Download PDF
Am J Perinatol 2018; 35(09): 815-822
DOI: 10.1055/s-0037-1620269
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Approach to Infants Born Through Meconium Stained Amniotic Fluid: Evolution Based on Evidence?

Munmun Rawat
1   Department of Pediatrics, University at Buffalo, Buffalo, New York
,
Sushma Nangia
2   Department of Neonatology, Lady Harding Medical College, New Delhi, India
,
Praveen Chandrasekharan
1   Department of Pediatrics, University at Buffalo, Buffalo, New York
,
Satyan Lakshminrusimha
3   Department of Pediatrics, University of California, Davis, California
› Author Affiliations Funding M.R.: American Academy of Pediatrics, Neonatal Resuscitation Program, Canadian Pediatric Society, Neonatal Resuscitation grant, Dr Henry C. and Bertha H. Buswell Fellowship, Salary support, University at Buffalo. P.C.: Dr Henry C. and Bertha H. Buswell Fellowship, Salary support, University at Buffalo. S.L.: 1RO1HD072929-0, American Academy of Pediatrics, Neonatal Resuscitation Program.
Further Information

Publication History

05 September 2017

10 December 2017

Publication Date:
16 January 2018 (online)

    Permissions and Reprints

Abstract

Meconium-stained amniotic fluid (MSAF) during delivery is a marker of fetal stress. Neonates born through MSAF often need resuscitation and are at risk of meconium aspiration syndrome (MAS), air leaks, hypoxic-ischemic encephalopathy, extracorporeal membrane oxygenation (ECMO), and death. The neonatal resuscitation approach to MSAF has evolved over the last three decades. Previously, nonvigorous neonates soon after delivery were suctioned under the vocal cords with direct visualization technique using a meconium aspirator. The recent neonatal resuscitation program (NRP) recommends against suctioning but favors resuscitation with positive pressure ventilation of nonvigorous neonates with MSAF. This recommendation is aimed to prevent delay in resuscitation and minimize hypoxia-ischemia often associated with MSAF. In this review, we discuss the pathophysiology, evolution and the evidence, randomized control trials, observational studies, and translational research to support these recommendations. The frequency of ECMO use for neonatal respiratory indication of MAS has declined over the years probably secondary to improvements in neonatal intensive care and reduction of postmaturity. Changes in resuscitation practices may have contributed to reduced incidence and severity of MAS. Larger randomized controlled studies are needed among nonvigorous infants with MSAF. However, ethical dilemmas and loss of equipoise pose a challenge to conduct such studies.

