JSS COLLEGE OF NURSING
1st MAIN SARASWATHIPURAM, MYSORE
SYNOPSIS SUBMISSION
BY,
Ms.NEETHU C JOSEPH
1ST YEAR M.Sc NURSING
CHILD HEALTH NURSING
JSS COLLEGE OF NURSING
MYSORE
GUIDE,
Mrs. AMBIKA K
Asst.PROFESSOR
CHILD HEALTH NURSING
JSS COLLEGE OF NURSING
MYSORE
BATCH : 2011 – 2013
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1 / NAME OF THE CANDIDATE AND ADDRESS / Ms. NEETHU C JOSEPH1st YEAR MSC NURSING
JSS COLLEGE OF NURSING
MYSORE
2 / NAME OF THE INSTITUTION / JSS COLLEGE OF NURSING
SARASWATHIPURAM
MYSORE
3 / COURSE OF STUDY AND SUBJECT / M.Sc NURSING
CHILD HEALTH NURSING
4 / DATE OF ADMISSION OF THE COURSE / 28.03.2011
5 / TITLE OF THE TOPIC / A STUDY TO ASSESS THE EFFECTIVENESS OF NESTING ON POSTURE AND MOVEMENTS AMONG NEWBORNS IN SELECTED HOSPITALS AT MYSORE
6 BRIEF RESUME OF THE INTENDENT WORK
6.0 INTRODUCTION
Newborns are the most vulnerable group to get adjust to the new environment. Following birth, the first few months act as a transitory period during which the baby adjusts from the aquatic to the aerial environment. As a result, the way in which he is positioned throughout this time is very important, his posture dictates the level of his well being & how his motricityy will evolve1.
Posture refers to the positioning or alignment of the various parts of the body in relation to one another. Good posture can help to improve circulation and digestion enhances sleep and prevents cramping of internal organs. Proper posture can improve quality of life.
Danielle Salducci, a pediatric physiotherapist, started to design and make ‘nest’ which would enable newborn to make movements similar to those made in their mother’s womb. If the newborn lies flat on his back on a very firm mattress, without the safe & secure feeling he had in the womb, he could feel he were falling into space. This posture could also be the start of various physical ailments1.
Developmental care, introduced in the mid 1980’s in an approach designed to address environmental concerns. Strategies used to modify the extra uterine environment include control of external stimuli, clustering of care activities, positioning or nesting of the preterm infant to mimic the intrauterine environment & provide containment & the provision of longer rest periods. One or more of these elements may be utilized, according to need, when providing developmental care to individual infants2.
Lying on a firm mattress in a batrachians posture with his arms folded back & upwards on either side of his body, baby either stares at the ceiling or turns his head inevitably to the same side – the one he adopted in his mother’s womb. Ultimately this can result in a non – symmetrical lateralization, potential delay in the child’s psychomotor development and an increase in the risk of plagiocephaly (a flattened head) observed amongst a growing number of young children today.
An article published in ‘Neonatal units in Trent Perinatal Network on positioning of preterm and sick neonates. In that its states that “ Positioning aim to provide safe comfortable and appropriate care for preterm infant who need help in coping with the environment outside their mother’s body”2.
The fetus in-utero has consistent, dynamic uterine boundaries that continually promote return to a flexed midline position following periods of activity. Conversely, infants in the neonatal intensive care unit are subjected to the effect of gravity and have a tendency to assume flattened postures especially when they are either preterm or sick. This places the infant at increased risk of developing a typical posture and movement patterns both in the short and long term. Careful supportive positioning can help promote the normal structural alignment and neuromotor control necessary for optimal development of an infant posture and motor skills. In addition, a contained midline flexed support position, using specially designed ‘bumpers’ to surround the baby and keep the limbs close to the body, is said to promote sucking and other calming behaviors2.
The correct positioning will help the baby to develop good posture and improve muscle control. Some hospital l actually have a little “nest” which is a toweling nest with cotton straps. The baby lies in the nest and the cotton straps are pulled across the baby so that they feel safe and secure. If the towel nesting is not available, nesting can be prepared by using sheets, preferably soft ones. Roll the sheets length way so that they are tubes. These are then placed round the baby so that he/she got sometime secure around them on both sides and under his/her feet. This will not only help them to feel safe but it will also encourage good posture and muscle movement and provide comfort positioning3
6.1 NEED FOR THE STUDY
Newborn have so many adjustment problems soon after the delivery. When they were in mother’s womb, the temperature is maintained & the also the flexed position provide much comfort to the baby. After the delivery there is an alteration in the posture. The striking difference between the intrauterine environment & the neonatal intensive care unit is obvious. The sensory impact of the NICU has been postulated to adversely influence the neurodevelopment outcome of pre term infants4.
