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5/2/2017
1
Welcome to the NICU Consortium
April 26, 2017
Agenda
9:00 am Welcome, Announcements
9:15 am Primitive Reflexes: Implications for infants and children home from the NICU
Jennifer Spiric, PT, DPT
10:15 am Break
10:30 am Early Intervention and Family Centered Developmental Care; servicing NICU graduates and their families. Why is this approach best practice?
Petora Manetto-Spratt, PT, DPT, PCS
11:30 am Adjourn
May 5, 2017 10 am to 11:45 am Jefferson County Department of Public Health
NICU Consortium Steering Committee and NICU Consortium Partnership Meeting
Building Partnerships
• 2016-2017 Pregnancy-related depression & anxiety public awareness campaign
Healthy Start
“Healthy Babies, Strong Families”
Families Forward Resource Center (FFRC) has an
opportunity to engage African American/Black women in an
open discussion about the rising infant mortality rate in our
community. Healthy Start addresses the underlining issues to
infant mortality such as: poverty, psychosocial issues, drugs
and health. Research has shown that infant mortality rate in
on average 3 times higher for African American/Black woman
in our community than for any other race.
March of Dimes Colorado Mission improve the health of babies by preventing birth defects,
premature birth and infant mortality.
• Our goal is to reduce Colorado’s current premature birth rate from 8.7% to 8.1% by 2020 and 5.5% by 2030.
•To reach these goals, our priorities for 2017-2020 are:
1. Increasing access to progesterone shots (“17P”) for women with a previous preterm birth
2. Optimizing birth spacing and pregnancy intentionality
3. Expanding access to group prenatal care
4. Improving health equity to reduce the number of preterm births among the non-Hispanic black population
“17 P” - What are progesterone shots? (AKA “17P”)
• Synthetic form of progesterone (a key pregnancy hormone) given by injection
• Reduces a woman’s risk of recurrent preterm birth by 33%
• One of the strongest clinical risk factors for preterm birth is a prior preterm birth1
• Maternal history of preterm birth confers a 1.5-fold to 2.0-fold increased risk for preterm birth in a subsequent pregnancy1
Primitive Reflexes Implications for infants and children home from the NICU
Jennifer Spiric, PT, DPT
Kids In Motion
Of Spiric Therapies, LLC
Pediatric Physical Therapist
Movement specialist
Child-led therapist
Developmental analyst
Mommy
Kids in Motion,
of Spiric Therapies, LLC
5/2/2017
2
Objectives 1. Understand the concept of a primitive reflex
2. Learn integrated movement patterns associated with three
important primitive reflexes
3. Understand the difference between an integrated and non-
integrated primitive reflex pattern
4. Learn how to identify signs and symptoms of non-integrated
reflexes in children who spent time in the NICU
5. Learn several strategies to help children integrate reflexes
to move and learn more freely
Kids in Motion,
of Spiric Therapies, LLC
So what is a reflex??
Stimulus
Movement
Kids in Motion,
of Spiric Therapies, LLC
A reflex is an unconscious, protective movement pattern
based on sensory stimuli from the environment.
And what are primitive reflexes?
Kids in Motion,
of Spiric Therapies, LLC
Primitive Reflexes are…
• Unconscious movements
• Based on genetic motor programs typical for all humans
• Variable in their presentation, integration, and form
• Foundational for coordinated conscious movements throughout
childhood and adulthood
• Related to all areas of development (motor, vision, sensory
system, speech/language, cognitive, emotional, behavioral)
• Permanent motor plans, but more or less visible/strong based
on life events
Kids in Motion,
of Spiric Therapies, LLC
A few primitive reflexes
Suck- swallow- breathe
Rooting
Asymmetrical Tonic Neck (ANTR)
Symmetrical Tonic Neck (STNR)
Tonic Labyrinthine (TLR)
Spinal Galant
Pull to sit
Moro
Landau
Babinski
Automatic gait
Protective extension
Trunk extension
Hands/toes grasp
Robinson Hands Grasp
Leg Cross Flexion-Extension
Foot tendon guard
Bauer crawling
Babkin Palomental
Spinal Perez
Kids in Motion,
of Spiric Therapies, LLC
Asymmetrical
Tonic Neck
Reflex (ATNR)
• “Fencer Pose”
• Typically active until age 4-6mo
• Foundational for rolling
• Impacted by torticollis
• Commonly affected in pre-maturity
• Essential for auditory development
• Important for auditory-visual coordination
Kids in Motion,
of Spiric Therapies, LLC
5/2/2017
3
Non-integrated ATNR reflex
symptoms • Difficulty with attention/focus
• Difficulty with sleep
• Difficulty eating
• Poor memory
• Easily over-stimulated in loud environments
• Difficulty reaching across midline
• Difficulty remembering R and L sides
• Mixed hand dominance
• Difficulty with throwing and catching
• Impacted coordination with running, swimming, skating
• Poor handwriting
Kids in Motion,
of Spiric Therapies, LLC
WAIT!
