As a brand-new physiotherapist barely twenty-four years old, I found myself working as the lead on the Burn Unit at a major trauma centre in North America. It was a wee bit intimidating. The specialised protocols, extensive need for precautions, and generalised fear of the “big screw-up” kept me on my toes. But sister, let me just say, the Burn Unit’s got nothing on the Neonatal Intensive Care Unit. That place will put the fear of the Almighty (meaning, of course, the nurses) into any physio.
NICU nurses are very protective of their charges – and rightfully so. Anything that disrupts the Zen in that place means additional stressors on amped-up bambini. So imagine the reaction that a physio might get if she entered the NICU and said, “Today, we try pool therapy!”
The History of Neonatal Hydrotherapy
I first became aware that physiotherapists dared to bring the benefits of “aquatic therapy” into the NICU in the 1990’s. At that time I was the Editor in Chief of the Journal of Aquatic Physical Therapy and I came across a pilot study published in 1983 by Jane Sweeney, PT, PhD, PCS. (Note: Sweeney’s name is now synonymous with many of the advances in water-based treatments on the NICU. Even the swaddled bathing techniques I outlined in an earlier blog borrowed heavily from her ideas.)
When I first heard of neonatal hydrotherapy, I pictured Sweeney rolling a mini Hubbard tank of sorts onto the unit, wrestling lines and leads and horrified parents; frankly, in my head, it looked insane. Of course my visualisation was nothing near reality, but the fascination was planted. From that original pilot study, I have kept tabs and read with delight every development in this esoteric field.
The Need For Neonatal Hydrotherapy
To a newborn, neonatal units must appear exceedingly loud, astonishingly bright, unbelievably chaotic and intermittently painful. Nurses do everything they can to maximise the peace and comfort of their charges, but there is only so much that can be done. So, any technique which can reduce pain, decrease physical stressors, induce sleep and increase hunger and the tendency to suck…. all without robbing the infant of energy is like a gift from the NICU gods.
Aquatic therapy, performed by a physiotherapist on the unit in a specialised warm basin, can be this gift. It’s not the same thing as swaddled bathing (although swaddled bathing borrows heavily from the protocols established by the physio Sweeney). In swaddled bathing, the intent is to handle, clean and calm the infant without producing physical stressor or temperature variation. The emphasis is on quickness and little is done to encourage specific movements. In aquatic physiotherapy (or neonatal hydrotherapy as it was originally called), the intent is different.
With aquatic physiotherapy, the goal is to improve the neonate’s capacity for sleep and quantity and duration of sucking, and to decrease pain, especially post-invasive procedure.
In 2015, the Cochrane Collection published their findings of the benefits of non-pharmacological management of infant and young child procedural pain. Their findings showed that these little ones gained the most benefit from non-nutritive sucking, swaddling/facilitated tucking, and rocking/holding. Neonatal hydrotherapy allows physiotherapists trained to work in the NICU to marry the use of rocking and holding patterns with immersion in soothing warm water environment. The techniques also make use of swaddling both during and after the session to help maintain temperature and decrease the stress which premature infants feel when they are not flexed and held closely bound.
Candidates For Neonatal Hydrotherapy
Infants who are being considered for aquatic sessions should be medically stable and have either lost their umbilical cord or have the cord covered with a bio-occlusive dressing, according to Sweeney. Children who remain on ventilator support, those whose temperatures remain unstable and those who are experiencing apnea or episodes of bradycardia are not candidates for this technique. (See Sweeney’s suggestions for greater details on evaluating a child’s candidacy.)
Performing Neonatal Hydrotherapy
As already discussed, neonatal hydrotherapy is not the same thing as swaddled bathing. An experienced clinician can manage a seven to eight minute swaddled bathing session without a helping hand, even on the littlest neonate. With neonatal hydrotherapy, it works best with two caregivers. While this is not essential, it makes more movement possible to have a caregiver at the head and shoulder area and another at the lumbar and pelvis region. The baby starts out swaddled in a flexed position, neutrally postured. Upon immersion there is an opportunity for water adjustment by the child. After a minute or two, guided movement patterns are performed from a base of stability. One clinician stabilises (e.g. the head and shoulders) and the other promotes movement (at the lumbar spine and pelvis).
