Open Access Original Article

Comparison of the Effects of Supine and Prone Positions

on Oxygen Saturation and Vital Signs in Premature
Infants: A Crossover Clinical Trial
Hamid Torabian1, Saeed Alinejad2, Akram Bayati1, Fatemeh Rafiei3, Sharareh
Khosravi1*
1. Department of Nursing, School of Nursing and Midwifery, Arak University of Medical Sciences, Arak, Iran
2. Department of Pediatrics, School of Medicine, Arak University of Medical Sciences, Arak, Iran
3. Department of Biostatistics, School of Medicine, Arak University of Medical Sciences, Arak, Iran

ABSTRACT
Background: Positioning of premature newborns significantly affects their health status. However, the most suitable
position remains controversial. The current study aimed to compare the effect of supine and prone positions on oxygen
saturation and vital signs in premature newborns.
Methods: In this crossover clinical trial, a total of 22 newborns admitted to the Neonatal Intensive Care Unit (NICU) of
Amir Kabir Hospital in Arak, Iran, were selected through purposive sampling technique, and then randomly assigned
into groups 1 and 2. Newborns in group 1 were first placed in a prone position (i.e., the first period for 3 h), and then in
a supine position (i.e., the second period for an additional 3 h). The reverse procedure was applied to the intervention
group 2. Heart rate, respiratory rate, and oxygen saturation were measured and recorded every 15 min.
Results: The mean oxygen saturation in the prone position (96.164±0.148) was higher than in the supine position
(90.479±0.513; P=0.0001). The mean heart rate in the prone position (138.24±1.87 beats/min) was lower than that in
the supine position (147.48±1.597 beats/min; P=0.0001). The mean respiratory rate in the prone position
(40.430±0.504 breaths/min) was lower than that in the supine position (46.773±0.685 breaths/min; P=0.0001).
Conclusion: The current study demonstrated that the prone position put the newborn admitted to NICU in a more
stable condition. However, the selection of the best position must be made based on the newborn’s health status and
situation.

Keywords: Oxygen saturation, Position, Premature newborn, Vital signs

Introduction
Annually, approximately 15 million neonates the most suitable position. The results of different
are born preterm, and this number is rising. studies have indicated the effect of positioning on
Complications of preterm birth are the leading the heart rate (HR), respiratory rate (RR), arterial
causes of death among children under 5 years of oxygen saturation (SaO2), respiratory pattern,
age; accordingly, these complications accounted pain intensity, gastroesophageal reflux, gastric
for approximately 1 million deaths in 2015. Across residual, salivary cortisol level, and skeletal
184 countries, the rate of preterm birth ranges and motor development of newborns. Placing
from 5% to 18% (1, 2). In a meta-analysis premature newborns in the most suitable position
conducted on the related studies in Iran, the significantly prevents the incidence of short- and
prevalence of premature birth was reported to long-term complications. Nurses need to consider
range from 5.5% to 19.85% (3). the newborn’s condition, as well as the advantages
One of the most important nursing care and disadvantages of each position in selecting the
practices for premature newborns is placement in best position for newborns (4-7).
* Corresponding author: Sharareh Khosravi, Department of Nursing, School of Nursing and Midwifery, Arak University of Medical
Sciences, Arak, Iran. Tel: +988634173501-7; Fax: +988634173524; Email: [email protected]

Please cite this paper as:

Torabian H, Alinejad S, Bayati A, Rafiei F, Khosravi Sh. Comparison of the Effects of Supine and Prone Positions on
Oxygen Saturation and Vital Signs in Premature Infants: A Crossover Clinical Trial. Iranian Journal of Neonatology.
2019 Jun: 10(2). DOI: 10.22038/ijn.2019.32928.1465
Effect of Positioning on Vital Signs in Premature Newborns Torabian H et al