“Non-integrated”??
Tonic Labyrinthine
(TLR) • When lying on tummy, arms and
legs are bent. When lying on back,
neck extensors and hip extensors
(kicking muscles) are active.
• Typically integrates at age 4 mo
• One of the biggest purposes of this
reflex is to move through the birth
canal
• Affects muscle tone
• Lays foundation for rolling,
crawling and walking
Non-integrated TLR reflex
symptoms • Fetus descended or C-section birth due to breech position
• Muscle reactivity or spasticity
• High or low muscle tone
• Decreased head righting reactions
• Poor posture
• Fear of heights or poor depth perception
• Impaired coordination
• Late crawling and/or late walking
• Dislikes swings, slides, gets dizzy/car sick easily
• Decreased endurance/early fatigue during physical activity
Spinal Galant • Activated when infant is lying
on stomach or side and is touched on the right or left side of spine
• Typically integrates by age 5-9mo
• Impacted by torticollis
• Affects digestion
• Foundational for trunk rotation in hands/knees crawling and arm swing in walking
• Impacts sensory integration
Kids in Motion,
of Spiric Therapies, LLC
Non-integrated Spinal
Galant reflex symptoms
• Incorrect hip rotation (apparent hip dysplagia)
• Scoliosis
• Enuresis, incontinence (including bedwetting), constipation, irritable bowel syndrome
• Difficulty with hands and knees crawling (prefers butt scooting, or non-reciprocal army crawl)
• ADHD
• Difficulty following instructions, decreased auditory processing
• Unable to sit still
• Poor posture
Kids in Motion,
of Spiric Therapies, LLC
5/2/2017
4
Integration Extinction
Kids in Motion,
of Spiric Therapies, LLC
Impact of NICU
environment on reflexes • Noise level
• Sleep/wake cycles
• Trauma (emergent birth, infection, illness, decreased time with biological mother, difficulty feeding/breathing, sensory overstimulation, etc)
• Surgeries
• Lines, tubes, machines
• Sudden or frequent unexpected movements
• Positioning
• Decreased proprioceptive input on all sides of neonate (front, back, sides), than other fetuses experiencing in the womb
Kids in Motion,
of Spiric Therapies, LLC
So…now that you’ve identified
non-integrated or affected
primitive reflexes…
What can you do?
Kids in Motion,
of Spiric Therapies, LLC
• Identify non-integrated primitive reflexes EARLY
and refer infant/child to physical, occupational
or other movement therapist
• Complete reflex integration continuing education
• Utilize positioning tools and blankets to provide
neonates and infants with natural
proprioceptive inputs (comfortable tightness) in
body alignments that make sense from a
reflexive standpoint
• Make tummy time frequent and FUN!!
• Help infants smoothly move from one position to
another during functional routines (lots of gentle
rolling, frequent visual tracking and reaching
opportunities, pulls to sit from diaper changes,
sitting up flowing through sidelying or hands and
knees instead of just placing child in sitting, etc) Kids in Motion,
of Spiric Therapies, LLC
Promote symmetry, symmetry,
symmetry!!!
Kids in Motion,
of Spiric Therapies, LLC
Tummy time ideas
Kids in Motion,
of Spiric Therapies, LLC
5/2/2017
5
Kids in Motion,
of Spiric Therapies, LLC
Move freely, learn effortlessly!
