Consensus on Science with Treatment Recommendations (CoSTR)
Luis Eduardo Miranda
Taking into consideration the results of the systematic review and the meta-analysis, and until future RCT´s prove oyherwise, I think it is about time to stop recommending routine tracheal intubation and aspiration in every non vigorous baby born with meconium-stained amniotic fluid. Being a NRP instructor in Brazil for a long time, I have testified the great difficulty most of the trainees have to perform intubation in 20 seconds and in his first attemp. It sounds better to teach how to ventilate properly these babies rather than wasting time trying to intubate.
Agree with the recommendations given the evidence that is presented. Appreciate the discussions from experienced neonatal providers, but at present the evidence points towards no advantage for immediate DL in non-vigorous infants with or without tracheal suctioning. These are recommendations and as the evidence is low, discretion is still in the hands of the providing physician.
Meconium in the amniotic fluid is a flag for increased risk to the depressed baby at birth, and the time for suctioning will vary. The key is to be prepared to suction below the cords if the airway is obstructed - with laryngoscope, endotracheal tube, suction, meconium adapter - when needed; this may be initially, or after going through the steps of MRSOPA. The wording of the current recommendation does allow this.
Congratulations for the outstanding work. The results of the doing the systematic review and meta-analysis studies made me be convinced that it is about time to stop doing (regular) tracheal intubation and aspiration on every non-vigorous newborn.
The data(do not intubation and do not suction) are weak.
I alway knews intubation and suctioning to be helpful in the delivery room or ER. and I have found that infants that get intubated and their airway cleared do much better.
I understand that if you do not have someone that is good at intubation, it can waste valuable time. if you have capable staff for intubation, the infant recovers much faster and a lot of them do not need to have prolonged stays in intensive care unit for long because of an effective resuscitation.
and also the motive to eliminate this step (suctioning) was more to protect hospitals for not having trained providers in the hospital in cases of meconium stained fluid. Better to educate and train than keep dumbing down the standards.
We agree with current recommendations. These studies reflect our current clinical experience. In my hospital we have not seen any increased incidence of MAS or PPHN with these recommendations. We have no control about long-term outcomes as they follow up in private clinics and we don't have a unified system of clinical information
Agree with author's recommendations. It would be useful to clarify that all nonvigorous infants with meconium should be gently suctioned to remove meconium from oropharynx and hypopharynx before stimulation, using the suction method that is within the scope of practice of the individual providing care to the infant. This may be performed with a suction catheter, bulb syringe in the cheek, or ET based on clinical experience and competence. When intubation is obviously needed for the most depressed neonates then brief suctioning can be done prn if there is visible meconium to allow clear passage of an ET tube as needed for optimal ventilation. Many practitioners practice in community settings and nurses may be the first to begin the initial steps. This clarification based on scope of practice and competency can aid in directing actions in each clinical setting. The key message is that all non-breathing infants (meconium and clear fluid) should be suctioned before PPV, with suctioning being brief and gentle, and followed by the rest of the initial steps before initiation of PPV.
I think routine laryngoscopy with or without intubation is not necessarily a "must-be-done-immediately" procedure in the non-vigorous newborns with MSAF, but current recommendation somewhat sounds as if this procedure should be strongly restricted. There is not enough scientific evidence that can support this recommendation as a one-fits-all methodology in various delivery settings around the world. In hospitals with experts in intubation procedure, there would be not much delay in establishing adequate PPV. Rather, in some circumstances, PPV without suctioning way exacerbate airway obstructions. Hence the recommendation should be more clear on the possibility for case-by-case decision, and present laryngoscopy with or without intubation as an acceptable (though not routine) option.