Childs Nerv Syst (2015) 31:2333–2340
DOI 10.1007/s00381-015-2905-1
ORIGINAL PAPER
Posture and movement in very preterm infants at term age
in and outside the nest
M. Zahed 1
&
J. Berbis 1 & V. Brevaut-Malaty 1 & M. Busuttil 1 & B. Tosello 1 & C. Gire 1
Received: 24 August 2015 / Accepted: 1 September 2015 / Published online: 5 October 2015
# Springer-Verlag Berlin Heidelberg 2015
Abstract
Objective The objective of this study is to evaluate the use of
nests on general movements (GM) and posture in very preterm infants at term age.
Method Seventeen high-risk preterm infants—less than
30 weeks of gestation (GA)—underwent a video recording,
lying in supine position, with or without nest. Posture, GM
quality, and movements made around the child’s midline, as
well as abrupt movements and frozen postures—in extension
or flexion of the four limbs—were analyzed.
Results Nest did not modify quality of GM. Children significantly adopted a curled-up position. The nest system was associated with an increase in movements toward or across the
midline, as well as reduction of the hyperextension posture
and head rotation movements. Frozen postures in flexion or
extension, as well as abrupt movements of the four limbs,
were reduced but not significantly.
* M. Zahed
[email protected]
J. Berbis
[email protected]
V. Brevaut-Malaty
[email protected]
M. Busuttil
[email protected]
B. Tosello
[email protected]
C. Gire
[email protected]
1
Aix Marseille University, Hospital Nord, Department of
Neonatology, Chemin des Bourrely, Marseille 13015, France
Conclusions Nest helps very preterm infants to adopt semiflexed posture and facilitates movements across the midline
and reduces movements of spine hyperextension, without GM
global quality modifications.
Keywords Preterm infants . Installation . Nest . Posture .
Spontaneous motor activity
Introduction
Very preterm infants are at risk of developing cognitive, motor, and behavioral impairments [1]. A recent Cochrane review [2], focused on quite heterogeneous intervention programs, has reported a positive influence on cognitive and motor development up to preschool age.
Children are generally placed in nests with their four limbs
semi-flexed, adducted in intensive care units (ICUs), to limit
environmental stimuli and stress and also to reduce orthopedic
malformations as part of an individualized program of developmental care (Newborn Individualized Developmental Care
and Assessment Program (NIDCAP)) [3].
Several studies have focused on preterm infants’ motor
behavior and posture in nests—in ICUs—and have demonstrated that posture improvement, in the nest, has beneficial
effects on the preterm infants’ motor behavior [4, 5]. There is
only one study analyzing nest’s effect on healthy very preterm
infants’ spontaneous motricity and posture [6]. The aim is to
put forward the efficiency of nests, recommended by neonatology units during hospitalization, and, depending on the
team, on very preterm (under 30 WA) motor risks and the
association of added comorbidity.
The first hypothesis was that, apart from endogenous spontaneous motor activity, some aspects of the preterm infants’
motor behavior could be improved when these children were
2334
placed in a nest after they have left the hospital. By removing
passive constraints, the nest should favor a midline children’s
head position, four-limb flexed posture, and limit abrupt arm
extension movements and movements triggering the
Moro reflex.
If motor behavior is improved, we could implement this
system for discharge from hospital until voluntary movements
appear, especially in high-risk preterm infants, in order to
assure a global posture support [7, 8]. But, the question about
which rhythm, and in addition to which support, is still open;
another study, to evaluate the after checkout, is required.
Thus, this study sought to evaluate the effect of a
preformed nest called BCocoonababy^ on the posture and motor behavior of very preterm infants (<30 GA, before
leaving hospital).
What we add, with this article, is that being placed in a nest
reduces abrupt movements, facilitates elegant wrist movements and movements toward and across the midline, and
promotes a flexed and adducted posture of the limbs, for
healthy and none healthy preterm infant.
