The Critically Ill Newborn and Aspects of the Premature Infant
Sophisticated technology in neonatal intensive care units (NICU) has resulted in remarkable improvements in the survival of the sickest and most premature newborn infants. Although fortunately the prevalence of disability among NICU graduates has not increased with such advances, the total number of these infants in the community has grown as a result. Many of these babies manifest complex residual health problems and are at risk for developmental difficulties. An understanding of the complications of prematurity and other neonatal illnesses as well as of their treatments can enhance the effectiveness of early intervention services, both in devising creative approaches aimed at promoting the optimal development of medically vulnerable infants and in supporting their families during prolonged periods of intense stress.
The purpose of Chapter 2 is to provide early intervention professionals with a basic familiarity and understanding of some of the newest technologies found in the NICU and explain many of the medical problems encountered by these babies. This section will include appropriate interventions for therapists to consider in designing treatment regimes for these tiniest of patients.
COMMON MEDICAL PROBLEMS
Respiratory Distress Syndrome (RDS) - the most common disorder facing neonates in the first few hours to days of life. Formerly known as hyaline membrane disease. Results from a deficiency of a fatty biochemical substance known as surfactant. This disease causes poor lung development requiring oxygen and may also require mechanical ventilation with use of a respirator or ventilator. RDS may lead to the development of a chronic lung disease known as bronchopulmonary dysplasia.
Bronchopulmonary dysplasia (BPD) - a chronic lung disorder resulting from a combination of lung immaturity and oxygen toxicity, with resultant lung inflammation and pressure-induced damage to the baby’s lungs. BPD causes breathing difficulties that may require supplemental oxygen for a long period of time. These babies are at increased risk for chronic lung disease and may have serious complications from any respiratory illness that would cause only a cold in a healthy infant. Due to the increased energy needs to breathe, these babies require maximal nutritional support. Children with BPD may have slower oral-motor develop and have more feeding problems compared to their peers. These babies seem to have difficulty coordinating their oral-motor function with the increased effort of breathing. Babies with BPD are at increased risk for gastroesophageal reflux (GER).
Therapeutic interventions for babies with RSD and BPD should be geared to the age of the infant. Newborn and premature infants benefit from quiet surrounding with interesting visuals and soft music. Stroking the infant, and holding and rocking the infant may be helpful to calm the baby to allow less energy to be exerted. Older infants should be followed according to developmental milestone progressions discussed in future chapters. Ventilator dependent children are usually motorally delayed due to their illnesses and the attachment and constraints of the very machines that keep them alive. Visual activities, and auditory stimulation may be appropriate. Passive range of motion in rhythmic motions and work on reflexes are suggested interventions.
Gastroesophageal reflux (GER) - is a disorder where the acidic stomach contents flow up the esophagus and can potentially be aspirated into the lungs, causing further lung damage. Infants who develop worsening lung disease, poor growth, frequent episodes of choking and spitting up, or refusal to eat may need evaluation for GER.
Therapeutic interventions include assisting with positioning while eating to maintain a more upright posture such as provided in a infant seat and allowing the baby to remain in this position for at least 45 minutes after eating to allow gravity assist to keep the stomach contents from regurgitation. The therapist should also investigate sleeping positions and recommend that the crib mattress be elevated with the baby positioned in a sidelying position using either a small bolster or bath towel wound into a roll to place behind the baby’s back and a smaller version along the baby’s front beginning at mid-chest downward. Instruct the caregivers to reduce jostling or bouncing the baby after eating and create a calm, quiet environment to reduce stress and excitability.
Babies with GER may proceed onto surgical interventions to reduce reflux. A common procedure is the Nissen Fundoplication whereby the surgeon wraps part of the stomach around the lower esophagus and tightens the stricture area to prevent regurgitation. This procedure commonly includes gastrostomy tube place in infants. These infants will be fed through in combinations through the g-tube and orally as tolerated.
Therapeutic interventions include positioning. When feeding through the g-tube, the caregiver should be encouraged to hold and cuddle the baby in a more upright position to assist gravity in holding the food in the stomach and to provide a nurturing environment for the child. The baby can be placed in the prone position for play and therapy interventions. The g-tube should be placed within the clothing when not in use as the baby will play and such on the tube if it is handy. In addition, a dangling tube is easily caught on items in the surrounding environment. When the g-tube is not in use, the child should be encouraged to interact within the environment at age appropriate activities. The child need not be restrained after the stomal site has healed.
