[Downloaded free from http://www.jcnonweb.com on Thursday, June 20, 2019, IP: 202.80.212.

115]

Original Article ›››

Meconium‑stained Amniotic Fluid as a Potential Risk Factor

for Perinatal Asphyxia: A Single‑center Experience
Veerendra Mehar, Nikhar Agarwal, Abhishek Agarwal1, Saksham Agarwal, Nandani Dubey, Harsha Kumawat
Departments of Pediatrics and 1Medicine, Sri Aurobindo Medical College and Post Graduate Institute, Indore, Madhya Pradesh, India

ABSTRACT
Background: The aim of this study was to find out immediate fetal outcome in meconium‑stained amniotic fluid in relation to perinatal asphyxia.
Materials and Methods: This retrospective study includes medical records of all neonates admitted to Neonatal Intensive Care Unit (NICU)
between September 2014 and July 2015. The variables reviewed are age, sex, weight, mode of delivery, gestational age, presence of meconium
aspiration syndrome (MAS) and perinatal asphyxia. Results: Out of 399 total admissions in NICU, 62.4% were male babies and remaining
37.6% were female babies. Of the total 6.8% were cases of MAS, making females (10.7%) more prone compared to male (4.4%) while perinatal
asphyxia came out to be 11.5%, making male (12%) more prone than female (10.7%). Postterm (odds ratio [OR] =3.50 [CI: 0.39–31.42]) and
term (OR = 2.58 [CI: 1.16, 5.75]) babies were having more risk of developing MAS compared to preterm (P < 0.01). Postterm (OR = 9.15 [CI:
1.91–43.75]) and term (OR = 2.67 [CI: 1.41–5.08]) babies were having more risk of developing perinatal asphyxia compared to preterm (P < 0.01).
MAS babies are having 6.62 (CI: 2.85–15.38) times more risk of developing perinatal asphyxia (P < 0.01). Conclusion: The management of
MAS, which is a perinatal problem, requires a well concerted and coordinated action by the obstetrician and pediatrician. Prompt and efficient
delivery room management can minimize the sequelae of aspirated meconium and decrease the chance of perinatal asphyxia.

Key words:
Meconium aspiration syndrome, Neonatal Intensive Care Unit, perinatal asphyxia

INTRODUCTION that the rate of MAS markedly increased with gestational

In early 2000, the prevalence of meconium aspiration
syndrome  (MAS) ranged from 0.20% to 0.54% in the
general population[1‑4] and from 1.0% to 6.8% in infants born
through meconium‑stained amniotic fluid (MSAF).[1‑4] In a
8 years span from 1990 to 1998, a total of ten reports were
reviewed that showed a total incidence of 0.52% of MAS,
13.1% of MSAF 4.2% of MAS among MSAF and 49.7% of
MAS needing ventilator support with a 4.6% mortality rate.[3]
However, a lower incidence of MAS was suggested due to
the scarcity of large population‑based studies: the National
US Birth Cohort Study conducted on the basis of singleton
term non‑Hispanic white live births  (1995–2001) showed
Address for correspondence:
Dr. Veerendra Mehar,
Department of Pediatrics, Sri Aurobindo Medical College and
Post Graduate Institute, Indore ‑ 453 111, Madhya Pradesh, India.
E‑mail: dr.veerendramehar@gmail.com
Access this article online
Quick Response Code:
Website:
www.jcnonweb.com
age (GA), that is, from 0.10% at GA of 37 weeks to 0.22 and
0.31% at GA 40 and 41 weeks, respectively.[5] The prevalence
of MAS could be extrapolated to 0.18% in this population
of term infants. In Australia, the rate of MAS requiring
mechanical ventilation in Level III units ranged between
0.024% and 0.046% at GA 36–40 weeks and then increased
to 0.080% at GA 41  weeks and 0.14% at GA 42  weeks.[6]
In France, the prevalence of mechanically ventilated MAS
was estimated to 0.043% by a retrospective national survey
among neonates born in 2000–2001.[7]
Among all live births approximately 13% neonates are
born through meconium‑stained amniotic fluid and out
of these 5–10% developed MAS, which increases neonatal
morbidity and mortality. Following the first description
of the pathophysiology of MAS in 1975, there has been a
marked improvement in the survival of infants with MAS[8]
This is an open access article distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as the
author is credited and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

How to cite this article: Mehar V, Agarwal N, Agarwal A,

DOI: Agarwal S, Dubey N, Kumawat H. Meconium-stained amniotic
10.4103/2249-4847.191246 fluid as a potential risk factor for perinatal asphyxia: A single-center
experience. J Clin Neonatol 2016;5:157-61.

