|Year : 2018 | Volume
| Issue : 3 | Page : 111-115
Pediatric physiotherapists' role in the neonatal intensive care unit: Parent and health-care providers' perspectives
Neha Sharma, Asir John Samuel, Vencita Priyanka Aranha
Department of Pediatric and Neonatal Physiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar Deemed-to-be University, Mullana, Haryana, India
|Date of Web Publication||2-Aug-2018|
Dr. Asir John Samuel
Department of Pediatric and Neonatal Physiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar Deemed-to-be University, Mullana...133.207, Haryana
Source of Support: None, Conflict of Interest: None
Neonatal Intensive Care Unit (NICU) is a specialized unit created for sick and premature newborns. Parents of admitted newborns came in stress when they came to know that their child is admitted to the NICU. In developing countries such as India, people having very less knowledge regarding physiotherapy interventions adopted in the NICU. Previously available literature from inception to 2017, searched with the keywords: “Parents perceptions,” “NICU Physiotherapy,” and “Medical staff perceptions” highlight the experiences of parents or stress levels in parents of hospitalized newborns in the NICU and perceptions of health-care providers' (HCP) toward patients' safety or the NICU research procedures adopted. Until now, there is no documentation on perceptions of both parents and HCP toward physiotherapy interventions adopted in the NICU.
Keywords: Developing countries, medical staff, Neonatal Intensive Care Units, parents, perception, physical therapists
|How to cite this article:|
Sharma N, Samuel AJ, Aranha VP. Pediatric physiotherapists' role in the neonatal intensive care unit: Parent and health-care providers' perspectives. J Clin Neonatol 2018;7:111-5
|How to cite this URL:|
Sharma N, Samuel AJ, Aranha VP. Pediatric physiotherapists' role in the neonatal intensive care unit: Parent and health-care providers' perspectives. J Clin Neonatol [serial online] 2018 [cited 2019 Jun 17];7:111-5. Available from: http://www.jcnonweb.com/text.asp?2018/7/3/111/238401
| Introduction|| |
Neonatal Intensive Care Unit (NICU) or intensive care nursery is a specialized unit created for sick and premature newborns. In developing countries, almost 99% of neonatal death occurs mostly because of prematurity and congenital defects. To decrease the neonatal mortality and morbidity and improving the survival rate of newborns, the NICU should be well organized. For the better prognosis of high-risk infants, diagnostic and therapeutic approaches were adopted in the NICU. Reasons for the NICU stay of newborns are preterm births (29%), severe infection (29%), birth asphyxia (23%), low-birth-weight babies, and congenital malformations. For mother and father, hospitalization of their infant in NICU is unexpected and a stressful event. The parents experienced heightened distress, depression, and anxiety due to the hospitalization of their infant in the NICU. Chest physical therapy techniques, such as percussions, vibrations, and compression, are performed in the NICU to prevent chest complications. Techniques such as kinesthetic stimulation are also effective in pain reduction. To fulfill parental needs, nurses pediatric physiotherapists, and pediatricians working in the NICU should have awareness regarding their needs and possibilities.
| Search Strategy|| |
Available articles from inception to December 2017 were reviewed from the electronic searches of PubMed, Medline, CINAHL, PsycINFO, Google Scholar, and EBSCO using the following keywords: “Parents perceptions,” “NICU,” “Physiotherapy,” and “Medical staff perceptions.” Data available on these databases were only limited to experiences or stress experienced by the parents of hospitalized newborns in the NICU and perceptions of health-care providers in the NICU toward research procedures and patient safety. To the best of our knowledge, there is no study available in India for reporting the perception level of parents and staff regarding physiotherapy interventions adopted in the NICU.
| Historical Background of Neonatal Intensive Care Unit|| |
The first premature infant center is established at Sarah Morris hospital at Chicago in 1923 marked as the foundation of concern for sick newborn, and the first intensive care nursery was opened at New Haven Hospital-Yale, by Louis Gluck in 1960. The NICU become an important and essential part of hospitals in 1970. Neonatal intensive care is subdivided into the “level of care.” The concept of “level of care” is given by the United States in 1976. These levels of care were based on the published guidelines of the American Association of Pediatrics.
