COLLEGE OF

PHYSICAL THERAPY

Care for High Risk

Newborn
Maybelle Anne L. Zamora
PTRP MSPT
 COLLEGE OF
PHYSICAL THERAPY
The Physical Therapist’s Roles and Responsibilities in
Neonatal Physical Therapy:

• Screen neonates to determine needs for physical therapy referral.

• Examine neonates and interpret findings.
• Develop and implement a plan to prevent neurobehavioral
disorganization and complications of prematurity in multiple
systems.
• Design, implement, and evaluate the efficacy of intervention plans
in collaboration with the family and medical team.
• Develop and implement discharge plans in collaboration with the
family, medical team, and community resources.
-Author/s (Year)
 COLLEGE OF
PHYSICAL THERAPY
The Physical Therapist’s Roles and Responsibilities in
Neonatal Physical Therapy:

• Consult with providers of specialized equipment or services in preparation for

community-based care.
• Consult and collaborate with health care professionals, families, policy
makers, and community organizations to advocate for services to support the
development of neonates.
• Incorporate evidence-based literature into neonatal practice.
• Communicate, demonstrate, and evaluate neonatal physical therapy care
procedures with NICU professionals and other caregivers.
• Develop a physical therapy risk management plan.
• Evaluate the effectiveness of a neonatal physical therapy program.

-Author/s (Year)
 COLLEGE OF
PHYSICAL THERAPY

LEVELS OF NEONATAL CARE

Level I-Basic Neonatal Care COLLEGE OF
PHYSICAL THERAPY

Neonatal resuscitation at delivery

• Postnatal care and evaluation for healthy newborn
• Stabilization and care for physiologically stable late
preterm infants aged 35–37 wks gestational age
• Stabilization for ill infants and infants <35 wks gestation
prior to transfer

-Author/s (Year)
Level II Specialty Neonatal Care COLLEGE OF
PHYSICAL THERAPY

Level II A • Level I capabilities Level II B • Level II A capabilities

• Resuscitate and stabilize ill or • Provide mechanical ventilation or
preterm infants prior to transfer CPAP for <24 hr
• • Care for infants ≥32 wk gestation
and ≥1500 g
• • Provide care for infants
convalescing after intensive care

-Author/s (Year)
Care
COLLEGE OF
PHYSICAL THERAPY

Level III A Level III B Level III C

• Level II B capabilities • Level III A capabilities • Level III B capabilities
• Comprehensive care for • Provide advanced respiratory • Provide extracorporeal
infants <1000 g and born support membrane oxygenation
• <28 wk gestational age • On-site and timely access to (ECMO)
• Provide CMV range of pediatric • Provide surgery for complex
• Provide minor surgery (central medical subspecialists cardiac malformations
venous catheter placement or • Provide urgent and routine requiring cardiopulmonary bypass
inguinal hernia repair) imaging and interpretation
of results
• Provide major surgery (repair of
abdominal wall
defects, necrotizing enterocolitis,
myelomeningocele)

-Author/s (Year)
 COLLEGE OF
PHYSICAL THERAPY

PRACTICE PATTERN
Dynamic System Theory COLLEGE OF
PHYSICAL THERAPY

• All system components interact to

produce meaningful, functional
behaviour
• The infant’s biological makeup (ie,
physiologic, behavioral, physical,
social, and psychological elements);
• The sociocultural (ie, professionals and
family) and physical environments in
which neonatal movements and
postural control develop
• The task or goal of the neonate, such
as self regulation of physiologic
processes, behavioural state, posture
and movement, and attention to an
interaction with caregiver
Synactive Theory of Development COLLEGE OF
PHYSICAL THERAPY

• Describes a behavioral organization process of

subsystem interaction and interdependence
(synaction) as the neonate responds to the
challenges of the extrauterine environment.

