Occupational Therapy For Premature Babies. Valerie Legendre

This episode is dedicated to Carmen, our niece, who lived her first

weeks in the neonatal intensive care unit

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May marks Mother's Day month in around 90 countries.

Well, it's a wonderful time to honor mothers absolutely everywhere.

And to help in this celebration, I am thrilled to welcome my

guest today, Valerie Legendre.

She will provide insights into what a neonatal intensive care unit is like

for premature infants, as well as how her role as an occupational therapist

supports both mothers and their children.

Valerie works at Presbyterian Hospital in the United States, and

many people may not realize just how crucial an occupational therapist is

in the neonatal intensive care unit.

Occupational therapists offer hope and support to both mothers and babies,

valerie Legendre, welcome to the show.

Oh, good morning.

It's so good to see you.

Good to have you on the show, and to learn about something

that is not well-known worldwide.

Now, you are an occupational therapist, and we are here to celebrate

moms, and I know you are a mother yourself, so Happy Mother's Day month.

Absolutely.

So let's get started.

Was there something that brought you to becoming an occupational therapist, or

was it something you just knew early on?

No, actually occupational therapy was

kind of an unknown for me.

It was a bunch of series of life steps and I kinda collided with an individual

during college that introduced me to it.

I always knew I wanted to do something with children and infants, and so

all of my experiences led up to that.

But it wasn't until I was in the midst of college that I ran into someone when I

was volunteering that, that really showed me the ropes and talked to me about it.

So yeah, it was a journey.

It was a process.

Wow.

So what did you learn about it that made you really wanna go towards that

from that, from that conversation?

Yeah, so originally my interest was medicine.

Growing up I did some volunteer work with within nursing and just

didn't really wanna do all the pokes and blood and all that stuff.

And so I thought, "Wow, I really love teaching," so I went to get

a degree in preschool education.

And when I was in the classroom with 20-some kids, I realized,

gosh, I don't know if I enjoy teaching 25 kids all at once.

So I really, really enjoyed the one-on-one time that I would get with kiddos.

And so, Different life circumstances and so, everything kinda landed and

pushed into a child development degree.

Um, Part of that was doing some volunteer work, and so I did that at the Child Life

play area at UNM and at Presbyterian.

And so I really enjoyed learning how to bring play into the aspects of

helping with children process the medical equipment and the medical

experience and that really intrigued me.

So for a moment I thought, "Well, maybe I'll become a Child Life

specialist." So, I was actually on my way to volunteer with the Child Life

program when I had an individual stop.

We were at a stop walk to cross the street, and she was going to do some

volunteer work, and she... I don't even know how it came up, but she was...

she started talking about this degree she just signed up for with occupational

therapy, and our lives were very similar, our interests were very similar, and she

convinced me that, "Gosh, you love to teach one-on-one. This would be teaching

little ones . You love to do the play therapy, and there's all sorts of play and

fun when it comes to helping kids achieve their milestones and their occupations."

And so then I just was looking at the pay difference was huge, too.

So, it just kinda navigated that route.

At the time, I was very interested in infants and NICU, and that

was an arena at the time, too, that OTs were branching into.

So all those things kinda collided and pushed me towards that direction for

furthering my education after I finished my bachelor's in child development.

It

Valerie, I love that story because you, you went full

circle into finding your niche i- in life, and that is awesome.

And that right there, that's inspiring for people to hear that you started

in one area because you love children, you wanted to work with children, but

maybe not in that classroom setting

. So I'm so glad you're here as occupational therapist and there's so much we do

not know, so much I don't know, and listeners don't know worldwide about

occupational- occupational therapist.

You said yourself that it was an area that you just didn't know about.

So let's go to this question of is the difference between physical

therapy and occupational therapy?

Yeah.

Well, in pediatrics we don't see

as big of a difference as we do in the adult population, for sure.

But if you look at the broad sweeping s- span of it, physical therapists obviously

work with individuals on strengthening and getting back to motor skills, and a lot of

it is expertise in ambulating and walking and running and all those great things.

OTs is a little broader in the sense that we help individuals

get back to what we call ADLs, activities of their daily living.

So for adults, that might be dressing or bathing or those kinds of things.

