Conformational Positioning Improves Sleep in Premature Infants with Feeding Difficulties

Published:October 11, 2014DOI:


      To determine whether premature infants' sleep organization, total sleep time, and arousals may be modulated while on a conformational positioner that provides boundaries, customized positioning, and containment compared with standard positioning (standard crib mattress).

      Study design

      A proof of concept trial using a within subject crossover design was conducted among 25 premature infants with feeding difficulties. Infants of 31.5 weeks gestational age served as their own control during overnight polysomnography at postconceptual age 38.4 weeks. Each baby received both interventions (order randomized), 1 for each one-half of the 10.5-hour study.


      Use of the conformational positioner resulted in higher sleep efficiency of 61% vs 54% for the standard mattress ( P < .05). The interventions did not differ for percent active sleep, percent quiet sleep, percent indeterminate sleep, or spontaneous arousals. Sleep efficiency was higher on the conformational positioner than standard positioning for surgical subjects and for subjects with necrotizing enterocolitis or gastroschisis (n = 10). The surgical subjects (n = 9) had lower sleep efficiency, lower percentage of active sleep, and more spontaneous arousals compared with the nonsurgical group.


      The use of the conformational positioner improved sleep efficiency vs the standard mattress in premature infants with feeding difficulties. Infants requiring surgery or with gastrointestinal diagnoses may be more susceptible to environmental stress.
      EEG ( Electroencephalography), NEC ( Necrotizing enterocolitis), NICU ( Neonatal intensive care unit), SSC ( Skin-to-skin contact)
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        • Graven S.
        Sleep and brain development.
        Clin Perinatol. 2006; 33 (vii): 693-706
        • Maquet P.
        • Smith C.
        • Stickgold R.
        in: Maquet P. Smith C. Stickgold R. Sleep and brain plasticity. Oxfort University Press, New York2003: 1-13
        • Calciolari G.
        • Montirosso R.
        The sleep protection in the preterm infants.
        J Maternal Fetal Neonatal Med. 2011; 24: 12-14
        • Whitney M.P.
        • Thoman E.B.
        Early sleep patterns of premature infants are differentially related to later developmental disabilities.
        J Dev Behav Pediatr. 1993; 14: 71-80
        • Birch J.L.
        • Newell S.J.
        Gastrooesophageal reflux disease in preterm infants: current management and diagnostic dilemmas.
        Arch Dis Child Fetal Neonatal Ed. 2009; 94: F379-F383
        • Orenstein S.R.
        • McGowan J.D.
        Efficacy of conservative therapy as taught in the primary care setting for symptoms suggesting infant gastroesophageal reflux.
        J Pediatr. 2008; 152: 310-314
        • Corvaglia L.
        • Monari C.
        • Martini S.
        • Aceti A.
        • Faldella G.
        Pharmacological therapy of gastroesophageal reflux in preterm infants.
        Gastroenterol Res Pract. 2013; 2013: 714564
        • van Manen M.
        • Hendson L.
        • Wiley M.
        • Evans M.
        • Taghaddos S.
        • Dinu I.
        Early childhood outcomes of infants born with gastroschisis.
        J Pediatr Surg. 2013; 48: 1682-1687
        • Machado R.
        • Woodley F.W.
        • Skaggs B.
        • Di Lorenzo C.
        • Splaingard M.
        • Mousa H.
        Gastroesophageal reflux causing sleep interruptions in infants.
        J Pediatr Gastroenterol Nutr. 2013; 56: 431-435
        • Liu W.F.
        • Laudert S.
        • Perkins B.
