F386

ORIGINAL ARTICLE

Posture and movement in healthy preterm infants in supine

position in and outside the nest
F Ferrari, N Bertoncelli, C Gallo, M F Roversi, M P Guerra, A Ranzi, M Hadders-Algra
...................................................................................................................................
Arch Dis Child Fetal Neonatal Ed 2007;92:386390. doi: 10.1136/adc.2006.101154

See end of article for

authors affiliations
........................
Correspondence to:
Professor Fabrizio Ferrari,
Department of Pediatrics and
Neonatology, Modena
University Hospital,
Modena, Italy; ferrarif@
unimore.it
Accepted 22 February 2007
Published Online First
7 March 2007
........................

Objective: To evaluate whether lying in a nest affects the posture and spontaneous movements of healthy
preterm infants.
Method: 10 healthy preterm infants underwent serial video recording in the supine position, when lying in a
nest and outside it, at three ages: 3033 weeks postmenstrual age (PMA) (early preterm), 3436 weeks PMA
(late preterm) and 3740 weeks PMA (term). The nest was shell-shaped, made by putting two rolled blankets
in a form of an oval. Posture was assessed both before and after general movements by scoring the
predominant postural pattern. Movements towards and across the midline, elegant wrist movements, abrupt
hand and/or limb movements, rolling to side, and frozen postures of the arms and legs were assessed during
four general movements. All data relating to motor and postural items were normalised into frequencies of
events per minute because the general movements varied in duration.
Results: When lying in the nest, the infants more often displayed a flexed posture with shoulder adduction and
elbow, and hip and knee flexion, and the head was frequently in the midline. The nest was also associated
with an increase in elegant wrist movements and movements towards and across the midline and a reduction
in abrupt movements and frozen postures of the limbs. The nest did not affect the occurrence of asymmetrical
tonic neck posture.
Conclusions: A nest promotes a flexed posture of the limbs with adduction of shoulders, facilitates elegant
wrist movements and movements towards and across the midline and reduces abrupt movements and frozen
postures of the arms and legs.

eonatal posture requires a number of active postural

control mechanismsthat is, neuromotor functions
which allow a living system to control its body posture at
rest, during displacement and during active movements.1
Postural control is intimately linked to motor control: dynamic
motor actions cannot be performed without first stabilising
body posture.2 This is true for voluntary as well for involuntary
movements.3
Systematic observations of fetal posture show that, although
the fetus does not have a preferred posture for most of the time,
it has a certain repertoire of repeated active postures. The
observed postures cannot be considered as random configurations of head and limb position: the fetus and the young infant
have an active, but variable, posture that is relatively unrelated
to the orientation of the force of gravity.1 4 As pregnancy
approaches its end, body size of the fetus increases and room
for movement inside the womb decreases; the head of the fetus
is predominantly flexed or semi-flexed, the shoulders and hips
are flexed and adducted, and the limbs are close to the trunk.
The neonatal intensive care unit (NICU) exposes the preterm
infant to a non-optimal physiological environment and to
invasive procedures and handling. These may induce pain and
stress, along with the frequent manipulations by medical and
nursing staff that disrupt rest activity cycles and sleep, which
may lead to chronic and prolonged stress in the preterm infant.5
Acute stress may induce abrupt movements and startles. In
addition, motor behaviour of the preterm infant is affected by
the force of gravity, the limited ability to control the position of
the head andif the infant is not placed in a nest-like
environmenta lack of containment and boundaries.6 As a
result, startles, rolling to the side, abrupt movements of the
limbs, frozen postures of arms and legs, either spontaneous or
induced by handling, are commonly observed behaviours in
preterm infants, in particular when the clinical condition is not
www.archdischild.com

