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Three Part Question

In a [neonate born through meconium stained amniotic fluid] is [suctioning necessary for both vigorous and non-vigorous] in [improving clinical outcomes of MAS]?

Clinical Scenario

A neonate of 41 weeks gestation was born through Meconium Stained Amniotic Fluid (MSAF) subsequently developing MAS necessitating invasive ventilation in the NICU.

Search Strategy

A pubmed literature review was performed based on the terms; ‘Meconium’, ‘Aspiration’ and ‘Resuscitation’.
Appropriate filters were applied to examine the literature; 1) Full texts, 3) Article type as Study or Trial 2) Non-animal studies only.

Search Outcome

The search generated 213 literatures. After filters were applied; 49 relevant articles remained.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Gregory GA, Gooding CA, Phibbs RH, Tooley WH. 1974 Dec USA	1000 consecutive newborn infants.	Prospective Study	The frequency MSAF, the incidence of radio- graphic abnormalities during the first hour of life, and, the incidence of respiratory distress.	88 of the 1000 newborns had Meconium Staining to some degree, with 80 requiring suctioning. No deaths.
Ting P, Brady JP 1975 Jul 15 USA	125 infants born through MSAF	Retrospective Study	Development of respiratory distress	28 infants who did not receive immediate tracheal suction, 16 became symptomatic and seven died of massive meconium aspiration pneumonitis (P less than 0.001)	Small sample size.
Carson BS, Losey RW, Bowes WA, Simmons MA. 1976 Nov 15 USA	273 newborns born through MSAF	Non-randomized study	Development of MAS	Lower incidence of MAS with the combined approach (1 out of 273 [4%]), although the difference between the groups was not significant (p=0.071).	No randomization.
Linder N, Aranda JV, Tsur M, Matoth I, Yatsiv I, Mandelberg H, Rottem M, Feigenbaum D, Ezra Y, Tamir 1988 Apr 1	572 newborns born through MSAF with 1 minute Apgar 8+.	Prospective Study	Development of Respiratory Distress	No mortality among infants in the study, but morbidity, mainly pulmonary and laryngeal disorders, occurred in six of the suctioning group (6/308)
Falciglia HS, Henderschott C, Potter P, Helmchen R. 1992 Nov 1 USA	428 infants with MSAF	Prospective Observational Study	Development of MAS	MAS developed in 38 (9%). Higher rates of fetal distress and lower Apgar scores (?6) vs. infants without MAS (58% vs 17% and 65% vs 13%, respectively; p < 0.001)
Wiswell TE, Gannon CM, Jacob J, Goldsmith L, Szyld E, Weiss K, Schutzman D, Cleary GM, Filipov P, Ku 2000 Jan 1st USA	2094 neonates gestational age >/=37 weeks, birth through MSAF of any consistency with apparent vigor immediately after birth.	Multicenter, international collaborative trial.	Incidence of respiratory distress, including MAS.	No significant differences between groups in the occurrence of MAS (INT = 3.2%; EXP = 2.7%)
Vain NE, Szyld EG, Prudent LM, Wiswell TE, Aguilar AM, Vivas NI. 2004 Aug 14 Argentina / USA	2514 term cephalic neonates with MSAF	Multicenter RCT	Incidence of MAS	MAS in 52 [4%] suction vs 47 [4%] no suction; relative risk 0.9, 95% CI 0.6-1.3
Ersdal HL, Mduma E, Svensen E, Perlman JM. 2012 Jul 1 Norway / Tanzania / USA	5689 liveborn infants	Observational Study	To assess the importance of initiating basic resuscitation within the first minutes after birth as it relates to neonatal outcome	Risk of death increases 16% for every 30 s delay in initiating FMV up to six minutes (p=0.045)
Kelleher J, Bhat R, Salas AA, Addis D, Mills EC, Mallick H, Tripathi A, Pruitt EP, Roane C, McNair T 2013 Jul 27 USA	488 neonates born at median of 39 weeks' gestation.	Randomised Equivalency Trial	Respiratory rate in first 24 hours.	Mean RR was 51 breaths per minutes in the wipe group and 50 in the suction group (95% CI -2 to 0, p <0.001)	Study type.
Chettri S, Adhisivam B, Bhat BV. 2015 May 1 India	162 term, nonvigorous babies born through MSAF	RCT	Incidence of MAS	No significant difference of incidence of MAS between the two groups.	Small sample size
Nangia S, Pal MM, Saili A, Gupta U. 2015 Dec 1 India	509 meconium stained term cephalic presentation, singleton neonates without major congenital malformations.	RCT	Development of MAS	82 neonates (16%) developed MAS. 40 in the intervention group (15.8%) and 42 (16.4%) in the non-intervention group (RR 0.86, 95% CI 0.60-1.54).
Nangia S, Sunder S, Biswas R, Saili A. 2016 Aug 1 India	175 term non-vigorous neonates born through MSAF	Pilot RCT	Occurrence of MAS	MAS present in 23/88 (26.1%) vs. 28/87 (32.3%) neonates in ‘No ET Suction’ and ‘ET Suction’ groups respectively (OR 0.4 (0.12-1.4); p = 0.14)

