BREASTFEEDING MEDICINE

Volume 13, Number 6, 2018

ª Mary Ann Liebert, Inc. DOI:
10.1089/bfm.2018.0028

Does the Post-Feeding Position Affect Gastric Residue in

Preterm Infants?

1 2 3 4
Emriye Hilal Yayan, Sibel Kucukoglu, Yeliz Suna Dag, and Nazlı Karsavuran Boyraz

Abstract

Background: Body position affects the gastric emptying rate and hence the amount of gastric residue.
Objective: This study aims to analyze the effect of the post-feeding position of preterm infants on gastric
by 180.252.99.83 from www.liebertpub.com at 09/08/18. For personal use only.

residue.
Materials and Methods: This experimental study was conducted in the neonatal intensive care unit (NICU) of a
_
¨ ¨
¨

university hospital (Inonu University Turgut Ozal Medical Center) in Eastern Turkey. The study included 40 preterm
infants weighing less than 2,000 g, who were fed orogastrically. The preterm infants were sequentially placed in
four positions and were fed before each change of position. The infants were sequentially placed in the right lateral,
left lateral, supine, and prone positions; their gastric residues were measured with a nasogastric tube. The gastric
residue was recorded in percentages at 30, 60, 120, and 180 minutes. Ethical principles were applied in all phases of
the study. Results: The lowest mean gastric residue level was observed in the right lateral position at 30 minutes
(58.16 – 12.71%) and 60 minutes (33.97 – 15.00%). The prone position showed the lowest mean gastric residue
level (1.74 – 1.08%), followed by the right lateral (3.06 – 1.97%), supine (3.53 – 2.18%), and left lateral position
(5.14 – 1.85%) at 120 minutes. The final measurements were taken at 180 minutes with the right lateral position
showing the lowest mean gastric residue level (0.38 – 0.34%).
Conclusion: The premature infants had similar lower levels of gastric residue in the right lateral and prone positions
and higher levels of gastric residue in left lateral and supine positions. The gastric emptying rate was found to be
highest in the right lateral position at 30, 60, and 180 minutes and in the prone position at 120 minutes.

Keywords: breastfeeding, gastric residue, position, preterm

Introduction the most appropriate way. Gastric residue is an important

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factor: it affects a premature infant’s feeding. It is used as a

O ne of the most important nursing care practices in-volving
premature infants in neonatal intensive care units is the
positioning these infants. Nurses usually change the infants’
positions and observe them using an observation form.1 Making
regular changes in infants’ positions usually prevents the
decubitus sores that occur when infants remain in the same
position. Positioning the preterm infant may posi-tively or
negatively affect its body systems.2 Inappropriate positioning of
premature infants causes motor and behavioral disorders, irregular
sleep-wake cycles, chronic pain, and, in the long term, permanent
posture disorders.2–4 Studies have also shown that the positions
premature infants are placed in affects
4–9
them in many ways.
Another important nursing care practice used for prema-
ture infants in neonatal intensive care units is feeding them in
significant source of data by the nurses responsible for an
infant’s well-being to decide whether to continue, increase, or
end nutrition.
8,10
Whereas studies have focused on position
and reflux, gastric emptying is quite important for the infant’s
tolerance for feeding, and only a limited number of studies
have been published on this subject. Gastric residue, fre-
quently observed in premature infants, is the most important
indicator of abdominal distension and that an infant is have
difficulty tolerating enteral feeding; consequently, gastric
11
residue is closely tracked by nurses.
Beginning enteral feeding in premature infants is important
for the improvement of the immature gastrointestinal system.
Beginning enteral feeding at an early stage enables premature
infants to tolerate feeding better and ensures that they expe-
rience fewer possible complications of parenteral feeding.

