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. 2023 Mar 9;9(3):e14388. doi: 10.1016/j.heliyon.2023.e14388

A systematic review of improved positions and supporting devices for premature infants in the NICU

Liu Yang a,1, Hua Fu b,1, Lingping Zhang b,c,∗
PMCID: PMC10031313  PMID: 36967878

Abstract

Background

In the neonatal intensive care unit, nurses often place premature infants in the supine, prone, and lateral positions. However, these positions do not always meet all the physiological needs of premature infants. Thus, many improved positions and various position-supporting devices have been studied to provide infants with a development-friendly and comfortable environment.

Aim

We aimed to help nurses recognize and understand the various improved positions and devices, and to provide nurses with more options in addressing the needs of preterm infants.

Study design

We searched PubMed, Web of Science, and EMBASE from 2012 to 2022 for studies on position management of preterm infants, and screened the search results according to inclusion and exclusion criteria. Then we extracted data and evaluated the quality of the included studies. Finally, we conducted a qualitative summary of the results.

Results

Twenty-one articles were included in this review. Fourteen were studies about improved positions, including hammock position, facilitated tucking position, ROP position, reverse kangaroo mother care position (R-KMC), and supported diagonal flexion position (SDF). Seven were studies on positioning devices, four on cranial deformity prevention, and three on reformative swaddling. They have a positive impact on sleep and flexion maintenance, in addition, they can prevent head deformity and reduce the pain of premature infants.

Conclusion

The position management of premature infants is diversified. Instead of sticking to a single position placement, nurses should adjust the position according to the unique physiological conditions of infants to reduce sequelae and promote their recovery and growth during long-term hospitalization. There should be more studies on position management with large sample sizes in the future.

Keywords: Premature infant, Position, Neonatal intensive care unit, Nursing

Abbreviations: NICU, Neonatal intensive care unit; DSC, Developmental supportive care; KMC, Kangaroo mother care; DP, Deformational plagiocephaly; R-KMC, Reverse kangaroo mother care; SDF, Supported Diagonal Flexion

1. Introduction

Infants with a gestational age of <37 weeks are defined as premature infants. It is estimated that there are 15 million preterm infants worldwide yearly, which continues to increase [1]. Premature infants must stay in the neonatal intensive care unit (NICU) due to their immature organ systems, which make them need professional care after birth and some even require lengthy hospitalization [2,3]. Although premature infants are treated and cared for in the NICU, they are inevitably subjected to various stimuli, exposure to stressful environments, or excruciating interventions during the prolonged hospital stay, leading to clinical instability in this population. Thus, the nursing of premature infants needs to be more meticulous. Body positioning as an easy-to-operate nursing practice is a non-invasive intervention of participants for therapeutic effect and is also one important strategy of developmental supportive care (DSC) [4,5].

The prone position is commonly used for critically ill premature infants as the physiologic benefits, accelerating premature infants' recovery from respiratory complications caused by immaturity [6]. The supine position has also been recommended by the American Academy of Pediatrics for convenience of observation and therapy operation, as well as for reducing the risk of sudden infant death syndrome [7]. In daily care, nurses in the NICU usually alternate preterm infants' positions throughout the day according to the need to ensure relaxation and prevent pressure lesions and postural deformities [8]. The left and right lateral positions are often used as transition positions for shifting. With medical advancement, kangaroo mother care (KMC) has been advocated and promoted to improve physiological stability and establish a close bond between infants and their mothers [9]. Besides, positioning devices and auxiliary tools are receiving increasing attention and favor. Nesting care, as part of developmental care, is widely used in the NICU due to its simplicity of operation, availability of materials, and no size restrictions. By adding boundaries around the newborn, it can maintain a curved limb position, reduce sudden movement and excessive expansion of limbs, and improve the sleep quality of the newborn [[10], [11], [12]].

All of the positions mentioned above are well known; however, NICU is not limited to saving lives now; people have begun to pay more attention to the life quality of premature infants, and work to reduce complications and sequelae. Therefore, these common positions are insufficient to cope with the difficulties that preterm infants encounter in the NICU. Thus, various modified positions and creative positioning devices have been developed to minimize harm to premature infants and improve their quality of life. However, the existing systematic reviews are only for one improved position [13,14], there are no studies that integrate and compare the different improved positions. This may lead to omissions when nurses learn knowledge of different positions or cause confusion and entanglement when choosing positions for premature infants. Thus, this review introduces positions and devices that are not well known, summarizes and analyzes the application condition between different positions or between different studies of the same position, and strengthens nurses' attention and cogitation on positioning management. Meanwhile, we aim to help nurses understand the advantages, disadvantages, usefulness, safety, and practicability of each position, and provide nurses with more options in personalized care.

