Suctioning Clear Amniotic Fluid During Neonatal Resuscitation in the Delivery Room (NLS #596): Scoping Review

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: None applicable.

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: None applicable

Task Force Scoping Review Citation

Udaeta E, Rudeger M, Ersdal H on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 2020 February 5. Available from: http://ilcor.org

Methodological Preamble and Link to Published Scoping Review

The continuous evidence evaluation process started with a scoping review of suctioning of clear fluid during delivery room resuscitation conducted by 3 content experts working with the ILCOR NLS Task Force Scoping Review team. Evidence for neonatal literature was sought and considered by the NLS Task Force. The NLS task force discussed the evidence and provided insights.

Scoping Review

We expect to submit this Scoping Review for publication in Spring of 2020.

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe) was defined as follows:

• Population: Among newborns delivered through clear amniotic fluid
• Intervention: does immediate routine suctioning (oropharyngeal or nasopharyngeal)
• Comparators: compared with no suctioning or no wiping
• Outcomes:
  • survival (critical)
• need for delivery room resuscitation and stabilization interventions (important) (i.e. use of oxygen supplementation, initiation of positive pressure ventilation, intubation, use of CPR/medications, Apgar scores);
• Respiratory complications (important) (i.e. respiratory distress, tachypnea),
• Side effects (important): (oxygen desaturation, injury or infection)
• (Time to reach heart rate > 100 (Important)
• Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion.

Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature search updated to November 30, 2019.

Search Strategies

Data sources: The following databases were searched on November 21st 2019: MEDLINE complete, Embase, Cochrane using the OVID search engine. The search of the “grey literature” was done manually in Scholar Google, Clinical trials gob, WHO International/ICTRP/ search and NDLTD Global ETD search. The searches that informed the 2010 and 2015 NLS CoSTR {Perlman 2010 S516; Perlman 2015 e169} were conducted on the following dates: Suction clear amniotic fluid August 7, 2009 and Suction meconium stained amniotic fluid February 20, 2014. The new search included published studies from 1997 until November 2019.

"infant, newborn"[MeSH Terms] OR "infant"[All Fields] AND "newborn"[All Fields] OR "newborn infant"[All Fields] OR "newborn"[All Fields] AND "infants"[All Fields] OR "newborn infants"[All Fields]) AND ("suction"[MeSH Terms] OR "suction"[All Fields]) AND ("mouth"[MeSH Terms] OR "mouth"[All Fields]) AND ("nose"[MeSH Terms] OR "nose"[All Fields]) oropharynx" [All Fields] OR "AND ("parturition"[MeSH Terms] OR "parturition"[All Fields] OR "birth"[All Fields]) AND ("amniotic fluid"[MeSH Terms] OR ("amniotic"[All Fields] AND "fluid"[All Fields]) OR "amniotic fluid"[All Fields])

For detailed search results please see Appendix.

Inclusion and Exclusion criteria

Studies are considered eligible for inclusion if they were randomized controlled trials (RCTs), non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) peer-reviewed human studies that prospectively or retrospectively compared the effects of interventions listed below on physiological outcomes (e.g. time to reach normal oxygen saturation and heart rate) or clinical outcomes (e.g. resuscitation and stabilization interventions: CPR/meds in delivery room; Apgar scores, oxygen supplementation, intubation); Delay in providing respiratory support; Inpatient morbidities: respiratory complications (respiratory distress, tachypnoea); Side effects (oxygen desaturation, injury or infection)

All years and all languages were included as long as there was an English abstract. Unpublished studies (e.g., conference abstracts, trial protocols) or studies published in abstract form only, manikin studies, animal studies, and studies that did not specifically address the PICO question were excluded.

Attachments

PRISMA Diagram and Data Tables

NLS-596-Suctioning-of-Clear-Fluid-Data-tables

NLS-PRISMA-596

Task Force Insights

1. Why this topic was reviewed.

Successful transition from the intra-uterine fetal to the extra-uterine newborn state requires the replacement of lung liquid within the airways with air. In order to support liquid clearance, oro/nasopharyngeal suctioning at birth, there was a long-standing practice of routine suctioning to remove secretions in vigorous infants at birth. The 2010 International Liaison Committee on Resuscitation 2010 Consensus on Science suggested against this practice for the first time {Perlman 2010 S516; Wyllie 2010 e260; Perlman 2010 e1319}. The 2015 American Heart Association Guidelines update emphasized “Suctioning immediately after birth, whether with a bulb syringe or suction catheter, may be considered only if the airway appears obstructed or if PPV is required” {Wyckoff 2015 S963}. The purpose of this scoping review was to identify the available evidence related to suctioning /clearing of the oropharynx immediately after birth in vigorous infants. This scoping review includes the available literature and studies of suctioning clear amniotic fluid at birth, and the outcomes examined to date.