| Neonatal Intensive Care Unit in Indian Scenario|| |
Prematurity is the main cause of neonatal death and the most common reason for antenatal hospitalization. In India, 23% of premature births are reported every year. The babies admitted to the NICU are very fragile, and generally die because of various birth complications and acquired infections. In India, a three-tier system of the NICU Level-1care (L-1), Level-2care (L-2), and Level-3care (L-3) is proposed according to the birth weight and gestational age. However, globally, L-2 is further subdivided into Level-2A care (L-2A) and Level-2B care (L-2B), and L-3 is subdivided into Level-3A care (L-3A), Level-3B care (L-3B), and Level-3C care (L-3C). India has given no further subdivisions of levels of the NICU and did not mention about the Level-4 care (L-4). In India, a majority of the NICUs are attached to the medical institutions and are very less in number. Birth asphyxia, prematurity, and low-birth-weight are the main causes, which lead to neonatal death. By improving the levels of care of the NICU help in reducing the mortality rates of newborns. Better levels of care in the NICU are essential to bring down the mortality rates in India.
| The Role of Physiotherapy in Neonatal Intensive Care Unit|| |
The neonatal physiotherapist should specialize in a range of motion exercises to overcome musculoskeletal problems. To understand and organize neonatal physiotherapy NICU practice regime should be known. The NICU practice regime is based on dynamic system theory of development that is (1) the worldwide classification of function, (2) disability and health, and (3) family-centered care. Parent's education and cooperation are very essential regarding the NICU physiotherapy and invasive procedures adopted in the NICU. Kinesthetic stimulation helps in preventing neuromuscular complications in admitted newborns in the NICU. Interventions such as kinesthetic stimulation and vestibular sensory systems show positive effects on very premature newborns. Techniques such as kangaroo care, swaddling helps in pain reduction and influences the positive neurobehavioral states. The early care interventions in premature newborn show positive effects on neurodevelopmental states. Due to prolonged immobilization, lack of physical activity leads to demineralization and growth retardation of bone in newborns. Studies tell that the range of motion exercises performed by therapist in different joints helps in increasing bone mineral density and weight gain in premature newborns. In the NICU, neonates experience long-term sequel of pain during invasive medical procedures. Hydrotherapy helps in pain reduction and improvement in sleep cycle of hospitalized stable premature newborn. Chest physiotherapy techniques such as percussions, vibrations, positioning for postural drainage, and airway suctioning are done for total 15 min, twice a day. At least 2—3 min should be spent on each affected site while giving chest physical therapy for the airway clearance and to maintain the adequate levels of oxygenation. Tabulated view summarizing the studies related to physiotherapy interventions adopted in the NICU is shown in [Table 1].
|Table 1: Studies related to physiotherapy interventions adopted in neonatal Intensive Care Units|
Click here to view
| Parental and Health-Care Providers' Perceptions Toward Medical Procedures Adopted in Neonatal Intensive Care Unit|| |
[Table 2] brief out the available literature related to the parents and staffs' perception toward medical procedures adopted in the NICU. The parents experience feelings of separation, depression, stress, disappointment, and shock when they came to know that their child is admitted to the NICU. Mothers experiencing much more and high level of stress than fathers. Medical staff who is working in the NICU also helps in reducing parental stress through effective communication and motivational support. Communication with health professional helps in reducing distress in parents of admitted newborn in the NICU. Antenatal counseling of parents helps in reducing parental stress and anxiety and provides satisfaction and support to them.
|Table 2: Studies related to perceptions of parents and medical staff toward newborn admitted to neonatal Intensive Care Unit|
Click here to view
| Discussion|| |
In developing countries such as India, people having very less knowledge regarding physiotherapy interventions adopted more specifically in the NICU. The neonatal physiotherapist should specialize in a range of motion exercises to overcome musculoskeletal problems. To understand and organize neonatal physiotherapy and to increase functional movement, the NICU practice regime is based on dynamic system theory of development that is (1) the worldwide classification of function, (2) disability and health, and (3) family-centered care. Many studies were performed to document the effectiveness of early interventions program for very premature and birth weight (<1500 g or 1500 grams) newborns. Researchers have concluded that early intervention programs such as stimulation of vestibular sensory system or kinesthetic stimulation shows positive effects on preterm neonates. Kinesthetic stimulation with massage helps in gaining weight in premature newborns. To establish this fact, total 60 premature infants were participated in the study and 20 newborns in each intervention group and control group, respectively. The experimental group receives six strokes of massage for 10 s each when the baby is in prone position. The areas where massage is given are on the head and neck, shoulders, upper and lower back, both lower limbs, and both upper limbs. The results from the study shows that infants with average birth weight >1000 g gained weight in experimental group compared to control.
