long term developmental consequences of positioning after
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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
Neonatal therapists, nurses and professionals have a unique opportunity to observe and promote development.
Sweeney & Gutierrez, 2002
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)
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),
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
Definitions: ● Scapular Retraction● Shoulder Elevation● External/Internal Rotation
● Hip Abduction● Hip External Rotation● Ankle Eversion
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.