        • Macmillan-York E.
        • Martin S.
        • Graven S.
        The development of potentially better practices to support the neurodevelopment of infants in the NICU.
        J Perinatol. 2007; 27: S48-S74
        • Maquet P.
        • Smith C.
        • Stickgold R.
        Sleep and brain plasticity.
        Oxford University Press, New York2003
        • Mirmiran M.
        • Ariagno R.L.
        Role of REM sleep in brain development and plasticity.
        in: Maquet P. Smith C. Stickgold R. Sleep and brain plasticity. Oxford University Press, New York2003: 181-187
        • Nedivi E.
        Molecular analysis of developmental plasticity in neocortex.
        J Neurobiol. 1999; 41: 135-147
        • Ludington-Hoe S.M.
        • Johnson M.W.
        • Morgan K.
        • Lewis T.
        • Gutman J.
        • Wilson P.D.
        • et al.
        Neurophysiologic assessment of neonatal sleep organization: preliminary results of a randomized, controlled trial of skin contact with preterm infants.
        Pediatrics. 2006; 117: e909-e923
        • Bertelle V.
        • Mabin D.
        • Adrien J.
        • Sizun J.
        Sleep of preterm neonates under developmental care or regular environmental conditions.
        Early Hum Dev. 2005; 81: 595-600
        • Liaw J.J.
        • Yang L.
        • Lo C.
        • Yuh Y.S.
        • Fan H.C.
        • Chang Y.C.
        • et al.
        Caregiving and positioning effects on preterm infant states over 24 hours in a neonatal unit in Taiwan.
        Res Nurs Health. 2012; 35: 132-145
        • Hernandez-Reif M.
        • Diego M.
        • Field T.
        Preterm infants show reduced stress behaviors and activity after 5 days of massage therapy.
        Infant Behav Dev. 2007; 30: 557-561
        • Loewy J.
        • Hallan C.
        • Friedman E.
        • Martinez C.
        Sleep/sedation in children undergoing EEG testing: a comparison of chloral hydrate and music therapy.
        Am J Electroneurodiagnostic Technol. 2006; 46: 343-355
        • Standley J.
        Music therapy research in the NICU: an updated meta-analysis.
        Neonatal Netw. 2012; 31: 311-316
        • Loewy J.
        • Stewart K.
        • Dassler A.M.
        • Telsey A.
        • Homel P.
        The effects of music therapy on vital signs, feeding, and sleep in premature infants.
        Pediatrics. 2013; 131: 902-918
        • Guzzetta A.
        • D'Acunto M.G.
        • Carotenuto M.
        • Berardi N.
        • Bancale A.
        • Biagioni E.
        • et al.
        The effects of preterm infant massage on brain electrical activity.
        Dev Med Child Neurol. 2011; 53: 46-51
        • Scher M.S.
        • Steppe D.A.
        • Banks D.L.
        Prediction of lower developmental performances of healthy neonates by neonatal EEG-sleep measures.
        Pediatr Neurol. 1996; 14: 137-144
        • Im H.
        • Kim E.
        • Cain K.C.
        Acute effects of Yakson and gentle human touch on the behavioral state of preterm infants.
        J Child Health Care. 2009; 13: 212-226
        • Axelin A.
        • Kirjavainen J.
        • Salantera S.
        • Lehtonen L.
        Effects of pain management on sleep in preterm infants.
        Eur J Pain. 2010; 14: 752-758
        • Pin T.W.
        • Darrer T.
        • Eldridge B.
        • Galea M.P.
        Motor development from 4 to 8 months corrected age in infants born at or less than 29 weeks' gestation.
        Dev Med Child Neurol. 2009; 51: 739-745
        • Hunter J.
        in: Kenner C. McGrath J.M. Developmental care of newborns and infants: A guide for health professionals. Mosby, St. Louis2004: 299-330
      1. Solutions S. Tortise Positioning System. 2014.

