NICU

Question 1

Objectives

Answer 1

• define terminology of the neonatal intensive care unit (NICU)
• describe sensory differences between the intra-uterine and extra-uterine environment and the impact
• 7 core features of the neonatal integrative developmental care (IDC)
• Brazelton’s 6 stages of arousal
• components necessary for safe feeding
• key features of evaluating in the NICU

Question 2

Stats

Answer 2

• in approximately 10% of births, there are complications that can be life threatening to the newborn and/or require ongoing care
• survival is possible for infants born 23-26 weeks, more than 50% go on to have significant delays because their brain, lungs, nervous system, bones, muscles were designed to grow and develop in the utero
• many infants in the NICU require life support

Question 3

Infants in the NICU

Answer 3

• largest group = preterm infants
• extremely preterm = at or before 28 weeks GA
• very preterm = 25-32 weeks GA
• moderately preterm = between 32-34 weeks
• late preterm = between 34-37 weeks

Question 4

NICUs are designated by “level” of care

Answer 4

• level I = support for healthy newborns
• level II = a few days of observation and monitoring of heart rate, oxygen, respiration; babies are able to be held and fed by the parents
• level III = more intensive support (Missouri Baptist)
• level IV = highly complex, life-saving interventions and surgeries (Mercy, Cardinal Glennon, and St. Louis Children’s Hospital)

Question 5

Person, environment, and occupations of infant in utero

Answer 5

• placenta feeds the baby
• consistent noise and temp
• mom’s heartbeat is steady and calming
• protective
• warm (flexed)
• getting proprioception input (when they move inside the uterus)
• no pain inside the uterus
• vestibular system is impacted (head down providing input)

Question 6

Environment

Answer 6

Womb:
- limited exposure to external sensory stimuli
- opportunities for active movement against fluid resistance
- boundaries that offer containment and support
- unrestricted access to the mother
NICU:
- beeping alarms
- fluorescent lights
- hard surface
- movement against gravity
- pain
- isolation from mother

Question 7

After birth, the newborn must…

Answer 7

• transition to extra-uterine circulation
• breathe air
• regulate body temperature (98.7 degreees inside the uterus)
• move against gravity
• activate the GI function
• adjust to light and noise
• endure frequent sleep disruptions

Question 8

Impacts of prematurity

Answer 8

• the preterm infant is not prepared for exposure to high levels of inappropriate sensory input repeatedly
• these changes alter normal brain development, neural organization, and adaptation patterns
• contributes to motor delays, cognitive delays, and behavior disorders

Question 9

Goals of the NICU Care

Answer 9

• provide medical interventions (topmost priority to keep the baby alive)
• promote brain and body development
• prevent future disability
• educate and support the family throughout the process

Question 10

Not just a concern of extreme prematurity and low birth weight

Answer 10

• late to moderately preterm infants born between 32-36 weeks were double the risk from neurodevelopmental disabilities at 2 years of age
• research assessed kindergarten readiness at school age in 4,900 children born full term and 950 late term preterm (37 weeks)
• late preterm were 52% more likely to be unprepared for kindergarten

Question 11

7 core features of Neonatal Integrative Developmental Care (IDC)

Answer 11

• healing environments
• partnering with families
• positioning and handling
• safeguarding sleep
• minimizing stress and pain
• protecting skin
• optimizing nutrition

Question 12

Healing environment (7 core features of IDC)

Answer 12

• physical environment = space, privacy, and safety (increasingly, NICUs are providing single-family room environments)
• sensory environment = temp, touch, proprioception, smell, taste, sounds, and light
• promotes healing by minimizing the artificial sensory environment on the development of the brain
• vestibular = move infant slowly without sudden movements
• touch = facilitate touch early, frequent, prolonged skin to skin contact (kangaroo care), encourage zero separation between parents and infants, positive touch like gentle, sustain touch in the context of nurturing care
• smell = smell-free unit and expose mothers’ scent when possible (breast pads, cloths) to facilitate bond
• taste = position hands near face (promotes nonnutritive oral) and provide colostrum or expressed breast milk per protocol
• auditory = calm, muted sounds, mindful of voice, and mindful of alarms and equipment
• visual = lights and decreased visual stimulation

Question 13

Partnering with families (7 core features of IDC)

