Are you concerned about abdominal distension?

Continuous Positive Airway Pressure (CPAP) is a widely used respiratory support for preterm infants. However, concerns about abdominal distension due to CPAP, often referred to as “CPAP belly,” have sparked discussions about its potential sequelae and called for innovative solutions.

In this blog, Ginny McGill discusses her journey with CPAP Belly. Ginny is the author of “Neonatal abdominal support to address CPAP belly: Two case reports and literature review” and the creator of the NeoBellyBand.

A Simple Strategy for a Common Problem

As a physical therapist working in NICUs for over 20 years, I have seen the miraculous work done to save the lives of premature infants. Neonatal therapists often enter this environment with an eye toward addressing or preventing the consequences of prematurity. From positioning in flexion rather than flat on a bed to modifying the environment to meet the needs of immature senses, many simple ideas have improved the care of these infants.

When observing bellies bloated by CPAP, I saw muscles that were stretched outside of their effective line of pull, placing the musculoskeletal system at a disadvantage to take over respiration after CPAP was removed. I saw arching and discomfort. This led me to embark on a journey to address and possibly prevent this unintended consequence of respiratory support.

The first attempts were on older infants to rehabilitate their weak abdomens after CPAP had been discontinued. The first trial involving half-time wear of an abdominal support resulted in these changes:

Before and After

This inspired further work, development of safety criteria, and trying on younger and younger babies to work towards prevention of CPAP belly. Prevention hoped to not just preserve muscle length and function but also to avoid the escalations in support sometimes used to try to overcome the respiratory inhibition which results from air in the GI system. I published two cases, one of treatment and one of prevention. When presenting these cases at a conference, it was clear this is a common issue from the line of therapists who stayed to discuss this further.

As one therapist in Anchorage, Alaska, with a simple idea, how do you help all these therapists? We are taught to communicate our work by publishing and presenting, and I had done that. And while I continue to gather data and prepare for further publication, it was obvious therapists were seeking support to help infants in their units. Some had already tried with different materials and differing success. I had done the groundwork, now how to get consistency in use for all these different units?

Source: McGill, V. (2022). Neonatal abdominal support to address CPAP Belly: Two cases report and literature review. Journal of Neonatal-Perinatal Medicine; 831-836. doi:10.3233/NPM-221047.

I am grateful Dandle•LION has been a partner in this cause. As a wise friend once said to me, you can do anything, but you can’t do everything. With a mind to provide consistency and safety for further use and study, the NeoBellyBand was born. Product development allows us all to know we are using what was used through the years of my CPAP belly journey and to know further study is all testing the same thing done the same way.

During this ongoing journey, the list of concerns about gaseous distension I hear from clinicians continues to expand. I started with weakness and concern for postural support for respiration now and movement development later. Those concerns expanded to the acute complications of distension during respiratory support, like the need for escalation of support to overcome a big belly. Others have expressed concerns about GI complications from feeding tolerance to SIP and still others the long-term consequences of visceral distension on digestion and possibly leading to ongoing inflammation.

These journeys take time, and all begin with one step. And while mine started on my own with a simple idea, it takes a team to make change. Thanks to Dandle•LION and all the clinicians I have spoken with since sharing this idea, who all hope to continue this journey towards improving the care of premature infants.

You are welcome to visit to learn more and participate in the conversation, including what parents are saying.

by Ginny McGill, PT, DPT, CNT, NTMTC

Ginny McGill graduated from Creighton University with a Doctorate in Physical Therapy in 2001. She has practiced in the NICU for 22 years, at Phoenix Children’s Hospital and Providence Alaska Children’s Hospital. She has received certifications in Neonatal Therapy, Neonatal Touch and Massage, as well as wound care and lymphedema. Ginny teaches locally and nationally. You may have seen her speak through her work with the Vermont Oxford Network (VON), Engage Grow Thrive, or Creative Therapy Consultants.

Baby in the Dandle® ROO2 positioning aid, laying on the Tranquilo® Soothing Mat.

What’s The Buzz About Vibration?

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.


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.

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

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.

Headshot of Elizabeth Jeanson, PT, DPT, CNT, NTMTC, DCS

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.

Isn’t It Sweet? 40% Glucose Gel Made Just For Babies

Sweet Cheeks® 40% Glucose gel— specifically designed for neonates, benefits babies and clinicians.

