Transition from Hospital to Home Cindy Redd, M.Ed Ann Marie Elmore, P.T

 Passage: the act of passing from one state or place to the next  Conversion: an event that results in a transformation  Change from one place or state or subject or stage to another  Cause to convert or undergo a transition wordnet.princeton.edu

 Needs, priorities, concerns, strengths, resources etc. are changing  Strategies for support and intervention must be assessed and adjusted frequently  Stress and anxiety may increase due to change even when change is positive.  Beginning and end of transition can be unclear.

 View transition as “bridge” from one place/state to the next.  Reflect and recognize progress and movement  Celebrate the baby steps of progress  Expect and support grief for what’s left behind

 Needs of Premature Infants  Needs of Families  Services Needed

 Feeding  Sleep  Self-Regulation  Social Interactions  Motor Development  Infection Control

 Taking everything by mouth (full po feeds) is a newly acquired skill, two or three days, therefore feeding is not well established and can be stressful for parents

 Chokes  Wants to Eat all the Time  Takes a Long Time to Eat  Sucks Frantically  Frequently Spits Up

 Difficulty coordinating suck, swallow, breathing.  Slow flow nipple  Side lying to feed  Assist baby with pacing and timing by tilting the bottle

 Babies sucking to feed and to self-regulate

 Only sleeps if being held  Sleeps all day, stays awake during the night  Catnaps throughout the day  Does not sleep thought the night when it’s age appropriate.

 Holding provides the supports babies need to sleep ◦ containment ◦ incline ◦ ventral support ◦ warmth  Mother’s body is “home” to baby ◦ Rhythms of breathing & heart beat familiar ◦ Mother’s smell is comforting

 It’s easier for premature baby to be awake when it is dark and quiet.  The “stress” of daytime activities can cause premature baby to “shut down.”  Strategies should support baby’s efforts to stay awake or asleep at the appropriate times.

 Place light and/or radio near the baby’s bassinet at night  Avoid social interactions and “invitation to play”

 Dark quiet environment is optimal environment for being awake/alert  Even dim natural light and buffered sounds can cause stress reaction.  Dim lights and close blinds, especially those in baby’s face  Minimize noise and social activity  Communicate “invitation to play” when baby wakes up during the day

 “My baby does no want to look at me”  Fussy ◦ Maybe self-regulation or reflux related

 Baby does not want to look at parents  Fussiness

 Decrease environmental stimulation  Read and respond to subtilities of infant cues

 Dispel myth – “baby just wants to be held”  Support infant’s effort to self-regulate ◦ Suck ◦ Hands together ◦ Hands to mouth ◦ Feet together  Give infant time to respond to support  Avoid constant repositioning  Vestibular Movement with containment

 Decrease stimulation  Understand how different environments and fatigue effects self-regulation

 Premature infants have strong extensor muscles ◦ If extension activities are encouraged then baby will develop extensor dominance ◦ Encourage flexion

 Hyper-extended Neck  Retracted Shoulders  Decreased Trunk/Pelvic Mobility  Frog Legged  Toe Walking

Facilitate  Flexion  Trunk/Pelvic Mobility  Weight Shifting

 Shoulders Forward  Hips Tucked and Together

 Activates Neck Flexors  Facilitates Shoulder Forward

 Hand to Feet Play  Pivoting on Stomach

 Lap Standing  Exersaucers  Johnny Jump Ups  Be sure heel cords are not tight

 With “back to sleep” infants spend more time on their backs, in infant carriers, car seats & swings and much less awake/play tummy time  Prior to 2 months (corrected age), babies will turn their head to the side when lying on their back  85% of newborns have right head preferenceright

 Baby’s heads are very moldable  Increase in abnormal head shapes

 Monitor head position  Alter sleep, carrying, and play positions  Head in midline in carriers, car seats, swings  Range of motion exercises- preferably active  Increase awake stomach time and sitting play

 Head tilted to the side and rotated to the opposite side  Torticollis can be obvious or subtle  Head position can lead to flat head

 Immature immune system  BPD and Cardiac conditions  RSV  Child care

 Emotional responses and support networks  Shift of trust from hospital to community providers  Compensatory Parenting

 Parent may “fall apart” after discharge even though baby is okay  Post-traumatic reactions to smells & sounds in the community that may trigger memory of NICU  FSN, March of Dimes, Hospital Reunions

 Neonatologist Pediatrician  NICU specialists EI/CSC providers  NICU nurse daily caregivers

 Tend to try to compensate for perceived loss  Parenting should be based on developmental info & family values  Parenting should not be based on fear and guilt

 Consultation & Anticipatory Guidance  Observation & Monitoring  Initial Home Visits  Coordination of Services

 Relationship begins with parent/caregiver and evolves toward infant  Parent brings expertise from NICU experience  Routine assessment of “how things are going?”  Partners in problem solving not solutions  Prepare family for “what to expect next”

 Looking for subtle qualitative differences not measurable delays  Should monitor over time since some differences may appear at various developmental stages.  Encourage families to stay enrolled in services at least until18 mos. when motor & language can be assessed.

 May need to be more frequent due to baby’s rapid growth & development  May take longer due to amount of concerns and mother’s need to “tell her story”  May be difficult to schedule due to other appointments, stress of having visitor and desire to “lay claim” on their baby.

 Services may include medical, developmental, legal, social and support.  Important to be sensitive to # of service providers involved with family  Communication& collaboration between providers is critical and challenging