Answer 13

• the key factor in neurodevelopmental outcomes is parental involvement
• crisis for families = unexpected, unprepared, family separation/stress, parent-infant bonding is altered
• parents are vital members of the team (getting them involved)
• supported in the role as most important caregivers
• facilities parents in having medically and developmentally appropriate interactions
• explain the medical and developmental needs of the baby
• teach the baby’s behavioral cues of stress, calm, and self-comfort

Question 14

Positioning and handling (7 core features of IDC)

Answer 14

• reference is positioning in the womb
• flexed, midline, contained
• provide swaddling during bathing and weighing
• promote hand to face contact
• reposition every 4 hours
• utilize positioning assessment tool (ex: Infant Positioning Assessment)

Question 15

Effects of therapeutic positioning

Answer 15

• musculoskeletal development = prevent deformities
• neuromotor development
• physiological function and stability
• temperature
• energy expenditure
• skin integrity
• sleep
• brain development
• provide postural symmetry and balance of tone

Question 16

Safeguarding sleep (7 core features of IDC)

Answer 16

• deep sleep is critical to brain health at all ages, particularly for high risk newborns
• protecting is challenging as babies are almost always appear asleep, it is difficult to tell what stage of sleep they are in, many sources of sleep disruption are not preventable (vision is not fully developed until 40 weeks)
• educate parents on sleep-wake cycles
• promote a quiet environment to ensure sleep
• cluster care between sleep-wake cycles
• use soft voice followed by gentle touch

Question 17

Brazelton’s stages of arousal

Answer 17

• deep sleep
• light sleep
• transitional state/drowsy
• quiet alert (green zone)
• active alert or fussy (yellow zone)
• crying
• infants in quiet alert stage are most ready to engage in occupations
• infants who are crying or in a deep sleep are not ready to learn these skills

Question 18

Minimizing stress and pain (7 core features of IDC)

Answer 18

• multiple sources of stress in NICU = extra-uterine environment, noxious sounds, bright lights, painful procedures, and separation from the mother
• “less is more”
• cluster caregiving to allow for longer periods of rest
• use validated and reliable pain assessment
• continuous observation of infants behavior and physiological response
• facilitate early, frequent, prolonged skin to skin contact

Question 19

Protecting skin (7 core features of IDC)

Answer 19

• provide appropriate positioning to prevent skin breakdown
• educate parents and caregivers on skin care and swaddled bathing
• use a validated skin assessment tool
• teach parents developmentaly appropriate infant massage to promote relaxation, bonding, and attachment

Question 20

Optimizing nutrition (7 core features of IDC)

Answer 20

• educate family on positive oral stimulation, infant feeding cues, and feeding techniques
• promote positive oral stimulation
• promote non-nutritive sucking (pacifier or gloved finger, allows practice coordinating breathing and swallowing, and provides comfort
• utilize valid assessment Feeding-Readiness and Infant Driven Feeding tools
• ensure feeding experiences are positive and pleasant
• generally the biggest barrier to an infant going home

Question 21

Necessities for safe feeding

Answer 21

• anatomic integrity = airway sufficient
• regulation of arousal = active engagement in suck/swallow
• reflexive and active swallow
• airway protection = gag and cough
• appropriate breathing rate
• oral motor posture and tone
• tolerance for handling
• timing of suck, swallow, breathing (suck reflex develops at 32-36 weeks)
• endurance (for feeding)
• motivation = timing of feeding and tube feeding creates hunger

Question 22

Key factors in evaluating in the NICU

Answer 22

• approach with respect for the medical and developmental vulnerabilities
• conduct ongoing assessment of neuro behavioral development (serial assessment)
• acknowledge the nurse’s role (the expert of the baby)
• observe the infant undisturbed, routine care, and learn patterns of regulation
• work as a team to limit hands-on assessment
• trained in structured assessment (NIDCAP)
• modify timing of assessment
• be mentored
• be aware of signs of immaturity = do not confuse it with pathology

Question 23

OTPF interventions

Answer 23

• create and promote (neurodevelopment)
• establish and restore
• maintain
• modify
• prevent
• discharge = when the infant transitions home, what services will support the parent and child

Question 24

Research

Answer 24

• extensive interdisciplinary research related to NICU infants (medical based research)
• current OT research focused upon supporting families

Question 25

Resources to enhance learning

Answer 25

- Parents Emotions Regarding the Neonatal Intensive Care Unit Experience and Transition Home - Mothers’ Experiences with Infant Co-Occupations After NICU Discharge