Despite the association between positioning The inclusion criteria were: 1) gestational age
and vital functions of premature newborns, a of 32-36 weeks, 2) chronological age of 2-28 days,
controversy still exists about the best position (8- 3) birth weight of ≥ 1,000 g, 4) spontaneous
11). Eghbalian et al. (2014) compared the impact respiration and absence of mechanical ventilation,
of supine and prone positions on SaO2 in 5) maximum oxygen of 5 L/min when using
premature newborns with respiratory distress oxygen in an incubator or hood, 6) stable body
syndrome and observed that SaO2 was significantly temperature, 7) lack of congenital disorders or
higher in a prone position (12). Oliveira et al. blood disorder, 8) hemoglobin level of ≥ 9 g/dL, 9)
(2009) also evaluated the impact of a prone nonuse of narcotics, corticosteroids, or surfactants,
position on thoracoabdominal asynchrony, and 10) nonumbilical catheter in place. The
respiratory pattern, and mean SaO2 in peripheral exclusion criteria were: 1) parental refusal to
blood among premature newborns. They reported continue the study, 2) transferring from NICU, 3)
that asynchrony was significantly reduced in cardiopulmonary resuscitation, 5) inotropic
a prone position; however, no changes were support of ≥ 5 µg/kg, 6) pneumothorax, 7)
observed in respiratory pattern and SaO2 (13). peripheral edema, and 8) insertion of an umbilical
Rayyani et al. (2014) compared the impact of catheter.
supine and prone positions on SaO2 in newborns Data were collected using a questionnaire,
admitted to Neonatal Intensive Care Unit (NICU) including two sections. The first section entailed
after being weaned from the ventilator and the newborns’ demographic information, including
observed that SaO2 was significantly higher in the diagnosis, gender, gestational age, chronological
prone position than in the supine position (14). age, type of delivery, 5-min Apgar score, birth
On the other hand, Torabi et al. (2012) reported weight and height, and height and weight at the
that a prone position was not better than a time of study. In addition, the second section
supine position in improving SaO2 in premature consisted of a checklist to record vital signs (i.e.,
newborns; in this regard, they observed that SaO2 HR and RR) and SaO2.
was significantly higher in the supine position At first, all the newborns were placed in a lateral
than in the prone position (5). position for 30 min. Levels of SaO2, HR, and RR
It was found that placing preterm infants in the were monitored and recorded during this period.
prone or supine position have effects on Then, the newborns in group 1 were turned to a
physiological factors, such as cardiorespiratory prone position, and group 2 were placed in a supine
function, thermoregulation, oxygen saturation, position (i.e., the first period of intervention).
and arousal from sleep (15). Regarding the Levels of SaO2, HR, and RR were recorded every 15
importance of selecting the most appropriate min in each position for 3 h. Afterward, the
position for premature newborns to improve their newborns were placed again in a lateral position
condition, the current study aimed to compare the for 30 min, and their studied parameters were
impact of the supine and prone positions on SaO2 recorded. Thereafter, the newborns’ position was
and vital signs in this population. changed to the opposite position of the first period
(i.e., prone to supine and supine to prone), and
Methods their physiologic parameters were recorded again
This randomized crossover clinical trial was every 15 min for 3 h (i.e., the second period of
conducted on newborns admitted to the NICU of intervention; Figure 1). The newborns were placed
Amir Kabir Hospital, Arak, Iran. Amir Kabir in a nest during positioning.
Hospital is an educational hospital affiliated to A pulse oximeter was utilized to evaluate the
Arak University of Medical Sciences, Arak, Iran. A level of SaO2. Vital signs were also electrically
total of 22 newborns (based on ref 16) meeting monitored. All instruments were provided by
the inclusion criteria were recruited through SAADAT™ (Pooyandegan Rah Saadat Co., Iran)
the purposive sampling technique. The study and calibrated by the exclusive agent of the
population was assigned into intervention groups manufacturing company. To minimize the influence
1 and 2 through the randomized block method. of confounding factors, such as environmental
noises and excessive brightness, the interventions
were performed during the night shift. The data
were collected by the main researcher.

