; higher

Within the synactive theory of development, expression of __________ subsystems can jeopardize the stability of the ____________ subsystems

Higher; lower

T/F: An infant that's born full term should have the ability to self-regulate within all sub-systems of the synactive theory.

TRUE

What is the ideal intrauterine environment?

- minimal noise, gravity, or visual stimulation

- warm, optimal temp regulation

- physiological flexion

T/F: Subsystems develop at the same rate in a pre-term/special care infant

FALSE

How are pre-term infants characterized?

- disorganized behavior

- signs of stress

- a disconnect between extra and intra uterine environments

T/F: We should emphasize and increase the amount of handling of a pre-term baby in the NICU.

FALSE. don't touch dat baby!

The general goal in the NICU is to...

- establish the intrauterine environment

- leave dat baby alone so it can conserve energy and develop more

What's the normal heart rate for a baby?

120-180 bpm

What's the normal respiratory rate for a baby?

40-60

What are signs of difficulty in the self-regulation of respiration?

- paling around the mouth, eye, and nose

- spitting up

- straining and hiccoughs

- bowel movements

What are signs of increased work of breathing?

- flared nostrils

- head bobbing

- costal retractions

What are the signs of increased stress in a baby?

- color changes

- vital sign changes

- visceral responses (gagging, hiccups, flatus, diarrhea)

- Sneezing and yawning

What are the signs of MOTOR stress in a baby?

- general hypotonia

- frantic flailing

- finger splaying

- hyper-extended trunk and shoulder girdle

What are signs of stress to a baby's higher behavioral state?

- diffuse sleep states

- glassy-eyed

- gaze aversion

- panicked look

- irritability

T/F: Infants have a higher sensitivity to noxious stimuli or input up until around 36-40wks when their pain mediating tracts are fully developed.

TRUE

What are some of the physiological signs and symptoms of pain in a newborn?

What are some of the behavioral signs and symptoms of pain in a newborn?

What is the negative impact that pain can have on a newborn?

- poor nutritional intake

- delayed wound healing

- impaired mobility

- sleep disturbances

- withdrawal

- irritability

What is the single most important cause of illness and death in preterm infants?

Respiratory Distress Syndrome (RDS)

*also most common cause of respiratory distress*

What is insufficiency noted in RDS that decreases the surface tension of alveoli and makes it hard to breath for infants?

Pulmonary immaturity causing decreased surfactant!

What is antenatal approach to alleviating/preventing RDS?

providing steroids to the mother up to 34 wks gestation to accelerate lung maturation

What is the postnatal approach to alleviating RDS?

giving the infant surfactant to help with lung compliance

usually given to high risk babies less than 30-32wks GA

What is the most common chronic lung disease in premature infants?

Bronchopulmonary Dysplasia (BPD)

When is BPD typically diagnosed?

36 weeks

What are the diagnostic criteria to determine the presence of BPD at 36 weeks?

- they require oxygen

- abnormal physical exam

- abnormal chest X-ray

What are the causes of BPD?

- very premature birth

- lung injury due to mechanical ventilation and oxygen support

What is chorionaminoitis?

a bacterial infection of chorion and amnion (membranes that surround the fetus)

What is the predictor of BPD?

Lower gestational age and ventilation at Day of Life (DOL) #7

Birthweight less than 1250 grams makes up 97% of the patients with BPD... just an interesting correlation

What typically dictates the severity of Bronchopulmonary Dysplasia (BPD)?

the longer and greater O2 support needed, the greater the severity.... especially when making diagnosis at 36 wks.

What is the name of respiratory distress caused by an infants first poop?

Meconium Aspiration Syndrome

What is the term for an infants first poop? when does it occur?

meconium

happens in the womb during late pregnancy

What is contraindicated with MAS?

use of a pressure tank

should also be known that suction is unhelpful

What percentage of infants with meconium aspiration syndrome have neurodevelopmental delays up to 3yrs old?

20%

What is the term for the fluid that the fetus typically floats in?

amniotic fluid

What are the common conditions of the cardiac system that impact infants?

- Patent Ductus Arteriosus

- Pulmonary Hypertension

- Pulmonary Atresia (incomplete formation of pulmonary valve leading to leakage between beats)

- Tetralogy of Fallot (pulmonary atresia with intraseptal defects)

- Coarctation of the Aorta (narrow aorta)

When do most intraventricular and periventricular hemorrhages occur?

within the first 48 hours of life

What's most likely to be damaged by an intra/periventricular hemorrhage due to it's proximity to the ventricles?

