Certified Neonatal Therapy Exam

NIDCAP stands for

Newborn Individualized Developmental Care and Assessment Program

Impact of NIDCAP

Founded by Heidi Als. Allowed infants, parents and staff more direct training to improve confidence in syntactic theory of development. Emphasized using neurodevelopmental care and individualized care. Increased knowledge regarding brain development.

Co-Occupation Theory Definition

Dance between occupations of 1 individual and another that sequentially shapes the occupations of both persons

Co-Occupation Theory Impact

Therapists should know expectation of parents. Approach bedside with attention, designate roles and knowing that how we interact with each other is crucial.

Co-Occupation Theory Stresses these 3 aspects

Personhood, humanity and integrity of each person and infant

Dynamic Systems Theory Definition

Includes 2 or more components that relate to each other. How a developing system works. Components affect each other or change over time.

Dynamic Systems Theory: Application

Infant + interaction with environment result in a behavior

Neurodevelopmental Care

Supports parent/infant relationship and neuromaturation. Minimizes adverse stimuli. Mimics intrauterine environment.

Neurodevelopmental Care Impact in Practice

Changes mode of care to individual family and supportive care. Procedural guided care changed to process guided care.

Synergistic Neurodevelopmental Systems

Neurobehavioral, neuromotor, neuroendocrine, musculoskeletal, sensory and psychosocial are all the foundation for the infant.

List the stages of brain development in order

Proliferation, Synaptogenesis, Migration, Organization and Myelination

Proliferation

Between 8-16 weeks. Production of neurons and glions. Continues until infancy. Cerebrum and cerebellum are last areas of neuronal proliferation to occur.

Synaptogenesis

8+ weeks. Synapse formation. Continues in a progression with neurons proliferating, differentiating and migrating to their appropriate location as development progresses. Synapses increase, this is a pre-req for interaction to occur within the CNS

Migration

Between 12-24 weeks. Migration of neurons by pathways into cortex where they will stay and then differentiate. Will go outward into cortex with deeper layer forming 1st then superficial forming last. Interaction between the infant and environment is believed to shape the neuronal connections.

Organization

24-28 weeks. Primitive reflexes begin. Begins establishment of layers of neurons in the cortex. Impulse conduction confirms functional operation of synapses. Synaptic pruning.

Myelination

24 weeks to adulthood. Covering that speeds conduction in nerve fibers. Corresponds to functional development of systems. Any inconsistencies in myelination are grounds for discrepancy in sensory and motor functions.

Germinal stages week 1: Events occurring post ovulation

Fertilization (day 1), first cell division (1.5-3 days), early blastocyst (4 days), implantation (5-6 days).

Zygote

Diploid cell formed when a sperm fertilizes an egg. Contains 46 chromosomes, half from each parent.

Fertilization of an egg is completed

Within 24 hours of ovulation

By week 3, we have 3 Germinal Layers

Endoderm, Mesoderm and Ectoderm

Endoderm

epithelial lining and glands of digestive and respiratory tracts

Mesoderm

middle germ layer; develops into muscles, and much of the circulatory, reproductive, and excretory systems

Ectoderm

outermost germ layer; produces sense organs, nerves, and outer layer of skin. Skin and nervous system.

Highlights of Fetal Development: 8 weeks

Neural fold begins to fuse, heart tube fuses, pharyngeal arches appear, four limb buds and future cerebral hemispheres are distinct. Four chamber heart established and sense of smell are established. Spontaneous involuntary movement. Essential external and internal structures complete.

Limb anomalies can occur

4-5th week

Growth of the embryo occurs

From head to tail and from midline to outward. Cephalocaudal, proximal-distal.

Fetal development weeks 9-11

Brain mass increases, folds of mouth fuse to form the palate, vocal cords form, umbilical cord forms, differentiation of sex genitalia, primitive reflexes develop

Fetal development weeks 12-15

Development of sucking pattern, back bone texture forms, heartbeat is detected, gender can be detected, arms have reached final proportions/growth, skin/muscle glands appear

Can detect the sex of the embryo by

Weeks 12-15

Fetal development weeks 16-20

Meconium begins to form in bowels, uterus fully formed in female fetus, vernix is formed covering the skin, vestibular system becoming functional, phases of sleep/wake cycles, placenta is fully formed.

