Pre term babies Normal term 42 weeks WHO
Pre term babies
• Normal term: 42 weeks • WHO Definition of Pre term baby: born before 37 weeks of Gestation
Indications for referral of Neonatal therapy • Biological Risk: Medical or Physiological conditions in Pre, Perinatal or Neonatal period. • Established Risk: associated with clearly established diagnosis • Enviornmental Risk
Biological Risks • Birth Weight of 1500 g or less. LBW: < 2500 g VLBW: 1000 – 1500 g ELBW: < 1000 g • Gestational age of 32 weeks or less • Small for gestational age • Prenatal exposure to drugs, alcohol • Ventilator requirements for 36 hrs or more
• Intracranial heammorhage grade 3 • Periventricular Leukomalacia • Muscle tone abnormalities ( hypotonia, hypertonia, assymetry of movement) • Recurrent seizures • Feeding dysfunctions • Symptomatic TORCH infection • Meningitis • Asphyxia with APGAR < 4 at 5 mins. • Multiple births.
APGAR Score of 0 Score of 1 Score of 2 Skin colour Blue, pale all over Extremities No cyanosis, blue, body pink extremities pink Appearance Pulse rate absent < 100 >or = 100 Pulse Reflex irritability No response to stimulation Feeble cry when stimulated Cry or pull away whwn stimulated Grimace Muscle tone None Some flexion Flexed arm Activity and legs that resist extension Breathing Absent Weak irregular gasping Strong, lusty cry Respiration
Interpretation Taken at 1 minute, 5 minutes and then as needed. • < or = 3: ctrically low • 4 to 6 : fairly low • 7 to 10: Normal Low scores at 1 minute: immediate attention needed Low scores at 5 minutes: Indication of long term problems
Established Risks • • • Hydrocephalus Microcephaly Chromosomal abnormality Musculoskelatal abnormality ( CDH, arthrogryposis, torticollis) Brachial plexus injury Myelodysplasia Congenital myopathies Metabolism errrors HIV Down syndrome
Enviornmental Risks • Suboptimal level of stimulation/ hyperstimulation • Maternal drug abuse • Behavioural state abnormalities ( lethargy, lability, irritability) • Single parent, parent < 17 yrs
Factors contributing to Neurological Dysfunction • Immaturity of Brainstem centers: asphyxia leading to brain damage • High metabolic demands in Germinal Matrix: vulnerability to hemorrhage • Low birth weight: Hypotonia
Fetal Circulation
Factors contributing to Pulmonary Dysfunction • Capillary bed not well developed till 26 weeks --- Increased pulmonary resistance --- Sustained Right to left shunt • Type 2 alveolar cells and surfactant production not matured till 35 wks of gestation ---- Decreased lung compliance • Elastic properties of lung not developed ---- Chances of airway collapse • Lung space decreaesed by relative size of heart • Type I fibres in diaphragm not developed ---- Diaphragm can fatigue faster
• Lack of fatty tissue, High surface area/ body weight ratio ------- Hypothermia and increased oxygen consumption • Reflexes depressed ---- Cough, gag reflex depressed, chances of aspiration, infection high.
Scales used in NICU • Calculation of Gestational age: - --- The Clinical Assessment of Gestational age in the Newborn Infant ( Dubowitz) ( 10 neurological and 11 physical characteristics) -- Done by nurses and physicians -- 4 point scale. ----- New Ballard Score 6 neurological, 6 physical signs. 5 point scale. Takes less time to administer.
Behavioral Assessment scale --- Neonatal Behavioral assessment scale by Brazelton and Nugent 6 Behavior states are examined: • Deep sleep • Light sleep • Drowsiness • Quiet alert • Active alert • Crying Baby is maneuvered between the states and responses are observed.
• 4 Dimensions of newborn behavior are analysed in Brazelton’s NBAS: --- Interactive ability --- Motor Behavior --- Behavioral state organisation --- Physiological organisation
Pain assessment • • Pain transmission : via unmyelinated C fibres. Distance covered is less Hence Increased sensitivity to pain This can cause stress syndromes. • Physiological response, motor response and general behavior are assessed with respect to pain stimulus • Scales used: Premature infant pain profile, Neonatal post operative pain assessment, Neonatal infant pain scale.
3 High Risk Profiles 1) Irritable, Hypertonic baby: -- Prone to overstimulation -- Predominant extension patterns seen -- Movements tremulous -- Poor midline orientation, poor antigravity activity -- Poor self quieting ability -- Visual tracking, feeding problems
• 2) Lethargic, Hypotonic baby --- Difficult to arose --- Infrequent crying --- Cry is weak, low volume ( related to hypotonic trunk, intercostals, neck accessory muscles, decreased lung capacities). --- Body gets moulded into any position. --- Depression of movements --- Fatigue during feeding --- Sometimes push themselves into extension --- Risk of sensory deprivation, failure to thrive.
3) Disorganised baby: --- Fluctuating tone --- Easily stimulatable with handling but inactive at other times. --- Sometimes show good feeding behavior, sometimes highly irritable --- Respond well to swaddling.
Management • Maintain, establish physiological stability • Ensure alignment and mobility • Facilitate normal motor patterns
Short term goals • Maintain Respiratory hygiene • Maintain/ develop a normal/near normal sensory profile • Ensure normal feeding • Aim for increase in weight of the baby • Promote age appropriate motor activity. • Pevent contractures, malalignment
Treatment strategies • Positioning: --- Neutral neck position, semiflexed trunk, Extremities in midline, neutral foot position --- Support with containment boundaries of rolls, blankets, avoid barriers to spontaneous movements --- Create positions that promote alert states for short interactions and comfort while sleeping. --- Positions that allow interaction and optimal stimulation ( tactile, auditory, visual.
--- Arrange ventilator tubes in ways so that neck is not in hyperextension. --- Sidelying is the best position for these purposes. --- Gel filled pillows, stockinets may be used for positioning --- Water beds: optimal vestibular, proprioceptive stimulation. --- Sidelying position: helps increase postural, oromotor tone
Splinting for containment
Colours used in NICU
• Sensory Modulation --- Visual: Pictures, Red and yellow colours, Tying a toy on the superior aspect of the bed to promote midline orientation --- Auditory: Female voices --- Tactile: Desensitization, Proprioceptive stimulation to activate muscles --- Vestibular: Swaddling, Hydrotherapy( 10 mins), Hydrotherapy scheduled 30 mins before feeding. --- Keep other enviornmental stimuli to the minimal --- Donot disturb sleep.
Take care of head position of intubated neonates
Chest Physiotherapy • Positioning: Sidelying, Prone • Nebulisation: Normal saline, prop up the baby’s upper body • Percussion , vibrations using the percussion cap • Oxygenation: If increased for suctioning, remember to decrease. • Follow strict hygiene
Oro-motor Therapy • Sensory modulation to normalise the tone • Semiflexed upright position with light support under the chin • Feeding bottles can be used with nipples that are flatter with larger holes so less activity needed. • Sidelying may improve tone of the tongue • Tactile and proprioceptive: stimulation arround oral cavity, inside the oral cavity, pressure on hard palate, stroking to the tongue.
Continue therapy even after discharge • • Parent education Regular follow-up Monitoring Thorough evaluation at 4 mths, 1 yr, 2 yrs, 3 yrs.
- Slides: 31