Statistical analysis
α=0.05, β=0.2, S1=15.04, S2=13.09, D=12, n=22 The data were analyzed in SPSS software

31 Iranian Journal of Neonatology 2019; 10(2)

Torabian H et al Effect of Positioning on Vital Signs in Premature Newborns

Figure 1. CONSORT flow diagram of the study process

(version 21). The normality of the data was established by the Iranian Ministry of Health and
examined using Kolmogorov-Smirnov test. Medical Education were considered by the
Descriptive (i.e., mean, standard error, and 95% researchers throughout the study. The study was
confidence interval) and inferential statistics (i.e., registered in the Iranian Registry of Clinical Trials
independent t-test and repeated-measures analysis (Code no. IRCT2017041633471N1).
of variance) were used for analyzing the data.
Results
Ethical considerations Table 1 summarizes the newborns’
The current study was approved by the Ethics characteristics.
Committee of Arak University of Medical Sciences The effect of period and the interaction
(Code no. IR.ARAKMU.REC.1395.150, date: July 18, between period and the intervention were
2016). The newborns were enrolled in the study investigated for all variables under study, and no
as soon as their parents signed the written effects were seen. The comparison of SaO2
informed consent form. The parents were free to between the two positions revealed that the mean
withdraw their newborn from the study at any SaO2 in the prone position (96.164±0.148) was
time. The ethical principles for medical research higher than that in the supine position

32 Iranian Journal of Neonatology 2019; 10(2)

Effect of Positioning on Vital Signs in Premature Newborns Torabian H et al

Table 1. Demographic characteristics of the newborns

Variable Percent (number)
Gender
Male 45.5 (10)
Female 54.5 (12)
Type of delivery
Cesarean section 40.9 (9)
Natural vaginal delivery 59.1 (13)
Diagnosis
Respiratory distress syndrome 36.4 (8)
Transient tachypnea of the newborn 18.2 (4)
Hyperbilirubinemia 18.2 (4)
Sepsis-induced hyperbilirubinemia 13.6 (3)
Pneumonia 9.1 (2)
Sepsis 4.5 (1)
Gestational age (week)
32-33 31.8 (7)
33-34 18.2 (4)
34-35 40.9 (9)
35-36 9.1 (2)
Mean age (days) 10.38±9.69
Mean birth weight (g) 2297.72±693.75
Mean weight at the time of the study (g) 2293.63±652.1
5-min Apgar score
4 4.5 (1)
5 9.1 (2)
6 18.2 (4)
7 31.8 (7)
8 27.3 (6)
9 9.1 (2)

Table 2. Comparison of the modified mean oxygen saturation, heart rate, and respiratory rate between the two positions
95%CI
Variable Groups Mean±SD P-value
Lower limit Upper limit
Prone 96.164 0.148 95.856 96.473
Oxygen saturation 0.0001
Supine 90.479 0.513 89.412 91.456
Prone 138.24 1.187 135.773 140.710
Heart rate 0.0001
Supine 147.48 1.597 144.162 150.803
Prone 40.430 0.504 39.382 41.478
Respiratory rate 0.0001
Supine 46.773 0.685 45.348 48.197

Table 3. Oxygen saturation changes in both periods of the study

(Pone-supine) (First period) (Supine-prone) (Second period)
Oxygen saturation Prone Supine P-value Supine Prone P-value
Mean±SD Mean±SD Mean±SD Mean±SD
Before 90.27±1.61 89.91±1.7 0.61 91.72±1.9 91.45±1.9 0.74
15 minutes 92.18±3.21 93.72±2.6 0.23 90.54±4.18 91.45±3.11 0.56
1 Hours 96.36±1.36 90.36±5.7 0.002 90.09±2.3 96±2.28 0.0001
2 Hours 98.09±1.81 90.45±4.43 0.0001 88.27±2.79 98.09±1.92 0.0001
3 Hours 98.81±1.88 92.45±3.64 0.0004 89.45±2.11 98.54±1.63 0.0001
F=18.17 F=2.672 F=1.579 F=16.728
Repeated measures ANOVA
P=0.0001 P=0.037 0.203=P P=0.0001

(90.479±0.513; P=0.0001) (Table 2). It was also decreased over time (P=0.0001) in the prone
found that SaO2 was significantly increased over position during both periods of the study (Table 4).
time in the prone position during both periods of The mean RR in the prone position (40.430±0.504)
the study (P=0.0001; Table 3). was also lower than that in the supine position
In terms of HR, the mean HR in the prone (46.773±0.685; P=0.0001; Table 2). It was also
position (138.24±1.187) was lower than that in the found that RR was significantly decreased over
supine position (147.48±1.597; P=0.0001; Table time in the prone position in both research
2). It was also found that HR was significantly periods (P=0.0001; Table 5).

