Protective Stabilization

Protective Stabilization in Pediatric Care: The Papoose Board

A clinical review of indications, sizing, monitoring requirements, and regulatory status.

By L.J. Relle, BBA, NRP, FP-C, CCP-CClinical Manager, Pacific Biomedical

Protective stabilization is the physical limitation of a patient's movement, by a person or by a device, for a finite period so that examination, diagnosis, or treatment can be provided safely.¹ The papoose board is the passive device most familiar to clinicians who work with children, and it remains in routine use in pediatric dentistry, emergency and urgent care, alternate care sites, and diagnostic imaging. This review covers what the device is and how to use it appropriately. For more clinical reference material, see the rest of the Clinical Resources library.

Terminology, Provenance, and Regulatory Status

Protective stabilization is the term the American Academy of Pediatric Dentistry adopted to replace physical restraint and medical immobilization, and it is the term that belongs in the record and on consent forms.¹ The shift in nomenclature has been documented in the dental literature.² Stabilization is described as active when a person does the holding and passive when a device does it. The papoose board is one of several passive devices the AAPD names.¹

The board is sold under the Olympic name, and that name traces to Olympic Medical Corporation of Seattle. Natus Medical acquired Olympic Medical in October 2006 and stated at the time that it planned to retain Olympic's operations together with its established brands and existing products.³ Canadian Hospital Specialties acquired the Papoose Boards line from Natus in October 2022 as part of the Nursery Essentials portfolio.⁴ CHS USA distributes it in the United States today via approved distributors.⁵ Those three names describe one continuous product line and not three competing devices. The board is still sold under the Olympic name, with the same catalog numbers CHS USA publishes today. Parts are listed against those same catalog numbers, and fit on an older frame is worth confirming with the supplier before ordering, since small product improvements have been made over the years.

The FDA classifies protective restraints under product code FMQ and regulation 21 CFR 880.6760 as Class I devices exempt from premarket notification, so the absence of a clearance number carries no regulatory significance.⁶ It follows that neither "FDA approved" nor "FDA cleared" is an accurate description of the device, and a vendor who uses either phrase has misread the classification.

Device Description and Sizing

The construction of the papoose board is straightforward. A flat backing board carries three sets of opposing canvas flaps closed with hook-and-loop fasteners, and because the board is cut on a diagonal the flaps cross one another at the midline, which spreads the hold across the trunk and limbs.⁵ A complete set consists of the board, a padded three-tier flap set, a padded head strap, and four arm wrist straps. Olympic, Natus, and CHS have all listed the board as MRI Safe, metal-free, and latex-free. The small board measures 30 inches in length and 7 inches at its widest point and weighs approximately 3 pounds. Flap sets and arm straps are machine washable or steam sterilizable, and the board itself is wiped down with a liquid disinfectant.⁵

Four sizes are published by age band: the small board (part number 50510) for infants up to 24 months, the regular board (50500) for ages 2 to 6, the large board (53600) for ages 6 to 12, and the extra-large board (54610) for teenagers and adults.⁵ No weight capacity is published for the small, regular, or large board. The extra-large is the exception, listed for patients of roughly 70 to 200 pounds with a maximum patient girth of about 40 inches, beyond which extension flaps are required.⁷ Children with special health care needs may fall outside their chronologic band in either direction, so selection should follow girth and limb length.

A head immobilizer in the matching size adds lateral control for procedures where a few degrees of rotation would invalidate the result, and extension flaps for the regular board widen the wrap for a larger child on an existing frame. Flap sets and arm straps should be treated as consumables, since the hook-and-loop closures may wear out well before the board does.

One point of technique belongs here, because it is the one most often executed incorrectly. The middle tier is intended to secure the arms and the pelvis. Closed instead across the abdomen of a small child, it restricts the diaphragmatic excursion that child depends on for proper ventilation. Correct placement leaves abdominal movement visible and gives the operator a continuous bedside check.

