Journal of Neonatal Nursing 26 (2020) 212–216

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Journal of Neonatal Nursing

journal homepage: www.elsevier.com/locate/jnn

Physiological parameters of preterm infants in different postures: An T

observational study
Fatemeh Cheraghia,∗, Mina kiani Mahabadib, Efat Sadeghianc, Leili Tapakd, Behnaz Basirie
a
Chronic Disease (Home Care) Research Center, Hamadan University of Medial Sciences, Hamadan, Iran
b
Pediatric Nursing and Midwifery Faculty, Hamadan University of Medical Sciences, Hamadan, Iran
c
Mother and Child Care Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
d
Department of Biostatistics and Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
e
Fatemieh Hospital, Hamadan University of Medical Sciences, Hamadan, Iran

ARTICLE INFO ABSTRACT

Keywords: Positioning is performed to provide support, comfort and physiological stability of preterm infants. This ob-
Infant servational study aimed to compare the physiological parameters of preterm infants with respiratory distress in
Intensive care unit different postures in Neonatal Intensive Care Unit. Ninety five preterm infants with respiratory distress under
Observational study continuous positive airway pressure or positive end-expiratory pressure were selected by non-probability sam-
Posture
pling. Each infant was placed 120 min respectively in prone, right-lateral, supine and left-lateral postures. The
Respiratory distress
arterial oxygen saturation, heart rate and respiratory rate were measured every 5 min in each posture and the
mean values were recorded during 120 min every 60 min. The mean arterial oxygen saturation value was
significantly higher in prone and left-lateral postures compared to supine (p < .01). While the respiratory and
heart rates were not significantly change between any four postures. Based on results, prone and left-lateral
postures had better outcomes than supine in terms of arterial oxygen saturation.

1. Introduction
Body positioning is an important nursing action not only to facilitate
respiratory work (Vendettuoli et al., 2015) but also to prevent asym-
metrical pressure to the head and body of hospitalized infants (King and
Norton, 2017; Gillies et al., 2012). The infant experiences ideal limb
flexion in lateral posture, similar to intrauterine (Madlinger-Lewis
et al., 2014). Besides, it reduces gastro-esophageal reflux (Boxwell,
2010) and right-lateral posture increases it (Omari et al., 2004). The
effects of lateral posture on respiratory function in preterm infants are
not clear, yet (Gouna et al., 2013). The key physiological purposes of
prone positioning are improving oxygenation and respiratory me-
chanics because of better movement of the chest wall (Gouna et al.,
2013; Malagoli et al., 2012); regulating the alveolar inflation; in-
creasing lung volume; facilitating the drainage of secretions (Pelosi
et al., 2002); and stabilizing the rib cage. Supine posture is commonly
used in caring of hospitalized infants because it allows better venous
access, hygiene care, clinical exams and observation of breathing pat-
tern of infants (Brunherotti and Martinez, 2013). Nevertheless, in
supine, lung compliance, and efficiency of gas exchange decrease due to
the limitation of the diaphragm movement (Brunherotti and Martinez,
2013; Rivas-Fernandez et al., 2016) and less synchronism between
thorax and abdomen (Rehan et al., 2000). Besides, there is maybe in-
creased respiratory workload (Rivas-Fernandez et al., 2016). Posi-
tioning plays an important role in pulmonary functions in preterm in-
fants with Respiratory distress (RD) (Gouna et al., 2013).
RD is a medical emergency and one of the most important causes of
preterm mortality (Gillies et al., 2012; Marcdante and Kliegman, 2018).
Important physiological signs of RD are arterial oxygen saturation
(SpO2) below 85%, respiratory rate (RR) of more than 60/min and
heart rate (HR) of more than 140/min in rest (Marcdante and Kliegman,
2018).
There are several studies on positioning for acute RD in hospitalized
infants and children. However, most available studies in preterm in-
fants have compared only the physiological outcomes between supine
and prone postures (Gillies et al., 2012; Brunherotti and Martinez,
2013; Rivas-Fernandez et al., 2016; Fransisco et al., 2001; Abdeyazdan
et al., 2010). Some studies show a significant improvement in

Corresponding author. Chronic Diseases (Home Care) Research Center, Hamadan University of Medical Sciences, Shahid Fahmide Bulv, P. O. Box: 65178,
∗