But when it comes to kiddos, obviously they do dress and, and get bathed as

well, but there's so much incorporating of parents as well in that dynamic.

There's like this nice little dyad of helping parents doing

those things, as well as play.

And then a new realm for me, which wasn't on my radar exactly when I

first started but then kind of migrated was even moving into the infant

population, and there's a lot of OTs that work obviously now in the NICUs.

But with infants and that is really focusing a lot more on helping the parents

and their activity of the infant care.

Feeding and dressing, bathing their infants, bonding,

all those things as well.

And so, really the unique piece I think of OTs is, is just that

functional activity and that daily living process, and then working

Within those systems and within all of those pieces to kinda help that come

together for either kiddos, infants, to adults and older individuals, so.

So is it mostly premature babies that you work with?

Yes.

So in the NICU, a majority of them are born prior to the, the term date.

There are some infants born that have other struggles that are in that term

bracket, and then there are infants that can stay there for a while.

But yes, it's, it's infancy in the NICU that brings them

in upon delivery typically.

What does that look like So, so my niece was born

prematurely, and unfortunately we did not have OTs at that hospital.

But she would stop breathing at times, and so what does the occupational therapist

do during those times to help mother and, and when you're bringing the baby home?

What kind of work is entailed in doing this to keep the baby breathing?

Yeah.

So, I guess if you're looking at just the breathing component

for occupational therapists we do help facilitate a lot of that.

So we're in New Mexico, and our elevation is higher, so a lot of

our babies are actually on high respiratory supports for longer--

and long durations than other areas.

And so that's actually one area that we have to have a keen eye

for and a therapeutic handling and touch and expertise in because

our babies are on higher supports and systems for oxygenation here.

So for us with OT, if we're just looking at airway and breathing early on, we

can help support families as they want to touch and, and hold infants with,

ET tubes or things that are helping to actually give them those breaths.

A lot of times there's extra maneuvering.

We work with our, closely with our respiratory therapists and our nursing

to get infants skin-to-skin, which is just that holding baby chest-to-chest

and holding for the very first times.

We help with that process.

As well as there's a respiratory support called CPAP that has this-

whole apparatus of the contraptions on their nose and then straps and chin

straps and a hat and the whole process.

And we're aware of the fact that that also then, although it's life-saving,

puts pressures on their jaw and it puts pressures on their nose and it fills

their bellies up sometimes with air.

And so, we can help with positioning as well as different strategies to

engage their abdominal core and all those things because even how their

diaphragm moves, all those things change.

So, we really have expertise and extra learning in the processes of

how those respiratory supports Can alter an infant's normal movements

and body mechanisms and supports to kind of help those move along a more

what we call normal trajectory, and then provide supports with families

on those strategies as well so that they can help them move forward.

So those are like the more extreme respiratory supports

that we see, like oral intubation typically and then the CPAP.

But we use those extra skills and learning to help educate family for those things.

I think overall, so respiratory is like a small piece too in the

grand scheme of what we offer.

So I don't know if it would be helpful to kind of go through some

Yes.

Yes, because all of this is hopeful and educational

Yeah.

So just prefacing, when I graduated from occupational therapy school,

I had a, a great knowledge of infants and child development.

My bachelor's degree is infant development.

However, not very many schools dive into the in-depth of anything

under the 40 weeks, right?

So learning all of the gestational expectations for motor and development

was something that we went and did extra courses in, and we had extensive

mentorship in so that we could really learn and know those systems.

And so all of us with in our team have done a lot of extra courses to get

certified in neonatal therapy, so we're all certified neonatal therapists, CNTs.

So that extra knowledge and information is kind of the core and crux to

help us as well, Be able to support these families in these unique ways.

So in that knowledge, we're educators and we're educating

family from the very beginning.

So the earliest right now in our hospital that we can see is twenty-two weeks

So a twenty-two weeker we would get an evaluation order on and we help with

families understand skin integrity and preservation, understand all of the

oxygen supports that they may have and then first touches, first diapers, first

cares, all those things as well as once they're stable enough, doing the holding.

And so we work through each week basically uh, depending on when

they're born and then how they move forward in their development.

We support the families in that education information with a huge emphasis on touch

and handling as well as information on how to support their brain development

and their development overall with what to expect all the way through.

