Premie Pouch to Manage Deformational Plagiocephaly in Very Low Birth Weight Infants

Brief Title

Premie Pouch to Manage Deformational Plagiocephaly in Very Low Birth Weight Infants

Official Title

Premie Pouch to Manage Deformational Plagiocephaly in Very Low Birth Weight Infants

Brief Summary

      This pilot project proposes to develop and test a new device to manage (defined as resolving,
      prohibiting, inhibiting or preventing) the development of Deformational Plagiocephaly (DP) in
      prematurely born infants weighing < 1 kilogram.

Detailed Description

      Prematurely born infants are prone to developing Deformational Plagiocephaly (DP), a
      flattened head shape from repeatedly being positioned in the same direction while on a flat
      or solid surface. Left untreated approximately 30-40% of infants retain this abnormal head
      shape at 3-4 years of age. According to reports DP has the potential to affect the infant's
      social and neurobehavioral development.

      Recent research on the PlagioCradle™ device demonstrates prevention and correction of DP in
      hospitalized infants. However, extremely premature infants, weighing < 1 kilogram cannot use
      the device known as the PlagioCradle™. This device only accommodates infants weighing > 1
      kilogram. When infants eventually reach 1 kilogram, healthcare providers have trouble fitting
      them to the smallest version of the PlagioCradle™ device and must place the infant in a layer
      meant for a larger infant. Use of the larger layer often requires that infants' lay in a
      side-lying position until their head shapes begin to improve. It is more desirable that
      infants be placed in the appropriate layer so that they may be positioned supine, prone,
      side-lying left and right, to ensure optimal development. This pilot project proposes to
      develop and test a new device to manage (defined as resolving, prohibiting, inhibiting or
      preventing) the development of DP in prematurely born infants weighing < 1 kilogram.

      NICU (Neonatal Intensive Care Unit) nurses have used waterbed therapy, air-filled mattresses,
      foam mattresses and repositioning procedures in an attempt to manage the development of DP,
      but these methods have had limited success. The reason these devices are not successful is
      because they do not provide structure or support for the soft cranium that has un-fused
      sutures and that have not become fixed or solidified. As a result, the soft, malleable
      cranium then takes the shape of the bedding or device it is placed upon, which is usually
      flat (including the aforementioned positioning devices).

      The PlagioCradle™ (previously known as the cranial cup) is an orthotic device developed by
      Gary Rogers M.D., J.D., M.B.A., M.P.H., a craniofacial surgeon formerly of Boston Children's
      Hospital and James Miller C.P.O. a licensed orthotist. The PlagioCradle™ is an anatomically
      correcting, repeatedly adjustable, concave-shaped resting surface for an infant's head and
      body that effectively eliminates uneven pressure on the infant's occiput while maintaining
      correct body alignment. In addition, the posterior neck area of the infant is supported by a
      fixed bridge section, which also serves to off-load or reduce contact pressure between the
      rest surface and the occiput, especially as the cavity of the device deepens. The
      PlagioCradle™ has been found to be an effective tool in preventing or correcting DP in
      preterm and term infants. The PlagioCradle™ accommodates infants weighing 1 Kg or larger.

      The Premie Pouch is meant to serve as precursor to the PlagioCradle™ by managing the
      development of DP starting immediately following birth. Like the PlagioCradle™, the
      concave-shaped foam insert will provide a resting surface for the infant's head and body that
      eliminate uneven pressure on the infant's occiput while maintaining correct body alignment.
      Also, the posterior neck area of the infant will be supported by a fixed bridge section of
      the foam insert. However the Premie Pouch is designed specifically for the VLBW infant.

      The rectangular shaped Premie Pouch device measures approximately 10X15 inches in size. The
      cover is made of a stretchy, washable fabric such as jersey or fleece. There are two pockets;
      one to accommodate a foam insert and another will accommodate a bladder insert of soft
      squishy pellets. The Premie Pouch will come with two cotton/Velcro positioning straps that
      can be used to provide containment of the infant's arms and/or legs, adding to their comfort
      when using the device.