yet stable.7 In turn, the abrupt movements and frozen postures

of the limbs may add stress to stress.
The nest, which has been adopted by most European NICUs,
aims to stabilise body posture, positioning the head towards the
midline, and facilitating a flexed or semi-flexed posture of the
head. It also seems to prevent abrupt and distressing movements.811 To our knowledge, no studies have evaluated whether
the use of a nest in preterm infants results in the above
mentioned effects.
The present explorative study aimed to evaluate the effect of
a nest on motor behaviour of preterm infants. We first
hypothesised thatnotwithstanding the endogenous origin of
the basic pattern of general movement12some aspects of
spontaneous motor behaviour of preterm infants may improve
when placed in a nest. We expected that the nest, by means of
its passive constraints, would favour a midline position of the
head and flexion/adduction postures of the limbs. We also
expected that placement in a nest would result in fewer large
and abrupt arm movements. These may trigger Moro-like
movements and startles, as at this early age, the proprioceptors
in neck, and the vestibulum, are very sensitive to stimulation.6 13 The Moro-like movements and startles in turn may
trigger abrupt Moro-like movements and startles. The abrupt
movements may also trigger frozen postures, as motoneurons at
this early age are easily triggered into the plateau phase of
bistability. This means that a single trigger, for instance, stretch
evoked by an abrupt movement, may elicit motoneuronal firing
for about 30 s.1416 Thus, our second hypothesis was that putting
an infant in a nest would increase the chances of the head
being positioned in the midline, flexion/adduction postures of
the limbs, limb movements towards and across the midline and
Abbreviations: NICU, neonatal intensive care unit; PMA, postmenstrual
age

Posture and movement in and outside the nest

F387

Five infants were excluded from the study because at the age of
2 years they showed an atypical developmental outcome as
determined by Griffiths scales of development19 and Touwens
neurological examination.20
All the 10 infants who participated in the study needed
respiratory support. One of them needed intermittent positive
pressure ventilation (IPPV) for six days, six infants required
IPPVintermittent mandatory ventilation for one to three days
and one needed high-flow oxygen for five days. All infants were
given continuous positive airway pressure (CPAP) for a few
days. Ultrasound scans, serially performed from birth until
term age, showed normal findings in six infants and transient
increased echogenicity lasting less than four days in three
infants; one infant had GMH-IVH (germinal matrix-intraventricular haemorrhage) grade 1.21

Figure 1 Infant in the nest: lying in the nest facilitates arm and hand
movement during which various parts of the body are touched, and
promotes flexion of arms and legs, and adduction of shoulders and hips.
Parental/guardian informed consent was obtained for publication of this
figure.

elegant wrist movements during general movements, and

decrease abrupt movements and frozen postures of the limbs.
To test these hypotheses we evaluated posture and motility in
10 preterm infants at three ages (early preterm, late preterm
and term) when placed in a nest and outside it.

SUBJECTS AND METHODS

Subjects
Ten preterm infants (five boys and five girls; gestational age at
birth 2531 weeks (median 30 weeks); birth weight 685
1650 g (median 1292 g)) participated in the study. The parents
of the infants gave informed consent and the ethics committee
of the University Hospital of Modena approved the study. The
infants had been admitted to the NICU at the University
Hospital of Modena between 1999 and 2001. We had strict
inclusion criteria: prematurity; birth weight .25th and ,90th
centile according to the American National Center for Health
Statistics growth charts17; uneventful pregnancy and delivery
according to a detailed list of optimal prenatal and paranatal
conditions18; and absence of obvious neurological syndromes,
severe sepsis, chromosomal defects or other recognisable
malformations of the brain or other organs, or metabolic
disorders. Between 1999 and 2001, 17 infants met these
inclusion criteria. Parents of two infants declined consent.

