9th NICU PICU Update

The Role of Medical

Rehabilitation in NICU
Luh Karunia Wahyuni
Pediatric Division of Medical Rehabilitation Department
Cipto Mangunkusumo Hospital
Jakarta - Indonesia
 MEDICAL DIAGNOSIS

Functional impact
• Physiologic stability problems • Self regulation
• Sensory modulation problems • Feeding
(arousal/alertness, state modulation, state transitions, sensory • Respiratory motor
processing, sensory modulation) control
• Motor control problems • Exploratory play
(muscle tone, muscle strength, endurance, reflex development)
• Mother-infant bond
• Reduced strength and control of oral structures
• Tactile comfort
(reduced oral-motor control, reduced coordination of sucking,
swallowing and breathing)
• Eye movement
• Pain • Postural control
• Immobilization • Gravitational insecurity
The Role of Medical Rehabilitation in NICU
• Evaluation of kinetic functional
(for all or any human body system, as needed)
• Assessment of existing impairments and disabilities
• Assessment and promotion of feeding readiness
• Minimizing impairments (e.g., muscle tone abnormalities, musculoskeletal
contractures, poor behavioral state organization) and prevention of disability
• Individualized developmental care
• Facilitation of normal growth and development
• Feeding interventions
• Parental education
 Clinical competencies ......
• Represents a highly specialized area of practice that requires trained, experienced with advanced
knowledge and skills, given the fragility of the infants, the vulnerable emotional status of the families,
and the intricacy of medical and social factors that affect the child and family unit as a whole
• Gain advanced knowledge in fetal/infant development, technological advances, impact of the
environment on the neonate’s homeostasis
• Implement specialized examination/evaluation using standardized tests
• Develop a risk management plan to prevent physiologic compromise and secondary musculoskeletal
complications
• Plan and implement neonatal interventions in collaboration with the family and the neonatal team
• Empower families to assume caregiver role
• Develop discharge plans in collaboration with family and community resources
• Provide consultation incorporate scientific literature into practice so that it’s evidence-based
Current knowledge basis in medical rehabilitation
in NICU....
• Functional concept
• Learning Process of skills
• Normal development of functional motor skills
(gross motor, fine motor, oral motor and respiratory)
• Sensory integration development
• Brain plasticity
• Biomechanical frame of reference
• Rehabilitation frame of reference
Medical rehabilitation intervention ...
• Positioning
• Handling techniques
• Environmental modifications
• Developmental care
• Neurodevelopmental treatment
• Sensory integration
• Splinting
• Feeding
• Range of motion
• Infant massage
• Respiratory therapy
Airway clearance, lung expansion, position in bed,
airway suction, drug inhalation, and cough assist)
during mechanical ventilation and up to 12 hours
following extubation
• Prevention of secondary complications
sensory-perception,musculoskeletal,
neuromuscular, respiration, etc.
Self regulation .....
 What contributes to developmental outcomes?
Positive
Goodness of fit between
the infant’s individual
threshold for stimulation
and sensory experiences
STRESS
• Physiologic instability
• Poorly regulated states of
arousal
• Disorganized behaviour
• Greater vulnerability to
pain
The Developing Infant in the NICU

• What influences these changes? .... exprience

• How does this occur?
Through input from the environment .....the senses
 The learning of skills
Sensory Processing Machine
Stimulus Central Response
• Temperature, taste, touch, Processing Cognitive, motor,
pain (orally), pressure, speech – language,
Analysis, Organization,
proprioception emotional output
Integration, Storage
• Olfactory
Memory
• Visual
• Auditif
• Tactile
• Vestibular Looking and listening
Attending appropriately to people
and objects
Remembering
Interacting with others
Learning
 The Senses Integration of Their Inputs End Products
Level 1 Level 2 Level 3 Level 4
2 months 1 year 3 years 6 years
Auditory (Hearing) Speech
Language
Vestibular (Gravity & Eye Movement Ability To Concentrate
Movement)
Posture Ability To Organize
Body Percept
Balance Self-Esteem
Muscle Tone Coordination of Two Self-Control
Sides of the Body
Gravitational Eye-Hand
Self-Confidence
Proprioceptive security Coordination
Motor Planning
(Muscles & Joints) Academic Learning Ability