1
Department of Child Health Nursing, Health Sciences of Faculty, Ino¨nu¨ University, Malatya, Turkey.
2
Department of Child Health Nursing, Nursing Faculty, Atatu¨rk University, Erzurum, Turkey.
3
Department of Child Health Nursing, Health Sciences of Faculty, Ino¨nu¨ University, Malatya, Turkey.
4 ¨ University, Malatya, Turkey.
Turgut Ozal Tıp Merkezi, Inonu¨¨
438
 FEEDING POSITION EFFECT ON GASTRIC RESIDUE
Conversely, inability of premature infants to tolerate feeding
12
increases mortality and morbidity for different positions.
The most important factor affecting nutrition in premature
11,12
infants is gastric emptying. Some studies have shown
that body position affects the gastric emptying rate and hence
7,8,13,14 13
the amount of gastric residue. Cohen studied the
effect at the end of the first hour of four different positions on
infants after feeding and found no difference between the
gastric residue in infants placed in prone and supine posi-
tions. On the other hand, he found a significantly lower level
of gastric residue in the infants placed in the left lateral and
8 Design
right lateral positions. Chen analyzed two different positions
after feeding (prone and supine) and reported that the prone
position was more effective for gastric emptying.
Most of the studies on this subject have shown contradictory
results: one study reported that the supine and left lateral po-
sitions were not helpful for gastric emptying and recommended
12
that nurses use these positions less often. Some studies showed
no difference between breast milk and formula in terms
15,16
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of gastric emptying. Clearly, the different methods used in
11,12,14
previous studies have led to different results. Four dif-
ferent positions are used with preterm infants in neonatal in-
tensive care units; however, there is no clear information on
which position is more effective for reducing gastric residue
after feeding or at which nutritional stage this position should
be used. The present study aims to analyze the effect of
position on gastric emptying in premature infants.
Background
Only a limited number of studies have been published that
examine the effect of post-feeding body position on gastric
residue in premature infants. The first study on this subject was
5
conducted by Yu. In that experimental study, the researcher
examined the effect of post-feeding position in four groups (term,
preterm, Respiratory Distress Syndrome [RDS] infant, and small-
for-age); each group included 12 infants. The results of the study
showed that there were no differences between the groups, but it
was found that gastric emptying occurred faster with infants in the
5
right lateral and prone positions. Another study, conducted by
17
Malhotra , compared the post-feeding ef-fect of prone and
supine positions on gastric residue in infants fed with breast milk
and formula. An experimental research design was used in the
Malhotra study; it included three groups (newborn [n = 50], size
appropriate-for-age [n = 38] and small-for-age [n = 12]). The
results of that study showed that the prone position is better than
supine position with respect to amount of gastric residue, but
there was no difference between feeding breast milk or formula. A
12
study conducted by Sangers exam-ined 147 preterm infants with
a gestational age of 28–36 weeks.
The amount of gastric residue for premature infants was
monitored during 24 hours in four different positions (right
lateral, left lateral, supine, and prone). The residue mea-
surement was performed twice in each position. The lowest
residue level was measured in the right lateral and prone
8 required, for instance, if mothers did not come to the clinic or
positions. A study conducted by Chen et al. examined the
post-feeding effect of prone and supine positions with 35
premature infants using a randomized controlled experi-
mental study design. In that study, infants were monitored for
three hours, and their gastric residue levels were measured
five times (at 30, 60, 90, 120, and 150 minutes). The amount
of residue found in prone position was significantly lower than
439
in the supine position. Another randomized controlled exper-
13
imental study was conducted by Cohen with 31 infants. The
gastric residue levels of these infants were measured in four
different positions (right lateral, left lateral, supine, and prone)
at the first and third hour after feeding, and their gastric emp-
tying rates were examined. The highest gastric emptying rate
occurred in the right lateral position, followed by the prone,
supine, and left lateral positions in that order.
Materials and Methods
A semi-experimental study design was utilized in this study.
Study sample
This experimental study was conducted in the neonatal in-
_ ¨
tensive care unit of Ino¨nu¨ University Turgut Ozal Medical Center in
Eastern Turkey. The neonatal intensive care unit was a primary level
intensive care unit with 20 beds. A total of 20 nurses work shifts in
the clinic. A nurse provides care for three patients during each shift.
The study included 40 preterm in-fants who met the following
inclusion criteria: a weight of 2,000 g, being fed orogastrically, being
breastfed at 3-hour in-tervals, being clinically stable, and not having
any metabolic problem. The infants were breastfed only and given a
minimum 50% of their total daily intake through an oral route; the
other 50% was given by parenteral nutrition/glucose solution. The
exclusion criteria were: being on mechanic ventilation; needing
oxygen to treat bronchopulmonary problems or other indica-tions;
having a nutritional problem resulting from necrotizing enterocolitis;
not being breastfed only; and any defect that posed a risk to
positioning, such as a neural tube defect.
Study procedure
The infants admitted to the clinic were given intravenous
glucose solution on the first day of life; they were then pro-
vided with parenteral feeding. Parenteral feeding was re-duced
(depending on their caloric needs) as the infants’ daily intake
increased. Oral intake by the premature infant de-pended on
the infant’s digestion. Feeding was not increased when the
infant’s gastric residue was above 50%, the infants have
abdominal distension, or if green or brown vomit was
observed. The oral nutrition food amount can be cut off and
delayed depending on the baby’s digestion. Daily oral intake
in infants without any problem was increased to 10 to 20
mL/kg/day. The infants who started to take half of their daily
required feeding through the oral route and who met the other
inclusion criteria were included in the study. In the routine
practice of the clinic, the nurses fed the infants through an
orogastric or nasogastric tube at the start of feeding. Breast
milk was obtained from the mothers of premature infants
using an electric pump in the clinic, and their breast milk was
usually given to the infants on the same day. Breast milk was
refrig-erated (between -4 and 0LC or -20 and -18LC) when
breast milk produced was more than the infant could consume.
The parents of the preterm infants included in the study were
interviewed and their informed consent was received. The preterm
infants were sequentially placed in four positions and were fed before
each change of position. The infants were first placed in the right
lateral position, followed by left lateral,
 440 YAYAN ET AL.

