Research
Physiological and behavioural
effects of preterm infant positioning
in a neonatal intensive care unit
P
remature births account for 11.1% of the
total number of births worldwide. In Brazil,
the percentage is slightly higher, at 11.9%
(World Health Organization (WHO), 2012;
Blencowe and Cousens, 2013; UNICEF,
2014). As a result of the demands often associated
with prematurity, the preterm infant generally requires
hospitalisation, in many cases for prolonged periods.
In addition, the preterm infant’s system and organ
immaturity can lead to difficulty in adapting to life in its
neuropsychomotor development, which may cause delays
and extrauterine alterations in the long term (Ministério
da Saúde, 2011a).
According to the synactive theory of newborn
behavioural organisation and development (Als, 1982),
the adaptation of the preterm infant to the neonatal
intensive care unit (NICU) environment varies according
to his or her ability to change their behaviour in response
to a stimulus; to achieve a well-regulated balance; and to
maintain the energy required to sustain life. This theory
is divided into five subsystems: physiological, motor,
behavioural state, attention, and interaction and regulatory
(Ministério da Saúde, 2011a). Neuropsychomotor
development is the result of a number of factors inherent
to the preterm infant and his or her environment, which
influence behaviour (Rodrigues and Bolsoni-Silva, 2011).
In this context, the hospital environment, along with
the preterm infant’s clinical conditions, can influence
physiological and behavioural responses, both during
hospitalisation, and after discharge from the NICU.
Studies show that preterm infants’ motor skills improve
when early stimulation is received (Rodrigues and
Bolsoni-Silva, 2011; Madlinger-Lewis et al, 2014).
As the musculoskeletal system of the newborn infant
is responsible for the positioning of the body during
hospitalisation, the movements that the preterm infant
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performs, as well as the postures adopted, contribute to
the formation of the spine, joints and skull. The NICU
team is therefore responsible for the preterm infant’s
alignment, posture and movement (Rodrigues and
Bolsoni-Silva, 2011).
British Journal of Midwifery, October 2017, Vol 25, No 10
Abstract
Aim To compare the effect of sleeping position on physiological and
behvioural responses in preterm infants.
Methods A quasi-experimental study was conducted in a neonatal
intensive care unit in the south of Brazil. The sample was 24 preterm
newborns with gestational age ≤32 weeks, who were randomly
separated into four groups: right side position, supine position, left
side position and prone position. The physiological and behavioral
variables were evaluated before, during and after positioning.
Findings During the intervention, heart rate decreased in right side
position, supine position, and prone position. The respiratory rate
reduced in all positions and peripheral oxygen saturation remained
stable in most positions. Behavioural scores were reduced in supine,
left side and prone positions.
Conclusions Positioning according to a standard operating
procedure was able to produce more positive responses in prone and
supine position groups during the intervention.
Keywords
Preterm   |  Infant positioning  |  Neonatal intensive care unit
Alessandra Madalena Garcia Santos
Masters student in Biosciences and Health,
Western Paraná State University, Brazil
Claudia Silveira Viera (corresponding author)
Lecturer in Biosciences and Health,
Western Paraná State University, Brazil
Gladson Ricardo Flor Bertolini
Lecturer in Biosciences and Health,
Western Paraná State University, Brazil
Erica Fernanda Osaku
Lecturer in Physical Therapy in Intensive Care,
Western Paraná State University, Brazil
Claudia Rejane Lima de Macedo Costa
Lecturer in Physical Therapy in Intensive Care,
Western Paraná State University, Brazil
Ana Tamara Kolecha Giordani Grebinski
Nurse, Neonatal intensive care unit,
Western Paraná University Hopsital
clausviera@gmail.com
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Adobe Stock/Steve Lovegrove

Positioning preterm infants according to a standardised operating procedure can have an effect on physiological,
behavioural and pain factors that influence the infant’s comfort and development