      Pocket #1 will accommodate a foam insert. Nurses will select one of 3 different sized
      pre-molded foam inserts, sized for infants weighing < 1 Kg. Once the appropriate insert is
      selected it will be placed inside pocket #1. As the infant's grows, nurses can select a new
      insert so that a neutral position is maintained and the head sits comfortably in the
      depression. When appropriately sized the head can move freely and a small gap, approximately
      1/8th inch, will be noted around the head.

      The foam insert will facilitate a normalized head shape by providing structure to the
      cranium. Border stitching of the cover around the foam will keep the insert in place when the
      device is moved. Infants can be positioned supine or side lying when using the top layer of
      the device holding the foam insert. The bottom layer of the device will be used for prone
      positioning when the foam insert is removed Pocket #2, the bottom layer of the Premie Pouch
      will contain a bladder of soft squishy pellets that offer a comfortable place for infants to
      rest when positioned prone (but that also remains in place when using the top layer with the
      insert in place). To use this layer of the device, the nurse need only remove the foam

      The Premie Pouches are to be constructed by an experienced seamstress hired to sew the
      devices and the bladder inserts that contain the pellets. Three foam inserts (each with a
      slightly different depression depth to ensure a semi customized fit) will be provided for use
      with each Premie Pouch device, along with three cotton covers Premie Pouch Care and
      Maintenance. Each infant participant will receive a new device and 2 extra sets of covers.
      The outer covering of the device can be laundered either by a laundry service or the infant's
      mother. The foam inserts and bladder inserts (housed in a water repellent polymer-coated
      fabric) will be able to be wiped down using antibacterial wipes routinely used for cleaning
      similar devices in the participating NICUs. The covers of the device are made of
      cotton/spandex blend.

      Purpose and Specific Aims:

      Technological improvements such as advanced MRI techniques allow researchers to detect
      diminutive changes in brain structure on infants with positional head shape deformities. In
      addition new developmental assessments allow researchers to detect a spectrum of
      neurobehavioral and motor development problems. These type of advances have allowed
      researchers to establish a relationships between DP, neurobehavioral problems and auditory
      processing disorders. These relationships suggest that DP may be more problematic than once
      thought, hence the need for preventative measures.

      At present time, nurses in NICU's across the nation manage DP by repositioning their
      patient's, as frequently as their condition permits, and with the use of gel pillows and
      other positioning aids like the Z flo. In this study the investigator is taking a proactive
      approach toward DP management through development of the Premie Pouch and investigation of
      its safety, feasibility and very preliminary information on its effectiveness.

      Research questions:

      Question 1. Is the Premie Pouch safe for use with premature infants weighing < 1 Kg as
      evidenced by the absence of adverse events? Question 2. Is the Premie Pouch feasible for use
      with premature infants weighing < 1 Kg as measured by the number of hours of use per day on
      the device? Question 3. Do bedside nurses caring for the study infant's rate the Premie Pouch
      easy to use? Question 4. What is the relationship between time (as measured in hours) spent
      on the Premie Pouch with the foam layer in place and head shapes (as measured by cranial
      index and cranial symmetry) in a sample of premature infants weighing < 1 Kg?


      Research Staff- Prior to the initiation of study procedures all research personnel will be
      Citi program trained. Also all study staff will receive training by the researcher or key
      study personnel on all study procedures and the use of the positioning device. During
      training, emphasis will be placed on procedures to ensure the safe use of the positioning
      device and procedures to ensure patient safety during head shape measures. A Manual of
      Operations at each study site will include directives for obtaining the head shape measures
      and examples of appropriate documentation on the data collection tools.

      NICU Staff- Prior to enrollment of study subjects or the initiation of any study procedures,
      staff in the NICUs will receive education on the use of the Premie Pouch device and on their
      role during the study. The NICU staff will also be given the opportunity to have any
      questions answered. A Manual of Operations will be provided to each of the NICUs that will
      store copies of the study protocol, consent, procedure for obtaining head shape measures and
      instructions on use, care and maintenance of the study device.

      Parent- Study staff will be responsible for educating parents about the study and reeducating
      them as needed during the course of their infant's participation.

