Occupational therapy is a major area need to be concern in NICU candidate or High risk infants.This power point elaborate and focus on assessment tools and therapy provide at right time for further development of child.

1. OCCUPATIONAL THERAPY
INTERVENTION OF HIGH RISK INFANT
TILL SCHOOL AGE
Neha Srivastava
MOT (Pediatrics)
Occupational Therapist

2. HIGH RISK INFANT
Any neonate, regardless of birth weight, size, or gestational
age, who has a greater than average chance of morbidity or
mortality, especially within the first 28 days of life.
(Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier.)

3. RISK FACTORS
(PEDIATR CLIN NORTH AM. 1993 JUN;40(3):479-90).NCBI
BIOLOGICAL FACTORS ENVIORMENTAL FACTORS
PRENATAL – Chromosomal disorder
Congenital infection
Congenital malformation
Intrauterine growth retardation
Maternal substance abuse
Bad environment affect the cognitive development.
PERINATAL- Premature baby (<37 weeks)
Preterm baby(<38 weeks)
Post term baby (>42 weeks)
Birth asphyxia
Caregiver-child interactions,
family resources.
POSTNATAL- Developmental delay
Lung disease
Meningitis
Physical properties and organization.
Within the area of caregiver-child interaction is
parenting ability.

4. RISK FACTOR GUIDELINES ACC TO NNF
(NATIONAL NEONATAL FORUM)
Highrisk
Babies with <1000g birth weight and/or gestation <28 weeks
Major morbidities such as chronic lung disease, intraventricular haemorrhage,
and periventricular leucomalacia
Perinatal asphyxia - Apgar score 3 or less at 5 min and/or HIE
Surgical conditions like Diaphragmatic hernia, Tracheo-oesophageal fistula
Small for date (<3rd centile) and large for date (>97th centile)
Mechanical ventilation for more than 24 hours
Persistent prolonged hypoglycaemia and hypocalcaemia
Seizures

5. HIGHRISKCONT…
Meningitis
Shock requiring inotropic/vasopressor support
Infants born to HIV-positive mothers
Twin to twin transfusion
Neonatal bilirubin encephalopathy
Major malformations
Inborn errors of metabolism / other genetic disorders
Abnormal neurological examination at discharge

6. Babies with weight – 1000 g- 1500g or
gestation < 33 weeks
. Twins/triplets
. Moderate Neonatal HIE
Hypoglycaemia, Blood sugar<25 m/dl
Neonatal sepsis
Hyperbilirubinemia > 20mg/dL
Hyperbilirubinemia > 20mg/dL or requirement
of exchange transfusion
Suboptimal home environment
NATIONAL NEONATAL FORUM (NNF)

7. MILD RISK
Preterm, Weight 1500 g - 2500g
HIE grade I
Transient hypoglycaemia
Suspect sepsis
Neonatal jaundice needing PT
IVH grade 1
NATIONAL NEONATAL FORUM (NNF)

8. PREDISPOSING FACTORS
 Pregnancy between age of 15 to 19 years
 Elderly women
 Wrong dates
 Multiple pregnancy
 Fetal anomalies
 hereditary

9. PHYSIOLOGICAL CHALLENGES
 Respiratory and cardiac
 Thermoregulation-
Hypothermia(less than 36c)
Hyperthermia(>38degree C)
 Digestive
 Renal

10. NEUROLOGICAL
CONDITIONS
HYPOXIC-
ISCHAEMIC
ENCEPHALOPA
THY(HIE)
PERIVENTRICULAR
LEUKOMALACIA
BRACHIAL
PLEXUS
INJURIES
NEONATAL
SEIZURES
CEREBRAL
PALSY
CONGENITAL
OBSTRUCTIVE
HYDROCEPHALUS
ERB’S PALSY
Hand book of neonatal intensive care(5th edition) st.louis: mosby (1976)
neurology of newborn(4th edition)

