EFFECTS OF HAMMOCK POSITIONING ON CLINICAL PARAMETERS IN PRETERM INFANTS ADMITTED TO A NEONATAL INTENSIVE CARE UNIT: A SYSTEMATIC REVIEW

Menger, Janaina de Lima; Mafaldo, Letícia Reck; Schiwe, Daniele; Schaan, Camila Wohlgemuth; Heinzmann-Filho, João Paulo

doi:10.1590/1984-0462/2021/39/2019399

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Revista Paulista de Pediatria

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REVIEW ARTICLE • Rev. paul. pediatr. 39 • 2021 • https://doi.org/10.1590/1984-0462/2021/39/2019399 copy

EFFECTS OF HAMMOCK POSITIONING ON CLINICAL PARAMETERS IN PRETERM INFANTS ADMITTED TO A NEONATAL INTENSIVE CARE UNIT: A SYSTEMATIC REVIEW

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To review the effects of the hammock positioning on clinical parameters of preterm newborn infants (PTNB) admitted to the Neonatal Intensive Care Unit (NICU).

Data sources:

This was a systematic review performed by searching the Pubmed, Lilacs, SciELO and PEDro databases. Intervention studies in English, Portuguese and Spanish that evaluated the effects of hammock positioning on clinical parameters of PTNB admitted to the NICU were selected. Three search strategies were used: 1) hammock positioning OR patient positioning AND intensive care units AND infant, newborn; 2) hammock positioning OR patient positioning AND intensive care units; 3) hammock positioning OR patient positioning AND intensive care units, neonatal. There was no restriction on the year of publication of the articles. Methodological quality was assessed by the PEDro scale.

Data synthesis:

Among 597 articles, only six were included and 139 neonates with gestational ages between 26 and 37 weeks and an average gestational weight <2240g were analyzed. Four studies included patients without any associated pathology and most of them placed the PTNB supine in hammock positioning. The duration of the intervention ranged from 15 to 180 minutes and most applied it at just one moment. There was an improvement in heart rate (HR), respiratory rate (RR) and pain (3/4 studies), as well as gains in peripheral oxygen saturation (SpO2) (2/4 studies). Only one study reported worsening of SpO2 with the intervention. The methodological quality of the studies was classified as low.

Conclusions:

Although this review suggests improvement with hammock positioning in HR, RR and pain in PTNB, the low methodological quality makes the results inconsistent.

Keywords:
Premature newborn; Patient positioning; Neonatal Intensive Care Units

Authors	Country	Sample Size	Outline	Purpose of the study
Ribas et al.²³23. Ribas CG, Andreazza MG, Neves VC, Valderramas S. Effectiveness of hammock positioning in reducing pain and improving sleep-wakefulness state in preterm infants. Respir Care. 2019;64:384-9. https://doi.org/10.4187/respcare.06265 https://doi.org/https://doi.org/10.4187/...	Brazil	26	RCT	Evaluate the effects of hammock positioning on reducing pain and improving sleep/wakefulness and vital signs
Jesus et al.⁴4. Jesus VR, Oliveira PM, Azevedo VM. Effects of hammock positioning in behavioral status, vital signs, and pain in preterms: a case series study. Braz J Phys Ther. 2018;22:304-9. https://doi.org/10.1016/j.bjpt.2018.03.002 https://doi.org/https://doi.org/10.1016/...	Brazil	28	Quasi-experimental	Evaluate the effects of hammock positioning on behavioral status, pain and vital signs
Queiroz et al.¹⁴14. Queiroz CM, Santos-de-Araújo AD, Ferreira LM, Silva JA, Bassi D, Souza CT, et al. Repercussions in newborns using hammocks and prone position. Rev Investig Bioméd. 2017;9:159-67. https://doi.org/10.24863/rib.v9i2.127 https://doi.org/https://doi.org/10.24863...	Brazil	20	Quasi-experimental with cross-over	Verify the use of hammocks and prone positioning for pain relief and vital sign behavior
Costa et al.⁸8. Costa KF, Beleza LO, Souza LM, Ribeiro LM. Hammock position and nesting: comparison of physiological and behavioral effects in preterm infants. Rev Gaúcha Enferm. 2016;37:e62554. https://doi.org/10.1590/1983-1447.2016.esp.62554 https://doi.org/https://doi.org/10.1590/...	Brazil	30	Quasi-experimental with cross-over	Compare the effects of hammock positioning and the nest on the level of pain, posture and organizational status
Keller et al.¹⁹19. Keller A, Arbel N, Merlob P, Davidson S. Neurobehavioral and autonomic effects of hammock positioning in infants with very low birth weight. Pediatr Phys Ther. 2003;15:3-7. https://doi.org/10.1097/01.PEP.0000049507.48347.26 https://doi.org/https://doi.org/10.1097/...	Israel	20	RCT	Examine the effects of hammock positioning on growth, autonomic stability and neuromuscular maturity
Zanardo et al.²⁴24. Zanardo V, Trevisanuto D, Dani C, Bottos M, Guglielmi A, Cantarutti F. Oxygen saturation in premature neonates with bronchopulmonary dysplasia in a hammock. Biol Neonate. 1995;67:54-8. https://doi.org/10.1159/000244143 https://doi.org/https://doi.org/10.1159/...	Italy	15	Quasi-experimental	Evaluate the effects of hammock positioning on peripheral oxygen saturation

