Inpatient Rehabilitation for NICU Graduates

Author: 
Rosauro Dalope, MD, FAAP, and Connie Koch, BSN, RN
After receiving the high level care of the neonatal intensive care unit (NICU), newborns with medically complex conditions can benefit from inpatient rehabilitation as part of a successful transition home.
 
Neonatal infants, who require intervention to foster developmental facilitation toward age appropriate skills, to prevent or decrease dependence on tube feeding, to streamline overall medical care and whose families or caregivers need training and education to facilitate transition to home, can benefit from a comprehensive inpatient rehabilitation program.
 
One of the biggest challenges that NICU infants have to overcome, as a result of their prematurity and the ICU environment, is the ability to gain auto regulation skills. Babies with immature nervous systems exhibit increased irritability to even the smallest amount of stimulation, including such rather innocuous sensory stimuli as music, light or soft touch.  Many of these babies cannot tolerate even the slightest changes in positions. Some of the
clinical manifestations indicative of their discomfort may include increased heart rate and blood pressure, respiratory distress, vomiting, increased tone and extensor posturing.
 
For these patients to acquire age-appropriate skills and to obtain medical stability, they need to learn how to react to various stimuli and situations positively. During inpatient rehabilitation, clinical team members strive to create a calming and pleasant experience while introducing sensory stimulation, new positions or activities.
 
Initially, treatments will be limited to the patient’s room under low lighting with no or low, soothing music. As infants show increased tolerance, treatment may be moved to other areas with increased lighting, and use of auditory and tactile toys is initiated. Eventually, the child adapts and tolerates increased stimulation and activities in a group environment within the unit. This adaptation facilitates medical stability, feeding and overall psychosocial wellness.
 
Case Study
 
Patient: Born at 26-weeks gestation, surviving twin 
Length of stay: 90 days
 
The patient presented with lower birth weight and multiple medical complications, including hypertension. He was at high risk for developmental delay and had retinopathy of prematurity with loss of vision, chronic lung disease and severe GE reflux. In addition, he had severe oral aversions and uncoordinated sucking and swallowing skills resulting in complete dependence on gastrostomy feeding on admission.
 
The patient was referred to GSRH Pediatric Unit to: address his overall medical care focusing on his chronic lung disease and oxygen need; facilitate developmental skills and to improve overall strength, endurance and auto regulation; improve oromotor skills and reduce dependence on gastrostomy tube for nutrition through intensive feeding therapy; and provide family training to assist transition to home.
 
Outcomes:
 
  • Discharge with only an occasional need for supplemental oxygen (due to chronic lung disease)
  • Hypertension resolved – off medications
  • Oral intake improved. The patient was eating by mouth during day, taking thickened formula via spoon and has gastrostomy feedings only at night upon discharge.
  • Improved self-regulation, psychosocial skills and improved strength and endurance
  • Able to tolerate prone and sitting positions, reaching some developmentally appropriate milestones
  • Family education completed. Referred for ongoing outpatient therapy to maintain progress.

Rosauro Dalope, MD, FAAP, is a board-certified pediatrician with a special interest in the care of children with medical complexity. He is the attending physician at Good Shepherd Rehabilitation Hospital Pediatric Unit in Bethlehem, PA.

Connie Koch, BSN, RN, is the clinical nurse manager at Good Shepherd Rehabilitation Hospital Pediatric Unit. She has been working in pediatric nursing for 22 years.