So that is a process that we are supporting families and educating families

from start to finish with that piece.

There is a, a wonderful quote in one of our i-- courses that we

had taken was to touch a premature baby is to touch their brain.

And so there's a, a heavy emphasis on the power of touch for

families as well as to the infant.

And so we're very cognizant of all of those things.

Then we also support early pre-feeding.

Obviously, infants have reflexes early on in utero that they would be utilizing in

the safeties and comfort of the womb and they will be doing that externally with

extra tubes and and touch that's medical.

So we work early on on helping families create both the external environment of

calm states and touch and positive touch and then pacifiers and non-nutritive sucks

as well as exposures to scent like that mother's scent with scent cloths, . So

we, we, we make a heavy emphasis too on that early feeding because feeding

becomes their primary job later on both for family members to learn as well as

infants, and it's not as smooth as when they have all those medical interventions.

So we try to, to create that education and knowledge early for the feeding.

Feeding is both bottle and breastfeeding typically in the unit,

and so we, we have a good knowledge of helping support that as well.

One of the things I personally did this year was seek out the certified

lactation consulting title and information just so that I can also

help families along that trajectory for breastfeeding in more detail.

So we have breastfeeding, bottle feeding expertise and then and then

we also support the bathing process.

So we can help support whatever adaptations we need early on for

whether that's a bed bath and sponge bath to all the way through the skin

integrity changes throughout the process.

And so knowing when we can use soaps and what types of soaps and

water, all that is is guided and, and supported and provided family

education on throughout as well.

So within each and every one of these tasks we're helping support,

educate, and provide the caregiver the knowledge and the confidence

to take that task on themselves.

To kind of pass that baton slowly over, "Okay, now you're-- you, you're

really good with getting your baby out and holding, and now you get to

do that on your own," and supporting the environment and everything to

kind of help them through that process so that they can become that primary

caregiver for the infant in that way and then advocate for them a-as well.

So, a lot of education and knowledge again on that... And I say dyad 'cause

you have to know the caregiver's role, support that, as well as what's

the infant's abilities and role.

And then you have to know how that all interacts with the environment, which

is this unnatural medical facility space with that limitation too.

And so, knowing all of those systems and how they interact with

each other, and they can change moment to moment and day over day.

We're just kind of working within that, that construct to help support

the family as a one unit get from start to finish and get home.

And our goal is that families can go home and know all the things to do to

support their infant's development as well as to have been bonded and supported

throughout a process when they're in such an unnatural environment to kind of finish

that growth process to get them home.

I love that, to get them home.

, it gives me goosebumps just when you think about it, because I

remember my niece being there.

So occupational therapists provide the education, but also that hope,

and that hope is also what you said is that confidence building.

Because when the caregiver is able to go home and care for the

baby, they have that confidence, which confidence is part of hope.

We, we build hope based on not just confidence, but on everything around

us, on you, what you're providing.

So is there a follow-up?

Do they come in to see you once they leave the neonatal care?

Yes.

We have a developmental follow-up clinic and they do have a scheduled

appointment to come back and be seen every three months or so, and then

for the first couple years of life as needed, just to make sure they're

hitting milestones, doing the things they need to, family still has all the

answers and, and supports they need because obviously as the baby grows

and changes, the needs change too.

And then also making sure that they're connected to the resources within

our community and, and that there's not any gaps there as best we can.

Our state has a lot of rural areas, and so, just making sure that everybody

has what they need as best that we can,

that is so awesome.

And I wanna go back to, , breastfeeding., People are under the misnotion

that breastfeeding happens very quickly and very naturally.

Oftentimes that's not the case.

And so occupational therapists are needed to help with that.

And I know that World Health really pushes breastfeeding worldwide

because of that immunity building aspect through breastfeeding.

Yeah.

So I guess breastfeeding starts for us w- from day one on the NICU in the sense

that depending on the age breast milk is definitely the number one source of food

that we want to support for these infants.

There's a lot of data and literature now that supports that breast milk

is best for their gut as it develops.

It really reduces the cases of NEC and other things that can happen to an

infant gut that's been born premature.

