Developmental Positioning in the Neonatal Intensive Care Unit and Its Impact on Head Shape Development in a Very Preterm Infant: A Case Report

Background & Purpose: The intended goal of the Back to Sleep program in 1994 was to decrease the incidence of Sudden Infant Death Syndrome (SIDS), while this has been achieved, an unintended consequence has been an increase in the prevalence of atypical cranial molding and torticollis since that time. It is now necessary to address these impairments to determine how to best support infant’s musculoskeletal development. Infants in neonatal intensive care units (NICUs) are very susceptible to these changes due to prematurity and environmental conditions. Current guidelines recommend that infants discharge home on the Back to Sleep program, however, the timeline of introduction during NICU stay is not well delineated. The purpose of this case report was to describe the developmental care plan utilized for a very preterm infant and to examine its effectiveness to promote typical head shape development.

Case Description: The infant was born at 30 weeks and 2 days gestational age and physical therapy evaluation was performed on day-of-life four. A care plan focused on the use of current evidence regarding positioning for neonates under 32 weeks gestational age was implemented and infant head shape was monitored throughout the stay. Nurses and parents were provided education on physical therapy goals and the plan of care. Additional education focused on the importance of developmental care to prevent sequelae due to prematurity and NICU stays.

Outcomes: The infant was seen for 17 treatments throughout the 38-day NICU stay. The parents of the patient were educated on Back to Sleep and the importance of implementing it at home. However, while being closely monitored in the NICU, the patient was placed in a variety of positions under close supervision to promote appropriate cranial molding. Cranial Index and Cranial Vault Asymmetry Index indicated that the infant’s head shape was within normal limits at all data collection points, including at discharge. The patient was discharged home at 35 weeks and 5 days gestational age.

Discussion: Normal head measurements throughout this patient’s NICU stay may indicate that consistent, intentional positioning prevented cranial deformation. Other factors could have impacted this case including multiple positive personal and environmental factors, minimal medical complications, and length of stay in the NICU. Since nurses often handle infants more than therapists, the importance of educating them on the positioning program and ensuring adequate skills to execute it cannot be understated. Furthermore, if the positioning program does not follow Back to Sleep, family education on the importance of implementing it when the child discharges home should begin early. Currently, no positioning protocol exists for infants older than 32 weeks. This case highlighted the use of a variety of positions for an infant up to 35 weeks gestational age with no adverse effects. It would be valuable to further study the implementation of a positioning protocol for infants older than 32 weeks to decrease the incidence of plagiocephaly and torticollis in infants with prolonged NICU stays.