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Lori Brittingham is a Neonatal Clinical Nurse Specialist and Dandle•LION Clinical Consultant with over 30 years of NICU experience. Having spent over 25 years at The Children’s Hospital of Philadelphia, she played a key role in developing neurodevelopmental care and small baby teams in the Level 4 NICU.

With recent roles at Reading Hospital-Tower Health in Pennsylvania and Nemours Children’s Health in Orlando, FL, Lori focused on aligning clinical practice with evidence, enhancing quality and safety outcomes, and advancing the clinical nurse specialist role. A former adjunct faculty member at the University of Pennsylvania School of Nursing Science (2014-2019), she holds a BSN from Temple University and an MSN from the University of Pennsylvania.

Lori served on the National Association of Neonatal Nurses board for 8 years, including a term as President (2016-2018). Recognitions include CHOP’s Nursing Leadership Award (2014), the Pennsylvania Nightingale Advanced Practice RN Award (2018), and the National Association of Clinical Nurse Specialists’ Clinical Nurse Specialist of the Year Award (2019). An inaugural recipient of NANN’s Developmental Specialist designation, Lori played a pivotal role in the inception and execution of this important recognition program.

Lori has also presented a Dandy webinar! You can watch the recording of her presentation, The Transition To Sleeping Safely in the NICU: What NICU Staff and Families Need To Know, and receive one free CE credit.

“Hospitalized preterm infants should be placed supine as soon as clinical status has stabilized and they have achieved positional stability, that is, when therapeutic or non-supine positioning is no longer medically indicated. This milestone is usually achieved by 32 weeks’ gestational age.” 

(AAP, 2022).

Following the recommendation of the American Academy of Pediatrics (AAP) (Committee on Fetus and Newborn, 2022), many NICUs enact Safe Sleep parameters at around 32 weeks postmenstrual age, which often involves removing all developmental positioning supports in an effort to model Safe Sleep for parents. 

Although implementing back to sleep as early as 32 weeks postmenstrual age is recommended, it is important to consider the musculoskeletal and sensory organizational processes occurring in the infant between 32 weeks and term gestation.  These factors should be considered when determining “positional stability”:

• Development of physiologic flexion posture as the foundation of normal motor development matures in the last weeks of pregnancy.
• Joint compression and resistance to active extension necessary for bone development is most prevalent in the last trimester of pregnancy.
• Calcium and phosphorus acquisition for bone ossification is maximized in the third trimester of pregnancy.
• The degree of prematurity directly affects an infant’s ability to maintain positional stability secondary to medical equipment required to support respiration and digestion, immaturity or atypical development of the central nervous system requiring cardiopulmonary monitoring,  and possibly delayed skeletal maturation.

When determining “positional stability,” each infant’s medical and developmental needs should be considered before removing developmental positioning supports at a predetermined gestational age. Choosing a wearable blanket or swaddle that promotes flexion of the extremities provides dynamic support, allowing free movement while promoting passive recoil to a flexed posture is a reasonable option that supports positional stability and meets the AAP guideline for Safe Sleep. This dynamic relationship between baby and boundary is an essential component of healthy physical and sensory development. 

Developmentally speaking, removing positioning aids early in the 3rd trimester may deprive the baby of the increasing physiologic flexion they would have experienced in the womb, which is vital to bone and muscle development.  

• A 32-week infant, for example, should still experience an additional 6-8 weeks of pregnancy before neurologic and physical development are optimal. However, not every 32-week infant is the same physiologically or neurodevelopmentally.
  • A 32-week baby born at 24 weeks gestation may have dramatically different physical and sensory support needs than a 32-week baby born at 31 weeks gestation. 
  • Babies born at earlier gestational ages with more severe illnesses or congenital anomalies may require robust developmental support beyond reaching full term, making traditional swaddles and wearable blankets ineffective in meeting their needs.

Positioning with Purpose

In the third trimester, the “resistance training” provided by the baby’s interaction with the dynamic, muscular boundary of the uterus facilitates proper development of the bones, muscles, and joints. Preterm infants are born prior to the completion of the third trimester, placing them at risk for altered physical development. 

