Tracheal suctioning of meconium at birth for non-vigorous infants: a systematic review and meta-analysis

doi:10.1016/j.resuscitation.2020.01.038

Resuscitation

Volume 149, April 2020, Pages 117-126

https://doi.org/10.1016/j.resuscitation.2020.01.038 Get rights and content

Abstract

Context

The International Liaison Committee on Resuscitation sought to review the initial management of non-vigorous newborns delivered through meconium stained amniotic fluid (MSAF).

Objective

To complete a systematic review and meta-analysis comparing endotracheal intubation and suctioning to immediate resuscitation without intubation for non-vigorous infants born at ≥34 weeks gestation delivered through MSAF.

Data sources

Medline, EMBASE, the Cochrane Database of Systematic Reviews, and other registries were searched from 1966 to November 7, 2019.

Study selection

Studies were selected by pairs of independent reviewers in 2 stages.

Data extraction

Reviewers extracted data, appraised risk of bias, and assessed Grading of Recommendations Assessment, Development and Evaluation certainty of evidence for each outcome.

Results

Four randomized controlled trials (RCTs) included 581 patients and one observational study included 231 patients. No significant differences were observed between the group treated with tracheal suctioning compared with immediate resuscitation for survival at discharge (4 RCTs; risk ratio [RR] = 1.01; 95 % CI, 0.96–1.06; p = 0.69; observational study; no deaths), hypoxic ischemic encephalopathy and meconium aspiration syndrome.

Limitations

The certainty of evidence was low for survival at discharge and very low for all other outcomes.

Conclusions

For non-vigorous newborns delivered through MSAF, there is insufficient evidence to suggest routine immediate direct laryngoscopy with tracheal suctioning.

PROSPERO

CRD42019122778.

Clinical Trials Registration: PROSPERO; CRD42019122778.

Section snippets

Protocol

This systematic review and meta-analysis was conducted in conformity with the Cochrane Handbook for Systematic Reviews of Interventions.¹⁴ The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for meta-analysis in health care interventions was used as a guide to conduct the review and analysis (PRISMA Checklist, Supplementary Table S1).¹⁵

The protocol was registered before article selection with the Prospective Register of Systematic Reviews (PROSPERO;

Literature search and study selection

The search strategy identified 1355 records; after removing 493 duplicates, 862 records were screened by title and abstract. Eighteen full-text articles were assessed for eligibility Fig. 1).23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40 The Cohen’s kappa coefficient was 0.63 (good) at the abstract stage and 1.0 (full agreement) at the full-text stage. Fig. 1 shows the PRISMA study selection diagram including the reasons for article exclusion. Search of clinical trial

Discussion

This systematic review and meta-analysis involving 812 non-vigorous newborns delivered through MSAF showed that an approach based on immediate laryngoscopy with tracheal suctioning did not improve survival at discharge when compared to immediate resuscitation without laryngoscopy. NDI at 9 months, incidence of HIE, MAS, need for respiratory support and mechanical ventilation, DR interventions, treatment of pulmonary hypertension and length of hospitalization were also comparable between the two

Limitations

This analysis has limitations that should be considered when interpreting the results. All considered studies had high or unclear RoB due to allocation concealment, personnel blinding or blinding of outcome assessors. Certainty of the evidence was low or very low due to RoB, inconsistency and imprecision. The definition of “non-vigorous” was not consistent across studies and may have been subjective. Survival at discharge was different between studies conducted in low- and high-resource

Conclusions

This systematic review and meta-analysis cannot exclude either benefit or harm of a strategy based on immediate laryngoscopy with or without tracheal suctioning compared to immediate resuscitation without laryngoscopy. For non-vigorous newborns delivered through MSAF, there is insufficient published human evidence to suggest routine immediate direct laryngoscopy with or without tracheal suctioning when compared to immediate resuscitation without direct laryngoscopy. A large high quality RCT for

Contributors’ statement

Daniele Trevisanuto prepared the protocol, prepared the tables, completed risk of bias and GRADE evaluations, completed the analysis, and prepared the first draft of the manuscript.