Therapists looking for potential movement patterns should consider the Accordion, Rotating Accordion, Near Leg and Far Leg Watsu patterns described by Schoedinger in Watsu in aquatic rehabilitation. Sessions are performed in near 98° fahrenheit (36.7° celsius) water in specialised basins lasting no more than ten minutes and end in swaddling and – when possible – nursing.
Practitioners who are interested in exploring the exploding world of physiotherapists working in the NICU are directed to Chokshi. Clinicians who are not yet sold on the need for swaddling during bath time should take a look at this 2014 study comparing the effects of swaddled and conventional bathing methods on body temperature and crying duration. The evidence is accumulating. Warm water immersion, especially when coupled with skilled movement exploration, is becoming an important, safe and viable option on the NICU.
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- Edraki, M, Paran, M, Montaseri, S, Nejad, MR & Montaseri, Z 2014, ‘Comparing the effects of swaddled and conventional bathing methods on body temperature and crying duration in premature infants: A randomised clinical trial’, Journal of caring sciences, p 83.
- Chokshi, T, Alaparthi, GK, Krishnan, S, Vaishali, K & Zulfeequer, CP 2013, ‘Practice patterns of physiotherapists in neonatal intensive care units: A national survey,’ Indian journal of critical care medicine: peer-reviewed, Indian Society of Critical Care Medicine, p 359.
- Lovelace-Chandler, BR 1990, The effects of neonatal hydrotherapy on selected vital signs, 118 leaves.
- McManus BM, Kotelchuck M 2007, ‘The effect of aquatic therapy on functional mobility of infants and toddlers in early intervention,’ Pediatr Phys Ther, pp. 275-82.
- Pillai Riddell, RR, Racine, NM, Gennis, HG, Turcotte, K, Uman, LS, Horton, RE & Lisi, DM 2015, ‘Non‐pharmacological management of infant and young child procedural pain: New search for studies and content updated (no change to conclusions)’
- Schoedinger, P, Becker BE & Cole AJ 2011, ‘Watsu in aquatic rehabilitation,’ Comprehensive aquatic therapy, 3rd edn, Washington State University: Butterworth-Heinemann, pp. 137-154.
- Sweeney, JK 1983, ‘Neonatal hydrotherapy: An adjunct to developmental intervention in an intensive care nursery setting,’ Physical & Occupational Therapy in Pediatrics, 3(1), pp. 39-52
- Sweeney, JK 2003, ‘Feeding proficiency in preterm neonates following hydrotherapy in the NICU setting,’ Pediatric Physical Therapy 15(1): p 63.
- Sweeney, JK 2007, ‘Neonates and infants at neurodevelopmental risk,’ Neurological rehabilitation, 5th edn, St Louis: Mosby, pp. 303-356.
- Vignochi, CM, Teixeira, PP & Nader, SS 2010, Effect of aquatic physical therapy on pain and state of sleep and wakefulness among stable preterm newborns in neonatal intensive care units, Revista Brasileira de Fisioterapia, Sao Carlos, Sao Paulo, Brazil, 14(3), pp. 214–220.
- Zhao, S, Xie, L, Hu, H, Xia, J, Zhang, W, Ye, N, Chen, B 2005, A study of neonatal swimming (water therapy) applied in clinical obstetrics, 17(1), pp. 59-62.
Andrea Salzman, MS, PT graduated from the University of Alabama at Birmingham with a Master’s degree in physical therapy in 1992. Over the last two decades, she has held numerous prominent leadership roles in the physical therapy field, with a heavy emphasis on academic writing and administrative functions. Between 1995 and 1998, Salzman served as the Editor-in-Chief of an American Physical Therapy Association (APTA) journal. In 2010, Salzman received one of the highest honors given to a physical therapist from the American Physical Therapy Association, the Judy Cirullo Leadership Award. Between 2012 and the present, Salzman has written 12 physical therapy courses for Care2Learn, Relias Learning and reviewed over 100 other course offerings. Currently, Salzman continues in her writing, leadership and administrative roles at Aquatic Therapy University and 10K Health.