Comment(s)

Meconium stained amniotic fluid (MSAF) is common in term and post term births. Approximately 13% of live births are born through MSAF with 5-12% of these progressing to Meconium Aspiration Syndrome (MAS). (1) A higher incidence of MAS is seen with post-date (>40 weeks) deliveries, accounting for 30% of the MAS cases. (2) MAS is defined as the occurrence of respiratory distress in an infant born through MSAF, whose symptoms cannot be otherwise explained, and with consistent radiographic findings. (3) The degree of respiratory distress can range from mild with a supplemental oxygen requirement, to severe requiring mechanical ventilation, pulmonary vasodilatory therapy and/or extracorporeal membrane oxygenation (ECMO), and can result in death. ECMO is indicated cases with high oxygenation index (OI >40) when there is failure of oxygenation despite maximal mechanical ventilation. Survival rates of >90% have been associated with use of ECMO. (4) Early opinion from the 1970s suggested that when the amniotic fluid has evidence of meconium staining, management with intratracheal suctioning could prevent the development of MAS. Ting (1975) et al. produced one of the first studies (retrospective) on the morbidity and mortality of 125 infants born through MSAF. It concluded that the only difference between the symptomatic and asymptomatic group, where symptomatic was defined as the development of respiratory distress, was the occurrence of immediate tracheal suction at birth. Of the neonates who did not receive tracheal suction, 57% died compared to <1% of neonates who did receive suctioning (P <0.001). (5) Routine tracheal suction became the standard of care for neonates born through MSAF. Carson (1976) et al. contributed to these findings with a non-randomized study looking at a combined approach of intrapartum suctioning, laryngoscopy and intubation when meconium was present distal to the vocal cords. This combined approach showed a lower incidence of MAS (0.4%) compared to those not receiving such intervention (1.9%). The sample size was double that of Ting and Brady et al. (n=273), but the difference between the groups was not significant (p=0.071). (6) Between 1973 through to 1987, the incidence of MAS was shown to steadily decline by Wiswell et al. after the introduction of routine tracheal suction (p=0.043). (7) The decline was attributed to improvements in perinatal care since the 1970’s. The combined results from the studies performed by Carson et al. and Ting et al suggested the decline was attributed to both routine oropharyngeal suctioning after delivery of the anterior shoulder and postpartum intratracheal suctioning respectively – coined ‘the combined approach’. In the following years, the combined approach was challenged with regard to the efficacy for intrapartum suctioning, and the necessity of suction and/or intubation in vigorous infants. The practice of intrapartum suctioning was initially challenged by Falciglia et al. (1988). Their study (n=755) analysed the outcomes of infants born through MSAF between oro-nasopharyngeal suctioning after delivery of the shoulders and/or chest with no suctioning. The incidence of MAS was similar between both groups (2%). (8-9) These findings were supported by Vain et al. (2004) with a larger multicentre RCT (n=2514). Neonates born through MSAF were found not to have any significant difference in the development of MAS (4% vs. 4%) between ‘suction’ and ‘no suction’ groups. (10) There was also no significant difference between need of mechanical ventilation (24 [2%] vs 18 [1%]; 0•8, 0•4–1•4) or mortality (9 [1%] vs 4 [0•3%]; 0•4, 0•1–1•5). (10) The use of postpartum suctioning has been a routine component of neonatal care in the delivery room, but it has been associated with reductions in both oxygen saturation and Apgar scores at 5 minutes. (11) Although the literature has shown there are no benefits to performing intra-partum or postpartum suctioning, there have been no reports of directly causing harm on the neonate. The intervention of suctioning itself however, may damage the mucosa of the airway increasing the risk of vertical transmission of infection and/or direct damage to the airways. (12) The possibility of increased risk of infection and/or airway damage further questioned the need for suctioning on delivery of the shoulders at the perineum and postpartum. Most recently a randomized equivalency trail performed by Kelleher et al (2013) was able to show that simple wiping of the nose and mouth of vigorous neonates born with MSAF had equal efficacy to suctioning in regards to primary outcome of respiratory rate and oxygen saturation during the first 24 hours after birth. (13) Supporting the NRP guidelines of clearing the airway of secretions as a primary step, over intrapartum suctioning. In terms of postpartum suctioning it was Linder (1988) et al. that suggested a consideration to review the need for immediate intratracheal suction in vigorous term neonates born through MSAF. (14) The primary concern was that intratracheal suctioning was not a harmless procedure. Complications include bradycardia, perforation of the larynx or pharynx, laryngeal nerve palsy, hypoxia and apnoea. (15) The non-randomized study performed by Linder et al. evaluating intubation and suction of vigorous infants (n=572) born through MSAF demonstrated, as a primary outcome, that intratracheal suction did not