Sandra R. Jungers, RN, BSN, MEd McArtor Neonatal Symposium Friday, May 15, 2015 Disclosure: —  President and Clinical Consultant –The Bimeco Group, Inc. Medical Sales and Distribution —  Clinical Consultant for DandleLION Medical —  Clinical Consultant for Draeger Medical, Inc. OBJECTIVES: —  Upon completion of the this lecture/demonstration the participant will be able to: —  Assess the positioning needs of the neonate to promote midline orientation and proprioception —  Discuss the benefits of appropriate developmental positioning: self calming; decreasing stress; improve oxygenation; and establish sleep patterns —  Position infants in a prone, side-­‐lying and supine position with appropriate supports and be able to apply the principles of developmental supportive positioning “My” Famous Quote… “ All truth passes through three stages: First, it is ridiculed Second, it is violently opposed Third, it is accepted as being self evident.” Arthur Schopenhauer (1788-­‐1860) Core Measures for Trauma-­‐Informed Age-­‐Appropriate Care Coughlin et al 2009; Coughlin 2011; Coughlin 2014 Age Appropriate AcFviFes of Daily Living —  Positioning and Handling —  Feedings —  Skin Care —  Partnering activities with parents IMPORTANCE of POSITIONING —  Provides the building blocks to promote physical development —  Self organization —  Improves sleep quality —  Conserves body heat and reduces energy expenditure —  Encourages midline and coordination —  Optimizes respiratory function —  Assists in visual skills PosiFoning and Handling —  Positioning effects —  Musculoskeletal development —  Neuromotor development —  Physiologic function and stability —  Thermal regulation —  Skin integrity —  Bone density —  Energy expenditure and growth —  Sleep facilitation All impact growth and brain development The Womb… —  Physiologic Flexion —  Head/neck midline —  Shoulder protraction —  Hands Midline and to mouth —  Posterior pelvic tilt —  Flexed upper extremities as well as lower —  Containment —  Foot bracing The Womb… —  Proprioceptive input —  Tactile input —  Muted sensory —  Mom’s rhythm —  Physiologic flexion – will Increase with gestational age Early Musculoskeletal Development —  Third week – day 20 —  Mesoderm begins to form somites —  Somites differentiate into: — 
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Sclertome (vertebrae / ribs) Dermomyotome (skin / muscle) —  Fourth week – day 21 to 28 —  Verterbral column developed —  Day 26 – limb buds appear Musculoskeletal System Development —  Five to Twenty weeks —  Skeletal muscles emerge —  Seven weeks —  Early Movements of the embryo at 7.5 weeks slow neck extension present —  Nine weeks —  General movements Musculoskeletal System Development Thirteen to Fifteen weeks — 
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Non-­‐nutritive sucking begins The VLBW and LBW infant presents us with an immature musculoskeletal system. Musculoskeletal System… —  Shaping of this system begins on admission —  System process continues during hospital stay —  Observations of early posture and movement are seen by caregivers —  Enhance appropriate motor development —  Prevent or minimize musculoskeletal issues Inappropriate Handling —  Contributes to undue stress and disorganization —  Hypoxia —  Increased intracranial pressure —  Vestibular over stimulation —  Average NICU Patient: —  130 care givers during stay —  Handled 82 times per day for medical reasons —  Handled an additional 132 times for other reasons Developmental Handling —  Slow gentle movements —  Provide containment —  Provide supports —  Eliminate unnecessary procedures and “routines” that have no benefit —  Co-­‐Bedding —  “Kangaroo Care” – skin to skin holding Our VLBW and LBW infant… —  Gestational age from 23 to 32 weeks —  Unable to overcome the forces of gravity —  Up to 28 weeks – completely hopotonic and lacks all physiologic flexion —  At 32 weeks – hips and knees begin to show some flexion while arms are extended —  36 weeks flexion present Musculoskeletal Development impacted by… —  Handling —  Positioning —  Caregiving Interventions Developmentally Appropriate —  Handling and Positioning should be implemented during the following: —  Admissions —  Assessments / Exams —  Procedures —  Transports —  Weights —  Feedings —  Bath Time —  Kangaroo Care / Skin to Skin Developmental Handling —  Slow gentle movements —  Provide containment —  Provide supports —  Eliminate unnecessary procedures and “routines” that have no benefit —  Co-­‐Bedding —  “Kangaroo Care” – skin to skin holding Containment / Firm posiFve touch Principle of AcFvity-­‐Dependent Development —  “Use it or loose it” framework —  Intrauterine environment constantly reinforces extremity flexion and midline orientation of the normal fetus —  The premature infant in the NICU that has no boundaries has active extension without reinforcement to return to flexion and midline Impact of Gravity Undeveloped
