Posición corporal para recién nacidos prematuros con apnea que respiran espontáneamente
References
Referencias de los estudios incluidos en esta revisión
Referencias de los estudios excluidos de esta revisión
Referencias de los estudios en espera de evaluación
Referencias adicionales
Referencias de otras versiones publicadas de esta revisión
Characteristics of studies
Characteristics of included studies [ordered by study ID]
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| Methods | Quasi‐randomised controlled cross‐over trial | |
| Participants | Participants: 21 preterm infants with 3 or more episodes of clinical apnoea not associated with feeds and with no other conditions (otherwise healthy) who were not receiving assisted ventilation including nasal CPAP Infants treated with theophylline had to show stability for at least 48 hours before study entry. 7 infants were receiving supplemental ambient oxygen and were nursed in convenient isolettes. Mean birth weight: 1220 grams Mean gestational age: 28.3 weeks | |
| Interventions | Lateral (experimental) vs prone (control) position Body position was changed every 3 hours, with each infant spending 12 hours in each body position for a period of 48 hours, and with each infant acting as his/her own control. Instrument(s) of measurement included: • a 3‐channel cardiorespiratory impedance monitor, used to record respiration pattern (channel 1), oxygen saturation (channel 2) and heart rate (channel 3); and • a pulse oximetry polygraph, used to record apnoeic events. | |
| Outcomes | Episodes of apnoea were defined as: • cessation of breathing for ≥ 20 seconds; and • cessation of breathing for < 20 seconds but associated with a simultaneous fall in heart rate to > 30% below baseline. Frequency of apnoea was measured as the number of apnoeic events that occurred for each body position. | |
| Notes | ||
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Infants were allocated to their specific positions by a Latin square randomisation design after they were randomly assigned a sequence. |
| Allocation concealment (selection bias) | High risk | "Prior to commencement of the study each subject was 'randomly assigned' to a sequence 1, 2, 3 or 4, and the prone and lateral positions were allocated using a Latin Square". However, infants were shifted every 3 hours to the other position of the sequence defined in the Latin square; thus anyone who knew the previous position of the infant could easily know the infant's sequence number. |
| Blinding of participants and personnel (performance bias) | High risk | High possibility of performance bias was due to knowledge of allocated interventions by personnel attending the infants. The statement "If the body position of the infant was changed during these time periods for routine medical or nursing interventions, the infant was returned to the 'appropriate position' of the sequence as soon as possible" indicates that personnel knew the sequence of all infants who had to receive some kind of medical or nursing intervention. |
| Blinding of outcome assessment (detection bias) | High risk | High possibility of detection bias was due to knowledge of allocated interventions by outcome assessors. However, no information was reported on whether blinding occurred at the data analysis stage. |
| Incomplete outcome data (attrition bias) | Unclear risk | No information was reported on missing outcome data or loss to follow‐up and how these were handled. The paper does not mention or tabulate how many or if all enrolled infants (21) had data provided. |
| Selective reporting (reporting bias) | Low risk | The study was undertaken as per protocol, and all predefined outcomes of interest were reported in the final manuscript. |
| Other bias | High risk | Carry‐over of treatment effect was noted. The order in which interventions were administered may have affected outcomes, especially because no "wash‐out" period between interventions was reported. |
| Methods | Quasi‐randomised controlled cross‐over trial | |
| Participants | Participants: 36 clinically stable preterm infants (19 males and 17 females) with a history of recurrent apnoea sustaining at least 3 clinical events documented during the previous 24 hours but with no evidence of intercurrent illness known to be associated with apnoea (otherwise healthy), who were not receiving assisted ventilation including nasal CPAP Infants with a diagnosis of gastro‐oesophageal reflux, with haemoglobin < 80 g/L or with development of grade 3/4 intraventricular haemorrhage were excluded from the study. Before study initiation, all infants received intragastric feedings to at least 90 mL/kg/d. After initiation of the study: • 29 infants (81%) received feedings with breast milk exclusively; • 29 infants (81%) received caffeine therapy and had to show a stable regimen for at least 24 hours before entry into the study; and • 17 infants (47%) were receiving supplemental oxygen (92%‐96% inspired oxygen). Only 1 infant developed grade 1/2 intraventricular haemorrhage. All infants were housed in incubators. Median gestational age at birth: 27 weeks (range 24‐33 weeks) Median postnatal age at entry to the study: 22.5 days (range 3‐77 days) Median birth weight: 1300 grams (range 800‐1900 grams) | |
| Interventions | Infants were initially allocated to 1 of 6 body positions ‐ prone 1, prone 2, right lateral 1, right lateral 2, left lateral 1 and left lateral 2 ‐ via assignment of a sequence number from 1 to 6, respectively, via a Latin square. Body position was changed every 4 hours over a period of 24 hours, with each infant acting as his/her own control and going through all 6 positions. When an infant was in any of the positions '1', he/she was placed in a horizontal or flat position. When the infant was rotated to any of the positions '2', he/she was placed in an elevated position on the mattress at a 15 degree elevation angle. An added seventh period of monitoring lasting for 4 hours at the end of each of the 6 sequences accounted for the remaining 4 hours of the 28‐hour monitoring period. Infants went through this 4‐hour period to reveal adverse effects that may have been associated with movement of the infant from the last position in the sequence to the next one in the sequence, just to show that the sequence of body positions makes no difference with regards to the outcomes of interest (Hypothesis 9). Instrument(s) of measurement included: • a neonatal cardiorespiratory monitor (Neo‐Trak 502 Infant Monitor; Corometrics Medical Systems Inc., Wallingford, Connecticut, USA), used to record respiratory effort (apnoeic events) and heart rate (bradycardiac events); and • a pulse oximeter (Nellcor Symphony N‐3000‐U20; Nellcor Inc., Chula Vista, California, USA), used to measure oxygen saturation. | |
