Decreased activity and oxygen desaturation in prone ventilated preterm infants during the first postnatal week

doi:10.1067/mhl.2002.120241

Heart & Lung

Volume 31, Issue 1, January–February 2002, Pages 34-42

https://doi.org/10.1067/mhl.2002.120241 Get rights and content

Abstract

Objective: To compare the effects of supine and prone positions on oxygen saturation (SpO₂), desaturation episodes (SpO₂ < 90% and ≥ 20 seconds), and motor activity in ventilated preterm infants during their first postnatal week. Design: With use of a crossover design, we randomly assigned infants to a supine/prone or prone/supine position sequence. Infants were placed in each position for 2 hours. A stabilization period of 10 minutes before observation of each position was allowed. During the protocol, care procedures were kept minimal and ventilator settings remained unchanged. Setting: Neonatal intensive care units at 2 tertiary care centers in Taiwan. Sample: The sample consisted of 28 infants receiving mechanical ventilation who were 25 to 36 weeks' gestation, without known congenital abnormalities, within 7 postnatal days of birth, and were not receiving sedation. Results: When prone, infants had higher SpO₂, fewer episodes of oxygen desaturation, and less motor activity than when supine. No significant differences in duration of SpO₂ less than 90%, 85%, and 80% were found between the 2 positions. Seventy-four percent of desaturation episodes were associated with vigorous motor activity and crying. Conclusion: The prone position results in less motor activity and may stabilize oxygenation for ventilated preterm infants. This may conserve energy and decrease complications of hypoxia for sick preterm infants. (Heart Lung® 2002;31:34-42.)

Section snippets

Design

A 2-period crossover design was used. Each subject was placed supine or prone for 2 hours, followed by the other position for 2 more hours in a consecutive period. Infants were randomly assigned to position sequence: supine/prone (S/P) or prone/supine (P/S), with a 10-minute stabilization period preceding observation in each position. To achieve an equal distribution of S/P and P/S position sequence, permuted block randomization was performed by a third person who selected balanced combinations

Results

Demographic information is shown in Table I.

. Characteristics of subjects (N = 28)

Infant characteristics	Mean ± SD or n	Range
Boy/girl	15/13
Birth weight (g)	1378 ± 522	687-2650
Body weight at study (g)	1335 ± 514	656-2550
Gestational age (wk)	29.5 ± 3.5	25-36
Postnatal age at study (h)	38 ± 31	5-120
Apgar score at 1 min	4.6 ± 1.9	2-8
Apgar score at 5 min	7.0 ± 1.0	4-9
Spontaneous delivery/cesarean section	16/12
Diagnosis of RDS/no RDS	20/8
Treatment with surfactant	18
Ventilator setting during protocol
Fraction of oxygen

Discussion

This study demonstrated that prone placement had a beneficial influence on oxygenation in ventilated preterm infants during their first postnatal week. This result is consistent with previous reports that studied arterial oxygen saturation and tension in nonventilated preterm infants8, 11, 26 and ventilated preterm infants later in their clinical course.10, 12, 14, 20, 27 During the study, prone placement resulted in consistently lower motor activity, a finding that has not been reported

Acknowledgements

The authors thank Dr Richard J. Martin for critical review on this manuscript and the staff of the Neonatal Intensive Care Unit at National Cheng Kung University Hospital and Sin-Lau Christian Hospital for their supports.

References (43)

J Lioy et al.
A comparison of prone and supine positioning in the immediate postextubation period of neonates
J Pediatr
(1988)
MJ Wagaman et al.
Improved oxygenation and lung compliance with prone positioning of neonates
J Pediatr
(1979)
JC Mendoza et al.
Postural effects on pulmonary function and heart rate of preterm infants with lung disease
J Pediatr
(1991)
RJ Martin et al.
Vulnerability of respiratory control in healthy preterm infants placed supine
J Pediatr
(1995)
RJ Martin et al.
Pathogenesis of apnea in preterm infants
J Pediatr
(1986)
MAVT Dimaguila et al.
Characteristics of hypoxemic episodes in very low birth weight infants on ventilatory support
J Pediatr
(1997)
R Woodson et al.
Heart rate estimates of motor activity in preterm infants
Infant Behav Dev
(1986)
P Franco et al.
Auditory arousal thresholds are higher when infants sleep in the prone position
J Pediatr
(1998)
JE Brazy
Effects of crying on cerebral blood volume and cytochromeaa₃
J Pediatr
(1988)
JJ Volpe
Intraventricular hemorrhage and brain injury in the premature infant
Neonatal Neurol
(1989)