Hamadan, Iran.
E-mail addresses: f_cheraghi@umsha.ac.ir (F. Cheraghi), mrmelnaz@yahoo.com (M. kiani Mahabadi), Parastoo_iran2003@yahoo.com (E. Sadeghian),
l.tapak@umsha.ac.ir (L. Tapak), b.basiri@umsha.ac.ir (B. Basiri).

https://doi.org/10.1016/j.jnn.2020.01.009
Received 12 September 2019; Accepted 17 January 2020
Available online 24 January 2020
1355-1841/ © 2020 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.
F. Cheraghi, et al.
oxygenation in prone posture in comparison with supine (Gillies et al.,
2012; Brunherotti and Martinez, 2013; Rivas-Fernandez et al., 2016;
Abdeyazdan et al., 2010; Curley et al., 2006; Leipälä et al., 2003). We
found a study that compared the effect of left-lateral and prone postures
with supine on lung function and breathing pattern in oxygen depen-
dent premature infants. The results indicated that SpO2 was higher in
left-lateral and prone postures than in supine. But, HR and RR were the
same (Gouna et al., 2013). The RR variation with changing posture was
not reported in other similar study (Antunes et al., 2003). However, the
higher RR was seen in prone posture in another study (Levy et al.,
2006). Dimitriou et al. (2002) stated that the maximum inspiratory
pressure (MIP) of infants were higher in supine than in prone posture
(Dimitriou et al., 2002).
Several studies have shown a variety outcome affected by different
body positioning of preterm infants. So, the effect of the positioning on
improving respiratory mechanisms, heart function and oxygenation
were not completely clarified yet. Moreover, fewer studies have been
conducted to discuss the beneficial effects of different body postures on
SpO2, RR and HR in preterm infants with RD. To fill these gaps in
knowledge, we designed this study to determine and compare the SpO2,
RR and HR of preterm infants with RD in prone, right-lateral, supine
and left-lateral postures as common postures in NICU.
2. Methods
This is an observational study wherein each infant was his/her own
control. The study was conducted at level 2B NICU of a university
hospital between March and December 2017. Level 2B NICU (special
care nursery) of Fatemieh Maternity Hospital has 13 beds which pro-
vide some respiratory assistance, such as continuous positive airway
pressure (CPAP) to neonates born between 32 weeks and 35 weeks
gestation or older and weigh 1500g or more. Those require some care
in level II, nursery. This level 2B NICU have all the capabilities of a
Level I nursery as well as pediatric hospitalists, four neonatologists,
three neonatal nurse practitioners and 15 trained nurse register nurses
(RN)on-site. The sample size was estimated based on the Standard de-
viation of SpO2 values1 in supine and prone positions that reported in
Abdeyazdan et al. study (Abdeyazdan et al., 2010) with P at .05 and
90% power. The equation of estimated of sample size was:
2 (sd2 + sd22)
(Z (1 /2) + Z (1 )) 1 eral postures were supported by placing a suitable towel on the back of
n=
d2
Ninety five preterm infants with RD were selected by non-prob-
ability convenience sampling. Inclusion criteria included: being aged at
birth between 1 and 7 days and gestational-age 32–35 weeks, being
under CPAP or positive end-expiratory pressure (PEEP), being in in-
cubator, feeding with nasogastric (NG) tube, no limit in changing po-
sitioning by doctor's order, and having similar drugs order. Exclusion
criteria included: having any kind of genetic disorder, need for surgery
and need for blood transfusion during the study, any deformities or
physical problems that prevent being to any positions, and infant's
parents or medical team have decided not to continue to participate.
Written informed consents were obtained from the preterm infants'
parents.
The data collection tools were demographic questionnaire; the re-
cording check list; and cardiac monitor. Demographic questionnaire
included demographic characteristics of infants and parents and clinical
parameters (temperature incubator, the amount of oxygen, oxygen
method). The check list was used to record SpO2, HR and RR. SpO2 and
HR were measured by cardiac monitor and RR was counted in 1 min.
Content validity of check list was proved by 10 nursing faculty
