Journal of Child Health Care

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The effect of positioning on preterm infants' sleep−wake states and stress

behaviours during exposure to environmental stressors
Niang-Huei Peng, Li-Li Chen, Tsai-Chung Li, Marlaine Smith, Yu-Shan Chang and Li-Chi Huang
J Child Health Care published online 3 October 2013
DOI: 10.1177/1367493513496665

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Article

Journal of Child Health Care

1–12
The effect of positioning on ª The Author(s) 2013
Reprints and permission:
preterm infants’ sleep–wake sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1367493513496665

states and stress behaviours chc.sagepub.com

during exposure to
environmental stressors

Niang-Huei Peng
Central Taiwan University of Science and Technology, Taiwan

Li-Li Chen
China Medical University, Taiwan; China Medical University Hospital, Taiwan

Tsai-Chung Li
China Medical University, Taiwan

Marlaine Smith
Florida Atlantic University, USA

Yu-Shan Chang
China Medical University Hospital, Taiwan

Li-Chi Huang
China Medical University, Taiwan; China Medical University Hospital, Taiwan

Abstract
Previous studies separately examined the effects of positioning or environmental stressors on
preterm infants’ sleep and stress. Since positioning and environmental stressors occur
simultaneously during infant hospitalization exploring these variables in the same study may
offer new insights. A quasi-experimental study by one-group interrupted time-series design. In the
current study, a total of 22 preterm infants were enrolled. Each infant was moved to either the
supine or prone position for an hour at a time. Infants were videotaped and the sleep–wake states,
stress behaviours and environmental conditions (light, noise and stimulation/handling) were
recorded during the observation period. A total of 80 observations from 22 infants were accrued.
In the supine position, preterm infants demonstrated more frequent waking states after adjusting

Corresponding author:
Li-Chi Huang, School of Nursing, China Medical University, 91 Hsueh-Shin Rd, Taichung 40402, Taiwan.
Email: lichi@mail.cmu.edu.tw

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2 Journal of Child Health Care

for various environmental stressors (p < .01). These infants demonstrated more frequent stress
behaviours in the supine position after adjusting for various environmental stressors (p < .01).
These results suggest that the prone position is a more favourable position for facilitating sleep and
reducing stress for preterm infants exposed to varying environmental stressors. Preterm infants
present different stress behaviours in response to varying types of environmental stimuli.

Keywords
Care, infant, neonatal

Introduction
The care outcomes of preterm infants have long been a focus of concern in neonatal nursing and
medicine. Several researchers have demonstrated that sensory overload within the environment of
the neonatal intensive care unit (NICU) interferes with the healthy development of the nervous
system of preterm infants, and this has been related to various sequelae that may compromise
health outcomes (Als et al., 2005; Bremmer et al., 2003; Browne, 2011; Fielder and Moseley,
2000). According to researchers, light, noise, handling and caregiving interventions are the main
sources of environmental stress that can be harmful to preterm infants in the NICU (Als, 1999;
Fielder and Moseley, 2000; Holditch-Davis et al., 2003). To date, studies have considered
exclusively on the roles of light (Fielder and Moseley, 2000), sound (Bremmer et al., 2003), quiet
periods (Slevin et al., 2000) and caregiver behaviours (Liaw et al., 2010) in reducing the beha-
vioural and physical effects of environmental stress. Although these studies did demonstrate the
significant effect of single interventions, findings were not universally supported (Symington and
Pinelli, 2009). Indeed, preterm infants are exposed to multiple environmental stressors (light,
sound and intervention), and thus, a study of the combined effects of these stressors on sleep–wake
states and stress behaviours would address a critical gap in the literature.
Research suggests that preterm infants placed in the prone nested position had fewer stress
behaviours (Antunes et al., 2003; Jarusa et al., 2011) and longer quiet sleep times (Bhat et al.,
2006). Improved pulmonary mechanics demonstrated by a greater tidal volume and improved
diaphragmatic function were also achieved in this position (Antunes et al., 2003). Although placing
infants in the prone position may improve respiratory function, it is only recommended under
continuous cardiorespiratory monitoring (Gillies et al., 2012). Other scholars have found no
evidence of clinical improvement associated with any particular body position during ventilation
(Balaguer et al., 2013). In addition, Constantin et al. (1999) have reported that sudden infant death
syndrome (SIDS) is not a risk for premature infants because they rarely adopt a face down position
when sleeping prone.
A concern with stress behaviours in preterm infants is that they may result in exhaustion and
depletion of the infants’ reserves for coping with ongoing stressors in the environment (Liaw et al.,
2012; VandenBerg et al., 2003). Several studies report that stress behaviours manifest during
exposure to stressors include finger splaying, brow raising, yawn, tremor and extension that are
followed by a decline in oxygen saturation and an increase in high heart rate (Grunau et al., 2000;
Harrison et al., 2004), a flexed body, extended legs and frown on painful stimulations (Holsti et al.,
2005). Observation of sleep–wake states provides additional information regarding central nervous
system maturation and organization (Scher et al., 2003) as well as developmental patterns
(Holditch-Davis et al., 2003; Giganti et al., 2001; Weisman et al, 2011). It is logical to assume that

