Neutral Head Positioning in Premature Infants for

N E O N A T A L N E T W O R KV O L . 3 0 , N O . 6 , N O V E M B E R / D E C E M B E R 2 0 1 1 © 2 0 1 1 S p r i n g e r P u b l i s h i n g C o m p a n y 3 8 1 h t t p : / / d x . d o i . o r g / 1 0 . 1 8 9 1 / 0 7 3 0 – 0 8 3 2 . 3 0 . 6 . 3 8 1

Accepted for publication May 2011.

Neutral Head Positioning in Premature Infants for Intraventricular

Hemorrhage Prevention: An Evidence-Based Review

Sheila Malusky, DNP, RN, NNP-BC Ann Donze, MSN, RN, NNP-BC

In the UnIted StAteS eAch yeAr, ApproxIMAtely 57,000 infants are born prematurely. With the advancement of

neonatal medicine during the past several decades, including improved methods of mechani-cal ventilation and the devel-opment of tota l parentera l nutrition (tpn) for neonates, even extremely low birth weight (elBW) infants are now living longer and surviving.1 of these infants, 20–25 percent of them will develop an intraventricular hemorrhage (IVh),2 with the incidence being inversely pro-portional to gestational age.3

the total financial cost that is estimated for these premature births is $26 billion or $51,600 for each individual prema-ture birth. these costs include medical care, delivery costs, early intervention services, educational services, and lost family income.4 Additionally, the average cost of an IVh adds another $53,600 to the cost of the initial hospi-talization.5 But the costs of IVh go far beyond the impact of the

injury in the individual and the financial burden to care for these babies. the impact can also be devastating to the family

who has the responsibility of caring for a disabled child. the lifelong commitments to care for these individuals tax the family structure, family resiliency, and bring about the additional need for community support.

there has been a multitude of research into the prevention of IVh in premature infants.6 Some of these studies examine prenatal factors such as antenatal steroid use.7 other studies have focused on antenatal factors such as delivery room resuscitation methods.8 Still other studies have focused on neonatal preven-tion methods such as pharmaco-logic interventions and neonatal care management methods.9

one neonatal care manage-ment activity that has been examined in association with IVh prevention is infant head positioning. First studied in adult patients, cerebral blood flow changes in response to head position were also examined in

neonates beginning in the 1980s.10–12

the purpose of this article is to review current evidence on midline head positioning in the prevention of IVh. the goal

AbstrAct

With the advancement of neonatal medicine during the past several decades, premature and critically ill infants are living past the neonatal period and surviving. the survival of these infants at smaller birth weights and younger gestational ages puts them at an increased risk for intraventricular hemorrhages (IVhs). Although shifts in cerebral perfusion have been linked to the development of these brain bleeds, many seemingly benign care activities have been linked to changes in cerebral blood flow patterns, possibly contributing to IVhs. the purpose of this article is to evaluate the current evidence to determine if the practice of midline positioning for infants born less than 32 weeks gestation for possible IVh prevention is supported by the literature. Many of the researchers involved in these studies attributed the consequential venule leakage of blood to occlusion of the jugular venous drainage system following a turn in the position of the head. Additionally, the articles that examined the connection between the effects of head tilting on brain hemodynamics attributed changes on the infants’ potential inability to autoregulate cerebral blood flow adequately. Both of these findings were linked to the development of IVhs. Based on physiologic data and expert opinion, the authors found support in the literature and recommend implementing a plan of care that includes midline head positioning for premature infants.

DisclosureThe author discloses no relevant financial interest or affiliations with any commercial interests.

3 8 2 N O V E M B E R / D E C E M B E R 2 0 1 1 , V O L . 3 0 , N O . 6N E O N A T A L N E T W O R K

of this review was to answer the clinical practice question: In infants born at ,32 weeks gestation, does midline head positioning along with head of bed tilted upward for the first 72 hours of life, when compared with standard posi-tioning, result in a lower incidence of IVH?

ETIOLOGY AND PATHOPHYSIOLOGY OF INTRAVENTRICULAR HEMORRHAGE

Although this potentially devastating medical condition can occur at any age, premature infants are at an increased risk because of their immature brain vasculature and also their inability to autoregulate shifts in cerebral perfusion, described as a pressure-passive circulatory state.13,14 Of the bleeds that occur, 90 percent will develop during the first 72 hours of life, a time when these infants are in their most critically ill state.3 Although extreme prematurity and illness have been associ-ated with shifts in brain perfusion, many seemingly benign care activities and environmental factors have also been shown to cause changes in cerebral blood flow patterns.2,13–16

Although there are many risk factors associated with the development of an IVH, some of which are noted in Table 1, one of the most prominent risks is prematurity.3,17 This increased risk is caused by the presence of the germinal matrix, a network of delicate blood vessels within the pre-mature brain that usually involutes between 32 weeks and term gestation.3 Within this region, the capillary–venule juncture is the originating site of these hemorrhages.3 The fragile blood vessels within the germinal matrix are easily ruptured with any rapid changes in the levels of cerebral perfusion, which may lead to bleeding into the brain tissue or ventricles.18 The structure of the venous system in this area of the brain can also lead to IVH because the system has a U-shaped vessel pattern prone to venous congestion near the germinal matrix, again causing vessel damage and bleeding. A cranial ultrasound view of a neonate without IVH can be seen in Figure 1, whereas Figure 2 shows a drawing of the U-shaped vascular anatomy.

A factor unique to this population is the inability of premature infants to autoregulate cerebral perfusion in response to physi-ologic and positional changes.13 Autoregulation is the ability of the body to maintain a constant blood flow to the brain despite cerebral perfusion.19 Inconsistencies in cerebral blood flow pat-terns have been observed during routine critical care of the premature infant.16 Impaired autoregulation can be markedly pronounced in infants who are sick or extremely premature.14,20

The mechanism of action that has been postulated is that during head rotation to the side, an occlusion or obstruction of the jugular venous–venule drainage system could occur on the ipsilateral side of the head. This is followed by increased venous congestion in this area leading to vessel rupture.

Figure 1 n Cranial ultrasound of a neonate without IVH.

TABLe 1 n Associated Risk Factors for IVH

Antenatal Risk Factors

Prematurity

Maternal infection

Maternal inflammatory responses

Maternal hypertention

Maternal bleeding disorders

Absent maternal steroid administration maternal diabetes

Placental insertion disorders

Oligohydramnios

Maternal alcohol use

Maternal smoking

Poor prenatal care

Infertility treatments

Out-born delivery and neonatal transport

Initial resuscitation efforts

Asynchronous ventilatory support

High continuous airway pressure

Rapid fluid administration

Rapid alteration in blood pressure

Hypotension

Hypocarbia or hypercarbia

Pneumothorax

Asphyxia

Hypernatremia

Hypoglycemia

Thrombocytopenia

Patent ductus arteriosis

Seizure activity

Routine NICU care: Tracheal suctioning, excessive handling, noxious stimulation, painful procedures, stress

Any disease process or care activity associated with alteration in cerebral perfusion.

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By maintaining a neutral head position, it is theorized that venous obstruction could possibly be avoided, potentially preventing IVH caused by head position.

INTRAVENTRICULAR HEMORRHAGE SEVERITY AND OUTCOMES

Diagnosed by cranial ultrasound, an IVH can occur fol-lowing serious illness of the infant or after no apparent insult at all. During the first four to five days of life, a time when premature infants are in their most critical state, 95 percent of all cases of IVH will develop.21 Depending on the severity, some of these bleeds may be accompanied by an acute deteri-oration in clinical status, whereas some infants may show few symptoms until they reach school age.22 Overall, Paige and Carney found the associated sequelae of IVH to range from minimally distinguishable effects (50 percent), to abnormal neurologic outcomes (20–30 percent), to an increase in inci-dence of mortality (10–30 percent).22

Although the IVH has been broken down into classifica-tions by grade, Volpe later developed an IVH labeling system based on a description of the neurologic pathology.3,23,24 This was caused by some abnormalities that can occur that do not fit into the original classifications. Such cases could include isolated ventriculomegaly or instances of white matter injury that are not associated with IVH.25 Volpe also advocated for the cessation of labeling white matter brain tissue hemorrhages, or parenchymal hemorrhages, Grade IV IVH.3 This was caused by the origination of these bleeds, at times, occurring secondary to parenchymal infarction and not always being associated with bleeding within the ventricles.25

The Papile IVH grading system also does not describe the site of origin for the IVH.25 Most often, intracranial hemorrhages in premature infants originate in the germinal matrix, a highly vascular and fragile region in the premature infant’s brain. Alternately, the choroid plexus can also be

an origination site, although this is more common in term infants.25,26 Regardless of site of origination or description of pathology, many bleeds are now being associated with the level of neurodevelopmental outcomes risk.25 Low-grade risk bleeds are associated with Grade I and II hemorrhages. High-grade risk bleeds are associated with Grades III and IV hemorrhages. See Table 2 for a description of IVHs and statistics for very low birth weight (VLBW [,1,500 g]) infants.

Because an IVH can be such a devastating event, there is a critical need to identify strategies to reduce IVH in this pop-ulation. One proposed strategy is the use of midline position-ing during the first 72 hours of life, a time when 90 percent of all IVH occur.3

DEVELOPING THE CLINICAL PRACTICE QUESTION USING PICO FORMAT

When completing an evidence-based review of the liter-ature, developing a question that helps focus the literature search is the first step. PICO is a mnemonic term used to focus and describe each part of the clinical practice question: “P” is the population, “I” is the intervention, “C” is the comparison group, and “O” is the outcome.33

The PICO question focuses on an intervention that is compared to the current standard of care. If there is evi-dence that an intervention may provide benef it without harm, an intervention may be implemented into practice. The PICO or clinical practice question that prompted this search was:

“Do infants born at ,32 weeks gestation who are posi-tioned with head in midline position and head of bed tilted upward for the first 72 hours of life have a lower incidence of IVH than infants who receive standard positioning?” P 5 In infants born at ,32 weeks gestation I 5 does midline head positioning along with the head of

bed tilted upward for the first 72 hours of life C 5 compared with standard positioning O 5 result in a lower incidence of IVH

LITERATURE SEARCH STRATEGIESA literature search using the keywords intracranial hem-

orrhages, cerebral ventricles, infant, and newborn was per-formed using Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Google Scholar. The search years were limited from 1980 to 2010. On the first search, 935 articles were found. The search was then limited to articles in English, human subjects, and infants from birth to 23 months of age. This search yielded 800 articles. The search was then altered to infant, premature, and cerebral ventricles and hemorrhage with the same limi-tations of English, human subjects, and infants from birth to 23 months of age. The reason that older research was admitted into this search is that this early time represents the initial study into IVH and premature infants. Many of the positioning studies were conducted during the 1980s

Figure 2 n U-shaped vascular anatomy.

