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

Khouloud Abdulrahman Al-Sofyani1,2,3, Mohammed Shahab Uddin4, Manal Alasnag5

  • 1Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.

Frontiers in Pediatrics
|February 23, 2026
PubMed

Insights

Prone positioning may reduce mortality in pediatric acute respiratory distress syndrome (ARDS). This systematic review found improved oxygenation but no clear reduction in ventilation duration or ICU stay for children with ARDS.

Area of Science:

  • Pediatric Critical Care Medicine
  • Respiratory Physiology
  • Evidence-Based Medicine

Background:

  • Acute respiratory distress syndrome (ARDS) in children presents unique challenges due to developmental differences.
  • Prone positioning is a known intervention in adult ARDS, but its efficacy in pediatric populations is debated.

Purpose of the Study:

  • To systematically review and meta-analyze randomized controlled trials (RCTs) on prone versus supine ventilation in pediatric ARDS.
  • To evaluate the impact of prone positioning on mortality, oxygenation, and ventilation duration in children with ARDS.

Main Methods:

  • Systematic review and meta-analysis of 13 RCTs involving 1,529 pediatric patients with ARDS.
  • Searched major databases up to October 29, 2025.
  • Assessed methodological quality using the Cochrane risk-of-bias tool.

Main Results:

  • Prone positioning was associated with a lower risk of death (RR 0.67; P=0.0443) and improved oxygenation (mean difference in PaO₂/FiO₂ ratio of 33.37 mmHg).
  • A slight reduction in mechanical ventilation duration was observed, but its clinical relevance was uncertain.
  • No clear reduction in intensive care unit (ICU) length of stay was found. Moderate to extreme heterogeneity was noted for outcomes.

Conclusions:

  • Prone positioning may reduce mortality and improve oxygenation in pediatric ARDS.
  • It does not clearly shorten mechanical ventilation duration or ICU stay.
  • Further high-quality RCTs are needed to optimize patient selection and implementation strategies for prone positioning in pediatric critical care.
Abstract

Keywords:
acute respiratory distress syndromeintensive care unitsmechanical ventilationmeta-analysispediatric critical careprone positioning

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