This study aimed to identify the use of prone position, as per physical therapist care, for newborns in public NICUs in Southern Brazil. Regarding the professionals evaluated, the prone position is considered necessary, and there is evidence of its benefits in neonatology, as well as later in the NPMD of newborns. However, factors external to the clinical condition of newborns were determinant in the use of prone position by the physical therapy professionals in these Units. Among the factors mentioned, the main aspects mentioned were the lack of exclusive or full-time professionals and the reduced number of professionals in the Units evaluated.
The second Ordinance of the Ministry of Health Nº 3.432 in force since August 8, 1998, the National Health Surveillance Agency16 and, more recently, Resolution 1909/2015, mention that there should be, on average, one professional physical therapist for every ten ICU beds or fraction, in the morning, afternoon and evening shifts, with full, uninterrupted 24-hour assistance available3,17. The follow-up by physical therapist of the newborn in need of intensive care was implemented and regulated by Ordinance N.3.432/SM/GM of August 12, 1983, which is considered essential in the rehabilitation and prevention of critically-ill patients5,18, aiming at reducing neonatal morbidity, shorter hospital stays, and lower hospital costs7,8.
The role of care performed by the physical therapist varies according to the indication (cardiorespiratory or motor)7,19, and the physical therapy team may have different levels of specialization and continuing education5,20. In this study, regardless of the geographical area, the level of education was similar among professionals, and most have specialization. However, aspects related to professional training (specialization in the area of neonatology or time of experience in the area) are not mandatory for the physical therapist working in the NICU. We also considered the lack of exclusivity and integrality of this professional in the NICU, which consequently translates into a reduced number of hours of assistance provided, especially during holidays and weekends. A trained team in the area of expertise is required1,3,4 aiming at the quality of care provided to hospitalized newborns1,5, due to the direct relationship between the interference of neonatal care and future changes in the newborn1,5,21.
The intrauterine aquatic environment lacks gravity, facilitates movements and a more flexed posture under vestibular stimulation of maternal movement and the containment provided by the uterine walls and placenta11,13,22. When positioned in the incubator, the newborn experiences a physical space different from the usual one, causing increased motor activity, irritability, and energy expenditure22, as well as physiological, behavioral, and motor disorder11,13.
Also to the above aspects, low muscle tone, inability to self-organize, and extensor posture may be favored, while flexion movements are hampered12,23,24, which may lead to the appearance of neuromusculoskeletal retractions and NPMD disorders11,23. Also, the length of stay in the NICU11,13 may involve inadequate stimulation and bed positioning most of the time in the same position25,26. In this study, we observed that a decubitus protocol is in place in most Units; however, no prone position protocol was found in most Services evaluated.
The indication of a prone position in the NICU is mainly related to the clinical condition of the newborn27,28. According to the respondents, the most cited factors determining the prone position were the presence of the stable cardiorespiratory condition and ventilation support. On the other hand, aspects such as the team’s lack of collaboration, either due to insecurity or resistance concerning this position, can be considered factors of interference in the decubitus alternation routine in the NICUs surveyed. When positioned in different positions, the newborns experience different pressure forces in the joints and muscles, acting positively in the development of mechanoreceptors, responsible for the coordination of movement, in order to prevent musculoskeletal deficits14,26,29.
Since the correct postural alignment of the newborn is essential, the first months of life are marked by the initial acquisition of postural control in lying positions14,15,26, and prone position is positively associated with typical motor development1,14,15. It is crucial to encourage positioning change from birth15,24,26. Also, the lack of guidance on other positions makes parents maintain their newborn in the supine position most of the time after hospital discharge24. Newborn follow-up was shown to be indicated after discharge from the NICU. However, for most professionals interviewed, the prone position was not included in these guidelines. The limited practice of alternating position during the hospitalization of the newborn, as well as the lower emphasis of prone position during orientations to family/caregivers, provide less practice of this position at home.
It is important to provide information on how to stimulate the newborn after hospital discharge to experience the environment, with the opportunity to explore it, as well as guidance to family members to continue multisensory stimulation protocols13,30. Also, from the NPMD viewpoint, experience in one position may interfere with the sequence and mechanism of motor milestones14,15. However, we often observed in this study that physical therapist care in the NICUs was hampered by the lack of professionals in the Service, both because the physical therapist did not have an exclusive performance in the NICU, and the reduced number of professionals concerning demand.
Limitations of this study are its cross-sectional design, the non-participation of all physical therapists working in each Service, as well as the exclusion of the NICUs due to the non-authorization of the coordinators or non-adherence by the professionals.