Prone Position as a Care Practice of the Physical Therapists in Public Neonatal Intensive Care Units in Southern Brazil Prone Position in NICU Southern Brazil

This study aimed to identify the use of prone position, by physical therapy care, for infants hospitalized in an NICU in the Southern Region of Brazil. This is a cross-sectional study on a public NICU in the Southern Region of Brazil between December 2015 and May 2018, using standardized questionnaires for physical therapists. We included 44 NICU, totaling 104 professionals interviewed, the mean age of the interviewed was 33.5 years (SD: 7.12) and the mean experience time in the area was 7.7 years (SD: 6.9), and 85.2% reported to have specialization. According to 68.3% of the respondents, there is a protocol for the change of position in the Unit, but the prone position is not indicated in most NICUs (59.6%). Most of the respondents (65.4%) answered affirmatively, but 73.1% reported limitations in their incorporation into the Services, often related to aspects external to the newborn (lack of exclusive or full-time professionals in the NICU (75%) and a reduced number of professionals (33.6%)). The prone position is generally not indicated in the hospital (57.7%). Conclusion: Aspects related to professional qualification and length of experience in neonatology may have contributed to the limited alternation of position during the hospitalization of the newborn and less emphasis of the prone position in the guidance to the family/caregivers. Also, a lack of exclusive or comprehensive physical therapists and the disproportion between demand and number of professionals has been observed.


Introduction
Given the increasing survival rate of newborns associated with a prolonged hospital stay, a direct relationship between neonatal care and newborns later evolution after hospital discharge is considered concerning risk for growth and developmental disorders [1][2][3][4] . This care is related to the use of technology, quality in neonatal care and multidisciplinary approaches, with emphasis on the importance of care based on humanization 1,5 and the integrality of care centered on family/caregivers [5][6][7] .
Aspects of complementarity and interdependence are found in different areas 1,5 among the different professionals involved in neonatal care. Regarding neuropsychomotor development (NPMD), physical therapists aim to minimize future changes resulting from the impact of Neonatal Intensive Care Units (NICUs) environment during the hospitalization period 4,8 . Therefore, they use therapeutic resources that stimulate vestibular, visual and tactile perception limited to the tolerance of the newborn, as well as care with bed functional positioning and reduction of harmful stimuli that favor inadequate motor and behavioral activity of these newborns 6,7,9,10 .
Care related to functional positioning includes the prevention of dermatological lesions in areas of pressure, and ischemia, improved oxygenation, facilitation of respiratory mechanics, and the promotion of mobilization of airway secretions 5,11 . Also, positioning itself is used to promote neurobehavioral and neuromotor stability 12,13 , which occurs from the alternation of newborns decubitus in NICUs5,13. The most significant opportunity for practice in the prone position is also related to infants with better development of motor and weight-bearing capacities against gravity 14,15  Two reviews were prepared on the central theme under study. Also, the term "prone position" was defined as the correct joint alignment and body symmetry, which favors motor development, promotes self-regulation and behavioral regulation; ideally, this position is described when the newborn is maintained in the physiological flexor position (shoulder, hip, and knee flexion, and lateralized head flexion) 16 .

Instruments
A questionnaire with 11 multiple-choice questions was applied to identify the physical therapy care regarding the prone position in the NICUs, which was answered in person to the same researcher in all participating Units. The information collected from the questionnaire was related to the period of hospitalization in the NICU and follow-up after discharge from the newborn: After getting in touch with the corresponding sector, the documentation requested for the research was arranged, and the medical coordinator of each Unit was contacted. Following clearance by coordinators through a letter of agreement, and subsequent acceptance of the research by the Ethics Committees of the involved institutions, the physical therapists were personally invited, in at least in two different moments, to participate in the study, and then collected the signing of the consent, followed by the application of the questionnaire. The professionals were identified by codes and identities were kept confidential; the preliminary and final results were made available to the medical coordinators of the participating institutions, and sent to the Health Secretariats of the three States ( Figure 1). professional could answer to more than one possibility. According to the period after hospital discharge, the variables were related to guidance provided to parents or caregivers and the recommendation of physical therapy follow-up.
Data were entered and consolidated in an Excel spreadsheet (Office Microsoft®), and presented from descriptive statistical analysis (mean ± standard deviation, absolute frequency, median, minimum and maximum). The significance level adopted was 5%.

