The Developmental Effects of NICU Positioning
Condition: Premature Birth of Newborn
MeSH terms: Premature Birth
Study type: Interventional

Summary: 
      The purpose of this study is to investigate the developmental effects of two different types
      of positioning used with premature infants in the neonatal intensive care unit.
    

Detailed description: 
      Infants born prematurely have a high risk of developmental impairment. Subsequently, preterm
      infants are often seen by therapy services in the neonatal intensive care unit and are often
      recommended for early intervention services at discharge. One of the earliest interventions
      for preterm infants in the Neonatal Intensive Care Unit (NICU) is positioning, as altered
      positioning can have a significant impact on later function.

      Preterm infants have a positioning disadvantage from early on in their development. The final
      trimester of pregnancy promotes the flexed position, when the infant is crowded by the
      uterine environment and experiences rapid brain growth, mediating flexion and midline
      orientation. When infants are born too soon, they miss the in utero flexion positioning. They
      lack the central nervous system maturity to enable flexion and do not have the tone and
      strength for movement against gravity. In addition, preterm infants are confronted with
      altered sensory experiences, resulting from static, extended positioning and environmental
      factors associated with life and medical interventions outside the womb. Therefore, early
      transition to the extrauterine environment is a challenge for premature infants, as they face
      overwhelming sensory stimuli that their bodies are not yet prepared to process.

      It has been demonstrated that the positioning of the preterm infant differs from that of a
      full term infant. The tightly flexed positioning of a full term newborn is called
      physiological flexion. It involves symmetrical flexion of the extremities, shoulder
      protraction, and posterior pelvic tilt.

      Physiological flexion has developmental importance. This positioning enables infants to
      remain motorically and physiologically organized and facilitates self-soothing and
      self-regulation behaviors, such as sucking and hand to mouth contact. The flexed position
      provides the infant with a sense of containment and security, which mimics the intrauterine
      environment. In addition, physiological flexion is associated with greater extremity contact
      with the trunk, which imitates the womb and gives infants sensory feedback.

      The benefits of early physiological flexion can have long term benefits on development. Many
      neonatal reflexes, such as upper and lower extremity recoil, palmar and plantar grasp, and
      pull to sit are mediated by flexion response. These early flexion responses form the
      foundation for later movement acquisition. Physiological flexion also promotes later
      development of normal balance and posture. Ideal posture supports the development of head
      control, sitting, crawling, walking, transferring from one position to another, and
      manipulating objects. Due to missing the third trimester, preterm infants are at risk for
      assuming suboptimal positions, thus missing the early benefits of physiological flexion.

      In utero, fetuses experience attenuated stimuli. Therefore, sensory experiences outside the
      womb are overwhelming for infants born prematurely (3). As a result, preterm infants are
      easily stressed, particularly when they are not properly positioned.

      Stress can produce severe consequences in the preterm infant including respiratory problems
      and intraventricular hemorrhage. Infants in an unsupported position may have frantic
      movements and startles in response to stress, and therefore have difficulty achieving the
      deep sleep state necessary for growth and brain development. This can lead to extended
      hospital stays. Optimal positioning enables premature infants to better cope with stressors
      and bring their hand to face and mouth for self-soothing.

      Positioning aids in the past have aimed at promoting containment and increasing flexion.
      However, the ability to promote flexion while enabling infant movement remained problematic.
      The new Dandle Roo and Dandle Wrap were developed by NICU professionals to support the
      neurodevelopment of the preterm infant. The Dandle Roo/Wrap provides all around contact,
      containment, and proprioceptive input, (which more closely mimics the uterine environment)
      and can decrease excitability and promote self-regulation, while also allowing for movement
      with recoil back to flexion.

      Despite the current evidence on effective positioning interventions for preterm infants, a
      recent meta-analysis on developmental care cited a need for more research of specific
      interventions, such as positioning, on short-term and long-term clinical outcomes. No studies
      to date have examined the effects of the new Dandle Roo and Dandle Wrap on clinical and
      neurobehavioral outcomes in preterm infants. Therefore, we propose a randomized controlled
      trial of the new Dandle Roo/ Dandle Wrap, postulating that infants positioned in the Dandle
      Roo/Dandle Wrap will experience beneficial effects.

      Objectives:

      Hypothesis - Preterm infants positioned in the Dandle Roo and Dandle Wrap will experience
      better neurodevelopmental outcome, less brain injury and need for respiratory support, and
      shorter hospital stays than infants positioned in traditional NICU positioning aids.

      Specific Aim - To conduct a randomized controlled trial on the effects of the Dandle
      Roo/Dandle Wrap versus traditional NICU positioning administered from birth through discharge
      from the NICU on neurodevelopmental outcome, brain injury, need for respiratory support, and
      length of stay in infants born less than 32 weeks postmenstrual age (PMA).

      Subjects: A power analysis revealed that 86 infants were needed to detect a difference in
      neurobehavioral outcome following a positioning intervention. To account for attrition, 100
      infants will be recruited.

      Inclusion Criteria - This is a prospective cohort with premature infants who are born at 32
      weeks or less PMA. This cohort will be hospitalized in the NICU at St. Louis Children's
      Hospital or the Barnes Special Care Nursery in St. Louis, Missouri and will be recruited
      within 72 hours of birth.