Material and methods
Material
The preterm infants included were children whose term age
was strictly 30 GA, or under, but over 24 GA; this is a highrisk population. They were out of the incubator; aged at least
37 GA at the time of video recording; had neither gene syndrome, progressive neurologic disease, nor malformative pathology; and whose parents or legal guardians had agreed to
the children’s participation in this study and had signed an
informed consent.
The non-inclusion criteria were as follows: children born at
a term age strictly over 30 GA, with a gene syndrome, progressive neurological disease, or malformative pathology;
who did not undergo a brain MRI; who were aged under 37
GA at the time of video recording; and whose parents or legal
guardians had refused to let their children take part in
the study.
This data helps us to describe the population and shows
that there are some infants with high risk.
Perinatal morbidity items described in the spreadsheet 1 are
the following:
CLD item was associated to all children in need of a ventilatory support at 36 GA (corrected age).
Patent ductus arteriosus (PDA) was defined by a significant
arterial canal persistence, in terms of hemodynamics, after
1 week of life.
Necrotizing enterocolitis (NEC) was defined by an enterocolitis appearance, with a clinical symptomatology and a radiological image suggestive of pneumatosis.
Childs Nerv Syst (2015) 31:2333–2340
The MRI examination was performed as usual, as we proceed in the current care unit with all the preterm infant under
30 GA, without sedation (after bottle-feeding), between 36
and 41 WG, by means of conventional T1-and T2-weighted
sequences, T2 gradient echo sequence, and diffusion sequence
(b 0, 500, 1000). The preterm infants’ lesions were classified
based on Paneth’s model, according to their anatomical distribution. MRI results were divided into two severity stages:
group I with normal MRI or moderate abnormalities (types
1, 2, 3, and 4) and group II with severe abnormalities (types 5
and 6) [9].
Methods
This was a prospective single-center study, during which each
child acted as his own control (when placed or not in the
Cocoonababy). The children were recruited in the study by
the neonatology department. The physician in charge of recruitment was responsible for explaining to the newborn’s
parents or legal guardians the study. The study was granted
authorization by the Comité de protection des personnes Sud
Méditerranée, regional research ethics committee.
The cocoon is a shell-shaped or circle foam device, depending on each units, which will be placed in the child’s
incubator or bed; it is very often used in neonatal units for
the comfort of the newborn (NIDCAP). In our study, each nest
system was then adapted to the child, by adjusting the height
of the wedge and position of the top of the child’s head, which
should be placed three fingerbreadths from the top of the nest.
Two sizes were available: a small and medium one (sizes 1
and 2, respectively) depending on the size of the child about to
be filmed (Fig. 1).
Video recordings for each patient were taken at term age,
20 min in the Cocoonababy nest, and then 20 min outside the
nest. The camera was placed on a stand, directly above the
child’s bed, and recordings were carried out without touching
the baby or seeking to catch the baby’s attention.
Each video recording was performed with quiet children,
with no soother, and outside periods of crying or eating. Preterm infants were filmed in supine position, undressed, but in
a room with pleasant temperature. An observer was present,
though hidden, in order to ensure the children’s safety, as well
as compliance with the above-mentioned conditions.
These recordings were viewed by two separate operators,
both trained in Prechtl’s method [10]. GM was assessed on a
qualitative and semi-quantitative basis [11]. The Bwrithing
movements^ (WM) were qualitatively classified as Bnormal,
^ Bcramped synchronized,^ Bhypokinetic,^ Bpoor repertoire,^
or Bchaotic.^ They were then classified on a semi-quantitative
basis, the analyzed parameters being movement fluidity and
amplitude, time and space variation, and movement speed
[12]. Interoperator agreement was 0.90. There is no order for
random with nest or without.
Childs Nerv Syst (2015) 31:2333–2340
2335
was also assessed. The outcome was evaluated by an age and
stage questionnaire.