JJ Volpe

Brain injury in the premature infant: overview of clinical aspects, neuropathology, and pathogenesis

Semin Pediatr Neurol

(1998)

JC Evans

Incidence of hypoxemia associated with caregiving in premature infants

Neonatal Network

(1991)

JG Long et al.

Excessive handling as a cause of hypoxemia

Pediatrics

(1980)

KL Peters

Does routine nursing care complicate the physiologic status of the premature neonate with respiratory distress syndrome?

J Perinat Neonat Nurs

(1992)

E. Dean

Effect of body position on pulmonary function

Phys Ther

(1985)

R Heimler et al.

Effect of positioning on the breathing pattern of preterm infants

Arch Dis Child

(1992)

American Academy of Pediatrics Task Force on Infant Positioning and SIDS

Positioning and sudden infant death syndrome (SIDS): update

Pediatrics

(1996)

American Academy of Pediatrics Task Force on Infant Sleep Position and SIDS

Changing concepts of sudden infant death syndrome: implication for infant sleeping environment and sleep position

Pediatrics

(2000)

RJ Martin et al.

Effect of supine and prone positions on arterial oxygen tension in the preterm infant

Pediatrics

(1979)

J Masterson et al.

Prone and supine positioning effects on energy expenditure and behavior of low birth weight neonates

Pediatrics

(1987)

TM Baird et al.

Improved oxygenation with prone positioning in neonates: stability of increased transcutaneous PO₂

J Perinatol

(1991)

Cited by (36)

