Neonatal Physiotherapy Intervention

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

Introduction[edit | edit source]

Infants who require admission to a neonatal intensive care unit (NICU) are considered vulnerable due to their prematurity and / or significant medical conditions.[1][2] 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,[3] 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.[2] 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.[4][3] The aim of physiotherapy in a NICU setting is to limit these negative neuroplastic changes through calming strategies and movements to simulate the intrauterine environment.[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:[3]

  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 the infant-family bond. Research shows that interventions with parent engagement have significant and lasting effects on behavioural and cognitive outcomes in infants.[2] A secondary benefit is that parents have decreased anxiety and increased confidence.[3]

The following sections discuss various interventions in the NICU.

Kangaroo Care[edit | edit source]

In the NICU environment, kangaroo care is frequently used to encourage mother-infant bonding. Kangaroo care is 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.[5]Other benefits include:[6]

  • reduced severe illness and infection
  • less maternal dissatisfaction with methods of care
  • improved outcomes of mother-child bonding and maternal confidence in caring for their newborn for some
  • improved likelihood of breastfeeding at the time of discharge
  • reduced maternal stress and depression

"So you can see lots of benefits for both mom and baby and so that's one [option] that is highly, highly recommended in the NICU environment."[6] -- Krista Eskay

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

High-priority functional activities in the NICU are sucking and swallowing. These actions should be supported by the physiotherapist and other caregivers. 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.[5]

Positioning[edit | edit source]

Developmentally supportive positioning for infants in NICU may help to reinforce normal skeletal alignment and provide opportunities for normal movement patterns.[7] 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.[5] 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.[5][7]

Current evidence on positioning:

  • A 2016 Cochrane systematic review[8] found low- to moderate-quality evidence that a prone position slightly improves oxygenation in neonates who are mechanically ventilated. But there was no evidence that "particular body positions during mechanical ventilation of the neonate are effective in producing sustained and clinically relevant improvement."[8]
  • A systematic review by Skelton et al.[9] found that there is limited good-quality evidence that positioning can have a positive effect on nonautonomic outcomes (e.g. sleep, pain, comfort, skin integrity, behaviours related to stress) in preterm infants, but that further research is needed.

Please note that regardless of positioning in NICU, when an infant goes home, they should transition to sleeping on their back. "It is really important because of the association of sleeping on your belly and Sudden Infant Death Syndrome (SIDS) that all infants sleep on their back in a crib that is flat. Without anything else in it, including no blanket, just a swaddle or their clothing because of the risk of SIDS."[6] -- Krista Eskay

Physical Activity[edit | edit source]

It has been proposed that a lack of physical stimulation might contribute to metabolic bone disease in preterm infants, leading to decreased bone mineralisation and growth. Therefore, physical activity has been explored as an intervention to help promote bone mineralisation and growth.[10]

Physical activity for neonates includes facilitating extension and flexion of the extremities, performing range of motion exercises, and holding patients into flexion to help to facilitate pushing against resistance. These exercises are usually completed for several minutes, several times a week for at least two weeks.[6]

  • Doğan et al.[5] note that passive range of motion exercises may be beneficial for bone development, especially when applied to an infant's proximal joints.
  • However, a Cochrane review found small short-term benefits, but no long-term effects on bone mineralisation and growth.[10]

"So unfortunately, [physical activity] is not currently recommended in the NICU environment, mostly because the evidence isn't strong for any long-term change and because of the high staff time commitment to be able to complete this physical activity protocol. That being said, I still see this in a lot of NICUs and there's not really any harm that comes out of doing it other than potentially not having the staff time to be able to participate in it." -- Krista Eskay

Massage[edit | edit source]

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, reduce the length of stay in the hospital,[5] reduce neonatal stress[11] and promote sleep.[12] Research by Lu et al.[13] has found that moderate pressure massage therapy can cause greater daily weight gain in preterm infants than light pressure massage therapy.

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 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.[5]

Environment[edit | edit source]

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.[7]

Lighting[edit | edit source]

"There 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."[14]

One Cochrane review looked at cycled light versus continuous bright light and near darkness. They found that there was some evidence to "strengthen our findings that [cycled light] versus [continuous bright light] shortens length of stay, as does [cycled light] versus [near darkness]".[15] However, the quality of the evidence was low and further research is needed.[15]

Based on current knowledge, 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[5]

Sound[edit | edit source]

There are often disturbing noises at irregular intervals for short durations in NICUs,[16] and it has been found that, in the preterm population, 2-10% of infants will experience hearing damage as opposed to 0.1% in the general paediatric population.[17] 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 45 decibels (dB)
  • temporary sound increases should not exceed 65dB[18]