Medullary veins

Choroidal vein

Thalamostriatevein

Vein of Golen

Terminalvein

Internalcerebral vein


and have not been repeated. The search then yielded 189 articles. When the term prevention was added to the search, 77 articles were found that most appropriately fit the clinical question.

Following this, a search of the Cochrane Systematic Review Database was completed. Although many reviews on IVH prevention were present, the reviews focused on the medical management of IVH, such as medication administration. There was one review regarding devel-opmental care and the prevention of morbidities, but no

systematic review of nursing care activities or positioning was found.34

Of the 77 articles reviewed, organization of the rest of the review consists of an evaluation of 11 articles. These articles most appropriately answered the review question regarding positioning the premature infant and IVH prevention. The other 66 articles that were discarded did not address research relating to positioning and IVH occurrence in the premature neonate. The following discussion synthesizes the evidence collected.

Table 2 n Intraventricular Hemorrhages

Papile’s Classification by Severity

Volpe’s Classification: Description by Pathology

Occurrence Rate

Morbidity and Neurologic Outcomes

Mortality Progression of Ventricular Dilatation

Grade I: least severe mild IVH

See Figure 3

Subependymal hemorrhage (SEH)—also called germinal matrix hemorrhage (GMH)

25%–30% for Grades I–II27

Ten percent motor disability. This rate is comparable to premature infants without documented hemorrhage.24

5%3 4%28

Grade II: considered mild-to-moderate IVH

See Figure 4

Intraventricular hemorrhage (IVH)—alternately called a SEH with progression into the lateral ventricles by ,50% without dilatation.

Most infants with Grade II IVH face the same neurologic outcomes associated with Grade I IVH, although the extent of bleed can lead to ventricular dilatation.18 Patra et al. found significantly poorer neurodevelopmental outcomes in extremely low birth weight (ELBW) infants (,1,000 g) with Grades I–II IVH at 20 months corrected age. This includes up to 15% of these ELBW infants with Grades I–II IVH who develop cerebral palsy (CP) and 9% who develop deafness.27

10%3 12%28

Grade III: considered moderate-to-severe IVH

IVH with ventricular dilatation—SEH with progression into the lateral ventricles by .50% and/or with dilatation of ventricles.

10%–12% for Grades III–IV29

Ventricular dilatation can result when blood blocks the cerebrospinal fluid pathway, leading to progressive ventricular dilatation and increased intracranial pressure. The morbidity related to posthemorrhagic hydrocephalus is significant, with up to 90% of these infants having some degree of neuromotor deficits and 25% with visual and auditory impairments.30 In total, 76% of these infants will have pronounced disability and 56% have multiple impairments.28 Fifty percent of these children will require some special education and enrichment programs.24

20%3 74%28

Grade IV: considered severe IVH

See Figure 5

Intraparenchymal hemorrhage (IPH)—hemorrhagic infarct into the white brain matter

Generally unilateral with the prognosis most often associated with poor motor deficits as well as significant cognitive impairments.24 Classified as the most severe IVH, many infants do not survive.

50%3 71%28

Periventricular leukomalacia (PVL)— parenchymal, or white brain matter, necrosis often occurring following Grade IV IVH or a parenchymal infarct.

Ten percent very low birth weight (VLBW) infants with PVL will develop CP with spastic diplegia and 50% will develop cognitive and behavioral deficits.31,32


Figure 3 n Ultrasound of Grade I IVH.

Figure 4 n Ultrasound of Grade II IVH.

Figure 5 n Ultrasound of Grade IV IVH.


SYNTHESIS AND SUMMARYDetails of all appraised studies can be found in the Appendix.

The Five Strengths of Evidence35

Type 1: strong evidence from at least one systematic review of multiple, well-designed randomized, controlled trials.

Type 2: strong evidence from at least one properly designed randomized, controlled trial of appropriate size.

Type 3: evidence from well-designed trials without random-ization, single group pre–post, cohort, time series, or matched case-control studies.

Type 4: evidence from well-designed, nonexperimental studies from more than one center or research group.

Type 5: opinions of respected authorities (based on clinical evi-dence), descriptive studies, or reports of expert committees.

There was no meta-analysis or randomized controlled trials. The studies included nine predesigns and postdesigns, two repeated measures design, and one expert review panel report. One of the studies used both a premethodology and postmethodology as well as a repeated measure design, total-ing 11 reviewed articles.36

When synthesizing the evidence gathered regarding the positioning of premature infants and the potential effects of these positions on cerebral hemodynamics, the information gathered was analyzed following the PICO format. The purpose of this analysis was to determine whether the studies reviewed were homogenous. This is an important step in evaluating whether the study simi-larities lend to the pooling of evidence that may support a practice change.

First, did all of the studies ask the same question? Not all of them. Although the articles were included in the review because of similar subject matter, the focus of some of these articles was not exactly homogenous. Eight of the articles studied changes in cerebral hemodynamic and two studied changes in intracranial pressure (ICP) in response to position changes. The final article gave expert opinion about infant positioning after benchmarking hospitals with low IVH rates.

Next, the articles were examined to determine the homoge-neity of the “P,” or population. Of the articles reviewed, nine studies examined preterm infants. A tenth article that exam-ined full-term infants was also included because this study is often cited as a seminal article that examines changes in neo-natal cerebral hemodynamic in response to position change.11

Of the articles examined, there was a wide variation in ges-tational age, weight, postnatal age, and level of illness. These infants ranged from the most premature and critically ill infants to infants who were described by the authors as healthy pre-mature infants. Because of the profoundly wide variation in levels of health and gestational age of the subjects, comparing outcomes for infants in this review was difficult. Additionally, none of these studies strictly examined the neonates during their first 72 hours of life, a time when most IVHs occur.32

Next, the articles were examined to determine the homoge-neity of the “I,” or interventions. The interventions reported

for these studies centered on positioning or altering position of the newborn infant. Some of these articles focused on the effects of midline head positioning, whereas others looked at the effects of changes in the tilting position. Regardless of particular position change that each individual study exam-ined, they all evaluated changes in cerebral hemodynamics or ICP in response to position change.

Following the positioning interventions, an evaluation of cerebral blood flow or ICP was assessed. There were various instruments used to assess these measures. In the 10 articles with patient enrollment, 5 used near infrared spectroscopy (NIRS), 4 used ultrasound, and 2 used a transfontanel pres-sure transducer. The transfontanel pressure transducers were used in the first studies, followed by the use of ultrasound, and then NIRS methodology because technology has pro-gressed. A brief description of the instrumentation used for the evaluations is listed in Table 3.

The articles were then examined to determine the homoge-neity of the “O,” or outcomes. When evaluating the outcomes reported in these studies, the groups could be separated into two divisions: those that evaluated the effects of head or body position changes and those that evaluated the effects of tilting. In those that evaluated head and body changes, several outcome measures were used and not all assessed the incidence of IVH, making the evaluation of the intervention difficult.

In general, these articles demonstrated alterations in cere-bral blood flow following position changes. One study found a significant decrease in tissue hemoglobin index and tissue oxygen index during head rotation in infants ,26 weeks ges-tation.37 A second study found a significant increase in cerebral blood volume (CBV) during 90-degree head rotation, which was pronounced in infants ,1,200 g.38 The third study found cerebral blood flow velocities were significantly higher in the

TABLE 3 n Definition of Study Instruments

Ultrasonography A non-invasive radiological exam that uses a transducer to pass sound waves through soft tissue and fluid. A picture is produced when the returning echo bounces off internal structures and returns to the transducer. The resulting picture is formed when the data entered into the transducer is read by the ultrasound computer and is analyzed to produce real-time images.44

Trans-fontanel Pressure Transducer

A non-invasive device that measures intracranial pressure through a probe secured over the anterior fontanel.10

Near Infrared Spectroscopy (NIRS)

A non-invasive neuro-imaging device that uses near-infrared light to evaluate real-time tissue oxygen and blood volume to interpret blood hemodynamics of the brain.43


supine position at one month of age during evaluation, and vertebral arterial flows in prone position were decreased.39 A fourth study found jugular blood flow was decreased during 90-degree head rotation.11 The three studies that evaluated ICP all found a significant decrease in ICP, with the head in midline position and the head of the bed elevated.10–12

The second group of studies examined the effects of tilting. These studies evaluated CBV and found a significant increase with the head lowered in a dependent position. These studies also found signif icant alterations in CBV in response to tilting, especially in preterm or brain-injured infants. Another study evaluated for biphasic responses in cerebral blood flow velocities, demonstrating autoregulatory responses in preterm infants, and found significantly more reliable responses were elicited as gestational age increased but IVH outcome was not evaluated.36 A complete description of the findings of these articles can be found in the Appendix.

Although the final article was not a research study, infor-mation from such an article can still be valuable. This article by Carteaux and colleagues detailed the work of a multidis-ciplinary focus group that was formed to complete an evi-dence-based literature review, benchmarking activities, and expert committee review. The purpose of this evaluation was to identify potentially better practices (PBPs) that could lead to the reduction of IVH and periventricular leukomalacia (PVL) in VLBW and premature infants.6

The group identified benchmark NICUs with the lowest incidence of IVH reported to the Vermont Oxford Network (VON). The VON, a consortium of more than 700 NICUs associated with the improvement of safety and quality of newborn care, formed a focus group to evaluate methods for reducing the incidence of IVHs in premature infants.40 It then developed an NICU practice questionnaire for VON sites. Four sites with low incidence of intracranial hemorrhage were iden-tified and used as a benchmark for clinical practice. Specific clinical practices at these sites were described through struc-tured questionnaires and site visits. The information obtained from these sites was analyzed and used to help identify NICU practices that might be related to IVH prevention. A complete literature review was then completed on each of these NICU practices. Following the benchmarking and literature review, the group identified a final list of ten recommended practices for NICUs that were PBPs, which could help with the reduc-tion of incidence of IVH. Use of midline positioning and bed elevation of 30 degrees was identified as PBPs.