decrease the incidence of MAS. The study also demonstrated that those in the intubation group experienced a greater number of complications from the procedure. This led to the more selective management of neonates born through MSAF in terms of intubation and suctioning. The progressive change was supported by several studies later performed by Wiswell (2000) et al., Chettri (2015) et al. and Nagia (2016) et al. leading to the necessary evidence based changes in the The Neonatal Resuscitation Programme (NRP) Guidelines, 7th edition published in 2016. Wiswell et al. (2000) performed a RCT which involved randomisation of vigorous neonates (n=2094) born through MSAF into intubate or expectant management groups. There was no significant difference in the incidence of MAS between the groups (3.2% vs 2.7% respectively). Their conclusion supported the need for selective management stating that intratracheal suctioning of vigorous neonates born through MSAF did not decrease the incidence of respiratory distress, when compared with expectant management. (16) Chettri et al. (2015) and Nagia et al. (2016) produced RCTs comparing the efficacy of endotracheal suctioning versus no suctioning in non-vigorous neonates born through MSAF. Chettri et al. performed randomization (n=122) to determine the effect of endotracheal suction versus no suction on development of MAS (primary outcome). There was an insignificant difference in mortality of 1.7% between the two groups. (17) For Nagia et al. the primary outcome was development of MAS and/or mortality, but the study showed no difference between both groups. (18) The need for respiratory support was also similar between both groups (OR 0.4 [CI: 0.12-1.4]; p = 0.14). Thus from these RCTs the use of endotracheal suction was seen as unsuccessful at reducing the risk of MAS in vigorous neonates born through MSAF. The suggestion was made that since meconium passage and aspiration was likely to occur in utero prior to suctioning, meconium would reside in the distal airways at birth upon transitioning making efficacy of endotracheal suctioning debatable. (18) 1. Gregory GA, Gooding CA, Phibbs RH, Tooley WH. Meconium aspiration in infants—a prospective study. The Journal of pediatrics. 1974 Dec 1;85(6):848-52. 2. Dargaville PA, Copnell B. The epidemiology of meconium aspiration syndrome: incidence, risk factors, therapies, and outcome. Pediatrics. 2006 May 1;117(5):1712-21. 3. Fanaroff AA. Meconium aspiration syndrome: historical aspects. Journal of Perinatology. 2008 Dec 5;28(S3):S3. 4. Short BL. Extracorporeal membrane oxygenation: use in meconium aspiration syndrome. Journal of Perinatology. 2008 Dec 5;28(S3):S79. 5. Ting P, Brady JP. Tracheal suction in meconium aspiration. American Journal of Obstetrics & Gynecology. 1975 Jul 15;122(6):767-71. 6. Carson BS, Losey RW, Bowes WA, Simmons MA. Combined obstetric and pediatric approach to prevent meconium aspiration syndrome. American Journal of Obstetrics & Gynecology. 1976 Nov 15;126(6):712-5. 7. Wiswell TE, Tuggle JM, Turner BS. Meconium aspiration syndrome: have we made a difference?. Pediatrics. 1990 May 1;85(5):715-21. 8. Falciglia HS. Failure to prevent meconium aspiration syndrome. Obstetrics and gynecology. 1988 Mar;71(3 Pt 1):349-53. 9. Falciglia HS, Henderschott C, Potter P, Helmchen R. Does DeLee suction at the perineum prevent meconium aspiration syndrome?. American Journal of Obstetrics & Gynecology. 1992 Nov 1;167(5):1243-9. 10. Vain NE, Szyld EG, Prudent LM, Wiswell TE, Aguilar AM, Vivas NI. Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates before delivery of their shoulders: multicentre, randomised controlled trial. The Lancet. 2004 Aug 14;364(9434):597-602. 11. Carrasco M, Martell M, Estol PC. Oronasopharyngeal suction at birth: effects on arterial oxygen saturation. The Journal of pediatrics. 1997 May 1;130(5):832-4. 12. Velaphi S, Vidyasagar D. The pros and cons of suctioning at the perineum (intrapartum) and post-delivery with and without meconium. InSeminars in Fetal and Neonatal Medicine 2008 Dec 1 (Vol. 13, No. 6, pp. 375-382). WB Saunders. 13. Kelleher J, Bhat R, Salas AA, Addis D, Mills EC, Mallick H, Tripathi A, Pruitt EP, Roane C, McNair T, Owen J. Oronasopharyngeal suction versus wiping of the mouth and nose at birth: a randomised equivalency trial. The Lancet. 2013 Jul 27;382(9889):326-30. 14. Linder N, Aranda JV, Tsur M, Matoth I, Yatsiv I, Mandelberg H, Rottem M, Feigenbaum D, Ezra Y, Tamir I. Need for endotracheal intubation and suction in meconium-stained neonates. The Journal of pediatrics. 1988 Apr 1;112(4):613-5. 15. Bent RC, Wiswell TE, Chang A. Removing Meconium From Infant Tracheae What Works Best?. American Journal of Diseases of Children. 1992 Sep 1;146(9):1085-9. 16. Wiswell TE, Gannon CM, Jacob J, Goldsmith L, Szyld E, Weiss K, Schutzman D, Cleary GM, Filipov P, Kurlat I, Caballero CL. Delivery room management of the apparently vigorous meconium-stained neonate: results of the multicenter, international collaborative trial. Pediatrics. 2000 Jan 1;105(1):1-7. 17. Chettri S, Adhisivam B, Bhat BV. Endotracheal suction for nonvigorous neonates born through meconium stained amniotic fluid: a randomized controlled trial. The Journal of pediatrics. 2015 May 1;166(5):1208-13. 18. Nangia S, Sunder S, Biswas R, Saili A. Endotracheal suction in term non vigorous meconium stained neonates—a pilot study. Resuscitation. 2016 Aug 1;105:79-84.