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Peng et al. 3

while minimizing stress, and in turn, the abnormal responses to stressful stimuli will reduce the
energy expenditure and improve neurological integration, growth and development of preterm
infants.
Most studies considering the effect of position on sleep–wake states and stress behaviours have
not included observations of concomitant environmental stressors. Preterm infants are routinely
exposed to a highly stressful environment, where multiple stressors are present simultaneously. It
is therefore essential to determine what effect placement in the prone and supine positions has on
sleep–wake states and stress behaviours of preterm infants, after adjusting for exposure to varia-
tions in stressors simultaneously occurring in the environment. The purpose of this study was to
examine the effects of sleeping positions on sleep–wake states and stress behaviours in the same
preterm infants exposed to various environmental stressors in the acute care setting.

Method
Design
This was a quasi-experimental study by one-group interrupted time-series design (Portney and
Watkins, 2000). For the purpose of this study, the position of the preterm infant was manipulated
either in the supine or prone positions. The infants served as their own controls, and measurements
were taken at intervals during which positioning and environments changed. Observations were
made during variations in exposure to environmental stressors of light, sound and intervention. The
preterm infant was observed in four inter-feeding time epochs on two days: two hours each day,
one hour in the morning in supine, then one hour in the afternoon in prone position and vice versa.
All data related to the variables were recorded every two minutes for one hour observation. In total,
30 intervals were cumulated in one hour. During observation, the researcher recorded the environ-
mental stressors (light, sound and intervention), the infant’s sleep–wake state and stress
behaviours. To facilitate coding, one digital video recorder was placed inside the incubator; this
recorded the infant’s sleep–wake state and stress behaviours. The data were collected in 2008.

Setting and participants

The research setting was an intermediate infant care unit in a level-three hospital in the central
district of Taiwan. The participants were recruited through convenience sampling methods. Infants
who were born at less than 37 weeks gestational age and within 28 days of chronological age were
enrolled in the study. All the participants were in an incubator at the time of the study. Exclusion
criteria included infants with serious complications including chronic lung disease, necrotizing
enterocolitis, serious infectious disease, congenital anomalies, haemorrhage/ischaemic brain
injuries above level III or impending surgeries and using ventilator. One preterm infant withdrew
from this research because of deteriorating medical condition. No parent declined for their infant to
participate. A total of 22 preterm infants were enrolled in the study.

Intervention: positioning
Infants were randomly assigned to be positioned in either the supine or prone position during the
first hour; the position was reversed for the second hour. Infants’ position was in the reverse order
on the following day. In the supine position, each infant was placed on her/his back with head
turned to either side or to the midline, with a small roll placed under the knees and a rolled towel

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4 Journal of Child Health Care

placed around the baby as a nest, to support the extremities. In the prone position, the infant was
placed lying on her/his abdomen with the head turned to either side. Flexion was assisted by
bringing the arms close to the body and the hands close to the head. A nest was also provided by
surrounding the infant with a soft roll. Each infant’s position was maintained as much as possible
during necessary nursing interventions during the observation period.

