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Positioning the NICU Infant

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Kathryn Bergstedt

on 1 December 2013

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Transcript of Positioning the NICU Infant

Positioning the NICU Infant
The Womb = The Ideal Position
Preemies Are At Risk
Developmental delays
Shoulder girdle alignment affects:
Midline activities
Weight-bearing on elbows
Shoulder rounding
Arm and shoulder instability in prone
Weight-bearing on hands – handwriting and fine motor coordination
Ideal Supported Positioning

Head in midline, neutral neck
Shoulder protraction
Hands to midline/mouth
Posterior pelvic tilt
Neutral hips and feet
Boundaries with some freedom of movement
Tactile input
Varied positions (while maintaining/supporting flexed posture)

How To Facilitate Ideal Supportive Positioning
Positioning aids
Snuggle up
Infant’s bottom at base of snuggle up for posterior pelvic tilt
Criss-cross straps for flexible boundaries
Can still use with biliblankets (cord of biliblanket at head of isolette/crib)
Baby bendy
Flat side down
Position right next to infant to provide surrounding boundary
Store straight as metal bars lose rigidity in bent position over time

DandleLION Medical: http://www.dandlelionmedical.com

Davis P., Robinson R., Harris L., Cartilidge P. (1993). Persistent mild hip deformation in preterm infants. Archives of Disease in Childhood, 69: 597-598.

Developmental Care of Newborns and Infants: A Guide for Health Professionals, second edition. Edited by Carole Kenner, PHD RNC-NIC FAAN, and Jacqueline M. McGrath, PhD RN FNAP FAAN.

Developmental and Therapeutic Interventions in the Nicu by Elsie Vergara Sc.D. OTR FAO and Rosemarie Bigsby SC. D. OTR FAO (Oct 31, 2003).

Fern, Dana. A NeuroDevelopmental Care Guide to Positioning and Handling the Premature, Fragile or Sick Infant; Supporting Infant Development A detailed guide for hospital and home caregivers.

Grenier, I.R., Bigsby, R., Vergara, E.R., & Lester, B.M. (2003). Comparison of motor self-regulatory and stress behaviors of preterm infants across body positions. American Journal of Occupational Therapy. Vol. 57, 289-297.

Malusky S., Donze A. (2011). Neutral Head Positioning in Premature Infants for IVH Prevention: An Evidence Based Review. Neonatal Networks, 3(6); 381-390.

Philips Mother and Child Care: http://www.healthcare.philips.com

Sundance Solutions: http://www.sundancesolutions.com

Sweeney J. (2002). Musculoskeletal Implications of Preterm Infant Positioning in the NICU. Perinat Neonat Nurs, 16(1): 58-70.

Time to Practice!!
Physiologic flexion
Head/neck midline/neutral
Shoulder protraction
Hands midline and to mouth
Posterior pelvic tilt
Flexed upper extremities and lower extremities
Global containment
Foot bracing
Preemies Miss Out on Womb Environment
Proprioceptive input (deep pressure)
Tactile input (through contact with uterine wall and constant input from amniotic fluid)
Muted sensory (lights, sound)
Mom’s rhythms (heartbeat, breath sounds, circulatory system, movement) to help develop levels of consciousness
Physiologic flexion (basis for all functional activity) which increases with gestational age

Preemies Are At Risk
Common Positioning Problems
No prone support
No posterior pelvic tilt
No foot support or opportunity for foot bracing
No humeral support
Hands not near mouth/face
Not enough give/space within swaddle for LE movement
Neck hyperextension

Preemies Are At Risk
Developmental Delays
Foot alignment/bracing affects;
Occurrence of tibial torsion, ankle eversion, foot pronation
Proper weight-bearing
Gross motor activities

Developmental Delays
Pelvic tilt and hip alignment affect:
Biomechanical interface with skilled movement

