1. For sample size calculation, the authors have assumed the incidence of MAS in babies born with MSAF as 15%, based on an old unpublished study. However, most of the recent studies have reported the incidence of MAS as 5-8% [3,4]. Moreover, in the present study itself, the incidence of MAS is quite less (1.4% in intervention arm and 2.2% in control arm). The authors should have used information from these studies to calculate the sample size for adequate power of their study.

2. We clearly miss the definition of ‘vigorous infant’ in the entire manuscript. Also, whether the authors also included babies with respiratory distress soon after birth is not clear.

3. One of the exclusion criteria mentioned in the methodology is; mothers receiving methyldopa. It is not clear why these babies were specifically excluded.

4. In this study, chest X-ray was done in all participants within 4 hours of birth, irrespective of symptoms. We feel that doing X-ray in an asymptomatic baby is not ethically justified. Also, MAS is defined based on presence of clinical symptoms and abnormal chest X-ray. Chest X-ray could have been done only in babies with respiratory distress.

5. For lavage, normal saline (10mL/kg) was used. As lavage was done before the baby was weighed, the clinician must have used approximations to estimate birth weight. It would have been better if volume used for lavage was weight independent.

6. Apart from the adverse effects studied, another potential harm of this intervention is being an hindrance to routine care. If, not for this intervention, a vigorous baby born through MSAF would have received immediate skin to skin contact and early initiation of breastfeeding. However, the need to perform gastric lavage before feeding hinders this practice. This adverse effect of performing this procedure should appear in the manuscript.