Statistics
Fig. 1 Cocoonababy®
Posture was defined as a cessation of movement for at least
10 s. Posture was analyzed at rest, before, or after a spontaneous movement. Out of four postures determined for each
child, we kept the most physiological or natural one. The
rating grid used ranged from 0 to 17 (Table 5) [6]. The following joints were observed: neck, shoulders, elbows, hips,
and knees. Depending on their location in space (flexion,
semi-flexion, extension, abduction, adduction, or neutral),
these joints were assigned 0, 1, or 2 points. The closer the
posture score was to 0, the more the child was in a physiological fetal position.
Finally, we analyzed whether there were normal or abnormal movements when the children were placed in supine position, flat on their backs, and then when placed in the
Cocoonababy. Its aim was to observe whether there were more
movements around the children’s midline inside the nest system (head rotation, hand-to-mouth contact, hand-to-head contact, hand-to-foot contact, and foot-to-foot contact), as well as
whether abnormal movements, such as abrupt movements and
four-limb frozen postures in extension and flexion, were reduced inside the nest (Tables 5 and 6) [6]. This assessment
was qualitative. We regrouped the total of different normal
and abnormal movements noted at the time of assessment
and assessed them on a semi-quantitative basis. The
Cocoonababy’s effect on the pattern of spine hyperextension
Data analysis was performed using SPSS software (Version 17.0). A descriptive analysis of the clinical variables, available with the inclusion of the whole sample,
was carried out. Qualitative variables were expressed as
proportions, while quantitative variables were given
using the central tendency characteristics (mean and
standard deviation). A comparative analysis was performed between both groups with and without the
Cocoonababy nest, using non-parametric tests for paired
samples: McNemar’s chi-squared test for qualitative variables or Wilcoxon’s test for quantitative variable. The
test significance threshold was set at 0.05. To help interpret the differences in the quantitative variable mean
scores’ clinical significance (WM score; mean posture;
movement around the midline; four-limb abrupt movements; four-limb frozen flexion-extension), effect sizes
were calculated in absolute value by dividing the difference between the mean score of the Bwith nest^ group
and the mean score of the Bwithout nest^ group, by the
without nest group’s standard deviation. We considered
an effect size of 0.2 to 0.49 as Bsmall,^ 0.5 to 0.79 as
Bmedium,^ and 0.8 or higher as Blarge.^
Results
Population: Table 1
The study population comprised 17 very preterm infants, who were treated in the neonatology department
and whose mean hospitalization length was 104.7 days
(±63.1). Mean age was 27 GA + 5 days (±1.75), and
mean weight was 1024.9 g (±237.1). Of the 17 children,
five (30 %) displayed a development delayed and ten
(60 %) had MRI grade II. Population characteristics are
provided in Table 1.
Spontaneous motor activity analysis inside and
outside the nest
When observed lying flat on their bed, 3 out of the 17 babies
from the group showed a chaotic repertoire (17 %), 1 cramped
synchronized movement (6 %), 2 a poor repertoire (12 %), and
11 babies displayed a normal repertoire (65 %). When the
Cocoonababy nest was used, five babies from the group
showed a poor repertoire (29 %) and 12 a normal one (71 %).
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Table 1
Childs Nerv Syst (2015) 31:2333–2340
Characteristics of the study population
Baby number
GA
BW (g)
Number of NI
CLD
NEC
PDA
MRI
Length of hospitalization (days)
DD
Baby 1
29+2 days
1005
5
Yes
No
Yes
II
140
Yes
Baby 2
29+5 days
1130
0
No
No
No
I
330
No
Baby 3
Baby 4
27+4 days
26+4 days
1100
965
3
2
Yes
Yes
Yes
No
Yes
Yes
II
I
103
113
Yes
No
Baby 5
Baby 6
25+1 day
28+1 day
880
1010
1
0
Yes
No
No
No
Yes
No
II
I
113
70
No
No
Baby 7
27+0 day
850
3
Yes
Yes
No
I
85
No
Baby 8
Baby 9
24+4 day
28+1 day
650
1000
2
1
Yes
Yes
No
No
Yes
No
II
I
119
49
Yes
No
Baby 10
Baby 11
29+4 days
24+0 day
1284
750
0
3
No
No
No
No
No
No
II
II
97
119
Yes
Yes
Baby 12
30+0 day
1330
0
No
No
No
I
32
No
Baby 13
Baby 14
29+2 days
27+6 days
1550
1120
2
1
Yes
No
No
No
Yes
Yes
I
II
96
81
No
No
Baby 15
Baby 16
28+0 day
27+6 days
720
1230
3
1
Yes
Yes
Yes
No
No
Yes
II
II
94
91
No
No
Baby 17
26+4 days
850
1
Yes
Yes
No
II
111
No
GA gestational age, BW birth weight, NI nosocomial infection, CLD bronchopulmonary dysplasia at 36 WG, NEC necrotizing enterocolitis, PDA patent
ductus arteriosus, MRI magnetic resonance imaging, severity stage, DD delayed walking or delayed development at 2 years
The chaotic repertoire or cramped synchronized movements which were observed outside the nest in four preterm infants from this population disappeared inside the
nest system.
