Effect of postural supports on neuromotor function in very preterm infants to term equivalent age

Biological and environmental factors may affect children's executive function through motor and sensorimotor development: Preterm birth and cerebral palsy

Disruptive biological and environmental factors may undermine the development of children's motor and sensorimotor skills. Since the development of cognitive skills, including executive function, is grounded in early motor and sensorimotor experiences, early delays or impairments in motor and sensorimotor processing often trigger dynamic developmental cascades that lead to suboptimal executive function outcomes. The purpose of this perspective paper is to link early differences in motor/sensorimotor processing to the development of executive function in children born preterm or with cerebral palsy. Uncovering such links in clinical populations would improve our understanding of developmental pathways and key motor and sensorimotor skills that are antecedent and foundational for the development of executive function. This knowledge will allow the refinement of early interventions targeting motor and sensorimotor skills with the goal of proactively improving executive function outcomes in at-risk populations.

Improving Diaper Performance for Extremely Low-Birth-Weight Infants

BACKGROUND

Extremely low-birth-weight (ELBW) infants face significant diapering challenges compared with their full-term peers, due to immature musculature, nervous system, and skin development. Advances in medical care have increased an ELBW infant's rate of survival, which creates a growing need for diapers to better serve these infants. Aim of research. The objective of this study was to identify and confirm the requirements for optimal diaper performance from the neonatal intensive care unit nurses' perspective, as well as to assess in-hospital performance to determine if new features improved key developmental care parameters.

METHOD

Two surveys were shared among nurses to address study objectives. Study 1 (N = 151) was designed for neonatal intensive care unit nurses to identify key requirements for ELBW diapers and rate the performance of existing ELBW diapers. Study 2 (N = 99) assessed in-hospital performance of the test diaper compared with the usual diaper, under normal usage conditions. Findings/results. The majority of nurses agreed that ELBW diapers must fit appropriately between the legs so that hips and legs are not spread apart and that ELBW diapers need to be flexible between the legs for positioning. Of the nurses-infant pair responses, 93% ( P < .0001) preferred the test ELBW diaper over their usual diaper.

CONCLUSION

Findings suggest that nurses should be included in the product design process to ensure both their needs and the needs of an infant are being met. Nurses are considering how diaper features may affect both acute and long-term medical outcomes and this information provides necessary guidance to diaper manufacturers and designers when developing better-performing diapers.

Posture and movement in very preterm infants at term age in and outside the nest

OBJECTIVE

The objective of this study is to evaluate the use of nests on general movements (GM) and posture in very preterm infants at term age.

METHOD

Seventeen high-risk preterm infants-less than 30 weeks of gestation (GA)-underwent a video recording, lying in supine position, with or without nest. Posture, GM quality, and movements made around the child's midline, as well as abrupt movements and frozen postures-in extension or flexion of the four limbs-were analyzed.

RESULTS

Nest did not modify quality of GM. Children significantly adopted a curled-up position. The nest system was associated with an increase in movements toward or across the midline, as well as reduction of the hyperextension posture and head rotation movements. Frozen postures in flexion or extension, as well as abrupt movements of the four limbs, were reduced but not significantly.

CONCLUSIONS

Nest helps very preterm infants to adopt semi-flexed posture and facilitates movements across the midline and reduces movements of spine hyperextension, without GM global quality modifications.

The effectiveness of quarter turn from prone in maintaining respiratory function in premature infants

AIM

The aim of this study was to determine the effectiveness of quarter turn from prone compared with supine and prone positioning in maintaining respiratory function in premature infants managed in a neonatal intensive care unit.

METHODS

The study was a prospective, randomised, cross-over trial with concealed allocation and intention to treat analysis. Fifty-four infants ≤32 weeks gestation were randomly allocated to the order of the positions supine, prone and quarter turn from prone. Distribution of ventilation was assessed by measurement of regional impedance amplitude, global inhomogeneity index and phase angle analysis using electrical impedance tomography 30 min after each position change. Physiological characteristics of heart rate, respiratory rate (RR), oxygen saturation and inspired oxygen were also measured.

RESULTS

There was a significant difference between positions for RR with the RR in quarter turn from prone significantly lower than for supine (mean difference 6.53 breaths/min; 2.04-11.02), but not compared with the prone position. No significant differences between positions were found for any of the other outcomes measured.

CONCLUSION

This study demonstrated that quarter turn from prone had an immediate positive positional effect on the RR of premature infants. The position of quarter turn from prone was comparable with prone in the maintenance of lung function and had a superior effect over supine on RR. These findings support the view that a quarter turn from prone can be confidently used in neonatal nurseries to manage premature infants.

