Cocaine

It is difficult to ascertain the exact frequency of cocaine use during pregnancy, but reports indicate that 1% to 45% of females have used cocaine during their pregnancy.²⁸ Cocaine is extracted from the leaves of the coca plant and can be smoked, inhaled, or injected into the bloodstream. Cocaine induces an intense and immediate euphoric state and can be very addictive. Unlike with opioids, physical dependence does not occur, but severe and intense cravings last for several months and can recur for years after cessation of cocaine use.

In the adult the actions of cocaine are mediated through several different neurotransmitter pathways in the brain. Cocaine may cause hypertension, tachycardia, and peripheral and coronary artery vasoconstriction via activation of adrenergic pathways. The sense of euphoria is mediated through dopamine pathways. Alterations in sleep-wake cycles are caused by the blocking of serotonin uptake. During pregnancy, cocaine causes decreased blood flow to the kidneys and is implicated in preterm labor, uterine irritability, premature rupture of membranes, and placental abruption.

Cocaine negatively affects neuronal proliferation, migration, growth, and connectivity, which distorts neuronal cortical architecture. However, the effects of intrauterine exposure to cocaine are difficult to determine because cocaine use is frequently associated with abuse of other illicit drugs, cigarettes, and alcohol. Other confounding variables include poor nutrition and limited prenatal care. In a large prospective blinded study, more infants exposed to cocaine in utero were delivered prematurely and exhibited decreased weight, length, and head circumference compared with matched controls.⁵³ However, cocaine exposure did not affect the incidence of congenital abnormalities.

The vasoconstrictive properties of cocaine increase the risk for HI injury and middle cerebral artery stroke. Neonates with prenatal cocaine exposure demonstrate tremors, hypertonia, irritability, and poor feeding ability. Cocaine-exposed infants have abnormal sleep patterns and are at a threefold to sevenfold increased risk of sudden infant death syndrome (SIDS). No difference was found in developmental testing⁵⁴ between cocaine-exposed infants and matched controls, but the tests did not effectively evaluate arousal, emotional control, and social interaction.⁵⁵ In utero cocaine exposure has been linked to increased incidence of behavioral problems and special education referrals in school-aged children. On fMRI, differences in the right frontal cortex and caudate nucleus are evident and indicate abnormalities in regulation of attention and cognitive abilities referred to as executive function.

Opioids

The opioids are used less frequently than cocaine during pregnancy, as less than 5% of pregnant woman test positive for opioids. Morphine, a naturally occurring opiate, and heroin, a synthetic opioid, readily cross the placenta and are highly addictive. Because heroin can be injected intravenously, there is an increased risk for infection, especially endocarditis, hepatitis, and human immunodeficiency virus (HIV) infection. Methadone, a synthetic opioid, is the standard for treatment of opioid dependence and has a significantly longer half-life than heroin and morphine. Over the past several years, a trend for increasing rather than decreasing methadone daily dose during pregnancy has helped to decrease maternal illicit drug abuse without increasing the incidence of withdrawal symptoms in the infant.

Opioid use during pregnancy has been associated with tubal pregnancies, premature rupture of membranes, uterine irritability, preterm labor, and preeclampsia. Infants exposed to opioids in utero are intrauterine growth retarded at birth, but methadone has a less severe impact on fetal growth. Infants exposed to opioids in utero are noted to have a decreased incidence of respiratory distress related to enhanced surfactant production⁵⁶ and decreased hyperbilirubinemia as a result of induction of the enzyme glucuronyl transferase used in the metabolism of bilirubin.

Withdrawal from narcotics occurs 2 to 3 days after delivery, but signs can be evident as long as 2 weeks after delivery. Methadone withdrawal usually occurs later than withdrawal from morphine or heroin related to its long half-life. Infants in withdrawal (neonatal abstinence syndrome [NAS]) exhibit gastrointestinal symptoms of vomiting and watery stools; neurological signs such as tremors; hypertonicity; high-pitched and incessant cry; hyperalert state; and sweating and fever. Infants with NAS have decreased ability to nipple feed despite excessive sucking on a pacifier. Seizures can be present in 2% to 11% of infants with NAS. Two commonly used scoring methods for severity of NAS are the Lipsitz⁵⁷ and the Finnegan⁵⁸ scales. The Lipsitz scale has 11 components that are scored from 0 to 3, with any score over 4 necessitating treatment.⁵⁷ The Finnegan scale is a more comprehensive assessment, with more than 30 elements, and treatment is recommended if the score is greater than 8.⁵⁸ A quiet, dimly lighted environment, decreased auditory stimulation, and swaddling or holding have been used to decrease neonatal irritability and pharmacotherapy. About 30% to 80% of in utero opioid-exposed infants will require medical treatment for NAS with morphine and either clonidine or phenobarbital. The goal of treatment is to decrease irritability, improve nippling efforts, and decrease vomiting and diarrhea.

Infants exposed to opioids in utero continue to demonstrate tremulousness, hypertonicity, irritability, and increased crying episodes. In addition, they are less able to interact with people, demonstrate decreased age-appropriate free play, and have delayed fine motor coordination. The incidence of apnea and SIDS is increased in opioid-exposed infants. An appropriate and nurturing home environment is essential after discharge from the hospital to maximize neurodevelopmental outcome.^59,60

Selective serotonin reuptake inhibitors

SSRI medications such as fluoxetine (Prozac, Fontex, Seromex, Seronil), sertraline (Zoloft, Lustral, Serlain, Asenta), paroxetine (Paxil, Seroxat, Sereupin, Paroxat), fluvoxamine (Luvox, Favoxil), escitalopram (Lexapro, Cipralex, Esertia), and citalopram (Celexa, Seropram, Citox, Cital) are commonly prescribed to treat depression and anxiety disorders. The SSRI drugs inhibit serotonin reuptake, potentiating serotonergic neurotransmitter signaling. At least 600,000 infants are born yearly to mothers who have a major depressive disorder during their pregnancy.⁶¹ Medical therapy is the most common form of treatment for depression during pregnancy. Approximately 6% of pregnant woman use SSRIs during pregnancy, and almost 40% of depressed women have been reported to use antidepressants at some time during pregnancy.⁶² The serotonergic system is present early in gestation and is important in brain development. Perturbations in this system are associated with alterations in somatosensory processing and emotional responses.

The SSRI medications readily cross the placenta and are linked to an increased risk of spontaneous abortion but not an increased incidence of malformations.⁶¹ A recently published meta-analysis found that maternal depression was significantly associated with an increased incidence of preterm labor and neonatal birth weight of less than 2500 g but not intrauterine growth retardation of the fetus.⁶³ Unfortunately, this study was unable to evaluate the effect of SSRI therapy on these outcomes. Infants exposed to SSRIs in the third trimester have symptoms similar to withdrawal from opioid exposure (irritability, tremors, jitteriness, agitation, and difficulty sleeping). Neonatal feeding difficulties are common, and seizures and abnormal posturing are occasionally present. These symptoms are transient, appearing 2 to 4 days after birth and disappearing by the second week of life.⁶⁴ It is difficult to identify any specific adverse neurodevelopmental outcomes in infants exposed prenatally to SSRIs from published studies because of the variability in the specific SSRI taken, the duration and timing of SSRI use, and the confounding factors of maternal depression and the use of multiple medications.⁶⁵

Biological risk

Biological risk refers to neurodevelopmental risk attributable to medical or physiological conditions in the prenatal, perinatal, or neonatal period.79–81 Biological risks include placental abnormalities, labor and delivery complications, prenatal infection, and teratogenic factors. Examples of biological risk factors include asphyxia, neonatal seizures, prenatal exposure to drugs or alcohol, and the brain lesions previously described. Birth weight is a strong predictor of outcome; in general, lower birth weight is associated with greater risk of adverse developmental outcomes.^82,83

Respiratory disease is generally considered an important risk factor for motor and cognitive disability in infants born preterm (Table 11-5).⁸⁴ Although the presence of respiratory disease alone does not appear to be predictive of neurodevelopmental outcome, severity of disease does appear to be related to long-term outcome.⁸² Infants with chronic lung disease or bronchopulmonary dysplasia have been found to be at increased risk for CP and other neurodevelopmental abnormalities compared with preterm infants without bronchopulmonary dysplasia.^85,86 Prolonged mechanical ventilation and duration of supplemental oxygen were associated with increased risk of neurodevelopmental disability.⁸⁷ Administration of surfactant in the neonatal period has reduced the incidence and severity of respiratory disease in very low–birth-weight infants but has not been associated with a decline in neurodevelopmental disability.⁸⁵

Established risk

Established risk is the risk for neurodevelopmental deficits associated with a diagnosis that is clearly established in the neonatal period. Included in this category are congenital malformations, chromosomal abnormalities, central nervous system disorders, and metabolic diseases with known developmental sequelae.

