Neonatal Physiotherapy Intervention

Original Editor - Robin Tacchetti based on the course by Krista Eskay
Top Contributors - Robin Tacchetti

Introduction[edit | edit source]

Preterm infants requiring the neonatal intensive care unit (NICU) are a particularly vulnerable population secondary to potential adverse neurological sequelae.[1][2]The last trimester of pregnancy is associated with rapid brain development and neuroplastic change which coincides with when most infants are in the NICU (between 22-40 weeks of gestation).[3] Preterm birth may disrupt genetically programmed patterns of brain development which can lead to neurodevelopmental impairments such as motor dysfunction and behavioural and cognitive problems.[2] Exposure to sensory overload in the NICU (monitors, lights, position changes, multiple episodes of handling) and sensory deprivation of the mothers heartbeat and voice may negatively affect brain maturation.[4][3] Limiting these negative neuroplastic changes through calming strategies and movements to stimulate the interuterine environment is the aim of NICU physiotherapy.[4]

Neonatal Interventions[edit | edit source]

Early intervention in the NICU may alter neuroplasticity and reorganisation of the brain in preterm infants. [2] The theory behind neonatal therapy is three-fold:

  1. protect the neonatal brain
  2. optimise the environment
  3. support the family [3]

Interventions are individualised and highly specialised with the goal of promoting development, preventing adverse sequelae and promoting infant-family bond. Research show that interventions with parent engagement have significant and lasting effects on behavioural and cognitive outcomes in infants.[2] A secondary benefit is parents have decreased anxiety and increased confidence of the neonatal situation.[3]

Kangaroo Care[edit | edit source]

In the NICU environment, a frequently preferred approach to mother-infant bonding is called kangaroo care also knows as skin-to-skin contact. Direct contact is established by removing the baby's clothes with the exception of the diaper and lying them in a prone position on the mother's chest. Literature reviews show kangaroo care has a direct neuroprotective aspect in supporting brain plasticity.[5]

Non-Nutritive Sucking/Swallowing[edit | edit source]

A high priority functional activity in the NICU that should be supported by the physiotherapist and other caregivers is sucking and swallowing. Non-nutritive sucking provides tactile stimulation to the intraoral structures and facial muscles through a pacifier or a glove-wearing finger. During feeding, positioning the infant's head in semiflexion while supporting the baby's cheeks from outside help facilitate sucking and swallowing. Research shows that non-nutritive sucking can help reduce the length of stay and improve feeding behaviours.[5]

Positioning[edit | edit source]

In the NICU, developmentally supportive positioning for the infant reinforces normal skeletal alignment and provides opportunities for normal movement patterns.[6] In addition, positioning can provide skin care and support respiratory function. The combination of these three benefits can allow the infant to improved and longer sleep patterns. [5] Research indicates NICU infants with long stays are at risk for positional plagiocephaly, torticolis and may demonstrate a decrease in the quality and spontaneity of movement. [5][6]

ROM[edit | edit source]

Passive range of motion exercises are beneficial for bone development especially when applied to the infant's proximal joints. The literature reveals that exercises can provide a temporary increase in weight gain and bone density in premature infants.[5]

Massage[edit | edit source]

Infant massage in the form of gentle and slow hand contact is an early intervention approach for the newborn's tactile sense. The literature supports massage for growth, weight gain for low birth weight and premature babies and reduces the length of stay in the hospital.[5] More specifically, research shows that moderate pressure massage therapy is found to have greater daily weight gain in preterm infants versus light pressure massage therapy.[7]

Family Education[edit | edit source]

Family education is a substantial component of interventional care in the NICU. Understanding how to care for the preterm infant is important for posture and movement development, parent-infant attachment and maintaining the baby's physiological stability. Coaching the family how to best support the baby's motor development encompasses topics related to:

  • feeding
  • dressing
  • sleep positioning
  • playing
  • communicating
  • therapeutic holding and carrying

** Training can be in the form of verbal information, video narration and/or written sources. [5]

Environment[edit | edit source]

The NICU developmental care plan often includes techniques to limit the consequences of negative stimuli such as excessive lights, sounds, etc. Environmental regulations geared specifically at these stressors help provide physiological stability. [6]

Lighting[edit | edit source]

Regulations in the NICU regarding lighting are as followins:

