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Targeted educational program improves infant positioning practice in the NICU
Abstract
Quality problem or issue:
Infant positioning may interfere with neuromotor development. Bedside education and Infant Positioning Assessment Tool (IPAT) improve nurses' and doctors' proficiency in applying proper infant positioning.
Initial assessment:
Nursing compliance with proper positioning is suboptimal due to many factors. One factor was the inadequate knowledge and practice of infant positioning, since the baseline mean IPAT score was 3.4.
Choice of solution:
Three experienced neonatal intensive care unit (NICU) nurses were chosen as position champions to help other NICU nurses apply proper positioning and monitor IPAT scores. Education and hands-on demonstration sessions were developed based on the observed baseline practice.
Implementation:
Periodic education with hands-on demonstration was given to NICU nurses and residents. Infants' positions were objectively scored using IPAT. Two Plan, Do, Study and Act cycles were completed and adjustments were made based on each cycle's achieved results.
Evaluation:
Mean IPAT scores increased from 3.4 at baseline and 6.3 in the second cycle to 7.3 in the third cycle of intervention.
Lessons learned:
A systematic approach targeting infants' positioning succeeded in improving nurses' and residents' clinical performance. Not reaching significant change until after 18 months highlights the difficulty and complexity in changing behaviors.
... Infant positioning assessment tool (IPAT; Philips Children's Medical Ventures), validated by several studies [11][12][13][14] was used to improve the positioning practices. Eligible neonates (birthweight <1800 g) were scored by a team of 'Positioning proponents (PP)', once in every shift and an average daily score was assigned to each baby. ...
... A significant improvement was noted in the proportion of admitted neonates with IPAT score ≥8 from the baseline of 16.6-83.3%. In coherence with other projects on position improvement [12][13][14], nursing teaching and demonstration sessions were found to be most impactful. Inclusion of mothers in the loop was the most important factor for sustenance policy. ...
... Compared to previous reports [12][13][14], the major difference in this project was the achievement of targeted improvement within a short time-span. The quick response was attributed to multiple PDSA cycles, adopting the changes and policy formation in each step. ...
... It was found that the preintervention score of resident doctors was more as compared to nurses due to knowledge of medical terms related to positioning were as the post intervention score of nurses was more as compared to residents which showed nurses are more compliant to this type of education. 10,11 The students of School of Occupational therapy at University of Indian police conducted a 14-week program on promoting the awareness of positioning among NICU staff using IPAT. They promoted information among nurses using various posters, educating them about the developing positioning and IPAT administration. ...
... The IPAT proved to be a useful tool to encourage nurses to apply learned skills in supporting infant positioning. 1,8,10 The nurse teaching and demonstration sessions were found to be most impactful. Many paediatric residents also found it to be useful a assessment of proper positioning was easy as well as physiological, neurological, motor, musculoskeletal changes were seen.1 , 10, 11, 14 The training sessions, hands on practice which were conducted proved to be useful as it improved the knowledge for administration of IPAT as well as the competence level among NICU staff. ...
... It benefitted family centred program. 1,10,11,14 No additional cost is required as no specialized equipment or hiring of new staff is required, hence cost effective and it could be tailored to the individual needs of any NICU. 1,14 IPAT is proving to be useful in many terms such as It provides hands on and bedside education which passes a positive experience on positioning an infant. ...
... of this tool have been established in previous studies [2,9,11,22,28]. ...
... Furthermore, the media were developed as educational videos so that participants could use them at any time [2,8]. Educational strategies such as lectures, small group discussions, and experiential activities were used to enhance the participants' learning [8,28,29]. We believe that it was possible to improve the DP knowledge of the participants in the intervention group. ...
... In this study, scores for DP knowledge, attitudes toward DP, and DP self-efficacy were higher in the intervention group than in the control group, so it is thought that their DP performance could be improved. This result is consistent with the results of previous studies that educating nurses on DP is effective in enhancing their DP performance [2,22,[28][29][30]. However, the previous studies were conducted as field studies [2,9,29,30] or quality improvement projects [22,28], making it difficult to provide consistent interventions due to the long intervention period, and there was a limitation in identifying the pure effect of the educational program on DP using a one-group pre-and posttest design. ...
Purpose:
This study aimed to develop and evaluate the effectiveness of an educational program on developmental positioning (EPDP) for nurses in neonatal intensive care units (NICUs).
Methods:
The study utilized a non-equivalent control group pretestposttest design. Sixty NICU nurses were recruited from two university hospitals in Daejeon, South Korea. The EPDP consisted of a 7-week program: 3 weeks of education and practice, followed by 4 weeks of encouragement messages using social networking services. Developmental positioning (DP) posters and DP aids were also provided during the intervention period. The intervention group (n=30) received the EPDP, but not the control group. The data were analyzed using the x2 test, the Fisher exact test, the independent t-test, and repeated-measures analysis of variance.