| Outcomes | • Episodes of apnoea, defined as cessation of breathing lasting ≥ 20 seconds, or lasting < 20 seconds with a concomitant fall in heart rate to > 30% below baseline • Episodes of bradycardia, defined as a fall in heart rate to > 30% below baseline for ≥ 10 seconds • Episodes of oxygen desaturation, defined as the number of episodes during which oxygen saturation fell to < 85% for > 10 seconds (the total time (minutes) each infant spent with oxygen saturation < 85% in each body position was also documented) • Episodes of severe bradycardia, defined as a fall in heart rate to > 30% below baseline for ≥ 10 seconds and a concurrent fall in oxygen saturation to < 85% • Episodes of mixed events (apnoea with bradycardia and desaturation), defined as cessation of breathing for ≥ 20 seconds and a fall in heart rate to > 30% below baseline and a concurrent fall in oxygen saturation to < 85% | |
| Notes | ||
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Infants were allocated to specific positions by a Latin square randomisation design after they were randomly assigned a sequence. |
| Allocation concealment (selection bias) | High 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". However, infants were shifted every 4 hours to the other position of the sequence defined in the Latin square; thus anyone who knew the previous position of the infant could easily know the infant's sequence number. "The randomization process was not blinded to the researcher, as it was imperative that all body positions were equally represented in the seven time zones of the study design". |
| Blinding of participants and personnel (performance bias) | High risk | High possibility of performance bias was due to knowledge of allocated interventions by nurses attending the infants. The statement "Position change times and correct body position sequences for each infant was outlined on the nursing care plan so that the nurses could readily follow the study protocol" indicates that nurses attending the infants knew the sequence of all of these infants. |
| Blinding of outcome assessment (detection bias) | Unclear risk | High possibility of detection bias was due to knowledge of allocated interventions by outcome assessors (nurses). "The nurse caring for the infant also recorded the clinical events". However, low possibility of data analysis bias was noted in that "The respiratory, cardiac, and oxygen saturation waveforms could only be accessed by the investigator during the data analysis phase of the project. Both investigator and clinician were blinded to the 'download' of these data until the infant completed the study". |
| Incomplete outcome data (attrition bias) | 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' by the investigator for analysis. Each of these 9 infants had one position (four hours) of lost data resulting in missing values sufficient to confound the multivariate analyses". "These 9 infants were removed to 'ensure consistency in the characteristics and number of subjects throughout all phases of the analyses". This left a cohort of 36 infants, who completed the study protocol with complete data sets provided for all. |
| Selective reporting (reporting bias) | Low risk | The study was undertaken as per protocol. |
| Other bias | Low risk | No carry‐over of treatment effect was noted. The order in which interventions were administered may have affected the outcomes; this was accounted for by introducing a seventh 4‐hour period position at the end of each sequence. |
| Methods | Randomised controlled cross‐over trial | |
| Participants | Participants: 14 preterm infants with recent clinical apnoea but with no other conditions (otherwise healthy) Infants did not receive supplemental oxygen or respiratory support at the time of the study. All infants were receiving enteral feeds ‐ bolus feeding by nipple or intermittent gavage. Eight (57%) infants received maintenance methylxanthines (dosage not mentioned). Nine infants had previous RDS and were intubated up to 8 days before study initiation. Infants with bronchopulmonary dysplasia were excluded from the study. More mature infants were studied at an earlier age. Mean gestational age at birth: 29.7 ± 2.8 weeks (range 26‐34 weeks) Postnatal age: 7‐59.5 days Mean birth weight: 1381 ± 474 grams (range 840‐2290 grams) | |
| Interventions | Supine vs prone position. Each infant had two 12‐hour consecutive nocturnal studies ‐ 1 in the prone position and 1 in the supine position. Infants spent most of the study time in assigned positions. No attempt was made to keep the head in the midline position, and neck and shoulders were supported to prevent neck flexion. Breathing pattern, nasal airflow, respiratory effort, heart rate and oxygen saturation were studied by nocturnal 12‐hour consecutive impedance cardiorespirography (pneumography) and were documented on a multi‐channel recorder. Episodes of obstructive or mixed apnoea ≥ 6 seconds were counted manually by an investigator who was blinded to the body position in use. Episodes of generalised body movements that resulted in an abrupt fall in heart rate pattern on the oximeter, without coincident bradycardia, were excluded from the analysis. | |
| Outcomes | • Episodes of apnoea, measured as the number of cessations of breathing per recording, with each lasting ≥ 6 seconds and classified by severity as: ‐ Mild (6‐11 seconds); ‐ Moderate (11‐15 seconds); or ‐ Severe (≥ 15 seconds). • Episodes of bradycardia, defined as a fall in heart rate to less than 100 beats/min for ≥ 5 seconds • Episodes of oxygen desaturation, defined as a drop in oxygen saturation to < 87.5% for ≥ 10 seconds | |
| Notes | ||
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | "The order was assigned at random by sealed envelopes", but it is unclear if the envelopes were opaque and sequentially numbered. |
| Allocation concealment (selection bias) | High risk | Infants assigned to either position can be easily identified. |
| Blinding of participants and personnel (performance bias) | High risk | High possibility of performance bias was due to knowledge of allocated interventions by personnel attending the infants. |
| Blinding of outcome assessment (detection bias) | Low risk | Low possibility of detection bias was due to blinding of allocated interventions by the outcome assessor. "Obstructive or mixed apnoea periods ≥ 6 seconds duration and oxygen desaturation were counted manually by one of the investigators (JL), who was blinded regarding the position during the recordings". Low possibility of data analysis bias was noted as well, because "pneumograms were analyzed using a Pediatric Diagnostic Service computer program". |
| Incomplete outcome data (attrition bias) | Unclear risk | Data on only 10 of 14 infants regarding duration of spells of apnoea and desaturation were reported. However, data for all other outcomes measured in the study were available on all participants with no missing data. |
| Selective reporting (reporting bias) | Unclear risk | We were unable to obtain the study protocol. |
