Recent discussions
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Виктория Антонова
It appears that there is no benefit for the use of immediate laryngoscopy with or without tracheal suctioning when compared to immediate resuscitation without laryngoscopy after reviewing the data that is available. -
Виктория Антонова
The science and current clinical trials are insufficient to make the recommendation of NO intubation and suctioning of a non vigorous infant. With a NRP provider who is skilled at intubation there is minimal delay in the initiation of effective ventilation in accordance to NRP guidelines. By not intubating and removal of meconium in the hypopharynx there is a chance of introducing additioanal meconium ino the tracheal and airways resulting in airway obstruction and inflammatory pneumonia and increased risk of airleaks. In the absence of high quality data regarding intubation and sucking it is inadvisable to may such a strong recommendation of not providing airway inspection and the option for suctioning. The absence of high quality data will continue until an appropriate RCT is conducting comparing one strategy versus the other. As meconium presence in the AF is a risk factor for poorer outcome, and is usually known prior to delivery there is ample opportunity to obtain consent from the mother for either option depending on randomization. The data presented do not give the number needed to harm if intubation is performed and meconium is suctioned in non-vigorous newly born infants. An appropriately powered RCT with appropriate outcomes is critical. Why make inappropriate recommendations when the data are lacking? -
Виктория Антонова
Back in 2000, when I started as a pediatric resident, I asked my senior resident why we intubated for meconium, since it seems to go against the fundamental principle of NRP, which is to avoid secondary apnea. He told me the only reason we do it is because we need the practice (even though that was the guideline at the time). It seems that this is one of those medical practices that someone thought up that then people continue to hold onto. I realize the evidence isn't great, but I am not sure why we need to continue to explore this question further. Glad to see that the task force did take on the job of reviewing the new articles for me and reaffirming their statement. -
Lloyd Jensen
Thanks for going through the process . It can be very difficult. -
Виктория Антонова
Thank you for doing this work. "Very low certainty evidence" exceeds the value of the anecdotes that resulted in the practice of immediate tracheal suctioning in the first place. Immediate tracheal suctioning delays the resuscitation of these non-vigorous infants at a time when every second counts. -
Виктория Антонова
Agree with the author's treatment recommendations -
Виктория Антонова
Agree with the evidence based recommendations as above. My only comment is as follows. Suctioning out the gastric fluid after resuscitation in depressed infants born through meconium stained amniotic fluid should be considered as the gastric contents may be meconium stained and get aspirated into the lungs espy in non intubated babies . The possibility may not be high and there is not much literature on it but this potentially is a clinical set up worth considering or looking into in future studies. -
Виктория Антонова
The data to not suction are weak. I have observed and reviewed several deliveries with non-vigorous meconium stained babies. I have found suctioning to be helpful in the delivery room. SInce the new standards were in place, I have witnessed more issues after birth in the NICU. I think the motive to eliminate this step (suctioning) was more to protect hospitals for not having trained providers in the delivery room in cases of meconium stained fluid. Better to educate and train than keep dumbing down the standards. PLEASE AAP stop diluting the standards to appeal to the least common denominator. Having practiced neonatology for decades, I notice this is happening. Hold the line please. -
Виктория Антонова
I would like to see outcomes relating to intubation stratified by "experience." I was trained in an era when all meconium stained infants (rightly or wrongly....mostly wrongly) were intubated. I wonder if, for those neonatologists that are still ACTIVELY practicing CLINICAL medicine, if their time to successful intubation and their percentage of successful first time attempts are higher than more junior practitioners that were trained in an era of decreased intervention (read - have had much less reps with intubation). That said, I wonder if ILCOR should look into these demographics and consider language that takes this into account (if the data supports that currently clinical active practitioners whose training occurred in the "intubate all meconium infants" are more adept at intubating than those practitioners who were trained in the "post- Wisell" era. -
Виктория Антонова
After 40 years of neonatal nursing I knew this recommendation for "no tracheal suctioning" was not a good recommendation. I have always thought at least one suction pass was best and then intubation if necessary for time restraints. But NO suctioning was a bad idea for non-vigorous infants with thick meconium. I would like to see the recommendation be for one tracheal suction pass, and then intubation if needed. Several passes will delay intubation and possibly not clear the airway that much better, and no suctioning is not a good practice.