Glucose Gel Use In Neonates

40% glucose gel has been demonstrated in the literature as an effective means of stabilizing blood glucose levels in the early newborn period for certain neonatal patients. By reducing the need for IV dextrose, the use of glucose gel in certain neonates has been shown in clinical studies to:

  • Decrease length of stay
  • Reduce admissions to neonatal intensive care units
  • Decrease total costs incurred by patients’ families

Glucose gel has also been shown in clinical studies to have a positive impact on the percentage of babies consuming a 100% human milk diet by decreasing the need for formula supplementation. Other clinical studies have shown that glucose gel is simple to use, well-tolerated by infants, and may allow parents and babies to stay together in the post-birth period.

Risks & Limitations of Commonly-Used Formulations

Historically, commercial glucose gels labeled for over-the-counter use in children over the age of two or adults have been repurposed for use in neonatal units. This method is not without risks and inefficiencies. The amount of glucose gel within a typical commercially available container far exceeds what is needed for neonatal administration. Facilities must therefore either repackage the gel into smaller containers, introducing the potential risk of contamination during transfer and decreasing the efficiency of clinical workflows or discard the excess glucose, potentially resulting in financial waste.

In commercial pediatric and adult preparations, uneven distribution of glucose within a single tube has been found in clinical studies. Glucose gels intended for pediatric or adult use are often intended to be ingested all at once, making any differences in concentration throughout the container less concerning in those populations. However, taking small aliquots from the same single over-the-counter container to administer the gel to neonates presents a risk of variation among the aliquots, potentially impacting the percentage of glucose received by each baby. This could unintentionally lead to variability in clinical response to the intervention.

A Neonatal Formulation Designed to Improve Efficiency & Reduce Waste

Gloved clinician administering Sweet Cheeks glucose gel to baby.

The apparent risks associated with using over-the-counter pediatric and adult glucose gels for neonates have largely been tolerated by clinicians due to the lack of a viable alternative. To address this important need, Dandle•LION Medical developed Sweet Cheeks 40% Glucose Gel

Sweet Cheeks is packaged inside an oral syringe in 3mL aliquots, making the administration of neonatal glucose gel simple and efficient with no age limitations. After verifying the ordered amount of glucose gel, clinicians simply squeeze out the excess gel, leaving only the gel needed for their patient. The gel is then squeezed onto a clean, gloved fingertip and applied inside the buccal cavity for direct absorption into the bloodstream.

To request a sample of Sweet Cheeks 40% Glucose Gel, please click here.

The PAL Family

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 (right) is next to the Dandle PAL for size reference.

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.

Washable Dandle PAL (left). Wipeable Dandle PAL (right).

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.

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

Positioning Babies In Critical Care

Commonalities exist in providing developmentally-appropriate support to babies in the NICU, CVICU, and PICU, particularly in managing:

  • Posture
  • Position
  • Pain
  • Sleep

One intervention common across these areas is head of the bed (HOB) elevation. 

Elevation aids digestion and secretion management, and reduces ventilator-associated pneumonia; a serious complication regardless of age. Elevation can also be important in post-surgical recovery.

The challenge presented with HOB elevation is the tendency for the infant to slip down the mattress.

Preventing Infants From Slipping Down The Mattress

Weighted Boundary

The infant will often roll, twist, or slide down the incline. Positioning techniques can reduce this migration through the use of physical support (such as a weighted boundary) combined with a comforting, developmentally-appropriate posture.

Dandle WRAP™ Stretch
Baby pictured in a weighted boundary that provides proprioceptive feedback.

A weighted boundary also supports sleep, calmness, energy conservation for healing, and feelings of security, while reducing pain. There are several ways to support an infant that promote postural symmetry, head rounding, natural body contours, and self-calming. Positional support also provides a tactile cue that nursing cares are complete and it is time to rest. 

A large flexible weighted boundary that contours to the child’s body provides:

  • Reduced migration on the bed surface
  • Postural support
  • Full visibility of the baby


Baby pictured in a swaddle wrap to provide dynamic support, with a smaller weighted boundary that provides support to the head.

In situations where full visibility is not necessary a dynamic, stretchy swaddle wrap can be added to provide 360 degrees of comfort through proprioceptive feedback and warmth.