| Other bias | Unclear risk | • Carry‐over of treatment effect ‐ The order in which interventions were administered may have affected the outcome. However, a 12‐hour "wash‐out" period between interventions was reported (low risk). ‐ Even though infants were assigned to the supine position, infants were nursed prone for 1 hour after feeds to 'prevent aspiration'. This may have influenced the outcome measure of apnoea during this period because both the supine group and the prone group were in the prone position 1 hour post feed (high risk). |
| Methods | Randomised controlled cross‐over trial | |
| Participants | Participants: 12 preterm infants (6 males and 6 females) with a history of recurrent apnoea and bradycardic and hypoxaemic events but with no other conditions (otherwise healthy) Nine infants were treated with aminophylline (dosage not mentioned) for at least 3 days but had a serum concentration within the normal therapeutic range (33‐76 micromol/L). Maintenance dose (6 mg/kg) was not changed during the trial. Eight infants received supplemental oxygen (inspired oxygen fraction range 23%‐32%). Infants with heart disease, intracranial haemorrhage, anaemia or infection were excluded. Mean gestational age at birth: 28 weeks (range 26‐31 weeks) Postnatal age: 6‐38 days Mean birth weight: 1145 grams (range 815‐1450 grams) | |
| Interventions | Prone horizontal (flat) vs prone elevated (15 degree tilt) head positions Total study time was 48 hours. Each infant remained for a total of 24 hours in each of the 2 compared positions ‐ horizontal position (HP, prone, 0 degrees) and horizontal head elevated tilt position (HETP, prone, 15 degrees). Position was changed every 6 hours on the first day. On the second day, the sequence of tilt and horizontal position was reversed. During the study, each infant was nursed in an incubator. The inspired oxygen fraction and air temperature were maintained at constant levels and were noted every 2 hours. Gastric residue was documented every 2 hours. Breathing movements were recorded by thoracic impedance pneumography, in which skin electrodes were attached to both sides of the chest; a Hellige Servomed (Freiburg, Germany) respiration monitor was used. Heart rate was monitored by a Hellige Servomed ECG monitor. Oxygen saturation was recorded by pulse oximetry (Nellcor N‐200; Pleasanton, California, USA) with the sensor placed on the right foot of each infant. | |
| Outcomes | • Episodes of isolated bradycardia, defined as a decrease in heart rate to < 90 beats per minute • Episodes of isolated hypoxaemia, defined as a drop in arterial oxygen saturation to < 80% • Episodes of mixed events, defined as a decrease in oxygen saturation to < 80% and a decrease in heart rate to < 90 beats per minute (Episodes of apnoea were not recorded.) | |
| Notes | ||
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | No data were reported on how randomisation was performed. |
| Allocation concealment (selection bias) | High risk | Infants were 'randomly' assigned to allocated positions and then were shifted to the other position every 6 hours. Thus, it would be easy to trace back the initial allocation position of each infant. |
| Blinding of participants and personnel (performance bias) | High risk | High possibility of performance bias was due to knowledge of allocated interventions by personnel attending the infants. |
| Blinding of outcome assessment (detection bias) | Low risk | Low possibility of detection bias was due to blinding of allocated interventions by outcome assessors. "Isolated and mixed events were counted without the knowledge of the position of the infant". Low possibility of data analysis bias was noted as well because "The data were analysed from masked files, and then, the results were combined with the allocated body position". |
| Incomplete outcome data (attrition bias) | Low risk | All participants completed the study, and researchers reported no losses to follow‐up, no treatment withdrawals and no trial group changes. Data are available for all 12 participants enrolled in the study. |
| Selective reporting (reporting bias) | Unclear risk | We were unable to obtain the study protocol. |
| Other bias | High risk | Carry‐over of treatment effect The order in which interventions were administered may have affected the outcome, especially because no "wash‐out" period between interventions was reported. |
| Methods | Randomised controlled cross‐over trial | |
| Participants | Participants: 22 preterm infants (10 males and 12 females) with symptomatic apnoea and bradycardia but with no other conditions (otherwise healthy) Infants were not studied for the first 24 hours after extubation or discontinuation of CPAP. Sixteen infants were receiving methylxanthines and 4 were receiving both methylxanthines and doxapram for treatment of apnoea. Sixteen infants were treated for RDS with mechanical ventilation and surfactant administration. Thirteen infants were receiving supplemental oxygen during the study. Infants with any condition that prevented them from being placed in the prone or supine position (e.g. gastroschisis and meningomyelocoele, respectively) were excluded from the study. Mean gestational age: 26.9 ± 1.8 weeks (range 24‐30 weeks) Mean postconceptual age: 31.9 ± 3 weeks (range 28‐36 weeks) Mean birth weight: 865 ± 235 grams (range 500‐1331 grams) | |
| Interventions | Supine vs prone position Each infant was studied in 6‐hour blocks in both prone and supine positions for a continuous 24‐hour period. The initial position was randomly assigned, and prone and supine positions were subsequently alternated. Infants remained in their allocated positions throughout the 6‐hour designated period, except during times of assessment and feeding within the period. Infants in the prone position had their face tilted to the side, whereas those in the supine position were allowed to assume a natural position. Heart rate and respiration were monitored with standard chest electrodes connected to a cardiorespiratory monitor that had event‐recording capability (Edentec Assurance 2000; Edentec, Minneapolis, Minnesota, USA). Oxygen saturation was measured with a pulse oximeter (Nellcor 200; Nellcor, Hayward, California, USA), which was connected to the event‐recording monitor. | |
| Outcomes | • Episodes of apnoea, measured as the number of cessations of breathing lasting ≥ 10 seconds and classified by severity as: ‐ Mild (< 15 seconds); or ‐ Clinically significant (≥ 15 seconds). • Episodes of bradycardia, defined as a drop in heart rate to < 100 beats per minute and classified by severity as: ‐ Mild (≥ 90 beats per minute); or ‐ Clinically significant (< 90 beats per minute). • Episodes of oxygen desaturation, defined as a drop in arterial oxygen saturation to < 90% and classified by severity as: ‐ Mild (≥ 80%); or ‐ Clinically significant (< 80%). | |
| Notes | ||
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | No data reported how randomisation was performed. |