-Author/s (Year)
Theory of Neuronal Group Selection COLLEGE OF
PHYSICAL THERAPY

• The brain operates as a selective system

• 3 tenets
• Developmental selection (Fetal Life)
• Experiential Selection (Post Birth)
• Reentrant Selection (Modified throughout lifetime)

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ICF Model COLLEGE OF
PHYSICAL THERAPY

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Family Center Model COLLEGE OF
PHYSICAL THERAPY

• Collaborative partnerships with families and

neonatal practitioners are the cornerstone for
caregiving success in neonatal physical therapy.
• Parents stress and anxiety

-Author/s (Year)
 COLLEGE OF
PHYSICAL THERAPY

MEDICAL ISSUES OF PREMATURITY

Respiratory Distress Syndrome COLLEGE OF
PHYSICAL THERAPY

• Pulmonary immaturity and inadequate pulmonary surfactant

(Type II)
• Antenatal steroids (24-34 weeks gestation)
• Clinical s/sx:
• Increased respiratory
• Rate, expiratory grunting, sternal and intercostal retractions,
• Nasal flaring, cyanosis, decreased air entry on auscultation,
• Hypoxia, and hypercarbia.

-Author/s (Year)
 COLLEGE OF
PHYSICAL THERAPY

• Ground glass appearance

• Mechanical Ventilaton
• Complications:
• ICH
• Retinopathy of prematurity
(ROP),
• Necrotizing enterocolitis
Patent Ductus Arteriosus COLLEGE OF
PHYSICAL THERAPY

• typically closes within 10 to 15

hours after birth (2-3 weeks
age)
• Oxygen (strongest stimulus)
prostaglandins
• S/sx
• Murmur
• Increased heart rate
• Respiratory distress
• Pulmonary edema
• CH
Hyperbilirubinemia (Physiologic COLLEGE OF
Jaundice) PHYSICAL THERAPY

• Accumulation of excessive
amounts of bilirubin in the
blood.
• Kernicterus (Athetoid CP)
• Etiology:
• Immature hepatic function,
increased
• Hemolysis of red blood cells
from birth injuries
• Polycythemia
Gastroesophageal Reflux COLLEGE OF
PHYSICAL THERAPY

• Involuntary movement of
gastric contents in a
retrograde fashion into the
esophagus and above.
(Lowes espophageal
sphincter)
• Poor oral feeding patterns
• Oral aversion,
• Excessive crying due to pain
Necrotizing Enterocolitis COLLEGE OF
PHYSICAL THERAPY

• Results from necrosis of the

intestinal mucosa, resulting in
intestinal infarction
• Bluish discoloration of
abdominal wall
• Poor weight gain
Germinal Matrix-Intraventricular COLLEGE OF
Hemorrhage PHYSICAL THERAPY

• MC type of brain lesion found

in premature infants (<1500 g
and at l<32 weeks’ gestation)
• Pre cursor to CP
• ICP monitoring
COLLEGE OF
PHYSICAL THERAPY
Periventricular Leukomalacia COLLEGE OF
PHYSICAL THERAPY

• Refers to specific areas of

white matter necrosis
adjacent to the external
angles of the lateral
ventricles.
• Frontal horn and body, and
optic and acoustic radiations.
Retinopathy of Prematurity COLLEGE OF
PHYSICAL THERAPY

• Vasoproliferative
disorder of the
developing retina
of premature
infants that can
potentially result
in visual
impairment and
blindness
 COLLEGE OF
PHYSICAL THERAPY

EXAMINATION AND SCREENING FOR

HIGH RISK NEW BORN
COLLEGE OF
PHYSICAL THERAPY
COLLEGE OF
PHYSICAL THERAPY
COLLEGE OF
PHYSICAL THERAPY
Computing for Corrected Age COLLEGE OF
PHYSICAL THERAPY

-Author/s (Year)
Review of System COLLEGE OF
PHYSICAL THERAPY

• Pre/Peri/Post Natal History

• Immunization
• Surgery
• Medication
• Complications
• Feeding Schedule
• Precautions
• Infection

-Author/s (Year)
Maternal History COLLEGE OF
PHYSICAL THERAPY

• Gravida (pregnancy)
• Parity (births) Full Term, Premature, Aborted, Living
• Example: G5P1223
• Five pregnancies
• 1 full term
• 2 premature
• 2 aborted
• 3 living

-Author/s (Year)
Corrected Age COLLEGE OF
PHYSICAL THERAPY

Formula: Corrected Age =Chronological Age- number of weeks premature

• Example: Baby XYZ is born 28 weeks (7months)
= 40 weeks (full term) – 28 weeks = 12 weeks premature

If Baby XYZ 6 months now (Chronological Age=24 weeks)

=24 weeks -12 weeks
=12 weeks (3 mos)
Therefore expect developmental milestones of a 3 months
old and above