© 2016 Journal of Clinical Neonatology | Published by Wolters Kluwer - Medknow 157

[Downloaded free from http://www.jcnonweb.com on Thursday, June 20, 2019, IP: 202.80.212.115]

Mehar, et al.: Meconium aspiration syndrome and perinatal asphyxia

due to improved intra‑  and post‑partum management of This study was undertaken to find out immediate fetal outcome
the same. Although there is a significant decrease in the in meconium‑stained liquor in relation to perinatal asphyxia.
occurrence of MAS and associated mortality in developed
countries MAS remains a major problem in developing MATERIALS AND METHODS
countries.
Study design and the participants
Meconium is derived from the Greek word “mekoni,” This hospital‑based retrospective observational study was
meaning poppy juice or opium. It is a sterile, thick, conducted in the Department of Pediatrics of a Tertiary
black‑green (resulting from bile pigments), odorless material Care Center, Indore. The study population included
first observed in the fetal intestine during the 3rd month patients admitted to Neonatal Intensive Care Unit (NICU).
of gestation which is the fecal material that accumulates Data were collected from the medical record department of
in the fetal colon throughout gestation. It consists of an the patients of NICU. The variable collected were age, sex,
accumulation of debris, comprising desquamated cells from weight, mode of delivery and GA.
the intestine and skin, gastrointestinal mucin, lanugo hair,
fatty material from the vernix caseosa, amniotic fluid, and Outcome variables
intestinal secretions.[9,10] Most infants have their first bowel MAS, perinatal asphyxia, and other neonatal infections.
movement after birth (within the first 24–48 h after birth).
Occasionally, a fetus can pass meconium in uteri. MAS Explanatory variables
refers to the aspiration of meconium and amniotic fluid by Factors at the individual level are GA and sex. GA
the fetus. This can occur when the fetus is still in the uterus, of <37 weeks are coded as preterm, >42 weeks as post‑term,
passing through the birth canal or when it takes its first and 37–42 weeks as term.
breath after birth.
Data management and statistical analysis
MAS is an important cause of respiratory distress in the The analysis was done using descriptive statistics and testing
term newborn, is a serious condition with high morbidity of hypothesis. The data were analyzed Statistical Package for
and mortality.[6,11] MAS has a complex pathophysiology the Social Sciences (SPSS) for Windows Version 20.0 (SPSS
and occurs due to a combination of airway obstruction, Inc., Chicago, IL, USA). P < 0.05 (two‑tailed) was used to
pulmonary hypertension, epithelial injury, surfactant establish statistical significance.
inactivation, and inflammation, when there is underlying,[11,12]
fetal asphyxia,[13] and infection.[14,15] An inflammatory RESULTS
response to meconium is seen in both newborns and animal
models with MAS.[16] Intratracheal instillation of meconium Table  1 depicts that females are  (10.7%) more prone
in animals results in an intense pulmonary inflammatory compared to males (4.4%). Postterm (odds ratio [OR] =3.50
reaction with the influx of polymorphonuclear leukocytes, [CI: 0.39–31.42]) and term  [OR  =  2.58  [CI: 1.16–5.75])
monocytes/macrophages, and T‑cells within a few hours. babies were having more risk of developing MAS compared
Parenchymal lung cell injury is worsened by the production to preterm (P < 0.01). From the above statistics, it is clear
of proinflammatory cytokines[17,18] and apoptotic epithelial that females formed a dominant group as compared to
cells are present in meconium containing lungs.[19,20] males among the babies born to MSAF. Along with this, it
can also be assumed that post and term neonates are having
MAS results in considerable respiratory morbidity in a larger risk of developing MAS.
term and near‑term infants. It is clinically characterized
by early onset of respiratory distress in an infant born
Table 1: Relation between demographic data and
through MSAF presenting with poor lung compliance and
meconium aspiration syndrome
hypoxemia. Chest X‑ray shows patchy opacification and
Variables MAS, n(%) P OR (CI)
hyperinflation.[21,22] Mechanical ventilation and intubation
Present Absent Total
is required among one‑third of infants suffering from
Gender
MAS.[23,24] Newer neonatal therapies include high‑frequency
Male 11 (4.4) 238 (95.6) 249 0.016 1
ventilation, inhaled nitric oxide, and surfactant.[25,26]
Female 16 (10.7) 134 (89.3) 150 2.58 (1.17-5.73)
Gestational age (weeks)
There has been a marked reduction in the incidence and
<37 12 (4.5) 252 (95.5) 264 0.001 1
risk of MAS over the past few decades, mostly restricted to 37-42 14 (10.9) 114 (89.1) 128 2.58 (1.16-5.75)
the developed world due to better obstetric practices with >42 1 (14.3) 6 (85.7) 7 3.50 (0.39-
great emphasis been paid on avoidance of postmaturity and 31.42)
expeditious delivery in case of fetal distress.[4,24,27] OR – Odds ratio; CI – Confidence interval; MAS – Meconium aspiration syndrome