Indications and Contraindications

The AAPD publishes the closest thing this field has to a standard, and the indication should be checked against it before the device is brought out.¹ Protective stabilization is indicated for:

• A patient requiring immediate diagnosis or urgent limited treatment who cannot cooperate because of developmental level, lack of maturity, or a medical or physical condition.
• A patient requiring urgent care whose uncontrolled movements would endanger the patient, the parent, the clinician, or staff.
• A previously cooperative patient who becomes uncooperative when cooperation cannot be regained through basic behavior guidance.
• An uncooperative patient with limited treatment needs where sedation or general anesthesia may not be an option.
• A sedated patient requiring limited stabilization to reduce untoward movement.
• A patient with special health care needs whose uncontrolled movements would be harmful or would significantly interfere with the quality of care.

It is contraindicated for:

• A cooperative non-sedated patient.
• An uncooperative patient when no clear need exists to treat at that particular visit.
• A patient who cannot be immobilized safely because of a medical, psychological, or physical condition.
• A patient whose history of physical or psychological trauma including abuse would create greater psychological risk during restraint.
• A patient with non-emergent treatment needs where the aim is full-mouth or multiple-quadrant rehabilitation.
• Practitioner convenience.
• A dental team lacking the requisite knowledge and skills in patient selection and restraining techniques.

Consent and Documentation

Informed consent should be obtained and documented before the device is applied, and fresh consent is required if the technique changes during the procedure. A parental request to stop obligates the practitioner to bring the procedure to a safe conclusion and end the appointment.¹

The patient record should contain the indication, the type of stabilization, the informed consent, the reason for parental exclusion where applicable, the duration of application, a behavior evaluation during stabilization, any untoward outcome such as skin marking, and the implications for future appointments.¹

Application and Positioning

The proper head position should be established before flap closure and verified by looking at the patient in profile. The patient's face should sit roughly level and the chin should be clear of the chest.

Additional padding may be used to accommodate the proportions of the patient. A folded towel placed as a shoulder roll, for example, lifts the torso until the head rests in a neutral position. That can correct the occiput-driven flexion an infant or toddler falls into when placed on a flat rigid surface.⁸

The Papoose Board does not have to remain flat, and 15 to 30 degrees of head elevation on a reclining chair or gurney may be helpful for patient comfort and airway management. Outer clothing should also come off before the wrap goes on, since the AAPD identifies overheating on a rigid board as a documented risk and treatment rooms are commonly set for the comfort of the operator.¹

Several conditions warrant additional evaluation during the pre-procedure assessment. The sedation guideline identifies children with Down syndrome, Marfan syndrome, or skeletal dysplasia as warranting evaluation for cervical spine instability, a consideration that carries obvious weight on a device that fixes the neck in one plane. A history of snoring or obstructive sleep apnea calls for careful evaluation, and anatomic airway abnormality or moderate to severe tonsillar hypertrophy requires what the guideline terms additional and individual consideration. Children with developmental disabilities demonstrate a threefold increased incidence of desaturation, and that group is also stabilized more often than any other.⁹ A gastrostomy tube should be identified before the middle tier is placed so the flap can be routed clear of it, and a recent upper respiratory infection is reason to reconsider the timing of an elective procedure.

Procedure checklist considerations may include:

1. Obtain and document consent.
2. Size the board before the child is placed on it and lay out the head strap and arm straps for the size in use.
3. Establish suction at the head of the patient and switch it on.
4. Position the head and check the profile. The chin should be clear of the chest.
5. Close the flaps snugly without restricting circulation or respiration.¹
6. Leave one hand or one foot exposed as the guideline directs⁹ and consider placing the pulse oximeter there for monitoring.
7. Lift one edge of the board and confirm the child and the board move together as a unit.
8. Observe abdominal excursion continuously and reassess tightness and duration at intervals.¹
9. Never leave the patient unattended.⁹
10. Document the indication, consent, duration, behavior, and any skin marking at the end.