Supportive Accessories

A smaller weighted boundary can be used to stabilize an extremity in extension to allow for proper intravenous catheter function. When asymmetry is present, these smaller boundaries can support the head in midline or head-turning.

Prone Positioner

Baby pictured on a prone positioner to provide a comfortable, flexed posture in the prone position.

In some situations, an infant may need to be placed on their abdomen. 

In these cases, a prone support device can ease the alignment of the ventilator tubing and the airway and allow the infant to assume the fetal position with arms and legs tucked close to the body, a typical position of comfort for infants. A prone support device is especially beneficial when caring for an ex-premature infant who still hasn’t reached term gestation.

For the very young infant in the CVICU or PICU, a consistent signal that the cares and all the “owies” are finished for the time being impacts trust building with caregivers and overall cooperation with unpleasant but necessary activities. Multiple strategies exist to support infants in CVICU or PICU.

A note from the team at Dandle•LION:

Dandle•LION Medical offers products that can provide a weighted boundary, dynamic swaddling, and prone positioning. Learn more about the following products:

Headshot of Elizabeth Jeanson, PT, DPT, CNT, NTMTC, DCS

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.

Consistency Is Key: Neonatal Positioning For Neurodevelopmental 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 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.


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.

Tackle The Challenge Of Integrating New Equipment

Adding a new piece of equipment into the daily routines of NICU baby care is challenging for many reasons; most prominently is a lack of familiarity with the product.  

When introducing a product similar to one already in use, staff adjust more quickly. However, when a product is unfamiliar, the transition takes more time. Helping the team become familiar with the new product is vital.

Pictorial Guides

There are many ways to accomplish this goal, but each takes time. For starters, place pictorial information about the product in all the common spaces such as the lounge, scrub station, bathrooms, and group charting areas. Using a picture of the device in use is extra helpful, plus a few bullet points explaining its purpose, population, and process. DandleLION has created a QR code linking the nurse or therapist to the website’s positioning products.

DandleLION offers various pictorial guides and in-service videos for our products on the website to expedite this step in the change process.

Hands-On Interaction & Feedback

Have a product open house! If available, place several product sizes in the staff lounge with general guidelines for use. Allow staff to interact with the products on a doll of different sizes, and allow for open discussion where team members can relay positive and negative attributes. This implementation gives staff hands-on familiarity and increases buy-in when asking to hear staff opinions. 

Mini Bedside Education

Offer mini bedside education sessions 5 minutes maximum length. In this “5 minutes to know,”  introduce why the product is necessary, how to use it and what benefits its use will yield. Offering a token reward for completion, a sticker for their badge, some candy, or a pen, improves motivation and provides peer pressure to others who see the token and want one too. DandleLION has created a badge card with a picture of each positioner and a QR code linking to the website. The badge card is a great reward and a ready reminder. 

Finally, create easy access to the product. Give the product a little front-shelf time, if possible. Make signs guiding staff to the product, and shelve it with other like or same process items such as midline head supports near the admission items. These simple steps can improve the ease of transition and the likelihood of use.

Headshot of Elizabeth Jeanson, PT, DPT, CNT, NTMTC, DCS

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

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

A Silent Threat: CMV In Mothers and Babies

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.

Farah Armstrong, founder of Maddie’s Mission and co-founder of the National CMV Foundation, and her husband at a Stop CMV Golf event.

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 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:

National CMV Foundation’s Stop CMV Golf event.
  • 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

The Armstrong family.

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.

5 Key Tenets of Neurodevelopmentally Supportive Positioning™ Deep-Dive

Infant positioning that mimics the intrauterine position positively impacts the healthy development of future motor milestones while having a substantial effect on the neurodevelopment of preterm infants. The DandleLION positioning system promotes the healthy development of the brain and body by more closely mimicking the womb, using the 5 Key Tenets of Neurodevelopmentally Supportive Positioning™.

Each of the 5 Tenets addresses a crucial aspect of intrauterine positioning. These tenets are the foundation of our FREE Positioning Competency Toolkit. We have created carousels for each tenet to provide a deep dive into what each tenet looks like when present, partial, or absent in infant positioning. Check them out below:


Flexion in utero is vital to many biologic functions, including swallowing, digestion, joint development, calming, and self-regulation. In the NICU, positioning babies in a flexed posture aids healthy physical development and promotes calm. Flexion can be absent, partial, or complete.