Usual procedure in the NICU is that the infant should
be positioned in alternate postures throughout the day, to
prevent pressure lesions and postural deformities, and to
improve respiratory rate and infant relaxation. Changing
an infant’s position is therefore recommended every 4
hours, or according to the infant’s need (Gomella et al,
2004; Olmedo et al, 2012).
When positioning is not properly carried out,
damage can be caused due to the immaturity of the
musculoskeletal system, which can generate body
alignment complications, such as neonatal hypertonia.
The maintenance of a proper positioning can, however,
provide control of sleep and wakefulness state, improve
cardiorespiratory function and promote energy
conservation. Positioning also improves an infant’s self-
regulation, which results in fewer stressful episodes to
the newborn infant (Cândia et al, 2014). When the
infant is able to achieve periods of deep sleep without
interruption, the creation of permanent neural circuits
takes place, stimulating the sensory-motor development
(Liaw et al, 2012).
During positioning, attention should be paid to
Gutierrez, 2002). Changing positioning and performing
an appropriate placement affects motor development
by positive stimulation of joints and muscles, which
influences the mechanoreceptors, in order to improve and
adapt the movements. As well as this, change promotes
improved respiratory mechanics and a greater chance of
relaxation for the preterm infant (Olmedo et al, 2012).
As a result, the preterm infant should therefore be
handled holistically in the NICU, which is responsible for
all aspects of the infant’s medical care, besides appropriate
positioning. Although positioning is a routine procedure
in the NICU, and there is a standardised way in which
this should be carried out, it is not always applied in the
NICU in Brazil (toso et al, 2015).
Study setting
In the NICU where this study was developed, the health
team did not have a standardised way of positioning
preterm infants. As part of a separate study (Toso et
al, 2015), the authors developed a standardised way of
positioning to be used in the NICU to fill this need.
This study presented here set out to apply this protocol,
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maintain the posture and movements, in order to
improve skeletal development and body alignment,
and to provide tactile and visual proprioceptive stimuli,
keeping newborn behaviour comfortable, and conserving
energy to prioritise vital functions (Sweeney and
comparing this standard operating procedure with usual
positioning in the NICU.
Study aims
This study was therefore developed to show NICUs the

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importance of following standrard operating procedures
that concern preterm infant positioning. It is necessary
to provide evidence that shows the influence of postural
maintenance on the behavioural and physiological
state of the preterm infant during hospitalisation in
the NICU. Health professionals should understand the
consequences of preterm infant positioning during
NICU hospitalisation and after hospital discharge.
The aim of this study was to compare the different
positions (lateral, prone and supine) performed as a
standard operating procedure (Toso et al, 2015) and to
examine whether there are differences related to pain,
behavioural and physiological responses of preterm
infants hospitalised in the NICU.
Materials and methods
Study design
This was a quantitative, quasi-experimental study that
took place in a university hospital in southern Brazil,
from June 2015–March 2016.
The study population was composed of preterm
infants admitted to the NICU during the study
period. The criteria for inclusion in the study sample
were infants of a gestational age ≤ 32 weeks, with no
congenital anomalies. Preterm infants whose parents
or legal guardians did not give consent; or infants with
a clinical diagnosis or treatment that would make it
impossible to change position, such as an umbilical
arterial catheter in situ, were excluded from the study.
Sample calculation was performed by the program
GPower 3.1, with a sample power of 0.94, with a size
effect of 0.25 and a significance level of 0.05.The sample
consisted of 24 preterm infants, who were randomised
anonymously with a simple draw, by throwing a dice.
Six preterm infants were allocated to each position:
right side position, supine position, left side position
and prone position. After randomisation, participants
were distributed in ascending order according to bed
availability in the NICU.
Data collection
Data were collected at birth to characterise the sample,
although the intervention did not begin until 72 hours
after birth. During the procedure, the variables evaluated
referred to the proposed synactive theory of newborn
behavioural organisation and development (Als, 1982),
which corresponded to physiological subsystem responses
(vital functions such as heart rate, respiratory rate and
peripheral oxygen saturation); the neurological motor
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subsystem (involving muscle tone, posture, and voluntary
and involuntary movements); and the behavioural state
subsystem, which comprises six states of consciousness:
deep sleep, light sleep, sleepy, awake, awake with activity,
and cry (Liaw et al, 2012).
British Journal of Midwifery, October 2017, Vol 25, No 10
Research
Usual procedure in the NICU is that the infant
should be positioned in alternate postures
throughout the day, to prevent pressure lesions
and postural deformities, and to improve
respiratory rate and infant relaxation
The dependent variable analysed the placement of
the preterm infant, taking into account behavioural,
physiological, and pain responses. The pain response was
measured by the Neonatal Infant Pain Scale (NIPS) and
the behavioural response was checked by the Neonatal
Beahviour Assessment Scale (NBAS) (Brazelton, 2011).
The NIPS scale is a multidimensional instrument
used routinely in the NICU to assess acute pain. The
scale evaluates behavioural and physiological responses
by scoring on six different parameters. The infant is
considered to be in pain when the score is greater than
or equal to 4 (Ministério da Saúde, 2011b).
The NBAS (Brazelton, 2011) (Ministério da Saúde,
2011b) evaluates six behavioural states: deep sleep,
light sleep, sleepy, awake, awake with activity, and cry
(Vignochi et al, 2010; Ministério da Saúde, 2011b). This
scale evaluates behaviour using direct observation of the
preterm infant, resulting in a behavioural classification,
scored from 1 to 6. Scores of 5 or 6 indicate that the
preterm infant presented some discomfort (Bueno et
al, 2014).
To record physiological responses, heart rate and
peripheral oxygen saturation were verified by the
Omnimed Omni 612 multiparameter monitor, while
the researcher observed and counted the respiratory rate
for 1 minute, once per hour during the intervention
period. The researcher was a physiotherapist qualified to
perform all the cited evaluations, and the preterm infants
were continuously monitored, following a pre-established
routine. All variables were evaluated 30 minutes before
the beginning of the procedure, during the 3-hour study
period, and 30 minutes after the intervention.The average
of the data collected during the 3-hour interval of the
standard operating procedure was made based on the
three-data measurement for each variable: physiological
(heart rate, respiratory rate, peripheral oxygen saturation),
behavioural (BSM), and pain (NIPS). Each variable
was measured five times: once before the intervention,
three times during the intervention, and once after the
intervention. As there were three measurements collected
during the intervention, an average was calculated to
compare with the data before and after.
All variables mentioned above were recorded in a
research form designed specifically for the survey, which
was pre-tested in its content and layout.
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Research

