Nesting for Neuroprotection and Stability: A Narrative Review on the Science, Practice, and Impact of Containment Strategies for the Preterm Infant

Abstract

Background: Preterm infants face a stark sensory mismatch between the contained intrauterine environment and the open Neonatal Intensive Care Unit (NICU), leading to physiological stress that detracts from neurodevelopment. Nesting the use of boundary-forming supports to maintain a flexed, midline posture is a foundational developmental care intervention designed to mitigate this challenge. Objective: This narrative review synthesizes the current evidence on the science and practice of nesting, with a particular focus on its profound impact on cardio-respiratory stability and its synergistic effects with therapeutic positioning. Findings: The review outlines the multi-faceted benefits of nesting, including improved thermoregulation, energy conservation, pain mitigation, stress reduction, and sleep organization. A core finding is its significant role in enhancing cardiorespiratory stability: nesting reduces pathological bradycardia and tachycardia, regularizes respiratory rate, and improves oxygen saturation by reducing energy expenditure and providing biomechanical support to the chest wall. Crucially, the benefits are position dependent. Evidence synthesis demonstrates that nesting in the supine position is essential for safety and stability, nesting in the prone position yields the greatest improvement in respiratory parameters under supervision, and nesting in the lateral position provides stable support for procedures. Conclusion: Nesting is a simple, cost-effective, and powerful neuroprotective intervention. It is most effective as a core component of a developmental care bundle. The review strongly recommends the universal implementation of individualized, safe nesting as a standard of care for all preterm infants to promote physiological stability, optimal positioning, and improved neurodevelopmental outcomes.