Environmental and social risk

Environmental and social risk involves developmental risk related to competency in parenting roles and factors in family dynamics. Such risk may be heightened by prolonged hospitalization of infants with the following characteristics: (1) suboptimal levels of stimulation and interaction (overstimulation or deprivation) in the NICU environment, (2) inadequate infant-parent attachment, (3) insufficient educational preparation of parents for caregiving roles, (4) meager financial resources of parents, and (5) limited or absent family support to assist in taking care of and nurturing the infant in the home environment.

It is common for neonates born preterm to have a combination of risk factors from more than one major category. For example, an infant born prematurely to a single mother in a drug treatment program for heroin use during pregnancy is considered to be at both biological and environmental risk.

Pain assessment

Despite immature myelinization, premature infants definitely perceive pain and retain the memory of painful experiences. Skin receptors are developed by 14 to 16 weeks’ gestation. In addition, the density of pain receptors in the skin of neonates at 28 weeks of gestation is considered similar to and even exceeds adult density during maturation from birth to 2 years of age.94–96 Blackburn⁹⁷ explained that although pain transmission in neonates occurs mainly through the slower, unmyelinated C fibers, the shorter distance in neonates that impulses travel to reach the brain compensates for the slower rate of transmission and creates substantial pain reception. Early pain experiences may create later increased sensitivity to pain and vulnerability to stress disorders.^98–100 If neonatal therapy assessment or intervention procedures immediately follow a noxious procedure in the NICU, handling techniques may need to be modified or therapy session rescheduled to avoid contributing to a cascade of aversive experiences for the infant.

Psychometric data and clinical use of the pain tools are described for infants as early as 28 weeks of gestation. Many elements in the pain assessments¹⁰¹ have been identified by Als (the Neonatal Individualized Developmental Care and Assessment Program [NIDCAP]) as signs of excessive stimulation and stress in the preterm infant. Specific extremity movements, such as hand to face, elevated leg extension, salute, lateral extension of arms, finger splay, and fisting, have been proposed as indicators of stress and/or pain.¹⁰²

In addition to practice guidelines on pain assessment developed primarily by neonatal nurses, numerous instruments are available to assess pain in infants. Pain scale data are integrated into NICU nursing assessments and can be a valuable adjunct to the neonatal therapist’s baseline and posttherapy observations.

Indicators of pain summarized across the instruments include the following categories: (1) physiological (heart rate, oxygen saturation, breathing pattern), (2) behavioral (eye squeeze, brow bulge, facial grimace, behavioral state including crying, sleeplessness), and (3) motor (tone and movement in extremities).

Clinical assessment of gestational age in the newborn infant

A method for clinical assessment of gestational age in the newborn infant was developed by Dubowitz and colleagues⁹² from data derived from a total of 167 preterm and term infants (28 to 42 weeks’ gestation) tested within 5 days of birth. The tool focuses on criteria for calculation of gestational age from a composite of 10 neurological and 11 external (physical) characteristics.

This test rates criteria on a 4-point scale; it is commonly administered by nurses or physicians in the newborn nursery. The accuracy (95% confidence limit) of the gestational age score is determined within a variation of ±2 weeks on any single examination. This measurement error can be decreased to approximately ±1.4 weeks when two separate examinations are performed. From the analyses of multiple tests on 70 of the 167 infants, the age score was equally reliable in the first 24 hours of age as during the next 4 days of life. The behavioral state of the infant during the examination is not considered a significant variable in testing.

Calculation of gestational age is an important adjunct to all other neonatal assessment tools. It guides practitioners in interpreting neurological and behavioral findings relative to the expected performance of neonates at various gestational ages. Additional guidelines on gestational differences in neurological, physical, and neuromuscular maturation can be found in the work of French pediatric neurologist Amiel-Tison.^88,89,108

Newborn maturity rating—ballard score

Ballard and colleagues109–111 designed a simplified modification of the Dubowitz gestational age tool. It has been widely adopted because of the time efficiency (3 to 4 minutes versus 10 to 15 minutes) and the elimination of active tone items, which are difficult to evaluate reliably in physiologically unstable newborns. The Ballard instrument involves only six physical and six neurological criteria, with a 0 to 5 scale and a maturity rating. It is designed to be used for neonates (20 to 44 weeks gestation) from birth through 3 days of age and has demonstrated concurrent validity with the Dubowitz gestational age calculation tool. The gestational age of the infant is based on the obstetrical dating criteria unless the clinical assessment of the infant deviates more than 2 weeks from the obstetrical calculation.

Neurological examination of the full-term infant

The Neurological Examination of the Full-Term Infant was designed by Prechtl¹¹² to identify abnormal neurological signs in the newborn period. The examination was developed from an investigation of more than 1350 newborns and was standardized on infants born at the gestational age of 38 to 42 weeks. If the test is used in premature infants who have reached an age of 38 to 42 weeks of gestation, lower resistance to passive movements (lower tone) may be expected. Delay of testing until a minimum of 3 days of age is advised to maximize the stability of behavioral states and neuromotor responses for improved reliability and validity of results.

The pattern of examination includes periods of both observation and examination. A 10-minute screening test is offered to determine if the full 30-minute examination of posture, tone, reflexes, and spontaneous movement is required. Although specific requirements for examiner training are not addressed, Prechtl offers a flow diagram (Figure 11-9) to assist clinicians with organizing the neurological examination process. Significant findings from the examination are summarized in the following categories: (1) quality of posture, spontaneous movement, and muscle tone (consistency and resistance to passive movement); (2) presence of involuntary or pathological movements (clonus, tremor, athetoid postures or movements); (3) behavioral state changes and quality of cry; and (4) threshold or intensity of responses to stimulation. (Because of the transient pattern of neurological signs and rapid changes in the developing nervous system, Prechtl advised repeated examinations to monitor neurological status.)

Neonatal behavioral assessment scale

To document individual behavioral and motor differences in infants at term gestation to 2 months of age, Brazelton and Nugent¹¹³ developed a neonatal behavior scale to assess neuromotor responses within a behavioral state context. The 30- to 45-minute examination consists of observing, eliciting, and scoring 28 biobehavioral items on a 9-point scale and 18 reflex items on a 4-point scale. This is an interactive test and assesses the infant’s ability to recover from stimuli and return to an alert state. The reflex items are derived from the neurological examination protocol of Prechtl and Beintema.¹¹⁴

The scale was designed to assess newborn behavior in healthy 3-day-old term (40 weeks of gestation) white infants whose mothers had minimal sedative medication during an uncomplicated labor and delivery. Use of this examination with infants born preterm requires modification of the examination procedure to the environmental constraints of an intensive care nursery and interpretation of findings relative to the gestational age and medical condition of the infant. For preterm infants approaching term gestation (minimum of 36 weeks of gestation), nine supplementary behavioral items are offered. Many of these items were developed by Als⁹ for use with preterm and physiologically stressed infants (see discussion of the APIB, later). In the manual,¹¹³ methods of adapting the Neonatal Behavioral Assessment Scale (NBAS) for preterm neonates with accompanying case scenarios are described to illustrate use of the findings to enhance parent-infant interaction and guide developmental interventions.

Six behavioral state categories are outlined in the NBAS: deep sleep, light sleep, drowsiness or semidozing, quiet alert, active alert, and crying. Behavioral state prerequisites are provided for each biobehavioral and reflex item to reduce the state-related variables in testing. During the assessment the examiner systematically maneuvers the infant from the sleep states to crying and back to the alert states to evaluate physiological, organizational, motor, and interactive capabilities during stimulation and physical handling. The scoring is based on the infant’s best performance, with flexibility allowed in the order of testing, repetition of items encouraged, and scheduling of the assessment midway between feedings to give the infant every advantage to demonstrate the best possible responses.

Four dimensions of newborn behavior are analyzed in Brazelton’s NBAS: interactive ability, motor behavior, behavioral state organization, and physiological organization. Interactive ability describes the infant’s response to visual and auditory stimuli, consolability from the crying state with intervention by the examiner, and ability to maintain alertness and respond to social or environmental stimuli.

Motor behavior refers to the ability to modulate muscle tone and motor control for the performance of integrated motor skills, such as the hand-to-mouth maneuver, pull-to-sit maneuver, and defensive reaction (e.g., removal of cloth from face). In the assessment of behavioral state organization, the infant’s ability to organize behavioral states when stimulated and the ability to shut out irritating environmental stimuli when sleeping are analyzed. Physiological organization is evaluated by observing the infant’s ability to manage physiological stress (changes of skin color, frequency of tremulous movement in the chin and extremities, number of startle reactions during the assessment). For analysis, the information is divided into seven clusters: habituation, orientation, motor, range of state, regulation of state, autonomic stability, and reflexes. The cluster systems are highly useful for clinical interpretation and for data analysis in clinical research. Performance profiles of worrisome or deficient interactive-motor and organizational behavior are identified by clusters of behavior associated with potential developmental risk.¹¹⁵

Definite strengths of the NBAS are the well-defined indicators of autonomic stress, analysis of coping abilities of high-risk infants experiencing external stimuli and handling, and quality of infant-examiner interaction. These features generate specific findings to assist therapists in grading the intensity of assessment and treatment within each infant’s physiological and behavioral tolerance and in guiding the development of parental teaching strategies to address the individual behavioral styles of infants. The NBAS has proved to be more sensitive to the detection of mild neurological dysfunction in the newborn period than have classic neurological examinations that omit the behavioral dimensions. This assessment is not predictive but gives a good analysis of the infant’s strengths and weaknesses. Improved performance from repeat examinations over time is a better predictor of the infant’s ability and potential.

