Endotracheal intubation at birth in vigorous term meconium stained babies
Routine endotracheal intubation at birth in vigorous, term, meconium-stained babies has not been shown to be superior to routine resuscitation, including oro-pharyngeal suction.
RHL Commentary by Ramji S
1. EVIDENCE SUMMARY
The review presents meta-analysis of two randomized controlled trials of endotracheal intubation at birth in meconium-stained, full-term, vigourous babies published by Linder et al.(1), and Daga et al.(2). A total of 334 babies were randomized to the intervention (oropharyngeal suction and intubation) group and 287 to the control group (only oropharyngeal suction). The results of the meta-analysis failed to reveal any significant differences between the groups with respect to the clinical outcomes measured, i.e. mortality, meconium aspiration syndrome (MAS), pneumothorax, need for oxygen, stridor, convulsions and hypoxic-ischaemic encephalopathy (HIE). It may be pertinent to note that the last three outcome variables were not uniformly reported by both studies. However, the reviewer considers the lack of any significant difference between the groups for mortality and MAS alone as sufficient justification to recommend that routine intubation of meconium-stained, full-term, vigourous babies should be abandoned until further evidence becomes available.
One of the main drawbacks of the studies included in the review is the lack of robustness of the randomization techniques used. Linder et al. (1) randomized the babies based on the alphabetic order of the participating paediatricians' names, and also included non-randomized babies into the intervention group. Daga et al., (2), have not provided details of the randomization method used.
The meta-analysis of the two trials did not find any benefit of the intervention. Therefore, it would have been useful for the reviewer to comment on the power of the individual studies and of the meta-analysis to be able to show a meaningful difference.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1. Magnitude of the problem
In developing countries, the reported prevalence of deliveries in which infants are exposed to meconium stained liquor (MSL) ranges from 5 % to 25 %, (3). The occurrence of MAS among babies born with exposure to MSL is approximately 25 % in developing countries. However, there is very little information available from developing countries about either the association between MAS and vigour of the baby at birth, or the impact of routine endotracheal suction on MAS. In a prospective study of infants born with MSL (4), at a large tertiary hospital in Northern India, the incidence of MAS was 18 % in vigorous term infants undergoing intubation at birth, and 26 % in those not intubated. In sharp contrast, Peng et al., (5), who studied 659 infants exposed to MSL in Virginia, USA, detected no case of MAS among the 343 vigorous term infants exposed to MSL; none of the babies had been intubated at birth. Both the incidence of MSL and of MAS seem to be higher in developing countries.
2.2. Feasibility of the intervention
The feasibility of endotracheal intubation cannot be considered before it's shown that its benefits outweigh the risk of possible harm. Even if it was beneficial, intubation at birth would be feasible only in a small proportion of hospital-born infants. Less than 20 % of all births in developing countries occur in hospitals and only a fraction of these have medical staff skilled in neonatal intubation. Therefore, the public health impact of this intervention would be low.
2.3. Applicability of the results of the Cochrane Review
Since the incidence of MAS in both asphyxiated and vigorous babies exposed to MSL is higher in developing countries than in developed countries, the results of the review may not apply in under-resourced settings. It can be argued that because of this difference there may be a potential role for endotracheal suction in developing countries.
2.4. Implementation of the intervention
Abandoning the practice of routine intubation and adoption of new routine procedures to be followed will need training at all levels of care. Such training will need to be supported by continued reinforcement at frequent re-training opportunities. Continued education and training requires financial as well as manpower resources, which are generally lacking in poor countries.
Given the findings of the Cochrane Review and considering the magnitude of MAS in developing countries, there is a need for primary research in the form of appropriately sized randomized controlled trials on the issue of intubation at birth in infants exposed to MSL. An issue of particular interest would be the identification of a sub-group of these infants who may benefit from intubation at birth.
- Linder N, Aranda JV, Tsur M, Matoth I, Yatsiv I, Mandelberg H, Rottem M, Feigenbaum D, Ezra Y, Tamir I. Need for endotracheal intubation and suction in meconium-stained neonates. Journal of pediatrics 1998;112:613-615.
- Daga SR, Dave K, Mehta V, Pai V. Tracheal suction in meconium stained infants: a randomized controlled study. Journal of tropical paediatrics 1994;40:198-200.
- Wiswell TE, Bent RC. Meconium staining and the meconium aspiration syndrome. Paediatric clinics of North America 1993;40:955.
- Suresh GK, Sarkar S. Delivery room management of infants born through thin meconium stained liquor. Indian paediatrics 1994;31:177-181.
- Peng TC, Gutcher GR, Van-Duraken JP. A selective aggressive approach to the neonate exposed to meconium stained amniotic fluid. American journal of obstetrics and gynecology 1996;175:296-303.
This document should be cited as: Ramji S. Endotracheal intubation at birth in vigorous term meconium stained babies: RHL commentary (last revised: 16 January 2002). The WHO Reproductive Health Library; Geneva: World Health Organization.