POSITIONING 3

This module covers

the following information:

Positioning
Introduction to positioning
Good handling and positioning
How to position your child
• Lying down
• Seated
• Standing
• Picking up
• Carrying
Monitoring progress
Sharing emotions and feelings

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 POSITIONING
Materials
Blankets, pillows and towels, sandbags, carpet on the floor, strong cardboard
or wooden box a doll with floppy limbs i.e. not a hard plastic doll, pictures
3.01a, b, c and d, positioning photographs.

Facilitator Tips:
You can decide if this module should be in one session or spread over two sessions.
It is important to explain why families and caregivers should use positions and
facilitating of movement in every day activities at home. Sometimes participants
know about the positions to use at home but do not understand the benefits for
themselves and their child. Also, some participants may be afraid to show that they
don’t know how to use some positions, or of hurting their child.

“ Parent experiences in Uganda include:

“I was using these positions at home but I didn’t know that these positions
were helping my child to develop and protecting him from other damage.”

”
“When I came here and learnt positioning, my child learned to sit.”

Icebreaker
Ask everyone to stand facing you with three people in each row. The front
person should stand with their back to you, facing the two behind.

Ask the person at the back to make an unusual shape with their body and
hold it.

The front person must get the middle person into the same position by giving
verbal instructions only – no touching or showing them what to do.

Repeat so everyone has a go in each role.

Explain
Explain what we will learn together today.

By the end of module 3, you will:

1. Understand the importance of good positioning

2. Be able to position your child well, and be able to show others

3. Understand ways to help your child move and be able to explain to others
how they can do this

4. Share some thoughts and feelings about looking after a child with a
disability.

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 INTRODUCTION TO
POSITIONING
Activity 1
Positions build a base for movement and in the next weeks we will discuss how
good positions are needed for eating and drinking, communication, play and
activities that we do every day. The key today is building a foundation of good
positioning and then to help your child to move.

Ask
In pairs, discuss:

“In which positions does your child like to be in most of the time?”

Allow time to discuss in pairs so that everyone identifies which positions their
children prefer to be in and start to think of why.

Facilitator Tips:
It is important to emphasise the relationship between good positioning and helping
children to develop. Some caregivers said that they were doing exercises and
stimulation at home but they did not know that those positions were helping their
child develop and protecting them as they grow. By learning about good positions,
their children learned new skills.

Display pictures
3.01a-d. In smaller
groups of 3-4
discuss why these
children may not be
positioned well.

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 Ask
Ask everyone to consider whether children in the photos will be able to:

• Play

• Eat

• Communicate

• Socialise

• Move (can she lift her arms?)

Explain
Explain that poor handling and positioning;

• Will slow your child’s development.

• Will make it more difficult for you to pick up, carry and handle her every
day.

• Can cause other problems, such as:

• Pressure areas – leaning or lying on a body part for too long can
stop blood from flowing through the muscles and cause painful sores.
These begin as dark red or purple areas, and can take a long time to
heal.

• Contractures – if a limb stays in one position for a long time muscles

become shorter and the joint becomes stiff.

• Deformities – spending too long in one position can cause her back
to become permanently crooked and twisted, and her hips can move
out of place or dislocate.

GOOD HANDLING
AND POSITIONING
Ask
“Why is good handling and positioning important for you and your child?”

Explain
After the group offers suggestions, explain.

How you handle your child affects all the activities you do with her, and good
positioning should be used all the time because it:

• Is the basis for all the activities you do with your child.

• Influences what she can do and how she develops.

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 • Helps to make eating, drinking, playing and communicating easier and
safer.

• Makes it easier for you to care for your child.

• Helps prevent other conditions which can cause further disability.

Explain
Explain how to position in more helpful ways, using the following steps:

1. Start to move your child

• You can’t force her into a position.

• If she is stiff you need to loosen her first. Ask a therapist how to do this.

2. Try to get your child into the best position that you can

• Aim for ‘ideal positions’ (see below).

• She may not be comfortable in a new position at first. Keep trying, and ask
the therapist for help if she is still uncomfortable.

• You may need to initially limit the amount of time she is in that new position,
and gradually increase the length of time as her tolerance increases.

3. Change your child’s position often, build up to about every 60

minutes

• Encourage or help her to change her own position.