Prolonged and recurrent hospitalizations, suboptimal nutrition, and varying degrees of brain injury due to oxygen deprivation or hemorrhage often result in delayed or disordered skills. The therapist should monitor motor skill development and direct intervention as warranted. These babies often have poor exercise tolerance and tire easily. Thus treatments should be short and directed at caregivers to carry-out throughout the day.
Persistent Fetal Circulation - severe respiratory difficult in a full-term newborn associated with high pressure in the blood vessels of the longs that prevents blood from moving properly from the right side of the heart of the lungs. Results in a critically infant that may be treated by extracorpeal membrane oxygenation (ECMO). ECMO is a type of heart-lung bypass machine. ECMO may be required for a few days up to a few weeks. ECMO has improved the mortality rates in infants, however it has complications. These babies are at increased risk for intracranial hemorrhage, chronic lung disease, feeding difficulties, gastroesophageal reflux, and developmental delays.
Treatment interventions are similar to infants with BPD and GER. In addition, these children seem to have an increased risk of developing behavior problems and failure problems in school. Thus, these children should be monitored throughout their early school years for problems associated with this disorder.
Retinopathy of prematurity (ROP) disorder of the eyes that may result in blindness felt partially due to oxygen toxicity causing disruption of blood flow to the blood vessels of the eye. In addition, lack of oxygen, poor nutrition, and excess light exposure have all been thought to play a role in ROP. ROP may cause myopia (nearsightedness), strabismus (crossed eyes), and other visual difficulties in addition to blindness. These babies require ongoing opthalmologic follow-up.
Therapeutic interventions should be considered in all infants at risk for visual impairment. Specific interventions include supporting the caregivers and teaching them techniques to stimulate the visually challenged child. Promoting maximal integration of the other sensory areas such as hearing, touch and taste should be encouraged. Working with the growing child on mobility and propioception will be important as the child matures.
Intraventricular hemorrhage (IVH) - bleeding within the brain is a common occurrence in premature infants. Intraventricular hemorrhages are graded in four levels:
Grade I - smallest type of bleed limited to the germinal matrix, usually resolve without significant neurodevelopmental abnormalities.
Grades III and IV have to worst prognosis and may give rise to neurodevelopmental disabilities such as cerebral palsy and hydrocephalus.
Grade II - the hemorrhage extends into the ventricles usually resolving without significant issues.
Grade III - the hemorrhage involves bleeding into the ventricle with swelling of that ventricle.
Grade IV - involves swelling of the ventricle plus bleeding into the substance of the brain itself.
Hydrocephalus - water on the brain - may result from IVH or develop for other genetic or environmental causes. The excess water puts pressure on the delicate brain cells causing damage. If medical management of the excess through the use of diuretics fails, than the next step is a vetriculo-peritoneal (VP) shunt. A VP shunt is surgically placed conduit that drains cerebral spinal fluid from the brain’s ventricle into the abdominal cavity. Shunt placements are symptomatic and often malfunction.
Therapeutic interventions include observation for shunt malfunction that include:
Periventicular leukomalacia (PVL) - is characterized by the appearance of cysts in the brain tissue surrounding the ventricles. PVL is thought to be related to a disruption of brain blood flow in the premature infant with subsequent injury of the nearby brain cells. PVL usually occurs on both sides of the brain and tends to result in problems such as spastic diplegia or quadriplegia, impairment of speech and vision, and general developmental delays, which can be severe.
Fever, vomiting, excessive sleepiness, seizures, prominent scalp veins, swelling along the shunt path, bulging of the fontanel, loss of previous achieved developmental milestones, balance or coordination problems and visual difficulties.
Therapeutic interventions should maximize motor function and normalization of muscle tone. Cognitive impairments may be present and there may be associated deficits in vision or speech that may be assisted by remediation and therapeutic assessments and treatment.
After hospital discharge of a critically ill newborn, therapeutic interventions should be tailored to the individual child and family rather than to a specific risk factor. The fact that an infant was premature or critically ill is not as relevant as whether there is residual visual impairment, muscle tone abnormalities, or language delays. However, this knowledge should alert the therapist to the likelihood of developmental problems and heighten the awareness to carefully monitor these children. There is an increasing need for therapists to be part of the medical team that treats premature and critically ill infants. This chapter was designed as an outline of the most common factors a therapist would be presented with in the NICU.
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