2. Narrative summary of evidence identified

Evidence supporting potential benefits of oro/nasopharyngeal suctioning is limited and the benefit of removing liquid from the oropharynx remains controversial.

• Three randomized controlled studies and one observational study were identified that were published since 2010. They compare the use of “suction clear amniotic fluid” with “no suction or wipe” in “premature, near term and term infant population” in 1545 patients
• The identified studies were from diverse geographical areas, and there were similar results in the interventions used.
• The published literature identified by this scoping review fell into two subgroups (route of delivery: vaginal or C-section, and gestational age at birth: preterm or term).
• The procedure can have serious side effects including bradycardia and apnea. {Cordero 1977 4471}.
• It is possible that nasopharyngeal suction may result in vagal-induced bradycardia as well as increase the risk of infection {McCartney 2000 46}.
• The procedure may take a significant time to complete {Konstantelos 2015 7777}
• It may delay initiation of ventilation in non-breathing infants {Ersdal 2012 8699}.
• Newborns who received suctioning compared to a control group had significantly lower oxygen saturation levels through the first 6 minutes of life and took longer to reach a normal range {Carrasco 1997 8328; Konstantelos 2015 7777).
• There is a concern that the procedure may have serious additional consequences such as irritation to mucous membranes and increased risk for iatrogenic infection {Gungor 2005 45310; Gungor 2006 911}, bradycardia {Cordero 1971 4411; Gungor 2006 911}, apnea {Cordero 1971 4411}, hypoxemia and arterial oxygen desaturation {Carrasco 1997 8328; Gungor 2005, 45310; Kohlhauser 2000, 27012}, hypercapnea {Skov 1992 38913}, impaired cerebral blood flow regulation {Van Bel 1988 2714; Perlman 1983 32915}, increased intracranial pressure {Fisher 1982 41616}, and development of subsequent neonatal brain injury {Kaiser 2008 3417}. Fluctuations in cerebral blood flow have been shown to cause intraventricular haemorrhage in premature infants and neonatal animals.

3. Narrative Reporting of the task force discussions

• The identified studies were from diverse geographical areas, and there were similar results in the interventions used.
• The published literature identified by this scoping review fell into two subgroups (delivered by vaginal or C-section and premature and term infants).
• The majority of the new literature does not appear to refute the current recommendation of no routine suctioning of the newborns in the delivery room
• However, because of the large number of patients (>1500) reported since 2015, a new systematic review including these patients may increase the certainty of the evidence through GRADE evaluation
• We suggest based on this Scoping Review to proceed to an update of the Systematic Review for this PICO question: “Among vigorous infants delivered through clear amniotic fluid (P) does immediate routine suctioning (oropharyngeal or nasopharyngeal) (I) compared with no suctioning or wiping C) change outcome (O)”
• There is extremely limited data on suctioning of preterm infants
• There is very limited data from RCTs with vigorous infants delivered through clear amniotic fluid

Knowledge Gaps

References

Bland RD, Bressack MA, MacMillan DD. Labor decreases the lung water content of newborn rabbits. Am J Obstet Gynecol. 1979;135: 364–67.

Brown MJ, Oliver RE, Ramsden CA, Strang LB, Walters DV. Effects of adrenaline and of spontaneous labor on the secretions and absorption of lung liquid in the fetal lamb. J Physiol. 1983;344: 137–52.

Carrasco M, Martell M, Estol PC, et al. Oronasopharyngeal suction at birth: effects on arterial oxygen saturation. J Pediatr. 1997;130:832–834.

Cordero L, Hon EH. Neonatal bradycardia following nasopharyngeal stimulation. J Pediatr. 1971;78(3):441-447.

Ersdal HL, Mduma E, Svensen E, Perlman JM. Early initiation of basic resuscitation interventions including facemask ventilation may reduce birth asphyxia related mortality in low-income countries. Resuscitation. 2012; 83:869-73.