1
sd1 = 1.7 (Standard deviation of SpO2 values in supine posture), sd2 = 0.26
(Standard deviation of SpO2 values in prone posture), d = 5.1, Z1-α/2 = 1.96,
Z1-β = 1.28.
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Journal of Neonatal Nursing 26 (2020) 212–216
members and neonatologists. Reliability of check list was verified by
evaluating of inter-rater agreement of the two observers. At the same
time, ten preterm infants were observed in the supine posture by the
data collector and a nursing staff and each of them separately com-
pleted the check list. The assistant nurse had two years of work ex-
perience at NICU. Pearson's coefficient was calculated to assess the
degree of agreement among observers. Reliability coefficient was cal-
culated only for respiratory rate (r = 0.98) by statistical supervisor,
because SpO2 and HR values were recorded from the cardiac monitor
and had similar values.
Cardiac monitor devices were Saadat model of Novin S1800 and
have been used since five years ago in NICU. Therefore, we expected
that the monitors had an acceptable validity (both sensitivity and
specificity assumed to be 100%). To determine the stability, the cardiac
monitors were calibrated by an engineer before and during of the
sampling with equal intervals.
The arrangement of placing participated infants at four positions
was determined randomly and then the same procedure was performed
for all infants. Each infant was placed for 120 min respectively in prone,
right-lateral, supine and left-lateral postures by the data collector. Each
positioning was usually begun between 10:00 and 11:00 in the morning
when the doctor's visiting or other therapeutic interventions or neces-
sary caring were almost finished. Also, Infants were awake and were
feed about half an hour ago. The choice of 120 min for placement of
infants in each posture was based on the intervals of routine assessment
and care. Moreover, through coordination with personnel, the partici-
pants received almost no treatment or care during these 120 min.
The physiological parameters of each participating infants, in-
cluding SpO2, HR and RR, were monitored continuously during
120 min by a data collector. In the first 15 min in each posture, infant
was under careful observation without touch or any other intervention
(resting phase). No data was recorded for the first 15 min (Wash out),
because repositioning and handling have often been associated with an
obvious deterioration in gas exchange. After the first 15 min, SpO2, HR
and RR were recorded every 5 min during 120 min. Then, three mean
values were calculated for each 60 min interval of monitoring (in
minute Zero, 60 and 120) in each posture. This interval was chosen to
increase the accuracy of comparing the physiological parameters in
each position. The infants' head were turned to one side in prone and
supine postures and to the same side in right- and left-lateral. The lat-
infants. In prone, RR was measured by observing the movements of the
abdomen from the side. Infants' condition was under strict and close
control with a cardiac monitor device all time.
2.1. Data analysis
Data were analyzed by SPSS 20 software. Kolmogorov–Smirnov test
showed that the data were normally distributed. Analysis of variance
with repeated measurements and Turkey's Post Hoc tests was used to
compare the physiological parameters in different postures. Confidence
level was 0.95.
2.1.1. Ethics approval and consent to participate
This study design and procedures were approved by the Institutional
Review Board (approval number: 950221675) and the Research Ethic
Board of X University of Medical Sciences (Ethical NO. was
IR.UMSHA.REC.1395.28.). Written informed consents were obtained
from the preterm infants' parents. The purpose of the study was ex-
plained to the parents. It is also important to note that the results of the
study were anonymously reported to comply with the ethical criteria.
3. Results
Ninety five preterm infants with RD under CPAP and or PEEP, with
mean gestational age 33.98 ± 1.62 weeks and age of 4.44 ± 1.58 days
F. Cheraghi, et al. Journal of Neonatal Nursing 26 (2020) 212–216