The studies show that disturbance in the posture cause spontaneous motor behavior. Normal position prevents frozen postures of arms & legs. In supine position movement towards & the midline, elegant wrist movement, abrupt hand or limb movement, rolling to side & frozen postures of arm & legs were assessed. If the newborn in nest, flexed posture with shoulders, adduction of elbow & knee flexion & the head was frequently in midline5.
Good posture during growth and development keeps bone and joints in correct alignment and prevent abnormal wear and tear as well as keeping spine from becoming fixing in an abnormal position. Good posture is very important to health and well being. While many people are aware of the importance of good posture it is still one of the most neglected method of improving health and fitness. One of the major causes of the bad posture is a misalignment of the skeletal bones. There are three major deviations of normal posture, lardosis, kyphosis and scoliosis. In addition to stressing the baby’s spine it can also negatively influence the development of baby’s hip joints6.
Observing the needs of the babies, Danielle Salducci, a pediatric physiotherapist, started to design and make nest which would enable newborns to make movements similar to those made inside their mother’s womb. Initial stage was to medically research and to determine a posture for the premature baby which could be described as a follow – up womb1.
When the baby is in nest, head is tilted slightly forward and he can make easy eye contact with his mother and father as soon as they bend towards him, facilitating the relationship between child and parent. With his arms in front of him and no longer in the batrachians or position his hands rapidly find his face. This in turn leads to a better ability to touch, feel and grasp. Less stressed by his new environment, calmed by the fact he can touch his face and aware of the limits of his own body, baby feels comforted and falls asleep more easily1.
A survey conducted by the FSLD & BLISS (2008) on positioning and posture of newborns. The study result shows that the consequences of unsupported positioning of newborns. i.e., asymmetrical skull deformation due to professional head turning to the right, Dolichocephaly- progressive lateral skull flattering that results in a narrow elongated head, increased active extension of the trunk and neck with subsequent motor asymmetries causing arching of the neck and back, shoulder external rotation and retraction with scapular adduction, lower extremity hip adduction, external rotation of the tibia and ankle eversion resulting in the frog leg position. This may delay motor skills such as crawling and walking in the first year of life and is associated with toe walking up to eighteen months7.
Another article on ‘Developmental care of newborns and infants’ is published in a guide for health professional. It suggests the positioning techniques. Therapeutic positioning will only be effective with ongoing care giver attention. In all positions aim for; head in midline, shoulders rounded, hands to mid-line or face, neural flexed position, boundaries to circle the whole infant. This must be balanced with the need to promote rest and handle minimally. Elevated head of bed to 30 degree to promote cardiovascular, pulmonary and gastrointestinal function. Provide boundaries using rolled up sheets and blankets or use commercially available positioning products such as nests, bean bags and bendy bumpers to contain infant. Boundaries should touch the baby and provide support but should not be restrictive or limit movements. Use of positioning aids, such as nests, necessitates careful monitoring of the infant’s temperature to avoid overheating containment. Positioning maneuvers during procedures such as blood taking or even routine cares and position changes has been shown to reduce the physiological and behavioral responses to stressful procedures8.
The extended position for long periods can lead to abnormal tone with consequent delay in the motor development. Sometimes, it is difficult to place the premature baby in a curled up, flexed position because of attachments of lines & sensors. Nesting is one of the key factor in maintaining beneficial position of a neonate & should be practiced routinely9.
An article on the topic ‘Developmental care of the newborn and infants’ in a journal “A guide for health care Professionals”. External supports compensate for the infants immature postural and motor control; a comfortable soft nest with secure and deep boundaries simulates the positioning benefits of the womb support head and trunk in neural alignment with extremities flexed and tucked towards midline. In supine, encourage head in midline boundaries that are shallow, don’t touch the infant or allow flat posture are ineffective10.
Several literature reviews revels that newborn care includes positioning and maintain posture and is an important aspects, it can play a major role in the development of newborns. Incidence of newborn death rate and developmental problems related to improper maintains of posture and movement is increased. As a nurse its our responsibility is to maintain the posture and movement as much as possible to provide maximum comfort to the baby to reduce further complication. And there is no much studies done on the ‘nesting’ on posture and movement and the society is not aware of the term , only in selected NICU setup this technique ‘nesting’ is practicing. So the researcher felt the need that to contribute newer practices in neonates and to improve their posture and movements as well as prevent further hidden consequences this study have to be done to find out the effectiveness of nesting on the posture and movement of newborns.
6.2 REVIEW OF LITERATURE
A study was conducted in the year 2007 Feb 22 to evaluate lying in a nest affects the posture and spontaneous movement of healthy preterm infants. For this study the researcher took 10 healthy preterm infants of 3 age group i.e., 30 – 33 week, 34-36 week, & 37 – 40 week. Infants underwent serial video recording in the supine position in & outside of nest. The posture was assessed both before & after general movements by scoring the predominant postural pattern & the study results shows that a nest promotes a flexed posture of the limbs with adduction of shoulders, facilitates elegant wrist movements towards & across the midline & reduces abrupt movements and frozen posture of the arms and legs5.