2. Materials and methods

2.1. Topic selection

When traditional positions and devices no longer meet higher standards of care and comfort for premature infants, the question arises as to what options are available to nurses for simple positions and tools to help them cope with the stimuli that preterm infants encounter in the NICU. The PICOS question (population, intervention, comparison, outcome, study design) consisted of preterm infants as the population; improved positions or devices as the intervention; traditional positions as the comparison; the outcome and study design were not restricted. This systematic review attempted to answer the following questions:

  • 1.

    What needs of premature infants can be addressed and met through the use of improved positions or devices?

  • 2.

    Are these improved positions or devices suitable for nurses to use in the NICU?

  • 3.

    What are the recommendations for future postural management of preterm infants?

A systematic review of improved positions and supporting devices for premature infants was conducted, which closely followed PRISMA guidelines (Supplementary Table 1) [15]. The study protocol has been registered with the international prospective register of systematic reviews (PROSPERO). The registration number is CRD42022374113.

2.2. Inclusion and exclusion criteria

2.2.1. Study inclusion criteria

(1) the improved positions of preterm infants, defined as the positions that differ from the standard supine, prone, lateral, and KMC positions; (2) or position-related supporting devices suitable for preterm infants.

2.2.2. Study exclusion criteria

(1) articles not in English; (2) review articles, letters, conference abstracts, case reports, protocols, notes, and editorials; (3) full-text not available; (4) articles related to the car seat; and (5) there were other different interventions remaining between groups besides position intervention for preterm infants.

2.2.3. Search strategy

We searched the literature from January 01, 2012, to December 31, 2022, using the following three databases: PubMed, Web of Science, and Embase. Medical Subject Headings terms combined with keywords were used in the literature search. The search strategy consisted of two core components linked using the AND operator: 1) Infant, Premature (e.g., preterm infants, neonatal prematurity), and 2) Patient Positioning (e.g., patient positionings, posture). Owing to the characteristics of the databases and the additional vocabulary, the final search terms of the three databases were different. Full details of the search strategies are provided in Supplementary Table 2. In addition, we manually searched the reference lists of the included studies to find additional literature in line with the topic.

2.2.4. Study selection

All the searched records were imported into EndNote (version X9; Clarivate Analytics). After eliminating duplicates, L.Y. and H.F. independently reviewed all titles and removed articles that are irrelevant to the topic and post type, then they removed some articles according to the inclusion and exclusion criteria by reading abstracts. Finally, the full text of the remaining articles was examined to determine whether articles were included in the final study. In the whole process, a third reviewer (L.Z.) participated in the consultation when a disagreement occurred.

2.2.5. Data extraction

We created tables to record the results of extraction. L.Y. and H.F. independently read the full text and extracted the characteristics of the included studies, including author, publication year, study type, sample size, inclusion criteria, intervention, main outcomes, findings, and device design. The data were integrated and checked by a third assessor (L.Z.), and the disagreement was discussed and resolved together.

2.2.6. Quality assessment

The methodological quality of the final included articles was evaluated using the Physiotherapy Evidence Database (PEDro) Scale. The scale was developed from the Delphi List, which consists of 11 items, to help users judge external validity (item 1), internal validity (items 2 to 9), and statistical reporting (items 10 to 11) of clinical trials [16]. Only the second to tenth items are scored for 10 points, <4 are considered ‘poor’, 4 to 5 are considered ‘fair’, 6 to 8 are considered ‘good’, and 9 to 10 are considered ‘excellent’ [16]. L.Y. and H.F. completed the quality evaluation, and the third reviewer (L.Z.) resolved any disagreement.

3. Results

In total, 4,875 articles were searched from the three databases, and 6 additional articles were found from reference lists. After removing duplicates, 3,654 articles were screened by title. Of the 424 articles eligible for the abstract assessed, only 29 met our study theme. After reading the full-text of these articles, we excluded 8 articles that did not meet the inclusion criteria. Ultimately, 21 articles were included in our study (Fig. 1). Due to the significant heterogeneity of the evidence base, we could not conduct a quantitative synthesis (meta-analysis) of the identified studies; therefore, we finally focused on a qualitative synthesis.

Fig. 1.

Fig. 1

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The flow diagram of the study selection strategy.

3.1. Study characteristics

Of the 21 articles included, 14 were studies on improved positions and 7 were studies on positioning devices. In the improved positions section, 4 were on hammock positions [[17], [18], [19], [20]], 7 were on facilitated tucking positions [[21], [22], [23], [24], [25], [26], [27]], 2 were on the derivation and modification of KMC [28,29], and 1 was on the ROP position [30]. The characteristics of the included studies regarding the improved position are shown in Table 1. In the devices section, 4 were studies on the prevention of deformational plagiocephaly (DP) [[31], [32], [33], [34]], and 3 aimed to provide more comprehensive surroundings and comfort for infants [[35], [36], [37]]. The characteristics of the included studies on positioning devices are shown in Table 2. The studies included randomized controlled trials, cross-over studies, quasi-experimental studies, pilot studies, and case-control studies, with sample sizes ranging from 11 to 100 participants. All the studies were on premature infants except one whose participants were infants ≥37 weeks [24]; however, we considered that vaccination was a common procedure for preterm infants in the NICU, so the study was retained.