supine, and prone positions, and stayed in each position for three
hours. The gastric residue levels were measured at 30, 60, 120,
and 180 minutes after each feeding. The amount of breast milk
given to the infants, which ranged between 20 and 42 mL, was
recorded at each time point. The gastric residue was calculated by
comparing the amount given to the infant versus the amount
consumed (gastric residue level = amount consumed at the hour
8 residue). The amount of gastric residue was analyzed for
of measurement·100/nutrition given + previous gastric resi-due).
Measurement was measured with nasogastric tube. The gastric
residue was recorded in percentage. The infants’ vital signs during
the process were monitored. During the procedure, the process
would be ended if any problem occurred. No problems were
observed in the infants, and the processes were completed as
planned. The entire process was recorded by a researcher and the
primary nurse caring for the infant.
Assessment of data
Assessment of data obtained as the result of the study
was conducted using the SPSS (Statistical Package for
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were placed while they were fed to find the position at
which the gastric emptying rate was better. The gastric
residue level was determined by calculating the proportion
of the breast milk given to the infants to the amount of milk
remaining in the stomach at the hour of measurement
(gastric residue percentage = the amount taken at the hour
of measure-ment·100/(nutrition provided+prior gastric
each position at specific time intervals.
The first measurement was taken 30 minutes post-feeding.
A statistically significant difference was found between the
positions at 30 minutes; Tukey analysis was used to deter-
mine which positions caused the difference. The lowest mean
gastric residue level was observed in the right lateral position
at 30 minutes; the level was almost half of the infants’ feeding
(58.16 – 12.71%). No significant difference in residue levels
was found between the right lateral and prone positions ( p =
0.120); however, a significant difference was found be-tween
residue levels in the left lateral ( p = 0.000) and supine ( p =

0.000) positions. The second lowest mean gastric resi-due

Social Sciences) 18.0 package program. Mean and standard level at 30 minutes was 67.77 – 10.48% in the prone position,
devia-tion and one-way ANOVA were used to analyze the which was similar to that in the right lateral position ( p =
data. The results were evaluated at the confidence interval 0.120). However, the left lateral ( p = 0.039) and supine lateral
of 95% and at the significance level of p < 0.05. ( p = 0.015) positions showed significant differences in
residue levels. Althoughh the left lateral (79.46 – 11.04%)
Ethical considerations position showed the third lowest mean gastric residue level,
and the supine (81.02 – 10.55%) position showed the highest
Ethical approval of the ethics committee of the mean gastric residue level, these mean gastric residue levels
university (Number and date: 2015/23), the permission of were similar; no significant difference was found between the
the clinic, and the informed consent of the premature left lateral and supine positions ( p = 0.983). The highest
infants’ parents were obtained.
gastric emptying rate was found to occur in the first 30
minutes in the right lateral position, followed by the prone,
Results left lateral, and supine positions, respectively.
Participants’ characteristics The post-feeding second measurement was taken at the end of the
first hour (at 60 minutes). A statistically significant dif-ference was
This study aimed to analyze the effect of the post-feeding position found between the positions in terms of gastric residue. The lowest
of 40 preterm infants on gastric residue. Of the pre-term infants, mean gastric residue level was found at the right lateral position
57.5% were male and 42.5% were female. The mean gestational age (33.97 – 15.00%). The second lowest mean gastric residue level was
of the preterm infants was 30.42 – 3.62 weeks and ranged from 28 to found at the supine position (36.37 – 12.94%), which was not
35 weeks. The mean birth weight of the infants was 1,231.25 – 452.3 significantly different from the right lateral position ( p = 0.962). The
g; their mean weight was 1,420.56 – 283.47 g when they entered the right lateral position was sig-nificantly different from the left lateral
study (Table 1). and supine positions. In addition, right lateral position was
significantly different from the left lateral and prone positions. The
The effects of the preterm infants’ position second lowest mean gastric residue was observed at the prone
on gastric residue position (36.37 – 12.94%), followed by the left lateral position (58.09
– 12.91%) and supine position (65.89 – 11.10%). The order of the
Four measurements were made at 30, 60, 120 and 180 positions at 60 minutes was close to the order at 30 minutes.
minutes during each position in which the preterm infants
The gastric residue of the preterm infants was reanalyzed at
Table 1. Demographic Characteristics 120 minutes after feeding. The prone position showed the
of the Participants lowest mean gastric residue level (1.74 – 1.08%), followed by
Demographic a the right lateral (3.06 – 1.97%), supine (3.53 – 2.18%), and
Mean – SD left lateral position (5.14 – 1.85%). The gastric residue level in
characteristics n Range
the right lateral position was not significantly different from
Gender 40 levels found in the supine ( p = 0.906) and prone ( p = 0.227)
Male 23 57.5% positions. However, significant differences in the gastric
Female 17 42.5% residue level were found between the right lateral and left
Gestational age 30.42– 3.62 28–35 lateral positions ( p = 0.020) and between the left lateral and
(weeks) – 452.3 prone positions ( p = 0.000). The order of the gastric emptying
Birth weight (g) 1,231.25 920–1,859
rate changed at 120 minutes: the prone position was the most
Actual weight (g) 1,420.56– 283.47 1,020–2,100
effective for gastric emptying, followed by the right lateral,
a
M – SD, mean – standard deviation. supine, and left lateral positions, respectively.
 FEEDING POSITION EFFECT ON GASTRIC RESIDUE 441
Table 2. Gastric Residual in the Four Positions at Feeding Volumes (%)