      Enrollment: Once the infant is in a critical but stable condition (which usually happens in
      the first two weeks of life), a member of the medical or nursing staff will ask the parent(s)
      of prospective study subjects if they are interested in hearing about this research study. If
      the parent(s) agree the researcher or study staff member trained in obtaining consents will
      approach them to explain the study. In addition, the researcher or study staff member will
      provide the parent(s) with written materials that describe the study and their infant's
      involvement. The parent(s) will be given the opportunity to ask questions. If the parent(s)
      agree to participate they will be asked to sign an informed consent and HIPPA form.


      All participants will receive the experimental treatment with the Premie Pouch. While using
      the device, nurses will (as per unit routines) routinely reposition infants every 3 to 4
      hours minimum, including prone. Nurses will utilize the Premie Pouch device whenever the
      infant is on the warmer, in the isolette or bed, unless specific procedures or medical
      interventions preclude it use. Nurses will be instructed to reposition infants frequently,
      ensuring that infants spend (equal time) approximately 1/2 of the day supine (or side lying)
      on the foam layer of the device. Nurses will be instructed to document device use on the
      daily positioning logs for the length of the study. Study staff will monitor device use,
      ensuring that the daily positioning logs are being completed.

      Repositioning infants every 3-4 hours minimum, is an important aspect of neonatal care. In
      addition to facilitating a normal head shape, repositioning helps to facilitate good skin
      integrity, skeletal development, biomechanical alignment, and provides exposure to
      proprioceptive, tactile, and visual stimuli. Similar to other positioning devices used in
      this population, long velcro straps (rough side up) that wrap around the device and the
      infant, will provided with the Premie Pouch device. Nurses can apply these straps to gently
      secure arms and legs in a comfortable position.

      Once the infant participants reach 1 Kg and outgrow the Premie Pouch device, participation in
      this study will end. At that time nurses will care for the infants using routine positioning
      techniques and devices available in the respective unit (such as but not limited to gel
      pillows and other positioning aids like the Z flo or Plagiocradle.

Study Type


Primary Outcome

Safety of Use of the Premie Pouch in VLBW Infants

Secondary Outcome

 Feasibility of Use of the Premie Pouch in VLBW Infants




Premie Pouch

Study Arms / Comparison Groups

 Premie Pouch
Description:  All participants will receive the experimental treatment with the Premie Pouch device.


* Includes publications given by the data provider as well as publications identified by National Clinical Trials Identifier (NCT ID) in Medline.

Recruitment Information

Recruitment Status


Estimated Enrollment


Start Date

June 2016

Completion Date

March 2019

Primary Completion Date

August 2016

Eligibility Criteria

        Inclusion Criteria:

          1. Infants weighing /= 22 weeks gestation.

          3. Infants  14 days from the
             time of enrollment.

          6. Every effort will be made to include infants from non-English speaking families as
             long as using all available resources; the parents can successfully communicate with
             the research team. The research team will utilize interpreter services and other
             resources (immediate family members and supports) to facilitate this process when

        Exclusion Criteria:

          1. Infants that require only prone positioning to maintain airway patency (such as those
             with Pierre Robin Syndrome/Sequence) will not be eligible to participate; this is
             because infants must be able to lie supine for at least part of the day.

          2. Infants requiring medical devices such as a continuous ventricular drain, subgaleal
             shunt, or intravenous catheters (unless placement of the IV is temporary) as they
             prevent proper positioning using the Premie Pouch.

          3. Infants with a craniofacial anomaly, craniosynostosis, cervical anomaly, or critical

          4. Infants with Cutis Aplasia or significant skin breakdown to the scalp, because the
             experimental device may worsen a preexisting condition.

          5. Infants that are to be transferred to a non-participating hospital within 14 days of
             enrollment as this timeframe may not allow adequate evaluation of the Premie Pouch.




N/A - 40 Days

Accepts Healthy Volunteers

Accepts Healthy Volunteers


Michele DeGrazia, PhD, NNP, , 

Location Countries

United States

Location Countries

United States

Administrative Informations



Organization ID


Responsible Party

Principal Investigator

Study Sponsor

Boston Children's Hospital


 Boston Orthotics & Prosthetics

Study Sponsor

Michele DeGrazia, PhD, NNP, Principal Investigator, Boston Children's Hospital

Verification Date

July 2018