The mean spontaneous motor activity’s semi-quantitative
score of the 17 preterm infants inside the nest was 14.94
(±3.61), as against 14.12 (±3.72) outside the nest, which
means it had slightly improved by 0.8 points but without significant (p=0.008).
The Cocoonababy did not significantly affect the overall
interpretation of GM, whether the analysis was qualitative or
semi-quantitative (Table 2).
system, 14 babies from the cohort (82 %) obtained a
score higher than 5, while with the nest, only 1 had
such a score (5.9 %) (p < 0.001). With the nest, the
mean score was 2.47 (±2.21) as against 8.12 (±4.03)
without it (p<0.001).
The nest system enabled the children to adopt a
curled-up position (score close to 0). Their shoulders
and hips were more flexed, adducted, and their elbows
and knees more bent.
Posture analysis inside and outside the nest: Table 2
There was an increase in movements toward or
across the midline when the child was placed in the
nest system. Children made a mean of four movements
when placed outside the nest, as against 5.6 inside of
The Cocoonababy nest had a significant effect on the
children’s postural behavior values. Without the nest
Table 2 Posture analysis inside
and outside the nest
Analysis of normal and abnormal movements inside
and outside the nest: Table 3
Writhing movements
Without the
nest (n=17)
With the nest
(n=17)
Abnormal repertoire
Chaotic repertoire
Cramped synchronized
Poor repertoire
Mean WM score
Mean posture
6 (35 %)
3
1
2
14.94 (±3.61)
8.12 (±4.03)
5 (29 %)
0
0
5
14.12 (±3.72)
2.47 (±2.21)
Z value
(Wilcoxon’s test)
p value
1
−2.585
−3.520
0.008
<0.001
Childs Nerv Syst (2015) 31:2333–2340
Table 3
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Analysis of normal and abnormal movements inside and outside the nest
Without the nest (n=17)
With the nest (n=17)
Z value (Wilcoxon’s test)
p value
Movement around the midline [10]
4.00 (±1.94)
5.65 (±1.46)
−3.336
<0.001
Abrupt movements of the four limbs [4]
0.88 (±1.22)
0.65 (±0.86)
−1.100
0.08
Frozen flexion-extension of the four limbs [4]
0.59 (±0.80)
0.18 (±0.39)
−2.333
0.03
Effect size: WM 0.22, posture 2.56, midline 0.85, abrupt 0.19, frozen 0.5
it, the difference being statistically significant
(p < 0.001).
Furthermore, without the nest, nine babies adopted a
pattern of spine hyperextension (53 %), while only two
babies displayed such a pattern (12 %) once they were
placed in the nest system. The Cocoonababy nest, therefore, significantly enabled seven children not to adopt
the hyperextension posture (p=0.016). It also promoted
a reduction in frozen postures, in flexion or extension
(0.18 inside vs. 0.59 outside the nest; p=0.031). The
test was at the threshold of significance. Four-limb
abrupt movements decreased by 0.15 points, though
the difference was not significant.