11. DEVELOPMENTAL
DISABILITIES
GLOBAL
DEVELOPMEN
TAL
DISABILITIES
AUTISM
SPECTRUM
DISORDER
LEARNING
DISABILITY
COGNITION
AND
PERCEPTION
MUSCULATURE
DYSFUNCTION
SPEECH AND
LANGUAGE
DELAY

12. RESPIRATORY
CONDITIONS
RESPIRATORY
DISTRESS
SYNDROME
APNOEA
PNEUMONIA
BRONCHOPULMO
NARY DYSPLASIA
(BPD)
PULMONARY
INSUFFUECIENCY
OF THE
PRETERM(PIP)
TRANSIENT
RESPIRATORY
DISTRESS OF
THE NEWBORN
Aggarwal, David et al(2003) classification of acute respiratory disorders of all newborns in a
tertiary care center . Journal of National Medical Association.

13. VISION AND HEARING
CONDITIONS
HEARING
LOSS,AUDITORY
PROCESSING
DISORDER
RETINOPATHY OF
PREMATURITY (ROP)
American academy of pediatrics, committee of environment health (1997)
Mental retardation and developmental disabilities research reviews; volpe (2001)

14. HEMOLYTIC AND
INFECTIOUS
COMPLICATIONS
SEPSIS
DISSEMINATED
INTRAVASCULAR
COAGULATION
(DIC)
ANEMIA

15. Congenital
heart defects
Atrial
SEPTAL
DEFECTS
(ASD)
TRICUSPID
ATRESIA
HYPOPLASTIC
LEFT HEART
TEROLOGY
OF FALLOT
(TOF)
CYNOTIC
CONGENITAL
HEART
DISEASE
PATENT
DUCTUS
STENOSIS(P
DA)
American heart association(2001)

16. GOALS
• Perinatal prevention
• Evaluate and manage
• Monitoring and Therapeutic modalities

17. CLINICAL MANIFESTATION
• Absence of vernix caseosa
• Loose skin and little subcutaneous fat
• Absence of lanugo
• Abundant hair on the head and long nails
• Skin is wrinkles
• Cracked and peeling
• Umbilical cord is thin

18. ASSESSMENT OF HIGH RISK INFANT
• INITIAL ASSESSMENT
• APGAR SCORE

20. EVALUATION OF HIGH RISK INFANT
• Demographic data
• History – Prenatal, Natal, Post natal
• Medical history – Current status of infant
Medical equipment used
Feeding method and schedule
Current medications
Level of physiological homeostasis
• Family history (e.g. socio economic and cultural factor and support
system)

21. • Avoid duplication of assessment items done simply to fill in the blanks on
an evaluation form.
• Time evaluation - Infant sleep cycle
Feeding schedule
Caregiving routine
• On examination – Muscle tone
Primitive Reflexes
Active and passive movements
Posture of the baby

22. ASSESSMENT AND INTERVENTION OF HIGH
RISK
NICU
EARLY
INTERVENTION
PRESCHOOL SCHOOL

23. NEONATAL INTENSIVE CARE UNIT
(NICU)

24. ASSESSMENT IN NICU
NEUROLOGICAL
ASSESSMENT
ENVIORMENT
ASSESSMENT
OROMOTOR
ASSESSMENT
FEEDING
ASSESSMENT
SENSORY
ASSESSEMENT

25. • Heidelise Als, PhD children's hospital
Boston
• It is based on synactive theory of
development.
Naturalistic
observation of
newborn
behavior(NONB)
(NIDCAP LEVEL 1)
• Structured observation of specific
behavior are repeated at 2 min intervals
before, during and after routine caregiving.
• Assessment of maturation and interplay of
infant neurobehavioral sub system.
Assessment of
preterm infant
behavior (APIB)
(NIDCAP LEVEL 2)

26. Dev. child med 2005 Feb;47(2):105-12.
The Infant Behavioural Assessment and Intervention Program to support preterm
infants after hospital discharge: a pilot study.
(Koldewin etal)
NICU NETWORK
NEUROBEHAVIOURAL
SCALE (NNS)
(NNNS) examines JoVE,
2014
Age group-34 wk. -45wk
range.
neurobehavioral
organization
neurological reflexes
motor development -
active and passive tone,
and signs of stress and
withdrawal of the at-risk
and drug-exposed infant.