• If you leave your child in one position for many hours, she may develop
pressure sores and her body may stiffen which will increase her disability.
She needs to be moved into many helpful positions throughout the day.

The best position will be different for each child. We are learning some options;
a therapist will help find the best position for your child on a home visit.

Encourage discussion and questions before starting the next activity.

HOW TO POSITION
YOUR CHILD
Facilitator Tips:
Everyone should look at the photos of different body positions, discuss what they
show and decide which positions are good or poor. The group should practice each
good position as they go along, as this is the best way of learning how to position
your child correctly.

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 Part 1: Lying Down Positions
Ask
Ask someone to volunteer to lie on the floor and copy the position of the child
in picture (3.02a).

The rest of the group should observe and change this position to make it more
helpful, using pillows or blankets. Encourage discussion as changes are made.

Return to the smaller groups.

Ask
Ask participants to look at the photographs of each position, describe the body
position and decide why the position is good or unhelpful.

• Head and body

• Legs and feet

• Shoulders and arms

After discussing each photo, return to the main group and ask a volunteer to
demonstrate helpful positioning and encourage mothers to work in pairs and
practice it with their own children. Ask them to support each other in correctly
positioning the child. Walk around the group providing additional support, as
needed.

POSITION 1: LYING ON BACK

Explain
Lying on the back can be a good position for resting in, but it does not help a
child develop control over their body and learn ways they can move their body
and head, as compared to being in other positions. The older your child gets,
the less time they should spend on their back when they are awake.

POOR POSITIONING

• Head is pushing back and turned to one side

which can be unsafe and uncomfortable.

• Hips turning in causing legs to cross.

• Toes are pointing down, which means she can’t

get them flat when she sits.

• Hands and arms are away from her body,

unsupported.

• Hands are closed in fists and may stiffen.

GOOD POSITIONING

Head and body

• Always make sure her head is comfortable.

• Her spine must be straight – support the sides of the body

with rolled up towels.
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 Legs and feet

• Bend her hips – this helps to release tension in her lower back, and helps to
relax stiff legs. Place support under knees to keep hips bent (not under feet).

• Keep legs open and uncrossed – use a pillow between them.

• Feet should look the same as they would in standing – if toes point down,
talk to a therapist about getting an ankle/foot orthosis.

Shoulders and arms

• Forward and supported. This helps to relax the upper back, and allows the
hands to open more easily.

• Lying in a hammock can help to relax tight muscles.

• Babies and small children can hang in a large towel (held by two adults) to
relax tight muscles.

NOW PRACTICE WITH YOUR CHILD

POSITION 2: LYING ON THE TUMMY

Explain
Lying on the tummy is really important for developing strength in the head,
neck and back. Children learn to roll, crawl and move, by spending time on
their front and then being encouraged to push up through their arms.

• Often children don’t like being on their front when they are not used to it, so
start with small amounts of time; build up slowly to longer periods.

• Sometimes a small rolled towel under your child’s chest or shoulders

and positioned around her on either side can help her to hold this front
-propping position for a longer time.

• Try and play with your child while she is on her front to help distract her.

POOR POSITIONING

• His muscles are not being used.

• He cannot see with his face flat on the floor.

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 • His legs may be crossed.

• His hands are in fists and he

cannot use them in this position.

• He will struggle to move from

this position.

GOOD POSITIONING

Head and body

• In a straight line.

• Encourage her to lift her head so she can play.

Legs and feet

• Push down on the hips or bottom and rock from side to side to help
straighten the hips, legs and feet.

• Support between the legs prevents them from crossing over.

Shoulders and arms

• Arms should be in line with or slightly in front of shoulders. Place a pillow or

towel under her armpits to help keep arms forward.

• If possible encourage her to open her hands and push down on them. You
may need to gently open her fingers.

• This position may not work for all children so consult a therapist before
trying it.

NOW PRACTICE WITH YOUR CHILD

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 POSITION 3: LYING ON THE SIDE
Explain
Side lying is an important position because:

• It is a comfortable position for children who are very stiff.

• It allows children to get hands together, which is really essential for

development and play.

• It is also very good for children who produce a lot of saliva as it helps the
saliva drain out of the mouth safely.

GOOD POSITIONING

Head and body

• Use a pillow to keep her head in the middle of her shoulders with her back
straight.

