body positioning for spontaneously breathing preterm infants with apnoea

Body positioning for spontaneously breathing preterm infants

with apnoea (Review)

Bredemeyer SL, Foster JP

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library

2012, Issue 6

http://www.thecochranelibrary.com

Body positioning for spontaneously breathing preterm infants with apnoea (Review)

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 1.1. Comparison 1 Supine versus prone, Outcome 1 Episodes of apnoea. . . . . . . . . . . . . 23

Analysis 1.2. Comparison 1 Supine versus prone, Outcome 2 Episodes of oxygen desaturation. . . . . . . . . 23

Analysis 1.3. Comparison 1 Supine versus prone, Outcome 3 Episodes of bradycardia. . . . . . . . . . . . 24

Analysis 2.1. Comparison 2 Prone horizontal versus right lateral horizontal, Outcome 1 Episodes of apnoea. . . . 24

Analysis 2.2. Comparison 2 Prone horizontal versus right lateral horizontal, Outcome 2 Episodes of oxygen desaturation. 25

Analysis 2.3. Comparison 2 Prone horizontal versus right lateral horizontal, Outcome 3 Episodes of severe apnoea. . 25

Analysis 2.4. Comparison 2 Prone horizontal versus right lateral horizontal, Outcome 4 Episodes of bradycardia. . . 26

Analysis 2.5. Comparison 2 Prone horizontal versus right lateral horizontal, Outcome 5 Episodes of severe bradycardia. 26

Analysis 3.1. Comparison 3 Prone horizontal versus left lateral horizontal, Outcome 1 Episodes of apnoea. . . . . 27

Analysis 3.2. Comparison 3 Prone horizontal versus left lateral horizontal, Outcome 2 Episodes of oxygen desaturation. 27

Analysis 3.3. Comparison 3 Prone horizontal versus left lateral horizontal, Outcome 3 Episodes of severe apnoea. . . 28

Analysis 3.4. Comparison 3 Prone horizontal versus left lateral horizontal, Outcome 4 Episodes of bradycardia. . . 28

Analysis 3.5. Comparison 3 Prone horizontal versus left lateral horizontal, Outcome 5 Episodes of severe bradycardia. 29

Analysis 4.1. Comparison 4 Right lateral versus left lateral, Outcome 1 Episodes of apnoea. . . . . . . . . . 29

Analysis 4.2. Comparison 4 Right lateral versus left lateral, Outcome 2 Episodes of oxygen desaturation. . . . . . 30

Analysis 4.3. Comparison 4 Right lateral versus left lateral, Outcome 3 Episodes of severe apnoea. . . . . . . . 30

Analysis 4.4. Comparison 4 Right lateral versus left lateral, Outcome 4 Episodes of bradycardia. . . . . . . . . 31

Analysis 4.5. Comparison 4 Right lateral versus left lateral, Outcome 5 Episodes of severe bradycardia. . . . . . 31

Analysis 5.1. Comparison 5 Prone horizontal with prone head elevated, Outcome 1 Episodes of apnoea. . . . . . 32

Analysis 5.2. Comparison 5 Prone horizontal with prone head elevated, Outcome 2 Episodes of oxygen desaturation. 32

Analysis 5.3. Comparison 5 Prone horizontal with prone head elevated, Outcome 3 Episodes of severe apnoea. . . 33

Analysis 5.4. Comparison 5 Prone horizontal with prone head elevated, Outcome 4 Episodes of bradycardia. . . . 33

Analysis 5.5. Comparison 5 Prone horizontal with prone head elevated, Outcome 5 Episodes of severe bradycardia. . 34

Analysis 6.1. Comparison 6 Right lateral horizontal versus right lateral elevated, Outcome 1 Episides of apnoea. . . 34

Analysis 6.2. Comparison 6 Right lateral horizontal versus right lateral elevated, Outcome 2 Episodes of oxygen

desaturation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Analysis 6.3. Comparison 6 Right lateral horizontal versus right lateral elevated, Outcome 3 Episodes of severe apnoea. 35

Analysis 6.4. Comparison 6 Right lateral horizontal versus right lateral elevated, Outcome 4 Episodes of bradycardia. 36

Analysis 6.5. Comparison 6 Right lateral horizontal versus right lateral elevated, Outcome 5 Episodes of severe

bradycardia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Analysis 7.1. Comparison 7 Left lateral horizontal versus left lateral elevated, Outcome 1 Episodes of apnoea. . . . 37

Analysis 7.2. Comparison 7 Left lateral horizontal versus left lateral elevated, Outcome 2 Episodes of oxygen desaturation. 37

Analysis 7.3. Comparison 7 Left lateral horizontal versus left lateral elevated, Outcome 3 Episodes of severe apnoea. . 38

Analysis 7.4. Comparison 7 Left lateral horizontal versus left lateral elevated, Outcome 4 Episodes of bradycardia. . 38

Analysis 7.5. Comparison 7 Left lateral horizontal versus left lateral elevated, Outcome 5 Episodes of severe bradycardia. 39

39HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iBody positioning for spontaneously breathing preterm infants with apnoea (Review)


40SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .

iiBody positioning for spontaneously breathing preterm infants with apnoea (Review)


[Intervention Review]

Body positioning for spontaneously breathing preterm infantswith apnoea

Sandie L Bredemeyer1, Jann P Foster2

1Perinatal Nursing, Centre for Nursing & Midwifery Research, RPA Women and Babies, School of Nursing, University of Sydney,

Sydney, Australia. 2Faculty of Medicine, Central Clinical School - Discipline of Obstetrics, Gynaecology & Neonatology„ University

of Sydney, Camperdown, Australia

Contact address: Sandie L Bredemeyer, Perinatal Nursing, Centre for Nursing & Midwifery Research, RPA Women and Babies, School

of Nursing, University of Sydney, Missenden Road, Camperdown, Sydney, NSW, 2050, Australia. [email protected].

Editorial group: Cochrane Neonatal Group.

Publication status and date: New, published in Issue 6, 2012.

Review content assessed as up-to-date: 30 March 2011.

Citation: Bredemeyer SL, Foster JP. Body positioning for spontaneously breathing preterm infants with apnoea. Cochrane Database of

Systematic Reviews 2012, Issue 6. Art. No.: CD004951. DOI: 10.1002/14651858.CD004951.pub2.


A B S T R A C T

Background

It has been proposed that the use of body positioning may be a more effective way to reduce clinically significant apnoea than the use

of more invasive measures.

Objectives

To determine the effect of body positioning on cardiorespiratory functioning in spontaneously breathing preterm infants with clinically

significant apnoea.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2011), MEDLINE (1966

to March 2011), EMBASE (1988 to March 2011) and CINAHL (1988 to March 2011), abstracts of conference proceedings and

citations of published articles.

Selection criteria

All studies in which infants or their sequence of body positioning was randomised or quasi-randomised. We included cross-over studies.

Data collection and analysis

We performed assessment of trial quality, data extraction and synthesis of data using standard methods of the Cochrane Neonatal

Review Group.

Main results

Five studies (N = 114) were eligible for inclusion. None of the individual studies or the meta-analyses showed a reduction in apnoea,

bradycardia, oxygen desaturation or oxygen saturation with body positioning (supine versus prone; prone versus right lateral; prone

versus left lateral; right lateral versus left lateral; prone horizontal versus prone head elevated; right lateral horizontal versus right lateral

head elevated and left lateral horizontal versus left lateral head elevated).

1Body positioning for spontaneously breathing preterm infants with apnoea (Review)


mailto:[email protected]

Authors’ conclusions

There is insufficient evidence to determine the role of body positioning on apnoea, bradycardia, oxygen desaturation and oxygen

saturation. Large randomised controlled trials are needed to determine the effect of body positioning on cardiorespiratory function in

spontaneously breathing preterm infants.

P L A I N L A N G U A G E S U M M A R Y

Body position and apnoea in the preterm infant

Apnoea is a condition in which an infant stops breathing. Apnoea is rare in infants born at term but the incidence increases with

decreasing gestational age. Apnoea is generally thought to be a normal occurrence in the well preterm infant. However, the long term

effects of frequent apnoea that lead to lower oxygen levels in unwell preterm infants remain unknown. In addition, there is little

agreement about what degree of apnoea is acceptable. It has been proposed that body position can prevent apnoea. Therefore, the

purpose of this review was to see if different body positions could prevent apnoea. The review authors searched the medical literature

and identified five eligible studies that recruited a total of 114 infants. We found no clear evidence that any one body position is

effective. This review is unable to recommend the use of one body position over another due to a lack of evidence.

B A C K G R O U N D

Description of the condition

Apnoea is usually considered a normal maturational process with

no long term pathological significance. While it can occur in

preterm infants in the absence of any obvious clinical problem, it

may also occur in conjunction with temperature instability, infec-

tion, intraventricular haemorrhage and following respiratory dis-

tress syndrome (Henderson-Smart 1995). The clinical significance

and long term consequences of frequent apnoea, bradycardia and

episodes of oxygen desaturation remain unknown. Uncomplicated

recurrent apnoea in the preterm infant is not independently asso-

ciated with adverse neurological outcomes such as cerebral palsy

and developmental delay (Tudehope 1986; Levitt 1988; Koons

1993). However, it is unknown what degree of hypoxia might be

harmful and whether more severe apnoea associated with recurrent

episodes of hypoxia is associated with adverse neurodevelopment

outcomes.

There is no consensus on when apnoea should be treated, or what

frequency or severity of apnoea is acceptable. Management of ap-

noea includes appropriate administration of supplemental oxygen,

(assisted ventilation if necessary), administration of methylxan-

thines to stimulate breathing, and utilisation of body positioning

and alignment techniques that will not compromise airway pa-

tency.