flexor tone
Absence of
musculoskeletal
support
Goals for Developmentally SupporFve PosiFoning… —  Maintenance of proper body alignment (midline orientation, flexion, & containment) —  Provide musculoskeletal support for ongoing growth and development. —  Provide comfort and security through pressure support from containment and facilitating hands to face for self-­‐soothing. —  Promote rest. Improper PosiFoning… —  Hip external rotation problems —  Negative cranial molding —  Shoulder retraction —  Delay in motor development —  Decreased lung, tidal volume affecting oxygenation —  Negative impact on parent-­‐infant bonding —  Altered self image as the child matures Unsupported posiFon in the NICU —  Flattened, abducted —  Externally rotated —  Gravity —  Dominance of extensor tone —  Lack of boundaries ImplementaFon of Appropriate PosiFoning… —  Initiate on admission —  Avoid complacency in positioning —  Educate staff on the physiololgic and developmental benefits to the infant —  Adopt as a unit based standard of care —  Opportunity to enhance your personal practice and make a difference ImplementaFon… —  “Nest” that offers comfortable and secure boundaries – simulate the intrauterine environment and its benefits —  Swaddling —  Appropriate sized diapers —  Protocol for repositioning —  Awareness of behavioral cues and interventions Common PosiFoning Problems… —  No prone support —  No posterior pelvic tilt —  No foot support —  No humeral support —  Hands out -­‐ not to face and mouth —  Bundled too tight – no ability to move —  Neck hypertension PosiFonal Development… —  Head Position —  Infants prefer head turning to the right —  Torticollis —  Lateral trunk curvature —  Deformational Plagiocephaly Abnormal head shape from prenatal or postnatal external molding forces —  Dolichocephaly — 
Narrow and elongated “preemie shaped” head Developmental Delays… —  Head / Neck Alignment affects: —  Head shaping — 
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Brachycephaly (posterior head flattening) Plagiocephaly (bulge in posterior quadrant with bulge in opposite anterior quadrant) Scaphocephaly —  Head centering and midline activities —  Head control in prone and sitting positions —  Limited downward visual gaze —  Long term developmental implications Improper PosiFoning – Developmental Delays… —  Shoulder girdle alignment affects: —  Midline activities —  Weight bearing on elbows —  Reaching —  Sitting —  Shoulder rounding —  Rolling —  Arm and shoulder instability in prone —  Weight bearing on hands – later issues with handwriting and fine motor coordination Developmental Delays… —  Pelvic tilt and hip alignment affect: —  Weight bearing —  Rolling over —  Crawling —  Sitting —  Weight bearing —  Balance —  Gait PosiFonal DeformiFes… —  “Frog” Leg —  Everted feet (turned out) —  Hyper extended neck and retracted shoulders —  Abnormal head shaping Developmental Delays…PosiFonal DeformiFes… —  “Frog Leg” — 
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Ability to transtion in/out of prone and sitting Hip stability in 4-­‐point crawl Prolonged wide-­‐based gait Excessive “out-­‐toeing” gait —  Everted Feet — 
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Increased out-­‐toeing Immature foot flat pattern with delay in heeltoe pattern —  Hyper extended neck and retracted shoulders —  Abnormal head shaping Developmental Delays… —  Foot alignment / foot bracing affects: —  Tibilal torsion —  Ankle eversion —  Foot pronation —  Proper weight bearing —  Gross motor activities — 
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Walking Running Developmental Delays… —  Overall extensor pattern —  Toe Walkers —  Insufficient play in prone —  Restricted mobility at the pelvis, scapulae, hips, feet and elbows Supported PosiFoning… —  Flexed —  Head in midline – neutral neck —  Shoulder protraction —  Hands to midline / mouth —  Posterior pelvic tilt —  Neutral hips and feet —  Boundaries with freedom of movement —  Tactile input —  Vary positions – continue to maintain and support flexed posture WHY???? SupporFve PosiFoning… — 
