Tummy Time in the NICU: Beyond the Isolette

A Quality Improvement Project

Lisa Glantz Williamson RNC-NIC, MSN, ARNP, NNP-BC, DNP Student

University of Missouri - Columbia

Background

• CPD is, “an asymmetrical flattening or deformity of the skull,” and can occur

in up to 50% of infants (Duderstadt, 2014, p. 123; Laughlin et al., 2011;

(Mawji, Vollman, Hatfield, McNeil, & Sauvé, 2013).

• The “Back to Sleep” program implemented by the AAP in 1992 significantly

reduced the incidence of SIDS (Miller, Johnson, Duggan, & Behm, 2011).

• The down side of “Back to Sleep” is less tummy time with roughly 25% of

infants not receiving TT despite the AAP recommendation due to a lack of

infant tolerance (AAP, 2011; Miller et al., 2011; Wen, Baur, Simpson, Rissel,

& Flood, 2011; Zachry & Kitzmann, 2011).

• CPD has significantly increased, reportedly as much as 600%, since the

implementation of “Back to Sleep” (Graham, 2006; Laughlin et al., 2011;

Looman & Keck Flannery, 2012; Miller et al., 2011).

• Strategies for the treatment of CPD are grounded in prevention and

positioning, with parental participation essential (Laughlin et al., 2011).

• TT is defined as kangaroo care or awake prone positioning and is

important for development of gross motor milestones (Miller et al., 2011).

• Safe demonstration of TT in the NICU has the potential to increase

tolerance of TT after discharge and allows opportunity for parental

education about the importance of TT beyond the NICU (Koren, Reece,

Kahn-D’angelo, & Medeiros, 2010).

Purpose Statement

The purpose of this project was to identify the effect of the implementation of a

TT algorithm on the incidence of CPD in NICU patients. A TT algorithm

provides guidance to the caregivers and the family in the NICU regarding the

importance of TT and serves as a guide to make TT part of daily NICU care

activities.

Objectives

1) 75% of NICU caregivers will receive TT education prior to program

initiation.

2) 75% of parents will receive education on TT.

3) A 50% increase in charting of TT in the EMR.

4) A 2% decrease in CPD at discharge in the EMR.

Introduction

Mode of Delivery

• Predominant mode of delivery was vaginal (48%, n = 78), followed by urgent cesarean section (34%, n = 34%), elective cesarean section

(11%, n = 11%), and emergent cesarean section (8%, n = 12) with no statistically significant difference between groups for mode of delivery, χ2

(3) = .22, p = .97.

• Assisted delivery occurred in 10% (n = 16) of deliveries with no statistically significant difference between groups, χ2 (1) = 1.25, p = .26.

Crib to Discharge

• Substantially fewer subjects in the follow-up group with the LOS varying between baseline (M = 17, SD = 23.77) and follow-up (M = 5, SD =

3.13). As such, LOS between groups was statistically significant, t(161) = .4.83, p = .00.

• However, the mean GA at discharge was 38 weeks at baseline (SD = 2.61) and follow-up (SD = 1.85), indicating no statistically significant

difference between groups, t(161) = .02, p = .98.

Materials and Methods

American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome. (2011). SIDS and other sleep-related infant deaths:

Expansion of recommendations for a safe infant sleeping environment. Pediatrics, 128(5), 1030-1039. doi:

10.1542/peds.2011-2284

Duderstadt, K.G. (2014). Head and neck. In K.G. Duderstadt (Ed.), Pediatric physical examination: An illustrated handbook (2nd ed., pp.

118-129). St. Louis, MO: Elsevier Mosby.

Graham, J.M. (2006). Tummy time is important. Clinical Pediatrics, 45(2), 119-121. doi: 10.1177/000992280604500202

Koren, A., Reece, S.M., Kahn-D’angelo, L., & Medeiros, D. (2010). Parental information and behaviors and provider practices related to

tummy time and back to sleep. Journal of Pediatric Health Care, 24(4), 222-230. doi: 10.1016/j.pedhc.2009.05.002

Laughlin, J., Luerssen, T.G., & Dias, M.S. (2011). Prevention and management of positional skull deformities in infants.

Pediatrics, 128(6), 1236-1241. doi: 10.1542/peds.2011-2220

Looman, W.S., & Kack Flannery, A.B. (2012). Evidence-based care of the child with deformational plagiocephaly, part I:

Assessment and diagnosis. Journal of Pediatric Health Care, 26(4), 242-250. doi: 10.1016/j.pedhc.2011.10.003

Mawji, A., Vollman, A.R., Hatfield, J., McNeil, D.A., & Sauvé, R. (2013). The incidence of positional plagiocephaly: A cohort study.

Pediatrics, 132(2), 298-304. doi: 10.1542/peds.2012-3438

Miller, L.C., Johnson, A., Duggan, L., & Behm, M. (2011). Consequences of the “Back to Sleep” program in infants. Journal of

Pediatric Nursing, 26, 364-368. doi: 10.1016/j.pedn.2009.10.004

Wen, L.M., Baur, L.A., Simpson, J.M., Rissel, C., & Flood, V.M. (2011). Effectiveness of an early intervention on infant feeding

practices and “tummy time”: A randomized control trial. Archives of Pediatrics and Adolescent Medicine, 165(8), 701-707.

doi: 10.1001/archpediatrics.2011.115

Zachry, A.H., & Kitzmann, K.M. (2011). Caregiver awareness of prone play recommendations. The American Journal of

Occupational Therapy, 65(1), 101-105. doi: 10.5014/ajot.2011.09100

Caregiver Education

• 72% of NICU caregivers received TT education via a Net Learning

PowerPoint presentation prior to program implementation.

