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Nesting and Positioning

Preterm and many sick term infants lack the typical physiologic flexion pattern. The flexion position is important for motor development and neuro-behavioral development of the baby.

WHY POSITION HIGH-RISK INFANTS?​

  • Promotes the flexion posture that is characteristic of normal full-term development.
  • Helps the baby to keep hands in midline promoting deep sleep and thus protecting the baby's developing nervous system and brain.
  • Promotes autonomic stability.
  • Saves energy and calories for growth, development and physiological stability in addition to giving a sense of security.
  • Provides the proprioceptive feedback that supports motor development and maintains muscle tone
  • Prevents or minimizes deformity

PRACTICAL POINTS FOR POSITIONING​

  • Use linen to make an oval shaped nest and cotton for extra support. If linen is not available then cotton can be utilized. Tape can be used to secure the nest.
  • Make sure that the baby's airways are open and the head is neither flexed nor extended. A shoulder roll can be used.
  • The nest must be tight enough to provide the nesting effect, but not too tight making breathing difficult.
  • The baby’s arms are to be flexed and their hands are to be placed towards their face/ mouth. Their feet are flexed and pulled towards the centre of the body. Avoid the frog position of the legs.
  • The baby’s position is to be changed every 2 to 4 hours. This is to prevent ulcers and edema, to better lung function, loosen secretion, increase motor development and improve head shape. Vary between left and right side, supine and prone position (all supported).
  • Supine positioning: Makes it easy to monitor the baby and easier to do procedures. Make sure the baby is properly supported so that the arms and legs do not fall out to the sides. The head and neck should not be extended to one side, but should be kept in a midline position. For some babies supine position is the only good option. In this case, make sure to give small varieties of the position by raising one side of the body slightly and gently twist the head slowly to the same side to maintain the midline position. A shoulder roll is often beneficial to improve open airways, however, be careful not to make the roll to big leading to overextension of neck. The roll must always be placed under the shoulders, not under the neck.
  • Prone positioning: Prone position is only for babies whose saturation is monitored. Prone position in NICU has been strongly supported physiologically. This position encourages body containment, but has to be done with proper support. Use cotton to support under thorax and abdomen to provide an open chest, support for knees and feet and shoulders rounded forward. Most babies also need support under the head to avoid a 90 degrees flexion of the head. The knees of the baby should be under the abdomen and the toes should be pointing towards head. Frogleg position should be avoided.
  • Right side and left side: Positions in which it’s easy to give the baby sufficient support. Some babies need extra support behind the upper shoulder to prevent the shoulder from falling back and decreasing the opening of the chest.
  • Most babies benefit from lying with a 30-degree headboard. This is especially important for preterm babies, low birth weight babies, babies with respiratory distress and babies that have a lot of secretion, digest poorly or vomits.
  • Allow for alteration for medical equipment and positional constraints. Use a half nest if a full nest is not possible, e.g., if on oxygen by hood or if IV or surgical site indicates a certain position.
  • As the baby gets improved postural tone, allow more freedom of movement.

FOR THE CARE OF BABIES​

  • Do not wake a sleeping baby if you have the opportunity to wait. As you would with any person before starting care - Softly greet / talk to the baby before touching - at the onset of any handling or procedure.
  • Minimize handling for all sick babies, but especially for very young preterm babies.
  • Use gentle but still, firm touch rather than light touches or tapping when touching a preterm. For full term sick neonates- observe their response to light touch and if they display a stress response try the still firm touch.
  • Sometimes when a young preterm baby is stressed by an experience just taking a brief break from the care to allow time without stimulation can help the baby to regain a calmer state.
tip

Document sound levels in NICU. Continuous background sound and operational sound should not exceed 45 dB to 50 dB and transient sound has an upper limit of 65 dB in NICU. All staff are responsible of keeping the environment in the nurseries quiet.

References​

  • Practical Procedures for the Newborn Nursery
  • A Manual for Physicians & Nurses. Deorari, Paul, Singhal, Scotland and McMillan
  • Neonatal Intensive Care by Merenstein & Gardner, 7 edition
  • Developmentally Supportive Care of the Preterm, Fragile and/or Critically ill Infant in the NICU. Dr Amitava Sengupta

Document Information​

Current Version

Version: 2.0
Published: August 20, 2015
Revised by: Dr Chetan Meena, Johanne M. E. Huurnink
Contributors: Teaching Nurses from Norway and FBNCU Nursing Staff, JK Lone Hospital, SMS Medical College, Jaipur
Previous Versions: v1.0