DISCUSSIONThe decision to make a practice change should be based

on the grade, quality, and strength of the evidence after synthesizing all data. Of the 11 articles reviewed, 10 of them involved clinical trials. Of these, all were Type 3 evi-dence with a quasi-experimental, nonrandomized conve-nience sample design with five studies including a control group. All of the studies were small and no power analy-sis was commented upon. Many of the studies were older,

and technology and medical practices may have changed. Finally, all nine studies that examined preterm infants would be considered “stable” neonates and may not reflect the group of patients who are at greatest risk for IVH, those who are severely premature during their first 72 hours of life. The final article, based on expert opinion, benchmark-ing, and review of the literature, reviewed multiple practices and their recommendations varied between level, depending on the strength of the evidence.6 The level of evidence for the recommendations on head positioning by VON was IV and VI.6 According to the Muir Gray schema of evidence that was used to rate the evidence, IV is defined as a well-designed, nonexperimental study, and VI is defined as an evidence supported by casual theory of disease.35 Although there are limitations to these 11 studies, they may still, however, provide some benefit to our patient population. Many investigators included discussion about how their study results could be interpreted. The expert opinion of many of the researchers attribute changes in cerebral oxy-genation, increased CBV, and/or increased ICP to occlu-sion of the jugular venous drainage system following a turn in the position of the head. The proposed consequential backup of cerebral blood is an ongoing theme presented by many of the authors, although jugular blood flow was only analyzed in one study.6,11,12,37–39 These authors then specu-late that the risk of IVH was increased because of ruptures in the cerebral venous–venule drainage system following blood accumulation secondary to the occlusion. Although jugular obstruction studies during head rotation have been documented in the adult population, results in the neonatal population are limited and similar results in this population are theorized.11,38 The researchers concluded that venous obstruction caused by head position could be detrimental to these infants who are already at increased risk for IVH.

A second observation that was discussed by the investiga-tors was the connection between the effects of head tilting on brain hemodynamics. Of the four studies that examined tilting, the experts attributed the results, an increase in CBV and/or increased ICP, to the infants’ potential inability to autoregulate cerebral blood flow adequately. Because these findings were sig-nificantly increased in infants with PVL, brain injury, and those who were premature, the authors further speculated these find-ings may put these infants at a greater risk for developing IVH.

All of the methods of measurement used throughout the studies showed a difference in cerebral hemodynamics when positioning was changed. These findings were present in the head rotation studies as well as the tilting ones. These differences were most marked in the ELBW infant. Present studies, unfortunately, only include outcome measures that were short-term and any changes in practice should include long-term outcome measurement.

The investigators who completed the expert review6 did discuss the lack of high-level evidence when evaluating infant positioning.6 The decision to recommend the use of neutral head position was based on the potential benefits of this


practice and the lack of harm. Based on these recommenda-tions, many NICUs currently use these positioning practices.

IMPLEMENTATION OF NEUTRAL HEAD POSITIONING

The decision to implement midline/neutral head posi-tioning and a 30-degree elevation in the HB in infants less than 32 weeks gestation for the first 72 hours of life can be recommended, at this point, based on physiologic data and the views of experts in the field. Furthermore, there have not been any adverse consequences identified when implement-ing these positioning changes.

For units considering a change in neonatal positioning practices for potential IVH prevention such as the implemen-tation of neutral head positioning, there are several impor-tant steps to facilitate change. These steps should only occur following critical appraisal of the evidence.

Gather the StakeholdersThe stakeholders incorporated in this practice change

should include registered nurses who care for the infants and understand the fine nuances of caring for the infants. The physicians, advance practice nurses (APNs), and bedside staff nurses would be essential in identifying infants appropriate for this practice change and for ordering this care practice. Physical therapists would be needed to assist with positioning and obtaining positioning devices needed on an individual bases. Respiratory therapists would be important to help posi-tion infants in neutral head positioning while still receiving the necessary respiratory support. Specialized equipment may be needed to positioning these infants midline, especially if the infant is on an oscillating ventilator. Pharmacists input to maintain patient comfort may also be a necessity. Our unit has developed a multidisciplinary IVH prevention taskforce com-prised of representation from all the mentioned stakeholders to evaluate the evidence and provide recommendations.

Create a Detailed Action PlanThe first steps to creating an action plan would be to

use the stakeholders to discuss potential obstructions, plan nursing and medical team education, and plan parent educa-tion. An audit of current positioning practices can help the team assess the degree of change that is being proposed for the unit. This can help the team determine the amount of time this change may require and the amount of support needed to be successful with this change.

Planning to assess outcome measures (IVH rates) prior to the practice change is important in evaluating if the practice change of midline positioning has made a difference in this patient population. Our unit has done this step in the IVH prevention taskforce.

Assessing Environmental ReadinessThe stakeholders must evaluate and address the organi-

zation, environment, and whether it is supportive to this evidence-based practice (EBP) change at this time. The three

areas to assess are organizational culture, organizational infrastructure, and organizational resources.41 In assessing organizational culture, one would assess the values of the unit. Do the caregivers understand the importance of imple-menting evidence-based recommendations? Do the nurses and other caregivers understand the potential benefits and how to achieve neutral head positioning? Does the practice change support family-centered care, an important value to NICU caregivers? Does this practice change support devel-opmental care practices, another important care value in NICUs? Have the team given input in identifying potential barriers to this practice change, including nursing barriers to care and equipment needs?

In assessing organizational infrastructure, one would assess the organization’s willingness to support evidence-based care practice changes. Does the unit have goals that state support of practices based on the most current evidence?41 Has the organization made efforts to hire or train employees in the evidence-based process?

The organizational resource assessment evaluates whether an organization is willing to support the man-hours needed to evaluate the evidence and implement these changes. Can the organization financially support the EBP process, which includes the evaluation, implementation, and assessment phase of this process? Is the organization willing to supply equipment and training time? If the organization cannot give full financial support for the practice change, are they willing to support further planning to identify creative alter-nates that support the evidence?

Use Multiple Implementation StrategiesWhen implementing a practice change, multiple imple-

mentation strategies can help ensure success. Does the education plan include multiple methods to reach the care-giving team, such as demonstrations of midline positioning and posters with pictures? Does the education presentations included multiple levels of medical knowledge, with the dif-ference being parental education being easier to understand for the layperson and the medical education, including a more pathophysiologic approach to address the caregivers under-standing of the rationale for change? When implementing these changes, are there multiple approaches to support the bedside nurses such as the team members available to address technical questions and nursing champions to encourage practice change use through exemplifying the practice?

EVALUATING OUTCOMESProcess Outcomes

Once the practice change has occurred, a method to assess the practice change is essential. Is the practice implemented as designed? Can the caregiving team describe midline posi-tioning and demonstrate this practice change correctly? Is midline positioning being performed routinely? Have the caregiving team identified further barriers to midline posi-tioning as the practice occurs on a routine basis? A quality assurance plan to assess that the practice change is being


executed regularly and correctly is essential. This is impor-tant because it assesses whether a practice change is truly being carried out as planned. A method to evaluate this could be the formation of “positioning super users” to audit patient positioning and evaluate the need for further educa-tion based on their findings. The identification of barriers and development of solutions to barriers is essential in the success of the implementation of this change.

Clinical OutcomesThe final step in this process is an evaluation of the clini-

cal outcomes. Has this change made an impact? How do the current IVH rates compare with the rates prior to the prac-tice change, as well as the rates of others such as NICUs? Can we follow long-term outcomes such as incidence of cognitive, behavioral, and physical disabilities?

Future DirectionAlthough the cause of IVH in premature infants may be

multifactorial and complicated, many investigators are cur-rently searching for prevention methods. Some neonatal units have adopted IVH prevention bundles or multiple care practice changes that can potentially reduce the incidence of IVH.42 Regardless of whether a unit is looking to make several practice changes or just one change at a time, there is little dispute that work toward a decrease in the incidence of IVH in premature infants should continue.

Additionally, further research into neonatal positioning for IVH prevention should continue. Although the strength of evidence to support this practice change could be stronger, the decision to adopt this practice change should be evalu-ated and discussed in individual neonatal units. The adoption of the practice of midline positioning could still be recom-mended based on its potential benefits.

With the increased survival of extremely premature infants, the incidence of IVH, a common neonatal morbidity, can be expected to rise proportionately. Although research into the prevention of this potentially devastating illness should continue, caregivers must continue to evaluate the litera-ture in evaluation of their current practices. Because IVH can be so devastating to the infant, caregivers must strive to provide evidence-based care that can potentially prevent these occurrences.

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Family-centered care and the pediatrician’s role. Pediatrics, 112(3 Pt. 1), 691–697.

2. McCrea, H. J., & Ment, L. R. (2008). The diagnosis, management, and postnatal prevention of intraventricular hemorrhage in the preterm neonate. Clinics in Perinatology, 35(4), 777–792. http://dx.doi.org/10.1016/ j.clp.2008.07.014

3. Volpe, J. J. (2008). Intracranial hemorrhage: Germinal matrix-intraventricular hemorrhage of the premature infant. In Neurology of the newborn (5th ed., pp. 517–588). Philadelphia, PA: Saunders Elsevier.

4. March of Dimes. (2009). About prematurity: The economic costs. Retrieved from http://www.marchofdimes.com/prematurity/21198_10734.asp

5. Russell, R. B., Green, N. S., Steiner, C. A., Meikle, S., Howse, J. L., Poschman, K., . . . Petrini, J. R. (2007). Cost of hospitalization for preterm and low birth weight infants in the United States. Pediatrics, 120(1), e1–e9. http://dx.doi.org/10.1542/peds.2006-2386

6. Carteaux, P., Cohen, H., Check, J., George, J., McKinley, P., Lewis, W., . . . McConnell, C. (2003). Evaluation and development of potentially better practices for the prevention of brain hemorrhage and ischemic brain injury in very low birth weight infants. Pediatrics, 111(4 Pt. 2), e489–e496.