Measurements
Environmental stressors. Environmental stressors were defined as level of light, sound and inter-
vention. These were measured through videotaped observations. A TES-1336 photometer (TES
Electrical Electronic Corp., Taipei, Taiwan), placed near the eyes of preterm infants, was used to
measure light in the incubator. The incubator was covered with a quilt while in the study. The
TES-1336 measuring range is 0–20,000 ft-c, which also calibrated accuracy to standard incandescent
lamp (+3% of reading, the 3% of measure value). Light is measured in units of foot candles (ft-c, 1
ft-c ¼ 10.76 lux) (Fielder and Moseley, 2000). Sound levels in the incubator were measured by a
Rion NL-10 phonometer (Rion Co, Japan); a dB-A weight scale was used because it measured sound
energy in the range of 500–10,000 Hz, which is the sound range most sensitive to the human ear
(Kellman, 2002). The devices were certified for accuracy at the technical company prior to imple-
menting the study. The devices could be recalibrated if any obvious mistake or damage was noticed.
According to Holditch-Davis et al. (2003), handling of infants during caregiver interventions
can be categorized by the quality, ranging from no contact to stressful and often painful interven-
tions. Therefore, a check of 0/1 was used to measure level of observed handling during care or
treatment interventions provided to the infant; 0 indicated no stimulation; 1 indicated any stimula-
tion, for example, opening the shade cloth of the incubator without touching the infant, and any
handling. No intervention appeared to cause pain as indicated by infant behavioural cues.

Sleep–wake states. Two outcome variables were measured in the study: infants’ sleep–wake states
and stress behaviours. Infants’ sleep–wake states were measured using a scale with six regular
sleep–wake states adapted from Holditch-Davis et al. (2005) and Brazelton’s (1984) behavioural
state scoring system. The six sleep–wake states were coded from videotaped recordings as follows:
1 ¼ deep sleep state, 2 ¼ alert sleep state, 3 ¼ drowsy state, 4 ¼ alert wake state, 5 ¼ fussy and
6 ¼ crying. However, for more accurate interpretation of the data, deep sleep (state 1) and alert
sleep (state 2) were combined as the sleep state, and drowsy (state 3), alert wake (state 4), fussy
(state 5) and crying (state 6) were combined as wake state. With this modification, only sleep states
or waking states were reported.

Stress behaviours. In this investigation, stress behaviours included face, extremities and trunk and
head disorganization signals. Stress behaviours in the face were identified as: mouthing, grimacing,
upward gazing, yawning, grasping the face and staring. Stress behaviours in the extremities were
finger splaying, airplane, saluting, sitting on air, fisting and leg bracing. Stress behaviours in the
trunk and head were the startle, diffusion squirming, twitching, tremor and arching (Als et al., 2005;
Holditch-Davis et al., 2003). Each stress behaviour was coded as present/absent (1/0). All the mea-
sures of stress behavioural responses were coded from videotaped recordings and defined in Table 1.

Reliability and validity of measurements. Measures of sleep–wake states and stress behaviours were
coded from the videotaped recordings. The content validity of the measurements was determined