Results:
Participants' knowledge (t=7.49, p<.001), attitudes (t=1.99, p=.001), self-efficacy (t=2.99, p=.004), performance of DP (t=2.98, p=.004) and Infant Positioning Assessment Tool (IPAT) scores (F=29.50, p<.001) were significantly higher in the intervention group than in the control group.
Conclusion:
The EPDP can be an effective and useful program for improving the performance of DP among NICU nurses by increasing their knowledge, attitudes, and self-efficacy of DP. However, further research involving various NICU settings is needed to gather more empirical evidence.
... Infant positioning assessment tool (IPAT; Philips Children's Medical Ventures), validated by several studies [11][12][13][14] was used to improve the positioning practices. Eligible neonates (birthweight <1800 g) were scored by a team of 'Positioning proponents (PP)', once in every shift and an average daily score was assigned to each baby. ...
... A significant improvement was noted in the proportion of admitted neonates with IPAT score ≥8 from the baseline of 16.6-83.3%. In coherence with other projects on position improvement [12][13][14], nursing teaching and demonstration sessions were found to be most impactful. Inclusion of mothers in the loop was the most important factor for sustenance policy. ...
... Compared to previous reports [12][13][14], the major difference in this project was the achievement of targeted improvement within a short time-span. The quick response was attributed to multiple PDSA cycles, adopting the changes and policy formation in each step. ...
Objectives:
To improve developmentally supportive positioning practices by 50% in neonates weighing <1800 g, admitted in a neonatal intensive care unit over 6 months.
Method:
Infant Position Assessment Tool (IPAT) scores were used for assessment of the ideal position. Proportion of neonates with IPAT score ≥8 and improvement of average IPAT score were the process and the outcome measures, respectively. At baseline, 16.6% of infants had optimum position. After root cause analysis, interventions were done in multiple Plan-Do-Study-Act (PDSA) cycles of educational sessions, positioning audits, use of low-cost nesting aids, and training of mothers.
Results:
Over 21 weeks, 74 neonates were observed at 714 opportunities. Over 6 months, mean (SD) IPAT score improved from 3.4 (1.4) to 9.2 (2.8). Optimum positioning was maintained in 83.3% neonates during sustenance phase.
Conclusion:
Low-cost interventions, awareness regarding standards of optimum positioning and involvement of primary caregiver can effectively improve infant positioning practices.
... Therefore, it is recommended that postural management training for neonatal nurses be redesigned to be more systematic, moving away from the current piecemeal learning model. Implementing structured educational programs will ensure that nurses are equipped with the knowledge and skills required for effective postural care, ultimately enhancing the quality of care delivered to premature infants [21]. ...
Background
Posture management is very important in the nursing care of premature infants. This study aimed to investigate the status quo and influencing factors of knowledge, attitude and practice in posture management of premature infants among neonatal nurses.
Methods
This study included the nurses worked in the department of neonates of our hospital as the survey population from May 1 to 25, 2023. The general information questionnaire and the neonatal nurses' knowledge, attitude and practice questionnaire were used to collect data. Multiple linear regression analyses were conducted to evaluate the factors influencing the knowledge, attitude and behavior of posture managements.
Results
One hundred fifty-two neonatal nurses were surveyed in this study. The average knowledge, attitude and behavior score on the posture management were (57.21 ± 6.33), (30.86 ± 5.61) and (52.25 ± 7.18) respectively. There were positive correlations in the nurses' knowledge, attitude and behavior scores on the posture management (all P < 0.05). Years of work experience, marital status and had accepted premature infants posture management training were the independent factors influencing knowledge, attitude and behavior on the posture management of premature infants in neonatal nurses (all P < 0.05).
Conclusions
Neonatal nurses attach great importance to the posture management of premature infants, but their knowledge and skills need to be improved, and there are many related influencing factors. Nursing managers should strengthen the training related to the postural management of premature infants and improve their knowledge and ability of posture management of premature infants.
... This helpful position promotes relaxation by keeping the newborn's hands near their face and feet together, which imitates the mother's uterus. So, it should be effective interventions are inexpensive, noninvasive, and rapidly applied to improve premature pain control, behavior, and physiological parameters like nesting positioning must be used (Charafeddine et al., 2018;Yazdanpanahi et al., 2020). Proper positioning can support healthy posture, steady physiological parameters, and muscular regulation among newborns. ...
... Proper positioning of the premature neonate in the NICU is important to reduce the complications associated with prematurity, especially musculoskeletal and neurodevelopment complications [13][14][15]. The proper position of the premature neonate is the position that mimics the position inside the womb where the fetus is confined to an enclosed space with well-defined boundaries [16]. ...
Background: Supportive positioning may mimic the intrauterine environment and enhance neonates' physiological and developmental outcomes. Limited research in Saudi Arabia examined the effect of supportive positioning aids (nesting) on infant outcomes in neonatal intensive care units (NICUs).
