3/4/2016 Objectives Neurobehavioral Assessment of High Risk Infants in the NICU • Discuss the purpose of the neurobehavioral exam. • Define different assessments available for use with high risk infants in the NICU. Bobbi Pineda, PhD OTR/ L Assistant Professor • Discuss how to administer and interpret assessment Program in Occupational Therapy, results. Department of Pediatrics Washington University School of Medicine , Co S Program in Occupational Therapy Program in Occupational Therapy How is My Baby Doing? Neonatal Assessment Myths • • Assessment of Risk: Medical Factors and Diagnoses Infants don’t do anything • Developmental functioning cannot be determined until • childhood Caregiver Report • Infants who sleep, poop, and eat look great! • • “Wait and see” is a good plan Advanced Imaging • • Parents and pediatricians always know the infant’s deficits EEG • CUS • MRI • I nfant Behavior Program in Occupational Therapy Program in Occupational Therapy What is the Neurobehavioral Comprehensive Evaluation is Critical to Assessment: Understand the Infant’s Whole Story… • • Functional evaluation of infant performance Self Regulation • CNS integrity • Attention • Incorporates the impact of environmental stress, brain injury, medical • Reflexes interventions, therapy • Movement • • Positional changes and challenges Relies on premise that each infant has inherent capabilities • • These capabilities can be altered by brain injury, disease, or the Feeding environment • Includes assessment of a wide range of responses Program in Occupational Therapy Program in Occupational Therapy 1
3/4/2016 Neurobehavioral Assessment Truths Behavior and Development • • Not something to address after all medical factors have Valid and reliable tools are available to assess during early infancy resolved. • Comprehensive evaluation of the young infant can uncover • Instead, something we should be addressing in tandem. strengths/ deficits related to foundations for later skill acquisition • Early identification can enable implementation of early intervention to optimize outcome • Neurobehavioral assessment can be used to guide parents to understand their infant’s strengths and areas of challenge Program in Occupational Therapy Program in Occupational Therapy Neurobehavioral Assessment in the NICU Knowing When to Assess… . • • Use caution and choose the right tools, based on the age, Special training and experience with high risk infants in the medical status, and vulnerability of the infant NICU • Stress and approach signals • Understand vulnerabilities of immature preterm infants and • Remain sensitive and flexible during any assessment understand complexities of engagement in the midst of medical complications • There are tools that rely on observation • Embrace change… • Others can be done when an infant is able to tolerate a diaper change without physiological compromise • There is an expanding repertoire of tools available as the infant’s medical factors resolve and as PMA advances Program in Occupational Therapy Program in Occupational Therapy Progression of Tolerance The Assessment of Handling • Not a painful procedure • Potential physiological compromise with any handling • Fluid, controlled movements • Learning, memory • Motor stress signs • It is an interaction • Short periods of handling with some compromise to • Responsive handling • states of arousal Sensitive • Can be therapeutic! • Increasing periods of alertness and tolerance of handling • Coping with environmental stressors and still available to interact with caregivers and meet needs (feeding) Program in Occupational Therapy Program in Occupational Therapy 2
3/4/2016 Why Are Assessments in the NICU First Year of Life Important? • Window of opportunity/ child ’ s brain becomes wired • High rates of developmental challenges among preterm • Early stimulation sets the stage for how children will learn infants and interact with others throughout life • Many infants have overcome medical barriers • Good or bad experiences affect the wiring of the brain and • Many can tolerate targeted interventions that can change connections to the CNS the foundations of early development and optimize • Stress results in increased cortisol, which causes brain cells outcome to die and reduces connections • Rapidly changing brain development • Window of opportunity Program in Occupational Therapy Program in Occupational Therapy Time in the NICU is Critical Too… 2 5 w eek • Rapid brain development • Neurobehavioral changes 3 0 w eek 3 3 w eek Term equivalent ( 3 7 w eeks) Program in Occupational Therapy Program in Occupational Therapy Premature Infants‐ Patterns of Development Developmental Consequences From 34 weeks Postmenstrual Age to Term • Evolution of developmental delay is evident by • Rapid changes in final 6 weeks of extra-uterine life term equivalent • • Our cohort: Changes in motoric function • Increasing hypertonia ( p < .001) • Compared to full term infants: • Decreasing hypotonia (p= .001) • Poor orientation ( p < .001) • Declining quality of movement ( p = .006) • Poor tolerance of handling ( p < .001) • Poor self regulation ( p < .001) • Changes in behavior • More sub-optimal reflexes ( p < .001) • Increasing arousal ( p < .001) • More stress ( p < .001) • Increasing excitability ( p < .001) • More hypertonicity ( p < .001) • Decreasing lethargy ( p < .001) • More hypotonia ( p < .001) • More excitability ( p = .007) Program in Occupational Therapy Program in Occupational Therapy 3
3/4/2016 Exploring the Early Development of the Assessment and Interventions Premature Infant in the NICU • Development in the NICU is not static • Tailored to the infant • Acquisition of medical factors and brain injury • Postmenstrual age • Brain development • Neurobehavioral changes • Medical status • Energy expense • Understanding early development can: • Other interactions • Allow a better understanding of factors that can be helpful or harmful in the NICU environment • Can equip the clinician with strategies to optimize development in the NICU • Environmental • Therapeutic • General positive experiences/Parenting Program in Occupational Therapy Program in Occupational Therapy WHAT DO NEONATAL NEUROLOGICAL & The Normal Newborn NEUROBEHAVIORAL ASSESSMENTS TYPICALLY INVOLVE? • Regulation/ State Cycling • Infant sleeps most of the day but wakes for 8-10 feedings per day • Muscle tone (active & passive; pattern of distribution) Greater emphasis in • Cries to indicate needs neurological examinations • Can self soothe • Reflexes • Hands to mouth/ hands to midline • Posture • Quality of movements • Physiological flexion-flexed hips, knees, and elbows with shoulder horizontal adduction • Relaxed tone at rest • Neurologic signs • Movement Patterns • Actively extends arms with return to flexion • Movements are mainly non-purposeful • In prone, infant raises head briefly • • Orientation / attention abilities Holds head in line with body when pulled to sit • In supported sitting, can right head to midline • In standing, supports weight and does stepping • Regulation (motor /physiologic /attentional /state) • Attention Greater emphasis in • Signs of stress • Visual focus and track neurobehavioral exams • Shifts gaze to auditory stimulation Program in Occupational Therapy Program in Occupational Therapy Breaking Down the Neurobehavioral Self Regulation • • Self Regulation Capacity to soothe him or herself when stressed • Motor • • Attention How the infant copes with the demands of the environment • Stress signs • Irritability/ excitability • Adaptive responses Program in Occupational Therapy Program in Occupational Therapy 4
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