• Using a pillow or towel along the back helps support the whole of the body.

Legs and feet

• Bending the top leg at the knee and keeping the bottom one straight helps
to relax stiffness, whilst allowing your child to support herself.

• Keep her top leg supported with pillows or blankets so it is level with the
hip. This will prevent dislocation of her hip.

• Regularly reposition her to lie on the other side to switch the supporting leg

Shoulders and arms

• The lower shoulder and arm must be

positioned forward so they are not
trapped underneath her body.

• Position both arms in front so she can

bring her hands together and use
them to play.

During the day this position should be

changed from one side to the other, or to
another position, every half an hour. This
is also a good position for your child to
sleep in.

NOW PRACTICE WITH YOUR CHILD

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 Part 2: Seated Positions
SITTING WITH A CAREGIVER, SITTING ON A CHAIR,
OR ALONE
Explain
If your child cannot sit on her own, it is really important to support her in a
sitting position. This helps her see more of the world around her and can also
help protect her hips from problems in the future (lying down all the time does
not help the hips develop in the right position and this can cause pain in the
future).
POOR POSITIONING

Sitting with a caregiver and on a chair this way is not best for a child, because;

• His head is hanging backwards or to the side, so he can’t see ahead of him
to use his hands or to communicate with anybody.

• His arms and hands are away from his body and not in a good position to
do anything.

• Shoulders are not supported, and are either flopping back or pushed too
far forward.

• His hips are not bent, so he is lying rather than sitting on his bottom.

• His body is leaning sideways and is unstable.

• His legs are twisted which can be harmful, and feet are not supported.

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 The kneeling position pictured is not best for a child, because:

• He does not need much control, so will not need to learn how to balance
her upper body.

• He may not develop good balance for sitting in other positions if always in
this position.

• This position can damage the knees and hips.

If this is the only way your child can sit independently then it should be done
safely but not too regularly.

GOOD POSITIONING

Photo by: Photo by:

CECHE Foundation CECHE Foundation

Head and body

• Upright with a straight back and head.

• If your child cannot hold her own head upright, make sure she is sitting up
straight with her back supported. Use your arms and hands to support her
head, chest, and hips in position.

• Buttocks are at the back of the seat.

• If there is a lap strap, make sure it is tight enough to prevent sliding down
the chair.

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 Legs and feet

• Bend her hips at a right angle to keep her upright and stop her sliding off
your lap or chair.

• Must be supported.

• She can sit independently with her legs crossed.

• She should sometimes sit with legs straight, not always bent
(to avoid stiffening).

Shoulders and arms

• Shoulders should be slightly forward so her arms and hands are in front of
her body, making it easier to play with a toy or person.

• Shoulders should be level.

• Arms should be supported slightly forward and in front of the body.

Ask
“How does your child sit in a chair or buggy?”

“How do you think you can help your child to learn how to sit? What things have
you tried at home?”

Your child will need to develop muscles to balance when she sits. You can
help her to play a game, or explore what her body can do with toys and other
objects.

Some easy ways to help your child sit with some support are:

• In a strong cardboard or wooden box, or basin covered with blankets/

bedcover to make them comfortable and help support them.

• Corner of room/ sofa/ chair: Make sure your child’s hips and knees are
bent. If your child pushes themselves backwards then this position can be
hard – try using a heavy rolled towel, bedspread or sandbag to stop them
pushing back.

Demonstrate both

NOW PRACTICE WITH YOUR CHILD

Return to sitting together with children on caregiver’s laps.

Ask
“How is your child sitting with you now? What should you change?”

Now practice with your child

Encourage caregivers to work together to change the position of their child and

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 to discuss what the most useful change for their child will be.

Ask
“What is one thing that you will do at home differently when your child sits with
you?”

Ask everyone to discuss in pairs the one thing that they will change at home.
Encourage participants to show others at home how to hold their child, and to
take photographs to show the group next week.

Part 3: Standing Positions

Ask
Ask everyone to stand on one leg. Hand out sheets of paper for everyone to
fold and tear into four equal parts while balancing.

Repeat the activity with everyone standing on both legs. Compare how much
easier it was with more balance.

Explain
Explain that this is the same for a child with developmental disabilities. Lack of
balance makes it difficult for her to do anything with her hands.