Objective: This study compared nesting care to non-nesting care in the short-term outcomes of premature neonates (heart rate, oxygen saturation, and pain) in Saudi NICUs.
Methods: A quasi-experimental design compared two groups of premature neonates from two NICUs regarding their heart rate, oxygen saturation, and pain level. Nesting was used in the first group, and not in the second group. Seventy premature neonates (35 per group) were recruited. An independent t-test was used to compare the two groups.
Results: Heart rate was significantly lower in the nesting group than the non-nesting group at baseline and after procedures (136bpm and 139bpm vs 144bpm and 148bpm, P ≤ 0.05). The pain level was significantly lower in the nesting group than the non-nesting group at baseline and after procedures (3.7 and 3.8 vs 4.7 and 4.6, P ≤ 0.05). There was no significant difference between the two groups in oxygen saturation.
Conclusion: Nesting care supported premature neonates in the NICU. It helped stabilize the heart rate and pain. NICUs in Saudi Arabia would benefit from educating NICU nurses and informing NICU managers and policymakers of nesting care.
... Despite these recommendations, optimal positioning practices appear to be variable and inconsistent which may be linked to limited education of nursery staff. 8,12 In fact, some PHDs may be avoidable altogether with strong positioning programmes and, when detected early, may be corrected with simple low-cost strategies. A study from Danner-Bowman & Cardin 13 demonstrated that the implementation of positioning guidelines (e.g. ...
Aim
To establish the prevalence of positional head deformations (PHDs) within a neonatal unit (NU) setting, and to evaluate the subsequent impact that PHDs have on NU graduates and their families.
Methods
A prospective audit was conducted over a six‐week period within a tertiary NU (Brisbane, Australia). Eligible babies were measured weekly using a craniometer where presence, type and severity of PHD were determined. Univariate analysis was undertaken to establish differences in clinical characteristics between babies with, and without, the presence of PHD.
A study‐specific survey was completed by a separate set of families returning for outpatient follow‐up services who represented similar clinical characteristics and risk factors for PHD.
Results
Fifty‐three babies were eligible for inclusion in the audit. PHDs were identified in 66% ( n = 35) of the cohort, the most common being scaphocephaly (52.8%, n = 28). Within that, 46% ( n = 13) were classed as mild, 25% ( n = 7) were moderate and 29% ( n = 8) were severe. Moderate correlation ( r = 0.55) was found between severity of scaphocephaly, and length of time spent in an isolette. Of the 10 (66% response from 15 families) surveys completed, 80% of respondents perceived that their child's PHD had impacted their life.
Conclusions
Two‐thirds of babies developed a PHD during their neonatal admission. Most families surveyed perceived this condition to have an impact on their lives beyond the confines of the nursery. Further research is needed to identify preventative interventions to decrease the prevalence and severity of this common condition.
Positioning and handling is a core measure of developmental care that has been universally difficult to implement in the technical NICU environment. Appropriate positioning has been shown to not only improve postural and musculoskeletal outcomes, but enhance sensory development, physiologic stability, thermal regulation, behavioral organization, sleep facilitation, and brain development. In order to improve the developmental positioning practices of bedside nurses in a level III neonatal intensive care unit, a quality improvement project was initiated. Guided by the Iowa Model for Evidence-Based Practice, this project included an evidence-based educational intervention and a standardized positioning assessment tool. After the intervention, there was improvement in knowledge scores, and positioning scores increased from an average of 8.81 +/− 0.19 to 10.93 +/− 0.15.
Since the publication of S tandards for QU ality I mprovement R eporting E xcellence (SQUIRE 1.0) guidelines in 2008, the science of the field has advanced considerably. In this manuscript, we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015 using (1) semi-structured interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group, (2) two face-to-face consensus meetings to develop interim drafts, and (3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasizes the reporting of three key components of systematic efforts to improve the quality, value, and safety of healthcare: the use of formal and informal theory in planning, implementing, and evaluating improvement work; the context in which the work is done; and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve healthcare, recognizing that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature ( http://www.squire-statement.org ).
J Contin Educ Nurs . 2015;46(11):501–507.
The Newborn Individualized Development Care and Assessment Program (NIDCAP) incorporates many aspects of developmental care and focuses on individualised family-oriented care.
To evaluate the effect of NIDCAP on neurodevelopmental and clinical outcomes in the preterm infant in the first 2 years.
MEDLINE database and the Cochrane Library.
Randomised controlled trials (RCTs) published from 1990 to 2011 in all languages.
Preterm infants less than 33 weeks of gestational age and less than 2500 g at birth.
The Mental Developmental Index (MDI) and Psychomotor Developmental Index (PDI) components of the Bayley Scales of Infant Development Second Edition (BSID II) were compared in NIDCAP intervention and standard of care (SOC) groups. The secondary outcomes were the Assessment of Preterm Infant's Behavior (APIB) scales, length of hospital stay, days of mechanical ventilation, Continuous Positive Airway Pressure (CPAP) therapy and oxygen therapy. Intraventricular haemorrhage, necrotising enterocolitis, bronchopulmonary dysplasia and retinopathy of prematurity are compared between the groups.
