NICU Part 1

Full term infant is born at

38-42 weeks GA

Preterm is considered

37 weeks or less

Neonatal periods refers to

the first 4 weeks of life

at what point must a physician resuscitate a premature infant as directed by law?

any neonate >23 weeks GA and >500 grams must be resuscitated

what preparation is required for a PT to work with premature infants in a NICU

-Advanced education with extensive training, NOT entry-level!

-Supervised clinical practice for a minimum of 2-3 months

-Certifications may be required

survival is directly related to

birth weight

neonates less than _______ grams have the lowest chance for survival

1,000

what factors contribute to premature infant survival?

gestational age and birth weight

T or F: There are genetic links to those born premature

True, 6 gene regions have been identified through 23andMe project

what genetic factors have been linked to length of pregnancy discussed in the ppt?

1. cells within the lining of the uterus

2. lack of selenium

In general, what are neuroprotective strategies?

interventions used to support the developing brain and/or to facilitate the brain after a neuron injury in a way that decreases neuronal cell death, and allows the brain to heal.

what are the 7 components of neuroprotective care?

1. promoting a healing environment

2. partnering with familities

3. positioning and handling

4. safeguarding sleep

5. minimizing stress and pain

6. protecting skin

7. optimizing nutrition

what is the survival rate of premature infants born at 24-25 weeks GA

24 weeks: 41.7%

25 weeks: 57.2%

Chance of fetus surviving greatly improves after how many weeks GA?

32 weeks

what factors define a "high risk" infant

-physiological instability/low APGAR score

-birth weight

-GA

-environmental/social factors (substance abuse)

what is the birth weight in grams that defines an infant as "high risk"

less than 1500 grams

what is the APGAR score that defines an infant as "high risk"

less than 4 at 5 minutes of age

what is the GA that defines an infant as "high risk"

less than 37 weeks GA (pre-term)

neonatologists define "high risk" as

mortality or morbidity

other professions such as PT, OT, SLP define "high risk" as

probability of having a developmental delay

"jaundice" means

excessive bilirubin in blood due to immature hepatic fxn

what is Kernicterus?

bilirubin deposits in the brain which can cause neurologic issues

what is a level 1 NICU?

Basic newborn care for healthy, full-term infants. Can identify high-risk pregnancies/neonates and provide emergency care/stabilization before transfer to a higher-level facility.

what is a level 2 NICU?

Advanced newborn care for infants born ≥32 weeks' gestation or infants recovering from more serious conditions. Can manage most maternal/neonatal complications and may provide brief mechanical ventilation.

what is a level 3 NICU?

Subspecialty newborn care for infants born

What is a level 4 NICU?

The highest level of neonatal care. Provides care for complex congenital/acquired conditions requiring surgical repair, with pediatric subspecialists and pediatric anesthesiologists available. Also provides transport and education outreach

what is extracorporeal membrane oxygenation (ECMO)

For severe cardiac respiratory issues. Blood is removed from body-->oxygenated-->returned to body

what is important to know if a neonate has a temperature probe?

May need to be moved by PT if changing positions and neonate should not lay on probe.

what is important to know if a neonate has a umbilical artery catheter?

it is used to draw blood painlessly and monitor BP. Prone is contraindicated

what is cluster care?

certain time when the neonate can be handled and multiple care tasks occur during a single interaction to minimize sleep disturbances and reduce stress. (this is the time that baths, PT, etc occur)

what is kangaroo care?

skin to skin contact between the baby's front and mothers chest.

what is the purpose of scent dolls?

has the scent of the parents to allow for a familiar smell in an unfamiliar environment, helps to reduce stress, promotes calmness

what is the equation for figuring out corrected age

40-GA=how early----->chronological-how early=corrected age

what is considered "extremely low birth weight"

less than 1,000g

what is considered normal birth weight

2500g or >

what are the 2 assessments done on the Dubowitz-Ballard Clinical Assessment of Gestational Age in Newborn Infant

1. physical maturity assessment (done in first 2 hours)

2. neuromuscular maturity assessment (done within 24 hours after birth)

what does a score of 25 mean when interpreting the Dubowtiz-Ballard Clinical Assessment of GA mean

34 weeks gestation (max score)

what are the components of the APGAR score?