| Allocation concealment (selection bias) | High risk | Infants were 'randomly' assigned to an allocated position, then were shifted to the other position every 6 hours. Thus, it would be easy to trace back the initial allocation position of each infant. |
| Blinding of participants and personnel (performance bias) | High risk | High possibility of performance bias was due to knowledge of allocated interventions by personnel attending the infants. |
| Blinding of outcome assessment (detection bias) | Unclear risk | Possibility of detection bias was low because all instruments used to measure cardiorespiratory parameters were equipped with intrinsic event‐recording monitors, which excluded the need for personnel to collect data. However, no information was reported on whether any blinding occurred at the data analysis stage. |
| Incomplete outcome data (attrition bias) | Unclear risk | No information was reported on missing outcome data or loss to follow‐up and how these were handled. The paper does not mention or tabulate how many or if all enrolled infants (22) had data provided. |
| Selective reporting (reporting bias) | Unclear risk | We were unable to obtain the study protocol. |
| Other bias | High risk | Carry‐over of treatment effect The order in which interventions were administered may have affected the outcome, especially as no "wash‐out" period between interventions was provided. |
CPAP: continuous positive airway pressure.
ECG: electrocardiogram.
HETP: head elevated tilt position
RDS: respiratory distress syndrome.
Characteristics of excluded studies [ordered by study ID]
Jump to:
| Study | Reason for exclusion |
| Supine and prone positions were randomised, and effects of body position on oxygen saturation and respiratory mechanics (primary outcomes) were measured in oxygen‐ and non‐oxygen‐dependent preterm infants before discharge. Episodes of apnoea and bradycardia were not documented. | |
| Body positions were not randomised. | |
| Body positions were not randomised. | |
| Means or standard deviations were not reported. We were unable to obtain additional data from the study author. | |
| This study was published as abstract only. Means or standard deviations were not reported. Study authors were contacted, but we were unable to obtain additional data. | |
| Primary outcomes were not relevant. | |
| Infants were receiving nasal continuous positive airway pressure (CPAP). |
Characteristics of studies awaiting assessment [ordered by study ID]
Jump to:
| Methods | Randomised controlled trial |
| Participants | Preterm infants |
| Interventions | 15‐degree head elevated prone position vs 3‐stair position |
| Outcomes | Heart rate Respiratory rate Oxygen saturation |
| Notes | In Chinese |
Data and analyses
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Episodes of apnoea Show forest plot | 2 | 72 | Mean Difference (IV, Fixed, 95% CI) | 1.09 [‐0.65, 2.82] |
| Analysis 1.1  Comparison 1 Supine versus prone, Outcome 1 Episodes of apnoea. | ||||
| 2 Episodes of oxygen desaturation Show forest plot | 1 | 44 | Mean Difference (IV, Fixed, 95% CI) | 0.80 [‐3.19, 4.79] |
| Analysis 1.2  Comparison 1 Supine versus prone, Outcome 2 Episodes of oxygen desaturation. | ||||
| 3 Episodes of bradycardia Show forest plot | 2 | 72 | Mean Difference (IV, Fixed, 95% CI) | ‐0.13 [‐3.20, 2.94] |
| Analysis 1.3  Comparison 1 Supine versus prone, Outcome 3 Episodes of bradycardia. | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Episodes of apnoea Show forest plot | 2 | 130 | Mean Difference (IV, Fixed, 95% CI) | 0.48 [‐0.19, 1.15] |
| Analysis 2.1  Comparison 2 Prone horizontal versus right lateral horizontal, Outcome 1 Episodes of apnoea. | ||||
| 2 Episodes of oxygen desaturation Show forest plot | 1 | 88 | Mean Difference (IV, Fixed, 95% CI) | ‐1.86 [‐4.29, 0.56] |
| Analysis 2.2  Comparison 2 Prone horizontal versus right lateral horizontal, Outcome 2 Episodes of oxygen desaturation. | ||||
| 3 Episodes of severe apnoea Show forest plot | 1 | 88 | Mean Difference (IV, Fixed, 95% CI) | 0.05 [‐0.45, 0.54] |
| Analysis 2.3  Comparison 2 Prone horizontal versus right lateral horizontal, Outcome 3 Episodes of severe apnoea. | ||||
| 4 Episodes of bradycardia Show forest plot | 1 | 88 | Mean Difference (IV, Fixed, 95% CI) | ‐0.59 [‐2.41, 1.23] |
| Analysis 2.4  Comparison 2 Prone horizontal versus right lateral horizontal, Outcome 4 Episodes of bradycardia. | ||||
| 5 Episodes of severe bradycardia Show forest plot | 1 | 88 | Mean Difference (IV, Fixed, 95% CI) | ‐0.32 [‐1.02, 0.39] |
| Analysis 2.5  Comparison 2 Prone horizontal versus right lateral horizontal, Outcome 5 Episodes of severe bradycardia. | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Episodes of apnoea Show forest plot | 2 | 131 | Mean Difference (IV, Fixed, 95% CI) | 0.20 [‐0.75, 1.15] |
| Analysis 3.1  Comparison 3 Prone horizontal versus left lateral horizontal, Outcome 1 Episodes of apnoea. | ||||
| 2 Episodes of oxygen desaturation Show forest plot | 1 | 89 | Mean Difference (IV, Fixed, 95% CI) | ‐1.44 [‐3.81, 0.92] |
| Analysis 3.2  Comparison 3 Prone horizontal versus left lateral horizontal, Outcome 2 Episodes of oxygen desaturation. | ||||
| 3 Episodes of severe apnoea Show forest plot | 1 | 89 | Mean Difference (IV, Fixed, 95% CI) | 0.11 [‐0.38, 0.60] |
| Analysis 3.3  Comparison 3 Prone horizontal versus left lateral horizontal, Outcome 3 Episodes of severe apnoea. | ||||
| 4 Episodes of bradycardia Show forest plot | 1 | 89 | Mean Difference (IV, Fixed, 95% CI) | ‐0.17 [‐0.94, 0.60] |
| Analysis 3.4  Comparison 3 Prone horizontal versus left lateral horizontal, Outcome 4 Episodes of bradycardia. | ||||
| 5 Episodes of severe bradycardia Show forest plot | 1 | 89 | Mean Difference (IV, Fixed, 95% CI) | ‐0.22 [‐0.94, 0.49] |
| Analysis 3.5  Comparison 3 Prone horizontal versus left lateral horizontal, Outcome 5 Episodes of severe bradycardia. | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Episodes of apnoea Show forest plot | 2 | 131 | Mean Difference (IV, Fixed, 95% CI) | ‐0.27 [‐1.10, 0.57] |
| Analysis 4.1  Comparison 4 Right lateral versus left lateral, Outcome 1 Episodes of apnoea. | ||||
| 2 Episodes of oxygen desaturation Show forest plot | 1 | 89 | Mean Difference (IV, Fixed, 95% CI) | 0.42 [‐2.42, 3.26] |
| Analysis 4.2  Comparison 4 Right lateral versus left lateral, Outcome 2 Episodes of oxygen desaturation. | ||||
| 3 Episodes of severe apnoea Show forest plot | 1 | 89 | Mean Difference (IV, Fixed, 95% CI) | 0.01 [‐0.40, 0.42] |
| Analysis 4.3  Comparison 4 Right lateral versus left lateral, Outcome 3 Episodes of severe apnoea. | ||||
| 4 Episodes of bradycardia Show forest plot | 1 | 89 | Mean Difference (IV, Fixed, 95% CI) | 0.42 [‐1.43, 2.27] |
| Analysis 4.4  Comparison 4 Right lateral versus left lateral, Outcome 4 Episodes of bradycardia. | ||||
| 5 Episodes of severe bradycardia Show forest plot | 1 | 89 | Mean Difference (IV, Fixed, 95% CI) | 0.09 [‐0.68, 0.87] |