7. Crowley, P. (2000). Prophylactic corticosteroids for preterm births. Cochrane Database of Systematic Reviews, (2), CD000065.

8. Kattwinkel, J., Niermeyer, S., Nadkarni, V., Tibballs, J., Phillips, B., Zideman, D., . . . Osmond, M. (1999). Resuscitation of the newly born infant: An advisory statement from the Pediatric Working Group of the International Liaison Committee on Resuscitation. Resuscitation, 40(2), 71–88.

9. Vohr, B., & Ment, L. (1996). Intraventricular hemorrhage in the preterm infant. Early Human Development, 44(1), 1–16.

10. Emery, J. R., & Peabody, J. L. (1983). Head position affects intracranial pressure in newborn infants. The Journal of Pediatrics, 103(6), 950–953.

11. Cowan, F., & Thoresen, M. (1985). Changes in superior sagittal sinus blood velocities due to postural alterations and pressure on the head of the newborn infant. Pediatrics, 75(6), 1038–1047.

12. Goldberg, R. N., Joshi, A., Moscoso, P., & Castillo, T. (1983). The effect of head position on intracranial pressure in the neonate. Critical Care Medicine, 11(6), 428–430.

13. Owens, R. (2005). Intraventricular hemorrhage in the premature neonate. Neonatal Network, 24(3), 55–71.

14. Perlman, J. M. (2009). The relationship between systemic hemodynamic perturbations and periventricular-intraventricular hemorrhage—A historical perspective. Seminars in Pediatric Neurology, 16(4), 191–199. http://dx.doi.org/10.1016/j.spen.2009.09.006

15. Ballabh, P. (2010). Intraventricular hemorrhage in premature infants: Mechanism of disease. Pediatric Research, 67(1), 1–8.

16. Limperopoulos, C., Gauvreau, K. K., O’Leary, H., Moore, M., Bassan, H., Eichenwald, E. C., . . . du Plessis, A. J. (2008). Cerebral hemodynamic changes during intensive care of preterm infants. Pediatrics, 122(5), e1006–e1013. http://dx.doi.org/10.1542/peds.2008-0768

17. Vergani, P., Locatelli, A., Doria, V., Assi, F., Paterlini, G., Pezzullo, J. C., & Ghidini, A. (2004). Intraventricular hemorrhage and periventricular leukomalacia in preterm infants. Obstetrics and Gynecology, 104(2), 225–231.

18. Bloch, J. R. (2005). Antenatal events causing neonatal brain injury in premature infants. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 34(3), 358–366.

19. Kaiser, J. R., Gauss, C. H., & Williams, D. K. (2005). The effects of hypercapnia on cerebral autoregulation in ventilated very low birth weight infants. Pediatric Research, 58(5), 931–935.

20. Wong, F. Y., Leung, T. S., Austin, T., Wilkinson, M., Meek, J. H., Wyatt, J. S., & Walker, A. M. (2008). Impaired autoregulation in preterm infants identified by using spatially resolved spectroscopy. Pediatrics, 121(3), e604–e611. http://dx.doi.org/10.1542/peds.2007-1487

21. Linder, N., Haskin, O., Levit, O., Klinger, G., Prince, T., Naor, N., . . . Sirota, L. (2003). Risk factors for intraventricular hemorrhage in very low birth weight premature infants: A retrospective case-control study. Pediatrics, 111(5 Pt. 1), e590–e595.

22. Paige, P. L., & Carney, P. R. (2002). Neurological disorders. In G. B. Merenstein & S. L. Gardner (Eds.), Handbook of neonatal intensive care (5th ed., pp. 644–678). St. Louis, MO: Mosby.

23. Papile, L. A., Burstein, J., Burstein, R., & Koffler, H. (1978). Incidence and evolution of subependymal and intraventricular hemorrhage: A study of infants with birth weights less than 1,500 gm. The Journal of Pediatrics, 92(4), 529–534.

24. Papile, L. A. (2002). Intracranial hemorrhage. In A. A. Fanaroff & R. J. Martin (Eds.), Neonatal-perinatal medicine: Diseases of the fetus and infant (7th ed., pp. 1001–1011). St. Louis, MO: Mosby.


25. Vasileiadis, G. T. (2004). Grading intraventricular hemorrhage with no grades. Pediatrics, 113(4), 930–931.

26. Annibale, D. J. (2010). Periventricular hemorrhage-intraventricular hemorrhage. Medscape. Retrieved from http://emedicine.medscape.com/ article/976654-overview

27. Patra, K., Wilson-Costello, D., Taylor, H. G., Mercuri-Minich, N., & Hack, M. (2006). Grade I-II intraventricular hemorrhage in extremely low birth weight infants: Effects on neurodevelopment. The Journal of Pediatrics, 149(2), 169–173.

28. Murphy, B. P., Inder, T. E., Rooks, V., Taylor, G. A., Anderson, N. J., Mogridge, N., . . . Volpe, J. J. (2002). Posthaemorrhagic ventricular dilatation in the premature infant: Natural history and predictors of outcome. Archives of Disease in Childhood. Fetal and Neonatal Edition, 87(1), F37–F41.

29. Ment, L. R., Allen, W. C., Makuch, R. W., & Vohr, B. (2005). Grade 3 to 4 intraventricular hemorrhage and Bayley scores predict outcome. Pediatrics, 116(6), 1597–1598. http://dx.doi.org/10.1542/peds.2005-2020

30. Chumas, P., Tyagi, A., & Livingston, J. (2001). Hydrocephalus—what’s new? Archives of Disease in Childhood. Fetal and Neonatal Edition, 85(3), F149–F154.

31. Perlman, J. M. (1998). White matter injury in the preterm infant: An important determination of abnormal neurodevelopment outcome. Early Human Development, 53(2), 99–120.

32. Volpe, J. J. (2003). Cerebral white matter injury of the premature infant-more common than you think. Pediatrics, 112(1 Pt. 1), 176–180.

33. Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia, PA: Lippincott, Williams & Wilkins.

34. Symington, A., & Pinelli, J. (2003). Developmental care for promoting development and preventing morbidity in preterm infants. The Cochrane Library, (4). Retrieved from http://www.nichd.nih.gov/COCHRANE/symington/symington.htm

35. Muir Gray, J. A. (1997). Evidence-based healthcare: How to make health policy and management decisions. London, United Kingdom: Churchill Livingstone.

36. Anthony, M. Y., Evans, D. H., & Levene, M. I. (1993). Neonatal cerebral blood flow velocity responses to changes in posture. Archives of Disease in Childhood, 69(3 Spec. No.), 304–308.

37. Ancora, G., Maranella, E., Aceti, A., Pierantoni, L., Grandi, S., Corvaglia, L., & Faldella, G. (2010). Effect of posture on brain hemodynamics in preterm newborns not mechanically ventilated. Neonatology, 97(3), 212–217. http://dx.doi.org/10.1159/000253149

38. Pellicer, A., Gayá, F., Madero, R., Quero, J., & Cabañas, F. (2002). Noninvasive continuous monitoring of the effects of head position on brain hemodynamics in ventilated infants. Pediatrics, 109(3), 434–440. http://dx.doi.org/10.1542/peds.109.3.434

39. Eichler, F., Ipsiroglu, O., Arif, T., Popow, C., Heinzl, H., Urschitz, M., & Pollak, A. (2001). Position dependent changes of cerebral blood flow velocities in premature infants. European Journal of Pediatrics, 160(10), 633–639. http://dx.doi.org/10.1007/s004310100806

40. Vermont Oxford Network. (2008). What is the Vermont Oxford Network? In About Us. Retrieved from http://www.vtoxford.org/home.aspx?p5about/index.htm

41. Smith, J. R., & Donze, A. (2010). Assessing environmental readiness: First steps in developing an evidence-based practice implementation culture. The Journal of Perinatal & Neonatal Nursing, 24(1), 61–71.

42. Bedwell, S. M., Sekar, K. C., & Bright, B. C. (2010, May). Decrease in the incidence of intraventricular hemorrhages after the introduction of an IVH prevention bundle in the NICU. Presented at the Pediatric Academic Society Conference, Neonatal Neurology Platform, Vancouver, British Columbia, Canada.

43. Bozkurt, A., Rosen, A., Rosen, H., & Onaral, B. (2005). A portable near infrared spectroscopy system for bedside monitoring of newborn brain. Biomedical Engineering OnLine, 4(1), 29. http://dx.doi.org/10.1186/1475-925X-4-29

44. U. S. Food and Drug Administration. (2008). Taking a close look at ultrasound. FDA Consumer Health Information. Retrieved from http://www.fda.gov/downloads/ForConsumers/ConsumerUpdates/UCM095487.pdf

45. Pichler, G., Urlesberger, B., Schmölzer, G., & Müller W. (2004). Effect of tilting on cerebral haemodynamics in preterm infants with periventricular leucencephalomalacia. Acta Paediatrica, 93(1), 70–75. http://dx.doi.org/10.1111/j.1651-2227.2004.tb00677.x

46. Pichler, G., van Boetzelar, M. C., Müller, W., & Urlesberger, B. (2001). Effect of tilting on cerebral hemodynamics in preterm and term infants. Biology of the Neonate, 80(3), 179–185.

47. Schrod, L., & Walter, J. (2002). Effect of head-up body tilt position on autonomic function and cerebral oxygenation in preterm infants. Biology of the Neonate, 81(4), 255–259.

About the AuthorsSheila Malusky is a neonatal nurse practitioner with over 19 years

of neonatal nursing care experience, currently working in the level III NICU at St. Louis Children’s Hospital. Her interests include neo-natal neurology and family-centered care. She would like to thank Dr. Lyla Lindholm at UMKC and St. Louis Children’s Hospital NICU IVH Prevention Taskforce. Ms Malusky would especially like to thank Ms. Donze for her continuing mentorship and caring guid-ance. Ms. Malusky received her undergraduate degree from Maryville University in St. Louis, her graduate degree from Barnes-Jewish College of Nursing and Allied Health, and her doctoral degree from the University of Missouri, Kansas City.

