Tiny Clients: Big Impact: OT Evaluation Across Early Care

OT in the NICU

- sensory regulation and state organization (bright light, negative touch from tubing, noises from machines, lack of skin to skin)

- positioning for physiologic stability (children who are premature usually have low tone)

- oral motor/feeding readiness

which NICU behavior signals a need for positioning support? answer is underlined

1) hand fisting (sign that they might be uncomfortable but not life threatening)

2) SpO2 dips

3) persistent eye closure

observation domains in the NICU

- motor and tone: antigravity control, primitive reflexes

- oral feeding: suck-swallow-breathe coordination

- state regulation: sleep-wake cycles, stress cues

- family coaching: handling cues, positioning strategies

neonatal therapy is

specialized

neonatal therapy

occupational, physical, or speech therapy in the NICU. it is an advanced practice area: infants are medically fragile, and even well-meant handling can cause physiologic harm

why advanced?

- immature nervous systems are easily overwhelmed

- handling changes heart rate, breathing, and SpO2 in real time

- the evaluation itself can be a stressor

how therapists prepare

• Mentored NICU experience beyond entry-level education

• Tool-specific training or certification (e.g., NIDCAP, GMA, NNNS)

• Optional credential: Certified Neonatal Therapist (CNT)

your role as an OT student/new grad

• Observe, read cues, and review the chart

• Hands-on only with direct supervision

• Know what you don't know, and ask

AOTA 2018: NICU practice is

high risk and specialized, and appropriate only for OTs with advanced neonatal knowledge and skills.

synactive theory (Als, 1982)

- the infant's subsystems develop together and constantly influence each other.

- Autonomic stability is the foundation. Stress in one subsystem affects the others

- Your evaluation question: At what level does this infant lose organization, and what helps them recover?

- "A baby can't pay attention to your face if their body is working overtime just to breathe."

synactive theory continued

Self-regulation spans every level: the infant's own efforts to stay balanced

autonomic: signs of stability (approach)

Regular breathing; stable heart rate and SpO₂; pink, even color

autonomic: signs of stress (avoidance)

Apnea, bradycardia, desaturation; pale, mottled, or dusky color; hiccups, yawns, sneezes, spitting up

motor: signs of stability (approach)

Smooth movements; flexed, midline posture; hand-to-mouth, grasping, foot bracing

motor: signs of stress (avoidance)

Limpness, or arching and extension; finger splay, "salute," legs held in the air; tremors, startles

state: signs of stability (approach)

Clear, robust sleep; smooth state transitions; periods of quiet alertness

state: signs of stress (avoidance)

Diffuse, hard-to-read states; abrupt transitions; fussing, crying, irritability

attention/interaction: signs of stability (approach)

Bright-eyed focus on a face or voice; brief sustained looking

attention/interaction: signs of stress (avoidance)

Gaze aversion; staring or "floating" eyes; panicked, hyperalert look

Single cues are

ambiguous. Als lists fisting as a motor stress behavior, but grasping and hand-to-mouth as self-regulatory. Read clusters of cues, not single behaviors.

gestational age (GA)

Weeks of pregnancy at birth. Term is about 40 weeks; preterm is under 37 weeks.

corrected age

Age since birth minus the weeks born early. Used after discharge to judge development

- stop using around 2 years old

periventricular leukomalacia (PVL)

injury to white matter around the ventricles, seen on

ultrasound or MRI. Linked to later motor impairment.

bronchopulmonary dysplasia (BPD)

Chronic lung disease of prematurity; still needing oxygen or breathing support at 36 wks PMA

intraventricular hemorrhage (IVH)

Bleeding into the fluid spaces (ventricles) of the brain. Graded I (mild) to IV (severe).

necrotizing entercolitis (NEC)

Serious inflammation and damage of the bowel wall, mostly

in preterm infants. Feeds are stopped; some need surgery.

OG/NG tube

Feeding tube through the mouth (orogastric) or nose (nasogastric) into the stomach.

Before You Touch, Prepare: Chart review and team huddle

• Birth history: GA at birth, birth weight, delivery events

• Current status: PMA, day of life, respiratory support, lines

• Neuro: head ultrasound or MRI (e.g., IVH grade, PVL),

seizures

• Medical: surgeries, NEC, BPD, medications that affect

arousal

• Feeding: route (OG/NG, oral), volumes, weight trend

• Nursing: tolerance of cares, care schedule, recent events

• Family: presence, language, preferences, concerns

• Precautions: infection control, handling and positioning

orders

Before You Touch, Prepare: know infant's ages

- PMA = GA at birth + chronological age

- Corrected age = chronological age − (40 −

GA at birth)

- Example: born at 28 wks, now 6 wks old → PMA 34

wks. At 16 wks old → corrected age 4 wks.

- Why it matters: judged by chronological age, a

preterm infant can look delayed when they are on

track for corrected age.

Born at 30 wks, now 12 wks old. What is the PMA? The corrected

age?