Activity level Visual Capacity for Abstract

Sucking Perception
Thought & Reasonig
Eating Attention Span Purposeful
Activity Specialization of Each
Side of the Body & the
Tactile (touch) Brain
Emotional Stability
Mother-Infant Bond

Visual (Seeing) Tactile Comfort

The senses integration of their inputs,& their end products (From Western Psychological Services, 12031 Wilshire Blud., Los Angles,
CA 90025.)
 Sources of Stress
Avoidable
Unavoidable • Temperature
• Initial • Crowding
separation • Lack of Privacy
from mother
• Light
• Medical • Sound
procedures
• Positioning
• Multiple
caregivers • Handling
• Inconsistent
caregivers
• Ongoing separation
from parents
Environmental sensory input ........
affects the developing premature infant

• The best environment for the stable preemie is his or her parents’ faces, voices,
and bodies
• They are familiar, appropriately complex, multimodal, specific to the infant's
individual expectations and needs, and can readily modify themselves according
to the baby’s responses

Als. H. Developmental care in the newborn intensive care unit.

Current Opinion in Pediatrics, 10(2), 1998; 138–42.
 Individuals vary in their
• sensory thresholds
• stimulus reactivity
• ability to register
• to process sensory experiences
• ability to inhibit irrelevant
or distracting stimuli
Physiologic homeostasis imbalance
• Changes in skin color: flushing,
pallor, mottling, or cyanosis
• Sweating • Specific medical
• Tachycardia or bradycardia conditions
• Tachypnea or apnea
• Medications
• Oxygen desaturation
• GER (spitting) • Abstinence from
• Gassiness or watery stools addictive substances
• Drop in body temperature
 Difficulty with self-regulation
Respond to environmental stimuli
with more sustained stress reactions

• Brisk trunk and extremity extension

• Gaze aversion
• Tongue thrust
• Yawning
• Spitting up
• Increasing or decreasing heart and
respiration rates
• Greater difficulty with self-calming
• May require caregiver intervention to regain
physiologic and motor stability
Characteristics of normal motor development
 Motor
Development
Physiological flexion
(midline control)
• shoulder flexion
• scapular protraction
• hip and knee flexion
• posterior pelvic tilt
 Normal Development of Functional Motor Skills of Newborn
Postural control Gross motor Reach Fine motor Vision Oral-motor/ Feeding Respiration- Phonation

Physiological flexion Movements limited Random arm Strong grasp Visual regard Strong gag response, Respiratory
– provides stability by available ROM movements within a reflex for rooting response, and Obligatory nose breather
for posture and Random movements 90° plane Hands open environment automatic phasic bite
random movement release pattern Belly breathing at rest and
• Rhythmical Positional hand-to- as arm Random during quiet breathing
Neck righting alternating hand contact and abduct disorganized Feeding
reflexive hand-to- eye Belly breathing with anterior rib
Labyrinthine righting movements of On bottle/breast, starts cage collapse/sternal retraction
beginning in prone limbs mouth contact in movements with true sucking pattern
side-lying during stressful/effortful
and supine • Total body Monocular using total pattern of oral activities and crying
Primary standing movements into vision movements
extension or Sustained, rhythmical breathing
reaction Begins suckling movements generally; asynchronous rhythm
flexion of oral area after antigravity
• Primitive reactions with effortful activity/crying
head extension starts
elicited by a developing Phonation/sounds
specific stimulus
Mixture of suckling/sucking Direct relationship between
• Distal isolated
on bottle/breast dependent phonation/sound production
movements
on head position when held and body movement
• Lifts and turns
head partway in Oral motor Produces cry or vowel-like
prone sounds primarily on exhalation;
Suckles/sucks when
• Automatic nasal in quality
hand/objects comes in
stepping Produces clicks/friction noises
contact with mouth
of short duration and low
Minimal drooling in supine intensity
or when reclined; increased
drooling in other position
Physiological flexion
• Body concept ( body awareness, body
schema, body image)
• Postural control
• Psychological emotional stability
(security)
• Muscle balance of development
against extensor group
• Background of core stability
• Nasal breathing
• Development of oromotor
• Development of eye movement
Respiration Function
• Due to the physilogical flexion , tight chest
wall, the cervical and thoracic spinal areas are
underdeveloped
• The chest shape appears triangular
• The ribs are horizontally aligned with no
intercostal spacing and litlle sternal stability
• Diaphragmatic breather with very little
respiratory reserve
• The infant’s sternum will depress due to its
inability to stabilize aginst the strong pull of
the diphragm
• Nasal breathing
Respiratory system