So we have donor milk that we can offer for infants as well as moms are

encouraged and supported to start pumping early on even before their

baby is at the, the level of being able to latch and, and feed on their own.

And so oftentimes our moms have a long course of breastfeeding where they've been

on a pump doing pumping eight times a day.

Every three hours around the clock waking up and, and, it's a full-time

job for them just to provide the milk for their babies while they're there.

And then we also really encourage that the process of infants

continuing that strength that they have of smell when they're born.

They all come out knowing mom's smell and being really connected to that.

And so we have scent cloths that mom can, can wear in between and put in the

ice sled or wherever the infant is so that they can continue to smell mom and

that that can continue to be encouraged because we know with breastfeeding

that a big piece of being able to get proper latch is that sense of smell.

And so we really encourage that too along with body positioning

and that kind of thing.

So they have the better motor capabilities of having that open

mouth and jaw posture, all the things they need to, to do a latch.

And then, yeah, when, when we get to that process where infant is ready for

feeding and then, and breastfeeding, we help with that process too.

A lot of that is early skin to skin and getting mom used to moving a

breast and positioning as well.

One of the, I would say lenses that OTs bring to the process of early

breastfeeding and especially premature baby is our ability to adapt the

environment as well as looking at mom and baby's body postures and positions and how

that can really be modified to encourage the proper movement and the proper

latch and, and, and all of those things.

So, I I love, love, love breastfeeding.

It's one of my passions and one of the things that I love to see is going

into a mom that has a baby that's really struggling and they can't get,

figure it out and we simply add a different pillow and add supports at

the feet and move baby an inch down or a diff- a different position and baby

is able to latch more successfully and have more of a calm state.

It's a lot of fun to watch just the little adjustments and how those can help.

I would say there is also a population of our late-term preemies that

struggle a lot with breastfeeding.

They get the nickname great pretenders because w- they're in these bigger

bodies and they're so close to due date and families anticipate that

they're just gonna behave like a term baby would, and they tend to, to not.

Many of them struggle with energy and are very, very sleepy which also makes

positioning them really well and heavily supported to be much more important.

They can be a little more limp noodles and have a hard time

sustaining that endurance.

And so that population, I think gets all of us a little bit 'cause everyone

looks at them like, "Oh, you should do great," and they're, like awake

and going and then fatigue so fast.

So I, I think, it, it creates a lot of discouragement for sure for families

who are thinking, "Gosh, we're so close to due date and we're gonna get out of

here," and then they fall asleep and they, they don't take a full feeding.

So we definitely are supportive along the whole processes for it.

But that group and population can sometimes be more discouraging

just because family is walking into it thinking, "Gosh,

We're gonna get out of here, and they're gonna be these great little feeders,"

and they look like term babies, and they act like little preemies, and they

need a little more support and a little more time and a little more patience.

A- and sometimes more adaptations is, like I said, more supports

positioning-wise at just to get latched on a breast and to do the job.

Now, worldwide, there seem to be more premature babies

born every year than in the past.

Is that because we have better medical where we're able to save the baby what

is the research saying about this?

I haven't really kept abreast of the most recent research.

I did run across an article but didn't read it in full depth, but it, it

And so I think it's a combination of our medical expertise.

When I first started OT in NICU, we-- 24 weeks was the earliest we were

intervening and now it's down to 22.

We have more technology and more supports to, to keep younger ones

going and blessing, but also, it, it definitely means that we have

more babies that are in our NICU.

And then also just other anomalies and things from environmental.

Who knows?

I don't...

I'm not really sure what exactly is causing them.

I know our NICU is also filled with babies that aren't just born early but might

have other diagnoses, cardiac anomalies or, or things like that, the diagnoses

that that makes them need a little m-more medical interventions to get home.

So I think it's probably a combination of all of the things.

But again, I, I haven't really looked into too de- too much depth of the

research that's current on explaining why those, those might be happening.

I know it's different for all of the babies, but what is the

average time span if a baby is born at 22 weeks early, how long would a

family be seeing a stay in the hospital in the neonatal intensive care unit?

always say our goal obviously is by due date

but a baby that's born much earlier and has more respiratory supports

or, or struggles in the respiratory department tend to stay,

after they pass that due date.

And a lot of times that's working on breathing, that kind of thing.