27. NEUROLOGIC
ASSESSMENT OF THE
PRETERM AND FULL
TERM NEWBORN
INFANT
• For preterm and term infants
• Assess – functional status of infant ,nervous system by assessing habituation
,posture, muscle tone ,head control, spontaneous movements, abnormal arousal
and alertness.
NEONATAL
NEUROLOGICAL
EXAMINATION
(NEONEURO)
• Normal and abnormal term infants during first week of life only
• More then 37 week of gestation.
• Examines posture tone, reflexes and auditory /visual orientation to assess infants
neurologic integrity
NEUROBEHVIOURAL
ASSESSMENT FOR
PRETERM INFANTS
(NAPI)
• It for medically stable preterm in range 32 week to 42 week postconceptional
age.
• Assess neurobehavioral maturity of infant over time and to detect neurologically
suspected performance
• Areas- motor development and vigor, scarf sign, popliteous angle, alertness and
orientation, irritability, vigor of crying and percentage of time spent sleeping.

28. INTERVENTION IN NICU
SENSORY AND
CAREGIVING
MODIFICATION
TACTILE STIMULUS(32wks GA)-
KANGAROO MOTHER CARELIGHT STROKE MASAGE
USE OF COTTON CLOTHING DURING FEEDING
VESTIBULAR-
SWADLE HOLDING POSITION
ELEVATION OF HEAD SIDE APPROX 3O DEGREE
AUDITORY-
ENVIORMENTAL MODIFICATION
CARE GIVING PRACTICES
VISUAL SYSTEM-AVOID ABRUPT LIGHT
MINIMIZE VISUAL STIMULATION
DECREASE NICU LIGHT SYSTEM

29. POSITIONING IN NICU

30. -The effects of supine and prone
positions on oxygenation in
premature infants undergoing
mechanical ventilation
Iranian Journal Nursing Midwifery
Research. 2010
The mean of SPO2 in the prone
position
significantly was higher than in
supine position.
PRONE POSITION
DEVELOPMENTAL
ADVANTAGES
Facilitates –
Flexor tone
Hand to mouth
activity
Active neck extension
Coping with extra
uterine enviourment
Prevent abnormal hip
contractures
MEDICAL ADVANTAGES
Improved oxygenation
and better ventilation
Reduced reflux
Term and pre term
sleeps more in prone
position
Decreased risk of
aspiration

32. SUPINE
POSITION
DEVELOPMENTAL
ADVANTAGES
Improve visual exploration by infant.
Facilitates midline position in
hammock.
Midline position to reduce lateral
flattening of head.
Encourage flexion(increased muscle
tone).
MEDICAL
ADVANTAGES
Easier access for medical care
Supine position in hammock
increase sleep time .
Reducing the risk of SIDS(Sudden
infant death)
The Joanna Briggs Institute. Positioning of
preterm infants for optimal physiological
development 2010; 14(18):1-4
Symptomatic preterm infants with signs of respiratory distress, very low birth weight and severe
gastroesophageal reflux may benefit from the prone position during sleep.
Results says - Healthy preterm infants should be positioned supine during sleep while in the NICU.

33. SIDE LYING POSITION
DEVELOPMENTAL
ADVANTAGE
Encourage midline orientation.
Promotes flexion adduction of
extremity.
Facilitate hand to mouth pattern
for self calming.
Facilitates hand to hand activity .
MEDICAL
ADVANTAGES
Better oxygenation for infant
with unilateral disease with good
lung positioned uppermost
This position can be used in to
treat pulmonary emphysema

34. POSITIONIG EQUIPMENTS USED BY
OCCUPATIONAL THERAPIST
DandleROO
Dandle Pal -make brest feeding easier

35. OROMOTOR AND FEEDING TECHNIQUES
 LACTATIONAL COUNSELING
 OROMOTOR STRENTHNING
 DEVELOP ORAL REFLEXES
 SUCK TRAINING
American Occupational Therapy Association. (2004). Guidelines for supervision, roles, and
responsibilities during the delivery of occupational therapy services. American Journal of
Occupational Therapy,.
Feeding problems in infancy and early childhood: Identification and management
Debby Arts-Rodas RD and Diane Benoit, MD FRCPC(PubMed)

