Suctioning of Newborn Neonates

I. Introduction

A. Clinical question: Does routine oropharyngeal/nasopharyngeal suctioning of newborn

infants' airways compared to no suction have an effect on mortality and morbidity with and
without meconium‐stained amniotic fluid?

B. Background

Description of the condition

Meconium is found in the gastrointestinal tract of the fetus as early as 14 to 16 weeks’

gestation. It is a complex substance, composed of water(nearly75%), gastric secretions, lanugo,
blood, pancreatic enzymes, free fatty acids, and squamous cells (Wiswell 1993; Wiswell 1999).
It accumulates in the gastrointestinal tract of the fetus throughout pregnancy and usually is first
passed within 24 hours after birth. Factors that prevent meconium passage in utero include a
viscous terminal cap, a contracted anal sphincter, and absence of propulsive forces. However,
meconium passage may occur in utero in post-term pregnancies and in response to fetal hypoxia,
acidemia, or infection (Miller 1981; Usher 1988). Once passed, meconium may be aspirated
from amniotic fluid into the distal airways either in utero or with the first few breaths after birth.
Breathing movements are observed in utero but are shallow. Therefore, amniotic fluid is not
drawn into the distal airway; rather, the net flow of alveolar lung fluid moves outward.

The birth of a baby is one of life's most wondrous moments. Few experiences compare to
this event. Newborn babies have amazing abilities. Yet they are dependent on others for feeding,
warmth, and comfort. The transition from fetus to newborn involves the clearing of lung fluid
and expansion of the lungs with air. While airway oro/nasopharyngeal suctioning can be
successful in clearing the airway immediately after birth. Respiratory diseases are the chief
reason for admission of premature neonates to NICUs. Maintenance of breathing and patency of
airway is the main objective in premature infant care. Due to low consciousness level of neonates
and weakness of their respiratory muscles, efficient removal of secretion could not happen by
coughing. Therefore, patients need to be suctioned, to prevent airway obstruction, atelectasis and
pulmonary infections.

Description of the Intervention

Oro/nasopharyngeal suction is a method used to clear secretions from the oropharynx or

nasopharynx, or both, through the application of negative pressure via a suction cathete or bulb
syringe (Waltman 2004). Negative pressure is used to clear secretions from the mouth, nose or
pharynx while attempting to avoid trauma to the mucosa. The negative pressure used to remove
secretions should not exceed 100 mmHg (13 kPa, 133 cmH2O, 1.9 pounds per square inch (psi))
(ARC 2010). Oro/nasopharyngeal suction can be performed before the delivery of the infant's
shoulders (intrapartum) (Vain 2004) or following vaginal birth (Gungor 2005) or caesarean
section (postpartum) of the infant (Gungor 2006). Traditionally, oro/nasopharyngeal suctioning
at birth has been used routinely to remove fluids in vigorous infants at birth.

II. Methodology

The review will include studies enrolling neonates born at term or at late preterm
gestation. Eligible studies should enroll non-vigorous neonates born through MSAF. Studies may
show some variation in the way they define “non-vigorous.” Most studies are likely to define
non-vigorous as per ILCOR/NRP guidelines, as “presence of any of the following at the time of
birth: no or gasping breathing efforts, poor muscle tone or bradycardia” (Wyckoff 2015).

A total of 155 singleton newborns infants born through MSAF who were non-vigorous at
birth were recruited. Of these, 76 were randomized to ‘ET suction group’and 79 to the‘no-ET
suction group’.The vigour of the baby was decided within 5–10 s of birth. A neonate was
considered vigorous when all of the following met: heart rate>100/min, reasonably good muscle
tone (actively moving or at least flexed extremities) and good respiratory efforts. Newborn, not
fulfilling either of these criteria was labeled non-vigorous.11 Infants who were vigorous at birth,
or<34 weeks gestational maturity, or having major congenital malformation and in whom
consent could not obtained were excluded. We will compare non-vigorous neonates born through
meconium-stained amniotic fluid who underwent endotracheal suction versus those who did not
receive endotracheal suction. The study was approved by the institutional ethics committee and it
was registered at Clinical trial registry of India.

