Body positioning for spontaneously breathing preterm infants with apnoea

Rami A Ballout; Jann P Foster; Lara A Kahale; Lina Badr

doi:10.1002/14651858.CD004951.pub3

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Figure 1

Study flow diagram: review update.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

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

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Analysis 1.2

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

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Analysis 1.3

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

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Analysis 2.1

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

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Analysis 2.2

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

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Analysis 2.3

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

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Analysis 2.4

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

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Analysis 2.5

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

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Analysis 3.1

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

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Analysis 3.2

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

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Analysis 3.3

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

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Analysis 3.4

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

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Analysis 3.5

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

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Analysis 4.1

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

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Analysis 4.2

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

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Analysis 4.3

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

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Analysis 4.4

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

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Analysis 4.5

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

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Analysis 5.1

Comparison 5 Prone horizontal versus prone head elevated, Outcome 1 Episodes of apnoea.

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Analysis 5.2

Comparison 5 Prone horizontal versus prone head elevated, Outcome 2 Episodes of oxygen desaturation.

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Analysis 5.3

Comparison 5 Prone horizontal versus prone head elevated, Outcome 3 Episodes of severe apnoea.

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Analysis 5.4

Comparison 5 Prone horizontal versus prone head elevated, Outcome 4 Episodes of bradycardia.

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Analysis 5.5

Comparison 5 Prone horizontal versus prone head elevated, Outcome 5 Episodes of severe bradycardia.

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Analysis 6.1

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

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Analysis 6.2

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

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Analysis 6.3

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

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Analysis 6.4

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

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Analysis 6.5

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

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Analysis 7.1

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

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Analysis 7.2

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

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Analysis 7.3

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

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Analysis 7.4

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

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Analysis 7.5

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

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Summary of findings for the main comparison. Supine versus prone positioning

Supine versus prone positioning
Patient or population: spontaneously breathing preterm infants with apnoea Setting: neonatal/special care Intervention: supine positioning Comparison: prone positioning
Outcomes	*Anticipated absolute effects (95% CI)**		Comments	Number of participants (studies)	Quality of the evidence (GRADE)
	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 (2 RCTs)	⊕⊝⊝⊝ Very low^a,b,c
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 (1 RCT)	⊕⊝⊝⊝ Very low^a,b,c,d,e
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 (2 RCTs)	⊕⊝⊝⊝ Very low^a,b,c,d
*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). CI: confidence interval; MD: mean difference.
GRADE Working Group grades of evidence. High quality: We are very confident that the true effect lies close to the estimate of effect. Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different. Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect. Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
^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.

Summary of findings for the main comparison. Supine versus prone positioning

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Summary of findings 2. Prone horizontal versus right lateral horizontal positioning


Patient or population: spontaneously breathing preterm infants with apnoea Setting: neonatal/special care Intervention: prone horizontal positioning Comparison: right lateral horizontal positioning
Outcomes	*Anticipated absolute effects (95% CI)**		Comments	Number of participants (studies)	Quality of the evidence (GRADE)
	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 (2 RCTs)	⊕⊝⊝⊝ Very low^a,b,c,d
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 (1 RCT)	⊕⊝⊝⊝ Very low^a,b,c,d,e
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 (1 RCT)	⊕⊝⊝⊝ Very low^a.b.c.d
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 (1 RCT)	⊕⊝⊝⊝ Very low^a,b,c,d,e
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 (1 RCT)	⊕⊝⊝⊝ Very low^a,b,c,d
*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). CI: confidence interval; MD: mean difference.
GRADE Working Group grades of evidence. High quality: We are very confident that the true effect lies close to that the estimate of effect. Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different. Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect. Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
^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.

Summary of findings 2. Prone horizontal versus right lateral horizontal positioning

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Summary of findings 3. Prone horizontal versus left lateral horizontal positioning


Patient or population: spontaneously breathing preterm infants with apnoea Setting: neonatal/special care Intervention: prone horizontal positioning Comparison: left lateral horizontal positioning
Outcomes	*Anticipated absolute effects (95% CI)**		Comments	Number of participants (studies)	Quality of the evidence (GRADE)
	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)	⊕⊕⊝⊝ Low^a,b,c
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)	⊕⊝⊝⊝ Very low^a,b,c,d,e
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)	⊕⊝⊝⊝ Very low^a,b,c,e
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)	⊕⊝⊝⊝ Very low^a,b,c,e
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)	⊕⊝⊝⊝ Very low^a,b,c,e
*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). CI: confidence interval; MD: mean difference.
GRADE Working Group grades of evidence. High quality: We are very confident that the true effect lies close to the estimate of effect. Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different. Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect. Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
^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.