Table 1.

Characteristics of the included studies about the improved positions.

Authors and published year Study type and sample size Inclusion criteria Type of intervention Main outcomes Findings
2019-Ribas et al. [20] A randomized controlled trial with 26 subjects. 30–37weeks Group 1: lying in the lateral position in a hammock.
Group 2: lying in the lateral position in a nest.		 Pain scores; sleep-wake state;
HR; RR; SpO2.		 Preterm infants in group 1 had less pain and an improvement of 41% in the sleep-wakefulness state, HR, RR decreased, and SpO2 increased.
2018-Jesus et al. [19] A quasi-experimental study with 28 subjects. <37 weeks,
<1500g		 Lying in the supine position in a hammock for 1 h after feeding. Pain scores;
HR; RR; SpO2; sleep-wake cycle.		 HR and RR decreased, pain scores and SpO2 kept unchanged, and promote infants into light sleep or deep sleep in a hammock.
2017-Costa et al. [17] A quasi-experimental study with a cross-over design with 30 subjects 32–35 weeks,
1400–1800g		 Lying in the right lateral position in the nest after changing the diaper, then lying in a hammock after the next diaper change. stress/pain level;
posture and organizational status.		 The stress pain of infants consistently scored below 3 points in the hammock, and the score decreased over time. Hammocks have advantages over nesting for maintaining therapeutic postures. Fewer infants were diagnosed with Disorganized Infant Behavior in the hammock.
2019-Costa et al. [18] A randomized controlled cross-over study with 20 subjects. 32–37weeks,
1300–2000g		 Group 1: lying in an O-shaped nest after changing the diaper, then lying in the hammock after the next diaper change.
Group 2: interventions were in reverse order.		 Sleep-wake state; HR; SpO2. The physiological variables and the sleep-wake state in the hammock group and nest group were not significantly different, but the hammock promoted sleep after a stressful stimulus (diaper change).
2014-Mona et al. [21] A randomized controlled cross-over study with 34 subjects. 29–37weeks,
>1200g		 Group 1: subjects were placed in the FT position during the first endotracheal suctioning, and the next suctioning without FT.
Group 2: interventions were in reverse order.		 Pain scores. The pain scores of infants who used the FT position decreased observably, and only 8.8% of infants with the FT position experienced mild to moderate pain during endotracheal suctioning.
2018- Gautheyrou et al. [22] A randomized controlled cross-over study with 50 subjects. <30 weeks, postnatal age <48 h Group 1: echocardiography was performed first with FT, and then performed in standard conditions.
Group 2: interventions were in reverse order.		 HR; SpO2; pain scores;
AT/RVET ratio;
NIPE index.		 HR and pain scores of infants in the FT position decreased, but AT/RVET ratio increased, other parameters were not influenced by the FT position.
2019-Davari et al. [23] A randomized crossover clinical trial with 40 subjects. 32–36 weeks,
>1200g		 Group 1: subjects were placed in the FT position in the first blood sampling, and then were placed in the supine position in the second blood sampling.
Group 2: interventions were in reverse order.		 PIPP scores. Although the mean severity of pain did not differ significantly between the two positions, the FT group had lower pain scores after blood sampling than the supine group.
2015- Kucukoglu et al. [24] A randomized controlled trial with 60 subjects. >37 weeks,
>2500g		 Group 1: vaccination with FT position.
Group 2: vaccination with the supine position.		 NIPS scores;
HR; RR; SpO2.		 NIPS pain scores and RR of the infants in the FT position were lower than those in the supine position.
2015- Lopez et al. [25] A quasi-experimental study with 42 subjects. 23–36 weeks Group 1: venepuncture with FT position.
Group 2: venepuncture under normal routine.		 PIPP scores PIPP scores in group 1 significantly decreased.
PIPP score rises with the increasing number of attempts at venepuncture.
2013-Sundaram et al. [26] A randomized controlled crossover study with 24 subjects. 28–36 weeks Group 1: first heel stick procedure with FT, then second heel stick procedure without FT.
Group 2: interventions were in reverse order.		 PIPP scores The PIPP scores decreased with the FT position.
2016-Valizadeh et al. [27] A randomized clinical trial with 32 subjects. 33–36 weeks
>1500g		 Group 1: infants were placed in the free body posture in the supine position;
Group 2: infants were placed in the free body in a lateral position;
Group 3: infants were placed in facilitated fetal tucking posture in the supine position;
Group 4: infants were placed in facilitated fetal tucking posture in the lateral position.		 Sleep and wakefulness states Facilitated fetal tucking posture facilitated sleep and reduced wakefulness, and lateral position increased the amount of sleep time.
2019-Metreş et al. [30] A randomized controlled trial with 70 subjects. 28–36 weeks postmenstrual age,
≤2000 g		 Group 1: ROP position + pacifier was used during eye examinations.
Group 2: only the pacifier was used during eye examinations.		 PIPP scores; crying time. PIPP scores and crying duration in group 1 were lower than in group 2.
2015-Padhi et al. [28] A pilot study with 20 subjects. Preterm infants at risk of ROP. All subjects were placed in the R-KMC position. HR; RR; SpO2; behavioral changes. Infants were comfortable or had mild-to-moderate stress in the R-KMC position when ROP screening was performed.
2020-Buil et al. [29] A matched-pair case-control study with 34 subjects. 27-31+6 weeks. Group 1: Infants were placed in traditional KMC.
Group 2: Infants were placed in the SDF position.		 Smiles, vocalizations, and gazes of mothers and infants. Infants in the SDF position were more likely to fall into a deep sleep, and SDF positioning created more opportunities for mother-infant communication and interaction
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Note: PIPP: Preterm Infant Pain Profile score; NIPS: Neonatal Infant Pain Scale; FT: Facilitated tucking position; RR: respiratory rate; HR: heart rate; SpO2: peripheral oxygen saturation; AT/RVET: the ratio of acceleration time/right ventricular ejection time; NIPE: Newborn infant parasympathetic evaluation index; ROP: Retinopathy of prematurity; NIPS: Neonatal Infant Pain Scale; KMC: Kangaroo Mother Care; R-KMC: reverse Kangaroo Mother Care; SDF: Supported Diagonal Flexion.

