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Three Part Question

In a [neonate born through meconium stained amniotic fluid] does [omitting suctioning] lead to [improved clinical outcomes/development of MAS] for both vigorous and non-vigorous neonates?

Clinical Scenario

A neonate of 41 weeks gestation was born through Meconium Stained Amniotic Fluid (MSAF). Mild tachypnea was noted at 1 and 5 minutes, that did not respond to gentle stimulation and wiping of the mouth. Subsequently, intratracheal suctioning was performed with resolution of respiratory distress after brief NICU observation.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Nangia S, Sunder S, Biswas R, Saili A. Aug 2016 India	175 term non-vigorous infants.	Pilot RCT	Occurrence of MAS	MAS present in 23/88 (26.1%) vs. 28/87 (32.3%) neonates in ‘No ET Suction’ and ‘ET Suction’ groups respectively (OR 0.4 (0.12-1.4); p = 0.14)
Chettri S, Adhisivam B, Bhat BV. May 2015 India	162 term, nonvigorous, born through MSAF	RCT	Incidence of MAS	Overall, 39 (32%) neonates developed MAS.
Kelleher J, Bhat R, Salas AA, Addis D, Mills EC, Mallick H, Tripathi A, Pruitt EP, Roane C, McNair T July 2013 USA	488 neonates born at median of 39 weeks’ gestation.	Randomised Equivalency Trial	Respiratory rate in first 24 hours.	Mean RR was 51 breaths per minutes in the wipe group and 50 in the suction group (95% CI -2 to 0, p <0.001)
Wiswell TE, Gannon CM, Jacob J, Goldsmith L, Szyld E, Weiss K, Schutzman D, Cleary GM, Filipov P, Ku Jan 2000 USA	2094 neonates gestational age ?37 weeks, birth through MSAF of any consistency with apparent vigor immediately after birth.	Multicenter, international collaborative trial.	Incidence of respiratory distress, including MAS.	No significant differences between groups in the occurrence of MAS (INT = 3.2%; EXP = 2.7%) INT = Intubation & Suction EXP = Expectant Management
Linder N, Aranda JV et al Apr 1988 Israel	572 ‘normal’ newborns born through MSAF with 1 minute Apgar 8+.	Prospective Study	Development of respiratory distress	No mortality among infants in the study, but morbidity, mainly pulmonary and laryngeal disorders, occurred in six of the suctioning group (6/308)
Ting P, Brady JP. July 1975 USA	125 infants born through MSAF	Retrospective Study	Development of respiratory distress	28 infants who did not receive immediate tracheal suction, 16 became symptomatic and seven died of massive meconium aspiration pneumonitis (P less than 0.001)

Comment(s)

Meconium stained amniotic fluid (MSAF) is common in term and post term births. Approximately 13% of live births are born through MSAF with 5-12% of these progressing to Meconium Aspiration Syndrome (MAS). (1) MAS is defined as the occurrence of respiratory distress in an infant born through MSAF, whose symptoms cannot be otherwise explained, and with consistent radiographic findings. (2) Early opinion (1970s) suggested if amniotic fluid has evidence of meconium staining, management with intratracheal suctioning could prevent the development of MAS. Ting (1975) et al. produced a retrospective study on the morbidity and mortality of 125 infants born through MSAF. It concluded the occurrence of immediate tracheal suction at birth reduced the development of respiratory distress. Routine tracheal suction became the standard of care for neonates born through MSAF. Linder (1988) et al. first suggested immediate intratracheal suction in vigorous term neonates born through MSAF was unnecessary. (3) Their non-randomized study evaluated intubation and suction of vigorous infants (n=572) born through MSAF and demonstrated intratracheal suction did not decrease the incidence of MAS. For non-vigorous infants it was the work of Chettri et al. (2015) and Nagia et al. (2016). Both produced RCTs comparing the efficacy of endotracheal suctioning versus no suctioning in non-vigorous neonates born through MSAF. Both studies showed insignificant differences between each group (4-5).The suggestion was supported by several trials, with this leading to changes in the Neonatal Resuscitation Programme (NRP) Guidelines, in 2016.

Clinical Bottom Line

Emphasis is now placed on respiratory support with oxygenation and ventilation.

References

1. Nangia S, Sunder S, Biswas R, Saili A. Endotracheal suction in term non vigorous meconium stained neonates—a pilot study Resuscitation Aug 2016, 79-84
2. Chettri S, Adhisivam B, Bhat BV. Endotracheal suction for nonvigorous neonates born through meconium stained amniotic fluid: a randomized controlled trial. The Journal of Pediatrics May 2015;1208-1213
3. Kelleher J, Bhat R, Salas AA, Addis D, Mills EC, Mallick H, Tripathi A, Pruitt EP, Roane C, McNair T, Owen J. Oronasopharyngeal suction versus wiping of the mouth and nose at birth: a randomised equivalency trial. The Lancet July 2013; 326-330
4. Wiswell TE, Gannon CM, Jacob J, Goldsmith L, Szyld E, Weiss K, Schutzman D, Cleary GM, Filipov P, Kurlat I, Caballero CL. Delivery room management of the apparently vigorous meconium-stained neonate: results of the multicenter, international collaborative trial. Pediatrics Jan 2000; 1-7
5. Linder N, Aranda JV et al Need for endotracheal intubation and suction in meconium-stained neonates The Journal of Pediatrics Apr 1988; 613-615
6. Ting P, Brady JP. Tracheal suction in meconium aspiration American Journal of Obstetrics & Gynecology July 1975; 767-71