• Research evidence demonstrates that active resistive movement is essential for skeletal development along with maximized infant nutrition.
• The interaction between the baby and the muscular-responsive uterus is essential in loading bones sufficiently to maximize bone accretion.
• During this formative period in pregnancy, an exponential increase in bone growth occurs, resulting in 80% of fetal bone being produced (Drake, 2022).

The Dandle® WRAP Stretch provides dynamic resistance to extension movements of the extremities while promoting the return to a flexed resting posture, mimicking the action of the uterus:

• Flexion and midline alignment of the infant in the womb is important for developing bones, joints, and muscles.  This posture also facilitates self-regulation and calming, physiologic functions like digestion, and attainment of future motor milestones like rolling, crawling, and walking. Only when an infant can maintain this posture should they be considered as having obtained “positional stability.”
• Commercially available swaddles and sleep blankets generally allow for free movement, but when applied to preterm infants in the NICU, they often do not provide recoil or promote a consistently flexed, midline posture— leaving the lower extremities unsupported in extension.

As the Dandle WRAP Stretch is secured under the baby’s head and neck, it meets the definition of a wearable blanket/sleep sack, meeting both the safety and developmental needs of the infant. The physiologic importance of continued developmental support into the third trimester is clear. Providing babies with dynamic support by using a Dandle WRAP Stretch supports the infant’s musculoskeletal and sensory organizational needs while meeting the AAP 2022 recommendations. 

Dandle•LION supports modeling Safe Sleep while encouraging hospitals to keep babies in their positioning aids for as long as possible within the context of their own unique policies/procedures around safe sleep. Our Dandle WRAP Stretch is compatible with AAP Safe Sleep recommendations and can be used even after “safe sleep” protocols have been implemented for a particular patient. 

Learn more about the Dandle® WRAP Stretch here.

Sources:

Drake, L. (2022). Positioning the neonate for best outcomes. National Association of Neonatal Nurses.

Shea, C.; Rolfe, R.; and Murphy, P.  The importance of foetal movement for coordinated cartilage and bone development in utero.  Cone Joint Res, 2015: 7:105-116.  Doi:10.1302/2046-3758.47.20000387.

Vibration is everywhere: in our cars while we drive, on our phones or pagers, in the laundry room from the running clothes dryer, and in the bathroom when the water is running. We even have vibrating toothbrushes. Anything with motion or a motor produces vibration.

Vibrating bouncy seats have long been a home staple for managing fussy newborns. Vibration is shown to ease acute pain, calm children with sensory processing differences, and reduce muscle tightness and spasms. According to the Gate Theory, it interrupts pain transmission in both the afferent and efferent pain pathways.

What about vibration used in the NICU?

According to the study completed by Sequi-Canet et al. (2022), the NICU incubator alone provides a constant source of vibration. High-frequency ventilators such as the Jet and oscillating ventilators also produce constant vibratory input to the infant. Several studies have shown how vibration at the site of the painful prick for blood collection can reduce the pain experience significantly.

Vibration has been used in pediatric to neonatal ICU to reduce the distress of neonatal abstinence and neonatal opioid withdrawal.  Zuzarte et al. (2017) demonstrated the effectiveness of vibration for NOWS symptoms, while Smith et al. (2015) demonstrated the regulatory effect of vibration on apnea and bradycardia in the newborn population. Vibration that is applied appropriately has become an effective pain management strategy in dentistry, intensive care, and the emergency room.

Vibration can be applied locally using a small vibrating tool, or across the body using a vibrating mat. Dandle•LION Medical provides the Tranquilo® Soothing Mat for this very purpose. There are several optional protocols for vibration use in the NICU. Protocols should be created from the literature evidence and hospital policies for safe equipment use.

References: 

Smith, V; Kelty-Stephen, D.; Ahmed, M; Mao, W; Cakert,K.; Osborn, J.; Paydarfar, D.  Stochastic Resonance Effects on Apena, Bradycardia and oxygenation: a Randomized Control Trial. Pediatrics (2015) 136 (6): e1561 – 1568.  https://doi.org/10.1542/peds.2015-1334.

Sequí-Canet JM, Rey-Tormos Rd, Alba-Fernández J, González-Mazarías G. Vibroacoustic Study in the Neonatal Ward. Healthcare. 2022; 10(7):1180. https://doi.org/10.3390/healthcare10071180.  

