In this article, I’ll be sharing the next B in the 4B’s of Developmental Care – Body.
I think we would all agree that therapeutic positioning along with minimizing sensory over-stimulation have been the cornerstone of developmental care since its inception. But if we are honest, we all still struggle with the implementation of both of these concepts.
A few weeks ago, I had the awesome opportunity to visit the NICU at one of the oldest and most beautiful hospitals in Sao Paulo, Brazil – Santa Casa.
  
As I toured the NICU at Santa Casa, I noticed a 30-week infant that had just been admitted and was laying flat on the bed with CPAP cap on and a huge diaper!!! I asked the staff a little bit more about the baby and commented that the baby’s hips were very abducted. They agreed and shared how difficult it is for them to position their small babies because they only have one size of diapers for all their babies.
If you are like me, and have been working in the NICU for more a while now, you will likely remember when this was the case for all the NICUs we worked in.   The little wee-diapers didn’t even come along until the early 2000’s.
I shared with the nurses and doctors one of my old-school tips on how to squeeze down the crotch of the large diaper (remember how we used to fold and tape up diapers) so that they fit better between the legs of the smallest babies.  I also mentioned that I would be discussing in my talk at the conference the next day, the essential elements of supportive positioning for a baby of this size and how to work with the supplies they have to improve alignment and outcomes.
As you can see from this story, the issue of proper body positioning for our small and sick babies is still an issue for all of us from Brazil to Brooklyn.
So let’s dive in to the WHY and the HOW behind proper body positioning:
The why of appropriate body position is easy… Optimal positioning is essential because it: prevents deformities, improves comfort, minimizes stress, improves oxygenation, promotes musculo-skeletal alignment, minimizes muscular tightness, and so much more.
With all these known reasons to ensure proper BODY positioning, you would have thought that figuring out how to do so would be easy, however implementation is very difficult.
So to keep the HOW of therapeutic positioning simple (like I always try to do) I’ll break this topic down in to 3 easy steps:
  1. Midline Orientation
  2. 360 degrees of boundaries
  3. Flexion

1. – Midline Orientation

Mindline orientation can be imagined as a straight line between the nose, nipples, knees and toes.  The infant can be supine or side-lying and still have mid-line orientation.  When the infant is lying in the prone position, their body can still be midline oriented, but their head (or nose) will need to be adjusted slightly … however this does not mean the infant has to have their head turned to the extreme left or right!

The knees and toes are an often overlooked part of midline orientation.   With the creation of micro-sized diapers, we do see less hip abduction than we used to, but we must pay close attention to the impact that the diaper has on the position of the lower extremities.  To correct this common misalignment we need to either select a more appropriate sized diaper (if available) or modify the “crotch” area of the diaper using a Z-fold technique so you can minimize hip splay (this is the old technique that I recently shared with the NICU team at Santa Casa.

2. – 360 Degrees of Boundaries

360 degrees of boundaries is necessary to provide the infant with some of the same sensory inputs (pressure points) that they have grown accustomed to in-utero.  These boundaries should not just be provided, but should be customized to the size of the infant.
Have you ever seen a line-up of admission beds sitting and waiting … and each incubator is set with one of those “pre-made blanket nests” made exactly the same size in every bed, regardless of which size baby will be admitted next?  
Just like a bird builds a nest to their size, we should be building our baby’s nests to their size.  The boundaries of the nest should actually touch them, snuggly. Their feet and legs should not hang over the edge and the boundary should not go between their legs.
Have you ever seen a baby that wiggles and wiggles out of their nest to find their way flat up against the wall of the incubator?  Any guesses what they are doing? That’s right, they are searching for their uterine boundaries that help to define their space in the world.
It has been said that the fetus has 3 pressure points in-utero. The back of the head, their butt, and their feet.  When you create a “nest” for your infant ensure that all three areas are being touched by your boundary and I can almost guarantee that you will likely see an noticeable improvement in your infant’s sleep.

3. Flexed (Not Restrained) Extremities

In order to fight gravity and lack of muscle tone it is often times necessary to use blankets or positioning aids to maintain a sick or premature infant in a flexed position.  When using these aids, it is important to provide containment but not restriction of movement!  The days of “tight” swaddling (a la straight jacket-ing) should be put behind us.  Infants need to be able to move in order to complete the sensory wiring of the brain.
Fetuses move in utero (sometimes for expectant moms, it feels like too much) and the infant in the NICU needs the same.  Also the ability to stretch their legs against the uterine wall helps to stimulate the laying down of bone in the fetus.  So if the positioning aid restricts this pressure input, bone development is compromised and has led some to believe places the infants at higher risk for fractures too.  What I love are some of the newer positioning aids that are now available, like the DandleLION Medical Roo which provides a pouch that provides both containment and movement.
Now that you’ve read this far, let’s chat about my favorite way to bring these concepts to the bedside for everyday use.
One of my favorite tool’s to assess and improve infant position is the Infant Positioning Assessment Tool (better known as the IPAT) — it’s both practical enough for easy bedside audits by the developmental care team or integrated in to the bedside nursing documentation; but it can also be used for QI or research projects to assess the impact of target staff education related to positioning.    The idea of the IPAT tool is addition not perfection.   To get started all you have to do is perform a quick head-to-toe scan of a baby and assign a score to their current position.  You assess 6 parts of their body (shoulder, hands, head, hips, knees, and ankles) and you give a score of 0, 1 or 2 to each part.  The higher the score, the better the positioning, and there is a maximum score possible of 12.

Let me show you how the use of the IPAT tool might play out in real life.
Let’s say that you do your first assessment and you total the baby’s IPAT score as 8.  Not bad, but what can you improve?  Can you adjust the diaper and bring the hips in to a more flexed and midline position?  Can you bring the hands from the trunk to the face?  Could you add a boundary to the feet and bring the ankles and toes in to better midline alignment?   As you can see using the IPAT tool is not time-consuming or difficult to use and it allows you to find practical ways to make significant improvement in the baby’s position gradually and in seconds.
The IPAT score is not a competitive sport, but I have known some nurses to be competitive about it.   That’s fine with me, if that helps to keep up people’s excitement.  The tool should never be used to blame or shame another member of your team.  But in the end, the tool is designed for you to assess a baseline and improve the position of the baby you are caring for during your shift, during every care interaction.  To learn more about the IPAT tool, click here.
If you’d like to continue your education about the 4 B’s of developmental care keep reading our blog or join us each month for our live Developmental Care Book Club discussion group.   Just click on the image below to get signed up.
REFERENCES:
  1. Humming bird photo: http://www.birdsandblooms.com/birding/attracting-hummingbirds/hummingbird-nest-facts/