For babies born prematurely, the tenuous first weeks of life often are filled with myriad medical interventions in the neonatal intensive care unit to help them adjust to life outside the womb. New research, however, suggests this time in the NICU is a critical window for some less-invasive approaches that can help these children catch up to their full-term peers: physical and occupational therapy.
Researchers at Washington University in St. Louis compared the reflex patterns, tone, stress levels and attentiveness of premature babies at term-equivalent age to full-term babies, and they found significant differences in all of these categories between the two groups. In addition, they tested the preterm infants twice during a six-week period and discovered that certain facets of motor function declined while the babies were in the NICU. The findings were published in October online in the Journal of Pediatrics.
"From a therapy standpoint, there are periods of time when we can make the biggest differences due to the brain’s ability to adapt and respond," said Bobbi Pineda, OTR/L, PhD, lead researcher of the study and a research assistant professor at Washington University School of Medicine in St. Louis. "Our findings suggest that therapy in the NICU prior to term age is important because drastic changes happen before the infant’s due date. This provides an opportunity to use therapy to mold their functional outcomes."
Trailblazing research
Although preemie physical therapy is becoming more common, Pineda said there has been little research investigating the development of preterm infants before term-equivalent age. "NICU therapists have observed developmental change clinically in preterm infants, but research has not yet documented and reported changes that occur prior to term," she said.
Pineda’s team evaluated 75 premature infants at St. Louis Children’s Hospital at 34 weeks gestation and again at 40 weeks, and these results were compared to those of full-term babies at 40 weeks. One of the most significant differences was in the level of tone. "When babies are in utero, they are curled up in flexion, and they basically will push off the uterine wall to gain strength," said Sandy Conner, PT, who works in the NICU at St. Louis Children’s. "When they come out as a preemie, they are very hypotonic and lack the muscle tone that a full-term baby has. They don’t have the strength to move up against gravity, and this can set them up for postural deformities. We facilitate the proper positioning to recreate that flexion."
To imitate the contained womb environment, Conner helped develop the "Dandle Roo," a stretchy fabric that wraps around a baby to provide resistance. Babies can extend against the material and move, but the material recoils them back into position. "Positioning is one of the most important things we do initially because it is the basis for all future movement for an infant," Conner said. "These preemies need to develop the tone closer to what term babies have in order to later learn to crawl, roll and sit up."
Pineda said she will continue to evaluate the preemies at ages 2, 4 and 6 to determine whether the children who receive physical, occupational or speech therapy after discharge experience improved outcomes.
Massage is another important therapy modality for these premature babies, said Rebecca Pendino, PT, DPT, who also works in the NICU at St. Louis Children’s. She teaches the techniques to parents, who often are eager to learn ways to connect with their fragile babies. Pendino said she encourages parents to start simply with a hand on the baby and slowly work toward firm but gentle strokes on the back, arms and legs.
"After a massage, the babies are often more relaxed and they sleep well, which can help with weight gain," Pendino said. "When they are stressed, they tend to use more calories. The massage also promotes infant-parent bonding, which allows the parents to feel like they are an active caregiver instead of feeling afraid to touch their babies."
PTs in the NICU always are attentive to any indications of stress that signal it is time to stop therapy for the moment. A baby may push out a hand like a stop sign, stiffen and extend the legs, grimace, or arch if the therapy is causing stress. Therapists also are watching for any change in vital signs, such as a drop in heart rate or oxygen saturation level, or discoloration of the baby’s skin to gray.
Consistency is key
While some hospitals do have a dedicated team of physical, occupational and speech therapists trained to work with preemies like St. Louis Children’s does, this model is not standard throughout the country, said Sue Ludwig, OTR/L, president and founder of the National Association of Neonatal Therapists. "Over time, I’ve seen a growing wave of neonatal therapists being integrated into the NICU," she said. "It has brought about improved relationships with the nursing and medical staff, and also broadened our perspective about what our roles can be."
Ludwig founded the NANT in 2009 because, frustrated with the lack of consistency in neonatal therapy throughout the country, she wanted to unite these therapists and establish consistent standards of care. Members can join online forums, participate in monthly webinars presented by experts in the field, attend annual conferences and participate in monthly mentoring calls with Ludwig. One of Ludwig’s longer-term goals is to create a certification for neonatal therapists.
"One thing that has become apparent in my work with this population is that preemies are not just little pediatric patients," Ludwig said. "They have their own set of problems and diagnoses and require therapists with a whole different skill set." •
For more about the NANT: NeonatalTherapists.com
(Source: news.todayinpt.com)
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