Neonatal Physiotherapy Intervention

Introduction

Preterm infants requiring the neonatal intensive care unit (NICU) are a particularly vulnerable population secondary to potential adverse neurological sequelae.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). 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. 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. Limiting these negative neuroplastic changes through calming strategies and movements to stimulate the interuterine environment is the aim of NICU physiotherapy.

Neonatal Interventions

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

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

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. A secondary benefit is parents have decreased anxiety and increased confidence of the neonatal situation.

Kangaroo Care

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.

Non-Nutritive Sucking/Swallowing

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.

Positioning

In the NICU, developmentally supportive positioning for the infant reinforces normal skeletal alignment and provides opportunities for normal movement patterns. 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. 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.

ROM

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.

Massage

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. 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.

Family Education

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.

Environment

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.

Lighting

In the neonatal intensive care unit, attention is paid to the following in the regulation of the light level; except for the procedures, the incubator area where the baby is should not be directly illuminated, in order to reduce the direct exposure to light, arrangements should be made to cover the incubator with the help of an incubator cover, blanket or cover. and back, protective equipment such as eye masks should be used for babies who need phototherapy. In addition, care should be taken to keep the ambient lighting at low settings at night, taking into account the night/day cycle of the baby’s sleep-wake times [34]. I

Sound

n order to adjust the sound arrangements and prevent noise in the neonatal intensive care unit, health professionals who make up the neonatal team should be trained on the subject. It should be known that the ideal sound level of the environment where the babies are located should not be higher than 50 dB, the sound level of the devices used should not exceed 40 dB, and the sound increase should not exceed 70 dB temporarily [34].

Temperature

While the ideal room temperature of the neonatal intensive care unit is set in the range of 21-24 °C, incubator temperature and humidity settings should be followed with various arrangements according to the gestational week of the baby, birth weight, and ability to provide physiological stability. While ideal incubator temperature values are set at an average of 32.4± 1.5 to 35.0± 0.5 °C in the first 24 hours postnatally, it is adjusted between 33.5±0.5 and 32.0± 1.5 °C between 5-14 days. While the humidity in the incubator is set at around 70% in the first 7 days postnatally, it can be reduced to 40% according to the baby’s ability to organize body temperature, and it can be stopped after 21 days depending on the baby’s ability to maintain body temperature [35].

Sounds

while the NICU environment consists of multiple high frequency noises that exceeding recommended value.may occur by simply opening or closing incubator doors or by the conversation between staff members (DePaul and Chambers, 1995; Marik et al., 2012; Philbin et al., 2017). Assume that these high sound levels may contribute to hearing damage or even hearing loss as diagnosed in 2–10% of preterm infants vs 0.1% of the general pediatric population

The sound environment in the NICU is louder than most home or office environments and contains disturbing noises of short duration and at irregular intervals. There are competing sound signals that frequently challenge preterm infants, staff, and parents

Lighting

here is increasing evidence that introducing robust light-dark cycles in the Neonatal Intensive Care Unit has beneficial effects on clinical outcomes in preterm infants, such as weight gain and hospitalization time, compared to infants exposed to constant light or constant near-darkness.

Music Therapy

It aims at relaxing and nurturing the infant as well as promoting safety and social interaction for the parent-infant dyad. A music therapist specially trained in CMT hums or sings in an infant-directed, improvised, lullaby style continually adjusting to the individual needs, expressions, and breathing pattern of the preterm infant. Based on the principles of family-integrated care, the family is incorporated individually in the therapeutic process, namely by delivering CMT during kangaroo care (KC) and by motivating and facilitating parental vocal interaction with their infant to strengthen the parent-infant bonding. CMT aims at relaxing, stimulating, and coregulating premature infants at a time when many other interventions are still risky and can overwhelm the vulnerable patient group. CMT may be advantageous not by educating and teaching parents, but rather by uncovering the intuitive capacities of parenting that are often overshadowed by the traumatic experience of preterm birth. However, CMT can only be provided when the infants are clinically stable. CMT with parental integration is feasible when parents are available and receptive to participate.

add resources course- 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.