Description of the most frequently observed normal
movements when using Cocoonababy (Table 4)
The proportion of children exhibiting hand-to-leg or
foot-to-foot contact was significantly increased inside
the cocoon. Placement in the nest also resulted in more
hand-to-head contact movements; the difference is approaching significancy. On the other hand, movements
of 180° head rotation appeared to be significantly limited by the nest (p=0.05).
Discussion
Nest and posture
Although already demonstrated in other research work
[6, 7], this study showed that the nest significantly imTable 4 Influence of the nest on
normal movements
Normal movements
Hand-to-leg contact
Foot-to-foot contact
Hand-to-head contact
180° head rotation
*Significant; p<0.05
proves posture. Children placed in the Cocoonababy
nest adopted a more curled-up position and were less
subject to the gravity force. Their joints were bent, so
muscle, tendon, and bone structures could develop more
harmoniously. Hyperextension patterns were also less
frequent inside the nest, which enabled an overall balance between extensor and flexor muscles. The
Cocoonababy nest, therefore, makes it possible for children, who are in a more physiological position, to promote some movements around the midline.
Nest and GM
General movement did not seem to be improved by
the nest system, but only modified. The cramped synchronized and chaotic movements were no longer observed in the nest but transformed into poor repertoire. This change in the neurological examination
could also be accounted for by the fact that some
movements were enabled around the midline, as well
as by the decreased number of four-limb abrupt movements, spine hyperextension, and frozen postures in
flexion or extension. Head rotation, however, seemed
to be reduced by the Cocoonababy system, contrary to
other systems.
Only few studies which have focused on the nest’s
direct effects on the spontaneous motor activity of preterm infants, who are close to term age, or on its potential consequences for the children’s future development are available.
Slevin et al. [14] investigated the effect of the placement in a nest on reducing retinopathy in children lying
in a nest during their ICU stay. De Graff [7] evaluated
Without the nest [13]
With the nest [13]
p value
3/17 (18 %)
15/17 (88 %)
<0.001
8/17 (47 %)
11/17 (65 %)
8/17 (47 %)
14/17 (82 %)
16/17 (94 %)
2/17 (12 %)
0.03*
0.063
0.07
2338
the immediate effects of identical Bnest^ systems at 1
and 5 months post-term in term newborns. The author
found that the nest support did not affect movement
quality but could promote some movements, especially
in the event of minor abnormalities. This was so in our
study during which movements made around the midline were allowed. It should be noted that our study
population was high-risk preterm infants with 41 %
brain MRI considered grade II. Overall, five children
exhibited a delayed development.
In our study, there were fewer abrupt movements at
term age, but the decrease was not significant, except
for spine hyperextension. On the other hand, frozen
postures were almost significantly reduced, while movements made around the midline were promoted. In this
curled-up position, it therefore appeared that the children were able to touch their head, legs, and feet more
significantly.
The nest system, therefore, improved movement complexity. Similarly, some stressful movements, such as abrupt
movements and frozen postures in flexion or extension,
seemed to be reduced.
Nest and abnormal movement
It seems that placing infants in the nest promotes complexity and variation in spontaneous motor activity,
while reducing some abnormal movements at term age.
In this way, the nest could have an impact on future
motor and cognitive development at least up to 2 months
of corrected age, as suggested by previous studies [13,
15–19].
It is interesting to observe this positive change,
toward more physiological pattern, before the hospital
checkout, especially with high-risk children, because
it is a sensitive sensorimotor period and probably very
conducive to early rehabilitation one. In order to reduce some postural and motor deviances, wich sometimes can become permanent failures? Since its present design requires further studies, focuses on the impact of these cocoons’ long-term use after leaving the
hospital and probably not as the only support system
[7, 8].
Several recent studies have shown that, apart from
the analysis of GM at 3 months of corrected age, the
automatic assessment, in particular, the stereotypy score
of arm movements, was an excellent predictor of CP,
whereas stereotyped repetitive movements of the legs
predicted no neurodevelopment impairment [17]. Similarly, at 3 months of corrected age, persistence of immature movements like startle response, lateral decumbent position, predominant shoulder rotation, and maintaining hip adduction was more frequently observed in
Childs Nerv Syst (2015) 31:2333–2340
case of intellectual disability. Such mature movements
like hand sucking, maintaining shoulder abduction,
shoulder adduction, elbow flexion, isolated hip adduction, hip abduction, and leg lift were less frequently
seen than in the normal preterm [13].