Soda-Pop Can Model model of

respiratory and postural control
 Body perception
• Foster centeredness and and
the sense of midline
• movement around a stable
point in three dimensional
space
• perceptual foundation for body
scheme, spatial orientation and
bilateral motor coordination
Background
of Core Stability
• lowering ribcage
• closed space between rib
cage and pelvis
• compact core stability
• development of muscles
on the proximal part of the
body
Development of Eye Movement
• Flexed neck provide
stabilization of the neck
• This stabilization provide
movement of the
muscles of eyes
• Eye-hand coordination
Application .......
• Swaddling
• Handling
• Positioning (supine, prone, sidelying)
• Feeding position
• Baby massage
• Exploratory play
Swaddle with optimal midline control
Swaddle with optimal midline control
 Positive Influences of
Positioning in the NICU

• Provide postural and structural alignment to prevent the

development of abnormal postures.
• Encourage self-regulation by impacting hand to mouth activity
that leads to less crying and conservation of calories needed for
growth.
• Influence the development of neuronal pathways and CNS
organization. Pathways that are rarely used weaken and
disappear while others that are frequently activated become
dominant.

Hunter, 2004; van Heijst, Touwen, & Vos, 1999; Penn & Schatz, 1999; Sweeney & Gutierrez, 2002.
 Negative Impacts of Positioning

• Development of postural and skeletal deformities including skull deformations,

abnormal spine curvatures, preferential head turning to the one side.
• Fine motor delays due to shoulder girdle tightness. Arms are positioned in
external rotation and retraction also known as the “W” position.
• Developmental delays including visual and functional preference for the right
hand, inability to perform midline skills.
• Gross motor delays including lower extremity tightness at hips, knees, and
ankles. Legs positioned in abduction and external rotation also known as
“frogged” or “M” position. All of which can influence rolling, sitting, walking,
and crawling.
Boere-Boonekamp, van der Linden-Kuiper, & van Es, 1997; Davis, Robinson, Harris, & Cartlidge, 1993; Fay,
1988; Hunter, 2004; Sweeney & Gutierrez, 2002.
‘Kangaroo mother care’ to prevent neonatal deaths due to preterm birth
complications
Joy E Lawn, Judith Mwansa-Kambafwile, Bernardo L Horta, Fernando C Barros,and Simon Cousens
Int J Epidemiol. 2010 Apr; 39 (Suppl 1): i144–i154.

