Timing and safety of prone positioning following median sternotomy in infants with single-ventricle physiology

Abstract Background: Prone positioning is an essential component of early rehabilitation and motor development in infants following cardiac surgery involving median sternotomy; however, restrictions remain variable due to concerns regarding sternal healing and safety. Due to a lack of guiding evidence, many institutions implement a time-based restriction to prone positioning. Methods: A retrospective cohort study was conducted of infants with single-ventricle physiology undergoing cardiac surgery via median sternotomy at a single paediatric centre between 2022 and 2025. Data collected included time to physical therapy evaluation, time to initiation of prone positioning, clinical factors influencing positioning, and sternal healing outcomes after discharge. Descriptive statistics were used to summarise timing and outcomes. Results: A total of 37 patients were included with 46 surgical encounters. The median age at first surgery was 65 days (interquartile range: 6–204). Physical therapy evaluation occurred at a median of 9 days post-operatively (interquartile range: 7–15; range: 3–29), and prone positioning was initiated at a median of 15 days (interquartile range: 10–22; range: 4–115). Timing differed by surgical stage, with earlier initiation following Glenn compared to Norwood procedures. Delays in prone positioning were associated with medical instability, delayed sternal closure, and the presence of invasive lines and devices. No cases of sternal dehiscence, infection, or adverse healing outcomes were identified at outpatient follow-ups. Conclusions: Prone positioning following infant cardiac surgery demonstrates variability in timing but appears safe when guided by clinical stability and patient-specific factors. These findings support a shift from time-based restrictions to individualised, criteria-driven approaches.