Neurodevelopmentally supportive positioning continues to be a widely recognized part of developmental care in the NICU, with an evidence base demonstrating outcomes such as improved physiologic stability, comfort, body alignment, support for sleep, and consistency of caregiving practice. Yet despite this recognition, one challenge remains: ensuring positioning practices are applied consistently across caregivers, disciplines, and shifts.
For neonatal therapists, developmental specialists, and NICU nursing leadership, the question isn’t whether positioning matters — it’s how to build a shared understanding of best practice that can be taught, measured, and sustained over time.
Standardization begins with a common framework.
A Shared Clinical Language
Developed by Dandle•LION Medical’s multidisciplinary clinical team and grounded in a synthesis of developmental care evidence — including work published by the National Association of Neonatal Therapists — the Positioning Competency Toolkit offers exactly that. It’s organized around the 5 Key Tenets of Neurodevelopmentally Supportive Positioning™:
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Flexion — spinal flexion from head to hips, with arms and legs flexed
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Containment — supportive boundaries surrounding the infant on all sides
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Midline Alignment — symmetrical posture, including the head and neck
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360° of Proprioception — responsive input that resists excessive extension
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Free Movement with Recoil — room to move within boundaries that guide the infant back to flexion
These five tenets provide each member of your team with common vocabulary for something that can otherwise feel subjective — and because the toolkit is device-agnostic, it layers onto whatever positioning system your unit already uses.
What’s Inside
Rather than a single resource, the free downloadable toolkit combines four components designed to work together:
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Positioning Pearls video series — introduces the 5 Tenets, then walks through scenario-specific positioning strategies for CPAP, phototherapy, postoperative care, ECMO/HFOV, and NAS/NOWS. Useful for orientation, refresher education, or just-in-time learning.
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5 Key Tenets Overview — a visual reference comparing traditional positioning to in-utero and tenet-supported positioning.
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Positioning Competency Tool — a structured, 16-parameter assessment of caregiver skill, scored on a novice-to-expert scale.
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NeoNAPP — an objective, pictorial bedside tool for scoring how closely an infant’s actual position aligns with each tenet, with clinical implications tied to the total score.
Putting the Toolkit Into Practice
Because it’s modular, units can pull individual components into whatever program already exists. Consider using it to:
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Enhance unit-based orientation by introducing new staff to the 5 Tenets from day one
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Support competency validation by building the Positioning Competency Tool into annual skills assessments
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Strengthen QI initiatives by using NeoNAPP to objectively score positioning practice and track it over time
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Sustain ongoing education through the Positioning Pearls library during developmental care rounds or just-in-time teaching
Importantly, the toolkit acknowledges clinical reality: critically ill infants can’t always receive every aspect of ideal positioning due to acuity or necessary equipment. Rather than an all-or-nothing standard, it encourages clinicians to thoughtfully provide as many of the 5 Tenets as possible, as completely as possible, given each infant’s specific needs — making it a practical tool for real bedside conditions, not just the ideal case.
Whether you’re onboarding new clinicians, strengthening a competency program, or leading a developmental care QI initiative, a standardized approach can help build consistency across your entire NICU team.
Download the Positioning Competency Toolkit to explore each component in more detail and find practical ways to bring evidence-based positioning education, competency assessment, and quality improvement into your own unit.
