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Laryngeal mask airway versus face mask ventilation or intubation for neonatal resuscitation in low-and-middle-income countries: a systematic review and meta-analysis
  1. Shivashankar Diggikar1,
  2. Roshani Krishnegowda2,
  3. Karthik N Nagesh3,
  4. Satyan Lakshminrusimha4,
  5. Daniele Trevisanuto5
  1. 1 Pediatrics, Oyster Woman and Child Hospital, Bengaluru, Karnataka, India
  2. 2 Pediatrics, Khoula Hospital, Mina Al Fahal, Oman
  3. 3 Department of Pediatrics, Manipal Hospitals, Bangalore, Karnataka, India
  4. 4 Pediatrics, UC Davis, Sacramento, California, USA
  5. 5 Department of Woman's and Child's Health, University of Padova, Universita degli Studi di Padova Dipartimento di Salute della Donna e del Bambino, Padova, Italy
  1. Correspondence to Dr Shivashankar Diggikar, Pediatrics, Oyster Woman and Child Hospital, Bangalore 560042, Karnataka, India; shiv.diggikar{at}


Objective To assess whether laryngeal mask airway (LMA) as compared with face mask (FM) or endotracheal intubation (ETT) is more effective in delivering positive pressure ventilation (PPV) during neonatal resuscitation in low-and-middle income countries (LMICs).

Study design We followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and searched Medline (PubMed interphase), Cumulative Index of Nursing and Allied Health Literature, Embase and Cochrane Registry between January 1990 and April 2022 for the studies that examined the effect of LMA in delivering PPV compared with the FM or ETT in infants during neonatal resuscitation. We included the studies conducted in LMIC only. We assessed the quality of all the included studies using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) recommendations.

Results Our search resulted in eight randomised studies Six studies compared LMA with FM and three studies compared LMA with ETT. When used as the primary device for providing PPV, the LMA as compared with FM resulted in a significant lower failure rate (relative risk (RR) 0.23, 95% CI 0.13 to 0.43) with moderate certainty of evidence (CoE) and lesser need for intubation (RR 0.21, 95% CI 0.07 to 0.58) with low CoE. There was no difference in the incidence of encephalopathy, neonatal admission, need for advanced resuscitations or death. No differences were observed between LMA and ETT. Studies comparing LMA to ETT were limited for any conceivable conclusion.

Conclusion LMA is more effective than FM in delivering PPV with less failure rates and reduced need for intubation during neonatal resuscitation in term infants and in LMIC without any difference in the incidence of encephalopathy or death. Studies comparing LMA to ETT are scarce with important methodological limitations.

PROSPERO registration number CRD42021283478.

  • Neonatology
  • Intensive Care Units, Neonatal
  • Resuscitation

Data availability statement

Data published is already available in public domain.

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Data availability statement

Data published is already available in public domain.

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  • Twitter @SDiggikar, @neosatyan

  • Collaborators NA.

  • Contributors SD conceived, conceptualised and designed the study, performed the initial screening of the articles, abstracted the data, performed meta-analyses including the risk of bias assessment, performed GRADE assessment and drafted the initial manuscript and responsible for overall content as the guarantor. RK double-checked the initial screening of articles and double-checked all the data extraction including the risk of bias assessment. KNN provided intellectual input in data analysis. DT and SL reviewed and edited the manuscript. SD, RK, KNN, DT and SL approved the final version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests DT is a member of the ILCOR Neonatal Task Force and a member of the European Resuscitation Council Neonatal Life Support Task Force. SL is a member of the American Academy of Pediatrics – Neonatal Resuscitation Program Steering Committee. The views expressed in this manuscript are individual opinions of the authors and do not reflect the official position of ILCOR or AAP.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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