Participation of the parent in the newborn assessment may yield long-term positive effects on infant-parent interaction and later on cognitive and fine motor development. Widmayer and Field¹¹⁶reported significantly better face-to-face interaction and fine motor-adaptive skills at 4 months of age and higher mental development scores at 12 months of age when teenage mothers of preterm infants (mean gestational age at birth, 35.1 weeks) were given demonstrations of the NBAS. These demonstrations were scheduled when the premature infants had reached an age equivalence of 37 weeks of gestation.

Nugent^117,118developed parental teaching guidelines for using the NBAS as an intervention for infants and their families. Published by the March of Dimes birth defects foundation, the guidelines offer strategies for interpreting each item according to its adaptive and developmental significance, descriptions of the expected developmental course of the behavior (item) over several months, and recommendations for caregiving according to the infant’s response to the items.

A three-step examiner training involving self-study, practice, and certification phases is coordinated through the Brazelton Institute, Children’s Hospital, Boston, Massachusetts.^119,120 Wilhelm¹¹⁵ recommended NBAS training for clinicians beginning to develop competence in examining at-risk infants. She explained that it provides a system for developing basic handling skills with healthy, term infants without concerns of stressing medically fragile preterm infants during the training period. Learning the NBAS in term infants before entering NICU practice provides familiarity with similar testing and scoring procedures for preterm infants.¹¹⁵

Newborn behavioral observations system

The Newborn Behavioral Observations (NBO) system, developed from the pioneering work and philosophy of Brazelton, is an interactive, observational tool for use with infants and parents in hospital, clinic, and home settings.¹²¹ The focus is on prematurely born infants and at-risk infants, with emphasis on cultural competence, family-centered care, and infant development. The NBO system helps determine the behavioral profile of the infant and allows the practitioner to provide parents with individualized and unique information about their infant. This behavioral information promotes positive parent-infant interaction and also a positive partnership between parents and practitioners.

Certification in administering, interpreting, and scoring the 18-item NBO assessment is arranged through the Brazelton Institute in a 2-consecutive-day format. The training encompasses the following observation categories: (1) habituation to external light and sound; (2) muscle tone and motor activity level; (3) behavioral self-regulation (crying and consolability); and (4) visual, auditory, and social-interactive abilities.^119,120

Neurological assessment of the preterm and full-term newborn infant

The Neurological Assessment of the Preterm and Full-Term Newborn Infant is a streamlined neurological and neurobehavioral assessment designed by Dubowitz and colleagues¹²² to provide both a systematic, quickly administered newborn examination applicable to infants born preterm or at term gestation and a longer infant examination for children to 24 months of age. A distinct advantage of this tool is the minimal training or experience required by the examiner and the ease of adapting it to the infant and the environment. The adaptability of the test and use of the scoring form with stick figure diagrams have made it useful for implementation in developing countries where English is not widely spoken.

The test includes the six behavioral state categories of the NBAS and seven orientation and behavior items scored on a 5-point grading scale and sequenced according to the intensity of response. The orientation and behavior items consist of the following categories: (1) auditory and visual orientation responses; (2) quality and duration of alertness; (3) irritability (the frequency of crying to aversive stimuli during reflex testing and handling throughout the examination); (4) consolability (the ability after crying to reach a calm state independently or with intervention by the examiner); (5) cry (quality and pitch variations); and (6) eye appearance (absent, transient, or persistent appearance of sunset sign, strabismus, nystagmus, or roving eye movements).

The 15 items that assess movement and tone and the six reflex items evolved from clinical trials on 50 term infants using the clinical assessment of gestational age by Dubowitz and colleagues,⁹² the neurological examination of the newborn by Parmelee and Michaelis,¹²³ and the neurological examination of the full-term newborn infant by Prechtl.¹¹² The examination format was then used during a 2-year period on more than 500 infants of varying gestational ages. After 15 years the authors revised the assessment in the second edition by eliminating seven items, expanding the tone pattern section, and developing an optimality score. Reliability data are not reported, but modification of examination procedures occurred during the pilot phase that promoted objectivity in scoring and a high interrater reliability among examiners, regardless of experience level.

The examination protocol is available in two formats: (1) Hammersmith Short Neonatal Neurological Examination and (2) Hammersmith Infant Neurological Examination (age range, 2 to 24 months). The examination forms are illustrated with stick figures and can accommodate both baseline and repeat assessments. For neonatal therapy examinations the forms can be effectively combined with a narrative impression, treatment goals, and plan of care. A numerical score for each item and a summary score are provided in the revised edition of the test. The authors advised that the scoring system was primarily intended for the purpose of research and for numerical charting of progress with sequential examinations. Because of the continued clinical emphasis on patterns of responses, selected parts of the protocol (without summary scoring) are appropriate for examining premature or acutely ill infants on ventilators, in incubators, or attached to monitoring or infusion equipment. Scheduling of examinations is recommended two thirds of the way between infant feeding sessions.

Evolution of neurological patterns in infants with IVH, PVL, and HIE is described in the test manual and correlated with brain imaging. Abnormal neonatal clinical signs associated with long-term neurological sequelae were persistent asymmetry, decreased lower-extremity movement, and increased tone. Infants with IVH had significantly higher incidence of abnormally tight popliteal angles, reduced mobility, decreased visual fixing and following, and roving eye movements. The authors cautioned that early signs of motor asymmetry in neonates with cerebral infarction may be associated with normal outcome, but normal neonatal neurological examinations after cerebral infarction do not exclude the possibility of later hemiplegia.¹²⁴

Long-term follow-up data beyond 1 year have not been reported with this examination. Dubowitz and colleagues¹²⁵ reassessed 116 infants (27 to 34 weeks of gestation) at 1 year of age. Of 62 infants assessed as neurologically normal in the newborn period, 91% were also normal at 1 year of age. Of 39 infants assessed as neurologically abnormal in the newborn period, 35% were found to be normal at 1 year of age. According to Wilhelm,¹¹⁵ the predictive value of a negative test result with this instrument was 92%, but the predictive value of a positive test result was only 64%.

Interpretations of evaluative findings from the Neurological Assessment for Preterm and Full-Term Newborn Infants for neonatal therapy practice are comprehensively described in a case study format by Heriza¹²⁶ and Campbell.¹²⁷ Dubowitz¹²⁸ discussed the clinical significance of neurological variations in infants and offered decision guidelines to clinicians on when to worry, reassure, or intervene with developmental referrals.

Assessment of preterm infants’ behavior

Als⁹ designed the APIB to structure a comprehensive observation of a preterm infant’s autonomic, adaptive, and interactive responses to graded handling and environmental stimuli. It involves six maneuvers with increasing challenging and complex interactions with a highly structured format. As previously described in the theoretical framework section of this chapter, this assessment is derived from synactive theory and is focused on assessing the organization and balance of the infant’s physiological, motor, behavioral state, attention and interaction, and self-regulation subsystems. The APIB has testing sequences and a scoring format similar to those used in Brazelton’s NBAS, with increased complexity and expansion for premature infants.

Administration and scoring of the APIB may require 2 to 3 hours per infant and often two or more sessions with the infant depending on examiner experience and infant stability. Although the APIB may be an instrument of choice for the clinical researcher, it is not usually practical (time efficient) for many neonatal clinicians with heavy caseloads in managed-care environments. Extensive training and reliability certification are required to safely administer and accurately score and interpret the test for clinical practice or research.

