Early Intervention in High Risk Infants -Dr. Quazi Ibtesaam Huma (MPT) Dr. Suvarna Ganvir (Phd, Prof & HOD) Dept. of Neurophysiotherapy DVVPF’s College of Physiotherapy Objectives By the end of the seminar one would know What is high risk infants? Determinants of high risk infants Monthwise neurodevelopment of infants in gestational age Early intervention General NICU guidelines for high risk infants Recent advances What is High Risk Infant? A High risk infant is broadly defined as one who requires more than the standard monitoring and care offered to a healthy term newborn infant. According to American Academy of Pediatrics, High risk infant may be defined as Preterm Infant Infant with special healthcare needs or dependence on technology Infant at risk because of family issues. Infant with anticipated early death. High-Risk Clinical Signs At 4 months of age, hypertonicity of the trunk or extremities is recognized as a high-risk clinical sign. Less alternate kicking movement compared with typically developing LBW infant. Abnormalities of kicking described by Prechtl as “cramped-synchronized,” that is, limited in variety and characterized by “rigid movement with all limbs and the trunk contracting and relaxing almost simultaneously,” Preterm Infant Preterm infant is the infant which is born before 36 weeks of gestation Usually preterm infant have low birth weight i.e. less than 2.5 kgs Determinants of High Risk Infant Biological Risk Attributed to medical/physical condition presence of Asphyxia Neonatal seizures Prenatal exposure to drugs or alcohol Brain-lesions Low birth weight Established Risk Associated with diagnosis that is clearly established like, Congenital malformation Chromosomal abnormalities CNS disorders Metabolic disease. Environmental & social risk Refers to competency in parenting roles and factors in family dynamics Suboptimal levels of stimulation and interaction in NICU Inadequate parent-infant attachment Insufficient educational preparation for caregiver roles Meager financial resources of parents Limited or absent family support to assist in taking care of and nurturing the infants in home environment. The systems of infants develop in their stipulated time during gestational period prenatal or preterm results in specific injury Commonest condition which requires early intervention Newborn Maturity Rating—Ballard Score Widely adopted because of the time efficiency Ballard instrument involves only six physical and six neurological criteria, with a 0 to 5 scale and a maturity rating designed to be used for neonates (20 to 44 weeks gestation) from birth through 3 days of age and has demonstrated concurrent validity with the Dubowitz gestational age calculation tool. Neonatal Behavioral Assessment Scale 30- to 45-minute examination consists of observing, eliciting, and scoring 28 behavioral items on a 9-point scale and 18 reflex items on a 4-point scale Six behavioral state categories are outlined in the NBAS: deep sleep,

1. Early Intervention in
High Risk Infants
-Dr. Quazi Ibtesaam Huma (MPT)
Dr. Suvarna Ganvir (Phd, Prof & HOD)
Dept. of Neurophysiotherapy
DVVPF’s College of Physiotherapy

2. Objectives
By the end of the seminar one would know
What is high risk infants?
Determinants of high risk infants
Monthwise neurodevelopment of infants in gestational age
Early intervention
General NICU guidelines for high risk infants
Recent advances

3. What is High Risk Infant?
A High risk infant is broadly defined as one who requires more than the standard
monitoring and care offered to a healthy term newborn infant.
According to American Academy of Pediatrics, High risk infant may be defined as
Preterm Infant
Infant with special healthcare needs or dependence on technology
Infant at risk because of family issues.
Infant with anticipated early death.

4. High-Risk Clinical Signs
At 4 months of age, hypertonicity of the trunk or extremities is recognized
as a high-risk clinical sign.
Less alternate kicking movement compared with typically developing
LBW infant.
Abnormalities of kicking described by Prechtl as “cramped-synchronized,”
that is, limited in variety and characterized by “rigid movement with all
limbs and the trunk contracting and relaxing almost simultaneously,”

6. Dominant asymmetrical tonic neck reflex in 4-month-old
infant with athetoid cerebral palsy.

7. Preterm Infant
Preterm infant is the infant which is born before 36 weeks of gestation
Usually preterm infant have low birth weight i.e. less than 2.5 kgs
Preterm Classification
Late preterm infant 34-36 weeks
Very preterm Less than or equal to 32 weeks
Extremely preterm Less than or equal to 28 weeks

8. Determinants of High Risk Infant
High Risk Infant
Biological Established Environmental

9. Biological Risk
Attributed to medical/physical condition presence of
Asphyxia
Neonatal seizures
Prenatal exposure to drugs or alcohol
Brain-lesions
Low birth weight

10. Established Risk
Associated with diagnosis that is clearly established like,
Congenital malformation
Chromosomal abnormalities
CNS disorders
Metabolic disease.

11. Environmental & social risk
Refers to competency in parenting roles and factors in family dynamics
Suboptimal levels of stimulation and interaction in NICU
Inadequate parent-infant attachment
Insufficient educational preparation for caregiver roles
Meager financial resources of parents
Limited or absent family support to assist in taking care of and nurturing the
infants in home environment.

12. The systems of infants develop in their stipulated time during gestational
period prenatal or preterm results in specific injury
Month Part Condition
1st month Neural tube Anencephaly
Encephalocoele
myelomeningiocoele
5th month Neuronal proliferation Microcephaly
Macrocephaly
3-6th month Neural migration Lissencephaly
Schizencephaly
Polymicrogyria
5th month after birth Organization Vulnerable to
hypoxia,medications,
ventilation

13. Commonest condition which requires early
intervention
Condition Characteristics
Respiratory distress syndrome Results in pulmonary immaturity and
inadequate surfactant
Broncho-pulmonary dysplasia Affects airway and parenchyma due to
injury caused by mechanical ventilator
at greater risk of CP.
Baby with surgery Congenital diaphragmatic hernia,
abdominal wall defects
Baby with asphyxia Hypoxic Ischaemic Encephalopathy

14. Newborn Maturity Rating—Ballard Score
Widely adopted because of the time efficiency
Ballard instrument involves only six physical and six neurological criteria,
with a 0 to 5 scale and a maturity rating
designed to be used for neonates (20 to 44 weeks gestation) from birth
through 3 days of age and has demonstrated concurrent validity with the
Dubowitz gestational age calculation tool.