Keywords

meconium - suction - hypoxia - pulmonary hypertension
 

  • References

  • 1 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 (05) 1712-1721
    CrossrefPubMedGoogle Scholar
  • 2 Tybulewicz AT, Clegg SK, Fonfé GJ, Stenson BJ. Preterm meconium staining of the amniotic fluid: associated findings and risk of adverse clinical outcome. Arch Dis Child Fetal Neonatal Ed 2004; 89 (04) F328-F330
    CrossrefPubMedGoogle Scholar
  • 3 Fanaroff AA. Meconium aspiration syndrome: historical aspects. J Perinatol 2008; 28 (Suppl. 03) S3-S7
    CrossrefPubMedGoogle Scholar
  • 4 Fuloria M, Wiswell TE. Resuscitation of the meconium-stained infant and prevention of meconium aspiration syndrome. J Perinatol 1999; 19 (03) 234-241
    CrossrefPubMedGoogle Scholar
  • 5 Tessler R, Pan J, Fiori HH, Belik J. Human meconium has a pulmonary vascular and airway smooth muscle relaxant effect. Pediatr Res 2008; 64 (01) 24-28
    CrossrefPubMedGoogle Scholar
  • 6 Farah OR, Li D, McIntyre BA, Pan J, Belik J. Airway epithelial-derived factor relaxes pulmonary vascular smooth muscle. Am J Physiol Lung Cell Mol Physiol 2009; 296 (01) L115-L120
    CrossrefPubMedGoogle Scholar
  • 7 Lindenskov PH, Castellheim A, Saugstad OD, Mollnes TE. Meconium aspiration syndrome: possible pathophysiological mechanisms and future potential therapies. Neonatology 2015; 107 (03) 225-230
    CrossrefPubMedGoogle Scholar
  • 8 Sehgal A, Athikarisamy SE, Adamopoulos M. Global myocardial function is compromised in infants with pulmonary hypertension. Acta Paediatr 2012; 101 (04) 410-413
    CrossrefPubMedGoogle Scholar
  • 9 Lapointe A, Barrington KJ. Pulmonary hypertension and the asphyxiated newborn. J Pediatr 2011; 158 (2, Suppl): e19-e24
    CrossrefPubMedGoogle Scholar
  • 10 Kinsella JP. Inhaled nitric oxide in the term newborn. Early Hum Dev 2008; 84 (11) 709-716
    CrossrefPubMedGoogle Scholar
  • 11 Ali N, Abman SH, Galambos C. Histologic evidence of intrapulmonary bronchopulmonary anastomotic pathways in neonates with meconium aspiration syndrome. J Pediatr 2015; 167 (06) 1445-1447
    CrossrefPubMedGoogle Scholar
  • 12 Gregory GA, Gooding CA, Phibbs RH, Tooley WH. Meconium aspiration in infants: a prospective study. J Pediatr 1974; 85 (06) 848-852
    CrossrefPubMedGoogle Scholar
  • 13 Ting P, Brady JP. Tracheal suction in meconium aspiration. Am J Obstet Gynecol 1975; 122 (06) 767-771
    CrossrefPubMedGoogle Scholar
  • 14 Carson BS, Losey RW, Bowes Jr WA, Simmons MA. Combined obstetric and pediatric approach to prevent meconium aspiration syndrome. Am J Obstet Gynecol 1976; 126 (06) 712-715
    CrossrefPubMedGoogle Scholar
  • 15 Aub-Shaweesh JM. Respiratory disorders in preterm and term infants. In: Martin RJ, Fanaroff AA, Walsh MC. eds, Fanaroff and Martin's Neonatal Perinatal Medicine. 9 ed. St. Louis, MO: Elsevier; 2010: 1157-1160
    Google Scholar
  • 16 Falciglia HS. Failure to prevent meconium aspiration syndrome. Obstet Gynecol 1988; 71 (3, Pt 1): 349-353
    PubMedGoogle Scholar
  • 17 Linder N, Aranda JV, Tsur M. , et al. Need for endotracheal intubation and suction in meconium-stained neonates. J Pediatr 1988; 112 (04) 613-615
    CrossrefPubMedGoogle Scholar
  • 18 Wiswell TE, Gannon CM, 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, Pt 1): 1-7
    CrossrefPubMedGoogle Scholar
  • 19 Halliday HL. Endotracheal intubation at birth for preventing morbidity and mortality in vigorous, meconium-stained infants born at term. Cochrane Database Syst Rev 2001; (01) CD000500
    PubMedGoogle Scholar
  • 20 Perlman JM, Wyllie J, Kattwinkel J. , et al; Neonatal Resuscitation Chapter Collaborators. Part 11: Neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122 (16) (Suppl. 02) S516-S538
