BRIEF OR NEW
S a clinical concern of many therapists, nurses,
Positional Support for
Pren1atLlre Infants
Carolyn Updike, Rosemary E.
Schmidt, Cheryl Macke, Judy Cahoon,
Mary Miller
Key Words: infant care. positioning
Carolyn Updike, OTR/L, is a staff therapist, Rehabilication
Medicine Depanmem, Good Samaritan Hospital, 3217
Clifton Avenue, Cincinnati, Ohio 45220-2489.
Rosemary E. Schmidt, MD, FAAP, is Director, High Risk
Newborn Follow-Up Program, Good Samaritan Hospital,
Cincinnati, Ohio.
Cheryl Macke, PT, Judy Cahoon, PT, and Mary Miller
OTR/L, are staff therapists, Rehabilitation Medicine De-
panmem, Good Samaritan Hospital, Cincinnati, Ohio.
712
Downloaded from http://ajot.aota.org on 12/28/2020 Terms of use: http://AOTA.org/terms
upported positioning ~or the premature infant is
and developmental pediatricians involved in
the care of infants in the newborn special care unit
(NDSCU). The global hypotonia normally observed
in the infant born prematurely at 28 to 30 weeks'
gestation enables gravity to have profound effects.
Without the liqUid milieu of the uterus, motility,
which would be typical in utero, is difficult to achieve
(Saint Anne Dargassies, 1979). Enhancing normal
movement is a challenge to occupational and physical
therapists who are experienced in the art of pOSition-
ing as a treatment technique. Understanding tonal
influences on posture and development is extremely
helpful in enabling the therapist to assist the prema-
ture infant in experiencing flexion as would a full-
term infant.
Positional disorders of postnatal origin are dis-
cussed by Desmond (1980). Prolonged immobiliza-
tion on a firm surface, along with the continuing
influence of gravity, results in a flattening of the body
against that surface. The following nursery-acquired
positional disorders may result:
1. A "frog-leg" position of the lower extremities,
which includes wide hip abduction, external rotation,
and ankle eversion. This pOSition is disadvantageous
for later weight bearing.
2. Shoulders that tend to retract and abduct with
the upper extremities in lateral flexion (a "w" posi-
tion) Persistence of this position reduces the ability
to rotate the shoulders forward, allOWing the hands
to approach each other at midline. This movement
precedes "hand regard" and "reaching to grasp"
3. Progressive head flattening, which is due to
the weight of the large head resting laterally on the
surface because of poor neck muscle tone. The sig-
nificance of a misshapen head is more than cosmetic.
The normal rotation of an el1iptical head in the supine
pOSition is difficult as the infant matures and neck
muscle tone improves.
4. Increased neck hyperextension and shoulder
elevation (Anderson & Auster-Leibhaber, 1984),
which may develop in infants with severe respiratory
distress syndrome (RDS) who have experienced pro-
longed supine positioning on ventilators.
These malpositions may be reduced by fre-
quently changing and supporting the resting infant in
prone, supine, and sidelying positions. Providing the
infant with the opportunity to feel movement in a
variety of positions is optimal. Premature infants often
demonstrate difficulty tolerating certain pOSitions.
The therapist then uses joint approximation, move-
ment, and stabilization techniques to prepare the
child to handle the position. The ability of the infant
to rest in neutral flexion is desired in prone, supine,
October 1986, Volume 40, Number 10
 and sidelying positions. The goals of positioning the Figure 2
premature infant are as follows: Infant Without Supine Support Pillow

• to stimulate active flexion of the trunk and

limbs,
• to achieve more rounded heads and active
head rotation,
• to encourage more balance between flexion
and extension,
• to allow for more symmetrical postures,
• to enhance midline orientation which contrib-
utes to eye/hand/mouth control, and
• to facilitate smooth antigravity limb movement.