in this period. The intervention occurred during 5

11:30am 12.00pm 12:30–3:30pm 4:00pm 4:30pm consecutive days and the positioning was done by the
responsible researcher.
The researcher started the collection of vital signs,
NIPS assessment and NBAS score 30 minutes before the
the preterm infant’s second positioning change of the
morning (Figure 1). After this, the preterm infants were
Positioning Positioning
positioned according to standard operating procedure
SOP NICU team
(Toso et al, 2015) and evaluations were repeated 30
Vital signs, Vital signs, Vital signs,
behavioural and pain behavioural and pain behavioural and pain minutes after every hour and 30 minutes after the end
before 1st, 2nd, 3rd, 4th hour after of the procedure, when the preterm infant received the
NICU’s routine positioning. The preterm infant was
Figure 1. Timeline of intervention always positioned according to the drawn group, and the
researcher took care not to disturb equipment such as
catheters. The researcher evaluated the integrity of the
skin throughout the intervention. The comfort of the
baby was emphasised in all positions, even in cases where
mechanical ventilation was used. Mechanical ventilation
did not interfere with the positioning.
The positioning according to the standard operating
procedure Toso et al (2015) can be seen in Figure 2. In
order to ensure the proper body positioning, nests, rolls
or other forms of support were applied. The standard
operating procedure consisted of:
●● Supine position: head positioned in the midline,
flexion and adduction of upper and lower limbs,
avoiding excessive abductions and external rotation,
Figure 2. Positioning of infants according to standard operating procedure (Toso keeping the chest exposed to enable assessment of the
et al, 2015) and using padded supports to maintain position respiratory pattern.
●● Side-lying position (right or left): slight flexion
Data analysis on the chosen physiological variables— of trunk, head positioned in the midline; support
respiratory rate, heart rate and peripheral oxygen placed between the legs to keep a neutral position
saturation—were based on a study by Peixe et al (2011). of extremities, upper limbs kept free to allow infant
In Peixe et al’s study, the average heart rate for a preterm to explore the mouth and facilitate self-comforting
infant was considered to be 125 beats per minute, movements.
ranging from 70–190 beats per minute, and the average ●● Prone position: scroll positioned horizontally to
respiratory rate was considered to be 30–50 breaths maintain the correct inclination of hip and pelvis.
per minute. Knee kept flexed appropriately. A lateral support for
Evidence (Watt and Strongman, 1985) has shown that the legs and feet kept in order to avoid excessive hip
preterm infants have a short sleep-wake cycle and that abduction and deformities.
many aspects of neonatal intensive care environments,
such as routine handling, invasive procedures, bright Data analysis
lighting and noise, can create stress, disrupt behaviour, Descriptive statistics (mean, standard deviation, median,
and interfere with sleep in premature infants. In this minimum and maximum) were used to analyse the
study, all participants were exposed to the same effects of sample. Inferential analysis from the one-way Anova and
the NICU environment. To control any effects during Friedman tests with a significance level of 5%, using the
the 4 hours of observation, all handling was registered, BioStat 5.0 program, were used.
in order to identify any alterations in vital signs, NBAS
score or NIPS assessment. Results
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Most of the preterm infants in the study were male, aged