Fisher DM, Frewen T, Swedlow DB. Increase in intracranial pressure during suctioning-stimulation vs. rise in PaCO2. Anesthesiology 1982;57(5):416–7.

Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J. 2009;26:91–108.

Gungor S, Teksoz E, Ceyhan T, et al. Oronasopharyngeal suction versus no suction in normal, term and vaginally born infants: a prospective randomized controlled trial. Aust N Z J Obstet Gynaecol. 2005; 45:453–456.

Gungor S, Kurt E, Teksoz E, Goktolga U, Ceyhan T, Baser İ. Oronasopharyngeal Suction versus No Suction in Normal and Term Infants Delivered by Elective Cesarean Section: A Prospective Randomized Controlled Trial. Gynecol Obstet Invest 2006; 61:9-14.

Kaiser JR, Gauss CH, Williams DK. Tracheal suctioning is associated with prolonged disturbances of cerebral hemodynamics in very low birth weight infants. Journal of Perinatology. 2008;28(1):34–41.

Kelleher J, Bhat R, Salas AA, Addis D, Mills EC, Mallick H, et al. Oronasopharyngeal suction versus wiping of the mouth and nose at birth: a randomised equivalency trial. Lancet. 2013;382(9889):326-30.

Kohlhauser C, Bernert G, Hermon M, Popow C, Seidl R, Pollak A: Effects of endotracheal suctioning in high‐frequency oscillatory and conventionally ventilated low birth weight neonates on cerebral hemodynamics observed by near infrared spectroscopy (NIRS). Pediatric Pulmonology 200;29: 270-275.

Konstantelos D, Ifflaender S, Dinger J, Rüdiger M. Suctioning habits in the delivery room and the influence on postnatal adaptation - a video analysis. J Perinat Med. 2015;43(6):777-82.

McCartney. Bulb Syringes in Newborn Care. The American Journal of Maternal/Child Nursing. 2000;25 (4):217.

Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol. 2018;18:143.

Perlman JM, Volpe JJ. Suctioning in the preterm infant: effects on cerebral blood flow velocity, intracranial pressure, and arterial blood pressure. Pediatrics. 1983;72:329–334.

Perlman JM, Wyllie J, Kattwinkel J, Atkins DL, Chameides L, Goldsmith JP, Guinsburg R, Hazinski MF, Morley C, Richmond S, Simon WM, Singhal N, Szyld E, Tamura M, Velaphi S; on behalf of the Neonatal Resuscitation Chapter Collaborators. Part 11: neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation. 2010;122(suppl 2):S516 –S538.

Perlman JM, Wyllie J, Kattwinkel J, Atkins DL, Chameides L, Goldsmith JP, et al. Neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Pediatrics. 2010;126(5):e1319-44.

Perlman JM, Wyllie J, Kattwinkel J, Wyckoff MH, Aziz K, Guinsburg R, et al. Part 7: Neonatal Resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2015;132(16 Suppl 1):S204-41.

Perlman JM, Wyllie J, Kattwinkel J, Wyckoff MH, Aziz K, Guinsburg R, et al. Part 7: Neonatal Resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (Reprint). Pediatrics. 2015;136 Suppl 2:S120-66.

Skov L, Ryding J, Pryds O, Greisen G. Changes in cerebral oxygenation and cerebral blood volume during endotracheal suctioning in ventilated neonates. Acta Paediatrica 1992;81(5):389–93.

Van Bel F, Van de Bor M, Baan J, Ruys JH. The influence of abnormal blood gases on cerebral blood flow velocity in the preterm newborn. Neuropediatrics. 1988;19(1):27–32.

Wyckoff MH, Aziz K, Escobedo MB, Kapadia VS, Kattwinkel J, Perlman JM, Simon WM, Weiner GM, Zaichkin, JG. Part 13: Neonatal resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S543–S560.

Wyllie J, Perlman JM, Kattwinkel J, Atkins DL, Chameides L, Goldsmith JP, et al. Part 11: Neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. 2010;81 Suppl 1:e260-87.

Wyllie J, Perlman JM, Kattwinkel J, Wyckoff MH, Aziz K, Guinsburg R, Kim H-S, Liley HG, Mildenhall L, Simon WM, Szyld E, Tamura M, Velaphi S, on behalf of the Neonatal Resuscitation Chapter Collaborators. Part 7: Neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation.2015;95:e169–e201.

Appendix