Kids in Motion,
of Spiric Therapies, LLC
Resources: • Masgutova Neurosensorimotor Reflex Integration (MNRI)
https://masgutovamethod.com/become-an-mnri-student
• Rhythmic Movement Training
http://rhythmicmovement.org/
• Brain Balance
https://www.brainbalancecenters.com/
• Pathways.org
• Brain Gym
http://www.braingym.org/about
Kids in Motion,
of Spiric Therapies, LLC
Thank you!!
Jennifer Spiric, PT, DPT
Kids in Motion,
of Spiric Therapies, LLC
kidsinmotionCO@gmail.com
Break Announcements and Updates
NICU Consortium Fellows – Please consider supporting the NICU Consortium by becoming an NICU Consortium Fellow – Only $25.00/year. Information on the Special Kids, Special Care Website
Benefits include:
• Certificate of Professional Development Education for 2 hours when you attend one of the NICU Consortium Meeting/Webinars and complete the program’s evaluation survey
• Recognition in the NICU Consortium newsletter, unless you prefer not to be acknowledged publicly
• “Fellows” registrations fees on other Special Kids, Special Care educational offering such as:
– Interdisciplinary Institute – held bi-annually
– NCAST Programs – Feeding and Teaching Scale
– Annual workshops
NICU Consortium Champions - represent small businesses, non-profit organizations, individuals, and
community and state organizations that care about families who have had a baby in the Neonatal Intensive Care Unit (NICU). We want to recognize your partnership n our continuing efforts to support families through the NICU Consortium Educational Meetings/Webinars, the NICU Consortium newsletter , and on the NICU Consortium webpage. For more information check out the Special Kids, Special Care website.
Special Kids, Special Care Website: www.specialkids-specialcare.org
Early Intervention and Family Centered Developmental Care; servicing NICU
graduates and their families. Why is this approach best practice?
Presented by Petora Manetto-Spratt, PT, DPT, PCS
Presented to the April 2017 NICU Consortium Meeting/Webinar
April 26, 2017 Colorado Department of Public Health and
Environment All slides are property of Petora Manetto- Spratt
Reproduction or distribution of slides is prohibited without written permission.
5/2/2017
6
DISCLOSURE
I have no actual conflict of interest or disclosures in relation to this presentation.
Objectives:
Understand what Early Intervention is, how it differs from medical model of service, and how infants and toddlers could benefit from EI services
Be able to access the resources for Early Intervention in Colorado and other states
Objectives (cont):
Acquire a brief knowledge of family centered
developmental care
Be aware of why provision of Early Intervention services for the NICU population and their families requires a specialized approach and be provided some evidence supporting this approach
Be introduced to the process that a small group of Early Intervention providers in the metro area have undergone, the development of this process, and its progress.
What is Early Intervention (EI)
Early intervention is a coordinated system to promote age appropriate growth and development, during the early years of
birth through two years of age, while supporting families in the process.
Early Intervention supports the development of the child within the family’s activities and community life
Brief History
1986- Congress established the Part C program of the IDEA (Individuals with Disabilities Education
Act) which is The Program for Infants and Toddlers with Disabilities
• Part C of IDEA requires "to the maximum extent appropriate to the needs of the child, early intervention services must be provided in natural environments, including the home and community settings in which children without disabilities participate." (34 CFR §303.12(b)).
• It is a federal grant program
Brief History (cont) • Provides services to children ages birth through age 2 years
and their families
• 2004- President Bush signed legislation reauthorizing IDEA
• Program participation is voluntary
• If a State is to participate, it is required that every eligible child and its family must have EI available
• All 50 states and eligible territories presently participate in the Part C program
http://ectacenter.org/contact/ptccoord.asp
5/2/2017
7
Brief History (cont)
• Child Find operates in every state to identify babies and toddlers who need early intervention services because of developmental delays or disability.