| Analysis 4.5  Comparison 4 Right lateral versus left lateral, Outcome 5 Episodes of severe bradycardia. | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Episodes of apnoea Show forest plot | 2 | 129 | Mean Difference (IV, Fixed, 95% CI) | ‐0.18 [‐1.09, 0.73] |
| Analysis 5.1  Comparison 5 Prone horizontal versus prone head elevated, Outcome 1 Episodes of apnoea. | ||||
| 2 Episodes of oxygen desaturation Show forest plot | 2 | 111 | Mean Difference (IV, Fixed, 95% CI) | ‐0.62 [‐2.81, 1.56] |
| Analysis 5.2  Comparison 5 Prone horizontal versus prone head elevated, Outcome 2 Episodes of oxygen desaturation. | ||||
| 3 Episodes of severe apnoea Show forest plot | 1 | 87 | Mean Difference (IV, Fixed, 95% CI) | ‐0.24 [‐0.83, 0.35] |
| Analysis 5.3  Comparison 5 Prone horizontal versus prone head elevated, Outcome 3 Episodes of severe apnoea. | ||||
| 4 Episodes of bradycardia Show forest plot | 2 | 111 | Mean Difference (IV, Fixed, 95% CI) | ‐0.14 [‐1.03, 0.74] |
| Analysis 5.4  Comparison 5 Prone horizontal versus prone head elevated, Outcome 4 Episodes of bradycardia. | ||||
| 5 Episodes of severe bradycardia Show forest plot | 2 | 111 | Mean Difference (IV, Fixed, 95% CI) | ‐0.28 [‐1.15, 0.59] |
| Analysis 5.5  Comparison 5 Prone horizontal versus prone head elevated, Outcome 5 Episodes of severe bradycardia. | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Episides of apnoea Show forest plot | 1 | 86 | Mean Difference (IV, Fixed, 95% CI) | ‐0.79 [‐2.26, 0.69] |
| Analysis 6.1  Comparison 6 Right lateral horizontal versus right lateral elevated, Outcome 1 Episides of apnoea. | ||||
| 2 Episodes of oxygen desaturation Show forest plot | 1 | 86 | Mean Difference (IV, Fixed, 95% CI) | 0.03 [‐3.06, 3.11] |
| Analysis 6.2  Comparison 6 Right lateral horizontal versus right lateral elevated, Outcome 2 Episodes of oxygen desaturation. | ||||
| 3 Episodes of severe apnoea Show forest plot | 1 | 86 | Mean Difference (IV, Fixed, 95% CI) | ‐0.14 [‐0.69, 0.41] |
| Analysis 6.3  Comparison 6 Right lateral horizontal versus right lateral elevated, Outcome 3 Episodes of severe apnoea. | ||||
| 4 Episodes of bradycardia Show forest plot | 1 | 86 | Mean Difference (IV, Fixed, 95% CI) | 0.34 [‐1.54, 2.22] |
| Analysis 6.4  Comparison 6 Right lateral horizontal versus right lateral elevated, Outcome 4 Episodes of bradycardia. | ||||
| 5 Episodes of severe bradycardia Show forest plot | 1 | 86 | Mean Difference (IV, Fixed, 95% CI) | 0.60 [‐0.25, 1.46] |
| Analysis 6.5  Comparison 6 Right lateral horizontal versus right lateral elevated, Outcome 5 Episodes of severe bradycardia. | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Episodes of apnoea Show forest plot | 1 | 87 | Mean Difference (IV, Fixed, 95% CI) | 0.46 [‐0.34, 1.26] |
| Analysis 7.1  Comparison 7 Left lateral horizontal versus left lateral elevated, Outcome 1 Episodes of apnoea. | ||||
| 2 Episodes of oxygen desaturation Show forest plot | 1 | 87 | Mean Difference (IV, Fixed, 95% CI) | 0.63 [‐2.09, 3.35] |
| Analysis 7.2  Comparison 7 Left lateral horizontal versus left lateral elevated, Outcome 2 Episodes of oxygen desaturation. | ||||
| 3 Episodes of severe apnoea Show forest plot | 1 | 87 | Mean Difference (IV, Fixed, 95% CI) | 0.18 [‐0.18, 0.54] |
| Analysis 7.3  Comparison 7 Left lateral horizontal versus left lateral elevated, Outcome 3 Episodes of severe apnoea. | ||||
| 4 Episodes of bradycardia Show forest plot | 1 | 87 | Mean Difference (IV, Fixed, 95% CI) | 0.08 [‐0.71, 0.88] |
| Analysis 7.4  Comparison 7 Left lateral horizontal versus left lateral elevated, Outcome 4 Episodes of bradycardia. | ||||
| 5 Episodes of severe bradycardia Show forest plot | 1 | 87 | Mean Difference (IV, Fixed, 95% CI) | ‐0.17 [‐0.93, 0.58] |
| Analysis 7.5  Comparison 7 Left lateral horizontal versus left lateral elevated, Outcome 5 Episodes of severe bradycardia. | ||||
Study flow diagram: review update.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Comparison 1 Supine versus prone, Outcome 1 Episodes of apnoea.
Comparison 1 Supine versus prone, Outcome 2 Episodes of oxygen desaturation.
Comparison 1 Supine versus prone, Outcome 3 Episodes of bradycardia.
Comparison 2 Prone horizontal versus right lateral horizontal, Outcome 1 Episodes of apnoea.
Comparison 2 Prone horizontal versus right lateral horizontal, Outcome 2 Episodes of oxygen desaturation.
Comparison 2 Prone horizontal versus right lateral horizontal, Outcome 3 Episodes of severe apnoea.
Comparison 2 Prone horizontal versus right lateral horizontal, Outcome 4 Episodes of bradycardia.
Comparison 2 Prone horizontal versus right lateral horizontal, Outcome 5 Episodes of severe bradycardia.
Comparison 3 Prone horizontal versus left lateral horizontal, Outcome 1 Episodes of apnoea.
Comparison 3 Prone horizontal versus left lateral horizontal, Outcome 2 Episodes of oxygen desaturation.
Comparison 3 Prone horizontal versus left lateral horizontal, Outcome 3 Episodes of severe apnoea.
Comparison 3 Prone horizontal versus left lateral horizontal, Outcome 4 Episodes of bradycardia.
Comparison 3 Prone horizontal versus left lateral horizontal, Outcome 5 Episodes of severe bradycardia.
Comparison 4 Right lateral versus left lateral, Outcome 1 Episodes of apnoea.
Comparison 4 Right lateral versus left lateral, Outcome 2 Episodes of oxygen desaturation.
Comparison 4 Right lateral versus left lateral, Outcome 3 Episodes of severe apnoea.
Comparison 4 Right lateral versus left lateral, Outcome 4 Episodes of bradycardia.
Comparison 4 Right lateral versus left lateral, Outcome 5 Episodes of severe bradycardia.
Comparison 5 Prone horizontal versus prone head elevated, Outcome 1 Episodes of apnoea.
Comparison 5 Prone horizontal versus prone head elevated, Outcome 2 Episodes of oxygen desaturation.
Comparison 5 Prone horizontal versus prone head elevated, Outcome 3 Episodes of severe apnoea.
Comparison 5 Prone horizontal versus prone head elevated, Outcome 4 Episodes of bradycardia.
Comparison 5 Prone horizontal versus prone head elevated, Outcome 5 Episodes of severe bradycardia.
Comparison 6 Right lateral horizontal versus right lateral elevated, Outcome 1 Episides of apnoea.
Comparison 6 Right lateral horizontal versus right lateral elevated, Outcome 2 Episodes of oxygen desaturation.
Comparison 6 Right lateral horizontal versus right lateral elevated, Outcome 3 Episodes of severe apnoea.
Comparison 6 Right lateral horizontal versus right lateral elevated, Outcome 4 Episodes of bradycardia.
Comparison 6 Right lateral horizontal versus right lateral elevated, Outcome 5 Episodes of severe bradycardia.
Comparison 7 Left lateral horizontal versus left lateral elevated, Outcome 1 Episodes of apnoea.
Comparison 7 Left lateral horizontal versus left lateral elevated, Outcome 2 Episodes of oxygen desaturation.
Comparison 7 Left lateral horizontal versus left lateral elevated, Outcome 3 Episodes of severe apnoea.
Comparison 7 Left lateral horizontal versus left lateral elevated, Outcome 4 Episodes of bradycardia.
Comparison 7 Left lateral horizontal versus left lateral elevated, Outcome 5 Episodes of severe bradycardia.