Continuous positive airway pressure (CPAP) is often used to facil-

itate extubation and provides a non-invasive and effective method

of respiratory support in the management of apnoea of prematurity

(Davis 2003). However, nasal CPAP requires more nursing care

and equipment, is costly and may interfere with maternal infant in-

teraction. The administration of methylxanthines such as caffeine

have potential short term complications such as irritability, feed

intolerance, gastric irritation and tachycardia (Henderson-Smart

2010).

Clinical apnoea is defined as a cessation of breathing for more

than 20 seconds or a shorter pause associated with a fall in heart

rate (bradycardia) or lack of oxygen (cyanosis) (AAP 2003). This

describes a threshold for apnoea that is most likely to identify clin-

ically significant events. In addition to respiratory rate, heart rate

and oxygen saturation are monitored to provide additional infor-

mation about the immediate effects of apnoea and the possible

need for intervention and further management.

There are three types of apnoea, central, mixed and obstructive.

Most short apnoea (less than 20 seconds in duration) are central

in type, while longer events frequently have an obstructive phase

as well and are described as mixed apnoea (Henderson-Smart

1995). In mixed apnoea, respiratory efforts resume after a central

apnoea but there is no airflow for a number of breaths as a result

of upper airway obstruction (Butcher-Puech 1985; Ruggins 1991;

Finer 1992). Obstructive apnoea is less common and usually only

observed in infants with upper airway abnormalities or infants with

rare brainstem anomalies such as Dandy-Walker malformations

(Henderson-Smart 1995).

The incidence of apnoea is inversely correlated with birth weight

(Daily 1969; Alden 1972) and gestational age (Henderson-Smart

1981; Tudehope 1984; Eichenwald 1997) and is considered rare



in infants born at term. The incidence of apnoea between 34 to 35

weeks gestation is 7% increasing to 54% between 30 to 31 weeks

gestation (Henderson-Smart 1981). In this same study, the high

mortality rate of extremely preterm infants born before 30 weeks

gestation limited the number of infants observed: however, the

incidence of apnoea was about 80% (Henderson-Smart 1981).

Description of the intervention

Whether the use of non-prone body positions in the management

of the spontaneously breathing preterm infant with recurrent ap-

noea can compromise physiological stability is an important clin-

ical question. Thus, we were interested in reviewing body posi-

tioning, when positioning was used with the primary intention of

affecting apnoea.

Use of developmental positioning (intermittent use of the prone,

side-lying and supine positions with spinal flexion and limbs

placed to midline) compared with the predominant use of prone

or supine positioning, has been advocated to prevent motor ab-

normalities and improve developmental outcomes in the preterm

infant (Anderson 1984; Updike 1986; Fay 1988). In addition, ver-

tical ’tilting’ of infants so that their upper body is higher (for ex-

ample, 10 to 15 degrees) than their lower body, has been reported

to improve oxygenation in neonates (Thoresen 1988).

While healthy infants (preterm and term) should be placed on

their backs (supine) well before discharge to reduce the risk of

sudden infant death syndrome (SIDS), the use of alternative posi-

tions in preterm infants with apnoea may be beneficial during ac-

tive management of apnoea. When infants are placed in alternate

positions (stomach or prone and side-lying or lateral), the reasons

should be explained to the parents. As apnoea of prematurity re-

solves and infants mature, they should exclusively be placed on

their back (supine), in preparation for care at home (Ward-Platt

2000; Fleming 2003; Platt 2003).

How the intervention might work

Placement of preterm infants so that they lie on their stomach

(prone), rather than on their back (supine), can improve oxygena-

tion and ventilation (Martin 1979a), lower rates of energy expen-

diture (Masterson 1987) and increase time in quiet sleep (Martin

1979b). There have also been physiological studies to strongly sug-

gest a plausible link between change in body position and alter-

ation in the work of breathing for preterm infants (Wolfson 1992).

It has been postulated that use of the prone position increases the

curvature of the diaphragm (Wolfson 1992). During inspiration

this results in more effective contraction of the diaphragm thus de-

creasing the work of breathing. This effect may be age related, that

is it may be more apparent in the extremely preterm infant where

incomplete ossification of the rib cage, increased compliance of

the chest wall and a flattened diaphragm may further reduce lung

volumes and functional residual capacity. It has been proposed

that tilting of the neonate’s upper body improves ventilation of

the lower segments of the lungs and also improves ventilation/

perfusion matching (Stark 1984).

Why it is important to do this review

Effective use of body position is a non-invasive procedure that,

when skilfully implemented, can provide comfort and contain-

ment and can facilitate interaction between the infant and par-

ents. If body positioning can reduce clinically significant apnoea,

then the use of more invasive measures to control apnoea may be

reduced. This would have a clinically important impact on opti-

mal management of preterm infants with apnoea. In a systematic

review of body position in infants receiving mechanical ventila-

tion, there was no evidence of sustained improvements in clini-

cally relevant outcomes despite a slight improvement in oxygena-

tion (Balaguer 2006). A Cochrane review found the prone posi-

tion to be significantly superior to the supine position in terms

of oxygenation. However, most of the participants were ventilated

preterm infants, and the authors concluded that the benefits of

prone positioning may be most relevant to these infants (Gillies

2005). To further inform clinical practice it is important to know

whether choice of body position has any benefits or harms in the

spontaneously breathing preterm infant.

O B J E C T I V E S

To determine the effect of body positioning on cardiorespiratory

function in spontaneously breathing preterm infants with clini-

cally significant apnoea.

Subgroup analyses

The effect of body positioning on the spontaneously breathing

preterm infant with apnoea will be examined in the following

subgroups:

1. gestational age < 28 weeks or less than 1000 grams;

2. infants with apnoea managed with methylxanthines;

3. infants with frequent apnoea (> 10 events per day);

4. by type of apnoea measured (central, mixed and

obstructive).

M E T H O D S

Criteria for considering studies for this review



Types of studies

Randomised or quasi-randomised trials, including cross-over trials

were eligible.

Types of participants

Spontaneously breathing preterm infants (not receiving any res-

piratory support apart from oxygen therapy) less than 37 weeks

gestational age with apnoea of prematurity, with or without man-

agement using methylxanthines.

Types of interventions

The following positions will be compared:

• supine versus prone (lying on back versus lying on front);

• supine versus right lateral (lying on back versus lying on

right side);

• supine versus left lateral (lying on back versus lying on left

side);

• prone versus right lateral (lying on front versus lying on

right side);

• prone versus left lateral (lying on front versus lying on left

side);

• right versus with left lateral (lying on right side versus lying

on left side).

Horizontal (flat) versus head elevated positions will be analysed

separately for all body positions:

• prone horizontal versus prone head elevated;

• supine horizontal versus supine head elevated;

• right lateral horizontal versus right lateral head elevated;

• left lateral horizontal versus left lateral head elevated.

Types of outcome measures

Primary outcomes

1. Episodes of apnoea - defined as a cessation of breathing for

more than 20 seconds or a shorter pause associated with

bradycardia or cyanosis (AAP 2003).

2. Episodes of bradycardia - defined as a fall in heart rate of

more than 30% below the baseline or less than 100 beats per

minute for greater than or equal to ten seconds.

3. Episodes of oxygen desaturation - defined as a spontaneous

fall in SpO2 ≤ 85% for longer than or equal to ten seconds in

duration.

Secondary outcomes

1. Episodes of severe apnoea - defined as a cessation of

breathing and a fall in heart rate more than 30 per cent below the

baseline or less than 100 beats per minute for greater than or

equal to ten seconds and a concurrent fall in SpO2 ≤ 85%.

2. Episodes of severe bradycardia - defined as a fall in heart

rate of more than 30% below the baseline (for greater than or

equal to ten seconds) and a concurrent fall in SpO2 ≤ 85%.

3. Type of apnoea measured in each body position (central,

mixed or obstructive).

4. Addition of assisted ventilation (IPPV and nCPAP).

5. Need for commencement of methylxanthines.

6. Complications associated with body position e.g. skin

breakdown.

7. Parental stress with type of body position using a validated

scale (e.g. Parental Stressor Scale: Neonatal Intensive Care Unit)

analysed during the intervention and remainder of hospital stay.

8. Duration of assisted ventilation (IPPV and nCPAP) (days).

9. Duration of use of methylxanthines (days).

10. Length of stay in hospital (days).

To be measured at follow-up:

1. short term motor development up to about 12 months

corrected age, as measured by a validated assessment tool;

2. longer term motor development up to about two years

corrected age, as measured by a validated assessment tool;

3. neurodevelopment assessed at about two years corrected

age, as measured by a validated assessment tool.

Search methods for identification of studies

Electronic searches

See Neonatal Collaborative Review Group search strategy. We

used the standard search strategy of the Neonatal Review Group

as outlined in The Cochrane Library. This included searches of

electronic databases: the Cochrane Central Register of Controlled

Trials (CENTRAL, The Cochrane Library to March 2011), MED-

LINE (1966 to March 2011), EMBASE (1988 to March 2011)

and CINAHL (1982 to March 2011). We searched for clinical tri-

als using the text terms apnoea OR apnea, bradycardia, body po-

sition OR position, supine, prone, lateral, side-lying, upright, tilt-

ing, preterm OR prematur*.mp OR infant*.mp OR newborn.mp

OR neonat*.mp.