III. Results

A. Study findings

A study done by , Valizadeh, Janani, and Galechi in 2014 states that NICU nurses
reported that CSS was a better method for premature infants. Advantage of CSS was a reduction
in all of these complications: lesions in the tracheal mucosa, pneumonia probability, time of
procedure in urgency situations, increase in intracranial pressure, IVH, septicemia, PEEP drop
and physiological instability. While, the low costs, less extubation risk, simplicity of procedure,
and easy cleaning of the circuit were the advantages of OES. The vital issues of protecting the
airway and maintaining ventilation in preterm infants makes tracheal suctioning an important
procedure.

Neonates born through MSAF are often depressed and need prompt resuscitation. With
the start of breathing efforts, meconium present in the upper airways and trachea can move into
the distal airways, resulting in MAS. Clearance of meconium from the airways before the start of
breathing may decrease the risk of MAS. Observational studies evaluating the effectiveness of
immediate tracheal suctioning have described variable results,with some studies suggesting
decreased likelihood of respiratory complications (Gregory 1974; Suresh 1994) after
endotracheal suctioning, and others suggesting no difference (Daga 1974) or increased risk
(Linder 1988; Yoder 1994). After examining the evidence for prevention of MAS, ILCOR
concluded in 2010 that available evidence neither supports nor refutes endotracheal suctioning of
depressed infants born through MSAF(Perlman2010). Clearing of the larger airways before
meconium can be aspirated distally into the lungs with the first few breaths seems a logical step
in neonatal resuscitation. The incidence of MSAF and MAS remains high, but a nurse or
physician with the skills needed for endotracheal intubation and tracheal suctioning may not be
available for every delivery (Chettri S 2015).

Intrauterine passage of meconium leading to meconium stained amniotic fluid (MSAF)

generally signifies underlying fetal hypoxia1 and is a risk for meconium aspiration syndrome
(MAS). Aspiration of meconium interferes with normal respiratory physiology by causing
airway obstruction, chemical irritation, inflammation, surfactant inactivation, meconium induced
apoptosis and there is increased risk to develop air leaks, Persistent Pulmonary Hypertension of
newborn (PPHN) and sepsis.2,3 Infants developing MAS exhibit signs of respiratory distress,
hypoxemia, carry a high risk of mortality, and long term respiratory and neuro-develepmental
morbidities. Incidence of MSAFrangesfrom5.6% to24%(median14%)andMASdevelopsin1.7 to
35.8% (median10.8%).4 Depressed neonates born through thick consistency MSAF are at
greatest risk for developing MAS.

All of the studies included in this review described the technique as mandatory that it
should be performed whenever necessary because the accumulation of tracheobronchial
secretions may impair ventilation and oxygenation; lead to ETT occlusion, atelectasis and
increased respiratory work; and predispose the individual to pulmonary infection. However, one
of the most controversial issues regarding endotracheal suctioning in neonates is the precise time
and frequency at which the technique should be performed on intubated individuals.

According to the AARC and Evidence-based guideline for suctioning the intubated
neonate and infant, the procedure is safer when certain variables are monitored before, during
and after it is performed. Moreover, the Center for Disease Control and Prevention standards for
invasive procedures must be respected during the procedure, the procedure must be conducted by
at least two professionals, a maximum of three probe insertions should be performed, with a
return to the ventilator between suctioning.

B. Outcomes

Primary outcomes

• Incidence of meconium aspiration syndrome (proportion). Meconium aspiration syndrome is

diagnosed when respiratory distress develops soon after birth in an infant born through
meconium-stained amniotic fluid with compatible radiological findings that cannot be otherwise
explained • Incidence of all-cause neonatal mortality (proportion) defined as all-cause neonatal
death (death before 28 days) • Incidence of hypoxic-ischemic encephalopathy (proportion)
(Sarnat 1976; Thompson 1997)

Secondary outcomes

• Need for mechanical ventilation (proportion) defined as the need for mechanical ventilation
(proportion) during the first 48 hours after birth.