Results
This study included 44 public NICUs from Southern Brazil (Figure 2) with the presence of a physical therapist; the other Units were excluded because of the lack of authorization from the coordinators (41 Units) or the non-adherence of the physical therapist to the research (seven Units). A total of 104 physical therapists interviewed, with a median age of 32 years, experience in the neonatology area, a median of six years, and 85.2% reported having specialization (Table 1).  Table 1 Most respondents (68.3%) stated that there is a protocol for decubitus change in the Unit where they work, however, in most NICUs included in this study, prone position is not indicated (59.6%). The prone position concerning NPMD was considered necessary by almost all respondents (99%), as most professionals considered this position beneficial and applicable in neonatology (97.1%).
Regarding the beginning of the prone position in the NICUs, the clinical situations cited by the interviewed physical therapists are described in Table 2. It is emphasized that each professional could answer more than one alternative to indicate this position. Table 2 We observed that 73.1% of the participants in this study stated that there were limitations in the incorporation of the prone position into the Service in which they work. These limitations were mainly related to aspects external to the clinical condition of newborns, for example, the lack of full-time physical therapist in the sector or the reduced number of professionals in this area, especially on weekends and holidays, leading them to prioritize cardiorespiratory interventions, compared to interventions related to the NPMD stimulation (Table 3). It is noteworthy that each professional could answer more than one alternative to indicate the difficulties to perform this position. Table 3 Regarding the interference of the prone position in the NPMD of newborn in NICUs, most respondents (65.4%) answered affirmatively; however, at discharge, the position of newborns in prone status is not usually mentioned (57.7%) in the guidance given to parents or caregivers, although physical therapist follow-up after discharge is recommended by most respondents (64, 4%).

Discussion
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 available 3,17 . 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 patients 5,18 , aiming at reducing neonatal morbidity, shorter hospital stays, and lower hospital costs 7,8 .
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 education 5,20 . 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 required 1,3,4 aiming at the quality of care provided to hospitalized newborns 1,5 , due to the direct relationship between the interference of neonatal care and future changes in the newborn 1,5,21 .
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 placenta 11,13,22 . When positioned in the incubator, the newborn experiences a physical space different from the usual one, causing increased motor activity, irritability, and energy expenditure 22 , as well as physiological, behavioral, and motor disorder 11,13 . Also to the above aspects, low muscle tone, inability to self-organize, and extensor posture may be favored, while flexion movements are hampered 12,23,24 , which may lead to the appearance of neuromusculoskeletal retractions and NPMD disorders 11,23 . Also, the length of stay in the NICU 11,13 may involve inadequate stimulation and bed positioning most of the time in the same position 25,26 . 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. 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 protocols 13,30 .
Also, from the NPMD viewpoint, experience in one position may interfere with the sequence and mechanism of motor milestones 14,15 . 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.

Conclusions
According to the 104 physical therapist professionals from the Southern Region of Brazil included in this study, the importance of the prone position is recognized, as well as its interference concerning the NPMD of newborns. Aspects related to the inadequate professional qualification, as well as the short time of experience in neonatology, may have contributed to the limited achievement of alternation of position during the hospitalization of the newborn and the lower emphasis of the prone position during family orientations. Also, there was often a lack of an exclusive or full-time physical therapist in the NICUs, as well as a disproportion between demand and number of professionals in care, especially on holidays and weekends.

Declarations
Conflict of Interest: The authors declare that they have no conflict of interest.
Funding: There is no funding source. Informed consent: Informed consent was obtained from all individual participants included in the study.

Author Contribution:
MM: conceptualized and designed the study, carried out the collection and analysis of data analyses, drafted the initial manuscript and approved the final manuscript as submitted.
CJ and FISS: carried out the analysis of data analyses, reviewed the manuscript, and approved the final manuscript as submitted.
MWLS: designed the data collection instruments, and coordinated and supervised data collection, critically reviewed the manuscript, and approved the final manuscript as submitted.

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Heimann K, Vaeben P, Peschgens T, Stanzel S, Wenzl TG, Orlikowsky T (2010) Impact of skin-to-skin care, prone and supine positioning on cardiorespiratory parameters and thermoregulation in premature infants. Neonatology (97) Legend: N = Number of interviewed.  Representation the number of Neonatal Intensive Care Unit (NICU) and interviewed professio