Ann Donze has over 34 years of experience in the NICU, with the past 15 years as a neonatal nurse practitioner. She has coordinated the neonatal nurse practitioner program at Barnes-Jewish College of Nursing and Allied Health. Ms. Donze currently cochairs the St. Louis Children’s NICU research committee. Ms. Donze received her nursing diploma from Barnes School of Nursing, her undergraduate degree from Maryville University, and her graduate degree from Southern Illinois University-Edwardsville.

For further information, please contact: Sheila Malusky, DNP, RN, NNP-BC E-mail: [email protected]


ap

pen

dix�

n S

umm

ary

of

Evid

ence

6,10

–12

,36

–39,

45–4

7

Art

icle

Cit

atio

nEv

iden

ce T

ype

Rat

ing

St

ren

gth

/Q

ual

ity

PIC

O Q

uest

ion

Pop

ulat

ion

Inte

rven

tio

nO

utco

mes

Stud

y Li

mit

atio

ns

The

effe

cts

of

pos

ture

on

bra

in

hem

odyn

amic

s in

pre

term

ne

wb

orns

not

m

echa

nica

lly

vent

ilate

d

Anc

ora

et a

l., 2

010

Qua

si-e

xper

imen

tal,

non-

rand

omiz

ed,

conv

enie

nce

sam

ple

, with

in-

subj

ect

bef

ore-

and

-aft

er d

esig

n w

ith p

artic

ipan

ts

serv

ing

as t

heir

own

cont

rols

Leve

l 2A

re t

here

al

tera

tions

in

the

bra

in

hom

odyn

amic

s of

pre

term

ne

wb

orns

fo

llow

ing

head

and

b

ody

pos

ition

ch

ang

es?

The

influ

ence

of

ges

tatio

nal

age,

pos

tnat

al

age,

and

nas

al

CPA

P w

as a

lso

eval

uate

d.

infa

nts

: 24

sta

ble

p

rete

rm in

fant

s.

All

with

nor

mal

b

rain

stu

die

s.

Elev

en o

n na

sal

CPA

P.

Mea

n G

a:

27.5

wee

ks

Mea

n W

eig

ht:

92

5 gr

ams

Mea

n a

ge

: 10

.3 d

ays

Met

ho

d: I

nfan

ts w

ere

mea

sure

d af

ter

pla

cem

ent

in

6 di

ffer

ent

pos

ition

s.

Hea

d: m

idlin

e he

ad p

ositi

on o

r he

ad r

otat

ed 9

0 d

egre

es t

o th

e si

de.

Bo

dy:

pro

ne o

r su

pin

e.

HO

B: f

lat

or e

leva

ted.

Ges

tatio

nal a

ge,

CPA

P an

d p

ostn

atal

ag

e w

ere

anal

yzed

as

ind

epen

den

t va

riab

les.

Stu

dy

inst

rum

ent:

Nea

r-in

frar

ed s

pec

tros

copy

(N

IRS)

.

Bio

log

ical M

easu

res:

C

hang

es in

tis

sue

hem

oglo

bin

(hg

b)

ind

ex (

nTH

I) a

nd t

issu

e ox

ygen

atio

n in

dex

(TO

I)

afte

r p

ostu

re v

aria

tions

.

AN

OVA

was

per

form

ed

to e

valu

ate

tiss

ue

hem

oglo

bin

ind

ex (

nTH

I)

and

tiss

ue o

xyg

enat

ion

ind

ex (

TOI)

in a

ll p

osit

ions

. No

sig

nific

ant

chan

ges

in n

THIs

or

TOI

for

infa

nts

. 2

6 w

eeks

g

esta

tion

. nTH

I was

si

gni

fican

tly

red

uced

in

infa

nt ,

26

wee

ks d

urin

g he

ad r

otat

ion.

nTH

I w

as in

sup

ine

pos

itio

ns

(bot

h fla

t an

d at

30

deg

rees

ele

vate

d)

wer

e si

gni

fican

tly

hig

her

than

su

pin

e p

osit

ion

wit

h he

ad r

otat

ed t

o th

e si

de

(p ,

0.0

5). T

OIs

rem

aine

d st

able

in a

ll p

osit

ions

. C

PAP

and

pos

tnat

al a

ge

wer

e no

t si

gni

fican

tly

asso

ciat

ied

wit

h ch

ang

es

in n

THI a

nd T

OI.

Smal

l sam

ple

si

ze w

ith o

nly

8 p

atie

nts

in

the

, 2

6 an

d ,

27

wee

ks

GA

gro

ups.

Infa

nts

spen

t onl

y 10

min

utes

in e

ach

posi

tion,

whi

ch

mig

ht n

ot b

e lo

ng

enou

gh fo

r ful

l ev

alua

tion.

No

pow

er a

naly

sis

per

form

ed t

o d

eter

min

e nu

mb

er

of s

ubje

cts

need

ed

to r

each

sta

tistic

al

sign

ifica

nce.

Effe

cts

of t

iltin

g on

ce

reb

ral h

emo

-d

ynam

ics

in p

re-

term

infa

nts

with

p

eriv

entr

icul

ar

leuc

ence

pha

-lo

mal

acia

Pich

ler,

Url

esb

erg

er,

Schm

olze

r, &

M

ulle

r, 20

04

Qua

si-e

xper

imen

tal,

non-

rand

omiz

ed

conv

enie

nce

sam

ple

, with

co

ntro

l gro

up

desi

gn.

Leve

l 2Fo

llow

ing

tiltin

g b

ed u

p

20 d

egre

es,

are

ther

e an

y ef

fect

s in

th

e ce

reb

ral

hem

odyn

amic

s of

pre

term

in

fant

s w

ith o

r w

ithou

t PV

L id

enti

fied

?

infa

nts

: 35

stab

le

pret

erm

infa

nts:

C

ontr

ol g

roup

—25

infa

nts

with

nor

mal

br

ain

stud

ies.

Ex

perim

enta

l gr

oup

—10

in

fant

s w

ith P

VL.

Mea

n G

a:

30 w

eeks

Mea

n W

eig

ht:

12

25 g

ram

s

Mea

n a

ge

: 14

day

s

Met

ho

d: I

nfan

ts w

ere

mea

sure

d b

efor

e an

d af

ter

pos

ition

cha

nges

by

tiltin

g b

ed u

p 20

deg

rees

.

Hea

d a

nd

Bo

dy:

Rig

ht la

tera

l.

HO

B: F

rom

HO

B fla

t to

elev

ated

.

The

10 in

fant

s w

ith P

VL

had

24 e

pis

odes

of h

ead

tilte

d up

20

deg

rees

for

30 m

inut

es,

and

19 e

pis

odes

hor

izon

tal

for

30 m

inut

es.

The

25 in

fant

s w

ith P

VL

had

24 e

pis

odes

of h

ead

tilte

d up

20

deg

rees

for

30 m

inut

es,

and

23 e

pis

odes

hor

izon

tal

for

30 m

inut

es.

Stu

dy

inst

rum

ent:

NIR

S

Alth

ough

bot

h gr

oups

had

si

gnifi

cant

ly in

crea

sed

cere

bra

l blo

od v

olum

e fo

llow

ing

a til

ting

dow

nwar

d m

aneu

ver,

ce

reb

ral b

lood

vol

ume

and

cere

bra

l hem

oblo

bin

oxyg

en in

dex

was

si

gnifi

cant

ly in

crea

sed

in in

fant

s w

ith P

VL

com

par

ed t

o in

fant

s w

ithou

t PV

L p

ost

tiltin

g (p

, 0

.01)

. Pos

t til

ting

up, i

nfan

ts w

ith P

VL

had

a p

rono

unce

d d

ecre

ase

in C

BV a

nd p

ost

tiltin

g d

own

had

a p

rono

unce

d in

crea

se in

CBV

.

Smal

l sam

ple

siz

e.In

vest

igat

ors

note

d th

at it

w

as s

omet

imes

d

iffic

ult

to r

ule

out

arti

fact

s.

Infa

nts

in P

VL

grou

p

had

sign

ifica

ntly

lo

wer

ges

tatio

nal

age,

bir

thw

eigh

t,

and

wei

ght.

The

y ha

d si

gnifi

cant

ly

high

er P

CA

and

chro

nolo

gica

l age

.

Onl

y 30

min

utes

in

each

pos

ition

and

no

t al

l inf

ants

wer

e ab

le t

o co

mp

lete

th

e se

que

nce.

No

pow

er a

naly

sis.

(con

tinue

d)


Bio

log

ical M

easu

res:

M

easu

red

Cer

ebra

l blo

od

volu

me

(CBV

) an

d ce

reb

ral

hem

oglo

bin

oxy

gen

ind

ex

(cH

bD

).

Inve

stig

ator

s al

so r

ecor

ded

EKG

, pu

lse

oxim

etry

, cap

nogr

aphy

, an

d re

spira

tory

eff

ort.

The

anal

ysis

was

com

ple

ted

usin

g St

uden

t t-

test

for

pai

red

anal

ysis

and

Man

n-

Whi

tney

U-t

est

usin

g St

atvi

ew s

oftw

are.

Eval

uatio

n an

d d

evel

opm

ent

of

pot

entia

lly b

ette

r p

ract

ices

for

the

pre

vent

ion

of

bra

in h

emor

rhag

e an

d is

chem

ic

bra

in in

jury

in

very

low

bir

th

wei

ght

infa

nts.

Car

teau

x et

al.,

20

03

Evid

ence

-bas

ed

liter

atur

e re

view

, b

ench

mar

king

, an

d ex

per

t co

mm

itte

e re

view

des

ign

Leve

l 4

Exp

ert

Com

mitt

ee

Rep

ort.

D

o th

ey

have

a

leve

l for

cl

inic

al

pra

ctic

e g

uid

elin

e?

This

rea

lly

fits

that

d

efin

ition

.

Can

an

eval

uatio

n an

d d

evel

opm

ent

of p

oten

tially

b

ette

r p

ract

ices

for

the

pre

vent

ion

of b

rain

he

mor

rhag

e an

d is

chem

ic

bra

in in

jury

in

very

low

bir

th

wei

ght

infa

nts

be

iden

tifie

d?