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Peng et al. 5

Table 1. Operational definitions of stress behaviours in the study.a

Stress behaviours Operational definition

Face
Mouthing More than one opening and closing of the mouth
Grimacing The infant’s face retracts and looks distorted. Infant looks uncomfortable.
Upward gazing The eyes are looking up over a visual object in front of the infant’s face.
Yawning The infant yawns
Grasping face This refers to a drooping open mouth configuration that is the result of decreased
lower facial tone. It gives the appearance of exhaustion and facial limpness.
Staring The infant demonstrates glassy-eyed alertness with eyes open. Eyes look glazed or
fixed and infant appears to be staring.
Extremities
Finger splaying Fingers extend with abduction
Airplane Shoulder abduction
Saluting Arm extension
Sitting on air Hips flexed and knees extended
Fisting Finger flexion into a fist
Leg bracing Lower limb extension to the wall of the isolette or a blanket nest.
Trunk and head
Startle Sudden large amplitude jumping movement of arms, trunk or legs.
Diffusion squirming Small wiggling movement of trunk
Twitching Small amplitude, brief contractile response of a skeletal muscle, elicited presumably
by a single maximal volley of impulses in the neurons supplying it.
Tremor Trembling or quivering of any apart of the whole body
Arching Trunk and head extension
a
Operational definitions of stress behaviours are adapted from the Assessment of Preterm Infants’ Behavior (Source:
reproduced with permission from Als, 2005; Holditch-Davis, 2003).

by an expert panel including two scholars in paediatric nursing, one senior nurse in preterm infant
care, one neonatal physician and one statistician. Two researchers served as the study observers.
Inter-rater reliability was determined before the study. Using a sample of video segments, two
researchers independently coded each segment and discussed any disagreements until consensus
was achieved. The inter-rater reliability of coding data was calculated and training continued until
a minimum criterion of 80% agreement between the two researchers occurred.

Ethical considerations
The study was approved by the Institutional Review Board of the university hospital. Parents
whose preterm infants met eligibility criteria were invited to participate and provided consent
while they visit infants in the unit. Parents were given detailed information about the procedures of
the study, and researchers answered all their questions. Parents were assured that care would not be
compromised should they choose not to participate, and they could decide to withdraw their infant
from the study at any time.

Data analysis
Descriptive statistics were used to characterize the distributions of the outcome variables. To
enhance the accuracy of measurement, the sleep–wake states and stress behaviours were assessed

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6 Journal of Child Health Care

every two minutes within one-hour observation period with a total of 30 measurements. The
percentages of wake state or stress behaviours were calculated by dividing the number of wake
states or stress behaviours within one-hour observation period by 30 and then multiplying by
100. Power of 95% is achieved with 22 infants placed in both supine and prone position, with
5% of two-sided type 1 error to detect a difference of 20% of sleep state in prone position compared
to those in supine position. This is calculated with the use of a two-sided z test based on the
assumption that there is a mean difference of 20 in proportion of sleep state with a standard devia-
tion of 25 between supine and prone positions.
The linear mixed model was used to examine relationships of infant position and environment
stimuli (light, sound and intervention) on sleep–wake states and stress behaviours by considering
the dependency from the repeated measurements within subjects. We used all available infant
data; no observations were deleted because of missing data for follow-up. The estimation
approach used in the mixed model for longitudinal data analysis yields unbiased estimates of
parameters when missing outcomes are assumed ignorable, that is, they are associated with either
observed covariates or outcome variables but not to unobserved variables (Little and Rubin,
2002). The infant position and environment stimuli were fitted as fixed terms and infant as
random term in the model. Adjusted effects of position and environmental stressors and their
p values were reported. All reported p values were those of two-sided tests; statistical signifi-
cance was set at p < .05. All analyses were performed using SAS version 9.2 (SAS Institute Inc,
Cary, North Carolina, USA).