Systematic Review of the Effects of Positioning on Nonautonomic Outcomes in Preterm Infants
2023, JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing
Citation Excerpt :
The effect of positioning on premature infant behaviors that indicate an infant is experiencing stress was a common theme that appeared in six articles. In five articles (Chang, Anderson, Dowling, & Lin, 2002; Jarus et al., 2011; Grenier et al., 2003; Liaw, Yang, Hua, et al., 2012; Peng et al., 2014), authors examined premature infants’ stress responses through the frequency and types of movements observed. Cândia et al. (2014) assessed infant stress using salivary cortisol levels.
To identify and synthesize the available evidence on the effect of different positions (prone, supine, and right and left lateral) on nonautonomic outcomes for preterm infants admitted to the NICU.
We searched the CINAHL, MEDLINE, Scopus, and Cochrane databases for reports of primary research studies using a three-step strategy. We also searched for gray literature and reviewed the reference lists of retrieved articles.
We included reports of quantitative studies published in English from database inception through February 2022 that focused on positioning and nonautonomic outcomes (pain, comfort, skin integrity, behavioral state, and sleep quality and duration) for preterm infants in the NICU. Two authors independently screened titles and abstracts and assessed articles in full text against the inclusion criteria.
Two authors independently extracted the data from the full-text articles using a standardized data extraction tool. We synthesized the data narratively because of the different designs and outcome measures among the included studies.
From a total of 550 records initially screened, we included 17 articles in our review. In the included articles, prone positioning improved sleep quality and duration, whereas supine positioning was associated with increased awakenings and activity. Infants demonstrated fewer self-regulatory behaviors in the prone position compared to supine or side-lying and were less stressed in the prone position. We found minimal evidence on the effect of positioning on skin integrity or pain.
There is limited good-quality evidence on the effect of positioning on nonautonomic outcomes in preterm infants. To inform clinical practice, high-quality randomized controlled trials focused on the positioning of premature infants are warranted.
Positioning Effects for Procedural Pain Relief in NICU: Systematic Review
2021, Pain Management Nursing
To systematically review the literature regarding the effectiveness of different positioning methods for procedural pain relief in neonates admitted to the Neonatal Intensive Care Unit (NICU).
A systemized search of the literature was carried out by means of two independent evaluators through the systematic search of electronic index databases.
A search for relevant studies was performed in four databases (Medline, Web of Science, Scopus, and BVS-BIREME).
Manual searches were conducted on suitable references from the included articles, and 1,941 publications were eligible for the analysis. The flowchart for the articles’ selection was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria, and in relation to bias risks according to the Physiotherapy Evidence Database (PEDro) scale.
Based on the inclusion criteria, only 20 publications remained. According to the PEDro scale, 75% of the studies presented good methodological quality, with scores between 6 and 8, and 5% scored ≤4 points. None of them were blinded in relation to the therapies, but all of them performed intergroup statistical comparisons. According to the results of this review, we recommend facilitated tucking by parents (FTP) in NICU of at least 30 minutes duration, starting 15 minutes before, during the painful procedure, and 15 minutes after to relieve pain and to stabilize the physiological, hormonal, and behavioral responses of the newborns.
Positioning should be used as a nonpharmacological strategy for procedural pain relief in newborns. This review showed that facilitated tucking by parents for 30 minutes was the best position for pain relief in premature newborns during procedures in the NICU. Positioning is recommended as a nonpharmacological method for pain relief; FTP of at least 30 minutes duration should be the first positioning choice during procedures in the NICU.
Oxygenation Instability Assessed by Oxygen Saturation Histograms during Supine vs Prone Position in Very Low Birthweight Infants Receiving Noninvasive Respiratory Support
2020, Journal of Pediatrics
To evaluate the effect of prone vs supine position on the oxygenation instability among very low birth weight (VLBW) infants receiving noninvasive respiratory support, as assessed by the average oxygen saturation (SpO₂) histograms.
Sixty-nine histograms from 23 VLBW infants were studied prospectively. Each infant was studied during 3 consecutive 3-hour periods of alternating positions; 12 infants started the study while prone and 11 infants started supine, by random order. Histogram classification system was used to quantify oxygenation stability and time spent in different SpO₂ ranges.
The fraction of inspired oxygen values were similar in both positions. Unstable histograms were more common in supine vs prone position (20/34 [59%] vs 10/35 [29%]; P = .02, respectively). Analyzing oxygenation stability as per position change revealed that a change from prone to supine increased oxygenation instability, and supine to prone decreased instability (P = .02). In the supine vs prone position, percent of time spent in SpO₂ ≤80% and <90% was higher (5.0 ± 4.2 vs 2.4 ± 3.4 [P < .001] and 24.1 ± 13.7 vs 13.2 ± 10.0 [P < .001], respectively), and percent of time in SpO₂ >94% was lower (39.7 ± 26.0 vs 52.4 ± 23.4 [P = .04]).
Prone positioning decreased oxygenation instability and resulted in higher oxygenation among VLBW premature infants on noninvasive respiratory support. SpO₂ histograms allow easy bedside assessment of oxygenation instability, and quantification of the time spent at different SpO₂ ranges.
The effect of nesting positions on pain, stress and comfort during heel lance in premature infants
2018, Pediatrics and Neonatology
Nesting positions are commonly used in procedural analgesic administration in premature neonates. The effectiveness of nesting positions is questioned. The aim of the this study was to assess the pain, stress, comfort and salivary cortisol and melatonin values in nesting positions during the heel lance procedure in premature infants at the NICU.
Experimental research; repeated measurement design. The sample comprised 33 premature neonates with gestational age of 31–35 weeks who had been hospitalized in the NICU. Nesting positions were given using linen or towels. The procedure of heel lance was recorded on camera. The camera recordings were evaluated according to the NIPS and the COMFORTneo scale. Saliva samples were obtained five minutes prior to and 30 min after the heel lance procedure. Salivary Cortisol and Melatonin were measured using the Salimetrics Cortisol Elisa Kit and the Salimetrics Melatonin Elisa Kit.
The crying time, the mean NIPS score, the COMFORTneo score, the COMFORTneo NRS-pain scores and the COMFORTneo NRS-distress scores for premature neonates who were in the prone position during the procedure were significantly lower than the scores in the supine position (p < 0.000). Furthermore, the level of salivary cortisol five minutes prior to and 30 min after the heel lance procedure had significantly decreased in the prone position; however, there were insignificant differences in the mean levels of salivary melatonin between the positions.
Nesting in the prone position has a pain reducing effect, enhancing comfort and reducing stress in premature infants.
Oxygenation Instability in the Premature Infant
2018, The Newborn Lung: Neonatology Questions and Controversies, Third Edition
Most premature infants present with significant oxygenation instability during the different phases of their respiratory course. This instability increases their susceptibility to episodes of hypoxemia and hyperoxemia. These episodes are more common in premature infants who remain on mechanical ventilation beyond the first weeks after birth and especially in those with evolving chronic lung disease. One of the most common mechanisms triggering episodic hypoxemia in these infants are spontaneous contractions of the abdominal musculature that splints the respiratory pump, resulting in periods of decreased lung volume, impaired lung mechanics, and hypoventilation. During routine care, intermittent hypoxemia is often followed by hyperoxemia induced by excessive oxygen supplementation in an attempt to correct the episodes or prevent their occurrence. Because of their frequency and persistence over days or weeks, episodes of intermittent hypoxemia may negatively affect long-term outcome. Thus it is critical to better understand the mechanisms and consequences of episodic hypoxemia to identify effective strategies to prevent them or attenuate their severity.
Special Considerations in Neonatal Mechanical Ventilation
2016, Critical Care Nursing Clinics of North America
Citation Excerpt :
Hough and colleagues64 identified that ventilation distribution in preterm infants follows an anatomic pattern and is not gravity dependent. There is mounting evidence that prone positioning enhances the contribution of the rib cage to tidal volume, improves thoracoabdominal synchrony, improves oxygenation, reduces apnea, reduces stress, and promotes sleep.65–67 For practical and developmental reasons, the prone position cannot be the sole positioning strategy used.