158 Journal of Clinical Neonatology | Vol. 5 | Issue 3 | July‑September 2016

[Downloaded free from http://www.jcnonweb.com on Thursday, June 20, 2019, IP: 202.80.212.115]
Mehar, et al.: Meconium aspiration syndrome and perinatal asphyxia
Table 2 shows that 11.5% of the total babies had perinatal
asphyxia. Twelve percent of males and 10.7% of female
babies suffered from perinatal asphyxia.
Postterm (OR = 9.15 [CI: 1.91–43.75]) and term (OR = 2.67
[CI: 1.41–5.08]) babies were having more risk of developing
perinatal asphyxia compared to preterm babies (P < 0.01).
MAS baby is having 6.62 (CI: 2.85–15.38) times more risk
of developing perinatal asphyxia (P < 0.01).
From the table, it can be stated that males are having more
risk of developing perinatal asphyxia as compared to
females. Postterm and term babies are having a greater risk
of developing asphyxia.
Thus, from the results of this study a strong relationship
between MAS and perinatal asphyxia can be established,
i.e.,  meconium aspirated neonates are more prone for
developing perinatal asphyxia.
DISCUSSION
The increased risk for pulmonary morbidity and
mortality among infants born through MSAF is well
recognized. Although many reports have noted a
clinical spectrum of pulmonary dysfunction from mild
tachypnea to severe pulmonary insufficiency, this study
also confirms that MSAF is associated with an increased
risk for pulmonary dysfunction. The risk for pulmonary
disease, however, is not manifested equally in all infants
with meconium staining. As it was shown by several
previous studies, the greatest risk for pulmonary disease
occurred among infants with associated signs of possible
intrapartum fetal compromise. Despite following
recommended guidelines of airway management, these
infants continued to manifest a high rate of pulmonary
morbidity.[25,28‑30]
Table 2: Relationship of perinatal asphyxia with
demographic data and meconium aspiration syndrome
Variables Perinatal asphyxia, n (%)
Present Absent Total
Gender
Male 30 (12.0) 219 (88.0) 249
Female 16 (10.7) 134 (89.3) 150
Gestational age (weeks)
<37 20 (7.6) 244 (92.4) 264
37-42 23 (18.0) 105 (82.0) 128
>42 3 (42.9) 4 (57.1) 7 9.15 (1.91-43.75)
MAS
Present 11 (40.7) 16 (59.3) 27 0.0001 6.62 (2.85-15.38)
Absent 35 (9.4) 337 (90.6) 372
OR – Odds ratio; CI – Confidence interval; MAS – Meconium aspiration syndrome
Journal of Clinical Neonatology | Vol. 5 | Issue 3 | July‑September 2016
The recommendation by the American Academy of
Pediatrics in 1983 did not suggest that all infants born
through thick MSAF necessarily require tracheal suction.
The second edition of these guidelines noted the absence of
additional studies to support or refute the practice of tracheal
suction for MSAF and recommended that “in the presence
of thick or particulate meconium, the larynx should be
visualized, and if meconium is present, the clinician should
intubate the trachea and apply suction.” The most recent
edition of the guidelines published in 1992, is less dogmatic
and recommended that depressed infants with meconium
in the hypopharynx to have tracheal suction. However, it is
further noted that cord visualization and tracheal suction
in the vigorous infant with thick meconium may not be
necessary. None of the Guidelines have recommended
tracheal suction of infants born through thin MSAF.[28,29]
Meconium aspiration syndrome with gestational age
The overall incidence of MAS and severe MAS increases
with GA as reported in recent population‑based studies.[5,6]
The overall rates of MAS in the USA[5] and Burgundy are
similar: 1.0 versus 1.1 per 1000 live births at 37 weeks; 1.1
versus 1.0% at 38  weeks; 1.5% versus 1.1% at 39  weeks;
2.2% versus 2.4% at 40  weeks; and 3.1% versus 2.6% at
41  weeks. Furthermore, the incidence of severe MAS
recorded in Australia[6] at 41 weeks (0.80%) is close to the