• Duration of oxygen therapy (hours/days) defined as the number of days of oxygen

supplementation during hospital stay

• Duration of mechanical ventilation (hours/days) defined as the number of days of mechanical

ventilation (invasive or noninvasive) during the hospital stay.

• Incidence of pulmonary air leaks (proportion) defined as the proportion such as pulmonary
interstitial emphysema, pneumothorax, pneumomediastinum, or pneumopericardium during
hospital stay • Duration of hospitalization (days)

• Incidence of neurodevelopmental delay (proportion) defined as the incidence of major

neurodevelopmental disability at > 18 months (major neurodevelopmental disabilities among all
participants or survivors (cerebral palsy, developmental delay (Bayley or Griffith assessment > 2
standard deviations (SD) below the mean) or intellectual impairment (IQ > 2 SD below the
mean), blindness (vision < 6/ 60 in both eyes), or sensorineural deafness requiring amplification)

IV. Ethical Section

A. Summary

B. Discussion

Intrauterine asphyxia, infection and post-maturity often lead to passage of meconium by

the fetus. Normally, fetal breathing activity results in movement of lung fluid out of the
trachea.19 However, prolonged/ severe fetal stress may stimulate fetal breathing and gasping,
can lead to aspiration of MSAF or aspiration can occur during initial breaths after delivery.20
The extent to which meconium has reached the distal airways by the time of birth and the effect
of tracheal suctioning of meconium just after birth in preventing or minimizing the respiratory
complications has still not been established. Our finding showed a marginal reduction in
incidence of MAS among non-vigorous infant undergoing ET suction, thus it supports the
possibility of aspiration during initial breaths after birth which can be minimized by prompt
postnatal tracheal suctioning. One of the important concerns with practice of ET suctioning is
delaying resuscitation of the already compromised infants which may potentially enhance
asphyxial injuries. However, we did not find any increase in the rate of PPV, chest compression
or adrenaline requirement at birth, support on mechanical ventilation, complications and
mortality in infants undergoing ET suctioning. The duration of hospital stay of patients with
MAS have been found to be variable in different studies depending on patient profile,
complications, level of care and discharge policy.

Overall, there was no difference between the oro/nasopharyngeal suction and no suction
groups for the outcomes mortality, need for resuscitation, admission to NICU, Apgar score at
five minutes, length of hospital stay, hypoxic ischaemic encephalopathy and infection. None of
the included RCTs reported on long‐term neurodevelopmental outcomes, cranial ultrasound
abnormalities, laryngospasm, episodes of bradycardia and episodes of oxygen desaturation,
cardiac arrhythmias and episodes of apnoea.

C. Conclusion

Our study suggest that endotracheal suctioning immediately after birth in non-vigorous
infants born through meconium stained amniotic fluid tends to decreases the incidence of MAS
and duration of stay in hospital, though, overall incidence of respiratory distress, severity of
MAS, and mortality remain unchanged. These findings need confirmation in other settings and
more specified population of non-vigorous newborn infants. Also, we concluded that a selective
approach to tracheal intubation and suction of infants with meconium-stained AF was not
associated with increased pulmonary morbidity or mortality. Postnatal management of neonates
at greatest risk of meconium aspiration syndrome does not necessarily prevent adverse
pulmonary outcome.

V. Reference Section

Nangia S, Thukral A, Chawla D. Tracheal suction atbirth in non-vigorous neonates born through
meconium-stained amniotic fluid. CochraneDatabaseof SystematicReviews 2017, Issue 5.
Art. No.: CD012671.

Monen L, Hasaart TH, Kuppens SM. The aetiology of meconium-stained amniotic fluid:
pathologic hypoxia or physiologic foetal ripening? Review. Early Hum Dev.
2014;90(7):325–328.

Chiruvolu A. et al. Delivery Room Management of Meconium-Stained Newborns and

Respiratory Support 2018, Pediatrics Vol. 142 No. 6 e20181485

Foster JP, Dawson JA, Davis PG, Dahlen HG. Routine oro/nasopharyngeal suction versus no
suction at birth. Cochrane Database of Systematic Reviews 2017, Issue 4. Art. No.:
CD010332. DOI: 10.1002/14651858.CD010332.pub2.