Table 2.

Characteristics of the included study about the devices of positioning.

Authors and published year Study type and sample
size		 Inclusion criteria Type of intervention Device design Main outcomes Findings
2014- Madlinger et al. [37] A randomized clinical trial with 100 subjects. ≤32 weeks Group 1: traditional positioning devices such as swaddling and blankets.
Group 2: alternative positioning device named Dandle Roo.		 The device, which is made of stretchable cotton, forms a boundary around the infant's head, wraps the lower extremities in a curved bag, and protects the upper extremities using adjustable straps. Gel pillows, cloth rolls, or headpieces are available. NNNS scale;
NOMAS scale; some clinical outcomes.		 Infants in group 2 showed less asymmetry of reflex and motor responses.
2017-Kitase et al. [36] A quasi-experimental study with 39 subjects. <36 weeks Group 1: conventional swaddling clothes group.
Group 2: a new type of swaddling clothing group.		 Swaddling clothing like a bag can extend in both longitudinal and transverse directions， the baby's entire body from the neck down can be wrapped in clothes. Sleep stage; vomit and apnea;
behavioral evaluation scores.		 Muscle tone score and total score improved in group 2, and sleep quality also improved in this group.
2015- Visscher et al. [35] A randomized crossover trial with 25 subjects. Premature infants with feeding difficulties. Group 1: infants were treated with conformational positioning first, then were turned to standard positioning.
Group 2: interventions were in reverse order.		 A commercially available fluidized system, around the infants to provide flexible boundaries. Sleep efficiency; polysomnography outcomes. A conformational positioner resulted in higher sleep efficiency in premature infants with feeding difficulties and surgical infants.
2016-Knorr et al. [31] A descriptive pilot study with 23 subjects. ≤35 weeks,
>1000g, and exhibited
visible head shape deformity		 All infants in this study received the cranial cup treatment. The device has a firm plastic base that includes four layers made from cross-linked polyethylene foam, and the cranial cup is covered with soft, washable jersey fabric. Cranial index and cranial symmetry; cardiorespiratory and emesis events. The median hours per day on the cranial cup was 12.7, and 83% of participants had normal cranial measurements.
2019-Knorr et al. [32] A descriptive pilot study with 11 subjects. ≤1 kg,≥22 weeks postmenstrual age All infants were used with a preemie orthotic device (POD). The device measures approximately 10 × 15 in and includes 4 foam inserts, which maintained a neutral position, and the infant's heads rest in the recessed area, with a fixed bridge section supporting the neck. A 7-item Ease of use questionnaire; untoward events;
cranial measures.		 The POD had a median of 21.2 h per day, 5 subjects had a normal cranial index at study completion, and no device-related events occurred.
2015- DeGrazia et al. [33] A stratified, randomized single-blinded study with 88 subjects Preterm infants born at ≥22 weeks gestation and < 14 days of age Group 1: moldable positioner.
Group 2: moldable positioner and cranial cup.		 The cranial cup, made from cross-linked polyethylene foam, supports the head and body of the infants, and it can adjust to the baby's growth by removing the foam layer. Cranial index and cranial symmetry; cardiorespiratory and emesis events. Emesis events were evenly distributed in both groups, the median hours per day on the cranial cup was 10.7, and group 2 had fewer abnormal cranial measures.
2020-Uchio et al. [34] A case-control study with 19 subjects. <1800 g,
<37 weeks		 Group 1: infants used this special pillow for at least 8 h a day from discharge to a corrected age of six months.
Group 2: infants used a pillow at home.		 A 22 × 27 cm pillow made of memory foam shaped like a doughnut with a central concavity, and has a removable cover. Classification of lateral plagiocephaly deformities; Neurodevelopment assessment; asymmetric motor performance. There was a statistically significant decrease in the classification of lateral plagiocephaly deformities at the corrected ages of six months in group 1, higher BSID-III cognitive composite scores in group 1, and ACS scores lower in group 1.
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Note: NNNS: NICU Network Neurobehavioral Scale; NOMAS: Neonatal Oral Motor Assessment Scale; BSID-III: Bayley Scales of Infant Development III; ACS: Asymmetric clinical scale.