Clinical Bottom Line

Accumulated evidence indicated that intrapartum suctioning before delivery of the shoulders is not recommended. For neonates born through MSAF, routine intubation and suctioning is no longer recommended. Emphasis is now placed on respiratory support with oxygenation and ventilation according to Neonatal Resuscitation programme 2016.

References

1. Gregory GA, Gooding CA, Phibbs RH, Tooley WH. Meconium aspiration in infants—a prospective study. The Journal of Pediatrics 1974 Dec 1;85(6):848-52
2. Ting P, Brady JP Tracheal suction in meconium aspiration. American Journal of Obstetrics & Gynecology. 1975 Jul 15;122(6):767-71
3. Carson BS, Losey RW, Bowes WA, Simmons MA. Combined obstetric and pediatric approach to prevent meconium aspiration syndrome. American Journal of Obstetrics & Gynecology. 1976 Nov 15;126(6):712-5
4. Linder N, Aranda JV, Tsur M, Matoth I, Yatsiv I, Mandelberg H, Rottem M, Feigenbaum D, Ezra Y, Tamir I. Need for endotracheal intubation and suction in meconium-stained neonates. The Journal of pediatrics. 1988 Apr 1;112(4):613-5.
5. Falciglia HS, Henderschott C, Potter P, Helmchen R. Does DeLee suction at the perineum prevent meconium aspiration syndrome? American Journal of Obstetrics & Gynecology. 1992 Nov 1;167(5):1243-9.
6. Wiswell TE, Gannon CM, Jacob J, Goldsmith L, Szyld E, Weiss K, Schutzman D, Cleary GM, Filipov P, Kurlat I, Caballero CL Delivery room management of the apparently vigorous meconium-stained neonate: results of the multicenter, international collaborative trial. Pediatrics 2000 Jan 1;105(1):1-7.
7. Vain NE, Szyld EG, Prudent LM, Wiswell TE, Aguilar AM, Vivas NI. Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates before delivery of their shoulders: multicentre, randomised controlled trial. The Lancet 2004 Aug 14;364(9434):597-602.
8. Ersdal HL, Mduma E, Svensen E, Perlman JM. Early initiation of basic resuscitation interventions including face mask ventilation may reduce birth asphyxia related mortality in low-income countries: a prospective descriptive observational study Resuscitation 2012 Jul 1;83(7):869-73.
9. Kelleher J, Bhat R, Salas AA, Addis D, Mills EC, Mallick H, Tripathi A, Pruitt EP, Roane C, McNair T, Owen J. Oronasopharyngeal suction versus wiping of the mouth and nose at birth: a randomised equivalency trial. The Lancet 2013 Jul 27;382(9889):326-30.
10. Chettri S, Adhisivam B, Bhat BV. Endotracheal suction for nonvigorous neonates born through meconium stained amniotic fluid: a randomized controlled trial. The Journal of Pediatrics 2015 May 1;166(5):1208-13.
11. Nangia S, Pal MM, Saili A, Gupta U. Effect of intrapartum oropharyngeal (IP-OP) suction on meconium aspiration syndrome (MAS) in developing country: A RCT. Resuscitation 2015 Dec 1;97:83-7.
12. Nangia S, Sunder S, Biswas R, Saili A. Endotracheal suction in term non vigorous meconium stained neonates—a pilot study. Resuscitation 2016 Aug 1;105:79-84