Podcast Episode 16
Introduction
If you are a NICU parent, it is very likely that you have interacted with an occupational therapist either while your baby was in the NICU or once they were discharged home with early intervention. But, what is a Neonatal Occupational Therapist? What is their role in the NICU and with Early Intervention?
For our 16th podcast episode, I sat down with Tracey Kondrasuk-Brander, a certified neonatal and early intervention occupational therapist. She explains the all-important role of the occupational therapist in the NICU and why it is so crucial for premature and critically ill infants to receive therapy while they are in the NICU as well as once they are discharged home.
Tracey and I discuss the importance of developmentally appropriate positioning of infants in the NICU and two-person care. We review why premature infants benefit from being positioned in a supportive, flexed position. Tracey explains how developmentally-supportive positioning for NICU infants places them into a calm state and ultimately improves their long-term neurodevelopmental outcomes.
We discussed the necessity of providing continual education to the parents regarding their infants development. While their infant is in the NICU, parents should be educated on proper positioning and developmental care as well as range of motion activities. In preparation for discharge, parents are educated on specific activities to focus on at home. And finally we break down the difference between an infant’s chronological or actual age versus their corrected gestational age (CGA). We discuss why accurately understanding the CGA plays such an important role in the parental expectations of and the infant’s ability to achieve each of their developmental milestones.
Tracey has over 20 years of experience with NICU infants and she is very passionate about her work within our special NICU population. I know you will learn some valuable information from our discussion!
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Meet Tracey Kondrasuk-Brander
Tracey lives in York, Pennsylvania and has 3 children. She is a Certified Neonatal and Early Intervention Occupational Therapist, Sleep Consultant and Massage Therapist. She has worked with premature infants and infants from birth to 3 years of age for over 22 years. She is the owner of Early Developmental Therapy Consultants and SleepTimeOT.
After her initial career left her questioning her long-term goals, she went back to school and became an occupational therapist. After 2 years in long-term care, she transitioned to acute care and eventually the NICU. She took several courses and achieved certifications in positioning, infant massage, NDT (neurodevelopmental therapy), became a feeding specialist, then a certified Neonatal Therapist. She avidly worked to help build the therapy program in the Level III NICU where she worked for 23 years.
Role of an Occupational Therapist in the NICU
A successful team approach
Therapy in the NICU needs to be a team approach. From an automated order placed by the provider for extremely premature infants, to collaboration with nursing, providers, and therapists for timing of assessments, lab draws, and developmentally appropriate positioning are all essential for appropriate developmental care in the NICU.
Developmentally appropriate positioning is crucial for premature, fragile, and critically ill neonates. Occupational therapists help to educate and guide the NICU care team and parents on beneficial positions for all of the infants in the NICU based on their clinical condition, IV lines, and additional equipment.
What is a Small Baby Unit and Two-person care?
Small Baby Units were developed in attempts to mimic the womb of the mother with the goal to improve outcomes for extremely low birthweight (EBLW) infants. The SBU is typically equipped for infants less than 28 weeks or those who weigh less than 1000 grams.
Without proper collaboration, frequent handling of preterm infants with their cares and diaper changes, disturbs their sleep and ultimately results in negative effects on their weight gain and brain development. Research has found significant benefits to infants receiving cares based on their cues, sleep, and arousal patterns. The infant’s care times, diaper changes, and position changes will be done once the nurse notices a change in the baby’s vital signs suggesting they are waking from their sleep.
Additional long-term neurodevelopmental benefits have been shown with two-person care. Once the infant shows cues of their arousal, two people will assist during their assessment, lab draws or painful procedure. The assessment is done slowly and guided by the infant’s tolerance of the exam and/or procedure. If parents are present, they can be and should be educated on how to be the second set of hands. With two-person care, one person will gently help to keep the baby contained with their extremities flexed to help minimize energy expenditures and additional stress for the baby while the other person performs the exam and/or procedure.
For me information on Small Baby Units, click below.
Why should preterm infants be placed in a flexed position?
As we mentioned, preterm infants no longer having the womb to ensure their flexed position, it is up to the NICU care team to support their development appropriately. It is also important to teach the parents about the rationale for developmentally supportive positioning. Many units utilize positioning aids in the NICU to support a preterm infant’s flexed position. The positioning devices help to keep the infant’s knees, ankles, elbows, and hands in the midline position.
Tracey explained that when an infant is in a flexed position, it keeps their hands and knees midline. The flexed, midline position improves a preterm infant’s muscle tone, builds a more mature nervous system, and places them in a calm state.
