Acute respiratory distress is one of the most frequent causes of hospitalisation and death in infants and young children globally. When children with severe respiratory distress are put in hospital, treatment may include additional oxygen or assisted ventilation which may damage the lungs. Infants and children with respiratory distress placed in particular positions may be more comfortable, breathe more easily and have better outcomes. However, different positions may also increase the risk of adverse outcomes. Therefore we searched the literature to identify controlled clinical trials comparing two or more body positions in the management of infants and children hospitalised with acute respiratory distress.
We included 24 studies with a total of 581 participants. Lying on the front (the prone position) was better than lying on the back (the supine position) for oxygenating the blood but the difference was small. The increase in oxygen saturation on average increased by 2%. This finding was based on data from nine studies (195 children, 165 preterm and 95 ventilated) measuring this outcome. The rapid rate of breathing with respiratory distress was slightly lower in the prone position (on average four breaths/minute lower) based on six studies (100 infants aged up to one month, 59 ventilated). No adverse effects were identified. There were no obvious differences with other positions. As most of the 581 children in these studies were preterm babies (60%) and (70%) ventilated by machine, the benefits of prone positioning may be most relevant to these infants.
***It is important to remember that these children were hospitalised. Therefore, given the association of the prone position with sudden infant death syndrome (SIDS), the prone position should not be used for children unless they are in hospital and their breathing is constantly monitored.
As the majority of studies did not describe how possible biases in the design of the study were addressed, the potential for bias in these findings is unclear. Also the findings of this review are limited by the small number of participants in studies, changes in infants and children were only measured for short time periods and the small changes in oxygenation which were seen in this review are not as meaningful as other measures of illness and recovery. Only five studies looked at children older than one year and few studies compared positions other than prone and supine.
The prone position was significantly superior to the supine position in terms of oxygenation. However, as most participants were ventilated preterm infants, the benefits of prone positioning may be most relevant to these infants. In addition, although placing infants and children in the prone position may improve respiratory function, the association of SIDS with prone positioning means that infants should only be placed in this position while under continuous cardiorespiratory monitoring.
Because of the association of prone positioning with sudden infant death syndrome (SIDS) it is recommended that young infants be placed on their backs (supine). However, the prone position may be a non-invasive way of increasing oxygenation in participants with acute respiratory distress. Because of substantial differences in respiratory mechanics between adults and children and the risk of SIDS in young infants, a specific review of positioning for infants and young children with acute respiratory distress is warranted.
To compare the effects of different body positions in hospitalised infants and children with acute respiratory distress.
We searched Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 3), which contains the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to April week 1, 2012), EMBASE (2004 to April 2012) and CINAHL (2004 to April 2012).
Randomised controlled trials (RCTs) or pseudo-RCTs comparing two or more positions in the management of infants and children hospitalised with acute respiratory distress.
Two review authors independently extracted data from each study. We resolved differences by consensus or referral to a third review author. We analysed bivariate outcomes using an odds ratio and 95% confidence interval (CI). We analysed continuous outcomes using a mean difference and 95% CI. We used a fixed-effect model unless heterogeneity was significant, in which case we used a random-effects model.
We extracted data from 53 studies. We included 24 studies with a total of 581 participants. Three studies used a parallel-group, randomised design which compared prone and supine positions only. The remaining 21 studies used a randomised cross-over design. These studies compared prone, supine, lateral, elevated and flat positions.
Prone positioning was significantly more beneficial than supine positioning in terms of oxygen saturation (mean difference (MD) 1.97%, 95% CI 1.18 to 2.77), arterial oxygen (MD 6.24 mm Hg, 95% confidence interval (CI) 2.20 to 10.28), episodes of hypoxaemia (MD -3.46, 95% CI -4.60 to -2.33) and thoracoabdominal synchrony (MD -30.76, 95% CI -41.39 to -20.14). No adverse effects were identified. There were no statistically significant differences between any other positions.
As the majority of studies did not describe how possible biases were addressed, the potential for bias in these findings is unclear.