| Supine versus prone positioning | |||||
| Patient or population: spontaneously breathing preterm infants with apnoea | |||||
| Outcomes | Anticipated absolute effects* (95% CI) | Comments | Number of participants | Quality of the evidence | |
| Risk with prone positioning | Risk with supine positioning | ||||
| Episodes of apnoea | Mean difference (MD) 1.09 (‐0.65 to 2.82) Favours prone positioning group Not statistically significant | Overall, episodes of apnoea were 1.09 more (0.65 fewer to 2.82 more) among preterm infants in the supine positioning group compared with preterm infants in the prone positioning group. | 72 | ⊕⊝⊝⊝ | |
| Episodes of oxygen desaturation | Mean difference (MD) 0.8 (‐3.19 to 4.79) Favours prone positioning group Not statistically significant | Overall, episodes of oxygen desaturation were 0.8 more (3.19 fewer to 4.79 more) among preterm infants in the supine positioning group compared with preterm infants in the prone positioning group.. | 44 | ⊕⊝⊝⊝ | |
| Episodes of bradycardia | Mean difference (MD) 0.13 (‐3.2 to 2.94) Favours supine positioning group Not statistically significant | Overall, episodes of bradycardia were 0.13 fewer (3.2 fewer to 2.94 more) among preterm infants in the supine positioning group compared with preterm infants in the prone positioning group. | 72 | ⊕⊝⊝⊝ | |
| *The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | |||||
| GRADE Working Group grades of evidence. | |||||
| aHigh or unclear risk of allocation concealment. bHigh or unclear risk of performance bias. cHigh or unclear risk of detection bias. dImprecision: broad confidence interval. eSingle study. | |||||
| Patient or population: spontaneously breathing preterm infants with apnoea | |||||
| Outcomes | Anticipated absolute effects* (95% CI) | Comments | Number of participants | Quality of the evidence | |
| Risk with right lateral horizontal positioning | Risk with prone horizontal positioning | ||||
| Episodes of apnoea | Mean difference (MD) 0.48 (‐0.19 to 1.15) Favours right lateral horizontal positioning group Not statistically significant | Overall, episodes of apnoea were 0.48 more (0.19 fewer to 1.15 more) among preterm infants in the prone horizontal positioning group compared preterm infants in the right lateral horizontal positioning group. | 130 | ⊕⊝⊝⊝ | |
| Episodes of oxygen desaturation | Mean difference (MD) ‐1.86 (‐4.29 to 0.56) Favours prone horizontal positioning group Not statistically significant | Overall, episodes of oxygen desaturation were 1.86 fewer (4.29 fewer to 0.56 more) among preterm infants in the prone horizontal positioning group compared with preterm infants in the right lateral horizontal positioning group. | 88 | ⊕⊝⊝⊝ | |
| Episodes of severe apnoea | Mean difference (MD) 0.05 (‐0.45 to 0.54) Favours right lateral horizontal positioning group Not statistically significant | Overall, episodes of severe apnoea were 0.05 more (0.45 fewer to 0.54 more) among preterm infants in the prone horizontal positioning group compared with preterm infants in the right lateral horizontal positioning group. | 88 | ⊕⊝⊝⊝ | |
| Episodes of bradycardia | Mean difference (MD) ‐0.59 (‐2.4 to 1.23) Favours prone horizontal positioning group Not statistically significant | Overall, episodes of bradycardia were 0.59 fewer (2.41 fewer to 1.23 more) among preterm infants in the prone horizontal positioning group compared with preterm infants in the right lateral horizontal positioning group. | 88 | ⊕⊝⊝⊝ | |
| Episodes of severe bradycardia | Mean difference (MD) ‐ 0.32 (‐1.02 fewer to 0.39) Favours prone horizontal positioning group Not statistically significant | Overall, episodes of severe bradycardia were 0.32 fewer (1.02 fewer to 0.39 more) among preterm infants in the prone horizontal positioning group compared with preterm infants in the right lateral horizontal positioning group. | 88 | ⊕⊝⊝⊝ | |
| *The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | |||||
| GRADE Working Group grades of evidence. | |||||
| aHigh or unclear risk of allocation concealment. bHigh or unclear risk of performance bias. cHigh or unclear risk of detection bias. dSingle study. eImprecision: broad confidence interval. | |||||
| Patient or population: spontaneously breathing preterm infants with apnoea | |||||
| Outcomes | Anticipated absolute effects* (95% CI) | Comments | Number of participants | Quality of the evidence | |
| Risk with left lateral horizontal positioning | Risk with prone horizontal positioning | ||||
| Episodes of apnoea | Mean difference (MD) 0.2 (‐0.75 to 1.15) Favours left lateral horizontal positioning Not statistically significant | Overall, episodes of apnoea were 0.2 more (0.75 fewer to 1.15 more) among preterm infants in the prone horizontal positioning group compared with preterm infants in the left lateral horizontal positioning group. | 131 (2 RCTs) | ⊕⊕⊝⊝ | |
| Episodes of oxygen desaturation | Mean difference (MD) ‐1.44 (‐3.81 to 0.92) Favours prone horizontal positioning Not statistically significant | Overall, episodes of oxygen desaturation were 1.44 fewer (3.81 fewer to 0.92 more) among preterm infants in the prone horizontal positioning group compared with preterm infants in the lateral horizontal positioning group. | 89 (1 RCT) | ⊕⊝⊝⊝ | |
| Episodes of severe apnoea | Mean difference (MD) 0.11 (‐0.38 to 0.6) Favours left lateral horizontal positioning Not statistically significant | Overall, episodes of severe apnoea were 0.11 more (0.38 fewer to 0.6 more) among preterm infants in the prone horizontal positioning group compared with preterm infants in the left lateral horizontal positioning group. | 89 (1 RCT) | ⊕⊝⊝⊝ | |
| Episodes of bradycardia | Mean difference (MD) ‐ 0.17 (‐0.94 to 0.6) Favours prone horizontal positioning group Not statistically significant | Overall, episodes of bradycardia were 0.17 fewer (0.94 fewer to 0.49 more) among preterm infants in the prone horizontal positioning group compared with preterm infants in the left lateral horizontal positioning group (0.94 less to 0.6 more frequent). | 89 (1 RCT) | ⊕⊝⊝⊝ | |
| Episodes of severe bradycardia | Mean difference (MD) ‐0.22 (‐0.94 to 0.49) Favours prone horizontal positioning group Not statistically significant | Overall, episodes of severe bradycardia were 0.22 fewer (0.94 fewer to 0.49 more) among preterm infants in the prone horizontal positioning group compared with preterm infants in the left lateral horizontal positioning group. | 89 (1 RCT) | ⊕⊝⊝⊝ | |
| *The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | |||||
| GRADE Working Group grades of evidence. | |||||
| aHigh or unclear risk of allocation concealment. bHigh or unclear risk of performance bias. cHigh or unclear risk of detection bias. dImprecision: broad confidence interval. eSingle study. | |||||
| Patient or population: spontaneously breathing preterm infants with apnoea | |||||
| Outcomes | Anticipated absolute effects* (95% CI) | Comments | Number of participants | Quality of the evidence | |
| Risk with left lateral positioning | Risk with right lateral positioning | ||||