Results
Descriptive data
A total of 22 preterm infants were recruited in this study. The participants’ gestational age ranged
from 30 to 35 weeks, with a mean of 32.82 weeks (+1.44 weeks). The mean birth weight was
1714.09 g (+316.91 g). During the time of study, the mean body weight was 1764.32 g
(+255.17 g) and the mean chronological age was 10 days (+9.66 days; Table 2). There were eight
observations missed, one in each supine and prone from one infant and six prone positions from six
different infants. A total of 80 observation periods from 22 infants were accrued. Mean percentage
were accounted from occurred variables (sleep–wake states and stress behaviours) of all supine or
prone observation periods.
In this research, the mean percentage of wake states in the supine position was higher than
when in the prone position (32.55 vs. 13.4%). The mean percentage of stress behaviours at
extremities in the supine position was higher as compared to the prone position (30.32
vs. 17.29%). The mean percentage of stress behaviours at face in the supine position was higher
as compared to the prone position (12.67 vs. 7.21%). Finally, the mean percentage of stress
behaviours at trunk in the supine position was higher than when in the prone position (17.79 vs.
5.52%; Table 3).
There were three types of environmental stressors: light, noise and interventions. During
the observation, the mean environmental light was 0.29 ft-c (+0.34), ranging from 0.06 to
5.6 ft-c; and the environmental noise level ranged from 42.2 to 98 dB with the mean noise
level at 53.07 dB (+4.69). In this study, 94.5% of interventions were categorized as creating
no stimulation (0), while only 5.5% were in the intervention-created stimulation (1) for the
baby.

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Peng et al. 7

Table 2. Demographic characteristics N ¼ 22.

Variable n (%) Min Max Mean SD

Gender
Male 9 (40)
Female 13 (60)
Gradational age (weeks) 30 35 32.82 1.44
30 1 (4.5)
31 2 (9.1)
32 7 (31.8)
33 5 (22.7)
34 3 (13.6)
35 4 (18.2)
Chronological age (days) 1 28 10 9.66
APGAR (1 min) 5 9 6.84 1.72
APGAR (5 min) 5 10 8.47 1.26
Birth body weight 1220 2655 1714.09 316.91
Study body weight 1323 2655 1748.30 308.91

APGAR: appearance, pulse, grimace, activity, respiration.

Table 3. The wake states and stress behaviours in prone or supine position.

Wakea Extremitiesa Facea Trunka

Position Mean + SD Mean + SD Mean + SD Mean + SD

Supine 32.55 + 24.83 30.32 + 13.79 12.67 + 11.84 17.79 + 13.21

Prone 13.40 + 15.52 17.29 + 8.54 7.21 + 6.55 5.52 + 6.00
a
Percentage of wake states or stress behaviours (face, extremities and trunk).

The effects of infant position on infants’ sleep–wake states when exposed to varying
environmental stressors
Table 4 summarizes the effects of position on the sleep–wake states of the infants exposed to
varying environmental stressors in the study. The main effect on sleep–wake states are position
(p < .01), intervention (p < .001) and noise (p < .05). When adjusted for the environmental
stressors, the mean percentage of wake state in the supine position was 12.41% higher than the
prone position.

The effects of infant position on infants’ stress behaviours in various environmental

stressors
Table 5 reveals that stress behaviours were significantly different based on position and
environmental stimuli. There was an increase in stress behaviours for preterm infants exposed to
the environmental stimuli of intervention. Preterm infants’ stress behaviours in their extremities
were significantly higher when preterm infants were placed in the supine position (p < .001) and

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8 Journal of Child Health Care

Table 4. Effect of position on wake state in the preterm infants.

Predictor Estimate Standard error t p Value

Intercept 14.567 18.961 .77 .451

Position (Ref: prone) Supine 12.405 3.904 3.18 .005**
Intervention (yes vs no) 1.544 .277 5.58 <.0001***
Light (ft-c) 6.749 7.862 .86 .395
Noise (dB) .234 .113 2.08 .043*
Body weight (per 1 g) .010 .01 .98 .33
*p < .05, **p < .01, ***p < .001.

Table 5. Effect of position on observed stress behaviours in the preterm infants.