Along with achieving these goals, a frequent outcome

of good positioning is enhanced comfort and reduced
stress. "Ex-utero, the fetus is compelled to fight and
adapt" (Saint Anne Dargassies, 1979, p. 45). Place-
ment on soft surfaces in a neutral flexed position has
been effective in quieting and comforting premature
infants in the NBSCU at Good Samaritan Hospital.
The use of positional aids has also been effective in
achieving the positioning goals. The aids that have
been used are lambskin, supine support pillows, Pre-
mie Comfort Pads, and water beds.
Supine Support Pillow
This pillow was designed by the therapists at Good
Samaritan Hospital after infants who showed frequent
irritability had been observed in extremely poor su-
pine positioning J Two-inch foam hospital bed level-
Figure 1
Supine Support Pillow
~._------
ers are used to make these pillows. The foam is cut
out in the middle, forming a nest for the infant's trunk
and head. The foam is contoured to slope gently
under the scapulae to assist the infant in fleXing the
upper extremities toward midline. The hips are sup-
ported in flexion, and the lower extremities chan-
nelled in slight abduction. The horseshoe-shaped
head support allows for head rotation (see Figure 1).
Infants demonstrate a dramatic difference in their
movement patterns as they are assisted in confronting
gravity when positioned on the pillow. The infant
photographed (see Figure 2) demonstrates the classic
difficulty of the premature infant in trying to achieve
and sustain symmetrical flexion in a supine position.
With support, the infant can move and relax into
flexion (see Figure 3).
Vinyl material was used to cover the foam in the
pillows. Disinfectant spray is used to clean the pil-
lows. The pillows are encased in quilted slip covers
while in use.

Lambskin
Flexion in prone and sidelying positions can be
achieved on naturallambskin 2 The tactile stimulation

I For more information on these pillows, interested readers

may contact the Ohio Medical Instruments Co., 315 W
Libert)' Street, Cincinnati, Ohio 45214
2 SUc/; lambskin can be purchased Fom Babycare Lamb-
skins, Baby Lamb Products, Inc, 31 Drakewood Lane,
Novato, California 94947

The American Journal of Occupational Therapy 713

Downloaded from http://ajot.aota.org on 12/28/2020 Terms of use: http://AOTA.org/terms
 Figure 3
Infant on Supine Support Pillow
from the lambskin facilitates flexion, especially in the
prone position. Placing water pillows made from
sealed plastiC bags under the lambskin helps to re-
duce the effects of gravity (see Figure 4)
In a side lying position, support across the pelvis
with a folded diaper can provide the key stabilization
that helps the infant sustain flexion. A folded diaper
between the infant's legs allows for neutral lower
extremity positioning. The infant can easily achieve a
hand-to-mouth pattern in this position. Additional
proprioceptive input along the back, buttocks, head,
or abdomen can be comforting and can quiet the
infant This can be achieved by positioning the infant
against blankets or lambskin rolls next to the isolette
walls or corners.
At times the infant may prefer the touch of lamb-
skin over that of the supine pillow and he or she may
be more content in a supine position on the lambskin.
Rolled blankets can be used to support these infants
in neutral flexion on the lambskin.
fants (weighing from 1,000 to 1,500 grams), espe-
ciallv those on ventilators. These very tiny infants
mus; be positioned very carefully to prevent neck
hyperflexion.
Laundering and cleaning techniques for all of
these positional aids have been approved by the In-
fectious Disease Control Department of this hospital.
The nurses have implemented the use of these aids
into their daily routine, and therapists are finding
them effective treatment aids. When the positional
aids are used, careful attention must be paid to the
infant'S medical status and feeding schedule. Com-
munication between the therapists and the medical
staff is essential for effectively monitoring the infant'S
responses. Supine positioning primarily occurs ap-
proximately V2 hour before feedings. Neutral align-
ment, comfort, and proper timing appear to reduce
the chances of aspiration. Aspiration at this facility has
not been associated with supine positioning. Respi-
ratOry function is monitored closely when infants who
are in the acute stages of RDS are put in the supine
pOSition. At times, these infants appear to tolerate
prone positioning better than supine or sidelying
positioning. Nursing regulates positioning in such
cases.
Summary
This paper identifies positional disorders and tonal
abnormalities that are associated with immobilization
and the effects of gravity on the preterm infant Inter-
vention methods to reduce these abnormalities focus
on assisting the infants in achieving movement into
Figure 4
Infant Flexed on Lambskin and Water Pillow