36. • Define as the use of an interactive helping process
to assist in maintenance of successful breast
feeding by the help of adaptive device and assistive
devices.
LACTATIONAL
COUNSELING
• Strength, Coordination , Range of motion , sensitivity
• Milk leaking from the mouth
• Weak suck
• Insufficient milk supply
• Nipple pain/soreness
• Improper positioning (mother and child).
• Oral aversion(tubing)
OROMOTOR
COMPONENT
• Rooting reflex , sucking reflex
• swallowing reflexes-*Biting reflex
• *Gag reflex
• *Coughing reflex
DEVELOP
ORAL
REFLEXES

38. SUCK TRAINING FOR INFANT
NON NURITIVE SUCKING(NNS)
• Development
• 27-28 wk – single suck with long
variable pause.
• 30-33 wk more regular pause
• .34 wk – swallowing after 6-8 sucks
• Rate pattern- 2 suck/sec
• Stimulus – sleep as in
Spontaneous mouthing movements
.
• Suck Swallow breath ration-at least
6-8 NNS sucks to prior to swallow.
NUTRITIVE SUCKING(NS)
• Development
• Occur in utero after first trimester
• Suck swallow breath coordination
at early 32 wks
• Rate pattern-1 suck/sec
• stimulus – liquid obtainable from
liquid .
• Suck swallow breath ration:- 1:1:1

40. • Follow Up Schedule (AIIMS)
Birth weight
less than 1800g
or GA >32
After 3-7 days
of discharge
Every 2 weeks
of discharge
until 3kg
6,10,14 age of
post natal age
2 weeks after
discharge
Other
conditions

41. EARLY INTERVENTION THERAPY
Review of literature
• Early intervention is a system of coordinated services that promotes the
child's age-appropriate growth and development and supports families during
the critical early years.
• Early Childhood Intervention is not limited to children with these disabilities.
• Persistent Effects of Early Childhood Education on High-Risk Children and
Their Mothers Craig T. Ramey University of Alabama at Birmingham Frances
A. Campbell et al University of North Carolina at Chapel Hill Sharon L.
Ramey University of Alabama at Birmingham

42. ASSESSMENT TOOLS USED IN EARLY
INTERVENTION
• Inventories measure a child’s development in five domains:
gross motor, fine motor, language, comprehension, and
person-social. Items tap the better predictors of
developmental status only. A 300-item assessment-level
version may be useful in follow-up
• the Infant Development Inventory (IDI), 3 - 72 months;
• Early Child Development Inventory (ECDI) for 3-18 months;
• Preschool Development Inventory (PDI)] each with 60 yes-
no descriptions. ; 3660 months
Child
Development
Inventories (CDI)
• 12 – 96 months
• The 96 items use a combination of direct assessment,
observation, & parental interview.
• The BDIST taps a range of discrete domains including
receptive & expressive language, fine & gross motor,
adaptive, personal-social, & cognitive/academic.
Battelle
Developmental
Inventory
Screening Test
(BDIST)

43. Bayley Infant
Neurodevelopmental
Screener (BINS)
• AGE GROUP-3 - 24 months
• The sets contain 11 to 13 items.
• The four conceptual areas of ability assessed by the BINS are basic neurological
functions/intactness; receptive functions; expressive functions; & cognitive process
Denver Developmental
Screening Test II
(DDST-II)
• AGE GROUP-1 month to 6 years of age
• Children's development in four areas of functioning: fine motor-adaptive, gross motor,
personal-social, and language skills
Early Childhood
Inventory-4 (ECI4)
• AGE GROUP-3 to 5 years
• screens for emotional and behavioural disorders in children.
• ,except that they do not cover schizophrenia but add reactive attachment disorder,
selective mutism, and eating, sleeping, and elimination problem
Developmental Screening and Assessment Instruments with an Emphasis on Social and Emotional
Development for Young Children Ages Birth through Five
Compiled by Sharon Ringwalt
May 2008