Searching other resources

We examined the references in all studies identified as potentially

relevant. We searched the abstracts from the annual meetings of

the Pediatric Academic Societies (1993 to 2011), the European So-

ciety for Pediatric Research (1995 to 2011), the UK Royal College

of Paediatrics and Child Health (2000 to 2011) and the Perinatal

Society of Australia and New Zealand (2000 to 2011). No new

trials were identified. Clinical trials registries were also searched



for ongoing or recently completed trials (clinicaltrials.gov; con-

trolledtrials. com; and who.int/ictrp).

Data collection and analysis

We used the standard systematic review methods of The Cochrane

Collaboration as documented in the Cochrane Handbook for Sys-

tematic Reviews of Interventions (Higgins 2009).

Selection of studies

The review authors independently assessed for inclusion all po-

tential studies identified as a result of the search strategy. At least

two of the review authors examined the title and abstract of each

retrieved study to assess for eligibility. We examined the full paper

if there was any uncertainty. A consensus was reached once the full

article was retrieved and examined. At least two of the reviewers

examined the full article against the selection criteria to determine

the ones appropriate for inclusion in the systematic review.

Data extraction and management

For eligible studies, all of the review authors extracted the data

using an agreed form. We resolved any discrepancies through dis-

cussion. Data were entered into Review Manager software (Review

Manager 2008) and were checked for accuracy by a second review

author. Information was sought from authors if any of the above

was unclear, or if we required authors of the original reports to

provide further details.

Assessment of risk of bias in included studies

Assessment of risk of bias in included studies

All three review authors separately extracted and independently

assessed risk of bias for each study using the criteria outlined in the

Cochrane Handbook for Systematic Reviews of Interventions (Higgins

2009). We resolved any disagreement by discussion.

(1) Sequence generation (checking for possible selection bias)

We described for each included study the method used to generate

the allocation sequence in sufficient detail to allow an assessment

of whether it should produce comparable groups.

We assessed the method as:

adequate (any truly random process, e.g. random number table;

computer random number generator);

inadequate (any non random process, e.g. odd or even date of

birth; hospital or clinic record number); or

unclear.

(2) Allocation concealment (checking for possible selection

bias)

We described for each included study the method used to conceal

the allocation sequence in sufficient detail to determine whether

intervention allocation could have been foreseen in advance of, or

during recruitment, or changed after assignment.

We assessed the methods as:

adequate (e.g. telephone or central randomisation; consecutively

numbered sealed opaque envelopes);

inadequate (open random allocation; unsealed or non opaque en-

velopes, alternation; date of birth); or

unclear.

(3) Blinding (checking for possible performance bias)

We described for each included study the methods used, if any, to

blind study participants and personnel from knowledge of which

intervention a participant received. We judged studies to be at low

risk of bias if they were blinded, or if we considered that the lack

of blinding could not have affected the results.


adequate, inadequate or unclear for participants;

adequate, inadequate or unclear for personnel;

adequate, inadequate or unclear for outcome assessors.

(4) Incomplete outcome data (checking for possible attrition

bias through withdrawals, dropouts, protocol deviations)

We described for each included study, and for each outcome or

class of outcomes, the completeness of data including attrition

and exclusions from the analysis. We stated whether attrition and

exclusions were reported, the numbers included in the analysis at

each stage (compared with the total randomised participants), rea-

sons for attrition or exclusion where reported, and whether miss-

ing data were balanced across groups or were related to outcomes.

We assessed methods as:

adequate (less than 20% missing data);

inadequate;

unclear.

(5) Outcome reporting bias

We described for each included study how we investigated the

possibility of selective outcome reporting bias and what we found.


adequate (where it is clear that all of the study’s prespecified out-

comes and all expected outcomes of interest

to the review have been reported);

inadequate (where not all the study’s pre-specified outcomes have

been reported; one or more reported primary outcomes were not

pre-specified; outcomes of interest are reported incompletely and

so cannot be used; study that failed to include results of a key

outcome that would have been expected to have been reported);

unclear.

(6) Other sources of bias

We described for each included study any important concerns we

have about other possible sources of bias (e.g. early termination of

trial due to data-dependant process, extreme baseline imbalance,

etc). We assessed whether each study was free of other problems

that could put it at risk of bias. We assessed other sources of bias

as:

yes;



no;

unclear.

(7) Overall risk of bias

Each criteria was judged as being at “low risk” of bias, “high risk”

of bias, or “unclear” risk of bias (for either lack of information or

uncertainty over the potential for bias).

Measures of treatment effect

We analysed treatment effects in the individual trials using Review

Manager software (Review Manager 2008).

Dichotomous data

Dichotomous variables were to be analysed using relative risks

(RR) and risk difference (RD) with 95% confidence intervals;

however, none of the eligible studies reported dichotomous data.

Continuous data

All of the outcome data for the included studies were continuous.

We analysed continuous variables using weighted mean difference

and 95% confidence intervals.

Unit of analysis issues

Cross-over trials

We analysed cross-over trials following the recommendations by

Elbourne 2002. These state that use of the cross-over design should

be restricted to situations where there is unlikely to be a carry-over

of treatment effect across periods. We included all of the eligible

cross-over trials in the meta-analysis, however, we assessed and dis-

cussed the likelihood of a carry-over effect from one intervention

to another (e.g. the different body positions). See Risk of bias in

included studies and Other potential sources of bias for further

discussion.

Assessment of heterogeneity

We planned to use RevMan 5 (Review Manager 2008) to assess

the heterogeneity of treatment effects between trials, using the two

formal statistics described below:

1. The Chi2 test for heterogeneity. We intended to calculate

whether statistical heterogeneity was present using the Chi2 test

with a P value of < 0.1 denoting statistical significance. Since this

test has low power when the number of studies included in the

meta-analysis is small, we set the probability at the 10% level of

significance (Higgins 2009).

2. The I2 statistic to ensure that pooling of data was valid. The

impact of statistical heterogeneity was to be quantified using I2

statistics available in Review Manager 2008, which describe the

percentage of total variation across studies due to heterogeneity

rather than sampling error. We graded the degree of heterogeneity

as: 0% to 30%: might not be important; 31 to 50%: moderate

heterogeneity; 51% to 75%: substantial heterogeneity; 76% to

100%: considerable heterogeneity.

If there was evidence of apparent or statistical heterogeneity, we

intended to assess the source of the heterogeneity using sensitivity

and subgroup analysis looking for evidence of bias or methodolog-

ical differences between trials.

Assessment of reporting biases

Funnel plots to identify publication bias were not examined due

to insufficient number of trials.

Data synthesis

We carried out statistical analyses using the RevMan 5 (Review

Manager 2008). Ideally, we would have used first period data from

the cross-over trials and combined these with data from parallel

studies. Elbourne 2002 recommends “the results of two or more

cross-over trials might be combined, but with this pooled result

kept separate from the data from parallel group trials”. However,

we were not able to obtain first period data for any of the included

cross-over studies. In addition, there were no eligible parallel trials

and, therefore, only cross-over design trials were meta-analysed.

We used fixed-effect inverse variance meta-analysis for combining

data where trials were examining the same intervention, and the

trial populations and methods were judged similar. If there was

insufficient similarity of populations, interventions and methods,

meta-analysis was not used.

Subgroup analysis and investigation of heterogeneity

The following subgroup analyses were planned:

1. gestational age < 28 weeks or less than 1000 grams;

2. infants with apnoea managed with methylxanthines;

3. infants with frequent apnoea (> 10 events per day);

4. by type of apnoea measured (central, mixed and

obstructive).

Subgroup analyses were not performed because data were unavail-

able.

If possible, subgroup analysis for postnatal age of infants will be

included in future updates of this review .

R E S U L T S

Description of studies

See: Characteristics of included studies; Characteristics of excluded

studies.

See: Characteristics of included studies table and Characteristics

of excluded studies table.



Results of the search

Our search strategy identified five small eligible cross-over trials

(N = 114) of body position for spontaneously breathing preterm

infants with apnoea (Bredemeyer 1992 (N = 21); Bredemeyer 2004

(N = 45); Heimler 1992 (N = 14); Jenni 1997 (N = 12); Keene

2000 (N = 22)).

Included studies

Population

All infants enrolled in these trials were spontaneously breathing

preterm infants less than 37 weeks gestation. Bredemeyer 1992

studied infants < 34 weeks gestation (mean gestation 28.3 weeks),

Bredemeyer 2004 studied infants < 33 weeks (median gestational

age 27 weeks), Heimler 1992 studied infants < 37 weeks gestation

(range 26 to 36 weeks, mean 29.7 weeks), Jenni 1997 studied

infants < 32 weeks (range 26 to 31 weeks, mean 28 weeks) and

Keene 2000 studied infants < 34 weeks (range 24 to 30 weeks, 26.9

weeks). There was a wide range of postnatal ages of the infants at

the time of enrolment in each of the trials (range 3 to 77 days). One

trial (Keene 2000) reported time of enrolment at postconceptual

age (range 28 to 36 weeks).

Interventions

All included studies were cross-over trials with alternating periods

in the different body positions. Heimler 1992 used a two-period

cross-over trial with each body position (supine or prone) stud-

ied over a 12 hour period, for two consecutive nights. Jenni 1997

used a multiple cross-over trial with the body position (prone hor-

izontal or prone elevated) changed every six hours for 48 hours.

Keene 2000 used a multiple cross-over trial with the body po-

sition (supine or prone) changed every six hours for 24 hours.

Bredemeyer 1992 used a multiple cross-over trial with the body

position (prone one, prone two, left lateral or right lateral) changed

every three hours for 48 hours. Bredemeyer 2004 also used a multi-

ple cross-over trial with the body position (prone horizontal, prone

elevated, right lateral one and two, or left lateral one and two)

changed every four hours. For further details see Other potential

sources of bias.