Neonatal individualized developmental care and assessment program

Als¹¹ and Als and colleagues^11,129 developed NIDCAP to document the effects of the caregiving environment on the neurobehavioral stability of neonates. This naturalistic observation protocol includes continuous observation and documentation at 2-minute intervals of an infant’s behavioral state and autonomic, motor, and attention signals, with simultaneous recording of vital signs and oxygen saturation. Documentation occurs before, during, and after routine caregiving procedures. The infant’s strengths, weaknesses, and coping skills are identified. A narrative description of the infant’s responses to the stress of handling by the primary nurse and to auditory and visual stimuli in the NICU environment is provided to assist caregivers and parents in identifying the infant’s behavioral cues and providing appropriate interaction. Options are described in the care plans for reducing aversive environmental stimuli and modifying physical handling procedures. This clinical tool allows neonatal therapists to determine the infant’s readiness for assessment and intervention by observing the baseline tolerance of the infant to routine nursing care before superimposing neonatal therapy procedures.¹³⁰ Sequential observations occur weekly or biweekly. Parental involvement is strongly encouraged and instrumental in facilitating a smooth transition to home. Examiner training in the NIDCAP may be coordinated through the National Training Center at Children’s Hospital Boston, Massachusetts, where priority is now given to training NICU teams rather than individuals.¹⁰

Nicu network neurobehavioral scale

Lester and Tronick¹³¹ developed a tool for preterm and drug-exposed infants from 30 weeks of gestation to 6 weeks postterm. The test includes items from the NBAS, APIB, Finnegan abstinence scale, and other neurological assessments and consists of 115 items in general categories of neurological and neuromotor integrity (tone, reflexes, and posture), behavioral state and interaction (self-regulatory competence), and physiological stress abstinence signs (drug-exposed infants). This test is state dependent and gives a comprehensive and integrated picture of the infant that is not divided into clusters. More than half¹¹⁸ of the test items are infant observations, and 45 items require physical handling of the infant. Test-retest reliability of preterm infants indicated correlations of 0.30 to 0.44 at 34, 40, and 44 weeks of gestation. This test is useful for management of drug-exposed infants but may have limited predictive value. Training and certification in administration and scoring of the test are coordinated through Brookes Publishing Company and available in the United States and internationally with use of videoconferencing for lectures and demonstrations.

Test of infant motor performance

Developed by Campbell and colleagues,¹³² the 42-item Test of Infant Motor Performance (TIMP) is focused on evaluating postural control, spontaneous movement, and head control for neonates at 32 weeks of gestation to 16 weeks postterm. Functional motor performance is assessed through observation of infant movement and through responses to various body positions and to visual or auditory stimuli. Psychometric qualities of the test include (1) construct validity¹³³ and ecological validity,¹³⁴ (2) concurrent validity at 3 months of age with the Alberta Infant Motor Scale (AIMS),¹³⁵ and (3) predictive validity at 5 to 6 years of age with the Bruininks-Oseretsky Test of Motor Proficiency¹³⁶ and at 4 to 5 years of age with the Peabody Developmental Motor Scales and Home Observation for Measurement of the Environment: Early Childhood.¹³⁷ Training on test procedures is available through 2-day workshops or through a self-guided training method with a CD-ROM from the test developer.¹³⁸

Neurobehavioral assessment of the preterm infant

The Neurobehavioral Assessment of the Preterm Infant (NAPI) was developed by Korner as a developmental test to assess medically stable infants from 32 weeks to term gestation using a sequence of specific movements. This test focuses on tone, reflexes, movement, response to visual and auditory stimulation, and observation of cry and state. This tool does not require a specific preassessment state as is required by the previously mentioned tests, but starts with the infant asleep. It does not take as long to administer (less than ½ hour) than the previously described tests and is easy to analyze. The data are categorized into seven clusters and compared with standardized scores. With repeated examinations over time, persistent deviations from the normative scores indicate that the infant is at risk for developmental delays and is in need of close follow-up. In addition, the NAPI has been shown to be predictive of short-term and long-term neurodevelopmental outcomes.¹³⁹

Qualitative assessment of general movements

The assessment tools reviewed so far in this chapter require direct handling of the infant. Infants born preterm are particularly vulnerable to developing physiological stress during the maneuvers required by most tools available for infant assessment. Instead, noninvasive, repeated longitudinal observation and assessment are needed to accommodate the concurrent motor variability, immature nervous system, and physiological vulnerability of the young, preterm infant.¹⁴⁰ Based on the pioneering work of Prechtl examining the continuity of prenatal to postnatal fetal movement,¹⁴¹ this criterion-referenced test focuses on evaluating the quality of spontaneously generated movements in preterm, term, and young infants until 16 weeks postterm. A wide repertoire of endogenously generated spontaneous motility in the fetus including isolated limb movements, stretches, hiccups, yawning, and breathing movements can be identified as early as 9 weeks.^141–143

General movements (GMs) are spontaneously generated complex movements involving the trunk, limbs, and neck. They vary in speed and intensity with a gradual onset, increase in speed and intensity, and a gradual end. These movements are among the number of movement patterns that emerge during fetal life and continue until approximately 16 weeks postterm, when goal-oriented and voluntary movements appear.¹⁴⁴ The quality of movement is assessed through observation and scoring of videotaped spontaneous movement of an infant in supine position without stimulation or handling.¹⁴⁴ A distinct difference occurs between the GMs in the preterm infant and those in the term and postterm infant. GMs in the term infant, and for the first 8 weeks, change in amplitude and speed, taking on a writhing quality. The writhing movements gradually give way to the fidgety movements, which are present in awake infants between 9 and 16 to 20 weeks postterm. Fidgety movements are small, circular movements of small amplitude and varying speed involving the neck, trunk, and extremities.¹⁴⁰ Other approaches to neurological assessment can be found in additional references.^140,144,145

This neonatal and young infant assessment instrument has gained substantial attention in the past 20 years for its high reliability, sensitivity, and predictive validity. In a comprehensive review of the psychometric qualities of neuromotor assessments for infants, the GM assessment was rated among the tools with the highest reliability, averaging interrater and intrarater correlation coefficient, or k, greater than 0.85.¹⁴⁶ Multiple studies have corroborated the predictive validity and sensitivity of this method. The sensitivity is lower during the preterm period and during the writhing movements, improving during the fidgety movement period. Sensitivity as high as 95% has been reported.^140,147

Testing variables

Neuromuscular and behavioral findings in the newborn period may be influenced by several variables. Increased reliability in examination results and in clinical impressions may occur when these variables are recognized. Medication may produce side effects of low muscle tone, drowsiness, and lethargy. Such medications include anticonvulsants, sedatives for diagnostic procedures (CT scan, electroencephalography, electromyography), and medication for postsurgical pain management. Intermittent subtle seizures may produce changes in muscle tension and in the level of responsiveness. Mild, ongoing seizures may occur in the neonate as lip smacking or sucking, staring or horizontal gaze, apnea, and bradycardia. Stiffening of the extremities occurs in neonatal seizures more frequently than clonic movement. Fatigue from medical and nursing procedures can result in decreased tolerance to handling, decreased interaction, and magnified muscle tone abnormalities. Fatigue may also result when neurodevelopmental assessment is scheduled immediately after laboratory (hematologic) procedures, suctioning, ultrasonography, or respiratory (chest percussion) therapy. Tremulous movement in the extremities may be linked to conditions of metabolic imbalance (hypomagnesemia, hypocalcemia, hypoglycemia), and low muscle tone may be associated with hyperbilirubinemia, hypoglycemia, hypoxemia, and hypothermia.^148,149

Summary

Practitioners must be aware of the normative and validation data and of the predictive characteristics of the test(s) administered to allow appropriate interpretation of the results. Specific clinical training with a preceptor is essential to administer, score, and interpret neonatal assessment instruments accurately; to establish interrater reliability; and to plan treatment based on the evaluative findings. Even low-risk, healthy preterm infants are vulnerable to becoming physiologically and behaviorally destabilized during neurological assessment procedures.150–152 This risk is reduced with precepted, competency-based clinical training in the NICU.

Physiological and musculoskeletal risk management

Many maturation-related anatomical and physiological factors predispose preterm infants to respiratory dysfunction (see Table 11-5). For this reason many preterm neonates require the use of a wide range of respiratory equipment and physiological monitors (Table 11-6). Pediatric therapists preparing to work in the NICU and those involved with designing risk management plans are referred to the neonatal nursing literature for evidence and perspectives on assessing and managing neonatal stressors during interventions in the NICU.^153–155 Because infants born prematurely or experiencing critical illness communicate via subtle behavioral cues, their understated language is “not easily interpreted unless caregivers understand how infants’ ability to respond to stress reflects their maturation and neurodevelopment.”¹⁵⁶ Their behavioral cues are considered more subtle and more likely to be disregarded than those of infants born at term gestation.

In this subspecialty area of pediatric practice, neonatal therapists are responsible for the prevention of physiological jeopardy in LBW infants while providing developmental services in the NICU. Before examination, discussion with the supervising neonatologist and clinical nurse are advised regarding specific precautions and the safe range of vital signs for each infant. Medical update and identification of new precautions before each intervention session are recommended because new events in the last few hours may not have been recorded or fully analyzed at the time therapy is scheduled. The nurse should be invited to maintain ongoing surveillance of the infant’s medical stability and provide assistance in interpreting physiological and behavioral cues during neonatal therapy activities in case physiological complications occur. If medical complications develop during or after therapy, immediate, comprehensive co-documentation of the incident with the clinical nurse and discussion with the neonatology staff are essential to analyze the events, outline related clinical teaching issues, and minimize legal jeopardy.