- corrected age: 2 wks old

- PMA: 42 wks old

You arrive at the bedside. The infant (33 wks PMA) is in quiet sleep, and hands-on cares are due in 30 minutes. What do you do first?

- Elicit a Moro reflex to check neurologic integrity

- Observe at rest (vitals, state, posture, environment), then time hands-on work with the scheduled cares

- Gently wake the infant to assess the quiet alert state

the evaluation flow 1: observe at rest

Baseline vitals, state, posture, light and sound

the evaluation flow 2: join caregiving

Evaluate during scheduled cares with nurse or parent

the evaluation flow 3: handle least to most stressful

Behavior → posture and tone → movement → reflexes → oral-motor

the evaluation flow 4: watch recovery

How long, and with what help, to return to baseline?

the evaluation flow 5: debrief

Share findings with family and nurse at the bedside

Practice principle:

If stress cues cluster or vital signs change, pause and support recovery. If the infant does not recover, end the session and finish another time. Recovery time is itself a finding.

what we asses: state and behavior

Brazelton states 1-6 (deep sleep to crying); range, robustness, and transitions

what we asses: posture and passive tone

Resting posture (premature babies typica;;y have lower muscle ton compared to full term babies because they have less passive and active tension when resting. Premies have to work harder to move

what we asses: active movement

Variety, fluency, and symmetry of spontaneous movement (general movement)

what we asses: reflexes

Rooting, suck, palmar and plantar grasp, Moro, & look at strength and symmetry

what we asses: sensory responses

Reactions to touch, sound, light, and movement; visual fixation and auditory orientation in quiet alert

what we asses: oral-motor readiness

Rooting and non-nutritive suck: rhythm, strength, and stability during sucking

NOMAS - Neonatal Oral Motor Assessment Scale:

a 28-item observational checklist of tongue and jaw movement. Following observation of non-nutritive sucking, the first two minutes of oral feeding are evaluated. Feeding is classified as normal, disorganized, or dysfunctional

TIMP - Test of Infant Motor Performance:

a motor outcome measure designed to assess posture and selective control of movement in infants.

NNNS - Neonatal Network Neurobehavioral Scale:

examines the neurobehavioral organization, neurological reflexes, motor development (active and passive tone).

APIB (Assessment of Preterm Infants' Behavior)

- 28 wks-1 mo post-term

- Subsystem organization; graded sequence of increasingly vigorous inputs

- 30-60 min; 1-2 yrs training

NIDCAP on Newborn Individualized Developmental

Care and Assessment Plan observation

- Hospitalized newborns, during care

- Naturalistic observation → individualized care recommendations (not a scored test)

- NIDCAP professional training

NNNS (Neonatal Network Neurobehavioral Scale)

- 30 wks-~4 mo (46-48 wks)

- Neurobehavior, tone, reflexes, stress and abstinence signs

- ~30 min; formal certification

NBAS (Neonatal Behavioral Assessment Scale)

- 36 wks-6 wks post-term*

- Behavioral and interactive capacities; strengths to share with parents

- 20-30 min; formal training

Dubowitz Hammersmith Neonatal Neurological Examination (HNNE)

- 0 wks-4 mo

- Tone, reflexes, movement, neurobehavior; optimality score (term norms)

- 10-15 min; no formal training

Evaluating Feeding in the NICU: before the feed/readiness

• Physiologic stability at rest

• Drowsy or quiet alert state

• Rooting, hands to mouth, non- nutritive suck

• Structured readiness scales exist (e.g., Infant Driven Feeding Readiness Scale)

Evaluating Feeding in the NICU: GMA (General Movements Assessment - Prechtl)

- Preterm to 40 mo (fidgety before 20 wks)

- video of spontaneous movement , minimal handling

- 10-30 min; 4-5 day course

Evaluating Feeding in the NICU: during the feed/skill

• Suck-swallow-breathe coordination and pacing

• Stability of heart rate, SpO₂, color, breathing

• Stress: gulping, loss of liquid, coughing, disengaging

• Rate quality, not just volume (e.g., IDF Quality Early Feeding Skills Assessment Tool, Neonatal Oral Motor Assessment Scale)

Evaluating Feeding in the NICU: across the feeds/pattern

• Endurance across a feed and a day

• Volume and weight trends (with the dietitian)

• Caregiver's ability to read cues and pace

• Concerns for aspiration: team discussion of an instrumental

study

evidence note:

A Cochrane review found no trials testing whether feeding-readiness instruments improve time to full oral feeding or length of stay (Crowe et al., 2016). Use these tools as structured observation, not proven protocols.

family is part of the

evaluation

- Evaluate with the family at the bedside, not for them in a report.

- Parents are the constant after discharge. Their confidence and cue-reading are evaluation findings too.

1: parent priorities

"What worries you? What do you hope to do with your baby?"

2: parent-infant interaction

How does the parent read and respond to cues? How does the infant respond in their arms?