Five

Ben

chm

ark

NIC

Us.

Fi

ve N

ICU

s w

ho w

ere

VON

m

emb

ers

par

tici

pat

ed in

a

QI p

roje

ct t

o ev

alua

te

pra

ctic

es in

ben

chm

arke

d ho

spit

al’s

IVH

pre

vent

ion

met

hod

s. T

hey

uti

lized

b

ench

mar

kin

g of

pra

ctic

es

in in

stit

utio

ns w

ith

low

in

cid

ence

of I

VH

an

d PV

L,

syst

emat

ic r

evie

w o

f th

e lit

erat

ure,

an

d ex

per

t co

nsut

atio

n, t

he

gro

up t

hen

m

ade

reco

mm

end

atio

ns.

Ten

pot

entia

lly b

ette

r p

ract

ices

wer

e id

enti

fied,

in

clud

ing

neut

ral h

ead

pos

ition

ing

and

the

use

of d

evel

opm

enta

l car

e st

rate

gies

.

Som

e of

the

PBP

s w

ere

bas

ed

on lo

wer

leve

l ev

iden

ce w

hen

no R

CTs

wer

e av

aila

ble

.

Non

inva

sive

co

ntin

uous

m

onito

ring

of t

he

effe

cts

of h

ead

pos

ition

on

bra

in

hem

odyn

amic

s in

ve

ntila

ted

infa

nts.

Pelli

cer,

Gay

a,

Mad

ero,

Que

ro,

& C

aban

as, 2

002

Qua

si-e

xper

imen

tal,

non-

rand

omiz

ed,

conv

enie

nce

sam

ple

, with

in-

subj

ect

bef

ore-

and

-aft

er d

esig

n w

ith p

artic

ipan

ts

serv

ing

as t

heir

own

cont

rols

.

Leve

l 2C

an t

he e

ffec

ts o

f he

ad p

ositi

on

on b

rain

he

mod

ynam

ics

or c

hang

es

in c

ereb

ral

veno

us b

lood

flo

w/

volu

me

in v

entil

ated

in

fant

s b

e id

enti

fied

?

Infa

nts

: 21

pre

term

in

fant

s. 1

3 on

co

nven

tiona

l ve

ntila

tors

, 8 o

n os

cilla

tors

Mea

n G

A:

30.9

4.9

wee

ks

Mea

n W

eig

ht:

15

75

80

3 gr

ams

Mea

n A

ge

: 5.

8 da

ys

Met

ho

d:

Infa

nts

mea

sure

d b

efor

e an

d af

ter

bei

ng p

lace

d in

mul

tiple

pos

ition

s.

Hea

d: m

idlin

e or

hea

d ro

tate

d 90

deg

rees

to

the

sid

e.

Bo

dy:

pro

ne o

r su

pin

e.

HO

B: F

lat o

r ele

vate

d 30

deg

rees

.

Infa

nts

mea

sure

d ev

ery

10 m

inut

es fo

r 30

min

utes

in

each

pos

ition

.

Stu

dy

Inst

rum

ent:

NIR

S H

US

was

obt

aine

d af

ter

stud

y to

d

etec

t ch

ang

es.

Bio

log

ical M

easu

res:

ch

ang

es in

cer

ebra

l blo

od

volu

me

(C

BV)

and

cere

bra

l b

lood

flow

(C

BF).

Cha

ng

e in

cer

ebra

l blo

od

volu

me

sig

nific

antl

y in

crea

sed

wit

h h

ead

turn

ed 9

0 d

egre

es.

(p 5

0.0

5). T

his

chan

ge

was

mos

t p

rono

unce

d in

infa

nts

, 1

200

gra

ms.

Th

ere

was

als

o a

sig

nific

ant

chan

ge

in c

ereb

ral b

lood

flo

w

rela

tive

to

tim

e sp

ent

in

sup

ine

wit

h h

ead

turn

ed

to s

ide

com

par

ed t

o h

ead

in m

idlin

e (p

5 0

.026

).

Ther

e w

as n

o si

gni

fican

t ch

ang

e in

cer

ebra

l b

lood

flo

w o

r an

y ot

her

p

hysi

olog

ic v

aria

ble

: BP

, ox

ygen

sat

urat

ion,

PC

O2.

Smal

l sam

ple

siz

e.

CBF

mea

sure

men

ts

wer

e un

succ

essf

ul

in 9

infa

nts.

Tri

ed

to m

inim

ize

bia

s by

ran

dom

ly

assi

gnin

g th

e st

artin

g p

ositi

on.

Als

o al

l HU

S an

d al

l NIR

wer

e re

ad

by t

he s

ame

inve

stig

ator

.

Ap

pen

dIx�

n S

umm

ary

of

Evid

ence

(co

ntin

ued)

Art

icle

Cit

atio

nEv

iden

ce T

ype

Rat

ing

St

ren

gth

/Q

ual

ity

PIC

O Q

uest

ion

Pop

ulat

ion

Inte

rven

tio

nO

utco

mes

Stud

y Li

mit

atio

ns

(con

tinue

d)


ap

pen

dix�

n S

umm

ary

of

Evid

ence

(co

ntin

ued)

Art

icle

Cit

atio

nEv

iden

ce T

ype

Rat

ing

St

ren

gth

/Q

ual

ity

PIC

O Q

uest

ion

Pop

ulat

ion

Inte

rven

tio

nO

utco

mes

Stud

y Li

mit

atio

ns

Effe

ct o

f hea

d-u

p

bod

y til

t p

ositi

on

on a

uton

omic

fu

nctio

n an

d ce

reb

ral

oxyg

enat

ion

in

pre

term

infa

nts.

Schr

od &

Wal

ter,

2002

Qua

si-e

xper

imen

tal

Leve

l 2In

pre

term

in

fant

s, a

re

ther

e an

y ne

gati

ve

effe

cts

of h

ead

elev

ated

bod

y til

t p

ositi

on

(HET

P) o

n sy

stem

ic

and

cere

bra

l ox

ygen

atio

n,

circ

ulat

ion,

an

d sy

mp

athe

tic-

vaga

l bal

ance

?

infa

nts

: 36

pre

term

in

fant

s

Mea

n G

a: 2

5-3

6 w

eeks

. Med

ian

GA

32.

5 w

eeks

.

Mea

n W

eig

ht:

88

0-2

980

gram

s. M

edia

n w

eigh

t 14

60 g

ram

s.

Mea

n a

ge

: 2 t

o 12

day

s of

life

.

Met

ho

d: P

rete

rm in

fant

s w

ere

mea

sure

d af

ter

bei

ng

pla

ced

in m

ulti

ple

hea

d/b

ody

tilt

pos

itio

ns.

Hea

d a

nd

Bo

dy:

sup

ine

HO

B: h

oriz

onta

l the

n el

evat

ed

30 d

egre

es w

ith e

ach

pos

ition

last

ing

at le

ast

20 m

inut

es e

ach.

Infa

nts

wer

e ea

ch m

easu

red

4 tim

es in

the

var

ious

pos

ition

s d

urin

g st

udy.

Stu

dy

inst

rum

ent:

NIR

s

Bio

log

ical

Mea

sure

: Tot

al

cere

bral

hem

oglo

bin

cont

ent.

Inve

stig

ator

s al

so r

ecor

ded

EKG

, Pu

lse

oxim

etry

, mea

n ar

teria

l p

ress

ure,

and

res

pir

ator

y im

ped

ance

cur

ve.

Con

tinuo

us r

ecor

din

gs

reve

aled

initi

al m

axim

al

fluct

uatio

ns o

f tot

al

cere

bra

l hem

oglo

bin

co

nten

t (t

Hb)

up

to 4

2%

fo

llow

ing

HET

P. A

fter

st

abili

zatio

n w

ithin

sev

eral

m

inut

es, p

rolo

nged

tilt

ing

did

not

res

ult

in a

ny

furt

her

sign

ifica

nt c

hang

es

of t

Hb,

hea

rt r

ate,

m

ean

arte

rial p

ress

ure

and

oxyg

en s

atur

atio

n.

Onl

y p

rete

rm in

fant

s ,

or

51,

500

gram

s sh

owed

a

sign

ifica

nt d

ecre

ase

of

reg

iona

l cer

ebra

l oxy

gen

sa

tura

tion

(rSO

(2))

of

ab

out

2–5%

from

da

y 2

to 8

, mea

sure

d by

p

ulse

oxym

etry

.

The

stud

y an

alys

is w

as

com

ple

ted

usin

g SP

SS

stat

isti

c p

rog

ram

. Non

-p

aram

etri

c te

sts

wer

e ap

plie

d.

Smal

l sam

ple

siz

e.

The

inve

stig

ator

s d

id n

ot c

omm

ent

on d

irect

ion

of

head

(m

idlin

e or

ro

tate

d).

Pow

er a

naly

sis

not

com

ple

ted.

Posi

tion

dep

end

ent

chan

ges

of

cere

bra

l blo

od

flow

vel

ociti

es in

p

rem

atur

e in

fant

s.

Eich

ler

et a

l., 2

001

Qua

si-e

xper

imen

tal,

non-

rand

omiz

ed

conv

enie

nce

sam

ple,

non

-eq

uivo

cal c

ontr

ol

grou

p be

fore

-an

d-a

fter

des

ign,

an

d Re

peat

ed-

mea

sure

s de

sign

.

Leve

l 2

Can

pos

ition

d

epen

den

t ch

ang

es in

ce

reb

ral b

lood

flo

w v

eloc

ities

b

e id

enti

fied

in p

rem

atur

e in

fant

s?

infa

nts

: 23

stab

le

pre

term

infa

nts

all w

ith n

orm

al

bra

in s

tud

ies

and

none

m

echa

nica

lly

vent

ilate

d.

Mea

n G

a:

26.7

wee

ks

Mea

n W

eig

ht:

10

27 g

ram

s

Mea

n a

ge

: A

ll in

fant

s w

ere

stud

ies

pos

tnat

al

3-5

day

s.