-Author/s (Year)
APGAR Scoring COLLEGE OF
PHYSICAL THERAPY

• 1st 1 minute
• 5 minutes
• Apnea or bradycardia <6
(resuscitation)
• 3 to 4 indicates the need for
bag and mask ventilation
• 5 to 7 requires blowby
oxygen
Observation (Stable Infant) COLLEGE OF
PHYSICAL THERAPY

Area Signs
Autonomics • Smooth, regular respirations
• Pink, stable coloring
• Stable digestion
Motor • Smooth, controlled posture and muscle tone
• Smooth movements of extremities and head
• Hand/foot clasp, leg brace, finger fold, hand to mouth, grasp, suck,
tuck, hand hold
State • Clear, well-defined sleep states
• Focused alertness with animated facial expression

-Author/s (Year)
Observation (Stress Infant) COLLEGE OF
PHYSICAL THERAPY

Area Signs
Autonomics • Respiratory pauses, tachypnea, gasping
• Paling, perioral duskiness, mottled, cyanotic, gray, flushed, ruddy
• Hiccups, gagging, grunting, emesis, tremors, startles, twitches, cough,
sneeze, yawn, sigh, gasp
Motor • Fluctuating muscle tone
• Flaccidity of trunk, extremities, and face
• Hypertonicity of trunk and extremities
• Frantic diffuse activity
State • Diffuse sleep with twitches, jerky movement, irregular
• breathing, whimpering sounds, grimacing, and fussing
• Diffuse wakeful periods with eye floating, glassy-eyed, strained
appearance, staring, gaze aversion, panicked, dull look, weak cry

-Author/s (Year)
Neuromotor Assessment COLLEGE OF
PHYSICAL THERAPY

• Primitive Reflex
• Sensorimotor
• Cranial Nerve
• Muscle tone

-Author/s (Year)
Management COLLEGE OF
PHYSICAL THERAPY

• Parent Education
• Expected progress
• probable complications
• Financial stability and assistance
• Social support

-Author/s (Year)
Kangaroo Care COLLEGE OF
PHYSICAL THERAPY

• Skin to skin
Benefits
• Increased maternal milk
production
• Improved breast-feeding
• Opportunities for more
positive interactions with their
infant
• An overall more positive view
of their infant
Positioning COLLEGE OF
PHYSICAL THERAPY

• Neutral head and neck position

• Chin tuck
• Scapular protraction to promote
upper extremity flexion and
hands midline
• Flexion of the trunk with
posterior pelvic tilt
• Flexion of lower extremities with
neutral abduction/adduction and
rotation of the hips
Supported Prone Position COLLEGE OF
PHYSICAL THERAPY

• Nested or unnested, fewest

stress behaviors compared
with infants placed in either
side-lying or supine.
• C/I umbilical cord or NGT
• unsupported prone position
promotes shoulder retraction,
neck hyperextension, truncal
flattening, and hip
abduction/external rotation
Sidelying COLLEGE OF
PHYSICAL THERAPY

• optimal effects of side-lying are

symmetry and midline
orientation of trunk and
extremities, which promotes
hands to mouth
• respiratory diaphragm is placed
in a gravity-eliminated plane,
which lessens the work of
breathing.
• GER is decreased in left side-
lying,
• Gastric emptying is increased in
right side-lying
Joint range of motion COLLEGE OF
PHYSICAL THERAPY

• Small, transient increase in weight gain and bone

mineral density immediately after a protocol of
passive range of motion to multiple joints in all
extremities 5 times per week for 3 to 4 week

-Author/s (Year)
Therapeutic neuromotor handling. COLLEGE OF
PHYSICAL THERAPY

• Asymmetrical movements
• Atypical movements
• Provided after discharge from NCU
• NDT, Brunnstrum

-Author/s (Year)
Multimodal sensory stimulation COLLEGE OF
PHYSICAL THERAPY

• Tactile, vestibular, auditory, and visual stimuli

• Multimodal sensory stimulation may be contraindicated
for infants with periventricular leukomalacia.
• Benefits:
• Reduced heart rate
• Increased visual-auditory orientation
• Increased sensorimotor skills

-Author/s (Year)
References COLLEGE OF
PHYSICAL THERAPY

• Tecklin, Jan S. (2015), Pediatric Physical Therapy 5th

Edition
• Neonatal Physical Therapy. Part II: Practice
Frameworks and Evidence-Based Practice
Guidelines

-Author/s (Year)