3: environmental context

In a meta-analysis, ~42% of NICU parents had anxiety and ~40% post-traumatic stress in the first month. Notice, validate, refer; do not diagnose.

4: culture, language, access

Interpreter use, family roles, barriers to visiting (transport, work, siblings)

5: environment

Light, sound, bed type, positioning supports, chances for skin-to-skin holding

findings

What you observed (cues, tone, movement, reflexes, feeding) with the PMA and conditions: state, time since feeding, respiratory support

interpretation

Compared with PMA expectations. One exam is a snapshot; trends across repeated exams matter. Integrate with imaging and the medical course.

recommendations

Positioning and handling guidance, environmental changes, feeding plan input, caregiver education needs, follow-up (NICU clinic, EI referral)

Document objectively

Instead of "Infant did not tolerate handling," write (hypothetical example): "During diaper change, SpO₂ fell to 84% with finger splay and gaze aversion; recovered within 90 seconds with hands-on containment."

case study Baby M:

• Born 12 weeks early, at 28 weeks of pregnancy

• Birth weight: 1,100 grams (about 2 lb 7 oz), Now 6 weeks old

• Room air, no oxygen; NG feeds, beginning oral feeding trials

• Head ultrasound shows a small bleed in the brain (grade II IVH, on a scale of I to IV: A bleed in the baby's brain, graded 1 to 4. Higher numbers mean more risk.)

• Nursing: desaturations and finger splay during diaper changes; calms with hands on head and feet

• Parents visit evenings. Mother asks, "Is she going to be behind?"

1. What is Baby M's PMA? (Hint: GA at birth + weeks since birth.) Which tools are age-appropriate today?

- 28 + 6 = 34 wks PMA

- General Movements Assessment (GMA) — specifically observing writhing movements

- TIMP (Test of Infant Motor Performance) can also be appropriate beginning around 32 weeks PMA.

2. Before you touch her, what are three things you would look up in her chart or ask her nurse?

- Current medical stability — recent oxygen/desaturation episodes, vital signs, and overall stability.

- Feeding status — when she last fed and whether she is currently tolerating oral/NG feeds.

- Recent procedures or medical changes — whether she has had anything stressful recently and whether there are any precautions for handling.

3. When is the best time of day to see her? Which of her stress signs would tell you to stop and let her rest?

- medically stable, awake/quiet-alert, and not immediately before or after a feeding or stressful procedure.

- Desaturation, Finger splay, Changes in breathing, Color changes, Increased fussiness or crying, Significant changes in heart rate, Loss of an organized/quiet state

4. Her mom asks, "Is she going to be behind?" No one can predict that yet. What could you say that is honest and kind?

5. When Baby M goes home, what are three things the Early Intervention team should know about her?

- medical and developmental history

- regulation and stress responses

- current feeding

what comes before EI?

• NICU Evaluation Prior to Discharge

• Goal: Determine readiness for home

• Interdisciplinary approach (OT, PT, Speech, Nursing, MD)

• OT evaluates: state regulation, motor tone, feeding readiness, caregiver bonding, reflexes, positioning tolerance

How does NICU care lead to EI (early intervention) referrals?

• Common diagnoses: prematurity, Hypoxic Ischemic Encephaly)HIE, cardiac or GI surgery, genetic conditions

• Automatic eligibility in many states for

Part C (IDEA): Early Intervention Services

• Ages: Birth to 3 years

• Provided in natural environments (home, daycare)

• Team creates the IFSP (Individualized Family Service Plan)

IFSP (individualized family service plan)

- birth to 3

- natural settings

- family-focused

- team writes plan with family

IEP (Individualized Education Plan)

- 3-21

- school settings

- child-focused

- team writes plan with school input

EI Evaluation Process: key steps

• Intake and eligibility determination

• Arena-style or transdisciplinary assessments

• Team uses standardized and observational tools

• Develop IFSP goals with family

*Cultural Competence & Coaching

OT Assessments in EI (IFSP Evaluation): Developmental Assessment of Younf Children (DAYC-2):

sed to identify children who may have delays in developmental areas.

OT Assessments in EI (IFSP Evaluation): Battelle Developmental Inventory (BDI-3):

evaluates a child's development, used to identify strengths and weaknesses, plan interventions, and track progress.

OT Assessments in EI (IFSP Evaluation): HELP (Hawaii Early Learning Profile)

provides a framework for assessing development, planning interventions, and monitoring progress

OT Assessments in EI (IFSP Evaluation): Bayley Scales of Infant Development

designed to identify infants and toddlers with developmental delays and to help plan intervention services

OT Assessments in EI (IFSP Evaluation): other

clinical observations

OT chooses a tool based on

child age, culture, language, and goals; emphasis on functional skills observed in daily routines.

OTs in Early Care Settings:

• Assess across medical and natural environments

• Observe infant behavior, caregiver interaction, and functional performance

• Use standardized tools + coaching

• Focus on developmental readiness, safety, and family goals