Table 1 Table 3
Demographic characteristics of the preterm infants with respiratory distress. The Results of Pairwise Comparison of SpO2 and RR Parameters among the
Times of Measurement in Prone and Supine postures.
Characteristics % Mean ± SD
Variable Posture Time Mean Difference Std. Error pvalue
Gender
Male 55.6 SpO2 (%) Prone Zero&60 −0.51
Female 44.4 Zero&120 −1.07 0.23 <.001**
Gestational age (weeks) 33.98 ± 1.68 60&120 −0.56 0.18 .001*
Birth age (days) 4.44 ± 1.58 Supine Zero & 90 0.27 0.18 .148
Temperature incubator (°C) 33.92 ± 1.04 Zero&120 0.93 0.26 .001*
Type of delivery 60 & 120 0.67 0.2 .002*
Cesarean section 60 RR(r/m) Prone Zero & 60 0.53 0.64 .411
Normal delivery 40 Zero&120 2.27 0.62 .001*
60 & 120 1.73 0.5 .001*
Note. SD = standard deviation; °C = degree of centigrade; lit/min = liter per
minute. *In the level <0.01 is significant.
**In the level <0.001 is significant.
were assessed. Of these, 55.6% were male and 60% were born through Note. Std. Error = standard error; SpO2 = arterial oxygen saturation.
cesarean section. The mean temperature of incubator was 32.92 ± 1.04 RR = respiratory rate; r/m = rate per minute.
(Table 1).
The mean SpO2 values were significantly different only in prone and Table 4
supine postures during 120 min (p < .01) (Table 2). Based on pairwise Comparison the Physiological Parameters between Different Body Postures by
ANOVA with repeated measurement.
comparison, it increased during 120 minutes in prone. In minute Zero,
60 and 120, the mean SpO2 values were 95.69±2.02, 96.20±2.07 and Variable Posture Mean ± SD pvalue
96.76±2.01, respectively in prone. The mean SpO2 value was de-
SpO2 (%) Prone 96.22 ± 0.28 .002*
creased after 60 minutes in supine. In minute Zero, 60 and 120, the Right-lateral 95.96 ± 0.19
mean SpO2 values were 95.8±1.84, 96.53±1.9 and 94.87±2.18, re- Supine 95.4 ± 0.27
spectively in supine (Tables 2 and 3). Left-lateral 96.13 ± 0.26
Only in prone posture, the mean RR values showed a significant HR (bpm) Prone 135.17-±1.74 .315
Right-lateral 135.8 ± 1.58
difference during 120 min (p < .01), the lowest mean RR values was
Supine 137.48 ± 1.87
seen after 120 min (53.11 ± 11.37) (Table 2.) Based on pairwise Left-lateral 136.01 ± 1.75
comparison, it decreased during 120 min in prone (Table 3). The RR(r/m) Prone 55.19 ± 11.51 .31
maximum mean RR value was higher than the normal range of 60/min Right-lateral 54.56 ± 10.85
in each postures, but it was slightly higher in left-lateral than the others Supine 56.33 ± 11.61
Left-lateral 54.76 ± 11.35
after 60 min (Table 2).
The mean HR values were not significantly different during 120 min *In the level <0.01 is significant.
in the different positioning arm of the study. However in prone, the Note. SD = standard deviation; Min = minute; Min-Max = minimum-max-
mean HR values were slightly lower during 120 min. The mean HR imum; SpO2 = arterial oxygen saturation; HR = heart rate; RR = respiratory
values fluctuated within normal range of 160/min in prone, while it rate; bpm = beat per minute; r/m = rate per minute.
was higher than normal range in other three postures. In others word,
the HR variability was lower in prone posture (Table 2). postures (p < .01) (Table 5). Therefore, compared to the supine, SpO2
Comparison of the mean SpO2, HR, and RR values between prone, was higher in prone and in left-lateral postures (Table 4).
right-lateral, supine, and left-lateral postures showed that only mean
SpO2 values was significantly different between the four body postures 4. Discussion
(p < .01). The RR and HR did not obviously change (Table 4). Based on
pairwise comparison, difference of the mean SpO2 values were sig- In the present study, we observed the behavior of physiological
nificant between prone and supine and between supine and left-lateral parameters in the preterm infants with RD under CPAP and PEEP, such