Time (minutes) Positions a F p

M – SD
30 Right side 58.16– 12.71 12.789 0.00
Left side 79.46– 11.04
Supine 81.02– 10.55
Prone 67.77– 10.48
60 Right side 33.97– 15.00 20.578 0.00
Left side 58.09– 12.91
Supine 65.89– 11.10
Prone 36.37– 12.94
120 Right side 3.06– 1.97 8.333 0.00
Left side 5.14– 1.85
Supine 3.53– 2.18
Prone 1.74– 1.08
180 Right side 0.38– 0.34 5.972 0.00
Left side 1.41– 1.22
Supine 1.13– 0.90
Prone 0.41– 0.38
Mean value was given as percentage.
use only.

a
M – SD, mean – standard deviation.
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The final measurements were taken at 180 minutes after
feeding. The right lateral position showed the lowest mean
gastric residue level (0.38 – 0.34%), followed by the prone
(0.41 – 0.38%), supine (1.13 – 0.90%), and left lateral posi-
tions (1.41 – 1.22%), respectively. The right lateral position
was not found to be significantly different from the supine and
prone positions in terms of gastric residue. However,
significant differences were found between the right lateral
and left lateral positions ( p = 0.006) and between the left
lateral and prone positions ( p = 0.008) (Table 2 and Fig. 1).
Discussion
This study analyzed the effect of the preterm infants’ post-
feeding position on gastric residue. Although the literature
contains insufficient data on this subject, previous studies
have partially analyzed the positional differences. In this
study, four measurements were taken at four positions to
analyze the effect of positioning on gastric residue.
The most effective position was the right lateral position at
30 and 60 minutes: this position produced the highest gastric
emptying rate. Measurements in the prone position were close
to those in the right lateral position at both times. The
advanced analysis showed no significant difference in gastric
emptying between the right lateral position and the prone
position. Results in the left lateral position and supine posi-
tion were similar to each other, both indicating slower gastric
emptying. Higher gastric emptying was observed in the first
30 minutes. The above-mentioned results were also observed
at the end of the first hour after feeding. The right lateral and
prone positions showed faster gastric emptying after feeding
compared to the supine and left lateral positions. Cohen et
13
al. analyzed the gastric residue levels of preterm infants at
the end of the first and third hours in these four positions.
These researchers also found that right lateral position yiel-
ded the lowest level of gastric residue and that the volume of
gastric residue was significantly different from the left lateral
position. They also reported that results in the prone position