Due to prolonged immobilization, lack of physical activity leads to demineralization and growth retardation of bone in newborns. Studies tell that the range of motion exercises performed by therapist in different joints helps in increasing bone mineral density and weight gain in premature newborns. Six studies conducted and stated that passive range of motion exercises given for five times a week for 1 month help in increasing bone mineral density and weight gain in preterm infants.
Hydrotherapy helps in pain reduction and improvement in sleep cycle of hospitalized stable premature newborn. To describe this, 12 premature infants (six females and six males) with gestational age below 36 weeks were participated in the study. Newborns that are participated in the study wrapped in a towel and placed in a liquid medium for 10 min. The results from the study concluded that hydrotherapy helps in encouraging movement, tactile stimulation, and kinesthetic stimulation and also help in facilitating flexor posture with the effect of buoyancy.
Parents of newborns experienced a higher level of distress and anxiety, when their child is admitted to the NICU. For them, this might be an unexpectable situation. For most of, does not need any specific psychological interventions. To verify this, this study included 447 parents with newborn, who is admitted to Level-4 NICU, during 12 months period whereas 189 parents with term babies not requiring NICU admission considered as a control group. The results show that overall in both parents groups, psychological stress is less when compared to the control parents. NICU parents appear that they adapt successfully to the NICU environment and they do not need any specific type of psychological interventions to overcome their stress and anxiety. The parents experience feelings of separation, depression, stress, disappointment, and shock when they came to know that their child is admitted to the NICU. From 1998 to 2008, number of studies related to parental perception when their child is admitted to the NICU is conducted. Many types of studies are done to know the perception of parents toward their child in the NICU at this time. The studies are performed to know, if the parents of admitted newborn feeling any kind of stress or to know the level of depression or anxiety, feeling of loneliness, or separation in them. Their findings confirmed that parents experienced distress, anxiety, and depression when their baby is in the NICU. A survey was conducted on medical staff perceptions to gather the knowledge regarding Intensive Care Unit physiotherapy service. Questionnaires were sent to the medical staff of critical care unit in five different countries covering 101 Intensive Care Units. The result showed that 79% of medical staff said that physiotherapy services provided by the physiotherapists are outstanding and very good. Physiotherapists should take part in research procedures to establish the evidence of their treatment interventions. Limited data are available regarding the family understanding of newborn involvement in minimum danger and slight raise over minimum danger in NICU study procedures. Hence, the study was drafted, focusing on neonates those who are admitted to the NICU. To gather information, 60 parents were participated in the study. The study includes five hypothetical research procedures. The study findings highlight that 31%-83% of parent's acceptability is ranged for each of the five studies. The results showed that there exists no difference between parents and the NICU staff regarding four of five research procedures. Few of mother, father, and professionals compared to the pediatricians concur that even this study would not help their own child. However, they involved their child in this study to help other future children. Communication with health professional helps in reducing distress in parents of admitted newborn in the NICU. The parents of 51 newborns are participated in the study and interviewed separately. The interview is taken for 20 min in private rooms. Specific questions are asked to them. Medical professionals counsel parents during the antenatal period on pain, death, finances, and severe disability reported by 75% of parents. About 60% of parents tell that they are not counseled by professionals during antenatal phase. Antenatal counseling of parents helps in reducing parental stress and anxiety and provides satisfaction and support to them. Previously, many studies were done on parent's perceptions of the NICU procedures or to know the level of stress in parents of admitted newborns in the NICU. Many studies were also done on staff perceptions toward the NICU research procedures or pain management in the NICU, however, the study on perspectives of both parents as well as the staff of the NICU toward physiotherapy interventions in the NICU does not perform yet. There is a real need for the study to know the perceptions of both parents as well the NICU staff toward physiotherapy interventions adopted in the NICU.
| Conclusion|| |
Here, we represented the level of perceptions of the NICU staff as well as parents of hospitalized newborns toward physiotherapy interventions adopted in the NICU. In developing countries such as India, people are not so aware regarding physiotherapy interventions performed in the NICU. There is no literature available on perceptions of parents as well NICU staff on physiotherapy interventions; hence, there is a real need for the study.