33 Iranian Journal of Neonatology 2019; 10(2)

Torabian H et al Effect of Positioning on Vital Signs in Premature Newborns

Table 4. Heart rate changes in both periods of the study

(Pone-supine) (Supine-prone)
Heart rate Prone Supine P-value Supine Prone P-value
Mean±SD Mean±SD Mean±SD Mean±SD
Before 140.9±7.09 141.18±6.67 0.92 145.27±3.7 145.45±3.55 0.91
15 minutes 148.72±14.16 148.81±10.3 0.98 148.36±6.07 147.9±7.13 0.872
1 Hours 141.36±11.35 148.18±10.17 0.15 147.36±7.33 140.18±5.17 0.015
2 Hours 133.45±7.72 147.9±10.71 0.001 147.72±5.13 132.9±4.57 0.0001
3 Hours 133.27±4.96 149.63±10.23 0.0001 147±5.47 133.36±3.47 0.0001
F=8.635 F=1.788 F=1.325 27.451= F
Repeated measures ANOVA
P=0.003 P=0.185 P=0.280 P=0.0001

Table 5. Respiratory rate changes in both periods of the study

(Pone-supine) (Supine-prone)
Respiratory Rate Prone Supine P-value Supine Prone P-value
Mean±SD Mean±SD Mean±SD Mean±SD
Before 44.18±7.05 44.18±6.94 0.999 91.72±1.9 91.45±1.9 0.940
15 minutes 46.27±3.84 46±4.6 0.882 90.54±4.18 91.45±3.11 0.753
1 Hours 41±2.75 46.9±3.01 0.0001 90.09±2.3 96±2.28 0.033
2 Hours 37.45±3.33 47.45±4.59 0.0001 88.27±2.79 98.09±1.92 0.0001
3 Hours 36.09±6.94 46.45±4.2 0.00004 89.45±2.11 97.54±1.63 0.0001
F=14.058 F=0.617 F=2.328 15.861=F
Repeated measures ANOVA
P=0.0001 P=0.588 0.063=P P=0.0001

Discussion
This crossover clinical trial aimed to evaluate (5). This difference can be attributed to the short
the effect of prone and supine positions on SaO2, duration of positioning (i.e., 30 min).
HR, and RR in premature newborns. The results The results of the current study indicated that
showed that the mean SaO2 in the prone position the mean HR in the prone position was
was significantly higher than that in the supine significantly lower than that in the supine
position. In agreement with the results of the position. Ghorbani et al. (2013) compared the
current study, Eghbalian et al. (2014) showed that effect of the prone position on HR in newborns
the level of SaO2 in premature newborns placed in under nasal CPAP and indicated that the HR was
the prone position was significantly higher than significantly higher in the prone position than that
that in premature newborns placed in the supine in the supine position (16). In another study, Yin
position (12). Malagoli et al. (2012) also evaluated et al. (2016) compared three positions (i.e.,
the effect of prone positioning on oxygenation in supine, lateral, and semi-prone) in premature
premature newborns during weaning from newborns under CPAP and showed that the mean
a ventilator. They reported that SaO 2 was HR and HR variations were not different among
significantly higher in the prone position than in the studied positions (10).
the supine position (17). Furthermore, Ma et al. (2015) evaluated the
Akbarian Rad et al. (2016) evaluated the effect impact of different positions on cardiac output in
of prone, supine, and lateral positions on SaO2 in premature newborns. They found no significant
very low birth weight newborns. They observed differences in HR among the studied positions;
better oxygenation in the prone position than in however, the stroke volume and cardiac output
the other two positions (18). On the other hand, showed significant reductions in the prone
Yin et al. (2016) compared three positions (i.e., position (7). Akbarian Rad et al. (2016) indicated
supine, lateral, and semi-prone) in premature better variations in HR in the prone position than
newborns under continuous positive airway that in the supine and lateral positions. However,
pressure (CPAP) and indicated that the mean SaO2 in the mentioned study, the mean HR showed
was not significantly different among the evaluated no significant difference among the studied
positions (10). Their results can be attributed to positions (18). This difference can be associated
the fact that the studied newborns received with the inclusion of very low birth weight
assisted respiration treatment. Furthermore, in newborns.
contrast to the results of the current study, Torabi In the current study, it was observed that the
et al., investigating premature newborns, showed mean RR was significantly lower in the prone
that the mean SaO2 in the supine position was position than that in the supine position. Yin et al.
significantly higher than that in the prone position (2016) showed that the mean RR was significantly