Major outcomes assessed

Four trials (Bredemeyer 1992; Heimler 1992 Keene 2000;

Bredemeyer 2004) reported outcomes for episodes of apnoea.

Bredemeyer 1992 and Bredemeyer 2004 defined apnoea as cessa-

tion of breathing for greater than 20 seconds or cessation of breath-

ing for less than 20 seconds if associated with a fall in heart rate of

greater than 30% below the baseline. Frequency was determined

by counting the number of apneic events in each body position.

Keene 2000 defined episodes of apnoea as total number (≥ 10

seconds); mild (< 15 seconds) and clinically significant (≥ 15 sec-

onds). Only the clinically significant definition of apnoea (e.g. ≥

15 seconds) was used in the meta-analysis. In contrast, Heimler

1992 defined apnoea as cessation of breathing for ≥ six seconds;

cessation of breathing for 11 to 15 seconds; cessation of breathing

for ≥ 15 seconds. Only the latter definition of apnoea was used

in the meta-analysis as these are more closely aligned with our a

priori primary outcome measure.

Bredemeyer 2004 was the only study to report outcomes for severe

apnoea which was defined as cessation of breathing and a fall in

heart rate of more than 30% below the baseline and a concurrent

fall in oxygen saturation to less than 85%.

The studies that examined the outcome of bradycardia used dif-

ferent definitions. Bredemeyer 2004 defined bradycardia as a fall

in heart rate of greater than 30% below the baseline associated

with a significant fall in oxygen saturation of greater than 10% and

an alteration in respiratory pattern suggesting decreased respira-

tory efforts, as determined by counting the number of bradycardia

events in each body position. Heimler 1992 defined bradycardia as

a fall in heart rate to less than 100 beats / minute for ≥ 5 seconds.

Jenni 1997 defined bradycardia as a decrease in heart rate < 90

beats per minute. Bradycardia was defined by Keene 2000 as the

total number of episodes of bradycardia (< 100 beats per minute);

mild (90 to 99 beats per minute) and clinically significant (< 90

beats per minute). We used the data from the latter definition in

the meta-analysis.

Two studies (Jenni 1997; Bredemeyer 2004) measured severe

bradycardia but used slightly different definitions. Bredemeyer

2004 defined severe bradycardia as a fall in heart rate of more than

30% below the baseline for greater than or equal to 10 seconds

and a concurrent fall in oxygen saturation to less than 85%. Jenni

1997 defined severe bradycardia as a fall in heart rate < 90 beats

per minute and a concurrent decrease in oxygen saturation of less

< 80%.

Three of the studies used the outcome ’episodes of oxygen de-

saturation’. Bredemeyer 2004 defined oxygen desaturation as the

number of episodes where oxygen saturation fell to less than 85%

for a duration of greater than 10 seconds when not associated with

an apnoea or bradycardia. Keene 2000 defined oxygen desatura-

tion as total number of oxygen saturations < 90%; mild (80 to

90%) and clinically significant (< 80%). For the meta-analysis we

used data in the < 80% oxygen saturation group. Jenni 1997 also

defined oxygen desaturation as < 80%.

Excluded studies

There were seven excluded studies (Dellagrammaticas 1991;

Kurlak 1994; Pichler 2001; Bhat 2003; Nimavat 2006; Reher

2008). See Characteristics of excluded studies table.

Risk of bias in included studies



Details of the methodological quality of each trial are given in

the Characteristics of included studies table and Risk of bias in

included studies table’

Allocation

All studies had adequate sequence generation. Allocation conceal-

ment for the Heimler 1992, Jenni 1997 and Keene 2000 studies

was unclear and we were unable to gain any further information.

Blinding

There was a high risk of performance and detection bias in the

Bredemeyer 1992, Keene 2000 and Bredemeyer 2004 studies.

There was also a high risk of performance bias in the Jenni 1997

study, however, there was adequate concealment of the allocated

interventions by the outcome assessors. There was a low risk of

performance bias in the Heimler 1992 study, but there was inad-

equate information to assess detection bias.

Incomplete outcome data

There were no losses to follow-up in any of the included studies.

Selective reporting

There was a low risk of reporting bias in the Bredemeyer 1992 and

Bredemeyer 2004 studies. There was an unclear risk of reporting

bias in the other studies as we were unable to obtain further infor-

mation or the study protocols.

Other potential sources of bias

In the Heimler 1992 study even though infants were assigned to

the supine position, the infant was nursed prone for one hour

after feeds to ’prevent aspiration’. This may have influenced the

outcome measure of apnoea during this period because both the

supine group and prone group were in the prone position one

hour post feed.

It is important that a “washout period” is used in cross-over tri-

als where there is potential for a carry-over effect from one treat-

ment period to the next. There was no “washout period” in the

Bredemeyer 1992, Jenni 1997, Keene 2000 and Bredemeyer 2004

studies. There was a change almost immediately from one inter-

vention (body position) to another. Heimler 1992 reported a 12-

hour “wash-out” period between each of the interventions (body

positions) thus decreasing the possibility of a cross-over effect from

one intervention (body position) to another.

Effects of interventions

Supine versus prone (Comparison 1)

Meta-analysis (Heimler 1992; Keene 2000, 36 infants) found no

significant difference for apnoea (MD 1.09, 95% CI 0.65 to 2.82).

The Chi2 test found moderate heterogeneity (I2 = 61%), but was

not statistically significant (P = 0.11). However, potential explana-

tion for the heterogeneity could be due to the different gestational

ages of the infants in the two studies. One study (Keene 2000)

found no significant difference for oxygen desaturation (MD 0.80,

95% CI 3.19 to 4.79) and meta-analysis (Heimler 1992; Keene

2000, 36 infants) found no significant difference for bradycardia

(MD -0.13, 95% CI -3.20 to 2.94). Severe bradycardia or severe

apnoea were not assessed.

Prone versus right lateral (Comparison 2)

Meta-analysis (Bredemeyer 1992; Bredemeyer 2004, 65 infants)

found no significant difference for apnoea (MD 0.48, 95% CI -

0.19 to 1.15). One study (Bredemeyer 2004) found no significant

difference for oxygen desaturation (MD -1.86, 95% CI -4.29 to

0.56), severe apnoea (MD 0.05, 95% CI -0.45 to 0.54), brady-

cardia (MD -0.59, 95% CI -2.41 to 1.23) and severe bradycardia

(MD -0.32, 95% CI -1.02 to 0.39).

Prone versus left lateral (Comparison 3)


found no significant difference for apnoea (MD 0.20, 95% CI -

0.75 to 1.15). One study (Bredemeyer 2004) found no significant

difference for oxygen desaturation (MD -1.44, 95% CI -3.81 to

0.92), severe apnoea (MD 0.11, 95% CI -0.38 to 0.60), brady-

cardia (MD -0.17, 95% CI -0.94 to 0.60) and severe bradycardia

(MD -0.22, 95% CI 0.94 to 0.49).

Right lateral versus left lateral (Comparison 4)


found no significant difference for apnoea (MD -0.27, 95% CI

-1.10 to 0.57). One study (Bredemeyer 2004, 45 infants) found

no significant difference for oxygen desaturation (MD 0.42, 95%

CI -2.42 to 3.26), severe apnoea (MD 0.01, 95% CI -0.40 to

0.42), bradycardia (MD 0.42, 95% CI -1.43 to 2.27) and severe

bradycardia (MD 0.09, 95% CI -0.68 to 0.87).

Prone horizontal with prone head elevated (Comparison 5)


found no significant difference for apnoea (MD -0.18, 95% CI -

1.09 to 0.73). Meta-analysis (Jenni 1997; Bredemeyer 2004, 56

infants) found no significant difference for oxygen desaturation

(MD -0.62, 95% CI -2.81 to 1.56). The Chi2 test found moderate

heterogeneity (I2 = 68%), but was not statistically significant (P =

0.08). One study (Bredemeyer 2004) found no significant differ-

ence for severe apnoea (MD -0.24, 95% CI -0.83 to 0.35). Meta-

analysis of two studies (Jenni 1997; Bredemeyer 2004, 56 infants)

found no significant difference for bradycardia (MD -0.14, 95%

CI -1.03 to 0.74) or severe bradycardia (MD -0.28, 95% CI -1.15

to 0.59).

Right lateral horizontal versus right lateral head elevated

(Comparison 6)



One study (Bredemeyer 2004) found no significant difference for

apnoea (MD -0.79, 95% CI -2.26 to 0.69), oxygen desaturation

(MD 0.03, 95% CI -3.06 to 3.11), severe apnoea (MD -0.14,

95% CI -0.69 to 0.41), bradycardia (MD 0.34, 95% CI 1.54 to

2.22) or severe bradycardia (MD 0.60, 95% CI -0.25 to 1.46).

Left lateral horizontal versus left lateral head elevated (Com-

parison 7)

One study (Bredemeyer 2004) found no significant difference for

apnoea (MD 0.46, 95% CI -0.34 to 1.26), oxygen desaturation

(MD 0.63, 95% CI -2.09 to 3.35), severe apnoea (MD 0.18, 95%

CI -0.18 to 0.54), bradycardia (MD 0.08, 95% CI -0.71 to 0.88)

or severe bradycardia (MD -0.17, 95% CI -0.93 to 0.58).

There were no studies comparing: supine versus right lateral,

supine versus left lateral, supine horizontal with supine elevated.

The primary outcome oxygenation, and the secondary outcomes:

type of apnoea measured in each body position (central, mixed or

obstructive), addition of assisted ventilation (IPPV and nCPAP),

addition of methylxanthines, complications associated with body

position, e.g. skin breakdown, parental satisfaction with type of

body position, duration of assisted ventilation (IPPV and nCPAP)

(days), duration of use of methylxanthines (days) and length of

stay in hospital (days), were not assessed in any of the included

studies.

