Monday, February 10, 2014

Motor Monday- Let's start at the very beginning

I wasn't sure what my first topic should be for Motor Monday, but then we got an email from someone at Geisinger asking us to answer some questions about our experience there in labor and delivery and the NICU. Answering those questions had us reflecting on our experience and me thinking about the NICU from a motor standpoint. I thought maybe we should "start from the very beginning" and talk a bit about the NICU and what the big deal is about being a preemie. (My apologies if you have the entire Sound of Music soundtrack stuck in your head now! I know I do!)  When we were in the NICU I was way too busy falling head over heels in love with our little trio and being nervous about their health (especially nutrition & breathing) to spend much time thinking or blogging about the NICU from a motor standpoint, so I might as well do it now.

Since most of you reading this blog probably aren't pediatric therapists or NICU nurses, I'll start with the basics.  What is the difference between preemies and term babies other than the obvious size difference? The general problem is that these tiny babies were born too early into a world they weren't quite ready for! Their nervous systems are not fully developed and for the most part they're so small that they haven't been squished in the uterus yet.  Because of this preemies look very different from term babies when they're laid down, either on their backs or their tummies.

Premature babies generally have low muscle tone, which means that they have less resting tension in their muscles and it takes more effort to essentially turn their muscles on.  I find that muscle tone is a challenging concept to explain to people.  In person, during my early intervention visits, I use my hands to explain the crossover of muscle fibers, but that's tricky to do in blog form, so let's try this metaphor.  First, imagine yourself sitting on a kitchen chair and think about the effort  required to stand up and start walking.  This is like "normal" muscle tone.  Now imagine yourself in lounge lizard or couch potato mode, sunken into a deep cushy La-Z-Boy recliner and the monumental effort it would require to walk to the kitchen for a beverage.  The second image is akin to having low muscle tone, or hypotonia.  It just takes more effort to get started because the muscles are starting out in a more "rested" state.  Babies with low tone are often described as "floppy babies" and feel squishier than babies with normal tone.  As they get older when you pick them up, it might feel like they're going to slip right through your hands and they may feel heavier than you expect because they don't hold their own weight.  People with low muscle tone also tend to be more flexible (hypermobile) and fatigue sooner (lower endurance).  I often have parents ask "can muscle tone change?" and generally my answer is no, but preemies can be an exception to that because their nervous system is still maturing similar to how it would in utero.  In my experience, not all preemies who are born with low tone present with hypotonia as kids.

Babies born full term are usually so big and so squished in mom's uterus for the last few months that when they are newborns they tend to rest in the aptly named "fetal position" with their hips and knees flexed (bent) and their arms in tight to their bodies, elbows flexed. In PT terms this is known as "physiological flexion."  Premature babies are born before they get big enough to be super squished for very long, if at all. As a result of this and their low muscle tone preemies don't naturally "ball up" like term babies and instead lie fairly flat. The classic preemie position is to have their legs in a frogged position out to the side and their arms flat out to their sides, often making the shape of a W. 

You can see how our babies are kind of "flattened out" when lying on their backs in their warming beds. And because they were triplets and a little more squished in there than single babies born at 34 weeks they're actually a little more flexed than some preemies.
"Gravity is rough guys!!!"

Ellie showing off the "W" arms I talked about--though fairly close
to her little body

even our "big boy" is struggling with the whole gravity thing
For's wikipedia's example pic of a newborn
one hour after birth.  Notice how flexed the hips are and how
arms are in by the chest

Ideally, we don't let babies stay in this position for long, but instead try to mimic the "everything pulled in tight" positioning of term babies. The normal fetal position is calming for babies, which is super important for preemies in the NICU being bombarded with monitor noise, heel sticks, IVs, and other medical procedures.  It's also important to be mindful of positioning to support preemies' motor development.  If they aren't positioned well the typical preemie postures can lead to delays in meeting milestones like rolling and sitting.

an example of ineffective attempts at positioning...the rolls are there
but they aren't really doing much to support her

ah...peaceful, calm baby all tucked in tight
knees flexed up under her belly and arms in tight to her body

Ellie in a nice sidelying position. Snug as a bug
(all my positioning pics seem to be of Ellie!)

Isaiah all swaddled up to help keep his limbs in tight
(he was the first one in clothes and a swaddle because he was maintaing his temp)
An example of a much smaller baby being positioned in NICU
(granted I wish her legs were flexed more!)
      nice "hands together" positioning here  
(Thanks Heather for sharing the pics!)

One other NICU thing parents need to be aware of is that the way the workstations are set up, the babies are almost always approached from the right. This sets them up to get torticollis, or a tightening of the neck muscles on one side that can make it hard to turn all the way to the left. This is one thing I actually talked to the NICU docs about while we were there because I have had more than one kiddo on my caseload from that NICU with this issue.  (See, even in the midst of semi-crisis I can't totally turn off my PT brain!) Also, because gravity is a beast, preemies' heads often fall to one side or the other and they rarely face up.  Even if they aren't always turned to the right, this can cause a form of plagiocephaly (or flattened head), called scaphocephaly, where the babies' head is flattened on the sides and longer in the back like the sketch below from Hanger Orthotics.  This was already starting to happen to Ellie from her time in the NICU I think.  Her forehead was more prominent and her head was pretty narrow at first. (though not to this extreme)
Or if the baby's head is partially turned a lot of the time to the same side it can result in a flat spot just on the back corner leading to a head shape like this one.

you an see how the eyes and ears can
become assymetrical when this happens
The take home message is the NICU nurses and therapists play an important role in helping premature infants start from a better place when it comes to motor development!  The goal is to mimic typical newborn postures and to be very conscientious about the position of the babies' heads during their stay in the NICU.  Understandably, there are a lot of other things for nurses to pay attention to, but if parents are also aware of these vulnerabilities then they can be advocates for their babies!  Okay, time to wrap up the inaugural Motor Monday post that I am just sneaking in before heading to bed.  I need to work on getting these written up over the weekend so I can post them first thing, but, well, I have triplets you know, so that might not happen!  Let me know what you think about Motor Monday and if you have any topic suggestions!


  1. I found this very interesting. They should have some non-nurse in the NICU who can turn beds and heads so that this isn't a problem. Lots of wires and breathing apparati might make that difficult, but I am sure it could be done.

  2. I have found it takes a lot of time building good relationships with NICU staff and families to convince everyone they are not as right-hand-dominant as they think they are. It is definitely a process and a culture shift that does not happen overnight. Keep up the good work, everyone!

  3. Mari, thanks so much for this! can you speak to twins and muscle tone a bit? it seems to me that the twins had to be squashed in utero, just by being twins. Mine were 5 weeks early and spent a week in the nicu. But then again, if Spencer has low muscle tone, does it matter now what happened in utero? What can we do to help him?


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