Preemies Are At Risk
Developmental Delays
Head/neck alignment affects:
Head centering and midline activities
Head control in prone and sitting
Limited downward visual gaze
Long term developmental implications
Head shaping

Preemies Are At Risk
Developmental Delays
Head shaping
Brachycephaly (posterior head flattening)
Weight-bearing on elbows
Plagiocephaly (bulge in posterior quadrant w/ bulge in opposite anterior quadrant)
Head turning preference
Scaphocephaly (side to side flattening)
Eye/vision problems

Preemies Are At Risk
Developmental Delays
Overall extensor pattern
Toe walkers
Restricted mobility at pelvis, scapulae, hips, feet and elbows
Insufficient play in prone

Preemies Are At Risk
Positional Deformities
“Frog” leg
Ability to transition in/out of prone and sitting
Hip stability in 4-point crawl
Prolonged wide-based gait
Excessive “out-toeing” gait
Everted feet (turned out)
Increased out-toeing
Immature foot flat pattern with delay in heel-toe pattern
Hyper extended neck and retracted shoulders
Abnormal head shaping

(recall how they would look flexed in the womb)
Benefits of Supportive Positioning

Promotes physiologic stability (joint stability, muscular development and tone, and alignment)
Increases 02 sats and decreases RR and HR
Promotes deep sleep
Facilitates different levels of consciousness/arousal
Promotes neurobehavioral development/stability
Promotes self-regulation
Reduces stress
Frees hands of caregiver
Provides graded input of proprioceptive, tactile and visual stimuli
May decrease need for analgesics and/or sedatives

Benefits of Varied Positions

Joint compression and input through all joints and the skull
Increased mechanoreceptor input
Decreased risk for skeletal deformities, muscle shortening, joint mobility issues
Promotes ossification and bone density

Head in Midline
Can help prevent IVH (Malusky, Donze, 2011)
Many factors contribute to IVH
Antenatal steroid use
Resuscitation methods
Pharmacological interventions
Positioning of head (regulate CBF?)
Midline/neutral head
30 degree HOB elevation for first 72 hours of life <32 weeks GA in addition to medical practices

How To Facilitate Ideal Supportive Positioning
Positioning aids
Large and small beanbag frogs
At head to provide boundary and position head in midline
Tuck frog arms around to nape of neck for better support
Frog arms can also be positioned under shoulders for better protraction
Position around infant’s bottom and sides in prone
Position infant in side-lying (infant’s arm/leg over one frog arm, other frog arm supporting infant’s back)
Act as another set of hands to contain/settle during cares

How To Facilitate Ideal Supportive Positioning
Positioning aids
Gel pillow
Under head and shoulders to facilitate neutral neck aligment and shoulder protraction
Assists in head shaping/comfort
Only one thin layer over pillow for optimal therapeutic results
Redistribute gel within pillow when repositioning
Warm gel pillow with warm water before first use
Use only in supine UNLESS – using full length of pillow in prone under head and as abdominal roll

How To Facilitate Ideal Supportive Positioning
Positioning aids
Abdominal rolls
From shoulders to hips
Round shoulders around roll for shoulder protraction
Legs flexed
DandleRoo Wrap/Lite
Womb-like environment
Soft, expandable cotton holds infant in flexed, midline posture
Infant can extend against material
Head piece can shield infant’s eyes from light
Lite – lighter model can be used under bili lights
o 70% of phototherapy lights penetrate material

We can help these tiny feet take tremendous steps by fostering nurtured, supported development during their NICU stay.
Things to Consider
Positioning aids can help facilitate infant thermo-regulation. This must be taken into consideration when monitoring the infant and adjusting isolette temp.
Infants should be repositioned at each scheduled caregiving time, alternating between back, stomach and side-lying on each side.
Infants on life support, medically fragile, sedated or paralyzed need special consideration to ensure varied positions are still achieved.
Plan to develop bedside positioning guideline checklist

Kathryn Bergstedt, MOTR/L
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