Long descending motor tracts that control leg movements

What is a grade 1 IVH?

Hemorrhage isolated to germinal matrix

What is a grade 2 IVH?

rupture into the lateral ventricles without dilation

What is a grade 3 IVH?

IVH with acute ventricular dilation

What is a grade 4 IVH?

Hemorrhage spreads into periventricular white matter (most severe and debilitating)

What is the name for an injury to cerebral white matter that is offen associated with IVH's and isrecognized at the leading known cause of CP?

Periventricular Leukomalacia (PVL)

What are associated risk factors for PVL?

- infection

- maternal obesity

What is the term for neonatal encephalopathy in infants that have heart rate or distress abnormalities?

Hypoxic Ischemic Encephalopathy (HIE)

What are the causes of Hypoxic Ischemic Encephalopathy?

- hypoxemia

- ischemia (more of the problem due to lack of glucose to neural tissue)

What is the clinical presentation of hypoxemic ischemic encephalopathy ?

- ABGs showing metabolic acidosis (pH

How often is the APGAR score administered?

1 and 5 minutes after birth, then every 5 minutes for problematic infants

What APGAR scores mean severely depressed?

0-3

What APGAR scores mean moderately depressed?

4-6

What APGAR scores mean excellent condition?

7-10

What is the treatment for HIE?

Whole body hypothermia at temperatures of 33-34 degrees celsius for 72 hours

best results if started within 6 hours after delivery

What are he outcomes of severe Hypoxic Ischemic Encephalopathy?

- 60% Mortality

- over 50% will have CP, seizure disorders, ataxia, atonic quadriparesis, hyperactivity, impaired attention, etc.

What are the conditions that occur under GERD?

- vomiting

- irritability

- poor weight gain

- dysphagia

- abdominal pain

- esophagitis

- respiratory complications

What is Necrotizing Enterocolitis?

acute inflammatory disease of the bowel

What is the treatment for necrotizing enterocolitis?

- discontinuation of oral feedings

- antibiotics

- surgery

What do you need to know about the integumentary system in a premature infant?

highly susceptible to pressure injuries (only 1-2 cell layers in stratum corneum at 24 weeks)

What is the cause of Retinopathy of Prematurity(ROP)? What can this lead to?

abnormal blood vessels in retina.... may lead to retinal detachment... ew.

The incidence of ROP ___________ with lower gestational age, birthweight, and BPD.

increases

What is the cause of Hyperbilirubinemia (physiologic jaundice)?

accumulation of excessive amounts of bilirubin in the blood

How is Hyperbilirubinemia treated?

phototherapy

What tool is used to determine the severity of withdrawals in infants?

Finnegan Scoring System

When must the dubowitz/ballard examination for gestational age be completed?

Within the first 24 hrs after birth (postpartum)

Which outcome measure is very predictive of CP through the identification of relevant movements and movement patterns?

General Movement Assessment

The test of infant motor performance can be used from...

34 wks GA through 4m of age

The test of infant motor performance is great for...

- teaching parents where their infant may have deficits as well as what they need to do to address it (HIGH ECOLOGICAL VALIDITY)

- high predictive validity for development on AIMs, Bayley, and Peabody

- Excellent test-retest and rater reliability

Through PT experiences, we need to provide infants with...

- sensory experiences

- movement opportunities

- developmental support w/ transitioning from NICU to home

ALL interventions should be embedded into care/routine of the infant

What are the goals for positioning (SL and Prone) as an intervention for NICU babies?

- encourages midline head position

- arms and legs flexed close to body (simulates intrauterine environment)

Prior to discharge, infant must transition to ________ for sleeping

supine

What massage interventions have been noted to increase weight gain and decrease length of stay by 4.4 days?

Containment holds and facilitated tucking

What can we do to alleviate pain for infants in the NICU?

- swaddling

- non-nutritive suck

- decrease stimuli

- tactile (deep) pressure

- rocking

- music

- vibration

- containment

- breast milk

What's the rule of thumb for the risk of morbidities and its relation to gestational age?

As the gestational age/birth weight decreases, the risk for long-term morbidities increases