44. Early
Intervention
services
Sensory
motor
Self-help skills
Postural
developmen
t
Mental health
counselling for
children,
parents, and
familiesMental health
counselling for
children, parents,
and families
Assisting
technology
devices and
services
Therapeutic
early
childhood
classrooms
Adaptive
behaviour and
play
"Predicting the Future of Premature Babies, Testing Previews Future Learning Problems." Vol.29, No.
14 -- Research -- On Campus, OSU's Newspaper for Faculty and Staff. Retrieved July 24,
2016. http://oncampus.osu.edu/v29n14/research.html.

45. EARLY
INTERVENTION
STRATEGIES
Encourage
Exploration
Guide and
limit behavior
Communicate
richly and
responsibly
Protect from
inappropriate
punishing
Rehearse and
extent new skill
Celebrate
developmental
advantage
Mentor in basic
skill
These 7 stages were given by Ramey and Ramey in 2004 Craig T. Ramey and Sharon L.
Ramey “Early Learning and School Readiness: Can Early Intervention Make a Difference?
Merrill Palmer, (2004), 471-491

46. CASE STUDY
• NAME- B/O MAMTA
• -18 DAY / MALE / 2.5Kg
PRESENTING COMPLAIN
• SWELLING AT RIGHT SIDE OF THE NECK 5-6 DAYS
• UNABLE TO TURN NECK RIGHT SIDE
CHILD HISTORY
• Child was FTNVD , HOME DELIEVERY
• CRIED IMMIGIATELY AFTER BIRTH
• H/O JAUNDICE AT DAY 3 OF THE CHILD ADMITTED TO SAFDARJUNG
HOSPITAL FOR PHOTHERAPY FOR 2 DAYS.
• MOTHER NOTICED SWELLING AT RIGHT SIDE OF THE NECK AFTER 6-7 OF
BIRTH.
• NO H/O OF SIMILAR COMPLAIN IN ANY OTHER FAMILY MEMBERS

47. ON EXAMINATION
• SWELLING IS VISIBLE ON RIGHT SIDE OF THE NECK THE HARD SWELLING WAS
PALPABLE UNDER STERNOCLEIDOMASTOID MUSCLE.
• IT IS FOUND THAT RIGHT STERNOCLEIDOMASTOID MUSCLE IS TIGHT.
• BABY PERSISTANTALY TURN HIS HEAD TOWARD LEFT SIDE DURING EXAMINATION
INVESTIGATION
USG –THYROID WAS DONE ON 17/6/2106 AT THE AGE OF DAY 15.
THERE WAS THICKENING OF MUSCLE BELLY OF RIGHT SIDE OF STM APPROX
2.2*1.8*1.2 cm WITHOUT ANY ABVIOUS INTRINSIC COLLECTION-SUGGESTIVE OF
MUSCLE HYPERTROPHY /PSEUDO TUMOR.
USG – SKULL (CRANIAL) - 17/06/2016
THERE WAS NO SUGGESTIVE ABNORMALITY SEEN.

48. OCCUPATIONAL THERAPY
TREATMENT
• Neck prom exercises – flexion
extention
lateral flexion both side
Turning of neck both side
( 5 times each movement )
• positioning explained
• light circular movement on the tumour- tds
After 1.5 month
• Mild stretching of STM muscle was started .
• home programme was explained to the mother
Child was called on regular OPD for the session of occupational therapy initially for 3 times in a
week after 2 months sessions were reduced to 2 times in a week ,and now patient is called for
follow up once in a week .

49. PROGRESS REPORT
• Child has shown remakable improvement
• treatment was continued for 3 and half month started from
( 17 june 2016 to 15/9/2016)
• Total no of session -17 were taken during this period .
• neck holding improved
• Neck rom improved,
• Very small amount of visiblity of the fibrous mass.