Predictor Estimate Standard error t p Value

Extremities
Intercept 6.717 10.025 .67 .51
Position (Ref: prone) Supine 10.193 2.216 4.6 .0002***
Intervention (yes vs. no) .611 .155 3.95 .0002***
Light (ft-c) 2.915 4.32 .67 .503
Noise (dB) .033 .062 .52 .604
Body weight (per 1 g) .0004 .005 .07 .941
Face
Intercept 3.185 8.535 .37 .713
Position (Ref: prone) Supine 2.606 1.809 1.44 .165
Intervention (yes vs. no) .633 .128 4.96 <.0001***
Light (ft-c) 4.512 3.599 1.25 .215
Noise (dB) .011 .052 0.21 .836
Body weight (per 1 g) .004 .004 1.02 .312
Trunk
Intercept 23.839 13.957 1.71 .102
Position (Ref: prone) Supine 12.352 2.229 5.54 <.0001***
Intervention (yes vs. no) .209 .164 1.28 .207
Light (ft-c) .113 4.829 .02 .981
Noise (dB) .059 .068 .87 .389
Body weight (per 1 g) .002 .007 0.32 .749
***p < .001.

exposed in intervention (p < .001). When adjusted for the level of environmental stressors, the
mean percentage of stress behaviours in the supine position was 10.19% more in their extremities
than when placed in the prone position. The intervention (p < .001) was significantly related to
observed stress behaviours in the face. There were no statistically significant differences in stress
behaviours in infants’ faces based on their positions. One variable, observed stress behaviours in
the trunk, was significantly higher (p < .0001) with placement in the supine position, which means
that mean percentage of stress behaviour in the trunk was 12.35% more in the supine position than
in the prone position. These stress behaviours were evident in the trunk and the extremities;
however, there was no statistically significant effect of position on stress behaviours in the face
after adjusting for the environmental stressors.

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Peng et al. 9

Discussion
The results reveal that preterm infants are more likely to remain in a sleeping state when they are in
the prone position. Similarly, researchers have reported that the prone position is better for
facilitating sleeping states in preterm infants in the NICU (Bhat et al., 2006; Grenier et al., 2003;
Liaw et al., 2012). However, these earlier studies did not include observations or reports of the
concurrent environmental stressors. In this study, the infants’ position was manipulated and
simultaneously environmental stressors were measured as well. Our findings confirm that the
prone position facilitates sleep, even when adjusting for variance in environmental stressors (noise,
light and stimulation/handling). Gillies et al. (2012) have stated that placing infants in the prone
position should only occur where full cardiorespiratory monitoring is available. In normal
circumstances, it is recommended that healthy infants should be placed in the supine position to
reduce the risk of SIDS. Therefore, the parents have to know the reasons of placing infants in the
prone position that could improve infants’ pulmonary function while under threaten of apnoea. It is
essential that parents are aware of the difference between the NICU and home environments and
that infants should be placed in the supine position exclusively once discharged. (Bredemeyer and
Foster, 2012).
In this study, most awakening states and observed stress behaviours occurred during inter-
ventions when adjusting for position and environmental stressors. However, this did not affect the
stress behaviours associated with the trunk in this study. In part, these findings help to confirm
previous findings (Bremmer et al., 2003; Evans, 1991; Liaw et al., 2010; Thomas and Uran, 2007)
indicating that interventions are the major disturbing stressors for preterm infants. For example,
lowering the mattress inside the incubator while changing the position was the loudest sound
experienced by infants in the NICU with a noise level of 87 dB (Thomas and Uran, 2007). Thus, it
has been argued that stimulation and handling associated with nursing interventions is as damaging
as environmental noise as a stressor. The supportive caregiving behaviours by nursing staff have
therefore been suggested, such as the slow and gentle provision of support, stroking, containment,
comforters and protection (Liaw et al., 2010). This study advices that nurses should be able to
recognize infant’s stress-associated cues during intervention and take appropriate behaviours to
reduce the stress. For very immature infants, social intervention can be equally as stressful as some
procedures. Regardless of whether a specific handling episode is considered a medical intervention
or a soothing measure, handling is a recognized stressor to the vulnerable preterm infant.
This study also observed that stress behaviours in the extremities and trunk occurred more in the
supine position than in the prone position when adjusting for environmental stressors. Although
stress behaviours in the face occurred more often in the supine than in the prone position (2.61%),
this difference was not statistically significant. A larger sample could produce more conclusive
findings with regard to the relationship between positioning and facial stress reactions. Positioning
may act as a self-regulating mechanism since infants in the prone position seem to have fewer
visible signs of stress; displaying fewer stress behaviours are associated with self-regulation (Als,
1982; Chang et al., 2002; Grenier et al., 2003). After adjusting for environmental stressors, this
study demonstrated that preterm infants in the prone position were less distressed, and this finding
is consistent with the results of previous studies.
The light level within the environment (mean ¼ .29 ft-c) in this study was much lower than the
recommended levels for room lighting. A Consensus Committee (2007) decision has recom-
mended that a light level of 60 ft-c is adequate for observation in the NICU. All participants in this
study were placed in an incubator covered with a quilt in order to simulate a uterine environment.