Among the nine articles included, which reported on studies with a total of 503 infants, the NIDCAP group significantly outperformed the control group for the MDI (difference: 11.66; 95% CI (6.47 to 16.85), I²=72%, p<0.0001) and the PDI (difference: 8.32; 95% CI (3.48 to 13.17), I²=57%, p=0.0008). Similar significant results were found for the APIB scales.
Compared to the SOC, NIDCAP has the potential to improve mental and psychomotor development clinically and statistically even if the long-term effect is uncertain.
Developmentally appropriate positioning is a core component of the Universe of Developmental Care Model, which was created to optimize neurodevelopmental outcomes of preterm infants (Adv Neonatal Care 2008;8(3):141-147). Neurodevelopmental positioning has been shown to have a direct effect on bone and joint development (Eur J Paediatr Neurol 2004;8:321-343; Phys Ther 2009;89(12):1354-1362; Phys Ther 1984;64:1874-1882) promote self-regulation/sleep (Early Hum Dev 2007;83:433-442; J Adv Nurs 2009;65(10):2239-2248) and to reduce pain responses (J Adv Nurs 2009;65(10):2239-2248; J Perinatol 2007;27(suppl):S48-S74) in preterm infants. The Infant Positioning Assessment Tool (Koninklijke, Philips Electronics, NV) was developed to standardize best positioning practice in neonatal intensive care unit (Newborn and Infant Nursing Reviews 2010;10(2):104-106). Failure to properly support the premature musculoskeletal system has been shown to have long-term deleterious effects on sensory and motor development.(J Perinatol 2007;27:S20-S28). Nurses at a level IIIB midwest neonatal intensive care unit had experienced various training opportunities aimed at improved positioning consistency; however, foot/leg deformity, torticollis, and plagiocephaly persisted. The purpose of this article is to describe how using the Infant Positioning Assessment Tool paired with one-to-one bedside education can improve positioning consistency across shifts and experience.
Neuroplasticity refers to the ability of the brain to make short- or long-term modifications to the strength and number of its synaptic neuronal connections in response to incoming stimuli associated with activity and experience. Neuroplasticity is a lifelong property of the human brain, which peaks during early life during the period of most rapid brain growth. The Neonatal Integrative Developmental Care Model uses neuroprotective interventions as strategies to support optimal synaptic neural connections, promote normal development, and prevent disabilities. Seven neuroprotective core measures for family-centered developmental care of the premature neonate are addressed: healing environment, partnering with families, positioning and handling, minimizing stress and pain, safeguarding sleep, protecting skin, and optimizing nutrition.
Although developmentally supportive positioning is acknowledged as a key element of care in the neonatal intensive care unit, the definition and standardization of what constitutes evidence -based positioning practices is nonexistent in a formalized format. As postural stability is a foundational milestone for motor development and premature infants are unable to exhibit postural stability without support, standardizing the definition of optimal positioning will lead to consistency in practice. This article introduces a positioning tool to be used as a resource for standardization and education on developmentally supportive positioning practice goals.
To compare motor performance in supine position at the age of 4-months corrected age (CA) in very preterm (VPT) infants cared for in a neonatal intensive care unit (NICU) before and after the implementation of the Newborn Individualized Developmental Care and Assessment Program (NIDCAP).
Assessments of motor performance in supine position according to level of motor development and quality of motor performance were made, using the Structured Observation of Motor Performance in Infants (SOMP-I).
VPT infants cared for in a NICU at a Swedish university hospital before, Group A (n = 68), and after, Group B (n = 58), the implementation of developmentally supportive care based on NIDCAP.
The infants who were treated after the introduction of NIDCAP showed higher level of motor development in the arms/hands and trunk. No significant group differences were noted in total deviation score for the respective limbs, but lower frequency of lateral flexion in head movements, extension-external rotation-abduction, extension-internal rotation-adduction and varus and valgus position in the feet was found in the NIDCAP group, compared with those treated before the introduction.
The infants who were treated after NIDCAP care had been implemented showed a higher level of motor development in arms/hand and trunk and fewer deviations in head, legs and feet at 4-months CA than infants treated before NIDCAP implementation. The observed changes may be due to NIDCAP and/or improved perinatal and neonatal care during the studied time period.
To investigate in a randomised controlled trial the effect of basic elements of developmental care (incubator covers and positioning aids) on growth and neurodevelopment in infants born at < 32 weeks.
Infants were randomised within 48 h of birth to a developmental care (DC) or standard care (C) group. Outcome measures at 1 and 2 years corrected age were growth, standardised neurological examinations, and mental (MDI) and psychomotor (PDI) development (Dutch version of the Bayley Scales of Infant Development II).