        • Hunter J.
        Therapeutic positioning: neuromotor development and beyond.
        in: Kenner C. McGrath J.M. Developmental care of newborns and infants: A guide for healthcare professionals. 2nd ed. National Association of Neonatal Nurses, Chicago, IL2010
        • Richardson D.K.
        • Gray J.E.
        • McCormick M.C.
        • Workman K.
        • Goldmann D.A.
        Score for neonatal acute physiology: a physiologic severity index for neonatal intensive care.
        Pediatrics. 1993; 91: 617-623
        • Moon R.Y.
        SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment.
        Pediatrics. 2011; 128: 1030-1039
        • Moon R.Y.
        SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment.
        Pediatrics. 2011; 128: e1341-e1367
        • Ednick M.
        • Cohen A.P.
        • McPhail G.L.
        • Beebe D.
        • Simakajornboon N.
        • Amin R.S.
        A review of the effects of sleep during the first year of life on cognitive, psychomotor, and temperament development.
        Sleep. 2009; 32: 1449-1458
        • Iber C.
        • Ancoli-Israel S.
        • Chesson A.
        • Quan S.F.
        • for the American Academy of Sleep Medicine
        The AASM manual for the scoring of sleep and associated events: Rules, terminology and technical specifications.
        1st ed. American Academy of Sleep Medicine, Westchester, Illinois2007
        • Kraemer H.C.
        • Hole W.T.
        • Anders T.F.
        The detection of behavioral state cycles and classification of temporal structure in behavioral states.
        Sleep. 1984; 7: 3-17
        • Anders T.F.
        • Keener M.
        Developmental course of nighttime sleep-wake patterns in full-term and premature infants during the first year of life.
        I. Sleep. 1985; 8: 173-192
        • Als H.
        A synactive model of neonatal behavioral organization: framework for the assessment of neurobehavioral development in the premature infant and for support of infants and parents in the neonatal intensive care environment.
        Phys Occup Ther Paediatr. 1986; 6: 3-55
        • Als H.
        Revised manual for the naturalistic observation of newborn behavior: Preterm and fullterm newborns.
        The Children's Hospital, Boston1995
        • Simakajornboon N.
        • Beckerman R.C.
        • Mack C.
        • Sharon D.
        • Gozal D.
        Effect of supplemental oxygen on sleep architecture and cardiorespiratory events in preterm infants.
        Pediatrics. 2002; 110: 884-888
        • Ammari M.
        • Djeddi D.
        • Leke A.
        • Delanaud S.
        • Stephan-Blanchard E.
        • Bach V.
        • et al.
        Relationship between sleep and acid gastro-oesophageal reflux in neonates.
        J Sleep Res. 2012; 21: 80-86
        • Jarus T.
        • Bart O.
        • Rabinovich G.
        • Sadeh A.
        • Bloch L.
        • Dolfin T.
        • et al.
        Effects of prone and supine positions on sleep state and stress responses in preterm infants.
        Infant Behav Dev. 2011; 34: 257-263
        • Goto K.
        • Maeda T.
        • Mirmiran M.
        • Ariagno R.
        Effects of prone and supine position on sleep characteristics in preterm infants.
        Psychiatry Clin Neurosci. 1999; 53: 315-317
        • Goto K.
        • Mirmiran M.
        • Adams M.M.
        • Longford R.V.
        • Baldwin R.B.
        • Boeddiker M.A.
        • et al.
        More awakenings and heart rate variability during supine sleep in preterm infants.
        Pediatrics. 1999; 103: 603-609
        • Bertelle V.
        • Sevestre A.
        • Laou-Hap K.
        • Nagahapitiye M.C.
        • Sizun J.
        Sleep in the neonatal intensive care unit.
        J Perinat Neonatal Nurs. 2007; 21 (quiz 149-50): 140-148
        • Sahni R.
        • Schulze K.F.
        • Stefanski M.
        • Myers M.M.
        • Fifer W.P.
        Methodological issues in coding sleep states in immature infants.
        Dev Psychobiol. 1995; 28: 85-101
        • Sahni R.
        • Saluja D.
        • Schulze K.F.
        • Kashyap S.
        • Ohira-Kist K.
        • Fifer W.P.
        • et al.
        Quality of diet, body position, and time after feeding influence behavioral states in low birth weight infants.
        Pediatr Res. 2002; 52: 399-404
        • Holditch-Davis D.
        • Scher M.
        • Schwartz T.
        • Hudson-Barr D.
        Sleeping and waking state development in preterm infants.
        Early Hum Dev. 2004; 80: 43-64