Neonatal Physiotherapy Intervention

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

Introduction

Infants who require admission to a neonatal intensive care unit (NICU) are considered vulnerable due to their prematurity and / or significant medical conditions. During the last trimester of pregnancy, there is rapid brain development and neuroplastic change - most infants in the NICU are born between 22-40 weeks of gestation, so this development occurs outside the womb. 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 mother's heartbeat and voice may negatively affect brain maturation. The aim of physiotherapy in a NICU setting is to limit these negative neuroplastic changes through calming strategies and movements to stimulate the interuterine environment.

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 the infant-family bond. Research shows that interventions with parent engagement have significant and lasting effects on behavioural and cognitive outcomes in infants. A secondary benefit is that parents have decreased anxiety and increased confidence of the neonatal situation.

The following sections discuss various interventions in the NICU.

Kangaroo Care

In the NICU environment, a frequently used approach to encourage mother-infant bonding is kangaroo care, also known as skin-to-skin contact. Direct contact is established by removing all the baby's clothes, except for their diaper, and lying them in a prone position on the mother's chest. It has been found that kangaroo care can be neuroprotective as it supports 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. Research shows that non-nutritive sucking can help reduce the length of hospital stay and improve feeding behaviours.

Positioning

Developmentally supportive positioning for infants in NICU 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 improved and longer sleep patterns. Research indicates that infants with long stays in NICU, who are not appropriately positioned, are at risk for positional plagiocephaly, torticollis and may demonstrate a decrease in the quality and spontaneity of movement.

Range of Motion

Passive range of motion exercises may be beneficial for bone development especially when applied to an infant's proximal joints. It has been suggested in the literature that exercises can result in a small, temporary increase in weight gain and bone density in premature infants.

Massage

Infant massage (i.e. gentle and slow hand contact) is an early intervention approach to help with a newborn's tactile sense. There is some evidence to suggest that massage can help with growth and weight gain for low birth weight and premature babies and reduce the length of stay in the hospital. Research by Lu et al. has found that moderate pressure massage therapy can cause greater daily weight gain in preterm infants than 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 on how to best support the baby's motor development should include topics such as:

• 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

Developmental care plans in NICU often include 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

Lighting regulations in the NICU are as follows:

• incubator area where the baby is should not be directly illuminated (except during procedures)
• use an incubator cover, blanket 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

** Evidence demonstrates that introducing robust light-dark cycles has beneficial effects on hospitilisation time and weight gain compared to infants exposed to constant near-darkness or constant light.

Sound

There are often disturbing noises at irregular intervals for short durations in NICUs. In an effort to reduce these disruptions, sound regulations in NICU are as follows:

• ideal sound level at the infant's location should not be higher than 50 decibels (dB)
• the sound level of devices should not exceed 40dB
• temporary sound increases should not exceed 70dB

** In the preterm population, 2-10% of infants will experience hearing damage as opposed to 0.1% in the general paediatric population.

Temperature

Temperature regulations in the NICU are listed below:

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

**This video by KK and Women's Hospital demonstrates a quick summary of various NICU interventions:

Resources

• Neonatal Intensive Care Unit
• Neonatal Physiotherapy Assessment
• Neonatal Pain Assessment
• Understanding Newborn Behaviour
• Infant Terminology and Reflexes