Review| Volume 149, P117-126, April 2020

Tracheal suctioning of meconium at birth for non-vigorous infants: a systematic review and meta-analysis



      The International Liaison Committee on Resuscitation sought to review the initial management of non-vigorous newborns delivered through meconium stained amniotic fluid (MSAF).


      To complete a systematic review and meta-analysis comparing endotracheal intubation and suctioning to immediate resuscitation without intubation for non-vigorous infants born at ≥34 weeks gestation delivered through MSAF.

      Data sources

      Medline, EMBASE, the Cochrane Database of Systematic Reviews, and other registries were searched from 1966 to November 7, 2019.

      Study selection

      Studies were selected by pairs of independent reviewers in 2 stages.

      Data extraction

      Reviewers extracted data, appraised risk of bias, and assessed Grading of Recommendations Assessment, Development and Evaluation certainty of evidence for each outcome.


      Four randomized controlled trials (RCTs) included 581 patients and one observational study included 231 patients. No significant differences were observed between the group treated with tracheal suctioning compared with immediate resuscitation for survival at discharge (4 RCTs; risk ratio [RR] = 1.01; 95 % CI, 0.96–1.06; p = 0.69; observational study; no deaths), hypoxic ischemic encephalopathy and meconium aspiration syndrome.


      The certainty of evidence was low for survival at discharge and very low for all other outcomes.


      For non-vigorous newborns delivered through MSAF, there is insufficient evidence to suggest routine immediate direct laryngoscopy with tracheal suctioning.


      Clinical Trials Registration: PROSPERO; CRD42019122778.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Resuscitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bhat R.Y.
        • Rao A.
        Meconium-stained amniotic fluid and meconium aspiration syndrome: a prospective study.
        Ann Trop Paediatr. 2008; 28: 199-203
        • Dargaville P.A.
        • Copnell B.
        • Australian and New Zealand Neonatal Network
        The epidemiology of meconium aspiration syndrome: incidence, risk factors, therapies, and outcome.
        Pediatrics. 2006; 117: 1712-1721
        • Moses D.
        • Holm B.A.
        • Spitale P.
        • Liu M.Y.
        • Enhorning G.
        Inhibition of pulmonary surfactant function by meconium.
        Am J Obstet Gynecol. 1991; 164: 477-481
        • Vidyasagar D.
        • Zagariya A.
        Studies of meconium-induced lung injury: inflammatory cytokine expression and apoptosis.
        J Perinatol. 2008; 28 Suppl 3: S102-S107
        • Carson B.S.
        • Losey R.W.
        • Bowes Jr., W.A.
        • Simmons M.A.
        Combined obstetric and pediatric approach to prevent meconium aspiration syndrome.
        Am J Obstet Gynecol. 1976; 126: 712-715
        • Gregory G.A.
        • Gooding C.A.
        • Phibbs R.H.
        • Tooley W.H.
        Meconium aspiration in infants—a prospective study.
        J Pediatr. 1974; 85: 848-852
        • Wiswell T.E.
        • Gannon C.M.
        • Jacob J.
        • et al.
        Delivery room management of the apparently vigorous meconium-stained neonate: results of the multicenter, international collaborative trial.
        Pediatrics. 2000; 105: 1-7
        • Vain N.E.
        • Szyld E.G.
        • Prudent L.M.
        • Wiswell T.E.
        • Aguilar A.M.
        • Vivas N.I.
        Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates before delivery of their shoulders: multicentre, randomised controlled trial.
        Lancet. 2004; 364: 597-602
        • Sterne J.A.
        • Hernan M.A.
        • Reeves B.C.
        • et al.
        ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions.
        BMJ. 2016; 355: i4919
        • Foglia E.E.
        • Ades A.
        • Napolitano N.
        • Leffelman J.
        • Nadkarni V.
        • Nishisaki A.
        Factors associated with adverse events during tracheal intubation in the NICU.
        Neonatology. 2015; 108: 23-29
        • Kamlin C.O.
        • O’Connell L.A.
        • Morley C.J.
        • et al.
        A randomized trial of stylets for intubating newborn infants.
        Pediatrics. 2013; 131: e198-e205
        • O’Donnell C.P.
        • Kamlin C.O.
        • Davis P.G.
        • Morley C.J.
        Endotracheal intubation attempts during neonatal resuscitation: success rates, duration, and adverse effects.
        Pediatrics. 2006; 117: e16-e21
        • Perlman J.M.
        • Wyllie J.
        • Kattwinkel J.
        • 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-S166
        • Higgins J.P.
        • Altman D.G.
        • Gotzsche P.C.
        • et al.
        The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials.
        BMJ. 2011; 343: d5928
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • Group P.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        PLoS Med. 2009; 6e1000097
        • Strand M.L.
        • Simon W.M.
        • Wyllie J.
        • Wyckoff M.H.
        • Weiner G.
        Consensus outcome rating for international neonatal resuscitation guidelines.
        Arch Dis Child Fetal Neonatal Ed. 2019; (1:F1-F3.)
        • Bayley N.
        Bayley scales of infant and toddler development.
        3rd ed. Harcourt Assessment, San Antonio, TX2006
        • Younge N.
        • Goldstein R.F.
        • Cotten C.M.
        • Eunice Kennedy Shriver National Institute of Child H, Human Development Neonatal Research N
        Survival and neurodevelopment of periviable infants.
        N Engl J Med. 2017; 376: 1890-1891
        • Sarnat H.B.
        • Sarnat M.S.
        Neonatal encephalopathy following fetal distress. A clinical and electroencephalographic study.
        Arch Neurol. 1976; 33: 696-705
        • Cleary G.M.
        • Wiswell T.E.
        Meconium-stained amniotic fluid and the meconium aspiration syndrome. An update.
        Pediatr Clin North Am. 1998; 45: 511-529
      1. Schunemann H, Guyatt G, Oxman A. GRADE handbook, The GRADE Working Group. (Accessed 3 April 2019).