If they have surgeries while they're in NICU for any reason, that

tends to increase their length of stay

You're not just growing, but you're also recovering from a medical intervention.

So every course is different obviously.

But we always say goal is typically by your due date, if courses, just

to grow and, and gain and all that.

Oh, that is just so interesting and so much hope.

What does that look like when they take the baby home?

Is

Our criteria for home would be the oxygen level has to be one

that can be supported on a home system.

, they have to be eating all our food by mouth or if they end up with a G-tube,

then be able to have the, the food in them, , based on their nutrition,

Assessment and then be gaining weight.

Obviously then families have

To go through all of their processes.

Some families will room in to kind of get at the hang of how things are

going, and then go through all the mark-offs that they have to for safety.

But those are the , main variables.

So we will have babies that can go home before their due date 36, 37 weeks,

whatever it lands in, where they're eating and growing, gaining, and, and

breathing on their own in a safe manner.

So that's really the medical criteria to go

home.

So we do for sure have babies going home before due date.

But I always encourage... Or in my mind, by due date, that typically is

when all of those things iron itself out on a typical course, unless, like

I said, there's other variables the baby is having to work through that

kind of extends it past that 40 weeks.

We do have interventions and, and infants that are born before anything

earlier than that 37 weeks, we, we talk to families about - an adjusted age.

So an - adjusted age would be, I always tell families,

everyone remembers due date.

So think about your baby being born on due date.

That's what their motor expectations and their output expectations are for us.

So they will get that adjusted age until they should catch

up by the time they're two.

So the adjusted age gives everyone kind of a gauge of are they starting

to catch up to their peers based on their birth date, as well as not

over-expecting something of a baby, especially when they first get home.

So if baby just gets home and they're hit that due date, then

I would expect motor-wise and interaction-wise, endurance-wise,

feeding, everything to kind of align more with a newborn day one than Maybe

they've been alive for two months.

I don't expect them to be hitting a two-month milestones.

Now, we will see what we call splinter skills, where maybe that

baby starts to pick up and, and is like its peers in some arenas.

And the earlier you're born prematurely, the more things you get to work on.

You have all those medical interventions and growing in an external medical

environment that we have to then work towards hitting those skills.

And then even within those skills, premature infants tend to engage

different muscles with their motor output and also have different sensory

inter- intervention or interactions that may need interventions or may

play out in a different way for them than they would had they had that full

time in utero to grow and develop.

It, it, it's just incredible.

It really is.

We were out in Europe, and I was so pleased to know that of those countries

extended leave for instances when a child is born with e- either prematurely or

with some sort of condition that is going to require more special care at home.

So Colorado, in United States, has added They call it maternity and

bonding leave, which I, I love.

, so they have 12 weeks for bonding with an additional 4 weeks for

serious health conditions related to pregnancy or childbirth complications.

And now this is still f- far behind Europe, but it's something, right?

Yeah, and it, that's one of the things that we

see with our families that's unique, right, is every, every family

has to leave their baby behind.

They don't get to take their baby home.

And so in our state, obviously, we have the, the bigger cities clustered

here, but then lots of rural towns.

So there may be families that are having to stay outside of their community

and stay in the Ronald McDonald House here to be close so that they

can provide the care and learn these things, because the, the number one

thing is bonding and holding and, and interacting and learning these things

so that they can have the best outcomes.

And so we definitely encourage that, but family members are having to

be away from their home environment potentially if they live out of town.

If people who live in town even, they have to schedule to come in, and if you

have multiple children, you're having to figure that out with a spouse.

So oftentimes even within married couples, the, the one is present and the

other one is home holding down the fort.

That's a divided process, which wouldn't necessarily happen if they

were in their home environment.

So, and then add in that dynamic of everyone figuring out how this

plays out with their work, and every work is different in what

they offer for families as leave.

But it, it's definitely a juggle and a process, and every single family

I've interacted with that has work thrown into that mix has to figure

out when am I taking my time off?

Am I gonna work while I'm still here so that I can have the

extra time when I get home?

Because we know we have that transition, and it's like having a newborn.

You gotta, you gotta go through all those processes as a family.