The authors would like to special thank to Dr. Kanimozhi Narkeesh, MPT, PhD, Professor and Principal, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar Deemed-to-be University, Mullana-Ambala, Haryana, India, for providing valuable encouragement for making this research report.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Magliyah AF, Razzak MI. Parents' perception of nursing support in the neonatal Intensive Care Unit (NICU). Int J Adv Comupt Sci Appl 2015;6:153-8.
Meharban S, editor. Organisation in NICU. In: Care of Newborn. New Delhi: CBS publisher; 2010. p. 3-25.
Palma IE, Von Wussow KF, Morales BI, Cifuentes RJ, Ambiado TS. Stress in parents of hospitalized newborns in a neonatal Intensive Care Unit. Rev Chil Pediatr 2017;88:332-9.
Mehta Y, Shetye J, Nanavati R, Mehta A. Physiological effects of a single chest physiotherapy session in mechanically ventilated and extubated preterm neonates. J Neonatal Perinatal Med 2016;9:371-6.
Álvarez MJ, Fernández D, Gómez-Salgado J, Rodríguez-González D, Rosón M, Lapeña S, et al.
The effects of massage therapy in hospitalized preterm neonates: A systematic review. Int J Nurs Stud 2017;69:119-36.
Levels of Neonatal Care: Policy statement by Committee on Fetus and Newborn constituted by American academy of Pediatrics. Pediatrics 2004;114:1341-1347
Singh H, Yadav G, Mallaiah R, Joshi P, Joshi V, Kaur R, et al.
INICU — Integrated Neonatal Care Unit: Capturing neonatal journey in an intelligent data way. J Med Syst 2017;41:132.
Cameron EC, Maehle V, Reid J. The effects of an early physical therapy intervention for very preterm, very low birth weight infants: A randomized controlled clinical trial. Pediatr Phys Ther 2005;17:107-9.
Cole J. A review of the effect of early intervention programmes on the developmental status of very preterm, very low birth weight infants. Aust J Physiother 1989;35:131-9.
Vignochi CM, Teixeira PP, Nader SS. Effect of aquatic physical therapy on pain and state of sleep and wakefulness among stable preterm newborns in neonatal Intensive Care Units. Rev Bras Fisioter 2010;14:214-20.
Chokshi T, Alaparthi GK, Krishnan S, Vaishali K, Zulfeequer CP. Practice patterns of physiotherapists in neonatal Intensive Care Units: A national survey. Indian J Crit Care Med 2013;17:359-66.
] [Full text]
Ranchod TM, Ballot DE, Martinez AM, Cory BJ, Davies VA, Partridge JC, et al.
Parental perception of neonatal intensive care in public sector hospitals in South africa. S Afr Med J 2004;94:913-6.
Obeidat HM, Bond EA, Callister LC. The parental experience of having an infant in the newborn Intensive Care Unit. J Perinat Educ 2009;18:23-9.
Massaro AN, Hammad TA, Jazzo B, Aly H. Massage with kinesthetic stimulation improves weight gain in preterm infants. J Perinatol 2009;29:352-7.
Carter JD, Mulder RT, Bartram AF, Darlow BA. Infants in a neonatal Intensive Care Unit: Parental response. Arch Dis Child Fetal Neonatal Ed 2005;90:F109-13.
Freibott C, Guillen U, Mackley A, Locke R. Parental and staff perspectives of NICU research procedures. BMC Pediatr 2016;16:63.
Jones AY. Intensive care physiotherapy — Medical staff perceptions. Hong Kong Physiother J 2001;19:9-16.
[Table 1], [Table 2]