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The RES-Q Infant Wedge was orthopedically designed to address the needs of the premature infant, special populations of the term infant, and to assist with the American Academy of Pediatrics (AAP) recommendations for "Tummy Time". One side of the wedge was designed for supine sleeping to address the SIDS "Back to Sleep" protocol implemented by the AAP and SIDS Alliance. The flip side of the wedge was designed to address prone sleeping for special populations where tummy sleeping is indicated because of specific diagnoses or physical recommendation.

The musculoskeletal consequences of poor positioning/body alignment over time in a preterm baby include tightness of neck extensors, shoulder/scapular retraction, low back extension, hip abduction and external rotation. Poor positioning can also affect cranial molding and head shape as well. Preterm infants are more at risk for cranial deformities as their skulls are softer and thinner than full-term infants (Monterososso L, 2002). Due to the forces of gravity and pressure of the mattress when lying with his or her head to the side, the preterm infant can also develop an elongated anterior-posterior diameter of the skull called dolicocephaly. Dolicocephaly can interfere with the development of midline position of the head in supine. Plagiocephaly is seen more frequently with term infants since the introduction of the "Back to Sleep" program by the AAP and SIDS Alliance in 1992. It is a unilateral posterolateral head flattening caused by prolonged supine positioning.

A 'nest' was purposefully designed into the RES-Q Infant Wedge to give infants some boundaries and a place to sit, thus taking pressure off of the back of the skull. In addition, the nest was 'rounded' to disperse pressure around the skull and to help assist with head molding. Other sleeping wedges and slings suspend infants against a flat foam or mattress surface without any crevice to provide stability. Premature infants without any containment or boundaries are more likely to experience muscular fatigue, particularly in the respiratory muscles. Because of the combination of hypotonia, gravitational forces, and loss of uterine constraints, the infant develops postures of extension, leading to discomfort and an imbalance of flexion and extension (Sweeney JK, 2002).

Both the curvilinear and nest sides of the wedge were designed to promote shoulder protraction by allowing the infant's shoulders to fall forward in a natural comfortable position. Shoulder protraction is important the first year of life to encourage good hand to midline activities. This forward scapular movement helps to address everything that an infant learns to do including eating, passing objects from one hand to another, and bringing food to their mouths. Since the "Back to Sleep" program was introduced, shoulder external rotation and retraction with scapular adduction has been seen more frequently (Hunter & Malloy, 2002 ; Montfort & Case-Smith, 1997). This is often referred to as "high guard" positioning and is caused when the infant's arms consistently rest in external rotation in supine positioning (Montfort & Case-Smith, 1997). Essentially, some infants get "stuck" in this position, which can affect hand-to-mouth activities, fine motor skills that involve hand midline play as well as reaching, and gross motor activities that require forearm propping (Hunter & Malloy, 2002). Although many infants who experience this are able to resolve it on their own, occasionally a few infants may require physical therapy. Providing prone playtime as well as facilitating midline hand skills will help prevent this condition. The RES-Q Infant Wedge provides proper shoulder positioning in both the prone and supine positions.

Premature infants can actually benefit from prone positioning when medically tolerated. Studies have shown that the prone position improves oxygenation and ventilation. Prone positioning also improves cerebral venous return, lowers intracranial pressure, promotes self-calming as well as sleep states, and the prone position helps to improve behavioral organization/self-regulation (Grenier IR et al, 2003). Studies of preterm infants positioned in supine have also found that infants experience shorter and more interrupted sleep periods, have more labored, less coordinated breathing, and have more episodes of gastroesophageal reflux (Adams JA, 1994).

While in the hospital, the medically fragile infant may be limited in positioning options depending on their medical condition. It is the role of the therapist, attending nurse, respiratory therapist, attending physicians, and even the parents to promote physiologic stability and comfort for each infant. The National Institute of Child Health and Human Development (NICHD) has addressed prone sleeping as it relates to the "Back to Sleep" program. In general, the NICHD public website has made this statement on prone sleeping:

"In published studies, the vast majority of babies examined were born at term and had no known medical problems. Babies with certain disorders have been shown to have fewer problems when lying prone. These babies include: infants with symptomatic gastro-esophageal reflux (reflux is usually less in the prone position), babies with certain upper airway malformations such as Robin syndrome (there are fewer episodes of airway obstruction in the prone position). If it is decided to allow a baby to sleep prone, special care should be taken to avoid overheating or use of soft bedding since these factors are particularly hazardous for prone-sleeping infants."

In summary, the RES-Q Wedge was designed to provide proper musculoskeletal alignment in prone and supine positions during sleep and play time that is absent in all other commercial wedges. I had found, as a clinician treating infant reflux, that physicians in the NICU had stopped using reflux wedges due to the many orthopedic problems that the available wedges were creating. As such, the RES-Q Wedge was created to address these issues and allow for a more natural, upright, sleeping or play time position. As health care professionals, our primary goal is to help infants sleep more comfortably in a natural position. In addition, the design of the RES-Q Wedge encourages proper positioning so each infant can acquire more milestones on target with their development.

Robynne Elkin, MOT, OTR/L, CKT Developmental Occupational Therapist



REFERENCES:
1. Adams,J.A., Zabaleta, Sackner,M.A. Comparison of Supine and prone non-invasive measurements of breathing patterns in full-term newborns. Pediatrtic Pulmonology.1994; 18: 8-12.
2. American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome. (2005). The changing concept of sudden infant death syndrome: Diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics, 116 (5), 1245-1255. Retrieved April 28, 2009 from http//www.nicchd.nih.gov/
3. Grenier I.R., Bigsby R., Vergara E.R., et al. Comparison of motor, self-regulatory, and stress behaviors of preterm infants across body positions. American Journal of Occupational Therapy. 2003; 57 (3) 289-297.
4. Hunter J, Malloy. Effect of sleep and play positions on infant development: Developmental concerns with SIDS prevention. Newborn and Infant Nursing Reviews. 2002; 2 (1): 9-16.
5. Monfort K.P., Case-Smith J. The effects of neonatal positioning on scapular rotation. American Journal of Occupational Therapy. 1997; 51: 378-384.
6. Monterososso L., Kristjanson L., Cole J. Neuromotor development and the physiologic effects of positioning in very low birth weight infants. Journal of Obstetrics, Gynecology, and Neonatal Nursing. 2002; 31 (2): 138-146.
7. Sweeney J.K., Gutierrez T. Musculoskeletal implications of preterm infant positioning in the NICU. Journal of Perinatal Nursing. 2002; 16 (1) 58-70.