And so these courses, if you have a 22-weeker or somebody that's born that

early and then they're there till that due date, that's a large chunk of time

already taken away from the normal systems and, and the way family's working, and

then that process then of going home.

And one thing that is unique for me is that I'm not just an OT that does

therapy with babies in the NICU, but I myself had a 28-week premature infant.

My son was three and a half, and we spent three months in the NICU with my daughter.

And I can attest to the stress of and the dynamics because

we lived through that process.

Not only have I seen families do it, we had to live through that process

of dad being home with son and helping there and then me coming in.

And the commute for us is 45 minutes.

so just figuring out our day-to-day and learning how to do that for that duration.

it definitely puts to light the personal aspects of it.

I often tell families biggest thing to focus on when you get home is just pretend

they're a newborn and bond as much as you can and try to get in routines because

everybody has this huge readjustment.

And it took a good year, I think, for us to really get in a good system and rhythm

with our family, adjust to the trauma.

There's a lot of trauma that happens both from mom's very traumatic

birth oftentimes to the processes of parenting in a hospital environment.

And it took us a good year, I feel like, for our family to finally take

a breath of , okay, we got this.

that's a long time that work doesn't account for, right?

So it's awesome to see that there's states really focusing on the extra time.

I love that they put bonding in there because when you go home, there is a lot

of bonding and a lot of adjusting working through that trauma that you've had.

I would say more is needed too.

So yeah, good starts.

I'm encouraged to see and I hope other states start to

jump on the wagon for sure.

You're, you're bringing hope, not just as an occupational therapist,

but also you had your, your premature baby and you went through all of the motions,

and you worked through it, and it, it, it brings hope, and it's inspirational.

Your job is certainly needed, but it's also emotional because you're

dealing with life, and it's the first part of life for these babies, and you

are the one that is there every day.

And that's really hard, I think, for a, a mother to realize is that

she's not there, can't be there with baby, and you are thank you for

all the work you're doing with the families as an occupational therapist.

So is there anything else that you wanted to share before we

get to your last inspiring words?

No.

Well, I think that maybe this would go into my last inspiring words.

One of the things in working with moms and families in the NICU and working

with extremely premature and sick babies, one of the, the most powerful

things that I've seen and encouraged to see is just the power of touch.

First touches, first holdings, the power of being able to wrap your

hands around a baby that is, is in a painful procedure or that is just

needing a minute how powerful that is and seeing how it, for a tiny little

human being, that can be so comforting.

I am in a position where I get to share that and teach families

that, and then seeing the results that come of it is, is amazing.

And so I guess for, for every mama or every person that's going in that that

journey of a premature baby or a sick baby or a hospitalized baby, I mean,

it even extends into older kiddos going to the hospital, is just not

to forget the power of human touch.

And one of the most joyful things that I can do is adapt, in my brain as the

OT, adapt the environment in any humanly possible way to allow to support parents

touching their children when they're in these moments, both for themselves and

for their child, and the power of healing that that has for everyone involved.

And so, I'm, I'm privileged.

I, I love what I do.

I, I, I'm passionate with what I'm doing, so never forget how

powerful our touch as moms are to our, our children, young and old.

Oh, I love that

I think that's incredible.

And Valerie, the power of touch for all ages is certainly an incredible piece

that we can bond together with humanity.

Thank

And that's just what you're doing in the family unit.

So Valerie LeGendre, thank you so much again for being here and sharing your

work as an occupational therapist, and the love that you have in doing so.

Thank you so much.

To learn more about neonatal therapy, go to neonataltherapist.com.

And to learn more about the power of touch, go to World Health Organization,

and that website is who.int, and within the site, search skin to skin.

And another website, Union of European Neonatal and Perinatal Societies,

and that website is uenps.eu/parents.

And this website brings more information to you regarding what happens now that I'm

bringing my baby home, plus more research.

And thanks for listening as we celebrate mothers around the

world during the month of May.

If you'd like to buy me a coffee to help fund the production

of this podcast, here's how.

Go to buymeacoffee.com/Yourpositiveimprint and any support you offer

will be greatly valued.

Thank you so much for your support and for listening to your positive imprint.

And until next time, enjoy listening to over 200 episodes of your positive

imprint, your positive imprint.

What's your P.I.?