Areas of particular concern during neonatal therapy activities include potential incidence of fracture, dislocation, or joint effusion during the management of limited joint motion; skin breakdown or vascular compromise during splinting or taping to reduce deformity; apnea or bradycardia during therapeutic neuromotor handling with potential deterioration to respiratory arrest; oxygen desaturation or regurgitation and aspiration during feeding assessment or oral-motor therapy; hypothermia from prolonged handling of the infant away from the neutral thermal environment of the incubator or overhead radiant warmer; and propagation of infection from inadequate compliance with infection control procedures in the nursery. Signs of overstimulation may include labored breathing with chest retractions, grunting, nostril flaring, color changes (skin mottling, paleness, gray-blue cyanotic appearance), frequent startles, irritability or drowsiness, sneezing, gaze aversion, bowel movement, and hiccups. Signals of overstimulation expressed through infants’ motor systems are finger splay (extension and abduction posturing), arm salute (shoulder flexion with elbow extension), and trunk arching away from stimulation.¹¹ Harrison and colleagues¹⁵⁴ found that motor activity cues of preterm infants were correlated with low oxygen saturation and should be carefully monitored during caregiving procedures to minimize physiological instability.

Even a baseline neurological examination, usually presumed to be a benign clinical procedure, may be destabilizing to the newborn infant’s cardiovascular and behavioral organization systems. The physiological and behavioral tolerance of low-risk preterm and term neonates to evaluative handling by a neonatal physical therapist was studied in 72 newborn subjects.¹⁵¹ During and after administration of the Neurological Assessment of the Preterm and Full-Term Newborn Infant, preterm subjects (30 to 35 weeks of gestation) had significantly higher heart rates; greater increases in blood pressure; decreased peripheral oxygenation inferred from mottled skin color; and higher frequencies of finger splay, arm salute, hiccups, and yawns than in term subjects. Neonatal practitioners must examine the safety of even a neurological examination and weigh the risks and anticipated benefit of the procedure given the expected physiological and behavioral changes in low-risk, medically stable neonates.^150,151

High-risk profiles

Three general high-risk profiles are observed from a dynamic systems perspective. In these profiles movement abnormalities, related temperament or behavioral characteristics, and interactional styles associated with motor status are identified.

The first high-risk profile involves the irritable, hypertonic infant. These infants classically have a low tolerance level to handling and may frequently reach a state of overstimulation from routine nursing care, laboratory procedures, and the presence of respiratory and infusion equipment. They may express discomfort when given quick changes in body position by caregivers and when placed in any position for a prolonged time. Predominant extension patterns of posture and movement are associated with this category of infants. Quality of movement may appear tremulous or disorganized, with poor midline orientation and limited antigravity movement into flexion as a result of the imbalance of increased proximal extensor tone. Visual tracking and feeding may be difficult because of extension posturing or the presence of distracting, disorganized upper-extremity movement. In addition, increased tone with related decreased mobility in oral musculature may complicate feeding behavior. Hypertonic infants frequently demonstrate poor self-quieting abilities and may require consistent intervention by caregivers to tolerate movement and position changes. These temperament characteristics and the signs of neurological impairment previously discussed may place infants at considerable risk for child abuse or neglect as the stress and fatigue levels of parents rise and as coping strategies wear thin during the demanding care required by irritable, hypertonic infants.^7,157 Hypertonic, irritable infants constituted large percentages of neonatal therapy caseloads in the 1970s through the 1990s, but advances in neonatal pulmonary management have now decreased the numbers of infants matching this neurobehavioral profile.

Conversely, the lethargic, hypotonic infant excessively accommodates to the stimulation of the nursery environment and can be difficult to arouse to the awake states, even for feeding. The crying state is reached infrequently, even with vigorous stimulation. The cry is characteristically weak, with low volume and short duration, and related to hypotonic trunk, intercostal, and neck accessory musculature and decreased respiratory capacity. These infants are exceedingly comfortable in any position, and when held they easily mold themselves to the arms of the caregiver. Depression of normal neonatal movement patterns is common. To compensate for low muscle tone when in the supine position, some preterm infants appear to push into extension against the surface of the mattress in search of stability. Although potentially successful in generating a temporary increase in neck and trunk tone, the extension posturing from stabilizing against a surface in supine lying interferes with midline and antigravity movement of the extremities. Such infants dramatically respond to containment positioning in side-lying and prone positions. Drowsy behavior limits these infants’ spontaneous approach to the environment and decreases their accessibility to selected interaction by caregivers. Feeding behavior is commonly marked by fatigue, difficulty remaining awake, weak sucking, and incoordination or inadequate rhythm in the suck-swallow process, with the need for supplementation of caloric intake by gavage (oral or nasogastric tube) feeding. The risk for sensory deprivation and failure to thrive is high for hypotonic infants because they infrequently seek interaction, place few if any demands on caregivers, and remain somnolent.

The third high-risk profile is the disorganized infant with fluctuating tone and movement who is easily overstimulated with routine handling but remains relatively passive when left alone. Disorganized infants usually respond well to swaddling or containment when handled. When calm, these infants frequently demonstrate high-quality social interaction and efficient feeding with coordinated suck-swallow sequence. When distracted and overstimulated, however, these infants appear hypertonic and irritable. Caregiving for intermittently hypertonic, disorganized, irritable infants can be frustrating for parents unskilled in reading the infant’s cues, in implementing consolation and containment strategies, and in using pacing techniques during feeding. This profile of infant motor and behavioral disorganization represents a large proportion of infants in a typical neonatal therapy caseload.

Although these profiles address the extremes in motor and behavioral interaction, they suggest a need for identifying different tolerance levels of handling for neonates with abnormal tone and movement even though long-term developmental goals may be similar. Few neonates will demonstrate all behaviors described in the high-risk profile, but outpatient surveillance of neonates with worrisome or mildly abnormal motor and interactive behavior is advised to monitor the course of those behaviors and the developing styles of parenting.

Timing

The timing of neurodevelopmental examination and treatment for infants with high-risk histories or diagnoses is based on the medical stability of the infant and, in some centers, gestational age. All therapy activities need to be synchronized with the intensive care nursery schedule so that nursing care and medical procedures are not interrupted.

Neonatal therapists should not interrupt infants in a quiet, deep sleep state but instead wait approximately 15 minutes until the infant cycles into a light, active sleep or semiawake state. Higher peripheral oxygen saturation has been correlated with quiet rather than with active sleep in neonates. Preterm infants reportedly have a higher percentage of active sleep periods in contrast to the higher percentage of quiet sleep observed in term infants.¹⁵⁸ Allowing the preterm infant to maintain a deep, quiet sleep by not interrupting is a therapeutic strategy for enhancing physiological stability.

Timing of parental teaching sessions is most effective when readiness to participate in the care of the infant is expressed. Some parents need time and support to work through the acute grief process related to the birth of an imperfect child before participation in developmental activities is accepted. Other parents find the neonatal therapy program to be a way of contributing to the care of their infant that also helps them cope with overwhelming fears, stresses, and grief.

Positioning

A diligently administered positioning program can greatly assist infants on mechanical ventilators, receiving hood oxygen, or in incubators to simulate the flexed, midline postures of the neurologically intact term newborn swaddled in a bassinet. Preterm infants characteristically demonstrate low postural tone, with the amount of hypotonia varying with gestational age. Infants born prematurely do not have the neurological maturity or the prolonged positional advantage of the intrauterine environment to assist in the development of flexion. They are instead placed unexpectedly against gravity and presented with a dual challenge of compensating for maturation-related hypotonia and adapting to ventilatory and infusion equipment that frequently reinforces extension of the neck, trunk, and extremities.

Imbalance of excessive extension may occur in preterm infants with prolonged mechanical ventilation who appear to gain postural stability in the nonfluid extrauterine environment by leaning into or stabilizing against a firm mattress while in the supine position. De Groot¹⁶⁰ explained the postural behavior of preterm infants as an imbalance between low passive muscle tone and active muscle power. She theorized that because preterm neonates have prolonged periods of immobility (often in the supine position), exaggerated active muscle power may be observed in the extensor musculature, particularly in the trunk and hips. This imbalance of extension is viewed as nonoptimal muscle power regulation that may negatively influence postural stability, coordinated movement, and later hand and perceptual skills.¹⁶⁰

Some neonates, especially those born at less than 30 weeks of gestation, may attempt to posturally stabilize by hyperextending the neck in supine or side-lying positions to compensate for maturation-related hypotonia.¹⁶¹ Neck hyperextension posturing, without a balance of movement into flexion, may trigger later development of a host of related abnormal postural and mobility patterns to compensate for inadequate proximal stability.¹⁶⁰ In some infants, excessive postural stabilizing into neck hyperextension may contribute to sequential blocking of mobility in the shoulder, pelvis, and hip regions. The potential components of this high-risk, hypertonic postural profile appear in Box 11-4.