Clinical Applications

Pediatric Dentistry

Pediatric dentistry is among the most common settings in which the Papoose Board may be helpful. The AAPD work group that developed the 2023 nonpharmacologic behavior guidance recommendations reported that it "found no studies that met the inclusion criteria on use of protective stabilization in healthy children presenting for preventive or dental treatment visits," and found none meeting its criteria for children with special health care needs either.¹⁰

A survey of mothers whose own children had been treated in a Papoose Board returned 50 evaluable responses, of which 90 percent approved of its use and 96 percent considered it necessary to complete the dentistry.¹¹

Utilization is lower than the older literature suggests, though the surveys measure different quantities and cannot be combined into a trend. A late-1990s survey of southeastern pediatric dentists found 82 percent reporting that they sometimes use a papoose board or Pedi-Wrap.¹² A 2004 national survey of AAPD members reported passive immobilization of a nonsedated child at 68 percent.¹³ A 2018 survey measuring the mean share of a provider's own patients found passive restraint at 9.2 percent overall.¹⁴

The most useful safety data come from a randomized crossover trial in which 74 children with special health care needs were analyzed, roughly two-thirds of them carrying a diagnosis of autism spectrum disorder. Blood pressure, heart rate, and oxygen saturation showed no significant change with the Papoose Board compared with basic behavior guidance, and the authors concluded that its use "is safe and has no discernible influence on the child's physiological responses," qualifying that conclusion as applying when the board is used properly.¹⁵ The finding is physiologic and says nothing about whether treatment was completed. It also describes an older cohort than the one most at risk, since the mean age was close to 10 years and the procedures were prophylaxis or simple restorations.

Emergency Care

Emergency clinicians usually frame the choice as stabilization versus procedural sedation. The Pediatric Sedation Research Consortium analyzed 30,037 sedation encounters performed outside the operating room and recorded no deaths and one resuscitation. Desaturation below 90 percent for longer than 30 seconds occurred 157 times per 10,000 sedations, unexpected apnea 24 times, and vomiting 47.2 times per 10,000.¹⁶ Those figures describe the sedation side of the comparison. The stabilization side carries no drug risk and substitutes the positioning, monitoring, and duration obligations set out above.

Diagnostic Imaging

Radiology has examined this question more carefully than other specialties, because an unsuccessful examination carries the risk of unnecessary radiation exposure. A 2019 literature review states that patient consent and the use of physical force are what fundamentally separate immobilization from restraint, and it concluded that restraint "should ideally be avoided unless justified through a risk-benefit analysis."¹⁷ A 2024 survey of 103 radiographers in Ireland found 95 percent using immobilization and 89 percent using restraint techniques, while 70 percent acknowledged a lack of training in restraint technique and 93 percent reported attempting distraction and negotiation first.¹⁸

Official guidance supports immobilization where motion would force a repeat exposure. The joint ACR, SPR, and STR practice parameter for portable chest radiography states that "young or uncooperative children should be immobilized when necessary to ensure adequate patient positioning and prevent motion artifact resulting in unnecessary repeat exposures."¹⁹

A mechanical immobilization device with radiolucent belts outperformed manual holding in a study of pediatric voiding cystourethrography, producing significant improvement in image quality and motion artifact together with significant reductions in shot number, fluoroscopy time, dose area product, and effective dose.²⁰ Non-pharmacologic measures still warrant an attempt first, and child life specialists working alongside the imaging team help decrease the need for general anesthesia, shorten procedure times, and improve image quality.²¹ In infants, feed-and-wrap is an effective technique that should be considered before any restraint device. One published series reported that 79 percent of scans fully answered the clinical question with a further 20 percent answering it partially, and a 2024 neonatal comparison reported a 95 percent success rate.^22,23 The format has one limitation worth understanding. The board stabilizes the trunk and, unless supplemental arm boards are used, contributes little on extremity work where controlled rotation is often the objective.

Magnetic resonance imposes a stricter standard and a more specific vocabulary. CHS USA describes the Olympic Papoose Board as MRI Safe and metal-free.⁵ The defined regulatory term is MR Safe, which under FDA guidance aligned with ASTM F2503 designates a device that "poses no known hazards resulting from exposure to any MR environment" and is "composed of materials that are electrically nonconductive, nonmetallic, and nonmagnetic."²⁴ Those two phrases are not interchangeable, authority rests with the ASTM F2503 marking on the device itself, and facility MR screening applies to this device exactly as it applies to anything else entering Zone IV.