Marya Strand prepared the protocol, screened studies, abstracted data and was involved in writing and editing the manuscript.

Mandira Daripa Kawakami prepared the protocol, screened studies and were involved in writing and editing the manuscript.

Jorge Fabres prepared the protocol, screened studies and were involved in

Funding source

This systematic review and meta-analysis received funding from the American Heart Association on behalf of ILCOR. The funder was involved in the ILCOR process, but had no role in this systematic review study design, data collection and analysis, or preparation of the manuscript.

Financial disclosure

The authors have no financial relationships relevant to this article to disclose.

Conflicts of interest

The authors have no conflicts of interest relevant to this article to disclose.

Acknowledgements

The authors would like to thank the following for contributing valuable support to improve this review: Laurie J Morrison (ILCOR Continuous Evidence Evaluation Working Group Liaison), Matt Buchanan (Advisor for Science and Health Advancement Emergency Cardiovascular Care Program, AHA), and Carolyn Ziegler (St. Michael’s Hospital Information Specialist).

Besides the authors Daniele Trevisanuto, Edgardo Szyld, Myra H. Wyckoff, and Yacov Rabi, members of the International Liaison Committee on

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Citation Excerpt :
Of note, suctioning the trachea through a tracheal tube (TT) is no longer recommended in newborns born through meconium-stained amniotic fluid unless resuscitation is ineffective because of airway obstruction. This change in practice is based on the lack of evidence for benefit from universal tracheal suctioning and the potential risk from delaying resuscitation and performing unnecessary laryngoscopy.16 Assessment of HR and oxygen saturation (Spo2) is an integral part of neonatal resuscitation and guides clinical management.
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An ILCOR systematic review of three RCTs involving 449 infants and one observational study of 231 infants demonstrated no benefit from the use of immediate laryngoscopy with or without tracheal suctioning compared with immediate resuscitation without laryngoscopy (RR 0.99; 95% CI 0.93–1.06; p = 0.87).1 Parallel meta-analyses including a further RCT with 132 infants derived similar conclusions.166–168 A post policy change impact analysis of the resuscitation of 1138 non-vigorous neonates born through meconium-stained amniotic fluid, found reduced NICU admissions and no increase in the incidence of Meconium Aspiration Syndrome (MAS) where suctioning was omitted in favour of immediate ventilation.169
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ReviewTracheal suctioning of meconium at birth for non-vigorous infants: a systematic review and meta-analysis

Abstract

Context

Objective

Data sources

Study selection

Data extraction

Results

Limitations

Conclusions

PROSPERO

Section snippets

Protocol

Literature search and study selection

Discussion

Limitations

Conclusions

Contributors’ statement

Funding source

Financial disclosure

Conflicts of interest

Acknowledgements

Am J Obstet Gynecol

Am J Obstet Gynecol

J Pediatr

Lancet

Pediatr Clin North Am

Int J Gynaecol Obstet

Ann Fr Anesth Reanim

Resuscitation

Clin Epidemiol Global Health

Meconium-stained amniotic fluid and meconium aspiration syndrome: a prospective study

Ann Trop Paediatr

The epidemiology of meconium aspiration syndrome: incidence, risk factors, therapies, and outcome

Pediatrics

Studies of meconium-induced lung injury: inflammatory cytokine expression and apoptosis

J Perinatol

Delivery room management of the apparently vigorous meconium-stained neonate: results of the multicenter, international collaborative trial

Pediatrics

ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions

BMJ

Factors associated with adverse events during tracheal intubation in the NICU

Neonatology

A randomized trial of stylets for intubating newborn infants

Pediatrics

Endotracheal intubation attempts during neonatal resuscitation: success rates, duration, and adverse effects

Pediatrics

Part 7: neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (Reprint)

Pediatrics

The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials

BMJ

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

PLoS Med

Consensus outcome rating for international neonatal resuscitation guidelines

Arch Dis Child Fetal Neonatal Ed

Review
Tracheal suctioning of meconium at birth for non-vigorous infants: a systematic review and meta-analysis