Shaping of the musculoskeletal system occurs during each body position experienced by neonates in the NICU. A variety of positional deformities in the extremities and skull can result from inattention to alignment. In Table 11-8, common neonatal positional deformities, musculoskeletal consequences, and functional limitations are outlined. Supporting the skeletal integrity of infants born prematurely is challenging in the midst of numerous equipment obstacles, restricted physical handling because of physiological instability, and limited spontaneous movement. Infants with gastroesophageal reflux are frequently positioned on wedges that make symmetrical, midline postures difficult to maintain. Skull flattening may continue to evolve after NICU discharge from overuse of infant seats, reflux wedges, and limited prone play experiences. Plagiocephaly (asymmetrical occipital flattening) and a secondary torticollis may emerge when a strong head turn preference remains and parents do not vary the direction of head turn for sleeping and infant seat use.

Retracted shoulder posture (scapular adduction with shoulder elevation and external rotation) may accompany excessive neck and trunk extension posture in preterm infants. This abnormal posture can interfere with later reaching, shoulder stability in the prone position, and rolling during the first 18 months of life.^162,163 Excessive tibial torsion and out-toeing gait were reported in preterm infants at 3 to 8 years of age and traced to prolonged “frog leg” (excessive abduction and external rotation with foot eversion) in the NICU.^164,165

Goals of neonatal positioning procedures include the following:

The use of blanket or cloth diaper rolls or customized foam inserts in a neonatal positioning program may modify increasing imbalance of extension in selected preterm or chronically ill infants and promote movement and postural stability from positions of flexion. After the infant is facilitated into a flexed posture in the side-lying position, posterior rolls behind the head, trunk, and thighs provide a surface against which the infant can posturally stabilize while a flexed midline posture is maintained (Figure 11-10). An additional anterior roll between the extremities and the use of a pacifier may promote further midline stabilization in flexion (Figure 11-11). Small neonates can be maintained in a flexed, symmetrical posture in a circular nest formed from a long blanket roll. Cloth buntings with circumferential body straps and a foot roll (Figure 11-12) provide positioning support and containment of extremity movement. Ferrari and colleagues¹⁶⁶ found increased frequency of extremity movements across midline and fewer stiff postures when neonates (25 to 31 weeks of gestation) were positioned in supine position in a circular nest compared with supine position without a nest.

Endotracheal tube placement frequently contributes to the neck hyperextension posture in infants who require mechanical ventilation (Figure 11-13). This iatrogenic component can be avoided by repositioning the ventilator hoses to allow enough mobility for slightly tucked chin and partially flexed trunk posture. For neurologically impaired infants with severe pulmonary disease necessitating prolonged ventilatory support, inattention to the alignment of the neck and shoulders may lead to the development of a contracture in the neck extensor muscles (Figure 11-14).

During the hospital stay, infants on ventilators (Figure 11-15) are now routinely positioned prone to enhance extremity and trunk flexion in the prone position, improve oxygenation, and decrease irritability.^167,168 Monterosso and colleagues¹⁶⁹ reported that using a small vertical roll along the torso (sternum to pubis) decreased scapular retraction in the prone position. Although placing infants on a sheepskin surface (see Figure 11-12) offers increased tactile input and has been correlated with increased weight gain in LBW infants compared with a matched group of infants on standard cotton sheets,¹⁷⁰ concern regarding the inhalation of microfibers from sheepskin has limited widespread use unless the sheepskin is covered by a thin blanket and used only to midchest level.¹⁷¹

After the infant has been moved from intensive care to intermediate care, transition to a standard mattress without positioning aids is recommended to allow time for adaptation to the type of mattress likely to be used at home. Infants are also transitioned to the supine sleeping position during the week before hospital discharge to reduce the risk of sudden infant death associated with the prone sleeping position and other factors.¹⁷¹

The neonatal therapist provides consultation on body alignment of infants in car seats when the LBW infant has not passed the peripheral oxygen saturation test in the car seat, which is usually conducted by the neonatal nurse before discharge. Some infants require the use of a car bed with body harness when they are unable to tolerate the semiupright position of a car seat without oxygen desaturation.

Preliminary evidence has been reported to support neonatal positioning programs emphasizing postures of extremities in flexion and head in midline.^166,172 Clinicians are referred to the work of Hunter^173,174 for detailed positioning techniques in the NICU. Continued research efforts are needed to measure effects of positioning and the risk-benefit effects of other neonatal therapy interventions to guide future directions of neonatal practice.

Extremity taping

The presence of perinatal elasticity encourages early management of congenital musculoskeletal deformities in the neonatal period (birth to 28 days of age). A temporary ligamentous laxity is presumed to be present in the neonate because of transplacental transfer of relaxin and estrogen from the mother. In addition to the influence of maternal hormones, the rapid growth of the neonate can foster correction of malalignment if the deforming forces are expeditiously managed. This peak period of hyperelasticity offers pediatric therapists with advanced orthopedic expertise many opportunities to manage congenital joint deformities.¹⁷⁵

Intermittent taping of foot deformities (Figure 11-16) has been more adaptable to the nursery setting than either casts or splints and is more effective in achieving mobility than range-of-motion exercises. Access to the heel for drawing blood, inspection of skin and determination of vascular status, and placement of intravenous lines can be accomplished with the tape in place or by temporary removal of the tape as needed. Therapists without a sound knowledge of arthrokinematic principles and techniques should not attempt the taping procedure, which involves articulation of the joint(s) into a corrected position before taping. Other components of the taping process include application of an external skin protection solution under the tape, application of an adhesive removal solution when removing the tape, observance of skin condition and vascular tolerance, development of a taping schedule beginning with 1 hour and increasing by 1-hour intervals as tolerated, and clinical teaching with selected neonatal nurses for continuation of the taping if needed on night shifts and weekends. Infants with congenital foot deformities required shorter periods of casting in the outpatient period after taping of the extremity (Figure 11-17) was implemented during the inpatient phase. Taping is not appropriate for medically fragile infants on minimal handling protocols or for infants younger than 30 to 32 weeks of gestation because of potential epidermal stripping from tape removal or vascular compromise from inadvertent, excessive compression by either the tape or the underwrap layer.

The availability of thin, self-adherent foam material now allows taping on an underwrap (bandage) layer rather than on the infant’s skin (Figure 11-18). Although this method creates a definite advantage in skin protection, it may cover the calcaneal region for blood drawing. Compromise in alignment may occur if the underwrap layer is applied loosely; conversely, restriction in circulation may be observed by edema or purple-blue color changes in the toes if the underwrap is excessively tight around the foot or ankle.

Infants with wrist drop from radial nerve compression related to intravenous line infiltration also benefit from the use of taping (Figure 11-19). The wrist is supported in a functional position of slight extension. As muscle function returns, the taping is used intermittently to reduce fatigue and overstretching of the emerging, but still weak, wrist extensor musculature.

Soft hand-wrist splint

Instead of using rigid, thermoplastic materials or taping, soft foam straps with Velcro closures provide an alternative method of support for wrist drop or hand-wrist malalignment (Figure 11-20). The splinting material is illustrated in Figure 11-21 with a small notch for the thumb on the longer strap placed across the palm and the shorter strap for the wrist band (longer strap attaches to posterior wrist band by Velcro). The wearing time is increased by 1-hour intervals to a 3-hour total wearing time and is often synchronized with nurse caregiving schedules (approximately 3-hour intervals) for alternate on-off application. Collaboration with neonatal nurses on wearing schedule, skin and vascular tolerance, alignment, and parental teaching is critical for successful integration of soft splints into the care plan.

Therapeutic handling

Use of tactile, vestibular, proprioceptive, visual, and auditory stimuli to facilitate infant development has been reported and reviewed by many authors.176–184 Selection and application of the sensory or neuromotor treatment options in neonatal therapy must occur with judicious attention to the prevention of sensory overload and related physiological consequences. Decision making on the type, intensity, duration, frequency, and sequencing of intervention within the context of infant physiological and behavioral stability can be learned only in a mentored clinical practicum in the NICU setting. The current general guidance on intervention is more observation, less handling, protection from bright lights and loud conversation, and readiness for handling determined on the basis of behavioral and physiological cues of the infant.^{11,177,183,184}

Primary aims of therapeutic handling include assisting the newborn to achieve maximal interaction with parents and caregivers and facilitating the experience of postural and movement patterns appropriate to the infant’s adjusted gestational age. Helping infants reach and maintain the quiet, alert behavioral state and age-appropriate postural tone appears to enhance opportunities for visual and auditory interaction and for antigravity movement experiences. The typical early movement experiences include hand-to-mouth movement, scapular abduction and adduction, anterior and posterior pelvic tilt, free movement of the extremities against gravity, and momentary holding of the head in midline.^127,185

Behavioral state and some movement abnormalities can be modified by creative swaddling and gentle weight shifts and nesting in the caregiver’s lap. Swaddling the infant in a blanket with flexed, midline extremity position appears to promote flexor tone, increase hand-to-mouth awareness, inhibit jittery or disorganized movement, and elicit quiet, alert behavior. These effects can also be accomplished in skin-to-skin holding of infants against the parent’s chest, a procedure now commonly adopted in NICUs in North America.^186,187 Application of neonatal therapy techniques must be contingent on both the infant’s readiness for interaction and the need for a recovery break in interaction because of sensory overload. Teaching parents and caregivers to read and respond to the infant’s motor cues for interaction, feeding, change of body position, and rest breaks is a critical quality-of-life component of the infant’s NICU therapy program.

