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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

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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

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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

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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

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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.

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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

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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?

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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].

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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

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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.

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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

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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