Intervention 28–32 weeks, and weighed 1000–1499 grams. Most
The procedure was not started until the preterm infant (n=21) were given some kind of oxygen therapy during
was 72 hours old, due to the high risk of developing the hospital stay. Of the 24 infants, 14 were not given
intracranial hypertension through excessive handling sedatives (Table 1).

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 Research

The relationships between physiological variables Table 1. Sample characterisation

and infant positioning are presented in Table 2. Analysis
showed that the heart rate was reduced in the right Variable Absolute frequency Relative frequency
side, supine and prone position groups during the Sex
intervention, compared to before the intervention.
Female 8 33.3%
While respiratory rate was reduced in all positions, the
peripheral oxygen saturation remained stable in most Male 16 66.6%
positions, slightly increasing in the right side position Gestational age
group.The maintenance of the peripheral oxygen and the
reduction of the heart rate and respiratory rate during the <28 weeks 4 16.6%
procedure demonstrate that the preterm infant achieved 28 to 32 weeks 20 83.3%
greater self regulatory competence when positioned
Birth weight (grams)
according to standard operating procedure (Toso et
al, 2015). <1000 5 20.8%
Table 3 shows analysis of behavioural variables and 1000–1499 16 66.6%
pain by infant position. In behavioural analysis, it was
observed that all preterm infants started the procedure 1500–2000 3 12.5%
with a median NBAS score of 2. The prone position Oxygen therapy
presented the maximum NBAS score at the beginning
Yes* 21 87.5%
of the procedure. During the procedure, the median was
reduced to 1 in the left side, supine and prone position No 3 12.5%
groups, although the maximum NBAS score in the Sedation
supine and prone position groups increased.
In all positions the median NIPS score before the Yes ** 10 41.6%
intervention was 1, which indicates no pain. However, No 14 58.3%
in the left side position, supine position and prone
* Use of any oxygen ventilatory support, invasive or non-invasive, during hospitalisation.
position groups, there was at least one preterm infant ** Administration of sedatives or drugs that altered the response to pain during the
with pain, since they scored 4 on the NIPS scale. During intervention
the procedure, the median pain score for all positons was
0, but the left side position, supine position and prone was placed in prone position, compared to the infant’s
position groups continued to present cases of pain, with initial position (or dorsal side) during hospitalisation in
a score of 4 in at least one preterm infant (Table 3).There NICU.The standardised and appropriate positioning used
was a significant reduction between the beginning and by Cândia et al (2014) was able to improve respiratory
the end of the intervention in the right side position capacity of the newborns, and the authors concluded that
group (P=0.03), between the beginning and during prone positioning reduced preterm infant stress based
the procedure in the supine position group (P=0.01). on the reduction of the respiratory rate, the salivary
Although the prone position did not present a significant cortisol level and Brazelton sleep score. In addition, the
reduction, it was likely to present a reduction between physiological stability that enables an improvement in
the beginning and during the intervention (P=0.07). respiratory pattern also enables a reduction in respiratory
rate (Empresa Brasileira de Serviços Hospitalares and
Discussion Ministério da Educação, 2015). Moreover, Gouna et al
The data showed that there was no change in heart (2013) noted in the comparison between positions of
rate within the different position groups, except during preterm infants that the left side and prone positions
the intervention, in which the heart rate showed a provided better results in pulmonary function and
greater reduction in the supine position. No statistically respiratory strategy in this population.
significant difference was identified. This observation In the evaluation of the peripheral oxygen saturation,
is similar to evidence from the Joanna Briggs Institute all groups started with the same mean and no statistical
(2010), where the heart rate also showed no changes significance was oberved. The highest mean was shown
between different positioning groups, or in incidences in the right side position group, which confirms the
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of bradycardia and apnoea. findings of Hough et al (2013), who assessed ventilation