A semi-inverted supine flexion position (Figure 11-22) with preterm neonates should be used with caution. This position may be used with older infants (6 months old) to facilitate elongation of neck extensor muscles and decrease the neck hyperextension posture, but with neonates the position may compromise breathing from positional compression of the chest and from potential airway occlusion associated with maximal flexion of the neck. The use of cardiorespiratory and oxygen saturation monitors during therapeutic handling activities is recommended for objective measurement of physiological tolerance. Although the peripheral oxygen saturation values from monitors may be intermittently unreliable because of motion artifacts from either the infant’s spontaneous movement or the therapist’s handling of the infant, reliable readings of oxygen saturation may be taken approximately 1 minute after the infant’s body is not moved.

Easily overstimulated preterm infants may not tolerate multimodal sensory stimulation but may instead respond to a single sensory stimulus.^79,181 Implementation of a positioning program, oral-motor therapy, and environmental modifications and reinforcement of developmental activities with parents can be instituted only in collaboration with the shifts of bedside nurses who are in charge of the infant’s 24-hour day in the NICU. Collaboration with nurses is a major component of precepted neonatal therapy training and requires integration into and valuing of the unique culture of the NICU.¹³⁰ Part of NICU culture is the unique ecology of environmental light and sound modifications, medical procedures, equipment, and caregiving patterns. Observing and analyzing the effects of the environment on an infant’s behavior, physiological stability, postural control, and feeding function are critical elements to establish a prehandling baseline status before each neonatal therapy contact.¹³⁰

Neonatal hydrotherapy

Modified for use in an intensive care nursery setting, the traditional physical therapy modality of hydrotherapy has been adapted and implemented into neonatal therapy programs in some NICUs. Neonatal hydrotherapy was conceptualized in 1980 at Madigan Army Medical Center in Tacoma, Washington, and results of a pilot study of physiological effects were first reported in 1983.¹⁸⁸

Indications for referral of medically stable infants to the hydrotherapy component of the neonatal therapy program include (1) muscle tone abnormalities (hypertonus or hypotonus) affecting the quality and quantity of spontaneous movement and contributing to the imbalance of extension in posture and movement (Figure 11-23); (2) limitation of motion in the extremities related to muscular or connective tissue factors; and (3) behavioral state abnormalities of marked irritability during graded neuromotor handling or, conversely, excessive drowsiness during handling that limits social interaction with caregivers and lethargy that contributes to feeding dysfunction.

Infants are considered medically stable for aquatic intervention when ventilatory equipment and intravenous lines are discontinued and when temperature instability and apnea or bradycardia are resolved. A standard plastic bassinet serves as the hydrotherapy tub, and the water temperature is prepared at 37.8° C to 38.3° C (100° F to 101° F). An overhead radiant heater is used to decrease temperature loss and enhance thermoregulation in the undressed infant. Agitation of the water is not included in the hydrotherapy protocol in the NICU.

After medical clearance and individualized criteria for the maximum acceptable limits of heart rate, blood pressure, and color changes during hydrotherapy have been received from the neonatal staff, the baseline heart rate and blood pressure values are recorded and pretreatment posture and behavioral states are observed. The undressed infant is swaddled and moved into a semiflexed, supine position. The blood pressure cuff is placed around the distal tibial region to continuously measure heart rate and blood pressure at 2-minute intervals during the 10-minute water immersion period. After being lifted into the water, the swaddled infant is given a short period of quiet holding in the water without body movement or auditory stimulation to allow behavioral adaptation to the fluid environment (Figure 11-24). A second caregiver (e.g., nurse or parent) is recruited to stabilize the infant’s head and shoulder girdle region while the neonatal therapist provides support at the pelvis (Figure 11-25).

Within the loosened boundaries of the swaddling blanket, the movement techniques involve midline positioning of the head and slow, graded movement incorporating slight flexion and rotation of the trunk, followed (if tolerated) by progression distally to the pelvic girdle region and finally to the shoulder girdle region. After guided trunk extensor flexion with partially dissociated movement at the shoulder or pelvic girdle, most infants will demonstrate active extremity movement in the water and the swaddling blanket is adjusted (or removed) to allow more movement or more stability depending on the response of the infant. The improved range and smoothness of spontaneous extremity movement is facilitated by the buoyancy and surface tension of the water. Movement experiences in the supine, side-lying, and prone positions are offered as tolerated. If the movement therapy becomes stressful, with agitation or crying by the infant, body movement is stopped immediately, and the infant is either consoled or removed from the water and held with warmed towels. Compromise in hemodynamic stability (increased heart rate, increased blood pressure, decreased respiratory rate) and decrease in arterial oxygen tension during crying have been well documented in neonates.¹⁸⁹ Careful monitoring of behavioral tolerance to hydrotherapy (with avoidance of crying) is considered critical for reducing physiological risk with hydrotherapy.

Multiple therapeutic benefits have been observed from the selective use of 10-minute aquatic intervention sessions. Improved postural tone with semiflexed posture is obtained with less time and effort by the therapist and with higher behavioral tolerance by the infant than when a similar therapeutic handling approach is used without the medium of water. Postural tone changes are frequently maintained for 2 to 3 hours when aquatic intervention is followed by flexed, midline body positioning in the side-lying or prone position on a water mattress or supported against rolls. Mild flexion contractures of knees and elbows and dynamic hip adduction contractures can be safely and quickly reduced by gentle muscle elongation techniques in warm water. Enhancement of visual and auditory orientation responses (e.g., visual fixing and tracking, auditory alerting, and localization to human voices), prolonged high-quality alertness, and longer periods of social interaction with caregivers are clinically observed during and after hydrotherapy sessions.

Improved sleep quality and behavioral organization were documented in 12 preterm infants (less than 36 weeks of gestation) after a 10-minute hydrotherapy session in a NICU in Brazil.¹⁹⁰ In this study the infants were used as their own controls, and responses were measured by a Neonatal Facial Coding System scale and by sleep-wake cycles from an adapted NBAS.

Feeding performance may improve when hydrotherapy is scheduled 30 minutes before feeding to prepare the infant for arousal to the quiet, alert state and for flexed, midline postural changes for optimal feeding. A sample of 31 preterm infants received both a 10-minute hydrotherapy session and a 10-minute rest period control condition (crossover design) before bottle feeding by a nurse blinded to the order of the treatment phase. Mean duration of feeding was significantly decreased (P < .004) after hydrotherapy compared with the rest condition. Mean daily weight gain after hydrotherapy was significantly higher (P < .026) than after the rest condition. All infants consumed 100% of the required feeding volume after the 10-minute hydrotherapy session, indicating that potential overstimulation or fatigue did not occur. On a short-term basis, weight gain was enhanced.¹⁹¹

Therapeutic bathing techniques are incorporated into the parental teaching program to foster early parental participation in child care and in specific neonatal therapy activities during the inpatient period to prepare for carryover into the home environment. This early pleasurable involvement of parent and child in hydrotherapy and therapeutic bathing may provide a strong base for future participation in aquatics as a family leisure sports activity and, if needed, as an adjunct to an outpatient therapy program.

When oriented to treatment goals and trained in specific hydrotherapy techniques for individual infants, the nursing staff can effectively carry on the hydrotherapy program established by the neonatal therapist. This release of the neonatal therapist’s role to nurses allows additional use of hydrotherapy on evening and night shifts and continued teaching and supervision of parents during evening and weekend visits (see Figure 11-25).

An additional advantage of neonatal hydrotherapy is cost-effectiveness, with the use of equipment readily available in the newborn nursery and the short time (10 minutes) required for therapeutic bathing. Hydrotherapy becomes labor efficient for the neonatal therapist when it is incorporated into nursing care plans and conducted by nurses and parents, with the therapist assuming a supervisory role.

Although many clinical benefits may be obtained by judicious use of hydrotherapy in the newborn nursery, pilot study data obtained on physiological changes in high-risk infants during hydrotherapy clearly indicate a physiological risk.¹⁸⁸ This risk (7% increase in blood pressure and heart rate in the pilot sample) must be carefully evaluated relative to each infant’s general medical stability and baseline heart rate and blood pressure status before hydrotherapy can be included safely in a neonatal therapy program. In collaboration with the neonatology and nursing staff, the therapist must use established criteria for general medical stability and the maximal limits during hydrotherapy for blood pressure, heart rate, and acceptable color changes; this step is essential for risk management. Physiological monitoring of mean blood pressure and heart rate with a neonatal vital signs monitor during aquatic intervention is recommended. The blood pressure cuff is a pneumatically driven device that is not electronically connected to the infant and can be safely immersed in water. Because hypothermia is a recognized risk with hydrotherapy, body temperature should be routinely measured before and after the hydrotherapy session by using a thermometer with a digital display. A risk-benefit analysis of the potential physiological risk to each infant and the expected therapeutic benefits is strongly advised before hydrotherapy techniques are incorporated into a neonatal therapy program.