Two other studies, conducted in preterm infants at term
age, demonstrated that jerkiness of spontaneous movements
at term age provides additional information for prediction of
CP [18]. Likewise, spontaneous movements, less active with
intermittent occurrences of limbs abrupt and synchronized
movements, were associated with psychomotor delays at
3 years [19].
Thus, the improvement of posture and of certain
movements affects neurological examination findings,
especially in high-risk preterm infants, as in our study
population. This improvement of motor behavior could
play a role in sensory and nociceptive stimulation with
improved central nervous feedback. Movement that
promotes sensory exploration can permit the development of synaptic connections, and a functional improvement could, therefore, be favored by this nest
system [20, 21].
It was noted that Cocoonababy reduced head rotation
movements in our patient population. This result was at
the significance threshold (p=0.057). The consequences
of such a limitation could lead to an increased rate of
plagiocephaly and inhibit eye exploration, which is required to ensure a good future development for the
child, as well as being responsible for a delayed development of isolated mature movement of the neck, this
being correlated with later psychomotor development,
especially when the child remains placed in the nest
system for a prolonged period without any other postural guidance [6, 7].
Study limitations
All the babies from the neonatology department were placed
in a cot system while being moved from the incubator (Bhome
nest^) to the bed (Cocoonababy nest). The 20-min recording
outside the nest constituted an abrupt, new change for the
children to which they had to adapt so as to regain their
balance.
But, the question about which rhythm, and in addition to
which support, is still open; another study, to evaluate the after
checkout, is required.
Furthermore, the observers were not blinded during the
study, which may have led to a subjective bias for the nest
effect.
Conflict of interest The authors declare no conflict of interest.
Childs Nerv Syst (2015) 31:2333–2340
2339
Table 6 (continued)
Appendix 1
Table 5
3. Abrupt abduction-extension of the four limbs
4. Abrupt rolling to side
frozen postures of the limbs (= abnormal movements)
1. Arms frozen in extension
2. Arms frozen in flexion
3. Legs frozen in extension
Items of posture assessment
-Shoulder:
0 = adduction (0–20°)
1 = neutral (21–90°)
2 = abduction (>90°)
-Elbow:
Yes/no
Yes/no
Yes/no
Yes/no
Yes/no
References
0 = flexion (0–30°)
1 = semi-flexion (31–150°)
1.
2 = extension (>150°)
-Hip:
0 = flexion (0–80°)
1 = semi-flexion (81–150°)
2.
2 =extension (>150°)
3.
-Knee:
0 = flexion (0–60°)
1 = semi-flexion (61–150°)
2 = extension (>150°)
4.
-Asymmetrical neck posture:
Absent
Present
-Head position:
5.
6.
0 = head in the midline (rotation <20°)
1 =head to side (rotation 20–70°)
7.
Score from 0 to 17 (the closer the score is to 0, the more the child is in a
physiological position)
8.
Appendix 2
9.
10.
Table 6 Detailed items of general and spontaneous movement
assessment
Movements around the midline (= normal movements)
1. Head rotation from side to midline
2. Head rotation from side to side
3. Hand-to-mouth contact
4. Hand-to-head contact
5. Opening of the hands
6. Hand-to-hand contact
7. Hand touching contralateral shoulder and trunk
8. Hand-to-leg contact
9. Foot-to-foot contact
wrist movements (= normal movements)
1. Rotational movements of the wrists
abrupt limb movements (= abnormal movements)
1. Abrupt opening of fingers
2. Abrupt abduction-extension of the arms
Yes/no
Yes/no
Yes/no
Yes/no
Yes/no
Yes/no
Yes/no
Yes/no
Yes/no
11.
12.
13.
14.
15.
Yes/no
Yes/no
Yes/no
16.
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