Fetal development weeks 20-24

Rapid brain growth, reacts to light/sound, maturation of lungs evolved, surfactant production begins, legs approach final proportion to body size, smell/taste is formed

Fetal development weeks 28-32

Auditory system matures, eyes open during awake and close during sleep, REM sleep established, head size pushes the skull outward, immune system begins to develop, fetal position.

Fetal development weeks 32-36

GI system very immature and eliminates nutrition through umbilical cord, respiratory system continues to develop, increasing fat stores improve, improved temperature stability, limbs flexed and close to body

Fetal development weeks 36-Term

Adipose tissue continues to assist in thermoregulation and insulation of the body

Theory of Neuronal Group Selection (Edelman)

Brain forms various networks based on various experiences in development. Large number of syntactic connections make us who we are. Comprised of 3 core elements. Primary variability, selection and secondary variability.

3 elements of the Neuronal Group Selection

How brain anatomy evolves, how brain networks form and how these networks communicate among themselves.

Cranial Nerves: 3 groups

Somatic efferent, pharyngeal arches and sensory nerves

Central Pattern Generator

Circuits that produce rhythmic motor patterns such as walking, breathing, swimming in the absence of any sensory or ascending information

Palmar reflex (grasp reflex)

place finger in infant's hand, pull away infant's hand grip tightens. Begins at 26 weeks gestation. Integrates at 5-6 months.

Abnormal Plantar Reflex (Babinski)

The big toe then moves upward or toward the top surface of the foot. The other toes fan out. Begins at 26 weeks gestation. Integrates at 8-9 months.

Rooting reflex

Begins at 27 weeks gestation. Integrates at 3 months of age.

Sucking reflex

Begins at 27 weeks gestation. Becomes volitional at 4-5 months.

Swallow reflex begins

28 weeks gestation

Moro reflex begins

30 weeks gestation. An infant when he or she is startled or feels like they are falling. The infant will have a startled look and the arms will fling out sideways with the palms up and the thumbs flexed. Integrates at 6-8 months.

Gag reflex begins

32 weeks gestation

Automatic walking reflex begins

32 weeks gestation

Suck/swallow/breathe reflex begins

32-34 weeks gestation and should be perfected by 34-37 weeks

Crossed extension reflex begins

35 weeks gestation. The examiner holds one of the baby's legs extended and applies firm pressure to the sole of the foot of the same leg. The baby's free leg flexes, adducts and then extends.

Doll's eye reflex begins

35 weeks gestation. baby's eyes move in the opposite direction of their head movement, like looking left when their head is turned right. This indicates an intact brainstem.

Feeding at 12-15 weeks gestation

Non nutritive sucking and swallowing occurs

Tongue thrusting occurs at

21 weeks gestation

Constant sucking/swallowing occurs at

24-26 weeks gestation

At 36 weeks, a fetus is swallowing

100-500mL of amniotic fluid per day

Term infant's physiological flexion develops

Cephalocaudal, from proximal to distal

Full term infant's flexor tone is aided by

Flexion contractors at the hip and knee joint

Preterm infants are ___ dependent

Gravity dependent due to lack of constraining in utero to support muscle development

Premature flexor tone development

Occurs in opposite direction. Caudal to cephalic. Distal to proximal.

Effects of medically fragile infants remaining in restricted positions

Cause prolonged joint compression and minimal refinement of mechanoreceptor action. Can predispose them to skeletal deformation, muscle shortening, restrict joint mobility, incomplete ossification, vulnerable to joint effusion during movement.

Optimal infant alignment

Neutral head and trunk, scapular abduction/protraction, hands to midline, hip flexion, posterior pelvic tilt, foot bracing.

Ways to optimize alignment in NICU

Provide supportive boundaries, containment and nesting, developmental diaper change, swaddling

Formal Assessments for musculoskeletal and Neuromotor function

Dubowitz, Hammersmith and Preemie Neuro Exam. Progress from least stimulation to most. Look at range, amplitude and speed.