D I S C U S S I O N

Eleven studies were identified (N = 114). Six were excluded (

Dellagrammaticas 1991; Kurlak 1994; Pichler 2001; Bhat 2003;

Nimavat 2006; Reher 2008) and five studies (Bredemeyer 1992;

Heimler 1992; Jenni 1997; Keene 2000; Bredemeyer 2004) were

included in these meta-analyses.

Overall, none of the individual studies nor the meta-analyses

showed a difference in the cardiorespiratory outcomes for supine

versus prone; prone versus right lateral; prone versus left lateral;

right lateral versus left lateral; prone horizontal versus prone head

elevated; right lateral horizontal versus right lateral head elevated

or left lateral horizontal versus left lateral head elevated.

All five included studies only had small sample sizes and most of

the meta-analyses only included one or two studies. There were

no studies investigating supine versus right lateral, supine versus

left lateral or supine horizontal versus supine elevated. None of

the secondary outcomes were investigated in any of the included

studies.

Summary of main results

Overall, there was insufficient evidence to determine the role of

body position on apnoea, bradycardia, oxygen desaturation and

oxygen saturation in preterm infants.

Overall completeness and applicability ofevidence

The largest analysis included only 66 infants suggesting an inability

to determine a moderate effect on any of the outcome measures.

Quality of the evidence

The limitations of the studies included in this review were their

small sample sizes (the five eligible trials included only 114 infants

in total), and the use of the cross-over design which removes the

ability to measure effects on late outcomes, e.g. long term neurode-

velopment. It is possible that the order in which treatments were

administered may have affected the outcome. Also, there may have

been a “carry-over” effect from one position to another because of

an absence of a “wash-out” period between the treatments in all

but one of the studies.

The allocation concealment was either inadequate or unclear in

all of the studies. See also Risk of bias in included studies.

Potential biases in the review process

We were unable to obtain first period data from the authors of any

of the cross-over trials.

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

Overall, there is insufficient evidence to determine the role of

body positioning on apnoea, bradycardia, oxygen desaturation and

oxygen saturation in preterm infants.

None of the trials reported complications or adverse effects relating

to the use of the supine, prone or lateral body positions. In all

of the studies the infants were only placed in each body position

for a short duration (three to 12 hours). Therefore, long term

effects associated with prolonged use of any body position such

as flattened posture, high extensor tone or head shape were not

reported.

It must be emphasised, however, that healthy preterm infants when

no longer monitored for apnoea of prematurity should be placed

supine well before discharge from the NICU because of the risk

of SIDS (Fleming 2003).

Implications for research

There is insufficient evidence to determine the role of body posi-

tioning in the management of the preterm infant. The benefit or

harm of one body position over another cannot be assured due to

the small numbers and weakness of the study designs. Therefore



large randomised control trials are needed to determine the ef-

fect of body positioning on cardiorespiratory function in sponta-

neously breathing preterm infants.

A C K N O W L E D G E M E N T S

We would like to thank Emeritus Professor David Henderson-

Smart for his invaluable support and substantial contribution to

this review.

We would also like to thank the Australasian Satellite of the

Cochrane Neonatal Group for supporting the development of this

review.

R E F E R E N C E S

References to studies included in this review

Bredemeyer 1992 {published data only}

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of apnoea in the preterm neonate. Midwifery Matters 1992;

6(4):7–10.

Bredemeyer 2004 {unpublished data only}

Bredemeyer S. Effect of body position on frequency of apnoea

in the preterm neonate [PhD thesis]. Sydney: University of

Sydney, 2004.

Heimler 1992 {published data only (unpublished sought but not used)}

Heimler R, Langlois J, Hodel DJ, Nelin LD, Sasidharan P.

Effect of positioning on the breathing pattern of preterm

infants. Archives of Disease in Childhood 1992;67(3):312–4.

Jenni 1997 {published data only}

Jenni OG, von Siebenthal K, Wolf M, Keel M, Duc G,

Bucher HU. Effect of nursing in the head elevated tilt

position (15 degrees) on the incidence of bradycardic and

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Keene 2000 {published data only}

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positioning increase apnoea, bradycardia, and desaturation

in preterm infants?. Journal of Perinatology 2000;20(1):

17–20.

References to studies excluded from this review

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S, Greenough A. Effect of posture on oxygenation, lung

volume, and respiratory mechanics in premature infants

studied before discharge. Pediatrics 2003;112(1):29–32.

Dellagrammaticas 1991 {published data only}

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in stable very low birthweight neonates. Archives of Diseases

in Childhood 1991;66:429–32.

Heimann 2010 {published data only}

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Nimavat 2006 {unpublished data only}

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C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of included studies [ordered by study ID]

Bredemeyer 1992

Methods Randomised cross-over study design

Participants Eligibility for the study:

• preterm infants < 34 weeks gestation

• 3 or more episodes of clinical apnoea not associated with feeds

• not receiving assisted ventilation including nasal CPAP

• if treated with theophylline a stable regime was necessary for at least 48 hours

prior to entry to the study

• treatment that did not preclude posturing in the appropriate positions

• no evidence of an intercurrent illness known to be associated with apnoea

• informed consent was obtained

Sample size: 21 infants

Mean birth weight: 1220 grams

Mean gestation: 28.3 weeks

Mean age at entry to the study: 25.6 days

Range of days to entry in the study: 5-60 days

Interventions The prone position was designated as the control group

The right and left lateral body positions were designated as the experimental group. All

infants received all interventions

Body position was changed every 3 hours with each infant spending 12 hours in each

body position - prone one, prone two, left lateral and right lateral (over a 48 hour

recording period). Polygraph recordings were used to record apneic events

Outcomes Episodes of apnoea were defined as cessation of breathing for greater than 20 seconds

or cessation of breathing for less than 20 seconds if associated with a fall in heart rate

of greater than 30% below the baseline. Frequency was determined by counting the

number of apneic events in each body position

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk Randomised cross-over study design

Allocation concealment (selection bias) Low risk Prior to commencement of the study each subject

was ’randomly assigned’ to a sequence 1, 2, 3 or

4. The prone and lateral positions were allocated

using a Latin Square



Bredemeyer 1992 (Continued)

Blinding (performance bias and detection

bias)

All outcomes

High risk Blinding of the intervention was not possible.

Possibility of detection bias due to knowledge

of the allocated interventions by the outcome

assessor

Incomplete outcome data (attrition bias)

All outcomes

Low risk No missing outcome data. However, authors

stated when motion artefact was identified, these

data were not included in the analysis

Selective reporting (reporting bias) Low risk The study was undertaken as per protocol

Other bias High risk Carry-over of treatment effect

It is possible that the order in which the interven-

tions were administered may have affected the

outcomes. There was no “wash-out” period be-

tween the interventions

Bredemeyer 2004


Participants Eligibility for the study:

• preterm infants < 34 weeks gestation

• clinically stable

• established enteral feeding to at least 90 ml/kg/day

• history of recurrent apnoea with at least 3 clinical events documented during the

previous 24 hours

• not receiving assisted ventilation including nasal CPAP

• if treated with caffeine a stable regime was necessary for at least 24 hours prior to

entry to the study

• treatment that did not preclude posturing in the appropriate positions

• no evidence of an intercurrent illness known to be associated with apnoea

• informed consent was obtained

Sample size: 45 infants

Median birth weight: 1100 grams (600-2100 grams)

Median gestation: 27 weeks (24-33 weeks)

Median age at entry to the study: 22.5 days

Range of days to entry in the study: 3-77

Interventions Six body positions were utilised - prone one and two, right lateral one and two and left

lateral one and two. When in position one the infant was placed in a horizontal or flat

position and in position two the infant’s position was elevated on a mattress at a 15

degree angle

Each subject spent 4 hours in each body position - prone one (horizontal or flat), prone

two (elevated), left lateral one, left lateral two and right lateral one and right lateral two

over a 28 hour recording period. Polygraph recordings were used to record frequency

and duration of apnoea, bradycardia and desaturation events




Outcomes Episodes of apnoea. Apnoea was defined as cessation of breathing for greater than 20

seconds or a fall in heart rate (bradycardia) of more than 30% below the baseline when

associated with shorter periods of apnoea that is less than 20 seconds

Episodes of apnoea with bradycardia and desaturation (severe apnoea) was defined as

cessation of breathing and a fall in heart rate of more than 30% below the baseline and

a concurrent fall in oxygen saturation to less than 85%

Episodes of bradycardia. Bradycardia was defined as a fall in heart rate of more than

30% below the baseline for greater than or equal to 10 seconds when associated with an

uncertain or indeterminate respiratory trace

Episodes of severe bradycardia. Severe bradycardia was defined as a fall in heart rate

of more than 30% below the baseline for greater than or equal to 10 seconds and a

concurrent fall in oxygen saturation to less than 85%

Episodes of oxygen desaturation. Oxygen desaturation was defined as the number of

episodes where oxygen saturation fell to less than 85% for a duration of greater than 10

seconds when not associated with an apnoea or bradycardia. The total time (minutes)

each infant spent with an oxygen saturation less than 85% in each body position was

also documented

All or combined events (apnoea and bradycardia) all episodes of apnoea and bradycardia

that met the above definitions

Notes

Risk of bias



bias)


Allocation concealment (selection bias) Low risk Prior to commencement of the study each subject

was ’randomly assigned’ to a sequence 1, 2, 3,

4, 5 or 6. The six body positions were allocated

using a Latin Square


bias)