Monitoring During Sedation

The AAP and AAPD sedation guideline addresses these devices by name. "Immobilization devices, such as papoose boards, must be applied in such a way as to avoid airway obstruction or chest restriction," and "the child's head position and respiratory excursions should be checked frequently to ensure airway patency. If an immobilization device is used, a hand or foot should be kept exposed, and the child should never be left unattended."⁹

Monitoring obligations follow the depth of sedation achieved. At moderate sedation the requirement attaches to ventilation monitoring, for which the guideline names capnography as the preferred method. EtCO2 monitoring is strongly recommended when bidirectional verbal communication with the patient is appropriate and possible, and it becomes required when that communication is not appropriate or not possible.⁹

At deep sedation the guideline states that capnography "should be used for almost all deeply sedated children because of the increased risk of airway/ventilation compromise," and expired carbon dioxide is among the values that must be documented at least every 5 minutes in a time-based record.⁹ A waveform earns its place here more than in most settings, because capnography shows obstruction before the saturation falls, and the upper flaps cover the chest wall so that the abdomen is the only excursion the operator can still see. A pediatric filtered EtCO2 and oxygen cannula delivers oxygen and samples carbon dioxide through a single interface for patients who are not intubated.

Blood pressure should be recorded at least every 10 minutes in a time-based record at moderate sedation, and vital signs including blood pressure at least every 5 minutes at deep sedation.⁹

Stabilization should be terminated and the patient reassessed on increasing work of breathing, falling oxygen saturation, absent or reduced abdominal excursion, a head position that cannot be corrected, or severe emotional distress. The AAPD requires termination as soon as possible when a patient experiences severe emotional stress, and it documents that a patient on a rigid board may overheat and that excessive catecholamine release may sensitize the heart and produce rhythm disturbances.¹

Restraint Classification

The CMS Conditions of Participation define restraint broadly and then exclude a specific list covering orthopedically prescribed devices, surgical dressings, protective helmets, and physical holding for routine physical examinations or tests.²⁵ The phrase "medical, dental, diagnostic, or surgical procedure" does not appear in the regulation. The procedural exclusion on which most hospital policies rely originates instead in CMS interpretive guidance, which states that "a positioning or securing device used to maintain the position, limit mobility or temporarily immobilize during medical, dental, diagnostic, or surgical procedures is not considered a restraint."²⁶ Local policy should be consulted.

Where a facility does classify the device as a restraint, 42 CFR 482.13(e)(5) requires an order from a physician or other licensed practitioner and (e)(6) prohibits standing and PRN orders outright.²⁵ The AAPD reproduces the CMS restraint definition in its own policy and then bounds duration with the phrase "a finite period of time" rather than with a numeric limit.¹

Duration

No professional body and no federal regulator sets a numeric time limit on protective stabilization in children. The AAPD frames the requirement qualitatively, defining stabilization as limitation of movement "for a finite period of time," requiring that "tightness and duration of the stabilization must be monitored and reassessed at regular intervals," and requiring termination as soon as possible in a patient experiencing severe stress.¹

The CMS restraint time limits are commonly referenced. The limits of 4 hours for adults, 2 hours for ages 9 through 17, and 1 hour for children under 9 are order-renewal intervals for restraint used in violent or self-destructive behavior. They are not duration caps, and they do not reach procedural immobilization. For non-violent restraint the regulation defers to hospital policy.²⁵

Recovery

If any sedation was administered, observation continues past removal of the device. The guideline directs that a child who received moderate sedation be observed in a suitably equipped recovery area with functioning suction and the capacity to deliver greater than 90 percent oxygen and positive-pressure ventilation, with vital signs recorded at specified intervals and continuous oxygen saturation and heart rate monitoring until discharge criteria are met in any patient who is not fully alert. The guideline also suggests one simple evaluation tool. The child should be able to remain awake for at least 20 minutes in a quiet environment.⁹

Conclusion

Protective stabilization is an important part of pediatric care for patients with special needs and considerations. Local clinicians should determine the risk and benefit of using protective stabilization to facilitate a procedure(s) on a patient by patient basis using sound clinical judgment and their local facility's patient care guidelines as appropriate.

Frequently Asked Questions

Definitions and Use

Safety, Duration, and Risk

Consent, Charting, and Regulation

Special Populations and Practical Use

Sizing, Materials, and Care

This article is intended for educational purposes for trained clinicians and does not replace institutional policy, medical or dental direction, applicable state regulations, or formal clinical training. Use of protective stabilization must follow current facility policy, the rules of the relevant state licensing board, and the informed consent requirements described above.