0.67% observed at 39–41 weeks in our series. Some studies
suggested that prevention of postterm pregnancy prevents
severe MAS.[31] This study showed that postterm (OR = 3.50
[CI: 0.39–31.42]) and term  (OR  =  2.58  [CI: 1.16–5.75])
babies were having more risk of developing MAS compared
to preterm (P < 0.01).
Meconium aspiration syndrome with sex
MSAF neonates were found in 78  (9.79%) out of 796
deliveries  (live birth) with a male:female ratio 1:1:1.[32]
In this study, male  (62.4%) showed preponderance as
compared to female  (37.6%), among which  (6.8%) were
cases of MAS, making female (10.7%) more prone compared
to male (4.4%).
P OR (CI)
Perinatal asphyxia with gestational age
For more than two decades, postterm pregnancy has been
0.676 1.147 (0.60-2.18)
defined as a pregnancy that persists beyond 294  days or
1
42  weeks of gestation.[33] For the assessment of GA in
0.001 1
pregnancy, the last menstrual period in cases with the regular
2.67 (1.41-5.08) menstrual cycle is the best physiological method. However,
a few women are sure of their dates and often cause anxiety
when they come with postdates.[34] The cause of postterm
pregnancy is unknown. Postterm pregnancies are associated
1 with higher risk of perinatal morbidity and mortality the
cause of which is largely unknown. The complications of
159
[Downloaded free from http://www.jcnonweb.com on Thursday, June 20, 2019, IP: 202.80.212.115]
Mehar, et al.: Meconium aspiration syndrome and perinatal asphyxia
postdated pregnancy include MAS, asphyxia neonatorum
respiratory distress syndrome, jaundice neonatorum,
sepsis neonatorum, oligohydramnios, macrosomia, fetal
birth injury, fetal distress, and increased rate of cesarean
section.[35] This study showed that postterm  (OR  =  9.15
[CI: 1.91–43.75]) and term  (OR  =  2.67  [CI: 1.41–5.08])
babies have more risk of developing perinatal asphyxia
compared to preterm (P < 0.01).
Perinatal asphyxia with sex
In numerous studies, asphyxia was more prevalent in male
than female.[36‑38] In this study, male preponderance is seen.
Out of 399 cases, perinatal asphyxia came out to be 11.5%,
making male (12%) more prone to female (10.7%).
CONCLUSION
The present study showed that MAS as an important risk
factor for perinatal asphyxia both in term and postterm
babies making perinatal asphyxia more common among
MAS babies.
There is need of a large randomized controlled trial to study
the roles of intrapartum nasopharyngeal and immediate
postpartum tracheal suctioning in neonates born through
MSAF in developing country setting.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Wiswell TE. Handling the meconium‑stained infant. Semin Neonatol
2001;6:225‑31.
2. Blackwell SC, Moldenhauer J, Hassan SS, Redman ME, Refuerzo JS,
Berry  SM, et  al. Meconium aspiration syndrome in term neonates
with normal acid‑base status at delivery: Is it different? Am J Obstet
Gynecol 2001;184:1422‑5.
3. Liu  WF, Harrington  T. Delivery room risk factors for meconium
aspiration syndrome. Am J Perinatol 2002;19:367‑78.
4. Yoder BA, Kirsch EA, Barth WH, Gordon MC. Changing obstetric
practices associated with decreasing incidence of meconium
aspiration syndrome. Obstet Gynecol 2002;99(5 Pt 1):731‑9.
5. Zhang  X, Kramer  MS. Variations in mortality and morbidity by
gestational age among infants born at term. J Pediatr 2009;154:358‑62.
6. Dargaville  PA, Copnell B; Australian and New  Zealand Neonatal
Network. The epidemiology of meconium aspiration syndrome:
Incidence, risk factors, therapies, and outcome. Pediatrics
2006;117:1712‑21.
7. Nolent P, Hallalel F, Chevalier JY, Flamant C, Renolleau S. Meconium
aspiration syndrome requiring mechanical ventilation: Incidence
and respiratory management in France  (2000‑2001). Arch Pediatr
2004;11:417‑22.
8. Vidyasagar D, Harris V, Pildes RS. Assisted ventilation in infants with