34 Iranian Journal of Neonatology 2019; 10(2)

Effect of Positioning on Vital Signs in Premature Newborns Torabian H et al

higher in the supine and lateral positions than in newborns.

the semi-prone position. They concluded that
premature newborns exhibited more normal Acknowledgments
respiration in the semi-prone position (10). On the The authors thank the parents of newborns
other hand, Malagoli et al. (2012) indicated that participating in the study. They also wish to thank
RR was significantly higher and peak airway the authorities of Amir Kabir Hospital of Arak as
pressure was significantly lower in the prone well as the NICU staff, particularly Mrs. Davari and
position (17). Mrs. Zarrinfar, for their cooperation.
Oliveira et al. (2009) evaluated the impact of
prone position on thoracoabdominal asynchrony Funding
in premature newborns and indicated that prone This study was extracted from a master’s
position significantly reduced such asynchrony thesis in pediatric nursing submitted to the Arak
without influencing the oxygenation pattern or University of Medical Sciences and was financially
SpO2 level (13). Gouna et al. (2013) investigating supported by the Deputy of Research and
premature newborns receiving positive-pressure Technology of Arak University of Medical Sciences.
oxygen found that left-lateral and prone positions
could improve the pulmonary function (19). It Conflicts of interests
must be noticed that in their study the newborns The authors declare no conflict of interest in
were under positive pressure oxygen. this study.
The findings of the present study can be useful
for nurses in selecting the best position for References
premature newborns based on their condition. In 1. Word Health Organization. Media Centre. Preterm
birth. Fact sheet. Geneva: Word Health Organization;
line with Pourazar et al. (2017), the selection of
2017.
the best position, development of standard 2. Howson CP, Kinney MV, McDougall L, Lawn JE.
positioning guidelines for premature infants, and Born too soon: preterm birth matters. Reprod
education of nurses to improve the quality of care Health. 2013; 10(1):S1.
in NICUs (20) could be mentioned as some of the 3. Sharifi N, Khazaeian S, Pakzad R, Fathnezhad
applications of the present study. Kazemi A, Chehreh H. Investigating the prevalence
of preterm birth in Iranian population: a systematic
Conclusion review and meta-analysis. J Caring Sci. 2017;
As the findings of the present study indicated, 6(4):371-80.
4. Picheansathian W, Woragidpoonpol P, Baosoung C.
in the prone position, SaO2 was significantly
Positioning of preterm infants for optimal
higher, and HR and RR values were significantly physiological development: a systematic review.
lower than in the supine position. Although in JBI Database Syst Rev Implementat Rep. 2009;
either positions, the measured variables were 7(7):224-59.
within the normal range, it can be said that the 5. Torabi Z, Ghaheri V, Falak Aflaki B. The effect of
newborns in the prone position were in a more body position on the arterial oxygen saturation of
stable condition than in the supine position in healthy premature neonate: a clinical trial. J
terms of the ranges of HR, RR, and SaO2. Mazandaran Univ Med Sci. 2012; 22(86):234-42.
Consequently, this position can be recommended (Persian)
6. Candia MF, Osaku EF, Leite MA, Toccolini B, Costa
for the newborns admitted to NICUs. It must be
NL, Teixeira SN, et al. Influencia do
considered that the newborns were studied in posicionamentoempronasobre o estresse no
NICU under monitoring; however, the prone recem-nascidoprematuroavaliada pela dosage de
position is not recommended for newborns at cortisol salivar: um estudopiloto. Rev Bras Ter
home. Intensiva. 2014; 26(2):169-75.
7. Ma M, Noori S, Maarek JM, Holschneider DP,
Study Limitations Rubinstein EH, Seri I. Prone positioning decreases
It should be considered that the results of the cardiac output and increases systemic vascular
current study cannot be generalized to all resistance in neonates. J Perinatol. 2015; 35(6):
424-7.
premature newborns since our study was
8. Blair PS, Platt MW, Smith IJ, Fleming PJ. Sudden
conducted on 22 newborns with a birth weight of neonate death syndrome and sleeping position in
> 1,000 g and gestational age of 32-36 weeks who pre-term and low birth weight neonates: an
were not under mechanical ventilation or CPAP. opportunity for targeted intervention. Arch Dis
Therefore, it is recommended to perform further Child. 2006; 91(2):101-6.
similar studies on a larger sample of premature 9. Poets CF, von Bodman A. Placing preterm neonates