All outcomes


Possibility of detection bias due to knowledge

of the allocated interventions by the outcome

assessor - no information provided


All outcomes

Low risk Of the 45 infants who entered the study there

were 9 infants whose data were incomplete due

to ’computer downloads that were not correctly

saved, and were unable to be recovered’. Each of

these 9 infants had one position (four hours) of

lost data resulting in missing values sufficient to

confound the multivariate analyses. This left a

cohort of 36 infants who completed the study

protocol with complete data sets. Authors state




when motion artefact was identified, these data

were not included in the analysis

Selective reporting (reporting bias) Low risk The study was undertaken as per protocol




outcomes. There was no “wash-out” period be-


Heimler 1992


Participants Sample size: 14

Gestational age at birth: 29.7 weeks (range 26-36 weeks)

Postnatal age: 7-59.5 days

Weight: 1270-2250 grams

Infants did not receive supplemental oxygen or respiratory support at the time of the

study. All infants were receiving enteral feeds

Eight (57%) of the infants received maintenance methylxanthines

Exclusion: Infants with bronchopulmonary dysplasia

Interventions Supine versus prone position

Each infant had consecutive nocturnal studies, one in prone and one in the supine

position. Infants were monitored for 12 hours and spent the majority of study time in

the assigned position

No attempt was made to keep the head in the midline position

The breathing pattern, nasal airflow, respiratory effort, heart rate and oxygen saturation

were studied by a cardiorespirogram (pneumogram) and recorded on a multichannel

recorder

Episodes of obstructive or mixed apnoea ≥ six seconds were counted manually by one

of the investigators who was blinded to the body position in use. Episodes of generalised

body movements displayed on the oximeter as an abrupt fall or change in heart rate

pattern without a coincident bradycardia were excluded from the analysis

Outcomes 1. Episodes of apnoea (defined as cessation of breathing for ≥ six seconds)

2. Episodes of apnoea (defined as cessation of breathing for 11-15 seconds)

3. Episodes of apnoea (defined as cessation of breathing for ≥ 15 seconds)

4. Episodes of bradycardia. Bradycardia was defined as a fall in heart rate to less than

100 beats / minute for ≥ 5 seconds

Notes

Risk of bias




Heimler 1992 (Continued)


bias)


Allocation concealment (selection bias) Unclear risk Assigned of position randomised by sealed en-

velopes. No further information supplied


bias)

All outcomes

Low risk “Obstructive or mixed apnoea periods ≥ 6 sec-

onds duration and oxygen desaturation were

counted manually by one of the investigators (JL)

, who was blinded regarding the position during

the recordings.” Possibility of detection bias due

to knowledge of the allocated interventions by

the outcome assessor - no information provided


All outcomes

Low risk All patients completed the study and there were

no losses to follow-up, no treatment withdrawals

and no trial group changes

Selective reporting (reporting bias) Unclear risk Unable to obtain study protocol

Other bias Low risk Carry-over of treatment effect



outcome. There was a 12-hour “wash-out” pe-

riod between each of the interventions

Even though infants were assigned to the supine

position, the infant was nursed prone for one

hour after feeds to ’prevent aspiration’. This may

have influenced the outcome measure of apnoea

during this period because both the supine group

and prone group were both in the prone position

one hour post feed

Jenni 1997


Participants Sample size: 12 neonates

Gestational age at birth: < 32 weeks (range 26-31 weeks)

Mean birth weight: 1145 grams (range 815-1450 grams)

Postnatal age: 6-38 days

History of recurrent apnoea, bradycardic and hypoxaemic events

Spontaneously breathing, although nine infants were treated with aminophylline for

at least 3 days but were within a normal therapeutic range (33 to 76 micromol/L).

Maintenance dose (6 mg/kg) not changed during trial

No underlying disease such as heart disease, intracranial haemorrhage, anaemia or infec-

tion



Jenni 1997 (Continued)

Eight infants were receiving oxygen therapy between 23-32%

Interventions Prone horizontal (flat) versus prone elevated (15 degree tilt)

Continuous long-term recordings of respiration, heart rate, and arterial oxygen satu-

ration were made and stored on IBM computer, model PS/2, by the data acquisition

system CODAS (Keithley, Akron, OH). The total study time was 48 hours. Each infant

remained for a total of 24 hours in each of the two compared positions - the horizon-

tal position (HP, prone, 0 degrees) and horizontal head elevated tilt position (HETP,

prone, 15 degrees). Position was changed every 6 hours for the first day. On the second

day, the sequence of tilt and horizontal position was reversed. The preterm infants were

changed to the tilted position smoothly within a few seconds after routine nursing pro-

cedures. The procedures performed on the baby (e.g. administration of drugs, nursing,

and feeding) were marked in the recordings and noted by the nursing staff. During the

study, each infant was nursed in an incubator). The inspired oxygen fraction and the air

temperature were maintained at constant levels and noted every 2 hours. Document on

gastric residue was performed every 2 hours

Breathing movements were recorded by thoracic impedance pneumography. Skin elec-

trodes were attached on both sides of the chest, and a Hellige Servomed (Freiburg, Ger-

many) respiration monitor was used. Heart rate was monitored using a Hellige Servomed

ECG monitor, and oxygen saturation was recorded using pulse oximetry (Nellcor N-

200, Pleasanton, CA). The sensor was placed on the right foot of each infant

Outcomes Episodes of bradycardia (decrease in heart rate < 90 beats per minute)

Episodes of severe bradycardia. Defined as a decrease in oxygen saturation < 80% and

decrease in heart rate < 90 beats per minute

Episodes of oxygen desaturation (< 80%)

Notes

Risk of bias



bias)


Allocation concealment (selection bias) Unclear risk Infants were ’randomly’ assigned to allocated po-

sition. No further information provided


bias)

All outcomes


“The data were analysed from masked files, and

then the results were combined with the allocated

body position.”


All outcomes


no losses to follow up, no treatment withdrawals





Jenni 1997 (Continued)




outcome. There was no “wash-out” period be-


Keene 2000


Participants Sample size: 22 infants with symptomatic apnoea and bradycardia were enrolled in the

trial but otherwise ’well’

Exclusion: Any condition that precluded them from being placed either prone or supine

(e.g. gastroschisis and meningomyelocoele, respectively). Infants were not studied for at

least 24 hours following extubation or discontinuation of CPAP

Gestational age: < 34 weeks (mean 26.9 ± 1.8 weeks; range 24-30 weeks)

Birth weight: mean 865 ± 235 grams; range 500-1331 grams

Postconceptual age: mean 31.9 ± 3 weeks; range 28-36 weeks

Weight at time of study: mean 1204 ± 391 grams; range 639-2095 grams

Interventions Supine versus prone position

Each infant was studied in 6-hour blocks in a prone and supine position for a continuous

24-hour period. Initial position was randomly assigned, and prone and supine positions

were subsequently alternated. Infants remained in positions with the exception of time

taken for routine assessments and feedings

Infants were placed in the prone position with their face to the side, whereas in the supine

position they were allowed to assume their natural position

Heart rate and respiration were monitored using standard paste-on electrodes connected

to a cardiorespiratory monitor with event-recording capability (Edentec Assurance 2000;

Edentec, Minneapolis, MN). Oxygen saturation was measured with a pulse oximeter

(Nellcor 200; Nellcor, Hayward, CA), which was interfaced with the event-recording

monitor

Outcomes Episodes of apnoea: Apnoea defined as: total number of apnoea (≥ 10 seconds); mild (<

15 seconds); clinically significant (≥ 15 seconds)

Episodes of bradycardia. Bradycardia defined as: total number (< 100 beats per minute)

; mild (90-99 beats per minute); clinically significant (< 90 beats per minute)

Episodes of oxygen desaturation. Oxygen desaturation defined as: total number (< 90%)

; mild (80-90%); clinically significant (< 80%)

Notes

Risk of bias



bias)




Keene 2000 (Continued)

Allocation concealment (selection bias) Unclear risk ’The initial position was randomly assigned’. Not

enough information provided


bias)

All outcomes


No information provided regarding knowledge

of allocated interventions by outcome assessors


All outcomes


no losses to follow up, no treatment withdrawals






outcome. There was no “wash-out” period be-


Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Bhat 2003 Supine and prone positions randomised and the effects of body position on oxygen saturation and respira-

tory mechanics (primary outcomes) were measured in oxygen and non-oxygen dependent preterm infants

prior to discharge. Episodes of apnoea and bradycardia were not documented

Dellagrammaticas 1991 Body positions not randomised

Heimann 2010 Body positions not randomised

Kurlak 1994 Means or standard deviations not reported. Unable to gain further data from author

Nimavat 2006 Published as abstract only. Means or standard deviations not reported. Authors contacted and unable to

gain further data

Pichler 2001 Primary outcomes not relevant

Reher 2008 Infants were receiving nasal CPAP



D A T A A N D A N A L Y S E S

Comparison 1. Supine versus prone

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 Episodes of apnoea 2 72 Mean Difference (IV, Fixed, 95% CI) 1.09 [-0.65, 2.82]