meconium aspiration syndrome. Pediatrics 1975;56:208‑13.
160
9. Singh  BS, Clark  RH, Powers  RJ, Spitzer  AR. Meconium aspiration
syndrome remains a significant problem in the NICU: Outcomes
and treatment patterns in term neonates admitted for intensive care
during a ten‑year period. J Perinatol 2009;29:497‑503.
10. Kattwinkel J, Perlman JM, Aziz K, Colby C, Fairchild K, Gallagher J,
et al. Part 15: Neonatal resuscitation: 2010 American Heart Association
Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation 2010;122 18 Suppl 3:S909‑19.
11. Cleary GM, Wiswell TE. Meconium‑stained amniotic fluid and the
meconium aspiration syndrome. An update. Pediatr Clin North Am
1998;45:511‑29.
12. Dargaville  PA, Mills  JF, Headley  BM, Chan  Y, Coleman  L,
Loughnan  PM, et  al. Therapeutic lung lavage in the piglet model
of meconium aspiration syndrome. Am J Respir Crit Care Med
2003;168:456‑63.
13. Paz  Y, Solt  I, Zimmer  EZ. Variables associated with meconium
aspiration syndrome in labors with thick meconium. Eur J Obstet
Gynecol Reprod Biol 2001;94:27‑30.
14. Katz VL, Bowes WA Jr. Meconium aspiration syndrome: Reflections
on a murky subject. Am J Obstet Gynecol 1992;166 (1 Pt 1):171‑83.
15. Ghidini  A, Spong  CY. Severe meconium aspiration syndrome
is not caused by aspiration of meconium. Am J Obstet Gynecol
2001;185:931‑8.
16. Vidyasagar  D, Lukkarinen  H, Kaapa  P, Zagariya  A. Inflammatory
response and apoptosis in newborn lungs after meconium aspiration.
Biotechnol Prog 2005;21:192‑7.
17. Zagariya A, Bhat R, Navale S, Vidyasagar D. Cytokine expression in
meconium‑induced lungs. Indian J Pediatr 2004;71:195‑201.
18. Davey  AM, Becker  JD, Davis  JM. Meconium aspiration syndrome:
Physiological and inflammatory changes in a newborn piglet model.
Pediatr Pulmonol 1993;16:101‑8.
19. Zagariya  A, Bhat  R, Chari  G, Uhal  B, Navale  S, Vidyasagar  D.
Apoptosis of airway epithelial cells in response to meconium. Life Sci
2005;76:1849‑58.
20. Holopainen  R, Aho  H, Laine  J, Peuravuori  H, Soukka  H, Kääpä P.
Human meconium has high phospholipase A2 activity and induces
cellular injury and apoptosis in piglet lungs. Pediatr Res 1999;46:626‑32.
21. Cleary GM, Wiswell TE. Meconium‑stained amniotic fluid and the
meconium aspiration syndrome: An update. Pediatr Clin North Am
1998;45:511‑29.
22. Wiswell  TE, Bent  RC. Meconium staining and the meconium
aspiration syndrome. Unresolved issues. Pediatr Clin North Am
1993;40:955‑81.
23. Coltart TM, Byrne DL, Bates SA. Meconium aspiration syndrome: A
6‑year retrospective study. Br J Obstet Gynaecol 1989;96:411‑4.
24. Wiswell TE, Tuggle JM, Turner BS. Meconium aspiration syndrome:
Have we made a difference? Pediatrics 1990;85:715‑21.
25. Bhutani  VK, Chima  R, Sivieri  EM. Innovative neonatal ventilation
and meconium aspiration syndrome. Indian J Pediatr 2003;70:421‑7.
26. Wiswell TE. Advances in the treatment of the meconium aspiration
syndrome. Acta Paediatr Suppl 2001;90:28‑30.
27. Sriram  S, Wall  SN, Khoshnood  B, Singh  JK, Hsieh  HL, Lee  KS.
Racial disparity in meconium‑stained amniotic fluid and meconium
aspiration syndrome in the United States, 1989‑2000. Obstet Gynecol
2003;102:1262‑8.
28. Yoder  BA. Meconium‑stained amniotic fluid and respiratory
complications: Impact of selective tracheal suction. Obstet Gynecol
1994;83:77‑84.
29. Liu WF, Harrington T. The need for delivery room intubation of thin
meconium in the low‑risk newborn: A clinical trial. Am J Perinatol
1998;15:675‑82.
30. Fuloria  M, Wiswell  TE. Resuscitation of the meconium‑stained
infant and prevention of meconium aspiration syndrome. J Perinatol
1999;19:234‑41.
Journal of Clinical Neonatology | Vol. 5 | Issue 3 | July‑September 2016
[Downloaded free from http://www.jcnonweb.com on Thursday, June 20, 2019, IP: 202.80.212.115]