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Promotes physiologic stability Increases O2 sats and decreases HR and RR Promotes deep sleep Facilitates different levels of consciousness and stability Promotes self-­‐regulation Reduces stress Provides proprioceptive, tactile, and visual stimuli ? Decreased need for analgesics / sedatives Promotes ossification and bone density Decreases risk for: — 
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skeletal deformities muscle shortening mobility issues Midline Head PosiFon… —  Can help to prevent IVH —  Contributors to IVH — 
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Antenatal steriod use Resuscitation methods Pharmacological interventions Thermoregulation Positioning of head —  Prevention —  Midline / neutral head —  30° degree HOB elevation for first 72 hours of life <32 weeks GA in addition to medical practices SupporFve PosiFoning can be implemented with… —  Positioning Aids: NEWEST to the market… —  DandleLION Roo’s – Roo 2 —  DandleLION Wraps – Regular / Lite —  PALS – positioner Previous and current generation… —  Snuggle-­‐Up —  Bendy Bumper (baby / regular) —  Bean Bag positioners – Fred the Frog —  Gel Pillows —  Z-­‐FLOW —  ZAKY —  THE STANDBY -­‐ Blanket Rolls Developmentally Appropriate PosiFoning… —  Provides for midline orientation —  Hands to Mouth —  Proper flexing of hips, shoulders, ankles, head and neck —  Self soothing and self regulating behavior —  Appropriate development —  Reduction in long term healthcare costs Medical and Developmental ConsideraFons in PosiFoning… —  Medical Stability a top priority —  Developmental support is necessary —  Education brings awareness —  Positioning —  Improves physiologic stability’ —  Increases infant comfort —  Minimizes positional deformities —  Facilitates optimal muscle tone and movement KANGAROO CARE… —  Implementation and practice needs implementation in all NICU’s —  Improves state organization —  Reduces oxygen needs, improves respiratory patterns —  Reduces apnea and brady’s —  Improves thermal regulation —  Enhances parent infant bonding, parental sense of competence —  Enhances cognitive and motor development Skin-­‐to-­‐Skin or Kangaroo Care FLEXION THE KEY TO EARLY MOTOR DEVELOPMENT IN THE PRETERM INFANT REMEMBER… —  Do not leave the preterm infant immobilized for long periods of time —  Prolonged exposure to static flattened positions/
postures lead to numerous deformities —  Influences of gravity cannot be overcome by the infant alone Summary —  Optimize alignment —  Support posture and movement with “containment boundaries” —  Individualize positioning and handling —  Appropriate positioning and handling promotes state regulation as well as sleep states so as to promote growth NICU is a TraumaFc Life Event… —  What do we need to do… —  Clinicians have got to be better prepared clinically and emotionally —  Evidence Based Practice should be mandated — 
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This incorporation into practice will minimize and mitigate the associated toxic stress and will favorably impact long term mental health outcomes. Muscular-­‐skeletal issues will have better outcomes which will enhance the mental health issues – mobility and independence ConfronFng Colleagues PosiFoning Techniques —  Supine —  Avoid neck rolls —  Round shoulders forward and place elbows in flexion —  Hips partially flexed and adducted toward midline —  Knees partially flexed with feet inside boundary so as to promote foot bracing PosiFoning Techniques —  Prone —  Neutral alignment of head and trunk —  Use of a prone roll to promote flexion (top of the head to the umbilicus) —  Stable boundaries to assist the infant to maintain a secure balanced position —  Secure lower boundaries to provide for foot bracing Sidelying —  Facilitates midline orientation —  Encourages hand to hand and hand to face and mouth activity —  Concerns by some as this position may promote atelectasis —  Provide boundaries and do not trap the bottom arm —  Hugging a item will facilitate forward tucking Begin the movement to change… Make a difference… Why is this important? —  500,000 preterm infants are born annually —  Prematurity and survival rates continue to rise —  $26.2 billion in societal cost annually for prematurity —  Unfavorable environment in the NICU can negatively affect brain growth and development —  Follow up studies are consistently finding reduced cognitive performance and increased behavioral problems Plato THANK YOU —  QUESTIONS and DISCUSSION