The immature muscular development of the hospitalized preterm infant prevents them from self-perpetuating flexion, which is typically facilitated by the womb. Containment promotes a flexed posture and provides proprioceptive input, positively influencing the development of the brain and body.

Midline Alignment

Neutral alignment of the head, neck, and extremities along the midline promotes symmetrical musculoskeletal development, self-regulation, and calming.

360º of Proprioception

Proprioceptive input allows the infant to form neuronal connections that establish, to the developing brain, where the body lies in space. During gestation, the uterus encases the baby, providing proprioceptive feedback to the infant regardless of the way the infant moves or stretches. ⁠

In the NICU, proprioceptive input can be provided at varying degrees:⁠

  • Absent or misplaced, with boundaries touching the baby but not in a way that provides proprioceptive feedback ⁠
  • Some proprioceptive input can be provided by boundaries around only the head or feet ⁠
  • Or ideally, 360 degrees of proprioception encases the baby, ensuring a feedback loop is provided to the baby with every movement

Free Movement & Recoil

The uterus allows for unrestricted movement and developmentally appropriate stimulation. Despite being an enclosed space with defined boundaries, there is freedom of movement that facilitates the development of proprioception. Using tools that provide gentle but dynamic resistance, regardless of the degree or direction of extremity extension, is essential to allowing the baby to move freely within the positioner while providing recoil to a flexed posture.

  • In the first example, a tightly swaddled hospital blanket does not allow for free movement and does not provide recoil
  • A simple positioning nest can allow free movement and may provide some recoil of the lower extremities, but the unsecured straps are unable to facilitate a return to flexion if they are loosened with startling
  • The ideal positioning support encircles the baby in a stretchy, responsive fabric covering that allows free movement and provides recoil, while promoting flexion, containment, and midline alignment and providing proprioceptive input

Learn more about how the Positioning Competency Toolkit can be utilized for your clinical practice by checking out our blog post or by downloading the Toolkit.

Clinician Spotlight: Elizabeth Jeanson PT, DPT, CNT, DCS, NTMTC

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.

9 Therapist Certifications To Enhance Your Clinical Practice

You may have seen our recent blog post about Nurse Certifications, but don’t think we forgot about our Therapist Certifications! Check out the different specialty certifications and certificates available to therapists in the NICU.

Professional Board Certifications

Certified Neonatal Therapist (CNT)

The CNT certification from the Neonatal Therapy Certification Board (NTCB) identifies NICU professionals who are qualified to administer therapeutic care to NICU patients. Find more information about the certification requirements here.

APTA Pediatric Specialist Certification

Governed by the American Board of Physical Therapy Specialties (ABPTS), this certification identifies “individuals who have demonstrated advanced clinical knowledge and skills in physical therapy specialty areas.” Learn more about the specialty areas offered here.

Board Certification in Pediatrics (BCP)

This certification, from the American Occupational Therapy Association (AOTA), recognizes those with “specialized knowledge and critical thinking in the area of pediatric occupational therapy,” according to the AOTA certification information page. Learn about the certification eligibility criteria here.

Additional Certifications and Certificates

Neonatal Touch & Massage Certification™ (NTMC)

This certification, according to the NTMC homepage, is “an exclusively neonatal, one-of-a-kind certification for neonatal healthcare providers.” It provides a combination of holistic, neonatal, and systems theory in its approach to massage. Learn more about this certification process here.

Neonatal Oral Motor Assessment Scale Practitioner (NOMAS)

The Neonatal Oral Motor Assessment Scale was developed in 1983 by Marjorie Meyer Palmer MA, CCC-SLP, and is used for evaluating “neonatal sucking patterns in preterm and term infants,” according to their international homepage. This certification requires a three-day training course, bedside practicum, and a test in order to become a certified NOMAS practitioner. Learn more about training and becoming certified here.

Neuro-Developmental Treatment (C/NDT)

The Neuro-Developmental Treatment Association is a not-for-profit association “consisting of therapists, consumers, and other professionals dedicated to the use and advancement of Neuro-Developmental Treatment (NDT) approach to multidisciplinary treatment of neuromuscular dysfunction,” according to their certification brochure

The NDT Certification™ ensures the continuous integration of current NDT Theory and Practice. Learn more about the certification and its requirements here.