Zuzarte I, Indic P, Barton B, Paydarfar D, Bednarek F, Bloch-Salisbury E (2017) Vibrotactile stimulation: A non-pharmacological intervention for opioid-exposed newborns. PLoS ONE 12(4):e0175981. https://doi.org/10.1371/journal.pone.0175981.

by Elizabeth Jeanson, PT, DPT, CNT, DCS, NTMTC

Elizabeth is a Clinical Consultant for Dandle•LION Medical and the Developmental Specialist and Neonatal Therapist in Neonatal Intensive Care at Sandford Children’s Hospital/USD Medical Center in Sioux Falls, South Dakota. Read more about Elizabeth in her Dandy Clinician Spotlight.

Our PAL Family consists of the Dandle® PAL, Polly PAL™, and the Mini PAL™! All three are weighted positioning aids that provide multiple uses during a baby’s stay in the NICU. Keep reading to learn about what makes each member of the family unique.

Mini PAL™

Say hello to the youngest member of the PAL Family!

The Mini PAL was designed specifically for the tiniest babies that need more support inside the extra small Dandle® ROO2 and ROO Lite. 

Like her older brother and sister, Mini PAL is a flexible positioning aid that can be used in a variety of ways:

• A tool for supporting medical equipment while taking up minimal space
• An insert in the XS Dandle ROO2 or Dandle ROO Lite to fill in space at the bottom so the wings and pouch fit properly
• A lightweight positioning accessory placed gently alongside the baby with the “legs” laid over the baby’s shoulders, hips, or behind the head

The Mini PAL has an outer and internal bag filled with silky micro discs and is currently available in a machine-washable version.

Coming soon for Mini PAL: a wipeable version with disposable and washable cover options!

Dandle® PAL

The Dandle PAL is a flexible boundary with dual-weighted pouches that can be easily nestled around an infant to provide containment and support.

The larger pouch comprises the “legs,” which provide support and flexion, while the smaller pouch gives height or extra support when needed. The unique twill tab allows clinicians to stack the two compartments over one another and secure them in place, providing stability and height where it’s needed most. The silky micro discs can be shifted to personalize care.

The Dandle PAL serves a variety of additional functions:

• Acts like a “second set of hands” to comfort the baby during patient care
• Holds medical devices in place to reduce the likelihood of malposition, unintended removal, or pressure injury
• Supports upper and lower extremities simultaneously when used in pairs

This product has a washable and wipeable version, along with disposable and washable covers for the wipeable Dandle PAL.

Polly PAL™

The Polly PAL is a smaller, single-bag weighted boundary that supports positioning in the NICU.

This boundary also serves a variety of functions:

• Around the head to encourage midline positioning
• Supports respiratory equipment or other medical tubing
• Behind the back, when the baby is side-lying
• A “second set of hands” to provide comfort during patient care
• Anywhere the baby needs a little bit more comfort or support

During gestation, babies receive consistent, predictable positioning and sensory input from the womb. Positioning and sensory interventions in the NICU should ideally promote consistency in practice across caregivers, such as using dedicated tools that decrease variability in positioning technique. Having consistent, evidence-based positioning support tools can be viewed as an important step toward improving developmental care.

Our social media series Consistency Is Key covered three main areas of neonatal positioning that benefit greatly from consistent neurodevelopmental support. Find all of the slideshows in one place with additional information about Swaddling, Nesting, and Prone Support below:

Swaddling

Swaddling has been used for centuries to provide babies with warmth and calming containment. Hospitalized babies— especially those born preterm— need consistent, neurodevelopmentally-supportive positioning that aims to bridge the gap between the experience of the womb and the experience of the NICU.

Traditional swaddling with blankets may not provide the right type of support to optimize growth and development. High levels of variation can exist in blanket swaddling techniques, resulting in a variable experience and position for the baby.

Babies also need dynamic boundaries that allow for free movement and periods of active extension, followed by passive recoil to flexion at rest. Traditional blankets may be stiff, preventing free movement and failing to promote recoil to flexion.

An ideal swaddling aid should make it easy to provide the right position and sensations for each baby, without the influence of caregiver preference or technique on the outcome.

Learn more about the Dandle® WRAP Stretch.

Nesting

Positioning nests crafted, folded, or molded by hand are a long-standing tradition in NICU environments.

