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Tracheal intubation for suctioning in non-vigorous infants born though meconium-stained amniotic fluid

Question Type:
Intervention
Full Question:
Non-vigorous infants at birth born through meconium-stained amniotic fluid (P), does tracheal intubation for suctioning (I), compared with no tracheal intubation (C), reduce meconium syndrome or prevent death (O)?
Consensus on Science:
For the critical outcome of mortality and/or meconium aspiration syndrome (MAS), we identified 1 randomized study involving 122 infants (low-quality evidence, downgraded for risk of bias and imprecision) (Chettri 2015, 1208) comparing tracheal intubation for suctioning versus no tracheal intubation for suctioning in nonvigorous infants showing no benefit to suctioning in either reduced mortality and/or MAS. For the critical outcome of mortality and/or MAS, we identified very-low-quality evidence from 3 studies (Yoder 1994, 77; Peng 1996, 296; Al Takroni 1998, 259) including 12 389 MSAF infants showing higher incidence of MAS in depressed infants (268/1022, 26%) who had tracheal intubation for suctioning compared with vigorous infants (34/11 367, 0.3%) who were not intubated (downgraded for indirectness). For the critical outcome of mortality and/or MAS, we identified evidence from 7 very-low-quality observational studies (Gregory 1974, 848; Ting 1975, 767; Fox 1977, 325; Falciglia 1988, 349; Wiswell 1990, 715; Wiswell 1992, 203; Chishty 1996, 104) demonstrating improved survival and lower incidence of MAS when infants (including depressed and/or vigorous infants) born through MSAF were intubated for tracheal suctioning (downgraded for indirectness and inconsistency). For the critical outcome of mortality and/or MAS, we identified evidence from 9 very-low-quality observational studies (Davis 1985, 731; Dooley 1985, 767; Hageman 1988, 127; Rossi 1989, 1106; Suresh 1994, 1177; Yoder 1994, 77; Peng 1996, 296; Al Takroni 1998, 259; Manganaro 2001, 465) demonstrating no improvement in survival and/or incidence of MAS (including depressed and/or vigorous infants) when infants born through MSAF were intubated for tracheal suctioning (downgraded for indirectness).
Treatment Recommendation:
There is insufficient published human evidence to suggest routine tracheal intubation for suctioning of meconium in nonvigorous infants born through MSAF as opposed to no tracheal intubation for suctioning. Values, Preferences, and Task Force Insights In making this suggestion, we place value on both harm avoidance (delays in providing bag-mask ventilation, potential harm of the procedure) and the unknown benefit of the intervention of routine tracheal intubation and suctioning. Routine suctioning of nonvigorous infants is more likely to result in delays in initiating ventilation, especially where the provider is unable to promptly intubate the infant or suction attempts are repeated. In the absence of evidence of benefit for suctioning, the emphasis should be on initiating ventilation within the first minute of life in nonbreathing or ineffectively breathing infants. Much of the deliberations focused on the wording of the treatment recommendation. There were 3 different treatment recommendation options. First “We suggest against the routine intubation of nonvigorous infants born through MSAF. Second “We suggest that routine tracheal intubation for suctioning of meconium in nonvigorous infants should not be considered as a standard of care but may be considered a reasonable alternative to no tracheal intubation in some settings. Third “We suggest that routine tracheal intubation for suctioning of meconium in nonvigorous infants should not be considered as a standard of care but may be considered a reasonable alternative to no tracheal intubation if a meconium plug is suspected There was concern that the legal profession could misinterpret the term standard of care. Consensus was reached on the final treatment recommendation.

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