Effects of Positioning on Complications of Preterm Infants with Respiratory Distress Syndrome Treated with Nasal Continuous Positive Airway Pressure: A Randomized Clinical Trial

Document Type : Original Article


1 Department of Pediatrics, Division of Neonatology, Child Growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

2 Child Growth and Development Research Center, Research Institute for Primordial Prevention of Noncommunicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran


Background: Nasal Continuous Positive Airway Pressure (N-CPAP) is the standard method of respiratory support in neonatal intensive care units, and this method is used for almost all infants with respiratory distress syndrome (RDS) for respiratory support. The position of infants under N-CPAP (prone and supine) affects the amount of blood supply. This study aimed to compare the prone \\and supine positions, followed by the investigation of their effects on various respiratory parameters and prematurity complications in premature infants with RDS treated with N-CPAP.
Methods: This randomized clinical trial was conducted on 127 premature infants under N-CPAP treatment in the neonatal intensive care units of Al-Zahra and Shahid Beheshti hospitals, Isfahan, Iran. Babies were placed in two groups of 68 and 59 cases with supine and prone positions, respectively. The duration of N-CPAP, the number of prescribed doses of surfactant, the need for mechanical ventilation, time to full feed, and positive end-expiratory pressure (PEEP) were investigated in this study. The obtained data were then analyzed using SPSS software (version 22).
Results: The mean±SD values of gestational age and birth weight of the neonates were 31.88±1.30 weeks and 1672.40±443.67 g, respectively. The frequency of using different modes of mechanical ventilation was significantly lower in the prone position group, compared to the supine position group ([17% vs. 32.4%], X2[3, N=127]=7.95, P<0.05). There was a significant correlation between position and using mechanical ventilation during the first 72 hours (P=0.04, Correlation Coefficient=0.182). Multivariate analysis indicated a significant correlation between position and mean time of PEEP (P<0.001, F=13.67), mean of surfactant use (P=0.013, F=6.38), and time to full feed (P=0.002, F=10.29).
Conclusion: The results of this study showed that placing preterm infants with RDS who are treated with N-CPAP in the prone position reduces complications related to being preterm or using N-CPAP.