2 Episodes of oxygen desaturation 1 44 Mean Difference (IV, Fixed, 95% CI) 0.80 [-3.19, 4.79]

3 Episodes of bradycardia 2 72 Mean Difference (IV, Fixed, 95% CI) -0.13 [-3.20, 2.94]

Comparison 2. Prone horizontal versus right lateral horizontal


studies

No. of



2 Episodes of oxygen desaturation 1 88 Mean Difference (IV, Fixed, 95% CI) -1.86 [-4.29, 0.56]

3 Episodes of severe apnoea 1 88 Mean Difference (IV, Fixed, 95% CI) 0.05 [-0.45, 0.54]


5 Episodes of severe bradycardia 1 88 Mean Difference (IV, Fixed, 95% CI) -0.32 [-1.02, 0.39]

Comparison 3. Prone horizontal versus left lateral horizontal


studies

No. of









Comparison 4. Right lateral versus left lateral


studies

No. of


1 Episodes of apnoea 2 131 Mean Difference (IV, Fixed, 95% CI) -0.27 [-1.10, 0.57]



4 Episodes of bradycardia 1 89 Mean Difference (IV, Fixed, 95% CI) 0.42 [-1.43, 2.27]

5 Episodes of severe bradycardia 1 89 Mean Difference (IV, Fixed, 95% CI) 0.09 [-0.68, 0.87]

Comparison 5. Prone horizontal with prone head elevated


studies

No. of


1 Episodes of apnoea 2 129 Mean Difference (IV, Fixed, 95% CI) -0.18 [-1.09, 0.73]


3 Episodes of severe apnoea 1 87 Mean Difference (IV, Fixed, 95% CI) -0.24 [-0.83, 0.35]



Comparison 6. Right lateral horizontal versus right lateral elevated


studies

No. of


1 Episides of apnoea 1 86 Mean Difference (IV, Fixed, 95% CI) -0.79 [-2.26, 0.69]


3 Episodes of severe apnoea 1 86 Mean Difference (IV, Fixed, 95% CI) -0.14 [-0.69, 0.41]


5 Episodes of severe bradycardia 1 86 Mean Difference (IV, Fixed, 95% CI) 0.60 [-0.25, 1.46]

Comparison 7. Left lateral horizontal versus left lateral elevated


studies

No. of









Analysis 1.1. Comparison 1 Supine versus prone, Outcome 1 Episodes of apnoea.

Review: Body positioning for spontaneously breathing preterm infants with apnoea

Comparison: 1 Supine versus prone

Outcome: 1 Episodes of apnoea

Study or subgroup Supine ProneMean

Difference WeightMean

Difference

N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Heimler 1992 14 2.3 (3.74) 14 0.4 (0.75) 75.4 % 1.90 [ -0.10, 3.90 ]

Keene 2000 22 4.1 (4.1) 22 5.5 (7.3) 24.6 % -1.40 [ -4.90, 2.10 ]

Total (95% CI) 36 36 100.0 % 1.09 [ -0.65, 2.82 ]

Heterogeneity: Chi2 = 2.58, df = 1 (P = 0.11); I2 =61%

Test for overall effect: Z = 1.23 (P = 0.22)

Test for subgroup differences: Not applicable

-50 -25 0 25 50

Favours Supine Favours Prone

Analysis 1.2. Comparison 1 Supine versus prone, Outcome 2 Episodes of oxygen desaturation.



Outcome: 2 Episodes of oxygen desaturation



Difference


Keene 2000 22 7.1 (5.9) 22 6.3 (7.5) 100.0 % 0.80 [ -3.19, 4.79 ]

Total (95% CI) 22 22 100.0 % 0.80 [ -3.19, 4.79 ]

Heterogeneity: not applicable



-50 -25 0 25 50




Analysis 1.3. Comparison 1 Supine versus prone, Outcome 3 Episodes of bradycardia.



Outcome: 3 Episodes of bradycardia



Difference


Heimler 1992 14 3.4 (3.74) 14 3.8 (5.61) 75.6 % -0.40 [ -3.93, 3.13 ]

Keene 2000 22 9.7 (12) 22 9 (8.8) 24.4 % 0.70 [ -5.52, 6.92 ]

Total (95% CI) 36 36 100.0 % -0.13 [ -3.20, 2.94 ]

Heterogeneity: Chi2 = 0.09, df = 1 (P = 0.76); I2 =0.0%



-50 -25 0 25 50


Analysis 2.1. Comparison 2 Prone horizontal versus right lateral horizontal, Outcome 1 Episodes of apnoea.


Comparison: 2 Prone horizontal versus right lateral horizontal


Study or subgroup Prone horizontal

Rightlateral

horizontalMean


Difference


Bredemeyer 1992 21 19.19 (14.65) 21 18.67 (11.3) 0.7 % 0.52 [ -7.39, 8.43 ]

Bredemeyer 2004 44 1.046 (1.94) 44 0.57 (1.189) 99.3 % 0.48 [ -0.20, 1.15 ]

Total (95% CI) 65 65 100.0 % 0.48 [ -0.19, 1.15 ]




-50 -25 0 25 50

Favours prone horizontal Favours right lateral



Analysis 2.2. Comparison 2 Prone horizontal versus right lateral horizontal, Outcome 2 Episodes of oxygen

desaturation.





Rightlateral

horizontalMean


Difference


Bredemeyer 2004 44 4.068 (4.39) 44 5.93 (6.919) 100.0 % -1.86 [ -4.29, 0.56 ]

Total (95% CI) 44 44 100.0 % -1.86 [ -4.29, 0.56 ]




-50 -25 0 25 50


Analysis 2.3. Comparison 2 Prone horizontal versus right lateral horizontal, Outcome 3 Episodes of severe

apnoea.



Outcome: 3 Episodes of severe apnoea


Rightlateral

horizontalMean


Difference


Bredemeyer 2004 44 0.5 (1.338) 44 0.45 (0.999) 100.0 % 0.05 [ -0.45, 0.54 ]

Total (95% CI) 44 44 100.0 % 0.05 [ -0.45, 0.54 ]




-50 -25 0 25 50




Analysis 2.4. Comparison 2 Prone horizontal versus right lateral horizontal, Outcome 4 Episodes of

bradycardia.





Rightlateral

horizontalMean


Difference


Bredemeyer 2004 44 1.318 (1.639) 44 1.91 (5.931) 100.0 % -0.59 [ -2.41, 1.23 ]

Total (95% CI) 44 44 100.0 % -0.59 [ -2.41, 1.23 ]




-50 -25 0 25 50


Analysis 2.5. Comparison 2 Prone horizontal versus right lateral horizontal, Outcome 5 Episodes of severe

bradycardia.



Outcome: 5 Episodes of severe bradycardia

Study or subgroup Prone Right lateralMean


Difference


Bredemeyer 2004 44 0.864 (1.519) 44 1.18 (1.833) 100.0 % -0.32 [ -1.02, 0.39 ]

Total (95% CI) 44 44 100.0 % -0.32 [ -1.02, 0.39 ]




-50 -25 0 25 50




Analysis 3.1. Comparison 3 Prone horizontal versus left lateral horizontal, Outcome 1 Episodes of apnoea.


Comparison: 3 Prone horizontal versus left lateral horizontal


Study or subgroup Prone horizontalLeft lateralhorizontal

MeanDifference Weight

MeanDifference


Bredemeyer 1992 21 19.19 (14.65) 21 19 (11.3) 1.4 % 0.19 [ -7.72, 8.10 ]

Bredemeyer 2004 44 1.046 (1.94) 45 0.84 (2.611) 98.6 % 0.20 [ -0.75, 1.16 ]

Total (95% CI) 65 66 100.0 % 0.20 [ -0.75, 1.15 ]




-50 -25 0 25 50

Favours prone Favours left lateral

Analysis 3.2. Comparison 3 Prone horizontal versus left lateral horizontal, Outcome 2 Episodes of oxygen

desaturation.






MeanDifference


Bredemeyer 2004 44 4.068 (4.39) 45 5.51 (6.764) 100.0 % -1.44 [ -3.81, 0.92 ]

Total (95% CI) 44 45 100.0 % -1.44 [ -3.81, 0.92 ]




-50 -25 0 25 50




Analysis 3.3. Comparison 3 Prone horizontal versus left lateral horizontal, Outcome 3 Episodes of severe

apnoea.






MeanDifference


Bredemeyer 2004 44 0.555 (1.338) 45 0.44 (0.989) 100.0 % 0.11 [ -0.38, 0.60 ]

Total (95% CI) 44 45 100.0 % 0.11 [ -0.38, 0.60 ]




-50 -25 0 25 50


Analysis 3.4. Comparison 3 Prone horizontal versus left lateral horizontal, Outcome 4 Episodes of

bradycardia.






MeanDifference


Bredemeyer 2004 44 1.318 (1.639) 45 1.49 (2.052) 100.0 % -0.17 [ -0.94, 0.60 ]

Total (95% CI) 44 45 100.0 % -0.17 [ -0.94, 0.60 ]




-50 -25 0 25 50




Analysis 3.5. Comparison 3 Prone horizontal versus left lateral horizontal, Outcome 5 Episodes of severe

bradycardia.




Study or subgroup Prone Left lateralMean


Difference


Bredemeyer 2004 44 0.864 (1.519) 45 1.09 (1.893) 100.0 % -0.22 [ -0.94, 0.49 ]

Total (95% CI) 44 45 100.0 % -0.22 [ -0.94, 0.49 ]




-50 -25 0 25 50


Analysis 4.1. Comparison 4 Right lateral versus left lateral, Outcome 1 Episodes of apnoea.


Comparison: 4 Right lateral versus left lateral


Study or subgroup Right lateral flat Left lateral flatMean


Difference


Bredemeyer 1992 21 19 (11.3) 21 18.67 (12.33) 1.4 % 0.33 [ -6.82, 7.48 ]

Bredemeyer 2004 44 0.569 (1.189) 45 0.84 (2.611) 98.6 % -0.28 [ -1.11, 0.56 ]

Total (95% CI) 65 66 100.0 % -0.27 [ -1.10, 0.57 ]




-50 -25 0 25 50

Favours right lateral Favours left lateral



Analysis 4.2. Comparison 4 Right lateral versus left lateral, Outcome 2 Episodes of oxygen desaturation.