Oral-motor therapy

Feeding difficulties in preterm neonates may be related to neurological immaturity, depressed oral reflexes, prolonged use of an endotracheal tube for mechanical ventilation and subsequent oral tactile hypersensitivity, or insufficient postural tone. Because behavioral state affects the quality of feeding behavior, feeding performance may be significantly improved by specific arousal or calming procedures before feeding. Other variables influencing feeding may include decreased tongue mobility, presence of tongue thrusting, decreased lip seal on nipple, nasal regurgitation, tactile hypersensitivity in the mouth, inefficient and uncoordinated respiratory patterns, insufficient proximal stability from hypotonic neck and trunk musculature, and hypertonic posturing of the neck and trunk in extension.^192,193

Three instruments for assessing oral-motor and feeding behaviors in the nursery are the Neonatal Oral-Motor Assessment Scale (NOMAS),¹⁹⁴ the Nursing Child Assessment of Feeding Scale (NCAFS),¹⁹⁵ and the Early Feeding Skills (EFS) Assessment for preterm infants.¹⁹⁶ The NOMAS is used to evaluate the following oral-motor components during sucking: rate, rhythmicity, jaw excursion, tongue configuration, and tongue movement (timing, direction, and range). Tongue and jaw components are analyzed during nutritive and nonnutritive sucking activity. Cutoff scores were derived from a pilot study with the instrument: a combined score of 43 to 47 indicated “some oral-motor disorganization”; a score of 42 or less indicated oral-motor dysfunction.¹⁹⁴ The absence of a category to evaluate breathing pattern, work of breathing or respiratory exertion, and physiological variables during feeding limits the use of this instrument to low-risk, healthy neonates.

The NCAFS is used to analyze parent-infant interaction during feeding. It provides a method for evaluating the responsiveness of parents to infant cues, signs of distress, and social interaction opportunities during the feeding process. In concurrent validity studies, NCAFS scores were positively correlated with findings of the Home Observation for Measurement of the Environment inventory at 8 months (r = 0.72) and at 12 months (r = 0.79).¹⁹⁵

The EFS Assessment is a 36-item observational measure of oral feeding readiness, feeding skill, and feeding recovery. The assessment tool includes examination of physiological and behavioral stability, behavioral feeding readiness cues, oral-motor coordination and endurance, coordination of breathing and swallowing, and postfeeding alertness, energy level, and physiological state. Preliminary content validity and intrarater and interrater reliability procedures were described as “stable and acceptable” (correlation data not reported) with predictive, concurrent, and construct validity testing in process.¹⁹⁶ This tool is specifically designed for feeding examinations in the NICU environment and with expanded psychometric testing will be a relevant instrument in managing neonates with feeding impairment.

General strategies during feeding may include semiflexed, upright positioning with light support under the chin (Figure 11-26). Techniques such as tactile facilitation of the facial muscles, use of a pacifier during gavage feedings, light manual support to the jaw or lip, and thickening of formula are frequent components of oral-motor therapy programs.^193,197 Scheduling of feeding based on the infant’s readiness (behavioral cues of hunger and alertness) is usually implemented by neonatal nurses and shown to be effective in helping infants advance the frequency of oral (rather than gavage) feedings.^198,199

For some infants, oral intake by bottle may be improved by individualizing nipple selection according to contour, length, hole size, texture, and compression resistance. Wolf and Glass^193,200 advised evaluation of the flow rate of liquid from various types of nipples and analysis of the effects of nipple size, shape, and consistency on an infant’s sucking proficiency. Feeding infants in the side-lying position may improve tongue position, particularly if marked tongue retraction is present (Figure 11-27). The timing of movement therapy or neonatal hydrotherapy 30 minutes before feeding may improve performance by preparing postural tone, facilitating oral musculature, and enhancing alertness.

Infants with orofacial anomalies (e.g., cleft palate, hypoplastic mandible) often respond to bottle feeding with a Haberman feeding system (Medela, McHenry, Illinois), which allows control of the flow rate through a valve in the bottle and manual compression of the nipple. The Haberman feeder is an ideal option for infants with large bilateral cleft lip and palate because of the long, flexible nipple, which allows formula to be released from manual compression of the nipple by caregivers instead of requiring negative pressure for suction by the baby (Figure 11-28). Placement of the nipple on the middle of the tongue is advised regardless of the location of the palate or lip defect.²⁰¹ The feeding performance of infants with severe cleft palate deformities may be improved by a dental obturator. This custom-fabricated prosthesis is inserted before feeding to cover the defect in the palate.

The increasing popularity of breast feeding has encouraged the development of breast-feeding aids (e.g., Lact-Aid, JJ Avery, Denver, Colorado). These devices allow supplementation of oral intake during breast feeding through a small tube that goes to the mouth from a sterilized bag containing infant formula.

Expected outcomes of oral-motor intervention supported by clinical research include (1) increased number of nutritive sucks after perioral stimulation,^202,203 (2) increased volume of fluid ingested during nipple feedings,²⁰⁴ (3) decreased number of gavage feedings and earlier bottle feeding,^203,205 (4) accelerated weight gain,²⁰⁵ and (5) earlier hospital discharge.²⁰⁵ Research evidence has emerged on the benefits of interventions to assist pacing to allow breathing pauses²⁰⁶ and to provide slower flow rate with specialized nipples²⁰⁷ for preterm infants during the process of learning to bottle feed.

Monitoring the infant’s physiological tolerance, breathing pattern, and work of breathing is critical during oral-motor examination, intervention, and feeding trials.¹⁹³ Heart rate values may be monitored from either the cardiorespirograph or with peripheral oxygen saturation from a pulse oximeter. Color changes, diminished tone in facial muscles, and behavioral stress cues (e.g., restlessness, trunk arching) must be carefully monitored to allow appropriate response to early signs of fatigue, overexertion, and potential airway difficulty. Regurgitation with aspiration of milk or formula into the lungs may occur during feeding trials, with complications of pneumonia, cardiopulmonary arrest, and associated asphyxia. Because of these risks, feeding trials should not be attempted by neonatal therapists untrained in managing the respiratory and general physiological monitoring components of neonatal feeding.²⁰⁰

Success during feeding activities enhances parent-infant interaction and perceived competency in parenting. Parents of infants with feeding dysfunction describe higher stress than that reported by parents of infants who are gaining weight and feeding satisfactorily. Oral-motor dysfunction has been reported as an early functional deficit in infants at high risk for later neuromotor sequelae²⁰⁸; early support for parents coping with a challenging feeding situation builds competence in caregiving and also commitment to continuity in outpatient developmental monitoring.

Parent/caregiver teaching

Components of the parental/caregiver teaching process may include (1) discussion of the program goals and services in the NICU; (2) orientation to the interdisciplinary follow-up plan after discharge; (3) guidelines for recognizing and understanding the infant’s temperament, stress, and stability cues; (4) methods of creating a calm environment with protection from aversive light and sound; and (5) specific instructions on selected corrected-age–appropriate developmental activities or therapeutic handling techniques. When used in conjunction with verbal instructions and demonstrations, a packet of written guidelines and pictures individualized to the infant’s needs may improve parents’ overall skills and understanding of the program.

Occasionally, when geographical distance prevents participation by parents in the neonatal therapy program, the infant’s individualized developmental plan may be mailed and later reviewed at discharge or during outpatient follow-up. During times of separation, telephone contact with parents helps foster attachment to the infant and explain the purpose and content of the home developmental intervention program as well as providing opportunity to discuss the critical need for follow-up. Parents need this ongoing dialogue to make the infant seem real to them and to allow communication of their fears and concerns during the separation.

Teaching strategies are most effective when they are adapted to the learning style of the parents. This adaptation may involve more demonstrations and an increased opportunity for supervised practice for some parents, particularly those with reading or language difficulties that limit use of a written instructional packet. Parents have shown preference for combined educational methods including demonstration, video, and written materials rather than one single method.^212,213 Cultural caregiving practices of the family may necessitate elimination of common procedures such as use of pacifiers for nonnutritive sucking or hand-to-mouth engagement.

With consultation from and in collaboration with the neonatal therapist, neonatal nurses can incorporate recommendations to support skeletal and motor development into their routine discharge teaching activities. General considerations for discharge teaching by nurses may include the following²¹⁴:

In the neonatal period, the quality of infant-parent attachment and comfort level and proficiency in routine caregiving and therapeutic handling set the stage for later parenting styles. Helping parents find and appreciate a positive aspect of the neonate’s motor or other developmental behaviors gives them a spark of hope from which emotional energy can be generated to help them through the marathon of the NICU experience. Empowering parents early in their parenting experience with the infant is crucial. In the life of the child, the effects of parent empowerment will last far longer than neonatal movement therapy and positioning strategies.