Authors	Age (weeks)	Birth weight (g)	Associated pathologies	Variables evaluated	Moment of evaluation
Ribas et al.²³23. Ribas CG, Andreazza MG, Neves VC, Valderramas S. Effectiveness of hammock positioning in reducing pain and improving sleep-wakefulness state in preterm infants. Respir Care. 2019;64:384-9. https://doi.org/10.4187/respcare.06265 https://doi.org/https://doi.org/10.4187/...	30 to 37	1620±0.51*	None	Pain, HR, RR, SpO₂ and sleep/wake	10 minutes before and after the intervention
Jesus et al.⁴4. Jesus VR, Oliveira PM, Azevedo VM. Effects of hammock positioning in behavioral status, vital signs, and pain in preterms: a case series study. Braz J Phys Ther. 2018;22:304-9. https://doi.org/10.1016/j.bjpt.2018.03.002 https://doi.org/https://doi.org/10.1016/...	28 to 36	<1500	None	Pain, HR, RR, SpO₂ and behavioral status	10 minutes before and throughout the intervention (2, 20, 40, 60 minutes) and after 10 minutes
Queiroz et al.¹⁴14. Queiroz CM, Santos-de-Araújo AD, Ferreira LM, Silva JA, Bassi D, Souza CT, et al. Repercussions in newborns using hammocks and prone position. Rev Investig Bioméd. 2017;9:159-67. https://doi.org/10.24863/rib.v9i2.127 https://doi.org/https://doi.org/10.24863...	32⁺	1932^$	RDS and BPD	Pain, HR, RR, SpO₂, SBP, DBP, MAP and body temperature	Before and after the intervention^#
Costa et al.⁸8. Costa KF, Beleza LO, Souza LM, Ribeiro LM. Hammock position and nesting: comparison of physiological and behavioral effects in preterm infants. Rev Gaúcha Enferm. 2016;37:e62554. https://doi.org/10.1590/1983-1447.2016.esp.62554 https://doi.org/https://doi.org/10.1590/...	32 to 35	1400-1800	None	Pain, flexing posture and organizational status	After changing diapers^#
Keller et al.¹⁹19. Keller A, Arbel N, Merlob P, Davidson S. Neurobehavioral and autonomic effects of hammock positioning in infants with very low birth weight. Pediatr Phys Ther. 2003;15:3-7. https://doi.org/10.1097/01.PEP.0000049507.48347.26 https://doi.org/https://doi.org/10.1097/...	26 to 30	<1500	None	HR, RR, weight gain and neuromuscular maturation	Before, during, and after the intervention^#
Zanardo et al.²⁴24. Zanardo V, Trevisanuto D, Dani C, Bottos M, Guglielmi A, Cantarutti F. Oxygen saturation in premature neonates with bronchopulmonary dysplasia in a hammock. Biol Neonate. 1995;67:54-8. https://doi.org/10.1159/000244143 https://doi.org/https://doi.org/10.1159/...	27 to 30	970-2240	BPD	SpO₂	15 minutes before, during, and after the intervention