35 Iranian Journal of Neonatology 2019; 10(2)

Torabian H et al Effect of Positioning on Vital Signs in Premature Newborns

for sleep: first prone, then supine. Arch Dis Child 15. King C, Norton D. Does therapeutic positioning of
Fetal Neonatal Ed. 2007; 92(5):F331-2. preterm infants impact upon optimal health
10. Yin T, Yuh YS, Liaw JJ, Chen YY, Wang KW. outcomes? A literature review. J Neonatal Nurs.
Semi-prone position can influence variability in 2017; 23(5):218-22.
respiratory rate of premature neonates using nasal 16. Ghorbani F, Asadollahi M, Valizadeh S. Comparison
CPAP. J Pediatr Nurs. 2016; 31(2):e167-74. of sleep positioning on cardiorespiratory rate in
11. Sahni R, Schulze KF, Ohira-Kist K, Kashyap S, Myers noninvasive ventilated premature neonates. Nurs
MM, Fifer WP. Interactions among peripheral Midwifery Stud. 2013; 2(2):182-7.
perfusion, cardiac activity, oxygen saturation, 17. Malagoli RD, Santos FF, Oliveira EA, Bouzada MC.
thermal profile and body position in growing low Influence of prone position on oxigenation,
birth weight neonates. Acta Paediatr. 2010; respiratory rate and muscle strength in preterm
99(1):135-9. neonates being weaned from mechanical
12. Eghbalian F. A comparison of supine and prone ventilation. Rev Paulista Pediatr. 2012; 30(2):251-6.
positioning on improves arterial oxygenation in 18. Akbarian Rad Z, Haghshenas Mojaveri M,
premature neonates. J Neonatal Perinatal Med. Hajiahmadi M, Ghanbarpour A, Mirshahi S. The
2014; 7(4):273-7. effect of position on oxygen saturation and heart
13. Oliveira TG, Rego MA, Pereira NC, Vaz LO, Franca rate in very low birth weight neonates. Caspian J
DC, Vieira DS, et al. Prone position and reduced Pediatr. 2016; 2(2):153-7.
thoracoabdominal asynchrony in preterm newborn. 19. Gouna G, Rakza T, Kuissi E, Pennaforte T, Mur S,
J Pediatr. 2009; 85(5):443-8. Storme L. Positioning effects on lung function and
14. Rezaeian M, SheikhFathollahi F, Abdolkarimi M, breathing pattern in premature newborns. J Pediatr.
Niknafs M, Bahman-Bijari M, Niknafs P, et al. 2013; 162(6):1133-7.
Comparison of supine and prone positions on 20. Pourazar F, Borimnejad L, Mohaghaghi P, Haghani
oxygen saturation in preterm neonates after H. Comparison of the effects of prone and supine
weaning from mechanical ventilation in NICU of positions on abdominal distention in the premature
Afzalipour Hospital of Kerman in 2014. J Rafsanjan infants receiving nasal continuous positive airway
Univ Med Sci. 2014; 13(9):885-95. (Persian) pressure (NCPAP). Iran J Neonatol. 2018; 9(1):7-12.

36 Iranian Journal of Neonatology 2019; 10(2)