Mehar, et al.: Meconium aspiration syndrome and perinatal asphyxia

31. Manganaro R, Mamì 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;29:465‑8.
32. Sharma  LM. A  Study of New Born Infant with Meconium Stained
Amniotic Fluid. XXX Congress of the Association for Paediatric
Education in Europe  (A.P.E.E.); September, 2000. Available from:
http://www.aeep.asso.fr/index.php/en/congress/55?task=view.  [Last
cited on 2012 Sep 29].
33. Mary Hannah M. The Maternal‑Fetal Medicine Committee of the
Society of Obstetricians and Gynaecologists of Canada. Post‑Term
Pregnancy. SOGC Clinical Practice Guideline No. 15; March, 1997.
Available from: http://www.sogc.org/members/guide/library_e.asp.
[Last assessed on 2015 Nov 16].
34. Bennett  KA, Crane  JM, O’shea P, Lacelle  J, Hutchens  D, Copel  JA.
First trimester ultrasound screening is effective in reducing postterm
labor induction rates: A randomized controlled trial. Am J Obstet
Gynecol 2004;190:1077‑81.
35. Cleary‑Goldman J, Bettes B, Robinson JN, Norwitz E, D’Alton ME,
Schulkin J. Postterm pregnancy: Practice patterns of contemporary
obstetricians and gynecologists. Am J Perinatol 2006;23:15‑20.
36. Badawi  N, Kurinczuk  JJ, Keogh  JM, Alessandri  LM, O’Sullivan  F,
Burton PR, et al. Antepartum risk factors for newborn encephalopathy:
The Western Australian case‑control study. BMJ 1998;317:1549‑53.
37. Badawi  N, Kurinczuk  JJ, Keogh  JM, Alessandri  LM, O’Sullivan  F,
Burton PR, et al. Intrapartum risk factors for newborn encephalopathy:
The Western Australian case‑control study. BMJ 1998;317:1554‑8.
38. Futrakul  S, Praisuwanna  P, Thaitumyanon  P. Risk factors for
hypoxic‑ischemic encephalopathy in asphyxiated newborn infants.
J Med Assoc Thai 2006;89:322‑8.

Author Help: Reference checking facility

The manuscript system (www.journalonweb.com) allows the authors to check and verify the accuracy and style of references. The tool checks
the references with PubMed as per a predefined style. Authors are encouraged to use this facility, before submitting articles to the journal.
• The style as well as bibliographic elements should be 100% accurate, to help get the references verified from the system. Even a
single spelling error or addition of issue number/month of publication will lead to an error when verifying the reference.
• Example of a correct style
Sheahan P, O’leary G, Lee G, Fitzgibbon J. Cystic cervical metastases: Incidence and diagnosis using fine needle aspiration biopsy.
Otolaryngol Head Neck Surg 2002;127:294-8.
• Only the references from journals indexed in PubMed will be checked.
• Enter each reference in new line, without a serial number.
• Add up to a maximum of 15 references at a time.
• If the reference is correct for its bibliographic elements and punctuations, it will be shown as CORRECT and a link to the correct
article in PubMed will be given.
• If any of the bibliographic elements are missing, incorrect or extra (such as issue number), it will be shown as INCORRECT and link to
possible articles in PubMed will be given.

Journal of Clinical Neonatology | Vol. 5 | Issue 3 | July‑September 2016 161