FIG. 1. Gastric residues as a

percent of feeding volume in
preterm infants in four
feeding positions.
 442
were similar to those in the right lateral position and that
gastric emptying in the prone position was significantly dif-
ferent from that in the left lateral position. In their study, the
supine position yielded similar results to left lateral position at
the end of the first hour. The first-hour results of the Cohen et
13
al. study were close to the first-hour results of the present
study, indicating that the highest gastric emptying occurred in
right lateral and prone positions. Another important point here
is that the slowest gastric emptying in the first hour occurred
in supine position in the present study.
8
Chen et al. analyzed the gastric emptying rate by mea-
suring the gastric residue in supine and prone positions at 30-
minute intervals after feeding was provided in two sepa-rate
volumes (50 and 100 mL/kg/day). They reported that the
gastric emptying rate was higher in the prone position at 30
and 60 minutes, similar to the results of the present study. The
other studies also indicated that gastric emptying rate in the
right lateral position was not lower than that of the other
positions and that the infants seemed more comfortable in
5,13,18,19
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this position after being fed. The most important
finding in this study is that the prone and right lateral posi-
tions and the supine and left lateral positions showed
similar amounts of gastric residue.
In the present study, the gastric residue levels measured at
the second and third hours were similar in the right lateral,
prone, and supine positions. Significant differences were
found between the left lateral and right lateral positions and
8
between the prone and supine positions. Chen et al. found
that gastric residuals were significantly lower in the prone
than in the supine position at the five measurement points;
measurements were taken at 30, 60, 90, 120 and 150 min. In
the present study, however, the advanced analysis showed no
significant difference in gastric residue between the supine
and prone positions at the second and third hour. Although
13
Cohen et al. did not find a significant difference between the
positions at the third hour, the present study revealed sig-
nificant differences between the positions both at the second
and the third hour. Another study on preterm infants, con-
12
ducted by Sangers et al. , found that, like the results of our
study, the lowest amount of residue was observed in the right
lateral and prone positions.
17
Malhotra et al. compared the gastric residue of formula
and breast milk feedings in the prone and supine position. The
authors reported that the prone position yielded better results
than did the supine position; however, they found no differ-
17
ence between the gastric residue of formula and breast milk.
Some studies that analyzed the effect of infants fed either
breast milk or formula on gastric emptying found no
difference between the groups and reported that breast milk or
7,15–17,19
formula feedings did not affect gastric emptying.
The present study included infants who were breastfed
only. It is recommended that the effect of breast milk and
formula feedings in the four positions also be analyzed.
Conclusion
This study analyzed the effect of the post-feeding position of
preterm infants on gastric residue. The premature infants had lower
gastric residue levels in the right lateral and prone po-sitions. The left
side and supine positions showed similar re-sults, but the gastric
residue level was higher at these positions. Based on these findings, it
can be recommended that nurses
YAYAN ET AL.
place premature infants in the right lateral or supine positions for the
first 30 minutes or one hour after feeding them. This study may be a
guide to neonatal intensive care unit nurses with respect to
appropriate positioning of preterm infants. But we recommend that
studies be conducted in preterm groups that receive only breast milk
or only formula and that the results be compared. Further studies
should be conducted to better un-derstand the effect of infant
positioning on gastric residue.
Relevance to clinical practice
Nurses can preferably use right lateral and prone positions
particularly in the first 30 minutes or one hour when posi-
tioning premature infants after feeding. The gastric residue
amounts in infants placed in the right lateral and prone po-
sitions and in those placed in the left lateral and supine po-
sitions after feeding were similar in the present study. This
finding suggests that the right lateral and prone positions and
the left lateral and supine positions can be used as an alter-
native to each other when positioning infants after feeding in
clinics. However, considering that the number of studies
conducted on this subject is limited, it is recommended that
the findings of the present study be supported with other
studies conducted with larger samples.
Limitations of the Study
A limitation of the study was the inadequate number of
infants who met the inclusion criteria. The study was con-
ducted for a longer period than planned because the prema-
ture infants were generally admitted to the neonatal
intensive care unit with an accompanying problem.
Another limitation was the requirement that the infants be
breastfed only. In the clinic’s routine, infants are supported
with formula when breast milk is insufficient, thus
excluding these infants from meeting the study criteria.
Authors’ Contributions
E.H.Y. conceived of the intervention and its design, was
the principal investigator, and directed the writing process.
E.H.Y. and S.K. provided the intervention and drafted the
initial manuscript. E.H.Y. conducted data collection and
analysis, carried out revisions of the manuscript and
assisted with the intervention. E.H.Y., Y.S.D and N.K.B
contributed to the intervention and interpretation of the
work. All authors contributed to the writing process and
approved the final manuscript.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Sibel Kucukoglu, RN, PhD
Department of Child Health Nursing
Nursing Faculty
Atatu¨rk University
Erzurum 25240
Turkey
E-mail: s_nadaroglu@hotmail.com