• Overall increase in TT knowledge from pre-education to post-education.

• 100% of caregivers agreed that TT is important.

• 99% of caregivers stated that TT education is important for their practice.

Parental Education

• Only 33% of parents received the TT tip sheet following admission with

20% receiving the tip sheet within a day of admission.

• After an interim evaluation and change in handout practice, the receipt rate

increased from 27% to 54% during the evaluation time period.

Frequency and Duration

• At baseline, 28% (n = 44) of infants did not receive TT during their NICU

stay. However, at follow-up only 14% (n = 23) did not receive TT during their

NICU stay.

• Although not statistically significant, χ2 (1) = .70, p = .40, this is a clinically

significant finding with a 50% reduction in the number of infants who did not

receive TT.

• Of the infants who received TT (n = 90) during their NICU stay, 82% (n =

74) received TT for > 60 minutes during the sessions, χ2 (2) = 7.64, p = .02.

Impact on CPD at Discharge

• 5 infants in the baseline group with none in the follow-up group. This finding

was not statistically significant, χ2 (1) = 2.18, p = .14.

• All male, AGA (n = 4) and LGA (n = 1), preterm (n = 3), late preterm (n = 1),

and term (n = 1).

• While not statistically significant, infants in the baseline group were nearly

1.5 times more likely to develop CPD than infants in the follow-up group,

OR = 1.44, 95% CI [1.29, 1.61].

• Small to moderate clinically significant effect (ϕ = .12) from TT on reducing

the incidence of CPD in the NICU patients.

Tummy Time Results

References

Results

The project director would like to thank Dr. Jan Sherman (Committee Chair),

Dr. Urmeka Jefferson (2nd Reader and Committee Member), Dr. K. Alanna

Rice (3rd Reader and Clinical Committee Member), and the Blank Children’s

Hospital NICU caregivers for their support and direction with this project.

Contact: lmg9d5@mail.missouri.edu, http://nursing.missouri.edu/index.php

Acknowledgements

Decrease in Cranial Deformations

Tummy Time Tip

Sheet

NICU Caregiver Education

Tummy Time

Algorithm

Follow-upChart

Review

• Chart review from all NICU admissions (n = 61).

• Variables

• Same as baseline except for addition of Tummy Time variables caregiver education and parental TT tip sheet.

Education

• Caregiver education via Net Learning module with pre- and post-education true/false 12 question survey.

• Project implementation March 15, 2016 after caregiver education.

• TT Tip Sheet to parents at admission to NICU, ideally within 1 day.

• TT for minimum 60 minutes daily.

Baseline Chart

Review

• Chart review from convenience sample with systematic random sampling from every 4th

NICU admission (n = 100).

• Variables

• Infant

• Maternal

• Pregnancy

• Labor/Delivery

• Infant Morbidities

• Tummy Time

Survey Question

Pre-

Education

% Correct

Post-

Education

% Correct

% Change

1 – Tummy time is important. 100% 99% -1%

2 – An example of tummy time is dressed chest to chest holding. 80% 98% 18%

3 – Term infants are the most vulnerable to developing cranial positional

deformities.

81% 84% 3%

4 – Parents have increased the amount of tummy time they provide since the

initiation of the “Back to Sleep” program.

80% 92% 12%

5 – Safely demonstrating tummy time in the NICU encourages parents to provide

safe tummy time at home.

100% 99% -1%

6 – Thirty minutes or less of tummy time daily is adequate. 64% 96% 32%

7 – Cranial positional deformities have increased 50% since the implementation

of the “Back to Sleep” program.

13% 42% 29%

8 – Tummy time helps develop gross motor skills. 99% 99% 0%

9 – Tummy time teaches infants to reach for toys. 80% 91% 11%

10 – An example of tummy time is prone positioning in an isolette. 66% 87% 21%

11 – An example of tummy time is an infant asleep prone in a crib. 84% 83% -1%

12 – This information is useful to your practice. 99% 98% -1%

Conclusions

1) Objective Not Met – 72% of NICU caregiver education was complete prior

to project implementation, falling just short of the 75% completion goal.

2) Objective Not Met – After a change in TT tip sheet process, the

percentage of parents educated about TT increased 50%, but still fell short

of the 75% goal.

3) Objective Met – The implementation of the TT algorithm decreased the

number of infants who did not receive TT by 50%, meeting the goal for an

increase in charting of TT in the EMR by 50%.

4) Objective Met – The 2% decrease in CPD at discharge goal was

exceeded with no CPD present at discharge at follow-up compared to 4%

at baseline.

The implementation of an evidence based algorithm for TT in the NICU

reduced the incidence of CPD and contributed to the expansion of knowledge

of TT to reduce CPD.

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