While these types of support can be effective with the right technique, the potential exists for high variability in positioning across caregivers, babies, and even shifts.

Nesting with products that provide close-fitting, easy-to-replicate positioning support will give the babies the redundancy and dynamic interplay characteristic of the womb. Womb-like positioning can promote deeper sleep, which benefits babies, their parents, and caregivers alike!

Learn more about the Dandle® ROO2.

Prone Support

Developmentally supportive prone positioning should facilitate a flexed posture, with the shoulders rounded, hips and knees flexed, and hands toward the face.

Prone supports that are built from blankets, burp cloths, pillowcases, or other flaccid materials may not be firm enough to promote and maintain proper prone positioning.

Learn more about the Dandy Prone Pad™.

To learn more about the 5 Tenets of Neurodevelopmentally Supportive Positioning™ check out the 5 Tenets Deep-Dive and/or download the Dandle•LION® Positioning Competency Toolkit.

In 2011, national legislation was passed designating the month of June as “National Cytomegalovirus (CMV) Awareness Month” and recommending that “more effort be taken to counsel women of childbearing age of the effect this virus can have on their children.” Even though congenital CMV is the leading viral cause of congenital disabilities and the leading non-genetic cause of childhood hearing loss, most adults have never heard of it. The National CMV Foundation was incorporated in 2014 with hopes of changing these statistics. The organization began with a mission to raise awareness and educate women of childbearing age about congenital CMV. A year later, the National CMV Foundation joined forces with three prominent CMV non-profit organizations: Maddie’s Mission, Stop CMV, and the Utah CMV Council to become the largest national advocacy organization focused on congenital CMV. The organization is focused on our vision to eliminate congenital cytomegalovirus (CMV) in the United States for the next generation. We are honored to share information about CMV for National CMV Awareness Month this month.

What is CMV?

Cytomegalovirus (sy·toe·MEG·a·low·vy·rus) or CMV, is a member of the herpes virus family. Coming into contact with the CMV virus is a common occurrence, typically harmless to the general population. A CMV infection causes cold-like symptoms, such as a sore throat, fever, fatigue, and swollen glands. These mild cytomegalovirus symptoms last for only a few short weeks and are rarely a cause for concern for healthy kids or adults.
 
It is important to note that the CMV virus can cause serious problems for people with weakened immune systems (immunocompromised) due to organ transplants, HIV/AIDS infection, chemotherapy, and specific medications, such as glucocorticoids, cytostatics, antibodies, and drugs acting on immunophilins.
 
The CMV virus can also cause severe disease in babies who were infected with CMV before birth (referred to as congenital CMV infection).
 
According to the Centers for Disease Control and Prevention (CDC), between 50 and 80 percent of people in the United States have had a CMV infection by the time they are 40 years old.
 
Once the CMV virus is in a person’s body, it stays there for life and can reactivate. A person can also be reinfected with a different strain of the virus.

Healthcare Provider Information and Resources

CMV can be a serious problem for babies who are infected before birth. This is referred to as congenital CMV and it occurs when a pregnant woman passes the virus to her unborn child. Congenital CMV can cause birth defects and developmental disabilities and more children will have disabilities due to congenital CMV than other well-known infections and syndromes, including Downs Syndrome, Fetal Alcohol Syndrome, Spina Bifida, and Pediatric HIV/AIDS. We have provided these resources for physicians, OB-GYNs, midwives, nurses, and clinicians to enable better identification, prevention, and treatment for congenital CMV.

In the United States, approximately 1 to 4% of women will have their first, primary CMV infection during pregnancy, and about 40% of these women who become infected with CMV for the first time during pregnancy will pass the virus to their babies. It is crucial that physicians and OB-GYN doctors share this information with women who are pregnant or preparing for pregnancy.

Looking for guidance on how to best counsel women about congenital CMV during pregnancy? The CDC offers a PDF download titled “CMV Facts for Pregnant Women and Parents” that may be helpful here.

About 1 out of every 200 babies (roughly 30,000 children annually) is born with congenital CMV making it the most common congenital viral infection in the United States. More than 6,000 children annually suffer permanent disability as a result. Severe complications from congenital CMV result in approximately 400 deaths nationwide per year.