Table 2
Comparison the Physiological Parameters in Different Body Postures by ANOVA with repeated measurement.
Posture Time (min) SpO2 (%) HR (bpm) RR(r/m)

Mean ± SD pvalue Mean ± SD pvalue Mean ± SD pvalue

Prone Zero 95.69 ± 2.02 <.001* 136.84 ± 12.53 .265 55.38 ± 11.12 <.01**
60 96.2 ± 2.07 136.31 ± 11.16 54.84 ± 11.03
120 96.76 ± 2.01 135.69 ± 11.16 53.11 ± 11.37
Right-lateral Zero 96.18 ± 1.59 .169 137.49 ± 10.49 .649 54.58 ± 11.33 .912
60 95.87 ± 1.31 137.24 ± 10.82 54.4 ± 10.43
120 95.82 ± 1.64 136.71 ± 9.392 54.71 ± 11.81
Supine Zero 95.8 ± 1.84 .001** 138.49 ± 11.8 .420 55.96 ± 11.74 .37
60 95.53 ± 1.9 138.80 ± 11.21 56.49 ± 11.86
120 94.87 ± 2.18 139.33 ± 10.99 56.53 ± 11.63
Left-lateral Zero 96.00 ± 1.977 .234 137.07 ± 10.39 .903 54.27 ± 11.04 .07
60 96.04 ± 1.75 137.33 ± 10.67 54.8 ± 11.7
120 96.36 ± 2.12 137.16 ± 10.37 55.22 ± 11.62

*In the level <0.001 is significant.

**In the level <0.01 is significant.
Note. SD = standard deviation; Min = minute; SpO2 = arterial oxygen saturation; HR = heart rate; RR = respiratory rate; bpm = beat per minute; r/m = rate per
minute.

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F. Cheraghi, et al. Journal of Neonatal Nursing 26 (2020) 212–216