    CrossrefPubMedGoogle Scholar
  • 21 Vain NE, Szyld EG, Prudent LM, Wiswell TE, Aguilar AM, Vivas NI. Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates before delivery of their shoulders: multicentre, randomised controlled trial. Lancet 2004; 364 (9434): 597-602
    CrossrefPubMedGoogle Scholar
  • 22 Fraser WD, Hofmeyr J, Lede R. , et al; Amnioinfusion Trial Group. Amnioinfusion for the prevention of the meconium aspiration syndrome. N Engl J Med 2005; 353 (09) 909-917
    CrossrefPubMedGoogle Scholar
  • 23 American College of Obstetrics and Gynecology (ACOG). Committee Opinion no. 346. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006; 108: 1053-1055
    CrossrefPubMedGoogle Scholar
  • 24 Kattwinkel J. Neonatal resuscitation guidelines for ILCOR and NRP: evaluating the evidence and developing a consensus. J Perinatol 2008; 28 (Suppl. 03) S27-S29
    CrossrefPubMedGoogle Scholar
  • 25 Myra H, Wyckoff KA, Marilyn B. Escobedo, Vishal S. Kapadia, John Kattwinkel, Jeffrey M. Perlman, Wendy M. Simon, Gary M. Weiner, Jeanette G. Zaichkin. Neonatal Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132: S543-S550
    CrossrefPubMedGoogle Scholar
  • 26 Perlman JMWJ, Wyllie J, Kattwinkel J. , et al; Neonatal Resuscitation Chapter Collaborators. Part 7: Neonatal Resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2015; 132 (16) (Suppl. 01) S204-S241
    CrossrefPubMedGoogle Scholar
  • 27 Chettri S, Adhisivam B, Bhat BV. Endotracheal suction for Nonvigorous Neonates Born through Meconium Stained Amniotic fluid: a randomized controlled trial. J Pediatr 2015; 166 (05) 1208-1213
    CrossrefPubMedGoogle Scholar
  • 28 Vain NE, Musante GA, Mariani GL. Meconium Stained Newborns: Ethics for Evidence in Resuscitation. J Pediatr 2015; 166 (05) 1109-1112
    CrossrefPubMedGoogle Scholar
  • 29 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
    CrossrefPubMedGoogle Scholar
  • 30 Nangia S. Reply to Letter: Endotracheal suctioning for meconium stained babies. Resuscitation 2017; 113: e19
    CrossrefPubMedGoogle Scholar
  • 31 Chabra S. Endotracheal suctioning for meconium stained babies: Re: Nangia S, Sunder S, Biswas R, Saili A. Endotracheal suction in term nonvigorous meconium stained neonates: a pilot study. Resuscitation 2016; 105:79-84. Resuscitation 2017; 113: e17
    CrossrefPubMedGoogle Scholar
  • 32 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 (06) 465-468
    PubMedGoogle Scholar
  • 33 Nangia S, Tiwari S, Saili A. Role of endotracheal suction on the occurrence of meconium aspiration syndrome (MAS) in nonvigorous meconium stained neonates: a randomized controlled trial. E-PAS 2014; 4680: 1
    PubMedGoogle Scholar
  • 34 Lakshminrusimha S, Mathew B, Nair J. , et al. Tracheal suctioning improves gas exchange but not hemodynamics in asphyxiated lambs with meconium aspiration. Pediatr Res 2015; 77 (02) 347-355
    CrossrefPubMedGoogle Scholar
  • 35 Shekerdemian LS, Ravn HB, Penny DJ. Interaction between inhaled nitric oxide and intravenous sildenafil in a porcine model of meconium aspiration syndrome. Pediatr Res 2004; 55 (03) 413-418
    CrossrefPubMedGoogle Scholar
  • 36 Carrasco M, Martell M, Estol PC. Oronasopharyngeal suction at birth: effects on arterial oxygen saturation. J Pediatr 1997; 130 (05) 832-834
    CrossrefPubMedGoogle Scholar
  • 37 Perlman JM, Volpe JJ. Suctioning in the preterm infant: effects on cerebral blood flow velocity, intracranial pressure, and arterial blood pressure. Pediatrics 1983; 72 (03) 329-334
    PubMedGoogle Scholar
  • 38 Velaphi S, Vidyasagar D. The pros and cons of suctioning at the perineum (intrapartum) and post-delivery with and without meconium. Semin Fetal Neonatal Med 2008; 13 (06) 375-382
    CrossrefPubMedGoogle Scholar