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10 Journal of Child Health Care

The light was significantly below the above criteria and therefore less stimulating and stressful for
the preterm infants.
The mean noise levels (53.07 dB) in this study were a little higher than desired for the
hospitalised preterm infants. The Consensus Committee (2007) has recommended that for new-
borns in the NICU, an hourly maximum of 45 dB with an impulse maximum not exceeding 70 dB
is sufficient. In our study, over 78% of observations revealed noise levels at above 45 dB, which
exceeded these recommendations. Moreover, 0.6% of noise levels were above 70 dB (not shown in
the table). However, these results are consistent with an earlier study by Thomas and Uran (2007)
showing that sound levels associated with caregiving, equipment and activities continue to be high
in the NICU. With higher noise levels in the NICU, there is an increased possibility of adverse
sequelae in preterm infants. Indeed this study supports the observations that environmental noise
affects sleep–wake states and that sound exposure is related to an infant’s awakening (Graven,
2000; Liaw et al., 2012; Thomas and Uran, 2007). Moreover, proper environmental designs that
can minimize the sound levels in the NICU have also been recommended to improve the
developmental needs of preterm infants (White, 2007, 2011a, 2011b). Nurses caring for preterm
infants are in the best position to monitor the environmental sound levels and the equipment-
related sound levels.

Conclusion
These results are consistent with several previous studies indicating that there are a variety of
potential benefits for prone positioning in preterm infants. However, previous studies failed to
adjust for typical environmental stressors present in the NICU. This study adds to the evidence for
preterm infant care by filling this gap in our knowledge and measuring additional stress-related
factors. This study confirms that prone positioning is optimal for promoting sleep and decreasing
the stress response in preterm infants after adjusting for environmental stressors.
The study demonstrates that environmental stimuli affect the infant by increasing stress beha-
viours and waking states. In this study, different environmental stressors affected sleep–wake states
and the observed stress behaviours of preterm infants differently. Stimulation with intervention
was the most distressing for preterm infants. Therefore, minimizing treatment interruptions by
clustering care could help to minimize the infants’ stress and allow more time for recovery between
stressful events. In the stressful NICU environment, placing infants in the prone position has
demonstrable benefits for promoting preterm infants’ sleep and diminishing stress. Preterm infants
are both dependent upon and vulnerable to the care provided in the intensive care environment.

Limitations
There are some limitations to this study. First, infants were observed over two consecutive days
during the inter-feeding epoch only, and this period of time may itself represent an event that influ-
ences the observed outcomes. Further study might randomly select different observation sessions
in order to minimize this effect. Second, the study sample was taken from stable preterm infants
with a gestational age of more than 30 weeks, indicating that the findings may not be generalized to
all preterm infants. Finally, a small sample size used would not include all the various variables for
the measurement in the study. Therefore, a large sample size with a broader range gestational age
range might provide stronger evidence of the effects of position on preterm infants’ state and stress
behaviours.

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Peng et al. 11

Acknowledgements
The authors would like to thank the participants for making this study possible. We also sincerely
thank all the parents who gave permission to include their child in this study.

Funding
This study was supported by China Medical University Research Grant (CMU100-TC-24).

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