• States have some discretion in setting eligibility
• Eligibility is based on diagnosis-established condition database
http://www.eicolorado.org/index.cfm?fuseaction=diagnoses.main
• States also differ on which state agency will be the lead agency
• Lead Agency who manages the grant and administers the program is designated by the Governor
Early Intervention in Colorado
• Lead Agency in Colorado is the Colorado Department of Human Services (CDHS), Office of Early Childhood, Division of Community and Family of which EI Colorado is the program (www.eicolorado.org/)
• The Colorado Interagency Coordinating Council (CICC) is mandated by federal law and is appointed by the governor to advise and assist the lead agency to implement the requirements of Part C
• Twenty Community Centered Boards(CCB’s) are contracted throughout the state of Colorado provide EI services
Qualification for EI Services
• Qualification varies among states
• In CO- need 25% or greater delay in one or more areas of development when compared with chronological age
• Automatic Qualifiers
• Have an existing delay or child is at risk of developing a delay-Requires evaluation for determination
• Informed clinical opinion of professionals
PROCESS
• Once determined eligible and referral is made, 45 days until the Individualized Family Service Plan (IFSP) needs to be completed
• Areas addressed in the IFSP: Physical, Cognitive, Communication, Social Emotional, Self Help/Adaptive. Additionally Hearing and Vision if needed
• 28 days from IFSP completion for services to begin
Services Provided through EI in CO
• Assistive Technology Services
• Audiology Services
• Developmental Intervention Services
• Health Services
• Medical Services
• Nursing Services
• Nutrition Services
• Occupational Therapy Services
• Physical Therapy Services
•Psychological Services
• Sign Language and Cued Language Services
• Social Emotional Services
• Speech Language Pathology Services
• Transportation Services
• Vision Services
EI vs. Medical Model Services
• Medical Model- PT, OT, SLP- hospital, clinic, home health based
• EI-Family centered model
• How does child benefit from EI?
5/2/2017
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Family Centered Developmental Care
• Family-centered care in the neonatal environment is the active partnership of the parents in the infant's care plan and delivery of care supporting the integrity of the family to promote infant and parent health [Byers et al., 2003].
Developmentally Supportive Care
• Definition: Care of an infant to support positive growth and development while allowing stabilization of physiologic and behavioral functioning - [National Association of Neonatal Nurses-2000]
• Newborn Individualized Developmental Care and Assessment Program (NIDCAP) provides developmentally supportive care in the NICU
Supporting Evidence • There is a relationship between developmentally supportive, family-
centered care and fewer behavioral stress cues, reduced parental anxiety,
reduced parenting stress, and increased comfort level and confidence
[Cooper, LG, 2007; Byers et al, 2006].
• Parents of infants who require hospitalization in the NICU experience a
great deal of stress largely due to the change in the anticipated
relationship with their infant [Browne et al, 2004; Cooper, LG, 2007].
Supporting Evidence • Preterm infants are at increased risk of persistent difficulties
across all developmental domains [van Baar, van
Wassenaer, Briet, Dekker, & Kor, 2005].
• Deprivation of developmentally appropriate experience may
reduce neural activity resulting in profound abnormalities in
brain organization and structure [Anda et al, 2006].
• In a Cochrane review of developmental care including 36
randomized clinical trials (RCTs) of both general and
individualized developmental care, some benefits and no
harmful effects were reported from neonatal developmental
care to infants born prematurely [Sweeney et al, 2010].
Supporting Evidence • Marked improvement in the survival rates among very
preterm infants born less than 30 wks gestation over past decades -[Holsti et al, 2002; Saigal et al, 2008]
• Working with these vulnerable infants with complex medical, physiological, and behavioral conditions requires a pediatric (physical therapist) with advanced and expanded training [Sweeney et al. 2009].
• There is often a delay or even a absence in the delivery of service [Pineda et al, 2013].
NIDCAP Approach
Transferred to EI
Environment, cont.
The “fourth trimester,” is a time when newborns are
both recovering from medical interventions and are
developing a basic foundation of regulatory skills on
which to build more typically defined developmental
milestones [Browne & Talmi, 2012].
5/2/2017
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A recent survey of educational needs of Colorado professionals working with fragile newborns and young infants revealed that many EI providers felt only slightly prepared to evaluate newborns and young infants and that most felt they could benefit from more training on assessment and intervention with this population [Browne & Talmi, 2012].
ship
Family-centered care in the neonatal environment is the active partnership of the parents in the infant's care plan and delivery of care supporting the integrity of the family to promote infant and parent health [Byers et al., 2003].
There was a particular need for
providers to understand the mental
health of the family and support the
parent-child relationship.