Certified Infant Massage Instructor (CIMI®)

The International Loving Touch Foundation Inc. is one of the world’s first established training programs for infant massage, its founder and director Diana Moor, MS, LMT, CIMI® has been teaching the subject since the early 1970s. 

The Certified Infant Massage Instructor program is accessible either asynchronously or synchronously online from their website. Learn more about their online certification program here.

Certified Manual Lymph Drainage Therapist (CMLDT)

From the Academy of Lymphatic Studies, this 5-day, 40-hour certification course is ideally structured to introduce the techniques and applications of the treatment known as Manual Lymph Drainage (MLD) — developed by Emil Vodder, Ph.D. Learn more about the course and its requirements here.

Trauma-Informed Professional Certificate (TIP)

This certificate is provided by Caring Essentials Collaborative, LLC. It is an assessment-based certificate program that “realizes the pervasiveness of trauma in everyday life and its lifelong lasting effects,” according to their certificate information. Learn more about this certificate here.

Image is of a baby in a NICU incubator, laying on a hospital blanket. A nurse's gloved hands are in the incubator, holding a stethoscope to the baby's exposed belly.

Enhance Your Clinical Practice With These Nurse Certifications!

Working in the NICU is a highly unique form of nursing that branches out further into multiple specialties depending on the specific population of infants a nurse works with. There are many different nurse certifications that allow for more specialized care. Here are a few:

American Association of Critical-Care Nurses (AACN)

Critical-Care Registered Nurse (CCRN®)

CCRN – Neonatal (Direct Care Eligibility Pathway)

This neonatal certification is for nurses who provide care to acutely or critically ill neonatal patients regardless of their physical location. According to the AACN, nurses who primarily or exclusively provide direct care to patients may be eligible for the Direct Care Eligibility Pathway. The majority of practice hours for the CCRN exam “must focus on critically ill patients.” Nurses interested in this pathway may work in NICUs, cardiac care units, trauma units, or critical care transport/flight.

Find more information here.

CCRN – Neonatal (Knowledge Professional Pathway)

This neonatal certification is for nurses who influence the care of acutely or critically ill neonatal patients in ways other than direct care. Nurses who qualify for the Knowledge Professional Pathway may work as an academic faculty, case manager, clinical director, clinical or patient educator, manager/supervisor, nursing administrator or transitional care coordinator.

Find more information here.

Neonatal Acute Care Clinical Nurse Specialist (ACCNS-N)

This is an entry-level advanced practice board certification “for clinical nurse specialists (CNSs) educated at the graduate level to provide advanced nursing care across the continuum of healthcare services—wellness through acute care—to meet the specialized needs of the neonatal patient population.”

Find more information here.

National Certification Corporation (NCC)

Registered Nurse Certified – Neonatal Intensive Care Nursing (RNC-NIC®)

According to the NCC summary, this certification “focuses on the care of the high-risk neonate. It demonstrates the specialty knowledge of Neonatal ICU nurses who provide care to acutely and critically ill neonatal patients and their families within an intensive care environment.” 

Find more information here.

Neonatal Neuro-Intensive Care (C-NNIC)

This certification “focuses on the neurological care of at-risk or impaired neonates within an intensive care environment,” according to the NCC certification summary. It was created for those working in neonatal intensive care who want “to improve overall outcomes for these extremely vulnerable patients.”

Find more information here.

Neonatal Pediatric Transport (C-NPT®)

This certification provides designation for a paramedic, physician, respiratory therapist, neonatal nurse, nurse practitioner, nurse, or physician assistant to “provide stabilization and transport interventions to critically ill neonatal and pediatric patients in all types of settings,” according to the NCC summary.

Find more information here.

Care of the Extremely Low Birth Weight Neonate (C-ELBW)

This subspecialty certification is designed for those who “provide care to acutely and critically ill extremely low birth weight neonates and their families within an intensive care environment to improve overall outcomes.”

Find more information here.

Low Risk Neonatal Intensive Care Nursing (RNC-LRN®)

This certification is for licensed registered nurses in the US and Canada who have a minimum of two years of specialized experience in “providing care to acutely and chronically ill neonatal patients and their families within level II, chronic care, special care, or step-down units.”

Find more information here.