15. Neonatal Behavioral Assessment Scale
30- to 45-minute examination consists of observing, eliciting, and scoring 28
behavioral items on a 9-point scale and 18 reflex items on a 4-point scale
Six behavioral state categories are outlined in the NBAS: deep sleep, light
sleep, drowsiness or semi dozing, quiet, alert, active alert, and crying
Four dimensions of newborn behavior are analyzed in Brazelton’s NBAS:
interactive ability, motor behavior, behavioral state organization, and
physiological organization.

16. Early intervention
Early intervention is a term that
refers to a broad array of activities
designed to enhance a young childs
development.

17. Principles of early intervention
Principles Characteristics
Developmental timing Interventions that begin earlier in development
and continue longer afford greater benefits
Program intensity More intensive (indexed by variables such as
number of home visits per week, number of
hours per day, days per week, and weeks per
year) produce larger positive effects.
Direct Vs provision of learning experiences Children receiving interventions that provide
direct educational experiences show more
benefits than learning through some
intermediary source.
Program breadth and flexibility provide more comprehensive services and use
multiple routes to enhance children's
development

18. Individual difference Some children show greater benefit than other
children
Ecological dominion and environmental
maintenance of development
Initial effects of early intervention diminish
environmental supports to maintain children's
positive attitudes and behavior.

19. Parent Education
Parents receiving early intervention services reported parent education on ways to
support infant motor development
They should have awareness of developmental capabilities & response to treatment
Skin to skin holding- kangaroo care
Benefits:
Improved thermoregulation
Improved respiratory patterns & O2 saturation
Decreased apnea and bradycardia
Develops mother-child bond

20. Swaddling an infant can also provide the bodily containment important for
pain relief in infants undergoing painful procedures
The womb provides almost constant vestibular stimulation to the developing
fetus, some contingent (fetal movement) and some noncontingent (maternal
movements).
The preterm baby in an NICU experiences primarily immobilization and
therefore reduced vestibular stimulation

21. Infant massage using firm strokes may be helpful to some infants and is a good
bonding activity for parents.
Gentle vestibular input in the form of gentle rocking or swinging can be effective
for some infants.

22. Positioning for comfort
Neutral head & neck
Slight chin tuck
Scapular protraction to promote
UE flexion & hands midline
Flexion of trunk with post pelvic
tilt flexion of LE with neutral hip
For infants who demonstrate
hypertonia and extended
postures, supine and standing
positions should be minimized.
For infants who demonstrate
hypotonia, supportive positioning
promoting symmetrical, flexed,
and midline postures is important.

23. PRONE
•Improves oxygenation & ventilation
•Increased cerebral venous return
•Lowers intracranial pressure
•Behavioural improvement
•Supported prone-
Roll under chest- shoulder protraction
Roll under hip- flexion of hip

24. Side-lying
Benefits- symmetry & midline orientation
of trunk & extremities–facilitates hand to mouth
Diaphragm- GEP- decreased WOB
Supported sidelying- always

25. Supine
Most inconvenient compared to prone & side-lying
Supported supine-
Promote midline symmetric flexion with head
& trunk midline, hands near mouth or face legs
tucked close to body
Benefits- increased visual exploration

27. General aims of NICU clinical management of infants at
risk for neurological dysfunction,
1. Promote posture and movement appropriate to gestational age and medical
stability
2. Support symmetry and biomechanical alignment of extremities, neck, and trunk
while multiple infusion lines and respiratory equipment are required
3. Decrease potential skull and extremity musculoskeletal deformities and
acquired joint-muscle contractures
4. Foster infant-parent attachment and interaction
5. Modulate sensory stimulation in the infant’s NICU environment to promote
behavioral organization and physiological stability
6. Provide consultation or direct intervention for neonatal feeding dysfunction and
oral-motor deficits

28. Recent advances
Effectiveness of motor interventions in infants with cerebral palsy: a systematic
review
Catherine Morgan, Johanna Darrah et al
Developmental medicine & child neurology,2016
Aim- To systematically review the evidence on the effectiveness of motor
interventions for infants from birth to 2 years with a diagnosis of cerebral palsy
or at high risk of it.

29. Neurodevelopmental therapy was the most common intervention investigated
either as the experimental or control assignment.
The two interventions that had a moderate to large effect on motor outcomes
(Cohen’s effect size>0.7) had the common themes of child-initiated movement,
environment modification/enrichment, and task-specific training.
Lack of sufficient information to replicate intervention protocols

30. References
Umphred DA, Lazaro RT. Neurological rehabilitation. Elsevier Health Sciences;
2012 Aug 14.
Tecklin JS, editor. Pediatric physical therapy. Lippincott Williams & Wilkins; 2008.
Bly L. Baby treatment based on NDT principles. Tucson, AZ: Therapy Skill
Builders; 1999 Jan.
Morgan C, Darrah J, Gordon AM, Harbourne R, Spittle A, Johnson R, Fetters L.
Effectiveness of motor interventions in infants with cerebral palsy: a systematic
review. Developmental Medicine & Child Neurology. 2016 Sep;58(9):900-9.

31. THANK YOU