Application of the NICU practice guidelines to treat an infant in a level III NICU

PURPOSE

The purpose of this case report was to determine how current physical therapy (PT) practice in the neonatal intensive care unit (NICU), with 1 infant, adhered to the neonatal PT decision-making framework that was developed as part of the NICU practice guidelines for clinical care.

SUMMARY OF KEY POINTS

Most PT interventions implemented in this NICU were supported by the algorithm, with some steps more readily implemented than others.

CONCLUSIONS

This case report highlights the utility of the NICU clinical decision-making algorithm for not only assisting with developing an evidence-based PT plan of care for an infant at high risk but also its usefulness in revealing NICU programmatic and policy strengths and areas for improvement.

RECOMMENDATIONS FOR CLINICAL PRACTICE

The NICU developmental and therapeutic teams are encouraged to conduct similar endeavors to assess the quality of PT care in their NICUs.

Neonatal physical therapy. Part II: Practice frameworks and evidence-based practice guidelines

PURPOSE

(1) To outline frameworks for neonatal physical therapy based on 3 theoretical models, (2) to describe emerging literature supporting neonatal physical therapy practice, and (3) to identify evidence-based practice recommendations.

KEY POINTS

Three models are presented as a framework for neonatal practice: (1) dynamic systems theory including synactive theory and the theory of neuronal group selection, (2) the International Classification of Functioning, Disability and Health, and (3) family-centered care. Literature is summarized to support neonatal physical therapists in the areas of examination, developmental care, intervention, and parent education. Practice recommendations are offered with levels of evidence identified.

CONCLUSIONS

Neonatal physical therapy practice has a theoretical and evidence-based structure, and evidence is emerging for selected clinical procedures. Continued research to expand the science of neonatal physical therapy is critical to elevate the evidence and support practice recommendations.

Avaliação neurológica de recém-nascidos pré-termo de muito baixo peso com displasia broncopulmonar

OBJETIVO: Descrever e comparar a avaliação neurológica e comportamental de recém-nascidos pré-termos com e sem displasia broncopulmonar (DBP). MÉTODOS: Recém-nascidos prematuros com peso ao nascer inferior a 1500g e idade gestacional menor de 32 semanas foram avaliados com 40 semanas de idade gestacional corrigida, no Centro de Atenção Integral à Saúde da Mulher da Universidade Estadual de Campinas. Utilizou-se a Avaliação Neurológica de Dubowitz, com 29 itens divididos em seis categorias: tônus, padrões de tônus, reflexos, movimentos, sinais anormais e comportamento. O estado de consciência do recém-nascido foi graduado segundo Brazelton (1973). Utilizaram-se os testes do qui-quadrado e exato de Fischer para variáveis qualitativas e o de Mann-Whitney para as numéricas não-paramétricas, com nível de significância de 5%. RESULTADOS: No período de janeiro de 2005 a setembro de 2007, 24 recém-nascidos, 12 com DBP e 12 controles, com idade gestacional ao nascer de 28±1 semana e peso de 884±202g no grupo com DBP e 31±1 semana e 1156±216g no Grupo Controle foram avaliados. Dos 29 itens avaliados, 18 foram homogêneos entre os grupos e a pontuação geral dos dois grupos não apresentou diferença (p=0,30). Observou-se maior anormalidade neurológica no grupo com DBP em oito itens e, no Grupo Controle, em três itens. CONCLUSÕES: A comparação da avaliação neurológica de Dubowitz de recém-nascidos pré-termos com e sem DBP não apresentou diferença significante com 40 semanas de idade gestacional corrigida. Nas categorias reflexos e postura/tônus, observou-se tendência a anormalidade no grupo DBP.

Positioning of Preterm Infants for Optimal Physiological Development: a systematic review

EXECUTIVE SUMMARY

Positioning of preterm infants is a basic task of neonatal nursing care. A variety of outcomes are affected by different body positioning of preterm infants. This review evaluates the clinical evidence of the effects of positioning of preterm infants with regard to physiological outcomes and sleep states.

OBJECTIVES

To conduct a systematic review to determine the best available evidence related to the positioning of preterm infants. The specific review questions addressed were: the physiological outcomes affected by different positioning, and the best position for promoting sleep.

CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW

This review considered all studies that included infants born before 37 weeks of gestational age in any hospital setting. Outcomes included measures for physiologic effects and sleep state. The review primarily considered any randomized clinical trails (RCTs) that explored different positions in preterm infant but also included quasi-experimental designs.