Method
All infants underwent three video recordings, each lasting an
hour. The recordings were done at 3033 weeks postmenstrual
age (PMA) (early preterm age), 3436 weeks PMA (late
preterm age) and 3740 weeks PMA (term age). The first video
recording was done when the infants clinical condition was
reasonably stable and respiratory support was no longer
necessary. The video recordings were done in a standardised
orderthat is, half an hour in the nest and half an hour outside
the nest, in an incubator or in a cot, in supine position, naked or
in a nappy, completely free to move.22 One infant missed one
early preterm age video recording.
The nest is oval-shaped and made of cloth (we use two
rolled-up blankets), in which the infant lies when inside the
incubator (fig 1). The infant is placed in the nest to facilitate a
semiflexed and adducted position of the shoulders and hips and
to reduce environmental stimuli. The postural support provided
by the nest is in accordance with the strategy of individualised
developmental care in the NICU.23 We placed a small roll under
the infants neck to help the proper alignment of the neck and
trunk. This was done mainly to provide an optimal position for
breathing.
Our analysis of the videos focused on motor behaviour during
activity periodsthat is periods with repeated general movements and other non-sporadic movement patterns.16 General
movements are gross movements involving the whole body,
lasting from a few seconds to several minutes.22 Four general
movements were randomly selected from each video. The
movement analysis focused on motor behaviour immediately
before, during and immediately after the four general movements. We took care that the posture after one general
movement did not overlap with the posture prior to another
general movement.
We analysed posture at rest immediately before a general
movement started and immediately after this general movement ended. The postural items analysed are given in appendix
A and were designed for the present study. A posture was
considered to be a posture (and no longer a movement) when it
lasted for at least 10 s. When evaluating the position of the
head, we used a simple dichotomy: midline position versus
rotated to either the right or the left side (2070). On the basis
of the four postures before and after a general movement, the
predominant postural pattern before and after general movements was determined. If two patterns were observed equally
often, the more flexed, adducted or midline pattern was
scoredthat is, for the elbows, hips and knees the flexed
posture, for the shoulders the adducted posture, for the head
the midline position, and absence rather than presence of the
asymmetrical tonic neck posture. We also evaluated the four
general movements. In the analysis of spontaneous motility we
focused on the items listed in appendix B.24
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F388

Ferrari, Bertoncelli, Gallo, et al

Table 1 Differences in posture during rest between general

movements in infants lying in and outside a nest
Early preterm age
(3033 weeks)

Late preterm age

(3436 weeks)

Term age
(3740 weeks)

Posture before general movements

NEST more adduction
NEST more adduction NEST more adduction
L shoulder*
L shoulder*
L shoulder**
R shoulder*
R shoulder*
R shoulder**
NEST more flexion
NEST more flexion
NEST more flexion
R elbow*
R hip*
L hip*
L hip*
R knee*
R hip*
R hip*
L knee*
L knee*
R knee*
NEST more often
Head in the midline*
Posture after general movements
NEST more adduction
NEST more adduction NEST more adduction
L shoulder*
R shoulder**
NEST more flexion
NEST more flexion
NEST more flexion
L elbow*
L elbow*
L hip*
L hip*
L hip**
R hip*
R hip*
R hip**
L knee*
L knee*
L knee**
R knee*
R knee*
NEST more often
Head in the midline*
L, left, R, right.
*p,0.05, **p,0.01: differences between lying in a nest and without a nest
(Wilcoxons signed rank test).

The video recordings were assessed by three observers. One

observer (MC) scored the postural items in eight infants and
another observer (CG) scored the items relating to spontaneous
movements in the same eight infants. A third observer (QB)
evaluated posture and motility data of the remaining two
infants. As three observers carried out the scoring, interobserver
agreement was calculated. For this, the three observers scored
posture and spontaneous movements in another five preterm
infants. The interobserver agreement for all items of appendix A
and most items of appendix B was between 81% and 100%. The
three items for which agreement was somewhat less were items
4, 5, 9 of the section movements towards and across midline,
varying between 61% and 80%.
We carried out the statistical analyses using SPSS (version
11.0). As the general movements varied in duration, all data
relating to spontaneous movements were normalised into
frequencies of events per minute per general movement.
Next, a median value was calculated per infant, age and the
condition. The effect of the conditionthat is, in the nest or
outside the nestwas evaluated using the non-parametric
Wilcoxons signed rank test as the data were not normally
distributed. A p value ,0.05 was considered to be statistically
significant (two-tailed test).