3.2. Studies reported the improved positions of infants

3.2.1. Hammock position

The hammock position is a simple and easy-to-implement method. A hammock can be formed by attaching a rectangular piece of cloth to the extremities of the incubator, which can simulate the intrauterine position and promote flexion [20]. Three studies reported the effect of hammock position on pain [17,19,20]; three studies reported the promotion of sleep by hammock position [[18], [19], [20]]; one study [17] reported that the hammock position had better flexion of the upper and lower limbs, better keeping the head in the midline, and feet at the foot end. Regarding the research participants selection, three studies selected premature infants who breathe spontaneously [17,18,20], while one study included infants with nasal catheter oxygen inhalation and non-invasive ventilation [19]. Two studies [17,18] excluded infants with a history of apnea, and two studies [17,19] excluded infants treated with phototherapy.

3.2.2. Facilitated tucking position and ROP position

Facilitated tucking position, in which the infant is held by the nurse's warm hands, with one hand on the infant's head and the other on the buttocks, essentially helps preterm infants maintain a flexed position, without strongly restraining the movement of the infant's body and limbs [38]. Of the seven articles on facilitated tucking position, six studies examined the role of position on pain in preterm infants [[21], [22], [23], [24], [25], [26]], and one study reported the effect of posture on sleep promotion [27]. The facilitated tucking position can be applied to various procedures that produce pain or recurring pain in premature infants, such as echocardiography performing [22], endotracheal suctioning [21], heel-stick procedure [23,26], vaccination [24], and venepuncture [25]. The ROP position is very similar to the facilitated tucking position: a nurse fixes the arms of infants to the left and right temporal region of the head, a cotton-staffed rolled pad can be placed under the head, and another nurse grabs the legs so that infants' legs are naturally bent when retinopathy screening is performed [30]. Both positions use tactile and thermal stimulation to reduce the pain response, facilitate self-regulation, and enhance behavioral stabilization during procedures [38,39].

3.2.3. Reverse KMC position and supported diagonal flexion position

Two articles focused on the evolving position of KMC: one was the reverse KMC (R-KMC) position. Similar to the KMC position, the infant usually wears only a diaper and is wrapped in a piece of cloth on the mother's chest, the difference is that the infant's head is turned outward, and the back is directly against the mother's chest [28]. The mother lay on the examination bed, holding the infant with her hands. It was used to decrease the adverse physiological changes caused by retinopathy screening in premature infants, and most infants felt comfortable or experienced mild-to-moderate pain.

Another was the Supported Diagonal Flexion (SDF) positioning, a great way to promote communication between mothers and infants. Although traditional KMC increased skin contact between mothers and infants, some mothers complained that eye-to-eye contact is difficult to achieve, and they prefer to keep face-to-face exchanges with their children [29]. Instead of lying vertically on the mother's chest in KMC, the infant is placed off the center line and is semi-reclined on the mother's chest, infant's head is located between the mother's nipple and clavicle, towards the mother's face [29]. This can enable the mother to send more communication signals to the child and increase more communication behavior of infants. Mothers vocalize, gaze at their infant's face, and smile more in this position [29,40].

