Physical Therapist's Guide to
Premature or preterm birth occurs at least 3 weeks before a baby’s due date. Full gestational age (full-term) is considered to be 40 weeks, and any baby who is born before 37 weeks is classified as a premature baby. In the United States, 1 in 9 babies, or about 11% of babies, are born prematurely, resulting in more than half a million babies born too soon each year. Prematurity is the leading cause of death for newborn babies. The premature birth rate has risen by more than 30% in the last 25 years in this country, in part due to improved technology that is saving younger newborns. Babies born as early as 22 weeks are now surviving. Any infant born prematurely is at risk for health and developmental disabilities. Babies who are born at term but are small (less than 5.5 pounds), also have many of the same health problems as babies born prematurely. The younger and smaller a baby is at the time of birth, the greater the risk for health problems.
What is Prematurity?
Infant prematurity is the term applied to babies born before the average due date. When a baby is born before 37 weeks gestational age (before the average due date of about 40 weeks), the baby is classified as premature. The majority of babies born prematurely are delivered by Cesarean section. When a baby arrives early, the baby can have difficulty with some functions, such as breathing, temperature regulation, and sucking. Significant growth and natural development continue into the last weeks of intrauterine life, making it important for babies to be born full-term.
Babies born after 34 weeks but before 37 weeks are classified as late preterm babies. While late preterm babies will weigh more than babies born at an earlier gestational age, these infants may still have health problems. Even babies born between 37 and 40 weeks may show some of the health concerns of premature babies.
The baby's or the mother's physical makeup may contribute to the possibility of premature birth. Genetic factors are known to influence at least 40% of spontaneous premature births—but all of the actual genes involved are not yet known. Recent research has shown that one of the genes contributing to prematurity may be carried by the mom, and the other gene may be carried by the baby. The presence of either of these genes may cause a pregnancy to be more prone to premature delivery. While several other risk factors are known, any pregnant woman may deliver prematurely, even if risk factors are not present.
Known prematurity risk factors include:
- Mothers who are younger than 19 years of age or older than 40 years of age.
- Mothers who had a previous preterm delivery.
- Defects in the mother's uterus.
- High blood pressure that begins in a mother after the 20th week of pregnancy.
- Premature ruptures of the placenta or the amniotic sac.
- Race/ethnicity (black women are at a higher risk to deliver premature babies).
- Lacking prenatal care.
- Having a low socioeconomic status.
- Using tobacco, cocaine, or amphetamines.
Signs and Symptoms
Several signs or symptoms may indicate that a premature birth is about to occur. An early onset of labor may be indicated by:
- Leakage of amniotic fluid
- Slight bleeding
If any of these signs occur, call your doctor immediately! Early labor can sometimes be stopped to allow the pregnancy to continue.
Mothers with increased blood pressure after the 20th week of pregnancy are at risk for early delivery, and are usually monitored very closely by their physicians.
The infant's signs and symptoms related to prematurity vary depending upon the age and weight of the baby, and the difficulty of the pregnancy, labor, and delivery. Infants born prematurely or with low birth weight for the gestational age are at risk for organ difficulties, vision and hearing problems, and language problems, among others. Infants born during the eighth or ninth month of pregnancy (33 to 40 weeks), spend more time in the hospital, and have more health problems during the first 2 years of life, than babies born at term.
How Is It Diagnosed?
Often, the expected due date of the baby is known and that date can be confirmed by tests. Therefore, the family will know if a baby is arriving before the due date. If it is known that the baby will arrive prematurely because of complications and the pregnancy cannot continue much longer, most physicians will admit the mother to a hospital and closely monitor the mother and baby until the baby is delivered.
If the due date is not known, the health practitioners attending the birth will estimate the age of the baby using several measures, including determining the weight, evaluating the respiration (breathing), assessing the amount of muscle tone and movements of the baby, examining the skin and hair, and testing the reflexes present at birth. Tests of gestational age will be administered in the hospital whenever prematurity is a possibility.
How Can a Physical Therapist Help?
A physical therapist is an important family treatment partner for any child born prematurely. Physical therapy should begin as soon as possible after the birth, when the baby's health status allows it.
Your physical therapist will work with other professionals to provide the best care possible. Often the baby will be in a neonatal intensive care unit (NICU), and all health practitioners will work together to maximize the infant's growth and maturation, and to prevent infection and any possible complications.
Your physical therapist will help you understand your baby's needs, and will work with you to learn the safest ways to provide care, such as how to hold and feed your baby, position the baby for quiet sleep, and other tasks. Your physical therapist can provide:
Evaluation. Guidelines exist for physical therapy care in the NICU, and your physical therapist will follow those guidelines. In the NICU, your child's physical therapist will perform an evaluation that includes a detailed birth and developmental history, and perform observational assessments to monitor the quality of the infant's movements, the infant's interactions with the environment, and the infant's ability to maintain a calm, alert demeanor. If necessary, gentle handling may be used to determine how the head, trunk, arms, and legs move, and assess the presence of certain reflexes. Physical therapists know the importance of addressing the child's needs within a team approach, and will review the evaluations of other professionals or recommend additional evaluations by other health care team members.
Treatment. Treatment in the NICU will focus on positioning, handling, feeding, and postural control. The therapist will educate the family on appropriate techniques for fostering interactions between the infant and the family, and for maximizing development. After discharge from the NICU, your physical therapist will work with you and your baby to foster movement and developmental skills, prevent or reduce muscle or joint tightening, and promote good head positioning, maintain or improve muscle strength, adapt toys or activities promoting movement and play, and increase daily activities to encourage participation, first in the family, and later in the community.
Treatments may include:
- Education on holding, carrying, and playing with the baby. Your physical therapist will make suggestions for positioning, holding, and carrying your baby. Your therapist will provide ideas for positioning the baby on the back for sleep, and on the stomach for play when the baby is awake.