192 infants were recruited (DC = 98; C = 94). Thirteen infants (DC = 7, C = 6) were excluded because they were admitted for <5 days or died within the first 5 days. In total, 179 infants met the inclusion criteria. In-hospital mortality was 12/91 (13.2%) in the DC group and 8/88 (9.1%) in the C group. Assessments were carried out on 147 children (DC = 74, C = 73) at 1 year and 142 children (DC = 72, C = 70) at 2 years. No significant difference in growth, neurological outcomes or MDI was found. A positive trend in PDI at 1 year (p = 0.05) did not continue once the children reached 2 years. There was no difference found when neurological and developmental scores were combined.
Basic developmental care has no positive effect on neurological and mental development or growth at 1 and 2 years of age in infants born at <32 weeks. A positive effect on psychomotor development at 1 year did not continue at 2 years of age.
Infant sleep position impacts the development of head shape. Changes in infant sleep position, specifically the movement toward supine sleep, have led to a redefinition of normal head shape for infants in the United States. Historically, a dolichocephalic (elongated) head shape was the norm. Currently the norm has changed to a more brachycephalic (shorter and broader) shape. Since the American Academy of Pediatrics' Back to Sleep Campaign, the incidence of positional plagiocephaly has increased dramatically with a concurrent rise in the incidence of torticollis. Infants who require newborn intensive care, particularly premature infants, are more prone to positional plagiocephaly and dolichocephaly. Both can be prevented or minimized by proper positioning. The infant with an abnormal head shape requires careful evaluation; treatment varies according to the etiology. Craniosynostosis, a less common but pathological etiology for plagiocephaly, should be considered in the diagnostic process. Successful treatment of positional plagiocephaly and dolichocephaly includes systematic positioning changes to overcome the mechanical forces of repetitive positioning, physical and/or occupational therapy to treat underlying muscle or developmental challenges, and in some cases, molding helmet therapy.
Prematurely born compared with term born infants are at increased risk of sudden infant death syndrome, particularly if slept prone. The purpose of this work was to test the hypothesis that preterm infants with or without bronchopulmonary dysplasia being prepared for neonatal unit discharge would sleep longer and have less arousals and more central apneas in the prone position.
This was a prospective observational study in a tertiary NICU. Twenty-four infants (14 with bronchopulmonary dysplasia) with a median gestational age of 27 weeks were studied at a median postconceptional age of 37 weeks. Video polysomnographic recordings of 2-channel electroencephalogram, 2-channel electro-oculogram, nasal airflow, chest and abdominal wall movements, limb movements, electrocardiogram, and oxygen saturation were made in the supine and prone positions, each position maintained for 3 hours. The duration of sleep, sleep efficiency (total sleep time/total recording time), and number and type of apneas, arousals, and awakenings were recorded.
Overall, in the prone position, infants slept longer, had greater sleep efficiency (89.5% vs 72.5%), and had more central apneas (median: 5.6 vs 2.2), but fewer obstructive apneas (0.5 vs 0.9). The infants had more awakenings (9.7 vs 3.5) and arousals per hour (13.6 vs 9.0) when supine. There were similar findings in the bronchopulmonary dysplasia infants.
Very prematurely born infants studied before neonatal unit discharge sleep more efficiently with fewer arousals and more central apneas in the prone position, emphasizing the importance of recommending supine sleeping after neonatal unit discharge for prematurely born infants.
A definitive cause for sudden infant death syndrome (SIDS) has not yet been identified, but some theories point to laryngeal or respiratory causes, in addition to theories of reduced arousal or reduced autonomic response. The occurrence of SIDS has dropped since the movement to place newborns to sleep in the supine position; however, some research has found a respiratory disadvantage for infants in this position. The current paper studied acoustic characteristics of infant pain cries to determine the potential differences related to prone versus supine positioning.
Fifty-one newborn infant cries were recorded during and following a blood draw screening procedure, with infants placed either in the supine or prone position. All infants were healthy, full-term infants. Complete crying episodes were audio-recorded, and results were based on compositional analysis and long-time average spectrum analysis across each crying episode.
Spectral analysis revealed acoustic differences related to infant positioning, and acoustic analysis also revealed that there were no respiratory differences between supine-positioned and prone-positioned infants. Overall, the acoustic differences suggest decreased arousal and/or a decreased response to pain for healthy infants recorded in the prone position.
As decreased arousal and prone positioning have been seen as possible causative factors for SIDS, the current results are seen as a successful step in evaluating the possibility of using acoustic analysis of infant cries as a means of evaluating SIDS risk for healthy infants.
Contexts:
Preterm infants are at an increased risk of neurodevelopmental delay. Some studies report positive intervention effects on motor outcomes, but it is currently unclear which motor activities are most effective in the short and longer term.
Objective:
The aim of the study was to identify interventions that improve the motor development of preterm infants.