        • Higgins J.P.
        • Thompson S.G.
        • Deeks J.J.
        • Altman D.G.
        Measuring inconsistency in meta-analyses.
        BMJ. 2003; 327: 557-560
        • Al Takroni A.M.
        • Parvathi C.K.
        • Mendis K.B.
        • Hassan S.
        • Reddy I.
        • Kudair H.A.
        Selective tracheal suctioning to prevent meconium aspiration syndrome.
        Int J Gynaecol Obstet. 1998; 63: 259-263
        • Chettri S.
        • Adhisivam B.
        • Bhat B.V.
        Endotracheal suction for nonvigorous neonates born through meconium stained amniotic fluid: a randomized controlled trial.
        J Pediatr. 2015; 166 (1208–1213 e1201)
        • Chiruvolu A.
        • Miklis K.K.
        • Chen E.
        • Petrey B.
        • Desai S.
        Delivery room management of meconium-stained newborns and respiratory support.
        Pediatrics. 2018; 142
        • Daga S.R.
        • Dave K.
        • Mehta V.
        • Pai V.
        Tracheal suction in meconium stained infants: a randomized controlled study.
        J Trop Pediatr. 1994; 40: 198-200
        • Kabbur P.M.
        • Herson V.C.
        • Zaremba S.
        • Lerer T.
        Have the year 2000 neonatal resuscitation program guidelines changed the delivery room management or outcome of meconium-stained infants?.
        J Perinatol. 2005; 25: 694-697
        • Manganaro R.
        • Mami C.
        • Palmara A.
        • Paolata A.
        • Gemelli M.
        Incidence of meconium aspiration syndrome in term meconium-stained babies managed at birth with selective tracheal intubation.
        J Perinat Med. 2001; 29: 465-468
        • Michel F.
        • Nicaise C.
        • Camus T.
        • et al.
        Management of newborns with meconium-stained amniotic fluid: prospective evaluation of practice.
        Ann Fr Anesth Reanim. 2010; 29: 605-609
        • Nangia S.
        • Sunder S.
        • Biswas R.
        • Saili A.
        Endotracheal suction in term non vigorous meconium stained neonates—a pilot study.
        Resuscitation. 2016; 105: 79-84
        • Peng T.C.
        • Gutcher G.R.
        • Van Dorsten J.P.
        A selective aggressive approach to the neonate exposed to meconium-stained amniotic fluid.
        Am J Obstet Gynecol. 1996; 175 (discussion 301–293): 296-301
        • Singh S.N.
        • Saxena S.
        • Bhriguvanshi A.
        • Kumar M.
        • Chandrakanta S.
        Effect of endotracheal suctioning just after birth in non-vigorous infants born through meconium stained amniotic fluid: a randomized controlled trial.
        Clin Epidemiol Global Health. 2019; 7: 165-170
        • Viraraghavan V.R.
        • Nangia S.
        • Prathik B.H.
        • Madarkar B.S.
        • Rani D.
        • Saili A.
        Yield of meconium in non-vigorous neonates undergoing endotracheal suctioning and profile of all neonates born through meconium-stained amniotic fluid: a prospective observational study.
        Paediatr Int Child Health. 2018; 38: 266-270
        • Whitfield J.M.
        • Charsha D.S.
        • Chiruvolu A.
        Prevention of meconium aspiration syndrome: an update and the Baylor experience.
        Baylor Univ Med Center Proc. 2009; 22: 128-131
        • Wiswell T.E.
        • Henley M.A.
        Intratracheal suctioning, systemic infection, and the meconium aspiration syndrome.
        Pediatrics. 1992; 89: 203-206
        • Yoder B.A.
        Meconium-stained amniotic fluid and respiratory complications: impact of selective tracheal suction.
        Obstet Gynecol. 1994; 83: 77-84
        • Kumar A.
        • Kumar P.
        • Basu S.
        Endotracheal suctioning for prevention of meconium aspiration syndrome: a randomized controlled trial.
        Eur J Pediatr. 2019; 178: 1825-1832
        • Aldhafeeri F.M.
        • Aldhafiri F.M.
        • Bamehriz M.
        • Al-Wassia H.
        Have the 2015 Neonatal Resuscitation Program Guidelines changed the management and outcome of infants born through meconium-stained amniotic fluid?.
        Ann Saudi Med. 2019; 39: 87-91
        • Edwards E.M.
        • Lakshminrusimha S.
        • Ehret D.E.Y.
        • Horbar J.D.
        NICU admissions for meconium aspiration syndrome before and after a national resuscitation program suctioning guideline change.
        Children. 2019; 6
        • Kalra V.
        • Lee H.
        • Sie L.
        • Underwood M.
        • Lakshminrusimha S.
        Meconium aspiration syndrome: impact of 2016 NRP ‘no-suction’ guidelines in California.
        J Investig Med. 2019; 67: 182
        • Phatak P.
        • Misra N.
        Developmental assessment scales for Indian infants (DASII) 1–30 months. Revision of Baroda Norm with indigenous material.
        Psychol Stud. 1996; 41: 55-56
        • Wiswell T.E.
        Appropriate management of the nonvigorous meconium-stained neonate: an unanswered question.
        Pediatrics. 2018; 142
        • Robinson M.E.
        • Diaz I.
        • Barrowman N.J.
        • Huneault-Purney N.
        • Lemyre B.
        • Rouvinez-Bouali N.
        Trainees success rates with intubation to suction meconium at birth.
        Arch Dis Child Fetal Neonatal Ed. 2018; 103: F413-F416