Difference


Bredemeyer 2004 44 5.932 (6.919) 45 5.51 (6.764) 100.0 % 0.42 [ -2.42, 3.26 ]

Total (95% CI) 44 45 100.0 % 0.42 [ -2.42, 3.26 ]




-50 -25 0 25 50


Analysis 4.3. Comparison 4 Right lateral versus left lateral, Outcome 3 Episodes of severe apnoea.






Difference


Bredemeyer 2004 44 0.454 (0.999) 45 0.44 (0.989) 100.0 % 0.01 [ -0.40, 0.42 ]

Total (95% CI) 44 45 100.0 % 0.01 [ -0.40, 0.42 ]




-50 -25 0 25 50




Analysis 4.4. Comparison 4 Right lateral versus left lateral, Outcome 4 Episodes of bradycardia.






Difference


Bredemeyer 2004 44 1.909 (5.932) 45 1.49 (2.052) 100.0 % 0.42 [ -1.43, 2.27 ]

Total (95% CI) 44 45 100.0 % 0.42 [ -1.43, 2.27 ]




-50 -25 0 25 50


Analysis 4.5. Comparison 4 Right lateral versus left lateral, Outcome 5 Episodes of severe bradycardia.




Study or subgroup Right lateral Left lateralMean


Difference


Bredemeyer 2004 44 1.182 (1.833) 45 1.09 (1.893) 100.0 % 0.09 [ -0.68, 0.87 ]

Total (95% CI) 44 45 100.0 % 0.09 [ -0.68, 0.87 ]




-50 -25 0 25 50




Analysis 5.1. Comparison 5 Prone horizontal with prone head elevated, Outcome 1 Episodes of apnoea.


Comparison: 5 Prone horizontal with prone head elevated


Study or subgroup Prone horizontal Prone elevatedMean


Difference


Bredemeyer 1992 21 19.19 (14.65) 21 18.57 (13.74) 1.1 % 0.62 [ -7.97, 9.21 ]

Bredemeyer 2004 44 1.046 (1.94) 43 1.23 (2.379) 98.9 % -0.19 [ -1.10, 0.73 ]

Total (95% CI) 65 64 100.0 % -0.18 [ -1.09, 0.73 ]




-50 -25 0 25 50

Favours prone horizontal Favours prone elevated

Analysis 5.2. Comparison 5 Prone horizontal with prone head elevated, Outcome 2 Episodes of oxygen

desaturation.






Difference


Bredemeyer 2004 44 4.068 (4.39) 43 5 (6) 97.6 % -0.93 [ -3.15, 1.28 ]

Jenni 1997 12 24.23 (19.91) 12 12.48 (14.66) 2.4 % 11.75 [ -2.24, 25.74 ]

Total (95% CI) 56 55 100.0 % -0.62 [ -2.81, 1.56 ]

Heterogeneity: Chi2 = 3.08, df = 1 (P = 0.08); I2 =68%



-50 -25 0 25 50




Analysis 5.3. Comparison 5 Prone horizontal with prone head elevated, Outcome 3 Episodes of severe

apnoea.






Difference


Bredemeyer 2004 44 0.5 (1.338) 43 0.74 (1.465) 100.0 % -0.24 [ -0.83, 0.35 ]

Total (95% CI) 44 43 100.0 % -0.24 [ -0.83, 0.35 ]




-50 -25 0 25 50


Analysis 5.4. Comparison 5 Prone horizontal with prone head elevated, Outcome 4 Episodes of bradycardia.






Difference


Bredemeyer 2004 44 1.318 (1.639) 43 1.49 (2.501) 98.9 % -0.17 [ -1.06, 0.72 ]

Jenni 1997 12 14.41 (11.17) 12 12.14 (10.03) 1.1 % 2.27 [ -6.22, 10.76 ]

Total (95% CI) 56 55 100.0 % -0.14 [ -1.03, 0.74 ]




-50 -25 0 25 50




Analysis 5.5. Comparison 5 Prone horizontal with prone head elevated, Outcome 5 Episodes of severe

bradycardia.






Difference


Bredemeyer 2004 44 0.863 (1.519) 43 1.14 (2.512) 98.4 % -0.28 [ -1.15, 0.60 ]

Jenni 1997 12 8.7 (9.95) 12 9.38 (6.94) 1.6 % -0.68 [ -7.54, 6.18 ]

Total (95% CI) 56 55 100.0 % -0.28 [ -1.15, 0.59 ]




-50 -25 0 25 50


Analysis 6.1. Comparison 6 Right lateral horizontal versus right lateral elevated, Outcome 1 Episides of

apnoea.


Comparison: 6 Right lateral horizontal versus right lateral elevated

Outcome: 1 Episides of apnoea

Study or subgroup Experimental ControlMean


Difference


Bredemeyer 2004 44 0.569 (1.189) 42 1.36 (4.731) 100.0 % -0.79 [ -2.26, 0.69 ]

Total (95% CI) 44 42 100.0 % -0.79 [ -2.26, 0.69 ]




-50 -25 0 25 50

Right lateral horizontal Right lateral elevated



Analysis 6.2. Comparison 6 Right lateral horizontal versus right lateral elevated, Outcome 2 Episodes of

oxygen desaturation.






Difference


Bredemeyer 2004 44 5.931 (6.919) 42 5.9 (7.643) 100.0 % 0.03 [ -3.06, 3.11 ]

Total (95% CI) 44 42 100.0 % 0.03 [ -3.06, 3.11 ]




-50 -25 0 25 50



severe apnoea.






Difference


Bredemeyer 2004 44 0.454 (0.999) 42 0.6 (1.547) 100.0 % -0.14 [ -0.69, 0.41 ]

Total (95% CI) 44 42 100.0 % -0.14 [ -0.69, 0.41 ]




-50 -25 0 25 50





bradycardia.




Study or subgroup

Rightlateral

horizontal Right lateral elevatedMean


Difference


Bredemeyer 2004 44 1.909 (5.931) 42 1.57 (2.275) 100.0 % 0.34 [ -1.54, 2.22 ]

Total (95% CI) 44 42 100.0 % 0.34 [ -1.54, 2.22 ]




-50 -25 0 25 50



severe bradycardia.




Study or subgroup

Rightlateral

horizontal Right lateral elevatedMean


Difference


Bredemeyer 2004 44 1.818 (1.833) 42 1.21 (2.203) 100.0 % 0.60 [ -0.25, 1.46 ]

Total (95% CI) 44 42 100.0 % 0.60 [ -0.25, 1.46 ]




-50 -25 0 25 50




Analysis 7.1. Comparison 7 Left lateral horizontal versus left lateral elevated, Outcome 1 Episodes of

apnoea.


Comparison: 7 Left lateral horizontal versus left lateral elevated




Difference


Bredemeyer 2004 45 0.844 (2.611) 42 0.38 (0.795) 100.0 % 0.46 [ -0.34, 1.26 ]

Total (95% CI) 45 42 100.0 % 0.46 [ -0.34, 1.26 ]




-50 -25 0 25 50

Left lateral horizontal Left lateral elevated


oxygen desaturation.






Difference


Bredemeyer 2004 45 5.511 (6.764) 42 4.88 (6.197) 100.0 % 0.63 [ -2.09, 3.35 ]

Total (95% CI) 45 42 100.0 % 0.63 [ -2.09, 3.35 ]




-50 -25 0 25 50





severe apnoea.






Difference


Bredemeyer 2004 45 0.444 (0.989) 42 0.26 (0.7) 100.0 % 0.18 [ -0.18, 0.54 ]

Total (95% CI) 45 42 100.0 % 0.18 [ -0.18, 0.54 ]




-50 -25 0 25 50



bradycardia.




Study or subgroup Left lateral horizontal Left lateral elevatedMean


Difference


Bredemeyer 2004 45 1.489 (2.052) 42 1.41 (1.726) 100.0 % 0.08 [ -0.71, 0.88 ]

Total (95% CI) 45 42 100.0 % 0.08 [ -0.71, 0.88 ]




-50 -25 0 25 50





severe bradycardia.




Study or subgroup Left lateral horizontal Left lateral elevatedMean


Difference


Bredemeyer 2004 45 1.089 (1.893) 42 1.26 (1.697) 100.0 % -0.17 [ -0.93, 0.58 ]

Total (95% CI) 45 42 100.0 % -0.17 [ -0.93, 0.58 ]




-50 -25 0 25 50


H I S T O R Y

Protocol first published: Issue 4, 2004

Review first published: Issue 6, 2012

Date Event Description

29 October 2008 Amended Converted to new review format.

C O N T R I B U T I O N S O F A U T H O R S

Sandie Bredemeyer: Protocol development, data extraction, analysis, drafting and finalisation of review.

Jann Foster: data extraction, analysis, drafting and finalisation of review.



D E C L A R A T I O N S O F I N T E R E S T

Sandie Bredemeyer was chief investigator on a trial that measured the effect of body position on apnoea, bradycardia and enteral feeding

in the preterm infant for her PhD thesis (2004).

S O U R C E S O F S U P P O R T

Internal sources

• Royal Prince Alfred Hospital, Australia.

• Faculty of Nursing, The University of Sydney, Australia.

External sources

• Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health,

Department of Health and Human Services, USA.

Editorial support of the Cochrane Neonatal Review Group has been funded with Federal funds from the Eunice Kennedy Shriver

National Institute of Child Health and Human Development National Institutes of Health, Department of Health and Human

Services, USA, under Contract No. HHSN275201100016C.

D I F F E R E N C E S B E T W E E N P R O T O C O L A N D R E V I E W

None



body positioning for spontaneously breathing preterm infants with apnoea

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