RESULTS
Lying in a nest had a clear effect on the infants postural
behaviour before and after a general movement (table 1).
Before a general movement, an infants shoulders were more
adducted and limbs somewhat more flexed in the nest than
outside the nest. After a general movement, lying in a nest was
particularly associated with an increase in limb flexion, and at
term age, also with an increase in shoulder adduction and head
in midline position. Interestingly, the asymmetrical tonic neck
posture was never a predominant posture in these relatively
healthy preterm infants.
Lying in a nest also had a substantial effect on spontaneous
motor behaviour. Throughout the early and late preterm and
term periods lying in a nest increased the number of
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Figure 2 Differences between the various spontaneous movements when

in and outside the nest. The short horizontal lines denote median values, the
boxes denote the interquartile ranges and the vertical lines denote the
ranges. Outliers are denoted by stars and dots. Foot foot, footfoot contact;
Hand hand, handhand contact; Hand head, handhead contact; Hand
mouth, handmouth contact; HL, handleg contact; HROT-SM, head
rotation from side to midline and back; HROT-SS, head rotation from side
to side; HST, hand touching contralateral shoulder and trunk; Open hands,
gently striking head with open hands. *p,0.05, **p,0.01 (Wilcoxons
signed rank test). Note that the differences in the early preterm age cannot
be seen clearly, but the statistical analysis shows a significant difference.

movements towards or crossing the midline (fig 2). In the same

period the nest also increased the occurrence of elegant wrist
movements (p,0.05; item considered separately, data not
shown). The nest was also associated with a reduction in frozen
postures and, from late preterm term onwards, abrupt movements (fig 3).

DISCUSSION
The present study has shown that placing an infant in a nest
facilitates a flexed and adducted posture, promotes elegant
wrist movements and movements towards or crossing the
midline, and it reduces abrupt movements and frozen postures.
The strength of the present study was the standardised and
detailed assessment of the effect of lying in a nest in relatively
healthy preterm infants. Each infant acted as its own control.
There were some weaknesses of this explorative study. First,
the infants, for the rest of their stay in hospital, were placed in
the nest. This meant that when they were taken out of the nest
to be studied, they experienced an abrupt interruption of the
environment and posture to which they had got used to.
However, we could not overcome this limitation because of the
strong opinion of the NICU nursing staff regarding the
beneficial effect of the nest. A firm belief in a method, despite

Posture and movement in and outside the nest

F389

What is already known on this topic

N
N

Being placed in a nest reduces the distress in the preterm

infant during screening for retinopathy of prematurity.
The nest-like support provided by pillows in young infants
after term age does not affect the occurrence of abnormal
general movements.

What this study adds

N
N
N
N
Figure 3 Upper panel: effect of lying in a nest on occurrence of frozen
postures of arms and legs. ARM-FR-FL, arms in frozen flexion and fisting;
LEGS-EXT, legs in frozen extension. Lower panel: effect of lying in a nest on
the occurrence of abrupt movements. ABD-EXT, abrupt abduction
extension movements of the arms; Open hand, abrupt opening of hands
and fingers; Startle, abrupt abductionextension of the four limbs; Rolling,
abrupt rolling to side. *p,0.05, **p,0.01 (Wilcoxons signed rank test).

the absence of research evidence, is a well-known obstacle in

the evaluation of new forms of developmental care.25 Second,
the observers, unavoidably, were not blinded to the nesting
condition and might have had a bias favouring the nest, and a
team of observers evaluated different aspects of motor
behaviour. Third, the conditions were not applied in a random
order, and there was no washout period. However, the data
did not reveal changes in motor and postural behaviour over
time within a conditionthat is, lying in the nest or outside it.
Until now few studies have addressed the effect of nest-like
support in preterm infants in the NICU.2630 There is no evidence
that lying in a nest shortens the duration of hospital stay and
increases weight before discharge.28 Slevin et al29 showed that
the distress caused by retinopathy of prematurity screening in a
cohort of preterm infants was considerably less in infants lying
in a nest that in the non-nested group, for both movement
activity and crying. De Graaf-Peters et al30 studied the
immediate effects of the nest-like support provided by pillows
in infants with and without minor neurological dysfunction at
15 months post-term age. They found that support using a
pillow did not affect the quality of general movementsthat is,
the occurrence of abnormal general movements. It did,
however, promote the variation in specific movementsmovements that can be considered as precursors of goal-directed
movements. The effect was particularly noticeable in the
infants with minor neurological dysfunction.
The nest affected posture and motility at all the three ages at
which this was studied. The overall effect was similar for the
three periods, but some age-related differences were observed:

during the early preterm age, the nest did not affect head
position, but from late preterm onwards it did;

Being placed in a nest reduces abrupt movements,

facilitates elegant wrist movements and movements
towards and across the midline.
Nest-like support promotes a flexed and adducted
posture of the limbs.

at term age the nest had the strongest effect on shoulder

adduction;
at early preterm age, lying in a nest was not associated with
a reduction of abrupt movements.