Summary of findings 3. Prone horizontal versus left lateral horizontal positioning

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Summary of findings 4. Right lateral versus left lateral positioning


Patient or population: spontaneously breathing preterm infants with apnoea Setting: neonatal/special care Intervention: right lateral positioning Comparison: left lateral positioning
Outcomes	*Anticipated absolute effects (95% CI)**		Comments	Number of participants (studies)	Quality of the evidence (GRADE)
	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 (2 RCTs)	⊕⊕⊝⊝ Low^a,b,c
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 (1 RCT)	⊕⊝⊝⊝ Very low^a,b,,d,e
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 (1 RCT)	⊕⊝⊝⊝ Very low^a,b,c,e
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 (1 RCT)	⊕⊝⊝⊝ Very low^a,b,c,d,e
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 (1 RCT)	⊕⊝⊝⊝ Very low^a,b,c,e
*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). CI: confidence interval; MD: mean difference.
GRADE Working Group grades of evidence. High quality: We are very confident that the true effect lies close to the estimate of effect. Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different. Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect. Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
^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.

Summary of findings 4. Right lateral versus left lateral positioning

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Summary of findings 5. Prone horizontal versus prone head elevated positioning


Patient or population: spontaneously breathing preterm infants with apnoea Setting: neonatal/special care Intervention: prone horizontal positioning Comparison: prone head elevated positioning
Outcomes	*Anticipated absolute effects (95% CI)**		Comments	Number of participants (studies)	Quality of the evidence (GRADE)
	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 (2 RCTs)	⊕⊕⊝⊝ Low^1,3,4
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 (2 RCTs)	⊕⊝⊝⊝ Very low^1,2,3,4
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 (1 RCT)	⊕⊝⊝⊝ Very low^1,3,4,5
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 (2 RCTs)	⊕⊕⊝⊝ Low^1,3,4
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 (2 RCTs)	⊕⊕⊝⊝ Low^1,3,4
*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). CI: Confidence interval; RR: Risk ratio; OR: Odds ratio;
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
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

Summary of findings 5. Prone horizontal versus prone head elevated positioning

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Summary of findings 6. Right lateral horizontal versus right lateral elevated positioning


Patient or population: spontaneously breathing preterm infants with apnoea Setting: Prone horizontal Intervention: Right lateral horizontal positioning Comparison: right lateral elevated positioning
Outcomes	*Anticipated absolute effects^ (95% CI)**		Comments	№ of participants (studies)	Quality of the evidence (GRADE)
	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 (1 RCT)	⊕⊝⊝⊝ Very low^a,b,c,d
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 (1 RCT)	⊕⊝⊝⊝ Very low^a,b,c,d,e
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 (1 RCT)	⊕⊝⊝⊝ Very low^a,b,c,d
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 (1 RCT)	⊕⊝⊝⊝ Very low^a,b,c,d,e
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 (1 RCT)	⊕⊝⊝⊝ Very low^a,b,c,d
*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). CI: confidence interval; MD: mean difference.
GRADE Working Group grades of evidence. High quality: We are very confident that the true effect lies close to the estimate of effect. Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different. Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect. Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
^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.

Summary of findings 6. Right lateral horizontal versus right lateral elevated positioning

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Summary of findings 7. Left lateral horizontal versus left lateral elevated positioning


Patient or population: spontaneously breathing preterm infants with apnoea Setting: neonatal/special care Intervention: left lateral horizontal positioning Comparison: left lateral elevated positioning
Outcomes	Anticipated absolute effects* (95% CI)		Comments	Number of participants (studies)	Quality of the evidence (GRADE)
	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 (1 RCT)	⊕⊝⊝⊝ Very low^a,b,c,d
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 (1 RCT)	⊕⊝⊝⊝ Very low^a,b,c,d,e
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 (1 RCT)	⊕⊝⊝⊝ Very low^a,b,c,d
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 (1 RCT)	⊕⊝⊝⊝ Very low^a,b,c,d
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 (1 RCT)	⊕⊝⊝⊝ Very low^a,b,c,d
*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). CI: confidence interval; MD: mean difference.
GRADE Working Group grades of evidence. High quality: We are very confident that the true effect lies close to the estimate of effect. Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different. Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect. Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
^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.

Summary of findings 7. Left lateral horizontal versus left lateral elevated positioning

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Comparison 1. Supine versus prone

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]

Comparison 1. Supine versus prone

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Comparison 2. Prone horizontal versus right lateral horizontal

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]

Comparison 2. Prone horizontal versus right lateral horizontal

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Comparison 3. Prone horizontal versus left lateral horizontal

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]

Comparison 3. Prone horizontal versus left lateral horizontal

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Comparison 4. Right lateral versus left lateral

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]

Comparison 4. Right lateral versus left lateral

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Comparison 5. Prone horizontal versus prone head elevated

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]

Comparison 5. Prone horizontal versus prone head elevated

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Comparison 6. Right lateral horizontal versus right lateral elevated

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]

Comparison 6. Right lateral horizontal versus right lateral elevated

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Comparison 7. Left lateral horizontal versus left lateral elevated

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]

Comparison 7. Left lateral horizontal versus left lateral elevated

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