A reduction in respiratory rate was identified in distribution in three different positions (lateral, supine
all positions, but no significant statistical difference and prone) and found no statistical significance.
was shown. A survey by Cândia et al (2014) found a No significant difference was found between or within
reduction in respiratory rate when the preterm infant groups in relation to NBAS score.The same was observed

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Research

Table 2. Cardiopulmonary responses by infant position

Right side Left side Supine Prone
position position position position
Variable Mean ± Mean ± Mean ± Mean ± P-value
Heart rate
Before intervention 161 ± 14 159 ± 13 156 ± 16 166 ± 17 0.51
During intervention 160 ± 12 159 ± 15 151 ± 12 163 ± 16 0.23
After intervention 160 ± 13 158 ± 14 152 ± 16 162 ± 15 0.53
Respiratory rate
Before intervention 49 ± 11 44 ± 10 47 ± 13 51 ± 11 0.54
During intervention 48 ± 9 42 ± 10 43 ± 10 47 ± 12 0.57
After intervention 51 ± 11 44 ± 10 43 ± 9 49 ± 9 0.57
Peripheral oxygen saturation
Before intervention 95 ± 2 95 ± 3 95 ± 2 95 ± 2 0.93
During intervention 96 ± 2 95 ± 2 95 ± 2 95 ± 2 0.65
After intervention 95 ± 2 95 ± 2 96 ± 1 95 ± 2 0.58

Table 3. Behavioural and pain responses by infant position

Right side Left side Supine Prone
position position position position
Median Median Median Median
Variable (min–max) (min–max) (min–max) (min–max) P-value*
Neonatal Behaviour Assessment Scale
Before intervention 2 (1–4) 2 (1–4) 2 (1–3) 2 (1–5) 0.83
During intervention 2 (1–4) 1 (1–4) 1 (1–4) 1 (1–6) 0.73
After intervention 2 (1–4) 1 (1–5) 1 (1–4) 2 (1–4) 0.63
P-value** 0.13 0.95 0.07 0.27
Neonatal Infant Pain Scale
Before intervention 1 (0–3)** 1 (0–4) 1 (0–4)** 1 (0–4) 0.91
During intervention 0 (0–3) 0 (0–4) 0 (0–4)** 0 (0–4) 0.78
After intervention 0.5 (0–3)** 0 (0–4) 0 (0–4) 0 (0–3) 0.88
P-value** 0.03** 0.35 0.01* 0.07
* P statistically significant at <0.05 (analysis between groups)
** P statistically significant at <0.05 (intra group analysis)

during the NIPS pain evaluation, where every position invasive procedures between preterm infants positioned in
group began with similar scores of 1, and maintained this a supine position or prone position. However, the preterm
value throughout the intervention. After, all groups scored infant positioned by a standardised procedure in a lateral
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0, with the exception of the left side position group, which
presented the lowest variation of all the positions, and no
statistically significant differences. In a study conducted
by the Joanna Briggs Institute (2010), there were also
no significant differences related to the pain response in
position showed a significant reduction in pain scores
compared to the preterm infant not positioned according to
this protocol.
The reduction in NBAS scores in different positions
demonstrated greater comfort and relaxation and reduced