3.3. Studies reported innovative devices for infants

3.3.1. Prevention of DP

One study compared the effects of a special pillow and a regular pillow on the cranial deformity and neurodevelopment in preterm infants, which was long enough from discharge to a corrected age of 6 months, the special pillow significantly reduced DP, improved cognition and fine motor ability, and reduced asymmetric motor function [34]. The remaining three articles on the prevention of cranial deformities were from the same team: two were prospective, descriptive pilot studies [31,32], and one was a stratified, randomized single-blinded study [33]. DeGrazia et al. [33] used a cranial cup that adjusts to preterm infants weighing ≥1,000 g, the control group only used a moldable positioner, and the intervention group used a moldable positioner and a cranial cup; infants in the intervention group weighing <1,000 g were given a moldable positioner and then alternated the use of a moldable positioner and a cranial cup when they weighed ≥1,000 g. The results showed that the control group had more abnormal cranial measurements. In Knorr's descriptive study [31], the included patients weighed ＞1,000 g; in a subsequent descriptive study [32], a preemie orthotic device was designed to adapt to extremely low birth weight infants whose weight was less than 1,000 g. By the end of the two studies, most infants achieved a normal cranial index and cranial symmetry, with improvement in DP. The median hours per day on the cranial cup also increased in three studies, from 10.7 h to 12.7 h, then to 21.2 h per day.

3.3.2. Reformative swaddling

Kitase et al. invented a new type of swaddling clothing: a bag-shaped garment that can be extended vertically and horizontally. Infants were wrapped from the neck to the feet, allowing them to maintain the appropriate position and move their limbs to some extent [36]. Compared with previous cotton swaddling clothes, the new type of swaddling clothing has considerable elasticity, avoiding wrapping clothes tightly to maintain an appropriate positioning [36]. The results showed that the new clothing was expected to maintain premature infants in a stable posture for an extended period and significantly improve muscle tone and sleep quality. The material used in Madlinger's research was stretchable cotton named Dandle Roo [37]. It also provided an optional gel pillow, cloth roll, or headpiece to ensure additional support and reduce head molding. Infants using this device showed less asymmetry of reflex and motor responses on the NICU Network Neurobehavioral Scale [37]. Visscher et al. studied the effect of conformational positioning on sleep, a conformational positioner that provides flexible boundaries and containment [35]. The results showed that conformational positioning increased sleep efficiency by 15%, and the same effect was also observed in surgical infants of feeding difficulty [35].

3.3.3. Quality of the evidence

We used the PEDro scale to evaluate the quality of the eighteen articles; five were rated as fair quality [17,19,28,31,32], fourteen were rated as good quality [18], [20], [21], [23], [25], [26], [27], [29], [30], [33], [34], [35], [36], [37], two were rated as excellent quality [22,24]. Inclusion and exclusion criteria were well reported in all studies, only six studies used both random allocation and concealed allocation [22,[24], [25], [26],33,37], all studies that grouped participants had baseline comparability, and none of the study operators could be blinded, as the operator must know the intervention of the infants. The results of the studies are shown in Table 3.

Table 3.

Evaluation of the methodological quality of the studies included in this review.

Evaluated criteria Item 1a Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8 Item 9 Item 10 Item 11 Total scores
Ribas [20] + + – + + – + + + + + 8/10
Jesus [19] + – – – + – – + + – + 4/10
Costa [17] + – – – + – – + + + + 5/10
Costa [18] + + – + + – + – – + + 6/10
Mona [21] + + – + + – + + + + + 8/10
Gautheyrou [22] + + + + + – + + + + + 9/10
Davari [23] + + – + + – – + + + + 7/10
Kucukoglu [24] + + + + + – + + + + + 9/10
Lopez [25] + + + + + – – + – + + 7/10
Sundaram [26] + + + + + – + + – + + 8/10
Valizadeh [27] + + – + + – + + – + + 7/10
Metreş [30] + + – + + – – + + + + 7/10
Buil [29] + – – + + – + + + + + 7/10
Madlinger [37] + + + + + – + + – + + 8/10
Kitase [36] + – – + + – – + + + + 6/10
Visscher [35] + + – + + – + + + + + 8/10
DeGrazia [33] + + + + + – + – – + + 7/10
Uchio [34] + – – + + – – + + + + 6/10
Knorr [32] + – – – + – – + + – + 4/10
Knorr [31] + – – – + – – + + – + 4/10
Padhi [28] + – – – + – – + + – + 4/10
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Note: Item 1: Eligibility criteria and source; Item 2: Random allocation; Item 3: Concealed allocation; Item 4: Baseline comparability; Item 5: Blinding of participants; Item 6: Blinding of therapists; Item 7: Blinding of assessors; Item 8: Adequate follow-up (>85%); Item 9: Intention-to-treat analysis; Item 10: Between-group statistical comparisons; Item 11: Reporting of point measures and measures of variability.

a

The item of the eligibility criteria does not contribute to the total score; + yes; -no.