      Exclusion Criteria - Infants with a known or suspected congenital anomaly at birth and
      infants who are moribund with severe sepsis or respiratory distress defined as physiologic
      instability requiring >80% FiO2 for 6 hours and/or more than 2 ionotropic drugs (excluding
      hydrocortisone), or in the attending or recruiting physicians' opinion the infant is likely
      to expire within 24 hours or would not tolerate any handling for the protocol

      Randomization - As soon after birth as possible, but no later than 1 week after admission,
      consecutive new admissions meeting the inclusion criteria will be recruited for the study.
      Upon parent's signing the informed consent, an infant will be randomly assigned to either
      Dandle Roo/Dandle Wrap positioning or to traditional NICU positioning for the entire length
      of stay.

      The positioning protocol assigned to each study infant would be clearly posted at each
      infant's bedside. Members of the research team would routinely check in to ensure that
      infants in the treatment arm were positioned correctly in the Dandle Roo/Dandle Wrap and to
      answer any questions. In addition, a log sheet would be placed at the infant's bedspace for
      each nursing shift. Here nurses would be instructed to identify if the infant was positioned
      in the assigned positioning aid and would be able to identify reasoning if the positioning
      was not implemented during a specific shift.

      Positioning protocols would be utilized during times when the infant is resting in the crib,
      isolette, or open warmer. However, the infant would be taken out of the positioning aids
      periodically for hands on care, for bedside evaluation, or to enable closer observation
      during acute episodes. In addition, parents could take the infant out of the positioning for
      holding and interaction.

      Clinical Data Collection:

      For all infants enrolled, routine clinical information from the infant's medical record would
      be accessed.

      In addition, each infant would undergo neurobehavioral testing by a member of the research
      team during the hospitalization. One trained and certified evaluator will conduct all
      neurobehavioral tests on all study infants. Testing would be conducted between 35 weeks
      gestation and 41 weeks gestation. Neurobehavioral assessment that will be used is the
      Neonatal NICU Network Scales (NNNS). Scores range from 0-13 in the following subscales:
      habituation, attention, handling, arousal, regulation, quality of movement, reflexes,
      asymmetrical responses, hypertonicity, hypotonicity, stress/abstinence signs. High scores are
      optimal on the following subscales: habituation, attention, regulation, and quality of
      movement. Low scores are optimal on the following subscales: handling, arousal, reflexes,
      asymmetrical responses, hypertonicity, hypotonicity and stress/abstinence signs.

      Developmental testing would only be conducted on infants who were medically stable and able
      to tolerate the exam. Video taping of each neurobehavioral assessment will be performed and
      stored anonymously. Videotapes will be conducted to enable close observation of the infant
      during the evaluation process with later scoring of the test from the videotape. In addition,
      testing from the ongoing developmental follow up clinic (Washington University Neonatal
      Developmental Follow-Up Clinic) would be accessed for outcomes at 6 months, 1 year, 2 years,
      and 3 years, when available.

      Dissemination of results:

      The findings from this research will be:

        -  Published in peer review scientific medical literature

        -  Presented at local and international conferences

        -  Disseminated, at the end of the study period, to all parents whose infants were enrolled
           in the study who expressed interest in the study outcome.

      Potential Benefits:

      Ideal neonatal positioning may improve neurodevelopment and decrease brain injury and need
      for respiratory support, with subsequent better developmental outcome. Optimizing positioning
      and facilitating more optimal in utero positioning during this time period could result in
      shorter hospital stays, decreasing expenditure of healthcare dollars. Early neurobehavioral
      testing, which is part of the study protocol, can enable parents to better understand the
      strengths and weaknesses exhibited by their infant to enable early therapeutic interventions.
      Benefits to society include a better understanding of effective positioning in the NICU as
      well as a possible understanding about how early positioning can be critical for later
      function.

      A member of the research team will conduct a comprehensive developmental test on the infant
      during the NICU stay. Parents will be informed of test results prior to or at NICU discharge.

      The WUNDER research group will be continuously reviewing the data results as they return and
      report any adverse effects monthly to the St. Louis Children's Hospital Neonatal Intensive
      Care Unit Joint Practice Committee. The biostatistician will also independently review data
      results and report any significant adverse effects monthly to the WUNDER research group and
      the Joint Practice Committee. All serious adverse events will be reported to the IRB: a)
      death - immediately; b) life-threatening within 7 calendar days; c) all other significant
      adverse events (SAEs) within 15 calendar days using the Electronic SAE System.

      Data Analysis:

      Data will be analyzed using linear and logistic regression models by a biostatistician. Data
      will be reviewed throughout the duration of the study. All data will be maintained in the
      strictest confidence and will only be available to members of the research team. It will be
      held in secure format in password-protected computer records. Hard copy and the records will
      be identified only by study number and stored in a locked file cabinet. A log of study number
      and identifying data will be kept by the site PI in a separate locked file cabinet. All file
      cabinets containing data are inside a locked office in a corridor accessible only with badge
      access.
    

Intervention name(s): Dandle Roo/Dandle Wrap; Traditional NICU Positioning
Intervention type(s): Device; Other
Intervention description(s): Infant remains in the Dandle Roo/Dandle Wrap throughout the NICU stay when the infant is lying in the isolette or crib, but is taken out for hands on care times or when held.; These methods aim at providing containment and flexion and may consist of interventions such as swaddling, use of boundaries around the infant, rolled blankets, Snuggly®, or Bendy Bumper®
Other intervention name(s): Dandle Roo; Dandle Wrap; Snuggly®; Bendy Bumper®
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: preterm