Background
‘Kangaroo mother care’ (KMC) includes thermal care through continuous skin-to-skin
contact, support for exclusive breastfeeding or other appropriate feeding, and early
recognition/response to illness
Conclusion
This is the first published meta-analysis showing that KMC substantially reduces
neonatal mortality amongst preterm babies (birth weight <2000 g) in hospital, and is
highly effective in reducing severe morbidity, particularly from infection. However,
KMC remains unavailable at-scale in most low-income countries
Therapeutic Massage
No fixed guidelines
• Tactile stimulation (moderate pressure)
• Kinesthetic stimulation (flexion and extension of the upper and lower extremities)
• Increase weight gain
• Better sleep-wake pattern
• Enhanced neuromotor development
• Better emotional bonding
• Stimulation of circulatory and gastrointestinal system
• Massage is given in 15 minute sessions starting with 5 minutes of tactile stimulation
followed by 5 minutes of kinesthetic stimulation and ending again with 5 min of tactile
stimulation.
• 45-60 minutes after feeding

Kulkarni A, Kaushik JS, Gupta P, Sharma H, Agrawal RK. Massage and Touch Therapy in Neonates: The Current Evidence. Indian
pediatric. Sept 2010 ; 47 : 771-776.
 Guidelines for Infant Massage

Guidelines for Infant Massage. Avaiable from https://patienteducation.osumc.edu/Documents/mass-gui.pdf

Guidelines for Infant Massage

Guidelines for Infant Massage. Avaiable from https://patienteducation.osumc.edu/Documents/mass-gui.pdf

 Moderate Versus Light Pressure Massage Therapy Leads to Greater
Weight Gain in Preterm Infants
Tiffany Field, Miguel A. Diego, Maria Hernandez-Reif, Osvelia Deeds, and Barbara Figuereido
Infant Behav Dev. 2006 Dec; 29(4): 574–578.

• During the behavior observations the moderate versus light pressure massage
group showed significantly lower increases from the pre-session to the session
recording on: 1) active sleep; 2) fussing; 3) crying; 4) movement; and 5) stress
behavior (hiccupping). They also showed a smaller decrease in deep sleep, a
greater decrease in heart rate and a greater increase in vagal tone.
• Thus, the moderate pressure massage therapy group appeared to be more relaxed
and less aroused than the light pressure massage group which may have
contributed to the greater weight gain of the moderate pressure massage therapy
group.
Feeding
 The primary oral motor mechanism
is the suck/swallow/breathe synchrony

• Feeding is a complex activity demanding

efficient coordination between the rhythmic
processes of sucking, swallowing and Sucking
respiration

• Each element supporting, enhancing and

interacting with each other to varying Swallowing
degrees depending on the activity
Breathing
• An intact synchrony is critical to many
elements of sensorimotor and cognitive
development
An intact synchrony is
critical to many elements
of sensorimotor and
cognitive
development including
speech and language,
state regulation, postural
control, feeding behavior,
ego development and
eye-hand coordination
General Purpose Oral Feeding Initiation and Advancement Pathway
• Non Nutritive Sucking
• Oral-perioral stimulation
• Colostrum application to mouth
tissue

Not every preterm infants can

fully breastfeed at this phase 
lack of SSB control, lack of
postural control, etc.

Nipple used as a TRANSITION

phase before neonates can
fully breastfeed

Gennattasio, et al, 2015. Oral feeding readiness assessment in premature infants. Wolter Kluwers Health. 2015; 40(2):96-104
Oral
motor
stimulation
Evidence-based systematic review: effects of oral motor interventions on
feeding and swallowing in preterm infants.
Arvedson J, Clark H, Lazarus C, Schooling T, Frymark T.
Am J Speech Lang Pathol. 2010 Nov;19(4):321-40

PURPOSE
To conduct an evidence-based systematic review and provide an estimate of the
effects of oral motor interventions (OMIs) on feeding/swallowing outcomes (both
physiological and functional) and pulmonary health in preterm infants.
RESULTS
• NNS alone and with oral/perioral stimulation showed strong positive findings for
improvement in some feeding/swallowing physiology variables and for reducing
transition time to oral feeding.
• Pre-feeding stimulation showed equivocal results across the targeted outcomes.
• None of the OMIs provided consistent positive results on weight gain/growth
Effects of pre-feeding oral stimulation on oral feeding in preterm infants:
A randomized clinical trial
Manon Bache, Emmanuelle Pizon , Julien Jacobs, Michel Vaillant, Aline Lecomte
Early Human Developement. 2014. P.1-5