4. Discussion

4.1. What needs of premature infants can be addressed and met through the use of improved positions or devices?

During the fetal period, the sleep-wake cycle begins to develop, and a normal sleep cycle is a prerequisite for learning and memory development [41]. When the fetus is in the uterus, the uterine wall restricts the excessive stretching of the fetus' limbs. However, when placed in the incubator, the arms and legs of the infants are in an extended position because of the action of gravity, especially in premature infants whose muscles have not yet gained tension, which is the opposite of that adopted in the uterus [42]. This increases insecurity and reduces self-soothing behaviors, making infants more likely to wake up. In addition to exposure to bright light, noise, and other environmental factors, pain is also an important cause of sleep deprivation in preterm infants. Preterm infants undergo more routine care and repeated nursing procedures during hospitalization, some invasive caregiving procedures can even cause moderate or severe pain. In addition, innocuous stimuli such as daily handling may also be perceived as painful and trigger a stress response [43]. Moreover, it is important to note that preterm infants stay on a firm bed mattress and are exposed to asymmetric external pressure on both sides of the skull for a long time, easily resulting in skull deformity [44], which is related to neurobehavioral problems. These are the problems that preterm infants often face in the NICU, and the improved positions and devices we assessed can meet the needs of preterm infants to some extent.

4.2. Pain management in preterm infants

Non-pharmacological pain-relief measures are a trend of pain management in preterm infants, with non-nutritive sucking, sweet oral solutions, breastfeeding, Kangaroo care, and skin contact among the most commonly used. In our study, the hammock and facilitated tucking positions can also be seen as non-pharmacological methods and can be used alone or in combination with other measures. One study combined non-nutritive sucking, oral sucrose, and facilitated tucking during heel sticks. The results showed that combining interventions effectively reduced the frequency of painful withdrawal behaviors, and stretching or wriggling of the limbs [45]. In theory, the hammock can also be used with other methods, but no related articles have been published, because of the higher use requirements of the hammock. First, infants using hammocks are suspended in an incubator, the quality and safety of the hammock are very important. Second, the lower jaw pressing against the bedding or steeply sloping of the hammock fabric easily causes occlusion of the airway of infants [46]. Third, once the baby learns to roll, it can easily cause face covering in a hammock [46]. In contrast, the facilitated tucking position has a wider range of applications, endotracheal suctioning, heel-stick procedure, vaccination, and venepuncture are frequently repeated nursing measures in the NICU, and nurses can fully consider the use of the facilitated tucking position to reduce pain reactions when performing these procedures. Although at least two nurses are usually needed, seeming to increase the scope and responsibility of nurses, this weakens the infant's pain response and reduces resistance, resulting in a higher operation success rate. One article reported that parents could be involved in this process to improve contact between infants and their parents [47]. Retinopathy screening examination is a painful procedure that preterm infants often undergo, and topical anesthetic drops and pacifiers are routine care to relieve pain [48]. The ROP and R-KMC positions also effectively reduce pain during the examination, but no other studies have examined the effects, except for these two articles in this review. Therefore, future randomized controlled trials with larger sample sizes are warranted.

4.3. Promote flexion and sleep in preterm infants

Mimicking the uterine environment and promoting flexion is the key to improving comfort and sleep cycles. The hammock and facilitated tucking positions mentioned in this review are ways to promote flexion, with the limbs close to the midline of the body, the neck slightly bent, and the hands close to the face and mouth, enhancing body symmetry. Therefore, premature infants can increase their sleep time, maintain a deep sleep state, and reduce the frequency of awakening [19,20,27]. Kangaroo care (skin-to-skin) has also been proven to be an effective way to improve sleep in preterm infants [9,49], it can increase sleep time [50], especially quiet sleep [51,52]. Buil et al. made adjustments to the KMC and reported the SDF positioning, adjusting from the upright vertically prone position to lie diagonally on the mother's chest, making infants spend 32% of the time sleeping and 17% in a deep sleep, much higher than the vertical group [29]. Moreover, this position enhances maternal adaptation to infant signals and increases visual and vocal contact between mothers and infants [29].

Regarding supporting devices, nurses usually use towels, sterile cloths, or other materials to make a bird's nest-like tool around the infant or a cotton swaddling cloth to wrap a preterm infant. However, these materials inevitably encounter some problems, including tight wrapping limiting the autonomous movement of the infants, too loose wrapping preventing maintenance of the flexion position, too small nest causing the infant's limbs to extend beyond boundaries, and a large nest lacking protection and restraint. The three articles included in this review provided references for solving these problems [[35], [36], [37]]. All three studies used materials with greater extensibility and elasticity to provide containment while ensuring free movement of the limbs. Madlinger et al. showed that infants were easier to maintain symmetric, flexed, and midline oriented in the alternative positioning device, symmetrical muscle tone is essential for the early development of infants [37]. Kitase et al. reported that swaddling clothing increased muscle tone, assisted in self-sedation, and prolonged quiet sleep [36]. Similarly, Visscher et al. reported improvements in sleep efficiency in premature infants using a conformational positioner [35]. Therefore, when the physical condition of premature infants is not suitable or for other reasons, nurses cannot place infants in a special position, professional auxiliary devices can be used to maintain the flexion position and promote sleep in infants.