Transmission

Transmission of CMV is very rare through casual contact. CMV is spread from one person to another, usually by direct and prolonged contact with bodily fluids, including saliva, urine, and breast milk.

CMV is common among healthy children 1 to 3 years of age who attend daycare and can easily spread CMV among their peers. CMV is not generally harmful to these children and most kids will not show any signs or symptoms of infection.

Contact with the saliva or urine of young children is a major cause of CMV infection among pregnant women, especially mothers, daycare workers, preschool teachers, therapists, and nurses. Women who are pregnant or plan to become pregnant should practice standard hygiene procedures around young children to reduce their risk of CMV infection because the virus can be transmitted to their unborn child.

Signs/Symptoms of CMV in the Pregnant Patient

Most people who contract CMV will show no symptoms and may not even know that they have been infected. Others may develop a mild illness and may have any of the following symptoms:

• High fever
• Fatigue
• General discomfort, uneasiness, or ill feeling
• Joint stiffness
• Muscle aches or joint pain 
• Night sweats
• Prolonged fever 
• Sore throat
• Swelling of the lymph nodes 
• Weakness
• Loss of appetite 
• Weight loss

Since these are also symptoms of other illnesses, most people may not realize that they have been infected with CMV. If you have a pregnant patient experiencing symptoms similar to a seasonal illness, order a test for CMV IgM and IgG antibodies.

Signs/Symptoms of CMV in Utero

If your patient is believed to have contracted CMV during their pregnancy, regular ultrasounds and/or amniocentesis are the preferred methods to determine if CMV has been passed to the baby in utero. The CDC includes information about the diagnosis, treatment, and ongoing monitoring in their PDF download, “Diagnose, treat, and monitor children with Congenital Cytomegalovirus (CMV) to help improve their health outcomes“. 

Signs of CMV infection in utero include the following:

• Placental thickening
• Organomegaly – abnormal enlargement of organs
• Hepatomegaly – abnormal enlargement of the liver
• Splenomegaly – abnormal enlargement of the spleen
• Pyelectasis – dilation of the renal pelvis, the funnel-like dilated proximal part of the ureter (muscular tubes that propel urine from the kidneys to the urinary bladder) in the kidney (also a marker for Down Syndrome)
• Megaloureter – abnormal dilation of the ureter
• Ascites – a gastroenterological term for an accumulation of fluid in the peritoneal cavity (is a potential space between the parietal peritoneum and visceral peritoneum, that is, the two membranes that separate the organs in the abdominal cavity from the abdominal wall)
• Fetal hydrops – accumulation of fluid in the fetal compartments
• Abnormality of amniotic fluid
• Microcephaly – small head circumference, more than two standard deviations smaller than average
• Cerebral ventriculomegaly – dilation of the lateral ventricles of the brain
• Intracranial calcifications – the build-up of calcium salts in the soft tissue of the brain
• Hyperdense image in thalamic arteries
• Periventricular echodensities
• Hepatic echodensities
• Intestinal echodensities
• Cystic structures in the germinal zone

Signs/Symptoms of CMV in the Newborn

About 90 percent of babies born with congenital CMV will appear healthy at birth, and the vast majority will not have any visible symptoms or long-term issues. Many times, health problems or disabilities caused by congenital CMV infection can sometimes appear roughly two or more years after birth. Signs of CMV infection that may be present at birth:

• Premature birth
• Small size at birth
• Small for Gestational Age (SGA)
• Intrauterine Growth Restriction (IUGR)
• Red or purple spots on the body caused by broken blood vessels (Petechiae / Purpura)
• Yellow skin and eyes caused by increased bilirubin levels in the blood (Jaundice)
• Liver problems
• Lung problems
• Spleen problems
• Low blood platelet levels (Thrombocytopenia)
• Small head size / small brain (Microcephaly)
• Seizures

If your infant patient shows any of the signs and symptoms listed above, test the infant for congenital CMV infection using a saliva or urine PCR test. It is important to note that congenital CMV can only be accurately diagnosed if the newborn is tested within 21 days of life because, after 3 weeks, it is hard to determine if the baby could have contracted the infection through nursing or by exposure to siblings or others who may be shedding the virus. Please refer to the CDC for additional information regarding interpreting laboratory tests.