Without supportive positioning, an infant may go into a “fight or flight” response activated by the sympathetic nervous system due to all of the overstimulation infants experience in the NICU. While in a flexed position, with either positioning aids, two-person care or with swaddling in older infants, Tracey reviewed how it activates the parasympathetic system and results in a a calm, relaxed state. In this state, it will minimize their pain, reduce their stress, so they can suck on a pacifier or their fingers in a soothing way.
Developmentally appropriate positioning in preterm infants assists in them achieving more periods of deep sleep as well which promotes brain maturation and development. Proper positioning also helps to minimize positional anomalies for preterm infants. Preterm infants are prone to torticollis, a flattened head, “W” sitting, tight muscles and/or low tone. With appropriate developmental care, infants are better equipped to reach their developmental milestones in the future. As Tracey explains, all of the components of developmentally supportive care build on one another and ultimately help with the infant’s long-term neurodevelopmental outcomes.
How to help parents with the transition to home
Parents are bombarded with information throughout their baby’s NICU stay. But, as previously mentioned, parents should also be educated on the importance of their infant’s developmental care while in the NICU and in preparation for home. Parents need to be taught about infant massage, range of motion exercises, positioning and feeding. Tracey said when she worked in the NICU, she would coordinate a time with parents to meet and review proper positioning, the need for appropriate tummy time, and specific areas to focus on for their individual infant.
Each individual infant and their discharge plan of care will be different. Many infants in the NICU will be followed by early intervention as well. Tracey pointed out that if any paperwork can be prepared beforehand to minimize the stress for parents and to prevent any delay of early interventional services is helpful.
What is the difference between chronological age and corrected gestational age?
Tracey explained the difference between an infant’s chronological age versus corrected gestational age (CGA) and why it is so important to understand when considering a preterm infant’s development.
Chronological age is the infant’s age in days, weeks or months from their actual birthday. Corrected gestational age (CGA) or adjusted age factors in or corrects for the baby’s prematurity. For example, an infant born at 24 weeks gestation who is now 5 months old would have a corrected gestational age of 1 month.
How to calculate a baby’s corrected gestational age
(infant’s actual age) – (weeks or months of prematurity) = (corrected age)
5 months – 24 weeks (4 months early) = 1 month corrected
Why is it so important to factor your baby’s corrected gestational age?
It is important to adjust for an infant’s prematurity for several reasons. First, all of those weeks the infant was born early are weeks that they missed out on intrauterine growth and development. We need to give those infants credit for the months they missed in utero. As much as we try to mimic the womb, it is impossible to completely do so.
Secondly, premature infants will develop more like their corrected gestational age as opposed to their chronological age. Meaning, as in our example above, a former 24 weeker, who is now actually 5 months old will developmentally act more like their corrected age of 1 month. The developmental milestones they are achieving will be those of a 1 month old, not a 5 month old.
Finally, for parents of premature infants, it is important for them to be fully educated on their infant’s corrected gestational age and what developmental milestones their baby should be achieving. If the parents are fully educated and prepared, they will not blame themselves or feel guilty if they believe their infant is falling behind developmentally.
What every parent of a NICU baby should remember?
Tracey offered some great advice for NICU parents. Parents should remember take a breath and not only show their babies some grace, but also themselves. In the first few days, weeks, or months, remember that your baby was fighting for their life. To get to the point to where they are today, required a large amount of their energy to live and breathe. Tracey reminded us, they will catch up in their own time.
As parents of babies who have spent time in the NICU, we must remember, that every baby is different. You cannot compare your infant and their progress to other infants. A 34 week infant will tend to catch up and sooner than a 24 week infant. Try to remain focused on your individual infant and all of their progress. As long as you are doing the proper follow-ups, exercises at home, and you see your infant progressing and improving, you are on the right track!
Closing
Tracey has such great information! She is so knowledgeable about proper positioning of our NICU infants and I love her simple explanation on the importance of why our infant’s should be placed in a comfortable, flexed position. It was a great reminder of how it helps to calm them from the overstimulating NICU environment they are constantly exposed to as well as improve and build a more mature nervous system.
I also hope the review on chronological age versus corrected gestational age brought you some clarity. It can be quite confusing, but it is an important concept to grasp especially if you have a premature infant. As you may already know, but it was reviewed today, your premature infant’s age is corrected up until they are 2 years old. This time allows them time to catch up with their developmental milestones since they were born so early.
Lastly, remember that each individual infant and when they reach their individual milestones will vary. The adjusted age provides parents with a better idea of what developmental milestones their infant should be achieving as opposed to their chronological or actual age.
If you are a NICU parent, make sure you give yourself and your baby some grace. Remember to focus on and follow your baby’s overall progression as a whole rather than comparing them to other children.
Tracey Kondrasuk-Brander
Early Developmental Therapy Consultants
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