Met

ho

d: I

nfan

ts w

ere

mea

sure

d b

efor

e an

d af

ter

4 p

osit

ion

chan

ges

on

3 s

epar

ate

occa

sion

s:

pos

tnat

al d

ay 3

-5, a

t on

e w

eek,

an

d at

on

e m

onth

.

Hea

d: C

ente

red

whe

n su

pin

e,

turn

ed t

o ei

ther

sid

e w

hen

sup

ine.

Bo

dy:

pro

ne o

r su

pin

e.

HO

B: N

ot d

iscu

ssed

.

Stu

dy

inst

rum

ent:

U

ltras

ound

Bio

log

ical M

easu

res:

C

ereb

ral b

lood

flow

vel

ociti

es

of in

tern

al c

arot

id a

rter

y,

vert

ebra

l art

ery,

and

bas

ilar

arte

ry.

Cer

ebra

l blo

od fl

ow

velo

citie

s w

ere

sign

ifica

ntly

hig

her

in t

he

sup

ine

pos

ition

at

the

one

mon

th o

f ag

e ev

alua

tion.

Th

e re

sear

cher

s fo

und

a d

ecre

ase

in v

erte

bra

l ar

teria

l flo

w in

pro

ne

pos

ition

, lik

ely

due

to

uni

late

ral v

esse

l co

mp

ress

ion.

Birt

hwei

ght

and

ges

tatio

nal

age

did

not

sign

fific

antly

in

fluen

ce c

ereb

ral b

lood

flo

w.

Smal

l sam

ple

siz

e.

6 in

fant

s lo

st t

o fo

llow

up

at 1

0 da

ys a

nd a

n ad

dito

nal i

nfan

t lo

st t

o fo

llow

up

at

1 m

onth

cor

rect

ed

age.

Att

empt

s to

elim

inat

e b

ias

incl

uded

the

us

e of

a s

econ

d in

vest

igat

or

blin

ded

to

infa

nt

pos

ition

s. (con

tinue

d)


Effe

cts

of t

iltin

g on

cer

ebra

l he

mod

ynam

ics

in

pre

term

and

ter

m

infa

nts

Pich

ler,

Boet

zela

r, M

ulle

r, &

U

rles

ber

ger

, 20

01

Qua

si-e

xper

imen

tal,

non

-ran

dom

ized

co

nven

ienc

e sa

mp

le, c

ontr

ol

grou

p b

efor

e-an

d-a

fter

des

ign.

Leve

l 2

Follo

win

g til

ting

bed

up

20

deg

rees

, ar

e th

ere

any

effe

cts

in

the

cere

bra

l he

mod

ynam

ics

of t

erm

and

p

rete

rm in

fant

s id

enti

fied

?

Thir

ty e

ight

in

fant

s: 2

5 p

rete

rm, m

ean

GA

33

wee

ks

and

mea

n w

eigh

t 18

99

gram

s. T

erm

: 13

infa

nts

with

m

ean

GA

39

wee

ks a

nd

mea

n w

eigh

t of

29

69 g

ram

s.

Met

ho

d: I

nfan

ts w

ere

mea

sure

d b

efor

e an

d af

ter

pos

ition

cha

nges

by

tiltin

g b

ed u

p 20

deg

rees

.

Hea

d a

nd

Bo

dy:

Rig

ht la

tera

l.

HO

B: F

rom

HO

B fla

t to

elev

ated

.

The

pre

term

infa

nts

had

24 e

pis

odes

of h

ead

tilte

d up

20

deg

rees

for

30 m

inut

es,

and

23 e

pis

odes

hor

izon

tal

for

30 m

inut

es.

The

term

infa

nts

had

12

ep

isod

es o

f hea

d ti

lted

up

20 d

egre

es fo

r 30

min

utes

, an

d 10

ep

isod

es h

oriz

onta

l fo

r 30

min

utes

.

Stu

dy

Inst

rum

ent:

NIR

S

Bio

log

ical

Mea

sure

s:

Mea

sure

d C

ereb

ral b

lood

vo

lum

e (C

BV) a

nd c

ereb

ral

hem

oglo

bin

oxyg

en in

dex

(cH

bD).

Inve

stig

ator

s al

so r

ecor

ded

EKG

, Pu

lse

oxim

etry

, cap

nogr

aphy

, an

d re

spir

ator

y ef

fort

.

Alth

ough

bot

h gr

oups

had

si

gnifi

cant

ly in

crea

sed

cere

bra

l blo

od v

olum

e fo

llow

ing

a til

ting

dow

nwar

d m

aneu

ver,

cere

bra

l blo

od v

olum

e (p

0

.01)

and

cer

ebra

l he

mob

lob

in o

xyg

en in

dex

(p

0

.001

) w

ere

bot

h si

gnifi

cant

ly a

ltere

d in

p

rete

rm in

fant

s in

bot

h til

ting

up a

nd t

iltin

g d

own

man

euve

rs. T

here

was

al

so a

cor

rela

tion

bet

wee

n p

ostc

once

ptio

nal a

ge

and

deg

ree

of c

hang

e in

ce

reb

ral b

lood

vol

ume

(p

0.0

5).

The

anal

ysis

was

com

ple

ted

usin

g St

uden

t t-

test

for

pai

red

anal

ysis

and

M

ann

-Whi

tney

U-t

est

usin

g St

atvi

ew s

oftw

are.

Smal

l sam

ple

siz

e.

Onl

y 30

min

utes

in

each

pos

ition

.

No

pow

er a

naly

sis.

Neo

nata

l cer

ebra

l b

lood

flow

ve

loci

ty r

esp

onse

s to

cha

nges

in

pos

ture

Ant

hony

, Eva

ns,

Leve

ne, 1

993

Qua

si-e

xper

imen

tal

non

rand

omiz

ed

conv

enie

nce

sam

ple

usi

ng

rep

eate

d m

easu

res

des

ign.

Leve

l 2

Cro

ss-

sect

iona

l st

udy

usin

g he

alth

y fu

ll te

rm

infa

nts

as

com

par

i-so

n gr

oup.

In n

eona

tes,

ca

n ce

reb

ral

blo

od fl

ow

chan

ges

, as

dem

onst

rate

d by

uni

pha

sic

or b

ipha

sic

resp

onse

s, b

e el

icite

d af

ter

chan

ges

in

pos

ture

?

Infa

nts

: 60

infa

nts

NIC

U In

fan

ts: 5

0,

all w

ith n

orm

al

brai

n st

udie

s.

Mea

n G

A:

28 w

eeks

Mea

n W

eig

ht:

11

50 g

ram

s

Mea

n A

ge

:

1 w

eek.

Met

ho

ds:

Infa

nts

mea

sure

d b

efor

e an

d af

ter

pos

ition

ch

ang

es b

y til

ting.

Hea

d, B

od

y, a

nd

HO

B:

In N

ICU

infa

nts,

mat

tres

s p

ositi

on w

as a

ltere

d fo

r ea

ch

test

ing

per

iod

20 d

egre

es u

p

and

20 d

egre

es d

own

from

ho

rizo

ntal

. Hea

lthy

infa

nts

wer

e p

lace

d in

a c

hair

with

a

tiliti

ng m

echa

nism

alte

rnat

ed

bet

wee

n up

righ

t an

d ly

ing

bac

k p

ositi

on.

Stu

dy

Inst

rum

ent:

U

ltras

ound

Dop

ple

r p

rob

e w

as a

ttac

hed

to e

ach

skin

ov

er t

emp

oral

bon

e.

Tota

l of 5

01 e

piso

des

in 6

0 ba

bies

wer

e m

onito

red.

In

crea

sing

per

cent

age

of b

ipha

sic

resp

onse

s in

cer

ebra

l blo

od fl

ow

velo

citie

s as

infa

nt g

ot

olde

r. Bi

phas

ic r

espo

nses

w

ere

cons

ider

ed s

econ

day

to a

utor

egul

ator

y re

spon

ses.

In t

he p

rete

rm

infa

nts,

nei

ther

a h

igh

Pco2

nor

a lo

w M

AP

(25

mm

HG

) in

fluen

ced

the

perc

enta

ge o

f bip

hasi

c re

spon

ses.

Unc

lear

if IC

U in

fant

s w

ere

sup

ine

or

pro

ne a

nd w

heth

er

head

was

in

mid

line.

Con

cent

rate

d on

ly o

n til

ting

tab

le.

Focu

s of

stu

dy

was

on

aut

oreg

ulat

ion.

Smal

l stu

dy.

Ap

peN

dIx�

n S

umm

ary

of

Evid

ence

(co

ntin

ued)

Art

icle

Cit

atio

nEv

iden

ce T

ype

Rat

ing

St

ren

gth

/Q

ual

ity

PIC

O Q

uest

ion

Po

pul

atio

nIn

terv

enti

on

Out

com

esSt

udy

Lim

itat

ion

s

(con

tinue

d)


Hea

lth

y Te

rm

Infa

nts

: 10

Mea

n G

A:

39 w

eeks

Mea

n W

eig

ht:

30

70 g

ram

s

Mea

n A

ge

:

1 w

eek

Bio

log

ical M

easu

res:

C

erb

ral p

erfu

sion

pre

ssur

e w

as m

easu

re a

t ea

ch

chan

ge

and

note

d to

be

equi

voca

l, no

res

pon

se,

unip

hasi

c (r

efle

ctin

g p

assi

ve

alte

ratio

n in

cer

ebra

l blo

od

flow

vel

ocit

y), o

r b

ipha

sic

(ref

lect

ing

initi

al p

assi

ve

alte

ratio

n, t

hen

acti

ve

resp

onse

to

chan

ge

in

cere

bra

l blo

od fl

ow v

eloc

ity)

.

Unc

lear

if

inve

stig

ator

s re

adin

g th

e C

BVV.

Cha

nges

in s

uper

ior

sag

itta

l sin

us

blo

od v

eloc

ities

d

ue t

o p

ostu

ral

alte

ratio

ns a

nd

pre

ssur

e on

th

e he

ad o

f the

ne

wb

orn

infa

nt.

Cow

en &

Tho

rese

n,

1985

Qua

si-e

xper

imen

tal,

non-

rand

omiz

ed

conv

enie

nce

sam

ple

, con

trol

gr

oup

bef

ore-

and

-aft

er d

esig

n.

