[PDF] - Healthy Start Our goal is to reduce Colorados current premature PDF Document

SLIDE 1

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

pportunity to engage African American/Black women in an
pen 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

n average 3 times higher for African American/Black woman

in our community than for any other race.

March rch of Dimes es Colo lora rado do Mission sion

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,

f Spiric Therapies, LLC

SLIDE 2

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,

f Spiric Therapies, LLC

So what is a reflex??

Stimulus Movement

Kids in Motion,

f 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,

f 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
n life events

Kids in Motion,

f 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,

f 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,

f Spiric Therapies, LLC

SLIDE 3

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,

f 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
n 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,

f 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,

f Spiric Therapies, LLC

SLIDE 4

5/2/2017 4 Integration Extinction

Kids in Motion,

f 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,

f Spiric Therapies, LLC

So…now that you’ve identified non-integrated or affected primitive reflexes… What can you do?

Kids in Motion,

f Spiric Therapies, LLC
Identify non-integrated primitive reflexes EARLY

and refer infant/child to physical, occupational

r 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

pportunities, 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,

f Spiric Therapies, LLC

Promote symmetry, symmetry, symmetry!!!

Kids in Motion,

f Spiric Therapies, LLC

Tummy time ideas

Kids in Motion,

f Spiric Therapies, LLC

SLIDE 5

5/2/2017 5

Kids in Motion,

f Spiric Therapies, LLC

Move freely, learn effortlessly!

Kids in Motion,

f 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,

f Spiric Therapies, LLC

Thank you!!

Jennifer Spiric, PT, DPT Kids in Motion,

f 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.

SLIDE 6

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

f 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

SLIDE 7

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
f 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?

SLIDE 8

5/2/2017 8 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
f service [Pineda et al, 2013].

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].

SLIDE 9

5/2/2017 9

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

SLIDE 10

5/2/2017 10 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

utcomes.

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.

SLIDE 11

5/2/2017 11 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

SLIDE 12

5/2/2017 12

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

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