50. BEFORE AFTER

51. FOLLOW UP PLAN
• Patient will be kept under follow up till the age of 7-8 months .
• Repeat usg will be advised in paediatric OPD.
• Patient called for follow up twice in a month .

52. PRESCHOOL AND SCHOOL SYSTEM
OCCPATIONAL THERAPY
Types of
schools
Charter
schools
SPECIAL
SCHOOLS
VOCATIONAL
SCHOOLS
ALTERNATI
VE
SCHOOLS
INCLUSIVE
SCHOOL

53. SCHOOL SYSTEM WORK ON IDEA(INDIVIDUAL
WITH DISABILITY ACT)
1. Free appropriate public education (FAPE)
2. Least restrictive environment (LRE)
3. APPROPRIATE EVALUATION
4. Individualized Education Programe (IEP)
5. Parent and student participation in decision making
6. Procedural safeguards

54. ASSESSMENT OF
PERFORMANCE
MOTOR PERFORMANCE
Peabody developmental
motor scales
Bruininks-oseterky test of
motor performance
Development of visual
motor integration
Sensory responsiveness
Sensory
profile(Dunn1999)
Sensory integration
inventory-revised for
developmental disabilities
Developmental Screening and Assessment Instruments with an Emphasis
on Social and Emotional Development for Young Children Ages Birth
through Five
Compiled by Sharon Ringwalt
May 2008

55. Assessment of
Performance cont..
Perceptual processing
Motor free performance
visualperformance(MVPT)(
2002)
Developmental test of
visual performance(DTVP-
II) (PEARSON)
Psychosocial
cognitive abilities
School environment
SFAActivity scale rate
behavior and cognition
using 10 scale.
Behavior evaluation scale -
2(Mccarney 1990)
Child behavior checklist
(!991)
Developmental Screening and Assessment Instruments with an Emphasis on Social
and Emotional Development for Young Children Ages Birth through Five
Compiled by Sharon Ringwalt
May 2008

56. OCUUPATIONAL THERAPY ACTIVITIES IN
PRESCHOOL AND SCHOOL
FINEMOTORACTIVITIES
Strenthning-
clay, Thera band, roll and taffy
Magnet peg boards
Visual motor and eye hand co-ordinatio-
Cut shapes
Lite bites
Use hammer and nails
Manipulation skills
Place stickers
Transfer beats and coins
keyboards
( Adapted from fine/motor activities and developed by school therapist. Deana (2004)

57. • AMUNDSON,S(1999) TRICKS FOR WRITTEN COMMUNICATION ,HOMER
PRE REFFERAL FORM: INTERVENTION STRATEGIES(2004)
ACTIVITIES FOR WRITING
IMPROVE POSTURE-
THERAPY BALL
SIT UPS
SIT AND MOVE
GRASPING PATTERNS-
STRINGING BEADS
PEG BOARDS
SPONGE BALL
LACING
TRIPOD GRASP PEG BOARDS
TWEEZER GAMES
MODIFIED PENCIL GRIPS
COLOR CODER TO IMPROVE LETTER FORMS
DOT TO DOT JOINING
USE PAPER WITH RAISD LINES
USE PAPERS WITH DIFFERENT COLORS

61. REFERENCES
• Hand book of neonatal intensive care(5th edition) st.louis : mosby (1976)
• neurology of newborn(4th edition)
• American academy of pediatrics, committee of environment health (1997)
• Mental retardation and developmental disabilities research reviews; volpe (2001)
• American heart association(2001)
• The Infant Behavioural Assessment and Intervention Program to support preterm
infants after hospital discharge: a pilot study.
• American Occupational Therapy Association. (2004). Guidelines for supervision,
roles, and responsibilities during the delivery of occupational therapy services.
American Journal of Occupational Therapy,.
• Feeding problems in infancy and early childhood: Identification
• Amundson,S(1999) tricks for written communication ,Homer
Pre referral form: intervention strategies(2004)
• ( Adapted from fine/motor activities and developed by school therapist. Deana (2004)