For comfort and development
- Poor positioning may cause:
- discomfort
- disturbed sleep
- physiological instability
- impaired cerebral blood flow
- increased intracranial pressure
- increased gastro-oesophageal reflux (GOR)
- poor thermoregulation
- compromised skin integrity
- flattened elongated head shape and postural deformities
- inability to interact socially
- poor parental perception of baby
- stress
- increased desaturations and bradycardias
- Positions described below aim to minimise these effects
Positions
- Consider for all, including ventilated babies. See also Kangaroo care guideline
| Position |
Use for |
Method |
| Prone |
- Respiratory compromise
- GOR
- Unsettled babies
- Older babies to encourage physical development – active neck extension, head control and subsequent gross motor skills. When awake/alert only, in response to cues
- Lifting
- Reducing the frequency of bradycardia and desaturations in very preterm babies
- Reducing the frequency of desaturations in preterm babies
|
- Tuck limbs with arms forward and hands near to face for self-calming
- Provide head support
- Place small, soft roll under baby from head to umbilicus to allow a rounded, flexed posture (prevents flattening of trunk and shoulder retraction – ‘W’ position)
- Support with good boundaries to prevent excessive hip abduction (‘frog’ position)
- Avoid neck hyperextension
- Always monitor a baby when in prone position. Give parents/carers information about FSID recommendations before discharge
|
| Supine |
- Some surgical and medical conditions
- Older babies ready for interaction
- Intubated babies where midline head support necessary (e.g. for cooling)
- Most difficult position for babies to work against gravity for self-calming and development of movement
- Safest sleeping position for babies not monitored – promote supine sleeping and feet-foot position before discharge
|
- Provide supportive boundary to allow hands-to-face/mouth for self-calming and prevent shoulder retraction (‘W’ position)
- Provide head support
- Avoid excessive neck rotation (impairs cerebral blood flow)
- If required, neck roll must be small and soft to avoid restricting cerebellar blood flow
|
| Side-lying |
- Most babies
- Best position for self-regulation and calming behaviours
- Left side-lying reduces GOR
- Lifting
- Use elevated side-lying position for preterm, hypotonic or babies with chronic lung disease or neurological impairment when learning to bottle feed
- May be appropriate for other medical conditions where increased risk of aspiration
|
- Provide back support. Gently curl back, flex hips and knees. Avoid excessive flexion which may impair respiration and digestion
- Position with feet against boundary to facilitate foot bracing
- Keep head in midline
- Keep upper shoulder slightly flexed to prevent baby falling backwards
- Support arms in midline, with hands close to face – use straps of nest/soft sheet. Give baby small soft toy/roll to ‘cuddle’ to support upper arm
|
| Sitting |
- Near term ready for more interaction/stimulation
- GOR
- Encourages midline position, chin tuck, eye/hand co-ordination
|
- Use reclining baby seat
- Maintain midline position – use blanket rolls to prevent slumping, asymmetry and plagiocephaly
- Keep hips in middle of seat
- Place padding behind back (from shoulder level) to allow head to rest in line with body
- Tuck rolls under shoulders to bring arms forward
- Avoid over-stimulation. Do not place objects too close to baby’s face
|
|
Car seats
(information for parents)
|
- Small and preterm babies are at risk of breathing difficulties while travelling in car seats
|
- Fasten straps before tucking blankets around baby
- Use inserts only if recommended/approved by car seat manufacturer
- Advise parents to refer to RoSPA website https://www.rospa.com/road-safety before purchasing car seat
- Advise parents to keep time baby spends in car seat to a minimum and observe closely during journey
|
Comfort score
- Observational tool to assess positioning as a guide to promote comfort and minimise postural deformity
| |
Least comfortable |
|
Most comfortable |
| 1 |
Aah! Factor |
Baby looks uncomfortable (include facial expression and colour) – you feel you want to do something about it |
0 |
1 |
2 |
3 |
4 |
5 |
Baby looks relaxed, comfortable, cosy, content
|
| 2 |
Head and trunk |
Trunk arched/rotated or curved with
a) Head extended or
b) Chin on chest or
c) Head flat to side with twisted neck
|
0 |
1 |
2 |
3 |
4 |
5 |
Head and trunk in line, with head in midline or three-quarters toward side of head (neck not fully twisted) |
| 3 |
Arms |
Flaccid or stiff, and stretched out or:
a) ‘W’ position with shoulders retracted (pushed back) or
b) Twisted/trapped under body or between body and bedding or immobilised
|
0 |
1 |
2 |
3 |
4 |
5 |
All the following:
a) Shoulders forward
b) Arms flexed or relaxed
c) Possible to reach mouth or face with ease
|
| 4 |
Hands |
a) Fingers splayed or
b) Hands tightly fisted or
c) Immobilised or restricted by clothing |
0 |
1 |
2 |
3 |
4 |
5 |
≥1 of the following:
a) Hands relaxed, open, or fingers softly folded
b) Hands together or clasped
c) Touching head/face/ mouth/own body
d) Holding/grasping onto something
|
| 5 |
Legs and feet |
a) Flaccid, with straight or ‘frog-like’ posture (abducted and externally rotated at hips) with feet pointing outwards or
b) Stiff, straight legs with toes splayed or curled tight, and/or pushing hard on bedding, turning outwards |
0 |
1 |
2 |
3 |
4 |
5 |
In all positions:
a) Flexed legs with feet touching each other, or resting against other leg and
b) Able to reach boundary to brace feet
In prone position, knees should be tucked under body, feet angled towards each other (not turning out)
|
| 6 |
Arousal |
a) Agitated, jerky, jittery movements and/or
b) Fussing or crying
c) Unconscious |
0 |
1 |
2 |
3 |
4 |
5 |
a) Sleeping restfully or quietly awake
b) Minimal or smooth movement |
| |
Total |
|
|
|
|
|
|
|
(Max score = 30) |
Reproduced with permission (Inga Warren, consultant occupational therapist, Winnicott Baby Unit)