Appearance, pulse, grimace, activity, respirations

when is the APGAR used

after every birth (pre-term or full-term) at 1 min and 5 min

what is considered a "normal" score on the APGAR

7-10

what is considered a high risk score on the APGAR

below a 4 at 5 min of age

what is an assessment that is designed to identify movements and movement patterns that are predictive of CP. PT's are able to do this assessment

Prechtl's general movement assessment

name the physiological state: no movement of body or eyes, optimal for growth and recovery

deep sleep

name the physiological state: body jerks and eye movements are seen, heart and respiratory rate responses to noise and lights noted on monitors

light sleep

name the physiological state: transitional state between sleep and wakefulness, eyes may open briefly, little spontaneous movement, behavioral signs of stress often present

drowsiness

name the physiological state: eyes open and eye contact made, relaxed face and facial expressions, movements are smooth, ready for interaction

quiet alterness

name the physiological state: eyes open or closed, facial grimace or hyperalert appearance, constant movements of extremities, trunk extension, behavioral signs of stress, increased HR/RR

active alertness

name the physiological state: eyes closed, stressed facial expression, extremity and trunk movements are seen, increased HR/RR

crying

what are some approaching behaviors?

hand clasping, foot clasping, hand to mouth, grasping, cooing, eye contact, "ooh" face, "flexion"

what are some avoidance behaviors?

arching, sighing, yawning, finger splaying, arm saluting, stop hand, emesis, eye aversion, frowning/grimace, hiccoughing

what is different about pain with premature infants?

they perceive higher levels of pain

why do premature infants perceive higher levels of pain

-Dorsal horn cells are more excitable at birth

-Pain modulatory tracks, including the endorphin system are not fully functional in pre-term neonates until 36-40 weeks gestation

what pain scale should not be used until the age of 2 months but can also be used with adults?

FLACC score

what pain scale is recommended for children less than 1 year old?

NIPS scale

what pain scale is particularly useful for critically ill, ventilated, or postoperative infants

N-PASS

what is a normal HR for newborn

120-200 bpm

what is a normal RR for newborn

20-60

what is a normal systolic BP for newborn

50-90

what is a normal diastolic BP for newborn

30-60

what is a normal O2 sat for newborn

low 90s-100%

when documenting vitals, it is important to document any

apneas, bradycardias, and desaturations

how can you differentiate between a tremor vs. a seizure

tremors do not exhibit abnormal gaze of eye movement, they can be normal, often stop with sucking

characteristics of a seizure

-uncontrolled, repetitive, rhythmic muscle jerking that continues even when the limb is held

-horizontal or vertical deviation of eyes

-apnea

-repetitive fluttering or blinking of eyes

-tonic posturing of limbs

when assessing ROM what would you expect to be decreased (normally)

hip ext, knee ext, ankle PF

when assessing ROM what would you expect to be increased (normally)

hip flexion, ankle DF, wrist flexion

how can a PT test a neonates vision

horizontal tracking, eye blinking with tactile stimulation, focus/fixation (8-10")

how can a PT test a neonates auditory senses

startle response, eye blinking, change in breathing or vital signs

how can a PT test a neonates tactile senses

grasp (palmar and plantar), reaction to handling (hypo/hyper)

what is considered normal with LE alignment of a newborn

should have mild tibial bowing, genu varum, forefoot adduction, no longitudinal arch, ER of hip

when is the rooting reflex present?

24 weeks

when is the sucking reflex present?

28 weeks

what are the ideal lighting conditions in a NICU

Non-direct, low-intensity lighting with alternating diurnal (day/night) light cycles.

what is the lighting intensity recommendation for neonates with immature visual processing

60 foot candles (=typical office)

Why should NICU lighting be low and non-direct for neonates?

Because neonates have immature visual processing and may be sensitive to excessive light.

What is the recommended maximum noise level in the NICU?

Noise should generally not exceed 45 dB; levels above 50 dB should occur only about 10% of the time, with a maximum of 65 dB.

Why should sound be minimized in the NICU?

Excessive sound can trigger the startle reflex, increase stress, and interrupt sleep which can negatively affect development. Sound is also amplified in an incubator

2 major environmental factors that can be controlled in the NICU

sound and lighting

a whisper is equivalent to what level of noise, which is also desired for sleep

less than 35 dBA

average home, light traffic is equivalent to what level of noise and is also the recommended level

less than 45 dBA

which theoretical framework: physiological stability/autonomic regulation must occur 1st before the infant is able to interact/attend to caregivers

synactive model of infant behavior

which theoretical framework: development is influenced by the dynamic interaction between the infant and their environment

dynamic systems

which theoretical framework: quality of relationship between the therapist and family sets the tone for: hope-empowerment and learned helplessness

hope-empowerment model

which theoretical framework: role of family goes beyond care of child, families are beneficiaries of interventions, optimal family functioning promotes optimal child development

family-centered care

what are some of the main therapeutic focuses

-modulate sensory info in the infants environment to promote behavioral organization and physiological stability

-promote posture and movement appropriate for GA and medical stability

-foster infant-parent attachment/interaction

-provide consultation or direct intervention for neonatal feeding dysfxn and oral motor deficienties

-support symmetry and alignment of extremities/trunk/neck

-decrease potential skill and MSK deformities, contractures

-prepare for hospital discharge and integration into home and community environment