• infant, newborn
• intubation
• endotracheal tube

Trumping even ‘the threshold of viability’ and tongue tie, intubation may be the most emotive subject in neonatology. Insertion of an endotracheal tube (ETT) for breathing support proved life saving for many apnoeic term babies and many preterm babies with respiratory distress. It was pivotal in defining the specialty. It provided a raison d’être to the buccaneering neonatologists who supplanted fatalistic paediatricians in the 1980s. When I began looking after babies as one of five senior house officers working long hours at a stand-alone maternity hospital in Dublin in the late 1990s, intubation was all the rage. We completed the Neonatal Resuscitation Program1 in our first week, intubating stiff plastic mannequins with gusto. We were taught that all babies born through meconium-stained liquor required intubation for tracheal suction.1 This should mean that about 20% of our babies were intubated; however, many of them were not. More often, a nervy junior doctor put a laryngoscope blade in the mouth of a conscious term baby who was neither sedated nor ‘muscle-relaxed’ and a fierce struggle ensued. I diligently suctioned many the oropharynx, oesophagus and stomach until one day, somewhat surprisingly, the larynx and vocal cords magically popped into view. I learnt how to acquire this view reliably and then learnt how to intubate. In those days, we routinely intubated preterm infants in the delivery room for surfactant administration and continued ventilation. Speed was of the essence; we were taught that intubation attempts should be successful within 20 seconds1 (though, unsurprisingly, it often took longer2). Proficiency at intubation was the yardstick by which we measured ourselves. My generation learnt to intubate while arm wrestling term babies, refined our skills on preterm babies, had punishingly long working hours in which to practise, and so became pretty slick at intubation.

But life evolves. A large …