Long Term Developmental Consequences of Positioning after the NICU StayMichelle Westengaard, OTR/L

Objectives:

1. Identify at least two important musculoskeletal changes that occur in the last trimester of development that plays a significant role in meeting developmental milestones.

2. Describe 3 "intentional positional" strategies to support musculoskeletal development

3. List 5 or more developmental implications that occur as a result of poor positioning in the NICU

Disclosures: I have no conflict of interests to disclose.

Neonatal therapists, nurses and professionals have a unique opportunity to observe and promote development.

Sweeney & Gutierrez, 2002

Vertebral System:

Sweeney & Gutierrez (2010)

Articular Structures● Joints- tissue that develops between bones at articulation points● Connective Tissue-A material made up of fibers forming a framework and

support structure for body tissues and organs. Cartilage and bone are specialized forms of connective tissue.

● Synovial Membranes- A layer of connective tissue that lines the cavities of joints, tendon sheaths, and bursae. The synovial membrane makes synovial fluid, which has a lubricating function.

Sweeney & Gutierrez (2010)

Muscle Tissue

High Oxidative Type-I muscle fibers (lower intensity - longer duration)

Low Oxidative Type II muscle fibers (more powerful-short bursts)

Sweeney & Gutierrez (2010)

Activity Dependent DevelopmentIntrauterine VS. Extrauterine

Drake (2017), Sweeney & Gutierrez (2010), Blackburn (2007) Hunter (2007)

Activity Dependent

Development

Kamal Nursing Lectures (2020)

Posture, Movement & Tone

Dubowitz & Dubowitz (1999)

Tone

● Dubowitz and Dubowitz (1999)● Afazal (2017) ● Allen and Capute (1990)● De Groot and colleagues,

(1991,1992,1993, 1997, 2000)● Ferrari et al., 2007

Intentional Strategies to Promote Development with Positioning in NICU: 1. Optimize Alignment2. Support Posture and Movement3. State Regulation4. Minimize Stress- Sensory Input5. Intentional Caregiving

Ferrari (2007), Hunter (2007)

Expectations: ● Maintain semiflexed extremity posture

in supine and prone positions● Move head side to side in supine and

prone● Lift head in prone and hold● Maintain head in line with trunk during

pull to sit ● Bring hands toward midline ● Sustain rhythmic suck, swallow and

breathing sequence● Support state regulation

Sweeney & Gutierrez (2007),

Clinical Implications for Neonatal Care

Vaivre-Douret (2004), Pathways

Typical Development

18 months*Walks independently *Walks upstairs with one hand held *Creeps upstairs *Walk backwards *Scribbles in imitation *Removes and places lid on container

24 months*Propels ride on toy *Throws ball over-hand *Kicks large ball *Runs fairly well *Places pegs in pegboard *Turns single pages *Strings large beads

12 months*Creeps *Pulls to stand independently *Cruises along furniture *Stands alone *Walk or with 1 hand assist *Uses neat pincer grasp *Voluntarily releases object *Uses index finger to poke *Attempts to stack objects

9 months*Sits independently- protective extension of arms to side and front *Transitions to and from sitting *Bears weight and bounces on legs *Crawls *Pulls to standing *Finger-thumb opposition *Eye hand coordination, but no hand preference

6 months*Purposeful full hand grasp *Roll over *Holds head in line with body when pulling to sit *Reaches for objects *Transfer objects from hand to hand *Plays with feet, lifts head when playing in supine *Sits momentarily, leaning on hands *Bears some weight in standing

3 months*Turns head to either side when lying on stomach *Lifts head and chest in prone *Visually track through midline *Attempts to roll from side to back *Randomly swipes toward dangling object *Briefly grasps at object placed in hand

Newborn*Random, uncoordinated, reflexive movements

Lally,(2019)

Developmental Red Flags2 months*Consistent asymmetrical head position

*Poor Midline Orientation

Jerky or stiff movements in UE/LE

*Increased neck or trunk extension

4 months*Poor head control

*Difficulty with hands at midline

*Poor reaching

*Persistent fisting

*Difficulty lifting head, WBing on elbows

*Resistant to passive UE/LE movment

*Dominant ATNR and/or scissored legs

6 months*Difficulty with grasp

*Not yet rolling

*Unable to sits with minimal support

*Bounces when in a standing position

*Not bearing weight on legs

12 months*Unable to pull to stand

*Unable to maintain 4 point crawl

*Cruise around furniture*Transition between basic positions

*Persistent asymmetry of control of extremities

8 months*Inability to sit or roll

*Inability to transfer objects between hands

*Persistent asymmetry of extremities

*Hyper/Hypotonicity in trunk or extremities

Developmental Implications: Plagiocephaly &Torticollis

Collett (2019)

Developmental Implications: Torticollis

Upper and Lower Extremity Posturing

Drake (2017), Hunter (2007)

Definitions: ● Scapular Retraction● Shoulder Elevation● External/Internal Rotation

● Hip Abduction● Hip External Rotation● Ankle Eversion

Questions?

References:Afzal, F. (2017). Role of Neonatal Reflexes in Development of Tone, Posture, Skills and Integration of Reflexes in Cerebral Palsy. International Journal of Medical Allied Health. 4 (1), (10-23).

Adolph, K. E., & Franchak, J. M. (2017). The development of motor behavior. Wiley Interdisciplinary Reviews: Cognitive Science, 8(1–2), e1430–n/a. https://doi.org/10.1002/wcs.1430

Allen, M.C., Capute, A.J. (1990). Tone and reflex development before term. Pediatrics, 85 (3 pt. 2), 393-399.