Neonatal Nurse Practitioner (NNP-BC®)

This Core certification provides an entry-level, competency-based examination for licensed registered nurses in the US and Canada who have completed a US-accredited nurse practitioner program to “provide care to acutely and critically ill neonatal patients and their families within hospitals or outpatient settings.”

Find more information here.

Other Certifications

Advanced Nurse Leader Certification — Neonatal & Perinatal (ANLC-N & ANLC-P)

The ANLC-P and ANLC-N certifications provide valuable insights, tools, and strategies to help you succeed in your leadership role and make a positive impact on your teams and organization. There are two types of certifications: ANLC-P for perinatal nurse leaders and ANLC-N for neonatal nurse leaders. Both certifications focus on improving expertise in areas such as mentorship, community, wellness, culture of quality and safety, strategy, and operations.

Find more information here.

Interested in therapist certifications? Check out our blog post 9 Therapist Certifications To Enhance Your Clinical Practice!

Laptop on a desk with the DandleLION Positioning Competency Toolkit webpage on it

Utilizing The Positioning Competency Toolkit

Learn about our latest educational tool for NICU clinicians— The Positioning Competency Toolkit. The Toolkit is grounded in the 5 Tenets of Neurodevelopmentally Supportive Positioning™ and explains how to use each part to achieve better outcomes for premature infants.

What’s Included

The Positioning Competency Toolkit, created by the interdisciplinary Dandle•LION Clinical Education team, is a multimedia resource designed to enhance positioning practice that can be used with any positioning system or device.

The Toolkit was developed to support the standardization of best practices and includes:

  • The Positioning Pearls video series, featuring an introductory video that sets the 5 Tenets™ as the foundation for NICU positioning
  • A visual overview of the 5 Tenets
  • Positioning Competency Tool for clinicians
  • Neonatal Neurodevelopmental Assessment of Posture and Positioning (NeoNAPP) tool to evaluate baby’s positioning against our 5 Tenets

Applications of the Positioning Competency Toolkit may include, but are not limited to:

  1. Unit based clinical orientation
  2. Clinical skills competency training
  3. Quality improvement projects designed to improve positioning practices

How To Use The Toolkit

The Positioning Pearls Video Series

There are seven scenario-based positioning videos in the series.  Start with Neurodevelopmentally Supportive Positioning, the first video of our Positioning Pearls series, that gives clinicians:

  • Familiarity with the 5 Tenets in less than 10 minutes
  • Real-world examples of each tenet in the clinical setting
  • Just-in-time inservice training prior to using the NeoNAPP

The 5 Key Tenets Overview Document

This overview document outlines the 5 Tenets and explains why they promote the healthy development of the brain and body.  By mimicking the womb as much as possible, this approach not only has a substantial impact on the neurodevelopment of preterm infants but also positively impacts the development of future motor milestones.

Positioning Competency Tool

This tool is a pre-and/or post-educational assessment of a caregiver’s skill. It promotes and encourages the proper flow of care and neurodevelopmental integrity by examining the positioning techniques of the assessed clinicians.

The Positioning Competency Tool provides clinicians with:

  • 16 care parameters that relate to proper caregiving and positioning before, within, and after the 5 Tenets
  • A quantifiable assessment that reflects novice to expert-level proficiency in Neurodevelopmentally Supportive Positioning
  • An indication of successful competency in providing the 5 Key Tenets of Neurodevelopmentally Supportive Positioning


The Neonatal Neurodevelopmental Assessment of Posture and Positioning (NeoNAPP) is a tool with pictorial examples that are used to assess a baby’s positioning based on the 5 Tenets. Scores on each tenet can range from 0 (absence of the tenet) to 2 (successful attainment of the tenet).

Clinical implications for the total score are listed at the bottom of the tool:

  • < 7 points – Needs Improvement: Increase positional support
  • 7–9 points – Good: Ensure midline alignment, flexion and containment
  • 10 points – Optimal: Maintain and document position

Why Is The Toolkit Important?

Neurodevelopmentally supportive positioning promotes both neuroprotective age-appropriate developmental care and trauma-informed care. It positively influences physiologic function and stability, sensory development, neurobehavioral organization, skin integrity, thermoregulation, bone density, and sleep, optimizing growth, brain development, and neonatal developmental outcomes. In alignment with work by the National Association of Neonatal Therapists and National Association of Neonatal Nurses, DandleLION Medical has created the 5 Key Tenets of Neurodevelopmentally Supportive Positioning.  The 5 Tenets can be viewed as the gold standard for positioning – flexion, midline alignment, containment, 360 degrees of proprioception, and free movement with recoil.