Return to the smaller groups and distribute the pictures showing standing
positions.

Activity 2
Discuss the images and why they show poor or good positioning. After
discussing each image, practice the good position with your child.

Facilitator should walk around the room helping each group as they discuss
and practice.
POOR POSITIONING

• She cannot stand on flat feet

with her knees and hips straight
probably due to stiff leg muscles.

• She is not able to balance without

holding on with both hands for
support or leaning on a caregiver.
This means she cannot do
anything else whilst standing.

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 GOOD POSITIONING

Photo by: The International Committee of the Red Cross

For images 3.08A and B:

• Balancing on a simple home made device puts less pressure on the rest of
her body.

• Her hips and knees are in a good position which helps to keep her feet flat.

• She does not need to hold on as she is well supported.

• Her shoulders and arms are forwards and hands are free to play.

For Image 3.08C

Head and body

• The frame keeps his back straight. Add a rolled up towel on either side if
your child’s body leans sideways.

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 • His head is upright and in the middle of his shoulders.

• His hips are facing the front.

• He is wearing a top so the frame is not touching or irritating the skin.

Legs and feet

• The frame supports the hips and knees in a standing position

• The soles of his feet are firmly on the ground with heels down and toes
facing forward.

• Make sure your child is putting enough weight on his feet by checking if
they can be easily moved. If you can move them loosen the frame whilst
supporting him and reposition his hips and feet.

• If it is difficult to get your child’s feet flat he should only start standing after a
home-visit assessment or if he is using orthotics.

• His arms should come forward onto the table (which should be at bent
elbow height) so he can use them.

NOW PRACTICE WITH YOUR CHILD

Part 4: Picking up
Ask
“Which picture shows the correct way to pick up a child?”

Explain
Explain the left image shows poor positioning and the right shows good
positioning.

POOR POSITIONING

• If you bend forward with your legs straight you can injure your back. Over
time you could develop painful back problems

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 GOOD POSITIONING

• Bend your knees, keep your back straight, and lift using the muscles in your
legs not your back. This will protect your back from injury.

• It can be easier to pick your child up with one foot slightly in front of the
other.

• Turn your child towards you, then lift and hold her close to your body before
standing up.

• If your child becomes too heavy for you to lift alone, ask someone to help
you.

• If lifting with another person, count before lifting so that both of you lift at
the same time.

NOW PRACTICE WITH YOUR CHILD

Part 5: Carrying
Activity 3
Show everyone the pictures.

In small groups, discuss the positions and

try out carrying techniques with the doll or
with your child. Everyone should try and find
the best position for them.

POOR POSITIONING

• Her head is unsupported and falling

backwards.

• She cannot see.

• Her body is stiff and straight not relaxed

or comfortable.

• Her arms and hands are not able to do

anything.

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 GOOD POSITIONING

Head and body

• Carrying your child in a more upright position

allows her to hold her head up and look
around.

Legs and feet

• Keep her hips and knees partially bent, and her

knees apart.

Shoulders and arms

• She can either hold on with her arms or use her

arms to do something else.

NOW PRACTICE WITH YOUR CHILD

MONITORING
PROGRESS
Ask
Ask everyone to act out one new position they have learnt today which they will
show to another family member.

Take Home Messages:

• It’s not possible to always attend to your child so you need safe and supportive
positions that you can leave her in when necessary.
• Good positioning helps make daily activities easier for your child.
• Instead of leaving your child in a poor position guide her into as helpful a
position as you can. You need to try different positions to see what works best
for your child.
• If you have access to therapists at your clinic or hospital ask for their advice on
how your child can benefit from positioning and therapy and what you can do
on a day to day.
• If you have equipment like buggies and positioners then use them. Ask your
hospital to help you get the most helpful items for your child.

Ask
Ask if anyone has any questions before ending the session.

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 SHARING EMOTIONS
AND FEELINGS
Ask
“How did you find talking about today’s subject? Did it raise any emotions or
feelings that you did not expect? How have you been feeling this week?”

Allow time for discussion and interaction with each other. This should be a
guided session between everyone with only short prompting from facilitators.

Facilitator Tips:
In the first sessions, everyone may not be comfortable to share their emotions. You
could help by recognising that talking about emotions can be tough.

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