View all citing articles on Scopus

^*: This study was supported by the National Science Council and College of Medicine Fund of National Cheng Kung University of Taiwan, Republic of China.

^**: Reprint requests: Ying-Ju Chang, PhD, RN, Department of Nursing, College of Medicine, National Cheng Kung University, No. 1 Ta-Hsueh Road, Tainan, Taiwan, 701, Republic of China.

View full text

Issues in Pulmonary NursingDecreased activity and oxygen desaturation in prone ventilated preterm infants during the first postnatal week*,**

Abstract

Section snippets

Design

Results

Discussion

Acknowledgements

J Pediatr

J Pediatr

J Pediatr

J Pediatr

J Pediatr

J Pediatr

Infant Behav Dev

J Pediatr

J Pediatr

Neonatal Neurol

Semin Pediatr Neurol

Incidence of hypoxemia associated with caregiving in premature infants

Neonatal Network

Excessive handling as a cause of hypoxemia

Pediatrics

Does routine nursing care complicate the physiologic status of the premature neonate with respiratory distress syndrome?

J Perinat Neonat Nurs

Effect of body position on pulmonary function

Phys Ther

Effect of positioning on the breathing pattern of preterm infants

Arch Dis Child

Positioning and sudden infant death syndrome (SIDS): update

Pediatrics

Changing concepts of sudden infant death syndrome: implication for infant sleeping environment and sleep position

Pediatrics

Effect of supine and prone positions on arterial oxygen tension in the preterm infant

Pediatrics

Prone and supine positioning effects on energy expenditure and behavior of low birth weight neonates

Pediatrics

Improved oxygenation with prone positioning in neonates: stability of increased transcutaneous PO2

J Perinatol

Issues in Pulmonary Nursing
Decreased activity and oxygen desaturation in prone ventilated preterm infants during the first postnatal week*,**

Improved oxygenation with prone positioning in neonates: stability of increased transcutaneous PO₂