Leve

l 2

Are

the

re

chan

ges

in

sup

erio

r sa

git

tal

sinu

s b

lood

ve

loci

ties

due

to

pos

tura

l ch

ang

es,

jug

ular

ven

ous

occl

usio

n,

and

incr

ease

d m

anua

l hea

d p

ress

ure

in t

he

new

bor

n?

Infa

nts

: 18

term

hea

lthy

new

bor

ns

Mea

n G

A:

39 w

eeks

Mea

n W

eig

ht:

36

83 g

ram

s

Mea

n A

ge

: 6

days

Met

ho

ds:

Infa

nts

wer

e m

easu

red

afte

r p

lace

men

t in

8 d

iffer

ent

pos

ition

s.

Infa

nts

wer

e al

so m

easu

red

whi

le a

pp

lyin

g ex

tern

al h

ead

pre

ssur

e an

d ju

gul

ar v

enou

s oc

clus

ion.

Hea

d:

mid

line

head

pos

ition

, he

ad r

otat

ed 9

0 d

egre

es t

o th

e si

de,

nec

k fle

xed

and

exte

nded

.

Bo

dy:

pro

ne, s

upin

e, o

r la

tera

l.

HO

B: f

lat

thro

ugho

ut t

he s

tud

y.

Stu

dy

Inst

rum

ent:

U

ltras

ound

Bio

log

ical M

easu

res:

C

ereb

ral b

lood

flow

vel

ociti

es

(CBF

V)

of t

he s

uper

ior

sag

itta

l sin

us.

Resu

lts r

evea

led

that

90˚

hea

d tu

rn o

cclu

des

the

jugu

lar

vein

on

the

ipsi

late

ral s

ide

and

occl

usio

n of

ven

ous

flow

on

the

cont

rala

tera

l si

de d

oes

not f

orce

blo

od

drai

nage

thr

ough

the

oc

clus

ion

with

sub

sequ

ent

incr

ease

d cr

ania

l pre

ssur

e ch

ange

s. E

xter

nal h

ead

pres

sure

als

o in

crea

ses

pres

sure

and

impe

des

veno

us d

rain

age.

Cer

ebra

l flo

od fl

ow

red

uctio

n:

Sup

ine

Bi

late

ral o

cclu

sion

of r

ight

an

d le

ft ju

gul

ar—

100

%

red

uctio

n in

flow

in a

ll su

bje

cts

Hea

d t

urn

ed 9

0 d

egre

es

to lef

t—O

cclu

sion

of

ipsi

late

ral j

ugul

ar r

esul

ted

in n

o ch

ang

e in

flow

in

25/2

6 su

bje

cts.

Occ

lusi

on o

f con

tral

ater

al

jugu

lar r

esul

ted

in 1

00%

oc

clus

ion

in 2

0/26

pat

ient

s

Incr

ease

in fo

ntan

el p

ress

ure

corr

elat

ed w

ith d

ecre

ased

ce

reb

ral b

lood

flow

ve

loci

ty. C

orre

latio

n co

effic

ient

of 0

.91.

Smal

l sam

ple

siz

e.U

ncle

ar r

egar

din

g re

liab

ility

of

font

anom

eter

us

ed t

o ac

cura

tely

m

easu

re

intr

acra

nial

p

ress

ure.

Inve

stig

ator

s st

ated

it

was

diff

icul

t to

ho

ld t

he h

and

held

Dop

ple

r tr

ansd

ucer

in p

lace

d

urin

g th

e st

udy.

In

vest

igat

ors

wer

e no

t b

lind

ed t

o in

fant

pos

ition

w

hen

inte

rpre

ting

resu

lts.

Old

er s

tud

y, b

ut c

ited

by m

any

othe

r st

udie

s.

Ap

pen

dIx�

n S

umm

ary

of

Evid

ence

(co

ntin

ued)

Art

icle

Cit

atio

nEv

iden

ce T

ype

Rat

ing

St

ren

gth

/Q

ual

ity

PIC

O Q

uest

ion

Po

pul

atio

nIn

terv

enti

on

Out

com

esSt

udy

Lim

itat

ion

s

(con

tinue

d)


Hea

d p

ress

ure

ante

rior

pos

-te

rior

, lat

eral

and

occ

ipita

l ar

eas

lead

to

varia

ble

re

sult

s. P

ress

ure

on p

oste

-ri

or fo

ntan

el a

lway

s re

sult-

ed in

dec

reas

ed c

ereb

ral

blo

od fl

ow v

eloc

ity

Hea

d p

ositi

on

affe

cts

intr

acra

nial

p

ress

ure

in

new

bor

n in

fant

s.

Emer

y &

Pea

bod

y,

1983

Qua

si-e

xper

imen

tal,

non-

rand

omiz

ed

conv

enie

nce

sam

ple

, con

trol

gr

oup

desi

gn.

Leve

l 2In

new

bor

n in

fant

s,

doe

s he

ad

pos

ition

aff

ect

intr

acra

nial

p

ress

ure?

Infa

nts

: 14

pre

term

in

fant

s— 6

with

a

hist

ory

of

asp

hyxi

a an

d 8

with

out.

Asp

hyx

iate

d

Infa

nts

: 6

Mea

n G

A:

35 w

eeks

Mea

n A

ge

: 54

hou

rs o

f life

.

No

n-

Asp

hyx

iate

d

Infa

nts

: 8

Mea

n G

A:

36 w

eeks

Mea

n A

ge

: 43

hou

rs o

f life

.

Met

ho

d: I

nfan

ts m

easu

red

bef

ore

and

afte

r 6

diff

eren

t p

ositi

on c

hang

es.

Hea

d: m

idlin

e or

90

deg

rees

he

ad t

urn

to r

ight

.

Bo

dy:

sup

ine

HO

B: F

lat,

ele

vate

d 30

deg

rees

or

dep

enda

nt 3

0 d

egre

es.

Stu

dy

Inst

rum

ent:

U

ltras

ound

and

tra

nsfo

ntan

el

pre

ssur

e tr

ansd

ucer

. M

easu

red

at le

ast

30 s

econ

ds

in e

ach

pos

ition

.

Bio

log

ical M

easu

res:

cer

ebra

l b

lood

flow

(C

Bf)

and

intr

acra

nial

pre

ssur

e (I

CP)

.

Stat

isti

cal A

naly

sis:

Stu

den

t p

aire

d t

test

usi

ng B

onfe

rron

i co

rrec

tion.

Sign

ifica

nt IC

P in

hor

izon

tal

and

dep

enda

nt p

ositi

on

whe

n he

ad t

urne

d to

the

ri

ght

(p

0.0

01)

for

bot

h gr

oups

.

Sign

ifica

nt in

crea

se in

ICP

with

hea

d m

idlin

e an

d tu

rned

whi

le in

dep

enda

nt

pos

ition

(p

0

.001

) fo

r b

oth

grou

ps.

Sign

ifica

nt d

ecre

ase

in IC

P w

hen

head

in m

idlin

e an

d el

evat

ed (

p

0.0

1) a

nd

even

mor

e d

ecre

ased

in

asp

hyxi

ated

infa

nts

(p

0

.02)

.

Smal

l sam

ple

siz

e

Old

er s

tud

y

The

effe

ct o

f he

ad p

ositi

on

on in

trac

rani

al

pre

ssur

e in

the

ne

onat

e w

as

stud

ied.

Gol

db

erg,

Josh

i, M

osco

so, &

C

astil

lo, 1

983

Qua

si-e

xper

imen

tal,

non-

rand

omiz

ed

conv

enie

nce

sam

ple

des

ign.

Leve

l 2

Are

the

re a

ny

iden

tifie

d ef

fect

s of

hea

d p

ositi

on o

n in

trac

rani

al

pre

ssur

e in

th

e ne

onat

e,

as is

foun

d in

the

ad

ult

liter

atur

e?

Infa

nts

: 26

pre

term

in

fant

s.

Mea

n G

A:

33 w

eeks

Mea

n W

eig

ht:

14

97 g

ram

s

Mea

n A

ge

: 3

days

, with

a

rang

e of

1-

10 d

ays.

Met

ho

d: I

CP

mea

sure

d ev

ery

1 m

inut

e fo

r 10

min

utes

in

each

of 4

pos

ition

s.

A 4

-min

ute

stab

iliza

tion

per

iod

was

giv

en a

fter

eve

ry

pos

ition

cha

nge.

Hea

d: m

idlin

e or

tur

ned

to t

he

righ

t.

Bo

dy:

sup

ine

HO

B: f

lat

or e

leva

ted

30

deg

rees

.

Stu

dy

Inst

rum

ent:

Lad

d m

onito

r to

stu

dy

intr

acra

nial

p

ress

ure.

The

resu

lts

sug

ges

t in

trac

rani

al p

ress

ure

was

sig

nific

antly

low

er

in m

idlin

e p

ositi

ons

com

par

ed t

o p

ositi

ons

with

the

hea

d tu

rned

.

The

intr

acra

nial

pre

ssur

e w

as a

lso

sign

ifica

ntly

lo

wer

in p

atie

nts

who

se

head

was

ele

vate

d to

30

deg

rees

.

The

pos

ition

with

the

low

est

mea

sure

d in

trac

rani

al

pre

ssur

e w

as h

ead

mid

line

with

hea

d of

bed

ele

vate

d 30

deg

rees

.

Smal

l sam

ple

siz

e.

Old

er s

tud

y.

Pow

er n

ot c

alcu

late

d.

10 m

inut

es is

a b

rief

tim

e p

erio

d fo

r st

udy.

To a

void

bia

s,

pos

ition

ord

er

was

ran

dom

ly

assi

gned

.

Ap

peN

dIx�

n S

umm

ary

of

Evid

ence

(co

ntin

ued)

Art

icle

Cit

atio

nEv

iden

ce T

ype

Rat

ing

St

ren

gth

/Q

ual

ity

PIC

O Q

uest

ion

Po

pul

atio

nIn

terv

enti

on

Out

com

esSt

udy

Lim

itat

ion

s

Documents

Neutral Head Positioning in Premature Infants for