- Fostering developmental skills. Some babies born prematurely have developmental problems. Your physical therapist will help your child learn to master motor skills, such as holding up the head, sitting up, crawling, pulling to standing, and walking. Physical therapists can help parents support their child's development by providing hands-on training for movement, feeding, and play. Your therapist also may suggest changes at home to encourage movement development, communication, hearing, vision, and play skills.
- Increasing strength. Some babies born prematurely may have decreased muscle strength or tone associated with the prematurity. Your physical therapist will teach you exercises and play activities to maintain or increase your baby's strength. Your therapist will identify games and fun tasks that promote strengthening.
Research has shown that gains in cognitive (thinking) and motor/movement skills can reasonably be expected following physical therapy treatment in an early intervention program. Early intervention therapy may be provided in the home or at another location, such as a hospital or physical therapy outpatient clinic.
Can this Injury or Condition be Prevented?
All pregnant women should seek excellent prenatal care and follow the vitamin and diet suggestions of health care practitioners. The best ways to prevent prematurity are to:
- Be in good health before getting pregnant.
- Get prenatal care as early as possible in the pregnancy.
- Continue to get prenatal care until the baby is born.
Premature labor contractions can sometimes be stopped or delayed by medications. Other medications given to mothers during premature labor may reduce some of the prematurity complications for the baby. Any woman who thinks she is in premature labor should seek medical help immediately!
The March of Dimes’ prematurity campaign, Healthy Babies are Worth the Wait® (HBWW), aims to avert preventable preterm births, with a focus on reducing elective deliveries before 39 weeks gestation. The March of Dimes funds research related to prematurity, and develops educational programs to inform women of risk factors.
Real Life Experiences
Robyn was born at 29-weeks gestational age following a Cesarean-section delivery. She weighed approximately 2 pounds and had some difficulty breathing just after birth. She was placed in the neonatal intensive care unit (NICU), in an isolette to keep her warm. A machine helped her breathe for 5 days. When she could breathe on her own, she remained on oxygen for about 2 weeks.
Robyn stayed free of infection and other illnesses. Her physical therapist began working with her family and other caregivers on a positioning program in the isolette when she was 1 week old. The goals of good positioning were to promote self-calming, improve digestion, reduce discomfort during medical procedures, promote development, prevent abnormal posturing, and promote good muscle tone.
Robyn's physical therapist taught her family how to wrap her in a blanket (swaddle her) to allow her to rest easily, and have good body alignment. She also helped the family understand the best postures for Robyn to encourage feeding, and helped them promote bonding with her.
She performed gentle neonatal massage to reduce Robyn's stress levels, and taught her parents some simple massage techniques also to improve their bonding. Her parents were encouraged to tuck Robyn against their chests and facilitate skin-to-skin contact, which can help with infant digestion and calming. When Robyn neared her full-term age, her physical therapist showed her parents how to encourage development of head control.
Robyn steadily improved, and was discharged at 9 weeks of age. Her physical therapist educated the family on the “back-to-sleep” program (making sure she lay on her back to sleep), on identifying areas of infant vulnerability in the home (eg, bright lights, noises, chilly rooms), and on promoting more developmental activities over the next several months. The family was referred to early intervention services in their community.
Robyn was seen by a community physical therapist once a month for 1 1/2 years. He reviewed her development, and helped her parents understand what movements a young baby should be performing at each month of life. He promoted healthy and fun activities that encouraged strengthening and active movements.
At 18 months of age, Robyn was performing like other toddlers her age, exploring her world with her happy and excited parents.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat a variety of conditions or injuries. You may want to consider:
- A physical therapist who is experienced in pediatrics. Many hospitals with NICUs will have a listing of early intervention services as well as a follow-up clinic. You may want to work with the physical therapist at the hospital and the physical therapist who has a local pediatric practice, who will work with you and your child in the home, a clinic, or community environments.
- A physical therapist who is a board-certified pediatric clinical specialist or who completed a residency or fellowship in pediatric physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to babies born prematurely.
- A team approach. Experienced pediatric physical therapists understand the importance of working with other health care professionals to maximize outcomes for children born prematurely.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping children with prematurity or other neuromuscular disorders.
- During your first visit with the physical therapist, be prepared to describe your child's symptoms in as much detail as possible, and report activities that make your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following resources and articles provide some of the best scientific evidence related to prematurity. The sites and articles listed here are linked either to a professional organization or to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Association of Women's Health and the Obstetric and Neonatal Nurses (AWHONN) has a campaign to help women deliver babies at term. The Go the Full 40 campaign emphasizes how women can minimize their risks and be healthy through an entire 40 week pregnancy. Accessed December 18, 2014.
March of Dimes provides educational materials for pregnant women to support having healthier, stronger babies. Accessed December 18, 2014.
US National Library of Medicine and the National Institutes of Health provides information on the Premature Infant through its Medline Plus site. Accessed December 18, 2014.
Centers for Disease Control and Prevention (CDC) has information on prematurity on the following website. Accessed December 18, 2014.
HealthyChildren.org provides information to help families developed by the American Academy of Pediatrics. Accessed December 18, 2014.
McQueen D, Lakes K, Rich J, et al. Feasibility of a caregiver-assisted exercise program for preterm infants. J Perinat Neonatal Nurs. 2013;27(2):184–192. Free Article.
Prins SA, von Lindern JS, van Dijk IS, Versteegh FG. Motor development of premature infants born between 32 and 34 weeks. Int J Pediatr. 2010;2010:1-4. Free Article.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine's MEDLINE database.
Authored by Venita Lovelace-Chandler, PT, PhD, board-certified clinical specialist in pediatric physical therapy. Reviewed by the editorial board.