  1. Agbeno EK, Osarfo J, Ashong J, Anane-Fenin B, Okai E, Ofori AA, et al. Determinants of preterm survival in a tertiary hospital in Ghana: A ten-year review. PloS one. 2021;16(1):e0246005.
  2. Ghorbani F, Asadollahi M, Valizadeh S. Comparison the effect of sleep positioning on cardiorespiratory rate in noninvasive ventilated premature infants. Nursing and Midwifery Studies. 2013;2(2):182-7.
  3. Hoshino Y, Arai J, Cho K, Yukitake Y, Kajikawa D, Hinata A, et al. Diagnosis and management of neonatal respiratory distress syndrome in Japan: A national survey. Pediatr Neonatol. 2023;64(1):61-7.
  4. Basnet S, Adhikari S, Jha J, Pandey MR. Neonatal Intensive Care Unit Admissions among Preterm Babies in a Tertiary Care Centre: A Descriptive Cross-sectional Study. J Nepal Med Assoc. 2022;60(248):364-8.
  5. Babaei H, Pirkashani LM, Soleimani B. Comparison of the effect of supine and prone positions on physiological parameters of preterm infants under nasal continuous positive airway pressure (N-CPAP): a cross over clinical trial. Çukurova Med J. 2019;44(4):1250-5.
  6. Curley MA, Arnold JH, Thompson JE, Fackler JC, Grant MJ, Fineman LD et al. Clinical trial designeffect of prone positioning on clinical outcomes in infants and children with acute respiratory distress syndrome. J Crit Care. 2006;21(1):23-32.
  7. Alinejad-Naine M. Neonatal positioning during care in neonatal intensive care unit. Iranian Journal of Cardiovascular Nursing. 2014;3(1):60-5.
  8. Balaguer A, Escribano J, Roque M. Infant position in neonates receiving mechanical ventilation. Cochrane Database Syst Rev. 2003;1(2):CD003668.
  9. Babaei H, Pirkashani LM, Soleimani B. Comparison of the effect of supine and prone positions on physiological parameters of preterm infants under nasal continuous positive airway pressure (N-CPAP): a cross over clinical trial. Çukurova Med J. 2019;44(4):1250-5.
  10. Gardner SL, Carter BS, Enzman-Hines MI, Niermeyer S. Merenstein & Gardner's Handbook of Neonatal Intensive Care-E-Book: An Interprofessional Approach. Elsevier Health Sciences; 2020 Feb 5.
  11. Eichenwald EC, Cummings JJ, Aucott SW, Goldsmith JP, Hand IL, Juul SE, et al. Diagnosis and management of gastroesophageal reflux in preterm infants. Pediatrics. 2018;142(1):
  12. Torabian H, Alinejad S, Bayati A, Rafiei F, Khosravi S. Comparison of the effects of supine and prone positions on oxygen saturation and vital signs in premature infants: A crossover clinical trial. Iran J Neonatol. 2019;10(2):30-6.
  13. Abdeyazdan Z, Nematollahi M, Ghazavi Z, Mohhamadizadeh M. The effects of supine and prone positions on oxygenation in premature infants undergoing mechanical ventilation. Iranian J Nurs Midwifery Res. 2010;15(4):229-33.
  14. Gouna G, Rakza T, Kuissi E, Pennaforte T, Mur S, Storme L. Positioning effects on lung function and breathing pattern in premature newborns. J Pediatr. 2013;162(6):1133-7.
  15. Eghbalian F. A comparison of supine and prone positioning on improves arterial oxygenation in premature neonates. J Neonatal Perinatal Med. 2014;7(4):273-7.
  16. Babuyeh T, Farhadi R, Zahed Pasha Y, Haghshenas Mojaveri M. The impacts of prone position on the blood oxygen saturations and heart rates of preterm infants under the mechanical ventilation. Caspian Journal of Pediatrics. 2018;4(2):301-5.
  17. Elder ED, Campbell GA, Doherty AD. Prone or supine for infants with chronic lung disease at neonatal discharge. Pediatr J. 2005;41(4):180-5.
  18. Torabi Z, Ghaheri V, Falak Aflaki B. The effect of body position on the arterial oxygen saturation of healthy premature neonates: a clinical trial. J Mazand Univ Med Sci. 2012;21(86):234-42.
  19. Kahn DJ, Habib RH, Courtney SH. Effects of flow amplitudes on intraprong pressures during bubble versus ventilator generated nasal continuous positive airway pressure in premature infants. Pediatrics. 2008;122(5):1009-13.
  20. Stevens TP, Blennow M, Myers EH, Soll R. Early surfactant administration with brief ventilation vs selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiratory distress syndrome. Cochrane Database Syst Review. 2009;1: CD 003063.
  21. Mazella M, Bellini C, Calevo MG, Campone F, Massocco D, Mezzano P, et al. A randomized control study comparing the Infant Flow Driver with nasal continuous positive airway pressure in preterm infants. Arch Dis Child Fetal Neonatal Ed. 2001;85(2): F86-90.
  22. Rojas MA, Lozano JM, Rojas MX, Laughon M, Bose CL, Rondon MA, et al. Very early surfactant without mandatory ventilation in premature infants treated with early continuous positive airway pressure: A Randomized Controlled Trial. Pediatrics. 2009;123(1):137-42.
  23. Baird TM, Paton JB, Fisher DE. Improved oxygenation with prone positioning in neonates: stability of increased transcutaneous PO2. J Perinatol. 1991;11(4):315-8.
  24. Gillies D, Wells D. Positioning for acute respiratory distress in hospitalised infants and children. Cochrane Database Syst Rev. 2005;2:
  25. Vafaienejad T, Fakhr-Movahedi A, Salimi T, Nooripur S. Comparing the effect of prone and supine positions on respiratory status of acute respiratory distress syndrome newborns treated by insure protocol. Nursing and Midwifery Journal. 2015;13(2):116-23.
  26. Balali F, Jafari Z, Dabirian A, Heidarzadeh M, Nasiri M. The effect of posture in premature infants on the arterial oxygen saturation, fraction of inspired oxygen and abdominal distension. Feyz Med Sci. 2017;21(5):470-6.
  27. Farhat A, Mohammad zadeh A, Alizadeh E, Amiri M. Effect of care position on oxygen saturation in healthy low birth weight infants. Med J Mashad Univ Med Scio 2005;48: 85-8.
  28. Speer CP, Sweet DG, Halliday HL. Surfactant therapy: past, present and future. Early Hum Dev. 2013;89(Supplement 1): S22-4.
  29. Walsh BK, Daigle B, DiBlasi RM, Restrepo RD. AARC clinical practice guideline. Surfactant replacement therapy: 2013. Respir Care. 2013;58(2):367-75.
  30. Lam R, Schilling D, Scottoline B, Platteau A, Niederhausen M, Lund KC, et al. The effect of extended continuous positive airway pressure on changes in lung volumes in stable premature infants: a randomized controlled trial. J Pediatr. 2020;217:66-72.