How It All Started
North Metro NICU Task Force formed in 2009
Task Force Vision Statement: All infants who begin their lives in the NICU will grow and
develop to their maximum developmental, cognitive, and social-emotional potential
Why We Felt the Need
• Assessment tools not specific enough
• Infants from the NICU under identified
• Poor social availability, difficulty feeding, poor regulation of sleep-awake cycles
• Team Trained by Drs. Joy Browne and Ayelet Talmi
• FIRST Training - Family Infant Relationship Support Training
• BABIES Model - (Biophysiological, Arousal and Sleep, Body Movement, Interaction, Eating and Self Soothing)
• Guided Observation of Premature Infant
• Case Study Reviews and Reflective Supervision with Trainers
Training Next Steps
• In 2013, another statewide survey was performed and similar results showed the need for training of EI providers in a developmentally supportive model of care
• Attempts to get more CCB’s on board to be trained were addressed
• In 2013, another CCB in the Denver area entered into a 12 month learning collaborative (LC) with Joy Browne and were trained in the FIRST and BABIES Model
• Presently a third CCB in the Denver area has started a year long LC
5/2/2017
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BABIES Model
• BABIES Model is based on concepts of NIDCAP
• BABIES Model can be used in training EI providers to provide and coach parents to provide developmentally-supportive care in the EI setting
BABIES Model
BABIES - Body Function
Arousal and Sleep
Body Movement
Interaction with others
Eating
Self Soothing
PreSTEPS - Predictability and continuity
Self-soothing supports
Timing and pacing
Environmental modifications
Positioning and handling
Sleep and arousal organization
BABIES Model (cont.) BABIES Model Relation to NIDCAP • BABIES is based on NIDCAP
• Detailed observation of the infant’s behavior before, during, and after – guides intervention and suggestions for caregiving
• Effect of stress on infant caregiver relationship
• Joint Reflection and assessment trained providers
-[Gretchen Lawhon, PhD, RN; Rod E. Hedlund, MEd J Perinat Neonat Nurs. Newborn Individualized Developmental Care and Assessment Program Training and Education. 22:2; 133–144 2008]
Results from the Adams County Team
• In 3 years, percent of referrals who actually received services almost doubled.
• All providers reported an increase in knowledge; greatest improvement was in Eating subset.
• Goals and objectives have been met as evidenced
by evaluations using the PSI and pre- and post-
retrospective surveys.
• Providers have found a change in practice since
being trained in this model and have seen improved
outcomes.
Results from the Adams County Team
Caregivers reported:
1. Knowledge of how to care for infant more than doubled.
2. Ability to read infant communication increased by 2/3.
3. Ability to encourage development more than doubled.
4. Closeness between parent-infant increased by a 1/3.
5. Confidence in parenting increased by more than 2/3.
6. Ability to handle stress improved by more than half.
5/2/2017
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Our NICU Team Today
• Team has been functioning almost 7 years. Consists of PTs, OTs, SLPs, IMH specialists, an RN, a dietician, and EI service coordinators. Several providers are bilingual.
• Providers found a change in practice since being trained in this model, reporting an increased knowledge; greatest improvement was in Eating subset.
• In the 3 year pilot project, percent of referrals who actually received services almost doubled.
• Goals and objectives were met as evidenced by evaluations
using the PSI and pre- and post- retrospective surveys.
• Collaboration with stakeholders to make for better
transitions between NICU and community
Thank you!
REFERENCES 1. http://www.wrightslaw.com/
2. http://ectacenter.org/
3. http://www.eicolorado.org/
4. Byers JF. Components of Developmental Care and their Evidence for use in the NICU. Am J Matern Child Nursg.. 2003;28: 175-180.
5. National Association of Neonatal Nurses-2000
6. Browne JV, Sanchez E, Langlois A, Smith-Sharp S. From visitation policies to family participation guidelines in the NICU.The experience of the Colorado Consortium of Intensive Care Nurseries. Neonatal,Paediatric and Child Health Nursing. 2004;72:16-20.
7.Cooper LG. Impact of Family centered care Initiative on NICU care, staff and families. J Perinatal.2007:27:S32-S37.
