Is omitting suction of newborns with meconium liquor really justified?
Date First Published:
September 15, 2018
Last Updated:
September 15, 2018
Report by:
Mark Mahon, Medical Student (Trinity College Dublin)
Search checked by:
Mark Mahon, Trinity College Dublin
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.
Search Details:
A pubmed literature review was performed based on the terms; ‘Meconium’, ‘Aspiration’ and ‘Resuscitation’. This generated 213 literatures. Appropriate filters were applied to examine the literature; 1) Full texts, 3) Article type as Study or Trial 2) Non-animal studies only. 49 relevant articles remained.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Endotracheal suction in term non vigorous meconium stained neonates—a pilot study Nangia S, Sunder S, Biswas R, Saili A. Aug-16 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) | |
| Endotracheal suction for nonvigorous neonates born through meconium stained amniotic fluid: a randomized controlled trial. Chettri S, Adhisivam B, Bhat BV. May-15 India | 162 term, nonvigorous, born through MSAF | RCT | Incidence of MAS | Overall, 39 (32%) neonates developed MAS. | |
| Oronasopharyngeal suction versus wiping of the mouth and nose at birth: a randomised equivalency trial. Kelleher J, Bhat R, Salas AA, Addis D, Mills EC, Mallick H, Tripathi A, Pruitt EP, Roane C, McNair T, Owen J. Jul-13 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) | |
| Delivery room management of the apparently vigorous meconium-stained neonate: results of the multicenter, international collaborative trial. Wiswell TE, Gannon CM, Jacob J, Goldsmith L, Szyld E, Weiss K, Schutzman D, Cleary GM, Filipov P, Kurlat I, Caballero CL. Jan-00 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 | |
| Need for endotracheal intubation and suction in meconium-stained neonates Linder N, Aranda JV et al Apr-88 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) | |
| Tracheal suction in meconium aspiration Ting P, Brady JP. Jul-75 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) |
Author Commentary:
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.
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.
Bottom Line:
Emphasis is now placed on respiratory support with oxygenation and ventilation.
References:
- Nangia S, Sunder S, Biswas R, Saili A.. Endotracheal suction in term non vigorous meconium stained neonates—a pilot study
- Chettri S, Adhisivam B, Bhat BV.. Endotracheal suction for nonvigorous neonates born through meconium stained amniotic fluid: a randomized controlled trial.
- 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.
- 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.
- Linder N, Aranda JV et al. Need for endotracheal intubation and suction in meconium-stained neonates
- Ting P, Brady JP.. Tracheal suction in meconium aspiration