Treating Congenital CMV During Pregnancy

If you have a pregnant patient who has been diagnosed with CMV during pregnancy, there are treatments and trials available. Recent studies indicate that Cytomegalovirus Immune Globulin Intravenous (CMV-IGIV) treatment may reduce the risk of congenital infection and/or disease in an unborn baby when given to pregnant women experiencing a primary CMV infection.

If you would like more information about clinical trials and the treatment options available to your patient during their pregnancy, please contact us.

Treating Congenital CMV in Newborns

Emerging research shows that antiviral drugs, Ganciclovir or Valganciclovir, may help newborns born with symptomatic congenital CMV. These antiviral treatments may prevent or lessen the severity of hearing loss and may improve head and brain growth. Ganciclovir and Valganciclovir can also help combat immediate medical concerns caused by CMV, such as thrombocytopenia, organ failure (most commonly spleen and/or liver), hepatitis, and pneumonitis. Treatments generally last from six weeks to six months and are administered orally or through an IV or PICC line.

Both Ganciclovir and Valganciclovir can have serious side effects, so be sure to consult with a doctor before and during the treatment period. Newborns receiving these antiviral treatments should have their regular blood counts taken to avoid problems with severe neutropenia or anemia.

If you have a newborn patient born with congenital CMV and you would like more information about antiviral treatments, please contact us. Ongoing Interventions & Therapies If you have a newborn patient diagnosed with congenital CMV, be sure to refer the patient to have their hearing and vision checked regularly to identify any early onset of hearing or vision loss. Early diagnosis is critical to experiencing long-term developmental successes.

If you are concerned about potential seizure activity in the newborn, ask the parent to record the baby’s behavior for your review. They may need to schedule a consult with a pediatric neurologist. Additional monitoring, including EEG, may be suggested to properly diagnose whether the child is experiencing seizures.

Refer your newborn patients born with congenital CMV to your local Early Intervention (EI) program to determine whether the child should be evaluated for EI services.

This information was provided by Farah Armstrong, founder of Maddie’s Mission and a co-founder of the National CMV Foundation. A graduate of the University of Texas, Farah has a Bachelor’s degree in Mechanical Engineering, with 10 years of work experience as an engineer with BP in Houston and a field development engineer with FMC Technologies in Singapore. When her daughter Madeline was born, they discovered she was severely affected by CMV, and she passed away after 12 days of life. In her honor, Farah began Maddie’s Mission. Her extensive engineering background gives her great expertise in planning, budgeting, and executing detailed operations, bringing together large groups of people from different backgrounds.

Dandle•LION is proud to partner with expert clinicians to provide the best available education and evidence-based care strategies. This month, we are excited to introduce you to Dr. Elizabeth Jeanson PT, DPT, CNT,  DCS, NTMTC. Elizabeth is the Developmental Specialist and Neonatal Therapist in Neonatal Intensive Care at Sanford Children’s Hospital/USD Medical Center in Sioux Falls, South Dakota!

In her role as the developmental specialist, Elizabeth has the opportunity to implement developmental care protocols and practices for the unit and complete yearly developmental care quality improvement projects. In her role as a neonatal therapist Elizabeth is involved in direct patient care, family support, and education at the bedside. 

Over the past 22 years, both Sanford Children’s Hospital and DuPont Hospital for Children have benefited from Elizabeth’s expertise and passion. Elizabeth completed NIDCAP training and Infant Behavioral Assessment certification. She is NeoNatal Neurobehavioral Scale (NNNS) and Neonatal Touch and Massage Therapy (NTMTC) certified, as well as being a certified neonatal therapist (CNT). 

As a firm believer in sharing information and experiences, Elizabeth has presented nationally on topics including sensory development, positioning, nonpharmacologic pain management, change management, quality improvement, and Infant Driven Feeding™ Implementation. She is a NANT, Neonatal Touch and Massage, and Dr. Brown’s Medical lecturer. 

Elizabeth has published two articles in peer-reviewed journals: One to One Bedside Nurse Education as a Means to Improve Positioning Consistency in 2013 and Applying the Four Disciplines of Execution to Promote Culture Change in the NICU in 2020. Currently, Elizabeth is formulating a change process mentoring system and working towards creative integration of trauma-informed care into the daily interactions with infants and families in the NICU.