Educational & Consultation Resources

Laptop sitting on desk, with "Introducing: Dandle Lion Positioning Pearls" and four preview images of positioning pearl videos on the screen.

Everything You Need To Know: Dandle•LION Positioning Pearls

The Positioning Pearls Series

The Positioning Pearls video series was born out of a need for clinically-focused positioning education that speaks to the nuances of positioning babies in various stages of hospitalization.  

Each video follows the same cadence: context, positioning goals, and positioning strategies. In under 10 minutes, each video provides NICU, PICU, and CVICU clinicians with practical advice for positioning their patients using Dandle•LION products with a focus on The 5 Key Tenets of Neurodevelopmentally Supportive Positioning™ (NSP).

The first Positioning Pearl, titled Neurodevelopmentally Supportive Positioning, gives an overview of the 5 Tenets™ with real-life examples of how each tenet might look in clinical practice.  The remaining videos build upon that knowledge, focusing on specific clinical situations: 

Why Neurodevelopmentally Supportive Positioning Is Important

NSP benefits patients, caregivers, and families. The foundations of NSP are the positioning and sensations provided by the womb, which are crucial to healthy infant development. When babies are in the NICU, they miss out on the experience of the womb, which can affect structural and functional development of the brain and body – including the muscles, bones, and senses.

To bridge the gap between womb and NICU and protect biomechanical, musculoskeletal, and neurosensory development, clinicians should focus on the 5 Key Tenets of Neurodevelopmentally Supportive Positioning™ regardless of which positioning aids are available at the bedside: 

  • Flexion 
  • Containment
  • Midline Alignment 
  • 360 degrees of proprioception
  • Free movement with recoil

Literature has demonstrated that providing hospitalized babies with NSP results in improved duration and quality of sleep, leading to:

  • Increased caloric preservation and growth
  • Protected brain development 
  • Decreased respiratory support 
  • Increased parent satisfaction 

With more sound sleep in the NICU, there may be other benefits for babies, clinicians, and parents including:

  • Decreased procedural touch time spent repositioning babies to achieve comfort 
  • Decreased nuisance alarms caused by movement, discomfort, or agitation 
  • Improved parental perception of their baby’s comfort 

For more information, see The National Association of Neonatal Therapists (NANT) white paper titled Development Matters that provides clinicians with a clinical reasoning tool to help grade positioning aids against the literature, and the comprehensive literature review published by the National Association of Neonatal Nurses (NANN) in 2017 titled Positioning the Neonate for Best Outcomes.

Suggested Uses for Positioning Pearls

  • Just-in-time training for new clinical staff, or for the first time caring for a particular type of patient 
  • Clinical skills competency teaching and evaluation
  • QI projects to improve positioning in a specific population

Accessing the Positioning Pearls

The Positioning Pearls video series can be found on our Vimeo Channel or on our website.

by Dandle•LION Director of Education Alex Luton MN, BS, RN

Clinician Spotlight: Liz Drake MN, NNP, CNS, RN-NICU, C-ELBW

Dandle•LION is proud to partner with expert clinicians to provide the best available education and evidence-based care strategies. We are excited to introduce you to Elizabeth Drake, MN, NNP, CNS, RN-NICU, C-ELBW, the current CNS in the NICU at CHOC Children’s of Orange County, Mission Viejo Campus!

Liz is also a published author, nationally recognized national conference presenter, consultant and Co-owner of @EngageGrowThrive, and co-developer of the Small Baby Care Specialist Program.

Liz Drake has been practicing in the NICU for 40 years. She has practiced in different roles throughout her career, but her time spent at the bedside with patients, families, and team members are most meaningful.

Extremely passionate about quality Improvement, caring for extremely low birth weight infants, and neuroprotective care, Drake has a strong desire to teach all members of the healthcare team about the uniqueness and language of the premature infant.

As an active clinician, she focuses on how every touch and relational experience we have with premature infants and their families can have an impact. Drake is actively involved with the California State Collaborative in order to partner with families and lead quality improvement initiatives.