# Protocols for Prone Positioning in Pediatric Patients with Hypoxemia: Impact on Oxygenation, Lung Function, and Clinical Safety

## TL;DR

This paper reviews how placing children with low blood oxygen on their stomachs can improve lung function and oxygen levels, while also highlighting the need for more research to determine the best protocols.

## Contribution

The study systematically evaluates existing protocols and outcomes of prone positioning in pediatric hypoxemia, identifying gaps in standardization.

## Key findings

- Prone positioning improved pulmonary function and oxygenation in pediatric patients with hypoxemia.
- SpO2 improvements ranged from 13% to 38%, and atelectasis reduction ranged from 8% to 47%.
- Adverse events were rare, and no significant differences in survival or ventilation duration were observed.

## Abstract

Background/Objectives: This review aims to identify existing protocols and evaluate the effects of prone positioning on oxygenation and clinical outcomes in pediatric patients with hypoxemia. Methods: A systematic review was conducted in accordance with the PRISMA guidelines and registered in PROSPERO (CRD42023457270). Literature research was performed in Scopus, PubMed, Web of Science, and ScienceDirect. The final search was completed in January 2025. Results: A total of 2033 studies were identified, with 5 meeting inclusion criteria. Forty percent applied prone positioning for 12 to 20 h, improving pulmonary function. Combined with alveolar recruitment, prone positioning increased functional residual capacity and reduced atelectasis, with SpO2 improvements from 13% to 38% and atelectasis reduction from 8% to 47%. Another 40% focused on oxygenation, reporting PaO2 increases from 52 to 59 mmHg and SpO2 improvements from 93.2% to 96.2% within 2 to 4 h. One study found a significant SpO2 difference between prone (98.3%) and supine (96.2%) positions (p = 0.003). Protocols commonly included facial tilt and pillows to reduce compression. Safety measures involved checking catheter and tube placement, suspending enteral nutrition 30 min before repositioning, and hemodynamic monitoring. Adverse events were rare, including two cases of tube obstruction and one hypercapnia. No significant differences were observed in ventilation duration, oxygen therapy length, or 28-day survival between groups. Conclusions: Prone positioning improves pulmonary function and addresses refractory hypoxemia in pediatric patients. However, the optimal duration remains unclear, underscoring the need for further research to establish standardized guidelines.