| Episodes of apnoea | Mean difference (MD) ‐0.27 (‐1.1 to 0.57) Favours right lateral positioning Not statistically significant | Overall, episodes of apnoea were 0.27 fewer (1.1 fewer to 0.57 more) among preterm infants in the right lateral positioning group compared with preterm infants in the left lateral positioning group. | 131 | ⊕⊕⊝⊝ | |
| Episodes of oxygen desaturation | Mean difference (MD) 0.42 (‐2.42 to 3.26) Favours left lateral positioning Not statistically significant | Overall, episodes of oxygen desaturation were 0.42 more (2.42 fewer to 3.26 more) among preterm infants in the right lateral positioning group compared with preterm infants in the left lateral positioning group. | 89 | ⊕⊝⊝⊝ | |
| Episodes of severe apnoea | Mean difference (MD) 0.01 (‐0.4 to 0.42) Favours left lateral positioning Not statistically significant | Overall, episodes of severe apnoea were 0.01 more (0.4 fewer to 0.42 more) among preterm infants in the right lateral positioning group compared with preterm infants in the left lateral positioning group. | 89 | ⊕⊝⊝⊝ | |
| Episodes of bradycardia | Mean difference (MD) 0.42 (‐1.43 to 2.27) Favours left lateral positioning Not statistically significant | Overall, episodes of bradycardia in the intervention group were 0.42 more (1.43 fewer to 2.27 more) among preterm infants in the right lateral positioning group compared with preterm infants in the left lateral positioning group. | 89 | ⊕⊝⊝⊝ | |
| Episodes of severe bradycardia | Mean difference (MD) 0.09 (‐0.68 to 0.87 ) Favours left lateral positioning Not statistically significant | Overall, episodes of severe bradycardia were 0.09 more (0.68 fewer to 0.87 more) among preterm infants in the right lateral positioning group compared with preterm infants in the left lateral positioning group. | 89 | ⊕⊝⊝⊝ | |
| *The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | |||||
| GRADE Working Group grades of evidence. | |||||
| aHigh or unclear risk of allocation concealment. bHigh or unclear risk of performance bias. cHigh or unclear risk of detection bias. dImprecision: broad confidence interval. eSingle study. | |||||
| Patient or population: spontaneously breathing preterm infants with apnoea | |||||
| Outcomes | Anticipated absolute effects* (95% CI) | Comments | Number of participants | Quality of the evidence | |
| Risk with prone head elevated positioning | Risk with prone horizontal positioning | ||||
| Episodes of apnoea | Mean difference (MD) ‐0.18 fewer (‐1.09 to 0.73) Favours prone horizontal positioning Not statistically significant | Overall, episodes of apnoea were 0.18 fewer (1.09 fewer to 0.73 more) among preterm infants in the prone horizontal positioning group compared with preterm infants in the prone head elevated positioning group. | 129 | ⊕⊕⊝⊝ | |
| Episodes of oxygen desaturation | Mean difference (MD) ‐0.62 (‐2.81 to 1.56) Favours prone horizontal positioning Not statistically significant | Overall, episodes of oxygen desaturation were 0.62 fewer (2.81 fewer to 1.56 more) among preterm infants in the prone horizontal positioning group compared with preterm infants in the prone head elevated positioning group. | 111 | ⊕⊝⊝⊝ | |
| Episodes of severe apnoea | Mean difference (MD) ‐0.24 (‐0.83 to 0.35) Favours prone horizontal positioning not statistically significant | Overall, episodes of severe apnoea were 0.24 fewer (0.83 fewer to 0.35 more) among preterm infants in the prone horizontal positioning group compared with preterm infants in the prone head elevated positioning group. | 87 | ⊕⊝⊝⊝ | |
| Episodes of bradycardia | Mean difference (MD) ‐0.14 (‐1.03 to 0.74) Favours prone horizontal positioning not statistically significant | Overall, episodes of bradycardia were 0.14 fewer (1.03 fewer to 0.74 more) among preterm infants in the prone horizontal positioning group compared with preterm infants in the prone head elevated positioning group. | 111 | ⊕⊕⊝⊝ | |
| Episodes of severe bradycardia | Mean difference (MD) ‐0.28 (‐1.15 to 0.59) Favours prone horizontal positioning not statistically significant | Overall, episodes of severe bradycardia were 0.28 fewer (1.15 fewer to 0.59 more) among preterm infants in the prone horizontal positioning group compared with preterm infants in the prone head elevated positioning group. | 111 | ⊕⊕⊝⊝ | |
| *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | |||||
| GRADE Working Group grades of evidence | |||||
| 1High risk or unclear allocation concealment 2 Imprecision: broad confidence interval 3 High risk or unclear risk performance bias 4 High risk or unclear risk detection bias 5 Single study | |||||
| Patient or population: spontaneously breathing preterm infants with apnoea | |||||
| Outcomes | Anticipated absolute effects* (95% CI) | Comments | № of participants | Quality of the evidence | |
| Risk with right lateral elevated positioning | Risk with Right lateral horizontal positioning | ||||
| Episides of apnoea | Mean difference (MD) ‐0.79 (‐2.26 to 0.69) Favours right lateral horizontal positioning group not statistically significant | Overall, episodes of apnoea were 0.79 fewer (2.26 fewer to 0.69 more) in preterm infants in the right lateral horizontal positioning group compared with preterm infants in the right lateral elevated positioning group. | 86 | ⊕⊝⊝⊝ | |
| Episodes of oxygen desaturation | Mean difference (MD) 0.03 (‐3.06 to 3.11) Favours right lateral elevated positioning group not statistically significant | Overall, episodes of oxygen desaturation were 0.03 more (3.06 fewer to 3.11 more) in preterm infants in the right lateral horizontal positioning group compared with preterm infants in the right lateral elevated positioning group. | 86 | ⊕⊝⊝⊝ | |
| Episodes of severe apnoea | Mean difference (MD) ‐0.14 (‐0.69 to 0.41) Favours right lateral horizontal positioning group not statistically significant | Overall, episodes of severe apnoea were 0.14 fewer (0.69 fewer to 0.41 more) in preterm infants in the right lateral horizontal positioning group compared with preterm infants in the right lateral elevated positioning group. | 86 | ⊕⊝⊝⊝ | |
| Episodes of bradycardia | Mean difference (MD) 0.34 (‐1.54 to 2.22) Favours right lateral elevated positioning group not statistically significant | Overall, episodes of bradycardia were 0.34 more (1.54 fewer to 2.22 more) in preterm infants in the right lateral horizontal positioning group compared with preterm infants in the right lateral elevated positioning group. | 86 | ⊕⊝⊝⊝ | |
| Episodes of severe bradycardia | Mean difference (MD) 0.6 (‐0.25 to 1.46) Favours right lateral elevated positioning group not statistically significant | Overall, episodes of severe bradycardia were 0.6 more (0.25 fewer to 1.46 more) in preterm infants in the right lateral horizontal positioning group compared with preterm infants in the right lateral elevated positioning group. | 86 | ⊕⊝⊝⊝ | |
| *The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | |||||
| GRADE Working Group grades of evidence. | |||||