SEARCH STRATEGY FOR IDENTIFICATION OF STUDIES

The search sought to find published and unpublished studies. The database search included: Pubmed, CINAHL, ProQuest, EMBASE, Science Direct, and Dissertation Abstracts International. Studies were additionally identified from reference lists of all studies retrieved.

ASSESSMENT AND DATA EXTRACTION

All studies were checked for methodological quality by two reviewers and data was extracted using tools developed by the Joanna Briggs Institute.

DATA ANALYSIS

The study results were pooled in statistical meta-analysis using Review Manager Software and summarized in narrative form where statistical pooling was not appropriate or possible.

RESULTS

Thirty two studies were included in the review. The results of this review support the prone position in preterm infants for improvement of arterial oxygen saturation, improved lung and chest wall synchrony of respiratory improvements, decreased incidence of apnea in infants with a clinical history of apnea, promoted sleep, and decreased gastroesophageal reflux. However, the prone position increased postural abnormalities, orthopaedic abnormalities of the feet, and delayed developmental musculature. The combined use of a postural support roll and a postural nappy while very preterm infants are nursed, improved hip and shoulder posture up to term postmenstrual age. The change in body position from horizontal to head-up tilt in very immature and unstable infants may affect the cerebral homodynamic. The management of position per se may not be sufficient for assisting preterm neonates to cope with the painful procedure. Furthermore, preterm infants are susceptible to oxygen desaturation in car seats and carrying slings.

CONCLUSION

Prone positioning was shown to have many advantages for prematurely born infants. But the longer, deep sleep period and fewer awakenings associated with a prone position would support higher vulnerability for preterm infants to sudden infant death syndrome (SIDS). Therefore, all preterm infants placed in the prone position should have continuous cardio-respiratory and oxygen saturation monitoring. Preterm infants should be placed in a properly supported position to ensure functional support of all parts of the body as well as ensuring physical safety. In addition, preterm infants should not be left unattended in car safety seats and carrying slings.

Comparison of chronological and corrected ages in the gross motor assessment of low-risk preterm infants during the first year of life

OBJECTIVE: To evaluate the need of chronological age correction according to the degree of prematurity, when assessing gross motor development in preterm infants, during the first year of life. METHOD: Cohort, observational and prospective study. Alberta Infant Motor Scale (AIMS) was used to evaluate 43 preterm infants with low risk for motor neurological sequelae, during the first year of corrected age. Mean scores were analyzed according to chronological and corrected ages. Children with motor neurological sequelae were excluded during follow-up. RESULTS: Gross motor mean scores in preterm infants tended to be higher when corrected age was used compared with those obtained when using chronological age, during the first twelve months. At thirteen months of corrected age, an overlapping of confidence intervals between corrected and chronological ages was observed, suggesting that from that period onwards correction for the degree of prematurity is no longer necessary. CONCLUSION: Corrected age should be used for gross motor assessment in preterm infants during the first year of life.

Toy-oriented changes during early arm movements: hand kinematics

In a recent cross-sectional study, we found that young infants changed their spontaneous arm movements in the presence of a toy, termed 'toy-oriented changes', in systematic ways beginning many weeks before their first consistent reaches [Bhat, A. N., Heathcock, J. H., & Galloway, J. C. (2005). Toy-oriented changes in hand and joint kinematics during the emergence of purposeful reaching. Infant Behavior and Development, 28(4), 445-465]. The purpose of the present study was to test specific hypotheses regarding toy-oriented changes in a longitudinal design.

METHODS

Thirteen infants were observed every other week from 8 weeks of age up to the onset of reaching. At each session, hand and joint motions were observed with and without a toy present using a high-speed motion capture system. This paper focuses on the toy-oriented changes in hand variables.

RESULTS

As predicted, infants displayed a meaningful pattern of toy-oriented changes, which systematically changed as infants approached the first week of reaching. During the Early phase (8-10 weeks before reaching), infants scaled down their movement length and speed in the presence of a toy. During the Mid phase (4-6 weeks before reaching), infants scaled up movement number and speed, increased movement smoothness, and decreased their hand-toy distance in the presence of a toy. During the Late phase (within 2 weeks of reaching), infants continued to change their hand's position to get closer to the toy and began contacting it. Interestingly, movement number and smoothness displayed similar developmental patterns, where movement length and speed displayed similar patterns.

CONCLUSION

Toy-oriented adaptation of arm movements emerges in the first months of life and forms a complex, yet tractable continuum with purposeful reaching. These results provide a foundation to test more specific hypotheses of hand and joint coordination in both typically developing infants and those infants born at risk for coordination impairments.