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energy expenditure. Both of these results therefore
contributed to the infant’s development and clinical
outcomes while in hospital.
Ammari et al (2009) evidenced in their study that
the preterm infant spent less energy to maintain the
thermal control when in a prone position. In addition,
proper positioning has been shown to contribute to
the maintenance of neuromuscular and osteo-articular
function, as well as the development of spontaneous
motor activity (Xavier et al, 2012). In their study, Xavier
et al concluded that the preterm infant had a higher
risk of cranial deformities due to the fact they remained
with their head in the same position for long periods
of time. The authors emphasised that the deformities
went beyond the aesthetic changes, leading to delays
in neuropsychomotor development, visual changes and
episodes of otitis media. A regular change of position
may therefore contribute to a reduction in the risks of
deformities and other developmental changes, although
this is beyond the scope of this article.
Based on the results of this study, which highlighted
the importance of following the standard operating
procedure for positioning (Toso et al, 2015), health
professionals should therefore prioritise the standardised
positioning of the preterm infant in NICU. Standardised
positioning (Toso et al, 2015) consists of body alignment;
the maintenance of the correct head position to avoid
inappropriate lateralisation; stimulation of the midline;
flexion of upper limbs; and lower limb support.
Standardised positioning can be facilitated by accessories
such as padded rolls and rings. Following these guidelines
will help to provide greater comfort to the preterm
infant during the hospital stay and reduce the risk of
changes in the motor development in the NICU and
after hospital discharge.
Conclusion
Positioning according to a standard operating procedure
can assist physiological responses and behavioural
adaptation of preterm infants. Despite no significant
statistical difference between the different positions, there
was a reduction in NIPS and NBAS scores, indicating
greater relaxation of the preterm infant during the
standard operating procedure positioning. Pain was
likely to be reduced when positioned in prone position,
and a significant reduction in pain scores? was noticed
while in the right side and supine positions. In short, this
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study shows the effects of preterm infant positioning by
following standard operating procedure guidelines.  BJM
Declaration of interests: The author has no conflicts of
interest to declare.
British Journal of Midwifery, October 2017, Vol 25, No 10
Research
Key points
●● The adaptation of the preterm infant to the neonatal intensive care unit
(NICU) environment varies according to his or her ability to change their
behaviour in response to a stimulus, to achieve a well-regulated balance and
to maintain the energy required to sustain life
●● Studies have shown that early stimulation, including positioning,
can influence physiological and behavioural responses, both during
hospitalisation, and after discharge from the NICU
●● Positioning infants accoring to a standard operating procedure can help
the adaptation of the physiological and behavioural responses of the
preterm infant
●● This study sought to measure physiological, behavioural and pain responses
in preterm infants, when positioned according to usual NICU protocol,
compared with positioning accoridng to a standard operating procedure
●● The use of the different postures for the preterm infant during the
hospitalisation was found to be an important part of therapeutic care which
should be adopted by the NICU team
Ethical approval: This study received ethical approval from the
Western Paraná State University, reference number 1.134.712.
Funding: This study received funding from the Conselho
Nacional de Desenvolvimento Científico e Tecnológico,
reference number 457109/2014-9.
Review: This article was subject to double-blind peer review
and accepted for publication on 18 September 2017
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Research
CPD reflective questions
●● What is the procedure for newborn positioning within your area of practice?
How does this differ for preterm infants?
●● Aside from positioning, what other factors need to be taken into
consideration when caring for the preterm infant?
●● What knowledge of assessing neonatal behaviour and/or pain have you
gained through formal teaching or clinical practice, and how do you use
this knowledge in your setting?
●● How would you communicate to parents the importance of maintaining
appropriate positions for their newborn once he or she is discharged
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Call for reviewers
If you are a midwife, midwifery lecturer or
a supervisor of midwives who would like
to review articles for BJM, we would be
interested in hearing from you.
Please email bjm@markallengroup.com with a brief
summary of your areas of expertise.
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[Source in Portuguese]
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pre-term newborn babies submitted to the Kangaroo-Mother
Care method in prone position. Fisioter Pesq. 2012;19(2):115–
121. https://doi.org/10.1590/S1809-29502012000200005
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respiratória pediátrica e neonatal. In: Sarmento GJV (ed).
Fisioterapia Respiratória em pediatria e neonatologia (2nd
edn). Barueri: Manole; 2011 [Source in Portuguese]
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on infant development. Revista Brasileira de Crescimento e
Desenvolvimento Humano. 2011; 21(1): 111–21
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infant positioning in the NICU. J Perinat Neonatal Nurs. 2002;
16(1): 58–70. https://doi.org/10.1097/00005237-200206000-
00007
Toso BRGO,Viera CS,Valter JM, Delatore S, Barreto GMS.
Validation of newborn positioning protocol in Intensive Care
Unit. Rev Bras Enferm. 2015; 68(6): 1147–53. https://doi.
org/10.1590/0034-7167.2015680621i
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eleições 2014. Brasília: UNICEF; 2014 [Source in Portuguese]
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therapy on pain and sleep and wakefulness of stable preterm
newborns admitted to a neonatal intensive care unit. Rev. Bras
Fisioter. 2010; 14(3): 214–20. https://doi.org/10.1590/S1413-
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states in in fullterm, preterm, and small-for-gestational-age
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© 2017 MA Healthcare Ltd
British Journal of Midwifery, October 2017, Vol 25, No 10