Authors	Type of intervention	Frequency	Duration	Statistical analysis	Pain	HR	RR	SpO₂	Other outcomes
Ribas CG et al.²³23. Ribas CG, Andreazza MG, Neves VC, Valderramas S. Effectiveness of hammock positioning in reducing pain and improving sleep-wakefulness state in preterm infants. Respir Care. 2019;64:384-9. https://doi.org/10.4187/respcare.06265 https://doi.org/https://doi.org/10.4187/...	Hammock positioning in LD Nesting position in LD	5 days	120 minutes	Intergroups	↓	↓	↓	↑	↑ Sleep and wake
Jesus VR et al.⁴4. Jesus VR, Oliveira PM, Azevedo VM. Effects of hammock positioning in behavioral status, vital signs, and pain in preterms: a case series study. Braz J Phys Ther. 2018;22:304-9. https://doi.org/10.1016/j.bjpt.2018.03.002 https://doi.org/https://doi.org/10.1016/...	Hammock positioning in supine	1 moment	60 minutes	Intra-groups	↔	↓	↓	↔	↑Behavioral status
Queiroz CMB et al.¹⁴14. Queiroz CM, Santos-de-Araújo AD, Ferreira LM, Silva JA, Bassi D, Souza CT, et al. Repercussions in newborns using hammocks and prone position. Rev Investig Bioméd. 2017;9:159-67. https://doi.org/10.24863/rib.v9i2.127 https://doi.org/https://doi.org/10.24863...	Hammock positioning in RLD Nesting position in RLD	1 moment	40 minutes	Intra-groups	↓ ↓	↔ ↔	↔ ↔	↑ ↑	↔ SPB, DBP, MAP ↔ Body temperature ↔ SPB, DBP, MAP ↔ Body temperature
Costa KSF et al.⁸8. Costa KF, Beleza LO, Souza LM, Ribeiro LM. Hammock position and nesting: comparison of physiological and behavioral effects in preterm infants. Rev Gaúcha Enferm. 2016;37:e62554. https://doi.org/10.1590/1983-1447.2016.esp.62554 https://doi.org/https://doi.org/10.1590/...	Hammock positioning in supine Nest positioning in prone	1 moment	40 minutes	Intergroups	↓	-	-	-	↑ Flexor posture ↑ Organizational status
Keller et al.¹⁹19. Keller A, Arbel N, Merlob P, Davidson S. Neurobehavioral and autonomic effects of hammock positioning in infants with very low birth weight. Pediatr Phys Ther. 2003;15:3-7. https://doi.org/10.1097/01.PEP.0000049507.48347.26 https://doi.org/https://doi.org/10.1097/...	Hammock positioning in supine Nest positioning in prone	10 days	180 minutes	Intergroups	-	↓	↓	-	↑ Neuromuscular maturation ↔ Body weight
Zanardo V et al.²⁴24. Zanardo V, Trevisanuto D, Dani C, Bottos M, Guglielmi A, Cantarutti F. Oxygen saturation in premature neonates with bronchopulmonary dysplasia in a hammock. Biol Neonate. 1995;67:54-8. https://doi.org/10.1159/000244143 https://doi.org/https://doi.org/10.1159/...	Hammock positioning in supine	1 moment	15 minutes	Intra-groups	-	-	-	↓	-

Evaluated criteria	Ribas CG et al.²³23. Ribas CG, Andreazza MG, Neves VC, Valderramas S. Effectiveness of hammock positioning in reducing pain and improving sleep-wakefulness state in preterm infants. Respir Care. 2019;64:384-9. https://doi.org/10.4187/respcare.06265 https://doi.org/https://doi.org/10.4187/...	Jesus VR et al.⁴4. Jesus VR, Oliveira PM, Azevedo VM. Effects of hammock positioning in behavioral status, vital signs, and pain in preterms: a case series study. Braz J Phys Ther. 2018;22:304-9. https://doi.org/10.1016/j.bjpt.2018.03.002 https://doi.org/https://doi.org/10.1016/...	Queiroz CMB et al.¹⁴14. Queiroz CM, Santos-de-Araújo AD, Ferreira LM, Silva JA, Bassi D, Souza CT, et al. Repercussions in newborns using hammocks and prone position. Rev Investig Bioméd. 2017;9:159-67. https://doi.org/10.24863/rib.v9i2.127 https://doi.org/https://doi.org/10.24863...	Costa KSF et al.⁸8. Costa KF, Beleza LO, Souza LM, Ribeiro LM. Hammock position and nesting: comparison of physiological and behavioral effects in preterm infants. Rev Gaúcha Enferm. 2016;37:e62554. https://doi.org/10.1590/1983-1447.2016.esp.62554 https://doi.org/https://doi.org/10.1590/...	Keller et al. ¹⁹19. Keller A, Arbel N, Merlob P, Davidson S. Neurobehavioral and autonomic effects of hammock positioning in infants with very low birth weight. Pediatr Phys Ther. 2003;15:3-7. https://doi.org/10.1097/01.PEP.0000049507.48347.26 https://doi.org/https://doi.org/10.1097/...	Zanardo V et al.²⁴24. Zanardo V, Trevisanuto D, Dani C, Bottos M, Guglielmi A, Cantarutti F. Oxygen saturation in premature neonates with bronchopulmonary dysplasia in a hammock. Biol Neonate. 1995;67:54-8. https://doi.org/10.1159/000244143 https://doi.org/https://doi.org/10.1159/...
Eligibility criteria*	+	+	+	+	+	+
Random allocation	+	-	-	-	+	-
Hidden allocation	-	-	-	-	-	-
Similar groups	+	-	-	-	+	-
Blind participants	+	+	+	+	+	+
Blind therapists	-	-	-	-	-	-
Blind evaluators	+	-	-	-	-	-
Adequate follow-up	+	+	+	+	+	+
Intention to treat analysis	+	+	+	+	+	-
Between group comparisons	+	-	+	+	+	-
Point estimates and variability	+	+	+	+	+	+
Total score	8/10	4/10	5/10	5/10	7/10	3/10

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[1] *Corresponding author: E-mail: joaopauloheinzmann@hotmail.com (J.P. Heinzmann-Filho).