  • incubator area where baby is should not be directly illuminated (exception for procedures)
  • use an incubator cover or cover to reduce direct exposure to light
  • babies requiring phototherapy should use eye masks
  • low settings at night for ambient light to follow night/day cycle[5]

** Evidence demonstrates that introducing robust light-dark cycles has beneficial effects on hospitilisation time and weight gain as opposed to infants exposure to constant near-darkness or constant light.[8]

Sound[edit | edit source]

The NICU contains disturbing noises at irregular intervals for short durations. [9] In an effort to reduce these disruptions, the NICU has sounds regulations which are listed below:

  • ideal sound level at the infants location should not be higher than 50dB
  • sound level of devices should not exceed 40dB
  • temporary sound increases should not exceed 70dB[5]

** In the preterm population 2-10% of infants will suffer from hearing damage as opposed to 0.1% in the general peadiatric population.[10]

Temperature[edit | edit source]

The temperature regulations in the NICU are listed below:

  • NICU ideal room temperature in the range of 21-24°C
  • ideal incubator temperatures first 24 hours postnatally: 32.4± 1.5 to 35.0± 0.5 °C
  • ideal incubator temperature between 5-14 days: 33.5±0.5 and 32.0± 1.5 °C
  • humidity in incubator first 7 days postnally: 70%
    • reduced to 40% according to infant's ability to organise body temperature
    • can be stopped after 21 days depending on baby's ability to maintain temperature[5]

Resources[edit | edit source]

References[edit | edit source]

  1. Craig JW, Smith CR. Risk-adjusted/neuroprotective care services in the NICU: the elemental role of the neonatal therapist (OT, PT, SLP). Journal of Perinatology. 2020 Apr;40(4):549-59.
  2. 2.0 2.1 2.2 2.3 Øberg GK, Girolami GL, Campbell SK, Ustad T, Heuch I, Jacobsen BK, Kaaresen PI, Aulie VS, Jørgensen L. Effects of a Parent-Administered Exercise Program in the Neonatal Intensive Care Unit: Dose Does Matter—A Randomized Controlled Trial. Physical Therapy. 2020 May 18;100(5):860-9.
  3. 3.0 3.1 3.2 3.3 Khurana S, Kane AE, Brown SE, Tarver T, Dusing SC. Effect of neonatal therapy on the motor, cognitive, and behavioral development of infants born preterm: a systematic review. Developmental Medicine & Child Neurology. 2020 Jun;62(6):684-92.
  4. 4.0 4.1 Haslbeck FB, Bassler D. Clinical practice protocol of creative music therapy for preterm infants and their parents in the neonatal intensive care unit. JoVE (Journal of Visualized Experiments). 2020 Jan 7(155):e60412.
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 Doğan İE, Balcı NÇ, Gündüz AG. Physiotherapy and Rehabilitation Approaches to Premature Infants in Neonatal Intensive Care Units. Journal of Physical Medicine Rehabilitation Studies & Reports. SRC/JPMRS/168. DOI: doi. org/10.47363/JPMRS/2021 (4). 2022;150:2-5.
  6. 6.0 6.1 6.2 Sweeney JK, Heriza CB, Blanchard Y, Dusing SC. Neonatal physical therapy. Part II: Practice frameworks and evidence-based practice guidelines. Pediatric Physical Therapy. 2010 Apr 1;22(1):2-16.
  7. Lu LC, Lan SH, Hsieh YP, Lin LY, Chen JC, Lan SJ. Massage therapy for weight gain in preterm neonates: A systematic review and meta-analysis of randomized controlled trials. Complementary Therapies in Clinical Practice. 2020 May 1;39:101168.
  8. Hazelhoff EM, Dudink J, Meijer JH, Kervezee L. Beginning to see the light: lessons learned from the development of the circadian system for optimizing light conditions in the neonatal intensive care unit. Frontiers in Neuroscience. 2021 Mar 18;15:634034.
  9. Almadhoob A, Ohlsson A. Sound reduction management in the neonatal intensive care unit for preterm or very low birth weight infants. Cochrane Database of Systematic Reviews. 2015(1).
  10. Bertsch M, Reuter C, Czedik-Eysenberg I, Berger A, Olischar M, Bartha-Doering L, Giordano V. The “Sound of Silence” in a Neonatal Intensive Care Unit—Listening to Speech and Music Inside an Incubator. Frontiers in psychology. 2020 May 26;11:1055.