Premie Comfort Pads

These are pillows filled with polystyrene beads; they
are like large bean bags. 3 Infants can be positioned
in a supine, siclelying, or prone position on this pad.
It has a variable surface, however, and skill is required
for optimal positioning. Presently, we find these pads
most useful in positioning very small premature in-

.~
The Premie Comfort Pad (patent pending) can be ob-
tainedfrom Patient Comjol-t Products, 3745 Purdue Street,
Dallas, Texas 75225.

714 October 1986, votume 40, Number 10

Downloaded from http://ajot.aota.org on 12/28/2020 Terms of use: http://AOTA.org/terms
 neutral flexion in prone, supine, and sidelying posi-
tions. Specific positional aids are discussed that help
reduce head flattening, enhance movement into flex-
ion, ancl enhance comfort while the infants are in the
NBSCU.
Acknowledgments
The authors thank Linda McEntyre, LPT, a former member
of the Pediatric Developmental Assessment and Therapy
Program team, who provided insights and ideas for posi.
tioning infants and for developing the pillow.
References
Anderson, ]., Auster·Leibhaber, J (1984). Develop·
mental ther<1PY in the neonatal intensive care unit. Physical
and Occupational Therapy in Pediatrics, 4(1), 89-106.
Desmond, M. M, Wilson, G S, Alt, E.]., & Fisher, E.
S (1930). The very low birth weight infant after discharge
from intensive care. Anticipatory Health Care and Devel-
opmental Course. Current Problems in Pediatrics, 10, 5-
59
Saint Anne Dargassies, S. (1979) Normal and patholog·
ical fetal behavior as seen through neurological study of the
premature newborn. Contrihution to Gynecology and Ob-
stetrics, 6, 42-56.

An Insightful, Practical Occupational

Exploration of the Role of
Learning In All Forms of Therapy Therapy Manpower:
Offering a broad theoretical perspective
A Plan for Progress
drawn from basic neurosciences and A report of the Ad Hoc CommiSSion on
psychology, Therapy as Learning by Richard K. Occupational Therapy Manpower of the
Schwartz presents a clear and comprehensive American Occupational Therapy Association
overview of the nature of the learning process Drawing on a broad range of social, health
and its important implications for both thera- care, economic, political, and educational
pist and client.
perspectives, this report represents a com-
Filled with practical suggestions for using prehensive profile of the occupational thera-
learning to improve py profession in the 1980s.
the quality of thera-
py, this book is
-- An invaluable resource guide and reference
a valuable and tool, Occupational Therapy Manpower pro-
necessary addition Therapy vides data on demographic and employ-
to the therapiSt's as . ment characteristics, geographic distribution
of manpower, and trends in education, prac-
professional library I.2arnlng tice, certification, and licensure.
139 pp. Soft cover. llIustrated
$17.00/A01A members; gr<llard K SdriJ'art: 84 pp Soft cover Illustrated.
$21.50I1olllnel11bers. $700IAOTA members, $900lnonmembers
Order from: AOTA Products
Order from: AOTA Products
1383 Piccard Drive
P.O. Box 1725 1383 Piccard Drive, PO Box 1725
Rockville, MD 20850-4375 Rockville, MD 20850-4375

The Americarl journal of Occupatiorlal Therapy 715

Downloaded from http://ajot.aota.org on 12/28/2020 Terms of use: http://AOTA.org/terms