Data sources:
An a priori protocol was agreed upon. Seventeen electronic databases from 1980 to April 2015 and gray literature sources were searched.
Study selection:
Three reviewers screened the articles.
Data extraction:
The outcome of interest was motor skills assessment scores. All data collection and risk of bias assessments were agreed upon by the 3 reviewers.
Results:
Forty-two publications, which reported results from 36 trials (25 randomized controlled trials and 11 nonrandomized studies) with a total of 3484 infants, met the inclusion criteria. A meta-analysis was conducted by using standardized mean differences on 21 studies, with positive effects found at 3 months (mean 1.37; confidence interval 0.48-2.27), 6 months (0.34; 0.11-0.57), 12 months (0.73; 0.20-1.26), and 24 months (0.28; 0.07-0.49). At 3 months, there was a large and significant effect size for motor-specific interventions (2.00; 0.28-3.72) but not generic interventions (0.33; -0.03 to -0.69). Studies were not excluded on the basis of quality; therefore, heterogeneity was significant and the random-effects model was used.
Limitations:
Incomplete or inconsistent reporting of outcome measures limited the data available for meta-analysis beyond 24 months.
Conclusions:
A positive intervention effect on motor skills appears to be present up to 24 months' corrected age. There is some evidence at 3 months that interventions with specific motor components are most effective.
Objective The purpose of this study was to determine when dolichocephaly develops in preterm infants, to establish factors that contribute to its development, and to determine its association with adverse motor outcomes. Study Design This study was a retrospective review of data collected from preterm infants born at < 32 weeks' gestation. The cranial index was measured by a physical therapist (PT) at three time points during hospitalization. Demographic data, neonatal morbidities, and motor outcomes at outpatient follow-up were collected. Results Overall, 54% of infants developed dolichocephaly during hospitalization. The presence of dolichocephaly was highest in infants between 32 and 34 weeks' postmenstrual age (PMA) (39%). Birth weight, gestational age, bronchopulmonary dysplasia, gastroesophageal reflux disease, and severe intraventricular hemorrhage were not associated with dolichocephaly. Infants with dolichocephaly at 32 to 34 weeks' PMA were more likely to either be receiving PT services or be referred to PT services by outpatient follow-up (p = 0.05). Conclusion The presence of dolichocephaly was highest in infants between 32 and 34 weeks' PMA and was associated with increased need for PT services in early infancy. Findings support early developmental intervention at < 32 weeks' PMA to prevent and/or treat cranial molding deformity and improve early motor outcomes.
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In order to improve the developmental proficiency of neonatal intensive care unit nurses, a standardised infant positioning assessment tool and a bedside education programme were introduced to the registered nurses in a 46 bed level III neonatal intensive care unit in the western United States. A developmental positioning team collected pre-intervention positioning scores on 54 preterm infants. This was followed by a survey of the registered nurses beliefs and attitudes, the introduction of the standardised assessment tool and an informal education programme. Post-intervention positioning scores were collected on 55 preterm infants, and analysis of the data indicated there was a statistically significant change in mean positioning scores. Additionally, the registered nurses identified several barriers to the implementation of developmental positioning. This research indicates the use of a standardised infant positioning assessment tool and bedside education may be useful strategies for improving the developmental positioning proficiency of NICU nurses.
Executive summary:
Positioning of preterm infants is a basic task of neonatal nursing care. A variety of outcomes are affected by different body positioning of preterm infants. This review evaluates the clinical evidence of the effects of positioning of preterm infants with regard to physiological outcomes and sleep states.
Objectives:
To conduct a systematic review to determine the best available evidence related to the positioning of preterm infants. The specific review questions addressed were: the physiological outcomes affected by different positioning, and the best position for promoting sleep.
Criteria for considering studies for this review:
This review considered all studies that included infants born before 37 weeks of gestational age in any hospital setting. Outcomes included measures for physiologic effects and sleep state. The review primarily considered any randomized clinical trails (RCTs) that explored different positions in preterm infant but also included quasi-experimental designs.
Search strategy for identification of studies:
The search sought to find published and unpublished studies. The database search included: Pubmed, CINAHL, ProQuest, EMBASE, Science Direct, and Dissertation Abstracts International. Studies were additionally identified from reference lists of all studies retrieved.
Assessment and data extraction:
All studies were checked for methodological quality by two reviewers and data was extracted using tools developed by the Joanna Briggs Institute.
Data analysis:
The study results were pooled in statistical meta-analysis using Review Manager Software and summarized in narrative form where statistical pooling was not appropriate or possible.
Results:
Thirty two studies were included in the review. The results of this review support the prone position in preterm infants for improvement of arterial oxygen saturation, improved lung and chest wall synchrony of respiratory improvements, decreased incidence of apnea in infants with a clinical history of apnea, promoted sleep, and decreased gastroesophageal reflux. However, the prone position increased postural abnormalities, orthopaedic abnormalities of the feet, and delayed developmental musculature. The combined use of a postural support roll and a postural nappy while very preterm infants are nursed, improved hip and shoulder posture up to term postmenstrual age. The change in body position from horizontal to head-up tilt in very immature and unstable infants may affect the cerebral homodynamic. The management of position per se may not be sufficient for assisting preterm neonates to cope with the painful procedure. Furthermore, preterm infants are susceptible to oxygen desaturation in car seats and carrying slings.