| aHigh or unclear risk of allocation concealment. bHigh or unclear risk of performance bias. cHigh or unclear risk of detection bias. dSingle study. eImprecision: broad confidence interval. | |||||
| Patient or population: spontaneously breathing preterm infants with apnoea | |||||
| Outcomes | Anticipated absolute effects* (95% CI) | Comments | Number of participants | Quality of the evidence | |
| Risk with left lateral elevated positioning | Risk with left lateral horizontal positioning | ||||
| Episodes of apnoea | Mean difference (MD) 0.46 (‐0.34 to 1.26) Favours left lateral elevated positioning group. Not statistically significant | Overall, episodes of apnoea were 0.46 more (0.34 fewer to 1.26 more) among preterm infants in the left lateral horizontal positioning group compared with preterm infants in the left lateral elevated positioning group. | 87 | ⊕⊝⊝⊝ | |
| Episodes of oxygen desaturation | Mean difference (MD) 0.63 (‐2.09 to 3.35) Favours left lateral elevated positioning group. Not statistically significant | Overall, episodes of oxygen desaturation in the left lateral horizontal positioning were 0.63 times more (2.09 fewer to 3.35 more) among preterm infants in the left lateral horizontal positioning group compared with preterm infants in the left lateral elevated positioning group. | 87 | ⊕⊝⊝⊝ | |
| Episodes of severe apnoea | Mean difference (MD) 0.18 (‐0.18 to 0.54) Favours left lateral elevated positioning group. Not statistically significant | Overall, episodes of severe apnoea in the left lateral horizontal positioning group were 0.18 more (0.18 fewer to 0.54 more) among preterm infants in the left lateral horizontal positioning group compared with preterm infants in the left lateral elevated positioning group. | 87 | ⊕⊝⊝⊝ | |
| Episodes of bradycardia | Mean difference (MD) 0.08 (‐0.71 to 0.88) Favours left lateral elevated positioning group. Not statistically significant | Overall, episodes of bradycardia in the left lateral horizontal positioning group were 0.08 more (0.71 fewer to 0.88 more) among preterm infants in the left lateral horizontal positioning group compared with preterm infants in the left lateral elevated positioning group. | 87 | ⊕⊝⊝⊝ | |
| Episodes of severe bradycardia | Mean difference (MD) ‐0.17 (‐0.93 to 0.58) Favours left lateral horizontal positioning group. Not statistically significant | Overall, episodes of severe bradycardia in the left lateral horizontal positioning group were 0.17 fewer (0.93 fewer to 0.58 more) among preterm infants in the left lateral horizontal positioning group compared with preterm infants in the left lateral elevated positioning group. | 87 | ⊕⊝⊝⊝ | |
| *The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | |||||
| GRADE Working Group grades of evidence. | |||||
| aHigh or unclear risk of allocation concealment. bHigh or unclear risk of performance bias. cHigh or unclear risk of detection bias. dSingle study. eImprecision: broad confidence interval. | |||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Episodes of apnoea Show forest plot | 2 | 72 | Mean Difference (IV, Fixed, 95% CI) | 1.09 [‐0.65, 2.82] |
| 2 Episodes of oxygen desaturation Show forest plot | 1 | 44 | Mean Difference (IV, Fixed, 95% CI) | 0.80 [‐3.19, 4.79] |
| 3 Episodes of bradycardia Show forest plot | 2 | 72 | Mean Difference (IV, Fixed, 95% CI) | ‐0.13 [‐3.20, 2.94] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Episodes of apnoea Show forest plot | 2 | 130 | Mean Difference (IV, Fixed, 95% CI) | 0.48 [‐0.19, 1.15] |
| 2 Episodes of oxygen desaturation Show forest plot | 1 | 88 | Mean Difference (IV, Fixed, 95% CI) | ‐1.86 [‐4.29, 0.56] |
| 3 Episodes of severe apnoea Show forest plot | 1 | 88 | Mean Difference (IV, Fixed, 95% CI) | 0.05 [‐0.45, 0.54] |
| 4 Episodes of bradycardia Show forest plot | 1 | 88 | Mean Difference (IV, Fixed, 95% CI) | ‐0.59 [‐2.41, 1.23] |
| 5 Episodes of severe bradycardia Show forest plot | 1 | 88 | Mean Difference (IV, Fixed, 95% CI) | ‐0.32 [‐1.02, 0.39] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Episodes of apnoea Show forest plot | 2 | 131 | Mean Difference (IV, Fixed, 95% CI) | 0.20 [‐0.75, 1.15] |
| 2 Episodes of oxygen desaturation Show forest plot | 1 | 89 | Mean Difference (IV, Fixed, 95% CI) | ‐1.44 [‐3.81, 0.92] |
| 3 Episodes of severe apnoea Show forest plot | 1 | 89 | Mean Difference (IV, Fixed, 95% CI) | 0.11 [‐0.38, 0.60] |
| 4 Episodes of bradycardia Show forest plot | 1 | 89 | Mean Difference (IV, Fixed, 95% CI) | ‐0.17 [‐0.94, 0.60] |
| 5 Episodes of severe bradycardia Show forest plot | 1 | 89 | Mean Difference (IV, Fixed, 95% CI) | ‐0.22 [‐0.94, 0.49] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Episodes of apnoea Show forest plot | 2 | 131 | Mean Difference (IV, Fixed, 95% CI) | ‐0.27 [‐1.10, 0.57] |
| 2 Episodes of oxygen desaturation Show forest plot | 1 | 89 | Mean Difference (IV, Fixed, 95% CI) | 0.42 [‐2.42, 3.26] |
| 3 Episodes of severe apnoea Show forest plot | 1 | 89 | Mean Difference (IV, Fixed, 95% CI) | 0.01 [‐0.40, 0.42] |
| 4 Episodes of bradycardia Show forest plot | 1 | 89 | Mean Difference (IV, Fixed, 95% CI) | 0.42 [‐1.43, 2.27] |
| 5 Episodes of severe bradycardia Show forest plot | 1 | 89 | Mean Difference (IV, Fixed, 95% CI) | 0.09 [‐0.68, 0.87] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Episodes of apnoea Show forest plot | 2 | 129 | Mean Difference (IV, Fixed, 95% CI) | ‐0.18 [‐1.09, 0.73] |
| 2 Episodes of oxygen desaturation Show forest plot | 2 | 111 | Mean Difference (IV, Fixed, 95% CI) | ‐0.62 [‐2.81, 1.56] |
| 3 Episodes of severe apnoea Show forest plot | 1 | 87 | Mean Difference (IV, Fixed, 95% CI) | ‐0.24 [‐0.83, 0.35] |
| 4 Episodes of bradycardia Show forest plot | 2 | 111 | Mean Difference (IV, Fixed, 95% CI) | ‐0.14 [‐1.03, 0.74] |
| 5 Episodes of severe bradycardia Show forest plot | 2 | 111 | Mean Difference (IV, Fixed, 95% CI) | ‐0.28 [‐1.15, 0.59] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Episides of apnoea Show forest plot | 1 | 86 | Mean Difference (IV, Fixed, 95% CI) | ‐0.79 [‐2.26, 0.69] |
| 2 Episodes of oxygen desaturation Show forest plot | 1 | 86 | Mean Difference (IV, Fixed, 95% CI) | 0.03 [‐3.06, 3.11] |
| 3 Episodes of severe apnoea Show forest plot | 1 | 86 | Mean Difference (IV, Fixed, 95% CI) | ‐0.14 [‐0.69, 0.41] |
| 4 Episodes of bradycardia Show forest plot | 1 | 86 | Mean Difference (IV, Fixed, 95% CI) | 0.34 [‐1.54, 2.22] |
| 5 Episodes of severe bradycardia Show forest plot | 1 | 86 | Mean Difference (IV, Fixed, 95% CI) | 0.60 [‐0.25, 1.46] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Episodes of apnoea Show forest plot | 1 | 87 | Mean Difference (IV, Fixed, 95% CI) | 0.46 [‐0.34, 1.26] |
| 2 Episodes of oxygen desaturation Show forest plot | 1 | 87 | Mean Difference (IV, Fixed, 95% CI) | 0.63 [‐2.09, 3.35] |
| 3 Episodes of severe apnoea Show forest plot | 1 | 87 | Mean Difference (IV, Fixed, 95% CI) | 0.18 [‐0.18, 0.54] |
| 4 Episodes of bradycardia Show forest plot | 1 | 87 | Mean Difference (IV, Fixed, 95% CI) | 0.08 [‐0.71, 0.88] |
| 5 Episodes of severe bradycardia Show forest plot | 1 | 87 | Mean Difference (IV, Fixed, 95% CI) | ‐0.17 [‐0.93, 0.58] |