Objective
To evaluate the effect of early oral stimulation before the introduction of oral
feeding, over the duration of concomitant tube feeding
Results
Breastfeeding rates upon discharge were significantly higher in the intervention than
in the control group (70% versus 45.6%, p = 0.02)
Conclusion
• A pre-feeding oral stimulation program improves breastfeeding rates in preterm
infants
• Oral stimulation does not shorten the transition period to full oral feeding neither
the length of hospital stay
Oral and nonoral sensorimotor interventions facilitate suck–swallow–
respiration functions and their coordination in preterm infants
Sandra Fucile, David H. McFarland, Erika G. Gisel, Chantal Lau
Early Human Development 88 (2012) 345–350

Aim:
• To further explore the effects of an oral (O), tactile/kinesthetic (T/K), and combined
(O+ T/K) sensorimotor intervention on preterm infants' nutritive sucking,
swallowing and their coordination with respiration.
Conclusion:
• The O intervention enhanced specific components of nutritive sucking. All three
interventions resulted in improved swallow–respiration coordination.
Sensorimotor interventions have distributed beneficial effects that go beyond the
specific target of input.
Airway Clearance Technique in NICU
 Indication for ACT
• Evidence of retained secretions (blood or sputum) not removed by suctioning,
coughing, and turning
• Radiological evidence of acute atelectasis or infiltrate
• Decrease in PaO2 or SpO2 as a result of secretion retention
• Prophylactic Use
Acute neurological diseases affecting the innervation of the intercostal, diaphragmatic, or
abdominal muscles
• Acute moderate to severe brain injury

Ciesla ND (1996) Chest physical therapy for patients in the intensive care unit. Phys Ther 76:609–625
General ACT Components
• Positioning
• Postural Drainage
• Percussion and Vibration
• Tracheal Suctioning
• Mechanical devices
• Manual lung /inflation
• Coughing
• Saline installation
• Breathing exercise
• Mobilization
Ciesla ND (1996) Chest physical therapy for patients in the intensive care unit. Phys Ther 76:609–625
 Which techniques are not recommended for
airway clearance?
• Thoracic percussion applied in NBs immediately after extubation is not
recommended
• We do not recommend airway de-obstruction techniques such as postural
drainage and/or chest vibration associated or not with manual hyperinsufflation
with aspiration in cystic fibrosis children undergone endotracheal intubation in the
perioperative period

Morrow B, Futter M, Argent A. A recruitment manoeuvre performed after endotracheal suction does not increase dynamic compliance in ventilated
paediatric patients: a randomised controlled trial. Australian Journal of Physiotherapy. 2007;53(3):163-169.
Clini E, Ambrosino N. Early physiotherapy in the respiratory intensive care unit. Respiratory Medicine. 2005;99(9):1096-1104.
Gregson R, Stocks J, Petley G, Shannon H, Warner J, Jagannathan R et al. Simultaneous measurement of force and respiratory profiles during chest
physiotherapy in ventilated children. Physiological Measurement. 2007;28(9):1017-1028.
 Contraindications, and possible adverse effects of
applying airway clearance techniques
• The major contraindications of these techniques include NBs with extremely low
birth weight and cases of gastroesophageal reflux disease
• Possible adverse effects include reduced arterial oxygen pressure (PaO2), increased
respiratory rate, reduced respiratory time, and decreased lung elastic recoil
pressure during manual hyperinsufflation

Bagley CE, Gray PH, Tudehope DI, Flenady V, Shearman AD, Lamont A. Routine neonatal postextubation chest physiotherapy:
a randomized controlled trial. J Paediatr Child Health. 2005;41(11):592-7.
Summary
The main goal of medical rehabilitaion in NICU is to optimize daily life
functions including the ability to feeding, postural control, respiration
motor control, self regulation
Prevent secondary complications and disability
Terimakasih ......