Conclusion:
Prone positioning was shown to have many advantages for prematurely born infants. But the longer, deep sleep period and fewer awakenings associated with a prone position would support higher vulnerability for preterm infants to sudden infant death syndrome (SIDS). Therefore, all preterm infants placed in the prone position should have continuous cardio-respiratory and oxygen saturation monitoring. Preterm infants should be placed in a properly supported position to ensure functional support of all parts of the body as well as ensuring physical safety. In addition, preterm infants should not be left unattended in car safety seats and carrying slings.
The near-term infant (NTI) refers to the infant born between 34 and 37 weeks' gestational age. These infants may initially be cared for in well-baby nurseries, special care nurseries, or neonatal intensive care nurseries. These infants have a unique set of abilities and needs, which do not always mimic the abilities and needs of either their older term or younger, more preterm, counterparts. Health care professionals must adapt their care practices and discharge teaching to meet the unique needs of the NTI. This article will address the unique needs of the NTI with regard to neuromotor maturation, positioning, and safe sleep practices, as well as how health care professionals can alter daily care practices and discharge teaching when working with this special population.
Objective
To provide a comprehensive literature review of neuromotor development and related physiologic effects of positioning in very low birth weight infants.
Data Sources
MEDLINE, CINHAL, Health Star, Current Contents, and the Australian Medical Index (1966–2000) databases were searched. Unpublished studies (e.g., dissertations, conference proceedings) and all relevant references listed in articles also were examined.
Study Selection
One hundred and eighty theoretical writings, research studies, and clinical papers related to neuromotor development, the physiologic effects of positioning, and interventions to minimize or prevent short- and long-term effects of positioning in very low birth weight infants were reviewed.
Data Extraction
Studies were assessed for scientific rigor, evidence of theoretical foundation, and clinical relevance. Comparisons were made across data sources to determine the most reliable, valid, and consistent findings.
Data Synthesis
Three compelling results emerged: (a) The development of posture and mobility in newborn infants requires an optimal balance between active and passive muscle tone, (b) the prone position is physiologically more beneficial for the preterm infant than supine and lateral positions, and (c) the prone position can lead to short- and long-term postural and associated developmental problems.
Conclusion
Use of empirically tested postural interventions appropriate for an infant's gestational age, health status, and overall organizational capacity is recommended.
In this prospective, descriptive study, we used a repeated-measures design to explore the 24-hour effects of caregiving and positioning on preterm infants' states and the factors associated with state changes. Thirty preterm infants (gestational age 27.6-36.1 weeks) were observed for 3 days in the neonatal intensive care unit to record six states: quiet sleep (QS), active sleep, transition, active awake, quiet awake, and fussy or crying. The occurrences of QS increased when infants received no caregiving, social interaction, non-nutritive sucking (NNS), and were laterally positioned. However, QS significantly decreased and fussy or crying state increased when infants received routine and intrusive caregiving. These results suggest that caregiving, NNS, and positioning should be appropriately provided to facilitate infants' sleep, and reduce fussiness or crying.
To provide a comprehensive literature review of neuromotor development and related physiologic effects of positioning in very low birth weight infants.
MEDLINE, CINHAL, Health Star, Current Contents, and the Australian Medical Index (1966-2000) databases were searched. Unpublished studies (e.g., dissertations, conference proceedings) and all relevant references listed in articles also were examined.
One hundred and eighty theoretical writings, research studies, and clinical papers related to neuromotor development, the physiologic effects of positioning, and interventions to minimize or prevent short- and long-term effects of positioning in very low birth weight infants were reviewed.
Studies were assessed for scientific rigor, evidence of theoretical foundation, and clinical relevance. Comparisons were made across data sources to determine the most reliable, valid, and consistent findings.
Three compelling results emerged: (a) The development of posture and mobility in newborn infants requires an optimal balance between active and passive muscle tone, (b) the prone position is physiologically more beneficial for the preterm infant than supine and lateral positions, and (c) the prone position can lead to short- and long-term postural and associated developmental problems.
Use of empirically tested postural interventions appropriate for an infant's gestational age, health status, and overall organizational capacity is recommended.
The purpose of this study was to examine the influence of prone and supine position in preterm infants during acute pain of blood collection.
Level III Neonatal Intensive Care Unit (NICU).
Thirty-eight preterm infants (birthweight 1339 [590-2525] g, GA 29 [25- 32] wks) were in 2 groups depending on their position in the isolette prior to and during heel lance at 32 weeks post-conceptional age. The study design was a comparison between groups (Prone, Supine) during 2 events (Baseline, Heel lance).