Cranial molding deformities

Lack of density, may result from prolonged positioning, can happen in utero

Plagiocephaly

asymmetry of the skull. Occipital flattening. May result in torticollis. May be caused by prolonged positioning, CPAP, type of crib.

Brachycephaly

Fetal head is elongated in the transverse diameter and shortened in the anteroposterior diameter.Prolonged supine sleep/positioning, uniform and symmetrical head flattening. Wide/short shape, toaster oven head.

scaphocephaly (dolichocephaly)

a very elongated, narrow skull shape. Side to side flattening.

Impacts of neurodevelopmental positioning and handling

Supports posture and movement, optimizes skeletal development, offers graded input of proprioceptive/tactile and visual stimuli, promotes a calm regulated behavioral state.

Principles and Interventions of Neurodevelopmental positioning/handling

Anticipatory caregiving, preparatory touch, facilitative tuck, continuous touch, gentle and supportive, and intentional movements/transfers

What positioning equipment has full boundaries?

Dandle roo and snuggle ups

Prone rolls are supportive

For the trunk

Z flow

Gel like material can use as a mattress and adapt it

Gel pillow

Helps with cranial modling

Bendy bumpers

More nest like boundary

Freddy frogs

Weighted bead like support, tactile input to help calm

Swaddle sacks

Give containment

Bili blankets

Provide containment with mesh like material

Development of Senses in Order

Tactile, vestibular, olfactory, gustatory, hearing and vision

Tactile Sense

Develops as early as 8 weeks, functional by 12-15 weeks

Tactile Sense Interventions

Preparatory touch, continuous touch, therapeutic touch, kangaroo care and massage

Vestibular Sense

Functioning by 5 months of gestation with signals perceived through the inner ear.

Vestibular Sense Interventions

Intentional caregiving, gentle handling, gentle transfers, parent/staff education. Rocking, swing, bouncing.

Olfactory Sense development

From 7-12 weeks gestation. Functioning by 29 weeks gestation

Olfactory sense interventions

Encourage access to mom's scent. Scent cloths. Remove noxious odors.

Gustatory sense

Taste buds develop by 12-13 weeks and receptors present by 16 weeks

Gustatory interventions

Tastes of EBM/DBM. Positive oral care/taste. Avoid medicine in milk.

Auditory System development

Maturation supports fetal hearing by 24-25 weeks. Timing of maturation of the cochlea, aud nerve and outer hair cells is approximately 32-34 weeks.

Auditory System interventions

Limit or adapt environmental noise, sound should not exceed 50db, parent recorded voice, sound machine.

Vision System

Eyelids generally open by 24-26 weeks and neurons form in the primary cortex by 28 weeks Reactive pupillary response does not appear until 30+ weeks to light and not intact until 36 weeks.

Vision system intervention

Cycled light, covering isolette, glasses for phototherapy, dimming lights. Ambient lighting levels in infant spaces shall be adjustable through a range of at least 300 to no more than 500 lux (approximately 30 to 50 foot candles), as measured on any plane at each bedside

SENSE stands for

Supporting and Enhancing NICU Sensory Experiences

Macroenvironment

What's happening in the bigger picture (what family sees around the bed space)

Microenvironment

What's touching the baby, what's in the bed space

HELLP syndrome stands for

H- hemolysis

EL- elevated liver enzymes

LP- low platelets

Symptoms of HELLP syndrome

nausea, vomiting, malaise, epigastric pain

Who is at risk for HELLP syndrome

Patients who have preeclampsia or eclampsia are at higher risk of developing HELLP syndrome

How is HELLP syndrome treated?

Typically needs immediate delivery of baby. Mom may be put on bedrest, blood pressure medication, magnesium sulfate to prevent seizures and corticosteroids for fetal lung development. Mom may need blood transfusion

ELBW stands for

extremely low birth weight

ELBW is less than

2,500 grams (5.5 pounds)

1800 grams in pounds

3.96 pounds

Types of Assessment in the NICU

Standardized, Non standardized, Norm Referenced, Criterion Referenced and Longitudinal

Framework for Assessment

Individualized, collaborative, family centered, education and environment