8 .van Baar AL, van Wassenaer AG, Briet JM, Dekker FW, Kok JH. Very preterm birth is associated with disabilities in a multiple developmental domains. J Pediatr Psychol.2005; 30(3): 247–55.
9. Anda RF, Felitti VJ, Bremner J.D, Walker JD., Whitfield C, Perry BD, et al. The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology. European Archives of Psychiatry and Clinical Neuroscience. 2006; 25:174-186.
REFERENCES (cont) 10. Sweeney JK, Heriza CB, Blanchard Y, PT, Dusing SC, Neonatal Physical Therapy. Part II: Practice Frameworks and Evidence-Based Practice Guidelines: Pediatr Phys Ther 2010;22:2-16.
11. Holsti L, Grunau RV, Whitfield MF. Developmental coordination disorder in extremely low birthweight children at nine years. J Dev. Behav. Pediatr 2002.Feb;23(10):9-15.
12. Saigal S, Doyle LW. An overview of mortality and sequelae of preterm birth from infancy to adulthood.Lancet.2008;371(9608):261-269.
13. Sweeney JK, Heriza CB, Blanchard Y. Neonatal Physical Therapy. Part I: Clinical Competencies and Neonatal Intensive Care Unit Clinical Training Models. Pediatr Phys Ther. 2009; 21:296 –307.
14.Pineda RG, Castellano A, Rogers C, Neil J, Inder T,. Factors Associated With Developmental Concern and Intent to Access Therapy Following Discharge From the NICU. Pediatr Phys Ther.2013;25:62–69.
15. Browne J, Talmi A. Developmental Supports for Newborns and Young Infants with Special Health and Developmental Needs and Their Families: The BABIES Model. Newborn & Infant Nursing Reviews. 2012;12(4):239-247.
16. Gretchen Lawhon, PhD, RN; Rod E. Hedlund, MEd J Perinat Neonat Nurs. Newborn Individualized Developmental Care and Assessment Program Training and Education. 22:2; 133–144 2008.
Newborn Hope for their support of the “Safe Sleep Going Home” Program
HCP – Colorado Department of Public Health and Environment, Program for Children with Special Health Care Needs for their continued support of the NICU Consortium Educational Meetings /Webinar
Thank You to our Grantors, Sponsors, and
In-kind Contributors
Tri-county for their support implementing the Consortium and the NICU Outreach and Transition Partnership
University Hills Rotary for their support of the “Safe Sleep Going Home” Program
NICU Executive Committee
Chair/Secretary
• Carolyn Kwerneland Tri-county Health Department - HCP Coordinator
Co-chair
• Lori McLean, RN, BSN Boulder County Health Department - HCP Coordinator
Treasurer
• Sarah McNamee, LCSW McNamee and Associates
NICU Representatives
• Kathy Farnum, RN, BSN, CCM Case Manager NICU North
Children’s Hospital Colorado
• Kendra Perkey, MS, RD, CNSC NICU Dietitian/Supervisor
Rocky Mountain Hospital for Children
Community Representative/ SKSC BOD
Liaison
• Renee Charlifue-Smith, MA, CCC-SLP University of Colorado Denver, JFK Partners,
ENRICH
• Sophia Yager, RN, BSN Nursing Supervisor
Jefferson County Public Health,
Parent Representative
• Amber Minogue Mom of Olive and Riley
Denver, Colorado
MCH Nursing Consultant
• Barbara Deloian, PHD, RN, CPNP,
IBCLC Special Kids, Special Care
5/2/2017
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NICU Consortium Meeting
• Next Meeting – July 26, 2017
9 AM to 11:30 AM
If you would like more information about the NICU Consortium Steering
Committee and NICU Consortium Partnership Meeting on May 5, 2017 10 am to 11:45 am, please contact Barbara
at -
www.specialkids-specialcare.org
specialkids@sk-sc.org
Special Kids, Special Care Sign Up
For info about either of these program send Barbara an e-mail at: specialcare@sk-sc.org NICU Outreach: Safe Sleep Going Home Program: Wearable Sleep Sac Blanket Requests
Family Support Grant - Applications for newborn cribs, respite care, lactation consultation, or other health support services needed by families
To receive announcement about future NICU Consortium Meetings, the newsletter, or other information, please sign up on the website Website: www.specialkids-specialcare.org
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