Pain measures were multidimensional, including behavioral (sleep-wake state and facial activity) and physiological (heart rate) responses measured continuously prior to (Baseline) and during blood collection (Lance).
Both groups of infants displayed statistically significant shifts in sleep-wake state to greater arousal, and increased facial activity and heart rate, from Baseline to Lance. Prone position was associated with significantly more deep sleep during Baseline, compared with Supine position, but there were no differences in sleep-wake state during Lance. Minor increased facial activity was shown in some time segments of Baseline for infants in Supine compared with Prone, but did not differ overall between positions. Prone and Supine position did not affect heart rate significantly during Baseline or Lance events.
Prone position promotes deep sleep in preterm neonates at 32 weeks post-conceptional age when they are undisturbed. However, placement in prone position is not a sufficient environmental comfort intervention for painful invasive procedures such as heel lance for blood sampling in the NICU. Neonates require other environmental supports to promote coping with this stressful event.
To determine the effect of different forms of education on nurses' abilities to position neonates in a developmentally supportive way and to determine nurses' perceptions of effectiveness of educational methods to enhance their positioning abilities.
In a one-group, repeated-measures, alternating-treatment design, the effectiveness of nurses' abilities to position neonates in the context of developmentally supportive care before and after different education approaches was scored using an instrument designed for this study. A self-administered survey was conducted with nurses to examine perceptions of positioning-related issues.
Formal education methods such as in-services and workshops improved nurses' abilities to position neonates in developmentally supportive positions; however, improvements declined in the absence of ongoing education. Nurses perceived workshops, physical therapy in-services, and bedside consultation to be more useful than audiovisual resources, independent reading, or general hospital in-services.
The results suggest that the physical therapist's role as a consultant is important to ensure continued performance of developmentally supportive care with respect to positioning of infants in the neonatal intensive care unit.
Swaddling was an almost universal child-care practice before the 18th century. It is still tradition in certain parts of the Middle East and is gaining popularity in the United Kingdom, the United States, and The Netherlands to curb excessive crying. We have systematically reviewed all articles on swaddling to evaluate its possible benefits and disadvantages. In general, swaddled infants arouse less and sleep longer. Preterm infants have shown improved neuromuscular development, less physiologic distress, better motor organization, and more self-regulatory ability when they are swaddled. When compared with massage, excessively crying infants cried less when swaddled, and swaddling can soothe pain in infants. It is supportive in cases of neonatal abstinence syndrome and infants with neonatal cerebral lesions. It can be helpful in regulating temperature but can also cause hyperthermia when misapplied. Another possible adverse effect is an increased risk of the development of hip dysplasia, which is related to swaddling with the legs in extension and adduction. Although swaddling promotes the favorable supine position, the combination of swaddling with prone position increases the risk of sudden infant death syndrome, which makes it necessary to warn parents to stop swaddling if infants attempt to turn. There is some evidence that there is a higher risk of respiratory infections related to the tightness of swaddling. Furthermore, swaddling does not influence rickets onset or bone properties. Swaddling immediately after birth can cause delayed postnatal weight gain under certain conditions, but does not seem to influence breastfeeding parameters.
BACKGROUND. The preterm infant is subject to the force of gravity: when its body lies pressed against the mattress on which it is placed.
The purpose of this study was to investigate short-term effects of varied post-natal lying positions in order to prevent neuromuscular and postural abnormalities.
60 low risk preterm infants of 31-36 weeks gestational age were enrolled for this randomised clinical trial. Initially each child underwent neurological and psychomotor assessments which included tonus and reflex protocols as well as behavioral, sensory motor and postural examinations. The lying positions of the treated group were varied (back, prone, and side) using a specially designed moldable mattress that maintained the functional position of the infant's body. The control group was placed on their stomachs, (the standard lying position used in 1994) with a standard orthopaedic bolster support under their hips. All infants underwent a second round of examinations upon discharge to assess any changes in neurological and psychomotor outcomes.
The sensory-motor skills examinations showed significant abnormalities in the control group: (1) dominance of the extensor muscles due to muscle shortening, (2) hyper abduction and flexion of the arms, and (3) global neuromuscular rigidity. Psychomotor and neurological exams of the control and treatment groups showed delayed developmental muscular acquisitions for infants in the control group.
Regular changes in posture, while retaining correct functional positions, allowed maintenance of normal neuromuscular and osteo-articular function and permitted the development of spontaneous and functional motor activity in low-risk perterm infants.
Low birth weight infants: neonatal care and follow-up
- JK Sweeney
- M Swanson
Sweeney JK, Swanson M. Low birth weight infants: neonatal care and
follow-up. Neuro Rehabil 2001: 203-53.
Standards for QUality Improvement Reporting Excellence 2.0: revised publication guidelines from a detailed consensus process
- G Ogrinc
- L Davies
- D Goodman