The study also suggests that the neonatal intensive care unit exposes the preterm infant to a non – optimal physiological environment & to invasive procedure & handling. These may induce pain & stress, along with the frequent manipulations by medical & nursing staff that disrupt rest activity cycles & sleep, which may lead to chronic & prolonged stress in the preterm infant. Acute stress may induce abrupt movements & startles. Nesting reduces the stress and provides comfort positioning5.
An article ‘A new way to understand your baby’s crying’ it states that providing comfortable position why nesting had seemed to be promising intervention to stop excessive crying and it gained popularity, however it is important to understand what the benefit, risk and consequences of nesting. About one fifth of the world’s babies are nested. It is really effective to reduce excessive crying and maintains of good posture and movement in newborns.
A group of scientists done a need based assessment among Pediatrician, Psychotherapist and Biologist & also being scientists regarding the effect of nesting in newborns. They all are interested in this topic and had several reasons to investigate nesting of babies. First, because from public health studies into the risk factor of crib death or sudden infant death. They came to knew that about half of the parents who still placed infants on their front to sleep which is very important risk factor for SIDS. In such position baby was not settling down when falling asleep or was crying. Second reason to investigate nesting was encouraged by the involvement in the children’s hospital with parents of babies who had injuries caused by shaking. Third reason was the fact they noticed that in well baby clinics nesting was used more & more often by parents as a method to stop crying & restlessness & to maintain posture & movement of newborns. They evaluated the evidence based methods and scientific studies was found that tested the effect of nesting on excessive crying and maintains of posture and movements in newborns11.
A study conducted by Ria, Blom, a Dutch maternal & Child Health Care Nurse in 1994 & she tested the use of nesting as a method that seemed to be able to reduce restlessness & crying and improve sleep & maintains normal posture and movements in newborns. She developed a holistic approach were nesting only during sleep periods was used. She has closely observed babies with crying, positioning, their posture and sleeping problems & over the years has developed methods for supporting families when newborns cry excessively. She wrote several books for parents & was willing to make her theory and practical experience available for research. The rhythm & uniformity approach used by Blom was rather similar to the approach by others in other parts of the world who demonstrated a positive effect of a certain rhythm in daily care of the newborns on the reduction of crying and maintains of normal posture & movements in the newborns studying the effect of nesting on excessive newborn crying & maintains of posture and movements was new. The final goal of the study to reduce excessive crying & maintains of normal posture & movements in newborns12.
A retrospective and descriptive study conducted in the US demonstrated fewer stress behavior in nested position. The provision of boundaries was also associated with more efficient self regulation, more physiologic control, better motor organization and improved the highest stress indicating behaviors13.
A study was carried out on developmental care interventions which may help preterm infants cope better with the environment of NICU. An unfavorable event can negatively affect the infant growth with the brain being particularly vulnerable. Data were extracted by the 2 authors. Meta-analyses were conducted for each intervention where the same outcome measures and or instruments were used with in comparable time points. Developmental care is a broad category of interventions the stress of the NICU environment. A number of elements are included under the umbrella of development care; positioning is also one of the elements and the nesting helps to provide similar to the intrauterine experience to the newborns14.
A study was conducted on the premature infant and painful procedures in the year 2000 June. Pain management for premature infants raises challenging questions for nurses. This group of infants is often physiologically fragile Painful procedures are harmful to the physiological stability and the ability to self regulate, which includes maintenance of motor control and stable sleep/ wake cycles. Assessment of pain in the premature infant is complex. Major indicators of pain include facial grimaces and physiological parameters such as heart rate and oxygen saturation. The Premature Infant Pain Profile is one tool designed specifically for preterm infant. Non pharmacological nursing measures such as swadding or nesting and offering a pacifier are useful strategies to help infant cope with pain procedures15.
In a prospective study conducted on retinopathy of prematurity screening, stress related responses, the role of nesting. In this study the degree of distress caused by retinopathy of prematurity screening in a cohort of preterm infant was assessed and the modifying effect of nesting in reducing their discomfort was evaluated. 38 preterm infant were included in the study. 19 infants were placed in a nest with boundaries (experimental group) and 19 infants were placed on a cot blanket (control group). Observations were made 2 minute before, throughout and 2 minute after ROP examination. The factors observed were crying response, neurobehavioral activity and physiological changes. Recording were made using a video camera for crying and neurobehavioral activity and an oxypleth monitor for Heart rate and oxygen saturation. The distress caused by ROP screening was significantly less for the nested group compared with the non-nested group of both movement activity. The study shows that ROP screening is distressing for preterm infants. Nesting can significantly reduce this discomfort16.