Prone positioning in pediatric acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials.

Summary

Across 13 pediatric RCTs (n=1,529), prone positioning reduced mortality compared with supine ventilation (RR 0.67, 95% CI 0.57–0.79) and improved oxygenation, without clear reductions in ventilation duration or ICU stay. The analysis used Cochrane risk-of-bias assessment and multi-database searches.

Key Findings

• Included 13 RCTs with 1,529 pediatric ARDS patients.
• Meta-analysis of 10 trials showed lower mortality with prone vs. supine (RR 0.67, 95% CI 0.57–0.79).
• Prone positioning improved oxygenation metrics.
• No clear reduction in mechanical ventilation duration or ICU length of stay.

Clinical Implications

Consider early, protocolized prone positioning as an adjunct in pediatric ARDS, coupled with lung-protective ventilation, while recognizing it may not shorten ventilation or ICU stay. Teams should optimize selection, timing, duration, and mitigate pressure and airway risks.

Limitations

• Heterogeneity across trials in protocols, timing, and duration of prone positioning.
• Potential small-study effects and variable reporting of secondary outcomes.

Future Directions

Large, multicenter RCTs to refine patient selection, timing/duration parameters, and safety monitoring; standardized reporting of oxygenation, ventilator-free days, and long-term neurodevelopment.