Brown-Belfort, M., Ramel, S. (2019) NICU Diet, Physical Growth and Nutrient Accretion, and Preterm Infant Brain Development. NeoReviews, 20 (7), 385-396.

Collett, B., Wallace, E., Kartin, D., Cunningham, C., and Speltz, M. (2019). Cognitive outcomes and positional plagiocephaly. Pediatrics,143 (2), 2018-2373.

de Groot, L. (2000). Posture and motility in preterm infants. Developmental Medicine and Child Neurology, 42(1), 65-68.

de Groot, L., Hopkins, B., Touwen, B.C. (1991). Development of the relationship between active and passive muscle power in preterms after term age. Neuropediatrics, 23, 298-305.

References Continued: de Groot, L., vd Hoek, A. M., Hopkins, B., Touwen, B.C. (1992). Development of relationship between active and passive muscle power in preterms after term age. Neuropediatrics, 23, (298-305).

de Groot, L., vd Hoek, A. M., Hopkins, B., Touwen, B.C. (1993). Development of muscle power in preterm infants: Individual trajectories after term age. Neuropediatrics, 24, 68-73.

Drake, E. (2017) Positioning the neonate for best outcomes. National Association of Neonatal Nursing.

Dubowitz,L.M.S, Dubowitz,V. (1999). The neurological assessment of the preterm and full-term newborn infant (2nd ed.). Clinics in Developmental Medicine (Vol. 148). Philadelphia: j.B. Lippincott.

Ferrari, F., Bertoncelli, N., Gallo, C., Roversi, M.F., Guerra, M.P., Ranzi, A., and Hadders‐Algra, M. (2007). Posture and movement in healthy preterm infants in supine position in and outside the nest. Arch Dis Child Fetal Neonatal Ed, 92(5): (386–390).

Grenier, I., Bigsby, R., Vergara, E., Lester, B. (2003). Comparison of motor self-regulation and stress behaviors of preterm infants across body positions. The American Journal of Occupational Therapy, 57(3), 289-297.

Guerra, C., de Moraes Barros, M., Goulart, A., Fernandes, L., Kopelman, B., dos Santos,. M. (2014). Premature infants with birth weights of 1500–1999 g exhibit considerable delays in several developmental areas. Acta Pediatrica. 103(1), 1-6.

References Continued: Hunter, J. (2010). Therapeutic Positioning: Neuromotor, Physiologic, and Sleep Implications. In C. Kenner, J.M. McGrath, (Eds.), Developmental Care of Newborns & Infants: A guide for Healthcare Professionals. 2nd ed. (285-331). Chicago, IL: National Association of Neonatal Nurses.

Lally. M., & Valentine-French. S. (2019). Lifespan Development. College of Lake County Foundation. http://dept.clcillinois.edu/psy/LifespanDevelopment.pdf.

Langston, S., Krakow, D., Chu., A. (2021).Revisiting Skeletal Dysplasias in the Newborn, NeoReviews, 22 (4) 216-229

Santos, J., Pearce, S., Stroustrup, A. (2015). Impact of hospital-based environmental exposures on neurodevelopmental outcomes of preterm infants. Current Opinion in Pediatrics, 27(2), 254-60.

Sharma, A., Cockerill, H., Ōkawa, N., & Sheridan, M. D. (2014). Mary Sheridan’s from birth to five years: children’s developmental progress (Fourth). London: Routledge

Side by Side Motor Development Video’s. (2020). Retrieved from https://pathways.org/side-by-side-motor-development-video-series/

Soleimani , F., Azari, N., Ghiasvand, H., Shahrokhi, A., Rahmani,N., Fatollahierad, S. (2020). Do NICU developmental care improve cognitive and motor outcomes for preterm infants? A systematic review and meta-analysis. Pediatrics, 13;20(1):67.

References Continued: Speltz, M., Collett, B., Stott-Miller M., , Starr, M., Heike, C., Wolfram-Aduan, A., King, D., Cunningham, M. (2010). Case-Control Study of Neurodevelopment in Deformational Plagiocephaly. Pediatrics, 125 (3), 537-542.

Sweeney, J., Gutierrez, T. (2010) The Dynamic Continuum of Motor and Musculoskeletal Development: Implications for Neonatal Care and Discharge. In C. Kenner, J.M. McGrath, (Eds.), Developmental Care of Newborns & Infants: A guide for Healthcare Professionals. 2nd ed. (235-251). Chicago, IL: National Association of Neonatal Nurses.

Vergara, E., Anzalone, M., Bigsby, R., Gorga, D., Holloway, E., Hunter, J., Laadt, G., , Strzyewski, S. (2006). Specialized knowledge and skills for occupational therapy practice in the neonatal intensive care unit. The American journal of occupational therapy. 60(6):659-68

Waitzman, K. (2007). The importance of positioning the near term infant for sleep, play and development. Newborn and Infant Reviews 7(2), 76-81.

Winders- Davis, D., Spruill Turnage-Carrier, C., Rector, L. (2010) Supporting Long-Term Development Beyond the NICU. In C. Kenner, J.M. McGrath, (Eds.), Developmental Care of Newborns & Infants: A guide for Healthcare Professionals. 2nd ed. (437-473). Chicago, IL: National Association of Neonatal Nurses.