This randomized controlled trial was done to assess whether endotracheal suctioning of nonvigorous infants born through meconium stained amniotic fluid (MSAF) reduces the risk and complications of meconium aspiration syndrome (MAS). Term, nonvigorous babies born through MSAF were randomized to endotracheal suction or no suction groups (n=61 in each). Risks of MAS, complications of MAS and endotracheal suction, mortality, duration of neonatal intensive care unit stay, and neurodevelopmental outcome at 9 months were assessed. In total, 39 (32%) neonates developed MAS and 18 (14.8%) of them died. There were no significant differences in MAS, its severity and complications, mortality, and neurodevelopmental outcome for the two groups. One infant had a complication of endotracheal suctioning, which was mild and transient. The authors conclude that current practice of routine endotracheal suctioning for nonvigorous neonates born through MSAF should be further evaluated.

Relevance: Fetal passage of meconium in utero is a worrisome event because of the risk of meconium aspiration syndrome (MAS), which carries threat of mortality to the extent of 5-40% [1]. In addition, there are several unpleasant sequelae affecting the respiratory system, and neuro-development in later life. Some of the dangerous respiratory consequences of MAS are related to airway obstruction and air-leak. However, there are also chemical effects mediated by inflammation and inactivation of surfactant. Formerly, the standard of care was nasopharyngeal and oropharyngeal suction of the infant’s airway even before delivery. However, the evidence of benefit from this intervention was not demonstrated in a meta-analysis of 4 trials [2], and this has now been abandoned altogether in active vigorous babies. In contrast, current guidelines still advocate inspection of the airway and endotracheal suctioning in depressed/non-vigorous babies [3,4], probably because of absence of evidence to change practice in this group of vulnerable neonates. The general practice in such babies is to look for particulate meconium and undertake endotracheal suction if it is present [5]. However, recent reports suggest that this may not significantly reduce the risk of MAS [6]. There are emerging views that non-vigorous babies may also not require endotracheal suction. Against this backdrop, the recent trial by Chettri, et al. [7] is a valuable addition to literature. The trial [1] details are summarized in Table I.

TABLE I Summary of the Trial Details

Critical appraisal: The RCT was planned and executed well. Table II summarizes the methodological characteristics. Overall, the trial qualifies for medium risk-of-bias status. There are several refinements that make this trial noteworthy. First, precise definitions have been used; and where relevant, components of definitions (of various clinically used terms) have also been explicitly clarified and defined. Further, the primary outcome (incidence of MAS) has been supplemented with data on a variety of clinically important parameters that are both patient-centric as well as relevant to the managing team. The instruments used to evaluate long-term outcomes were designed for Indian infants, and hence are likely to have reliability and replicability in Indian settings. The investigators have drawn conservative conclusions from their findings, suggesting that this trial demands further evaluation of the time-honored practice, rather than immediate change in practice. This is pertinent because data from 122 babies may be insufficient to identify any subgroups of non-vigorous neonates that may benefit (or alternatively be harmed) from endotracheal suction.

Table II Methodological Appraisal of The Trial

Extendibility: The RCT was conducted in a teaching hospital in India itself, making it easier to replicate the procedures followed in the trial, and extend the results to other similar institutions in the country and region. The trial site is a tertiary care institution, and hence better equipped in terms of manpower and resources, to deal with exigencies that arise. This may be particularly important because proper endotracheal suction itself needs considerable training, and can be associated with complications [9]. For this reason, the results of the trial may not be similar in other units caring for newborn babies.

Another issue is that the trial found similar outcomes in babies not receiving endotracheal suction and in those receiving suction; however neither was superior (or inferior) for any outcome parameter. This suggests that neonatology units and specialists can consider change in practice only after carefully collating existing local data (for a reasonable period of time), so that the impact of change (if any) can be documented and interpreted correctly. On the research front, the data from this trial would contribute to a systematic review and meta-analysis of similar trials (as and when they are reported).

Conclusions: This well conducted randomized trial shows that in babies born through meconium stained amniotic fluid, who are non-vigorous at birth, omission of the practice of endotracheal suction, yields comparable short-term and long-term outcomes to those who receive endotracheal suction.

Department of Pediatrics,
PGIMER, Chandigarh, India.
Email: [email protected]

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2. Halliday HL. Endotracheal intubation at birth for preventing morbidity and mortality in vigorous, meconium-stained infants born at term. Cochrane Database Syst Rev. 2001;1:CD000500.

3. Roehr CC, Hansmann G, Hoehn T, Bührer C. The 2010 Guidelines on Neonatal Resuscitation (AHA, ERC, ILCOR): similarities and differences – what progress has been made since 2005? Klin Pediatr. 2011;223:299-307.

4. Kattwinkel J, Perlman JM, Aziz K, Colby C, Fairchild K, Gallagher J, et al. Part 15: neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S909 –19.

5. Green DA. Adaption of suction connectors for use in meconium aspiration syndrome. Trop Doct. 2010;40:33-7.

6. Michel F, Nicaise C, Camus T, Di-Marco JN, Thomachot L, Vialet R, et al. Management of newborns with meconium-stained amniotic fluid: prospective evaluation of practice. Ann Fr Anesth Reanim. 2010;29:605-9.

7. Chettri S, Adhisivam B, Bhat BV. Endotracheal suction for nonvigorous neonates born through meconium stained amniotic fluid: A randomized controlled trial. J Pediatr. 2015;166:1208-13.

8. No authors listed. Rationale for Concern About Bias. Available from: http://handbook.cochrane.org/chapter_8/8_13_1_rationale_for_concern_about_bias.htm. Accessed June 13, 2015.

9. Velaphi S, Vidyasagar D. The pros and cons of suctioning at the perineum (intrapartum) and post-delivery with and without meconium. Semin Fetal Neonatal Med. 2008; 13: 375-382.