Table 5 in premature infants (Yin et al., 2016). Similar the present study, some
The results of pairwise comparison of SpO2 between different body postures. studies did not show any significant or clinically differences in the RR of
Posture Mean Difference Std. Error p value
preterm infants between prone and supine (Brunherotti and Martinez,
2013; Cox et al., 2001) and between prone, supine and lateral postures
Prone and Right-lateral 0.08 0.2 1 (Gouna et al., 2013).
Prone and Supine 0.52 0.24 .008*
In the current study, the lowest mean HR value was seen in prone
Prone and Left-lateral 0.26 0.23 1
Supine and Right-lateral 0.56 0.22 .1
and the highest one was observed in the supine posture, while the HR
Supine and Left-lateral 0.73 0.2 .006* variability was not significant between different body postures. Besides,
Right-lateral and Left-lateral 0.18 0.23 1 the HR was statistically the same in four different body postures during
120 min. The maximum of mean HR value fluctuated within normal
*In the level <0.01 is significant.
range of 160/min in prone, while it was higher than the normal range
Note. Std. Error = standard error; SpO2 = arterial oxygen saturation.
in other three postures. In others word, the HR variability was lower in
prone than the other postures. In similar studies, no significant differ-
as SpO2, HR, and RR in prone, right-lateral, supine, and left-lateral
ences were found between the HR in the different positioning arm of the
postures over a period of 120 min. Based on the results, the SpO2 was
study (Gillies et al., 2012; Malagoli et al., 2012; Brunherotti and
improved in prone and left-lateral postures compared with supine,
Martinez, 2013).
while the RR and HR were not significantly different between four
Our findings are useful for health professionals and improving
different postures. Moreover, according to the mean of values, the RR
nursing care in NICUs. We recommend the routine use of prone and
was slightly decreased, SpO2 was improved and HR variability was
side-lying postures for preterm infants with RD for prolonged periods of
lower in prone posture than the other postures during 120 min. In su-
time, accompanied by close cardiorespiratory monitoring. Current
pine posture, the SpO2 was slightly decreased after 60 min. In the right-
study shows supine posture has not risk of adverse disadvantages to
and left-lateral postures, the SpO2, RR, and HR had no noteworthy
physiological outcomes during 60 min. It's important to remember that
changes during 120 min.
keeping infants in supine facilitate observation, caring and handling.
Other similar studies showed improvement in oxygenation after
A limitation of the present study was the small number of partici-
placing infants with RD in prone posture (Gillies et al., 2012; Rivas-
pants from one NICU due to time constraints. Physiological changes in
Fernandez et al., 2016; Leipälä et al., 2003). According to Malagoli
the preterm infants were only measured in a short time period and the
et al. (2012), the SpO2 was higher in prone versus supine posture while
small changes in oxygenation, HR, and RR which were seen. So, similar
preterm infants being weaned from mechanical ventilation (Malagoli
studies with larger samples from different level of NICU for longer time
et al., 2012), Brunherotti et al. showed that the SpO2 of preterm infants
periods could increase the validity of data and help improve outcomes.
in prone posture was higher than supine (Brunherotti and Martinez,
It is also recommended performing this study by comparing these four
2013). Gouna et al. (2013) found that the SpO2 of premature infants
postures with nest positioning in preterm infants and in infants under
with respiratory failure was higher in both prone and left-lateral pos-
CPAP, PEEP and or mechanical ventilation. Further trials are needed to
tures than supine. They concluded that the infants receiving mechanical
detect which types of patients can benefit more effectively from prone
ventilation could tolerate the lateral as well as prone posture (Gouna
or left-lateral postures, and or from the duration, length and frequency
et al., 2013). These results were consistent with the results of the pre-
of different body postures.
sent study. Nevertheless, some studies with different infants' popula-
tions had different findings. In a study, there was no difference between
prone, supine and left-lateral postures in terms of oxygenation in in- 5. Conclusions
fants with acute RD (Gillies et al., 2012). Vendettuoli et al. (2015)
suggested that prone positioning was not important advantages in lung Prone and left-lateral postures had better outcomes than supine in
mechanics in mechanically ventilated infants with respiratory distress terms of SpO2. But based on SpO2, RR and HR, Prone positioning can be
syndrome (RDS) (Vendettuoli et al., 2015). Another study showed that beneficial for the preterm infant with RD during 120 min. Supine
although SpO2 in supine was statistically decreased, there was no dif- posture also has not risk of adverse disadvantages to physiological
ference between SpO2 in preterm infants under mechanical ventilation outcomes during 60 min, accompanied by cardiorespiratory monitoring
in supine and lateral postures (Rivas-Fernandez et al., 2016). Elder et al. in the protected environment of the NICU.
(2005) stated that SpO2 of preterm infants with chronic lung disease
(CLD) was better in supine than prone posture. They suggested that the
Human and animal rights
supine posture seems suitable for preterm infants with CLD going home
from hospital (Elder et al., 2005). The different results of the present
No Animals were used for current study. The purpose of the study
study could be due to the need of oxygen, because the oxygen need of
was explained to the parents of the participant infants. Infant's parents
infants participating in Elder's study was different, while in the present
have right to decide not to continue to participate. All infants were
study, all infants had the same conditions.
under supervision and cardio-respiratory monitoring.
The present study showed that the RR was slightly decreased during
120 min in prone posture. The maximum mean RR value was higher
than the normal range of 60/min in all different postures during Consent for publication
120 min and it was slightly higher in left-lateral posture. However, RR
variability was not significant between different postures. According to The results were anonymously reported to comply with the ethical
a study, RR of preterm infants with RD was decreased in prone after 6 h criteria. Therefore, we did not ask for an informed consent for pub-
(Leipälä et al., 2003). Also, Vendettuoli et al. (2015) showed that RR in lication from the parents of participants. All authors have read the final
infants with broncho-pulmonary dysplasia (BPD) was lower in prone version of the paper. Paper presented has been confirmed by all au-
(Vendettuoli et al., 2015). Another study indicated the highest mean RR thors. All authors had access to data and a role in writing and approving
value in supine posture without an elastic band and it decreased in the submitted version.
prone with an elastic band compared with supine posture with and
without an elastic band in preterm infants with RD (Brunherotti and
Funding
Martinez, 2013). However, in the other study, RR was decreased in
semi-prone and supine posture after 1 h compared with lateral posture
No external funding.

215
F. Cheraghi, et al.
Ethics approval and consent to participate
This study design and procedures were approved by the Institutional
Review Board (approval number: 950221675) and the Research Ethic
Board of Hamadan University of Medical Sciences (Ethical NO. was
IR.UMSHA.REC.1395.28.). Written informed consents were obtained
from the preterm infants' parents. The purpose of the study was ex-
plained to the parents. It is also important to note that the results of the
study were anonymously reported to comply with the ethical criteria.
Declaration of competing interest
None.
Acknowledgments
We would like to thank the vice-chancellor of education and the
vice-chancellor of research and technology at Hamadan University of
Medical Sciences. We would like to thank of personnel of the Fatemiyeh
hospital in Hamadan, Iran and parents of preterm infants who did not
hesitate his own collaboration.
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