In 2009, Abou Turk et al.[19] conducted a randomised controlled trial (RCT) that compared the use of silicone earplugs to no earplugs in very low birth weight newborns. They found that earplugs may "facilitate weight gain" in these infants.[19] There was also a significant difference in Mental Developmental Index on the Bayley Scales of Infant and Toddler Development (II) for infants who used the earplugs at 18 to 22 months corrected age.[20]

  • Please note the study authors stated the following: "This study was a preliminary study for a larger RCT. Our [institutional review board] IRB would not approve the larger RCT mostly because they were concerned newborns would be deprived of speech input".[20]

Current strategies to help reduce the effects of sound on infants in a NICU include decreasing conversations or sounds near the infant, using isolettes and using a blanket over the isolette to help muffle sound.[6]

Temperature[edit | edit source]

Temperature regulations in the NICU are listed below:[5]

  • 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

Pain[edit | edit source]

Infants face noxious stimuli in the NICU. Helping to decrease the pain response by providing sensory input can be performed in a number of ways:

  • swaddling
  • providing non-nutritive suck
  • tactile comfort measures
    • tapping their bottom
    • gently rocking them
  • promoting physiologic flexion[6]
    • Francisco et al.[21] found that positioning (i.e. facilitated tucking by parents for 30 minutes) "was the best position for pain relief in premature newborns during procedures in the NICU" and that it could "be used as a nonpharmacological strategy for procedural pain relief in newborns".[21]

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

Brace Fabrication[edit | edit source]

Braces might be created for infants in NICU, particularly for those with orthopaedic conditions that require them to be supported and positioned in a way that facilitates appropriate alignment. Aquaplast or thermoplastic materials are often used as they can be moulded to specifically fit the patient. Braces must be checked frequently. Occupational therapists are often involved in wear schedules and provide education to the rest of the care team and caregivers on their use.[6]

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 3.4 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 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. 2022;150:2-5.
  6. 6.0 6.1 6.2 6.3 6.4 6.5 6.6 Eskay K. Neonatal Physiotherapy Intervention Course. Plus, 2023.
  7. 7.0 7.1 7.2 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.
  8. 8.0 8.1 Rivas-Fernandez M, Roqué I Figuls M, Diez-Izquierdo A, Escribano J, Balaguer A. Infant position in neonates receiving mechanical ventilation. Cochrane Database Syst Rev. 2016 Nov 7;11(11):CD003668.
  9. Skelton H, Psaila K, Schmied V, Foster J. Systematic review of the effects of positioning on nonautonomic outcomes in preterm infants. J Obstet Gynecol Neonatal Nurs. 2023 Jan;52(1):9-20.
  10. 10.0 10.1 Schulzke SM, Kaempfen S, Trachsel D, Patole SK. Physical activity programs for promoting bone mineralization and growth in preterm infants. Cochrane Database Syst Rev. 2014 Apr 22;(4):CD005387.
  11. Álvarez MJ, Fernández D, Gómez-Salgado J, Rodríguez-González D, Rosón M, Lapeña S. The effects of massage therapy in hospitalized preterm neonates: A systematic review. Int J Nurs Stud. 2017 Apr;69:119-36.
  12. Firmino C, Rodrigues M, Franco S, Ferreira J, Simões AR, Castro C, et al. Nursing interventions that promote sleep in preterm newborns in the neonatal intensive care units: an integrative review. International Journal of Environmental Research and Public Health. 2022; 19(17):10953.
  13. 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.
  14. 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.
  15. 15.0 15.1 Morag I, Ohlsson A. Cycled light in the intensive care unit for preterm and low birth weight infants. Cochrane Database Syst Rev. 2016 Aug 10;2016(8):CD006982.
  16. 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).
  17. 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.
  18. Casavant SG, Bernier K, Andrews S, Bourgoin A. Noise in the neonatal intensive care unit: what does the evidence tell us?. Advances in Neonatal Care. 2017 Aug 1;17(4):265-73.
  19. 19.0 19.1 Abou Turk C, Williams AL, Lasky RE. A randomized clinical trial evaluating silicone earplugs for very low birth weight newborns in intensive care. J Perinatol. 2009 May;29(5):358-63.
  20. 20.0 20.1 Almadhoob A, Ohlsson A. Sound reduction management in the neonatal intensive care unit for preterm or very low birth weight infants. Cochrane Database Syst Rev. 2015 Jan 30;1:CD010333. doi: 10.1002/14651858.CD010333.pub2. Update in: Cochrane Database Syst Rev. 2020 Jan 27;1:CD010333.
  21. 21.0 21.1 Francisco ASPG, Montemezzo D, Ribeiro SNDS, Frata B, Menegol NA, Okubo R, et al. Positioning effects for procedural pain relief in NICU: systematic review. Pain Manag Nurs. 2021 Apr;22(2):121-132.