4.4. Prevention of DP

Nurses often manage DP by repositioning infants with water-bed therapy, water-filled pillows, gel pillows, air-filled mattresses, foam mattresses, etc., to promote normal head shape [32,33]. However, these methods do not always achieve the goal, and some devices have been designed to help nurses effectively manage DP in premature infants. In the four articles included in this review for DP prevention, the design of the head position of premature infants was no longer flat and consistent. Instead, the designer leaves a special concavity for the position of the head, making the infant's head or external occipital protuberance fit into the recessed area. In Uchio's study [34], a special pillow with concavity was used, such designs also appear in Wilbrand's research [53]. This concave design can better maintain the infant's head in a midline position, and distribute external pressure evenly on both sides of the skull. In Knorr's [31,32] and DeGrazia's [33] studies, except for the concave part of the head, the device even included parts of the infant's body, fitting traditional NICU bedding, and can be adjusted according to the size of the infant's body. Although Knorr surveyed the feasibility of the device and respondents thought it was easy to use and did not interfere with nursing care, further research is needed to confirm its applicability [32].

4.5. Are these improved positions or devices suitable for nurses to use in the NICU?

Through this literature search, we found five improved positions (hammock position, facilitated tucking position, ROP position, R-KMC position, and SDF position) and five devices (special pillow, cranial cup, conformational positioner, swaddling clothing, and alternative positioning device). Although the importance of positioning devices in the position management of preterm infants has been recognized, and more research has been devoted to the design and invention, each hospital has great differences in the production or purchase of the equipment. By contrast, placing appropriate positions for infants according to their needs is relatively simple and easy to operate, as long as the nurses are professionally trained and guided. However, the application of these positions is also limited by the circumstances and situations. The hammock and facilitated tucking positions have greater flexibility and can be combined with the supine or lateral position according to the infants' condition and treatment needs. The facilitated tucking position and ROP position require the participation of at least two nurses; one nurse helps place the position, and the other performs operations. In contrast, the hammock position requires only one nurse to place the infant in the hammock. The R-KMC and SDF positions require the mother's participation. The nurse first explains the benefits of the position to the mother and then instructs her on how to cooperate. However, due to the particularity of the NICU environment, it is difficult for some care units that do not have separate maternal and infant wards. Additionally, the mother's education level, understanding ability, and degree of cooperation affect the application of these two positions. Therefore, nurses should consider the effectiveness and feasibility of selecting positions for premature infants.

4.6. What is the advice for future postural management of preterm infants?

Through this systematic review, we found that the improved positions of premature infants were diversified. Position management, which cannot be unified and absolute, should be a key point of nursing. Each hospital should explore a suitable plan, from the invention or purchase of devices to the training of personnel and then to the optimization of the routine nursing process, each step should be developed according to the actual situation of the care unit. It is recommended that departments integrate personalized position management into the routine nursing process and boost the education and training of nurses, no longer stuck in a single, unchanging position, to meet the diverse needs of premature infants, and promote high-quality development.

4.7. Strength and limitation

Our review was the first to report improved positions and devices for preterm infants and provided a new choice for clinical nurses for personalized position care in preterm infants. However, this review had several limitations. First, not all included studies were randomized controlled trials, and some studies had small sample sizes and poor quality. Thus, the results could be biased. Second, our research was limited to qualitative research, and we could not conduct a meta-analysis. Third, this review only provided references and suggestions for clinical nursing, but the clinical acceptance and practicality were unknown, and future studies should pay more attention.

4.8. Further research

Randomized controlled trials with larger sample sizes are needed to verify the feasibility and safety of each position and device involved in this study. In addition, difficulties and barriers to the widespread use of these positions or devices and nurses' views on them have not been researched. Future studies should focus on this to systematically and comprehensively solve the problem of personalized position management in premature infants.

5. Conclusion

Our findings suggest that adopting positions or devices is feasible to meet some of the unique care needs of preterm infants during long-term hospitalization. Placing premature infants in special positions can relieve pain, improve flexion and sleep, and reduce the head deformity. Encourage nurses to perform position management and improve the prognosis of premature infants in the NICU.

Author contribution statement

All authors listed have significantly contributed to the development and the writing of this article.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability statement

No data was used for the research described in the article.

Declaration of interest’s statement

The authors declare no conflict of interest.

Acknowledgments

Not applicable.

Footnotes

Appendix A

Supplementary data to this article can be found online at https://doi.org/10.1016/j.heliyon.2023.e14388.

Appendix A. Supplementary data

The following are the Supplementary data to this article:

Multimedia component 1
mmc1.docx (33.1KB, docx)
Multimedia component 2
mmc2.docx (14.4KB, docx)

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