These age-related effects might be related to the changes that

occur in the nervous system around 3638 weeks PMA. After
these changes, general movements become slower and have a
writhing aspect, which probably counteracts the production of
abrupt movements.31
Our study indicates that lying in a nest reduces the abrupt
movements that increase the stress in the infant, and it
facilitates age-specific postures and movements. The agespecific flexed and adducted posture of the limbs promotes
movements towards and across the midline. This, in turn,
enhances contact of the limbs with other parts of the body,
just as in fetal life. Handhand contact, handhead contact, hands touching the contralateral shoulder and trunk,
handleg contact and footfoot contact offer rich and continual exteroceptive and proprioceptive feedback to the
central nervous system. This type of self-generated feedbackthat is, continuous motor and sensory exploration
is currently considered to be a major driving force of motor
development.32 33
The intrauterine environment and postural stability offered
by the womb represent the ideal setting for the preterm infant.34
The results of our study underscore the importance of
individualised developmental care523 to promote age-adequate
postures, thereby reducing the distressing conditions of
extrauterine life in preterm infants.
31

ACKNOWLEDGEMENTS
We are grateful to Quinta Bergman and Manuela Corradini for their
help in data collection.
.......................

Authors affiliations
F Ferrari, N Bertoncelli, C Gallo, M F Roversi, M P Guerra, A Ranzi,
Department of Pediatrics and Neonatology of Modena University, Modena
University Hospital, Modena, Italy
M Hadders-Algra, Department of NeurologyDevelopmental Neurology,
University Medical Center Groningen, Groningen, the Netherlands
Parental/guardian informed consent was obtained for publication of fig 1.
Competing interests: None.
www.archdischild.com

F390

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Ferrari, Bertoncelli, Gallo, et al

APPENDIX A
Items in the assessment of posture
Item

Description

(1) Left shoulder

0 = adduction
1 = neutral
2 = abduction
0 = flexion
1 = semiflexion
2 = extension
0 = adduction
1 = neutral
2 = abduction
0 = flexion
1 = semiflexion
2 = extension
0 = flexion
1 = semiflexion
2 = extension
0 = flexion
1 = semiflexion
2 = extension
0 = flexion
1 = semiflexion
2 = extension
0 = flexion
1 = semiflexion
2 = extension
= absent
= present
0 = head in the midline
1 = head to side

(2) Left elbow

(3) Right shoulder

(4) Right elbow

(5) Left hip

(6) Left knee

(7) Right hip

(8) Right knee

(9) Asymmetrical
tonic neck posture
(10) Head position

020
2190
.90
030
31150
.150
020
2190
.90
030
31150
.150
080
81150
.150
060
61150
.150
080
81150
.150
060
61150
.150
Rotated ,20
Rotated 2070

APPENDIX B
Items in the assessment of details of general movements
and spontaneous movements

Movements
towards and
across the
midline
(1) Head
rotation from
side to
midline and
back
(2) Head
rotation from
side to side
(3) Hand
mouth contact

(4) Handhead
contact
(5) Gently
striking head
with open
hands
(6) Handhand
contact
(7) Hands
touching
contralateral
shoulder and
trunk
(8) Handleg
contact
(9) Footfoot
contact

Abrupt hand
and/or limb
movements
Frozen postures
Elegant wrist and
of arms and
movements
rolling to side legs
(1) Wrist
movements with
superimposed
rotations

(1) Abrupt
(1) Arms in
opening
frozen extension
of hands and
fingers
(2) Abrupt
abduction
extension of
the arms
(3) Abrupt
abduction
extension of
the four limbs
(4) Abrupt
rolling to side

(2) Arms in
frozen flexion
and fisting
(3) Legs in
frozen extension