Neonatal Life Support

Octubre - 2020



1.- Warming Adjuncts (NLS 599: EvUp)

Maintenance of normal temperature is a key initial step in stabilization of the newborn at birth. There are multiple strategies to prevent hypothermia of the newborn. The NLS Task Force published the most recent CoSTR summarizing the evidence supporting warming adjuncts in 2015.1,9,10 In 2020, the NLS Task Force undertook an EvUp to identify any additional studies that would warrant consideration of a new SysRev.


Population, Intervention, Comparator, Outcome, Study Design, and Time Frame

  • Population: Preterm neonates less than 32 weeks’ gestational age who are under radiant warmers in the hospital delivery room

  • Intervention: Increased room temperature, thermal mattress, or another warming adjunct

  • Comparator: Compared with plastic wraps alone

  • Outcome21:

    • Primary: Hypothermia (less than 36.0ºC) on admission to neonatal intensive care unit (NICU)

    • Secondary:

      • Survival (critical)

      • Morbidities associated with hypothermia (important)

      • Hyperthermia and associated morbidities (important)

The EvUp (see Supplement Appendix C-2) identified 13 studies (5 SysRevs and 8 RCTs) supporting the 2015 CoSTR.1,9,10 Although the 2015 treatment recommendations were limited to very preterm babies born at less than 33 weeks’ gestational age, the recommendations remain relevant. The task force agreed to suggest the need for a SysRev on the topic of warming adjuncts in the near future. The task force also suggests division of the target populations to separately analyze effects and pertinent outcomes for term versus preterm infants.

Treatment Recommendation

These treatment recommendations (below) are unchanged from 2015.1,9,10
Among newborn preterm infants of less than 32 weeks’ gestation under radiant warmers in the hospital delivery room, we suggest using a combination of interventions that may include environmental temperature 23°C to 25°C, warm blankets, plastic wrapping without drying, cap, and thermal mattress to reduce hypothermia (temperature less than 36.0°C) on admission to NICU (weak recommendation, very low-certainty evidence). We suggest that hyperthermia (greater than 38.0°C) be avoided because it introduces potential associated risks (weak recommendation, very low-certainty evidence).


2.- Suctioning of Clear Fluid (NLS 596:ScopRev)

Rationale for Review

Transition from an intrauterine (fetal) to an extrauterine (newborn) physiology involves the replacement of lung liquid in the airways with air. To support liquid
clearance, oropharyngeal/nasopharyngeal suctioning at birth was traditionally used to remove oral and nasal secretions in vigorous infants at birth. The 2010 CoSTR for NLS suggested against this routine practice for the first time.12–14 Similarly, the 2015 American Heart Association Guidelines Update for CPR and ECC for neonatal resuscitation emphasized that “suctioning immediately after birth, whether with a bulb syringe or suction catheter, may be considered only if the airway appears obstructed or if PPV is required.”22 The balance of risks and benefits associated with routine suctioning remain controversial. Because this literature has not been systematically reviewed in over a decade, the task force agreed that a ScopRev would determine if there is sufficient evidence published after 2010 to warrant a new SysRev in the near future.

Population, Intervention, Comparator, Outcome, Study Design, and Time Frame

  • Population: Newborns delivered through clear amniotic fluid

  • Intervention: Immediate routine suctioning (oropharyngeal or nasopharyngeal)

  • Comparator: No suctioning or wiping

  • Outcome21:

    • Survival (critical)

    • Need for delivery room resuscitation and stabilization interventions (important)

    • Oxygen supplementation, use of PPV, intubation, CPR/medications, Apgar scores, time to reach heart rate greater than 100/min (important)

    • Complications following procedure (desaturation, delay in initiation of PPV, tissue injury, infection)

    • Respiratory complications (respiratory distress, tachypnea) (important)

    • Other inpatient morbidities (important)

  • Study design: RCTs and nonrandomized studies (non-RCTs, interrupted times series, controlled before-and-after studies, cohort studies) were eligible for inclusion

  • Time frame: All years and languages were included if there was an English abstract; unpublished studies (eg, conference abstracts, trial protocols) were excluded. Literature search was updated to November 30, 2019.

Summary of Evidence

Evidence supporting potential benefits of oropharyngeal/nasopharyngeal suctioning is limited and the practice remains controversial. Oropharyngeal suctioning
does not impact liquid removal from the lung.


The procedure can have serious side effects.

  • It is possible that nasopharyngeal suctioning may result in vagal-induced bradycardia as well as increased risk of infection.23

  • The procedure may take significant time to complete.24

  • Suctioning may delay initiation of ventilation in nonbreathing infants.3

  • Newborns who received suctioning compared with a control group had significantly lower oxygen saturation through the first 6 minutes of life and took longer to reach a normal saturation range.24,25

  • There is a concern that suctioning may have serious additional consequences, such as irritation to mucous membranes and increased risk of iatrogenic infection,26,27 bradycardia,26,28 apnea,28 hypoxemia and arterial oxygen desaturation,25,27,29 hypercapnia, 30 impaired cerebral blood flow regulation,31,32 increased intracranial pressure,33 and development of subsequent neonatal brain injury.34

The entire ScopRev can be found in Supplement Appendix B-2.

Task Force Insights

The NLS Task Force noted several strengths and limitations of the evidence identified by the ScopRev :

  • The identified studies were from diverse geographical areas, but the results were similar.

  • The literature identified by this ScopRev allowed comparisons in 2 types of subgroups (vaginal versus cesarean delivery and preterm versus term infants).

  • Most new studies appear to be consistent with the current recommendation of “no routine suctioning” of the newborns in the delivery room.

  • Because of the large number of patients (greater than 1500) reported in studies published since 2015, a new SysRev including these patients is likely to increase the certainty of the evidence through GRADE evaluation.

The NLS Task Force suggests consideration of an updated SysRev for this PICO question: “Among vigorous infants delivered through clear amniotic fluid (P), does immediate routine suctioning (oropharyngeal or nasopharyngeal) (I) compared with no suctioning or wiping C) change outcome (O)?” Until such a SysRev is completed and analyzed, the current 2010 treatment recommendation remains.12–14


Treatment Recommendation

This treatment recommendation (below) is unchanged from 2010.12–14
Routine intrapartum oropharyngeal and nasopharyngeal suctioning for newborn infants with clear or meconium- stained amniotic fluid is no longer recommended.

3.- Tracheal Intubation and Suction of  Nonvigorous Meconium-Stained Newborns (NLS 865: SysRev)

Meconium-stained amniotic fluid is present in 5% to 15% of all deliveries and is more common in neonates who are nonvigorous at birth.35,36 Approximately 3% to  5% of neonates born through meconium-stained amniotic fluid develop meconium aspiration syndrome (MAS), which remains a significant cause of neonatal morbidity and mortality, particularly in developing countries. 37 Optimal management of neonates born through meconium-stained amniotic fluid remains a topic of debate. For decades, routine intubation and endotracheal suctioning for nonvigorous, meconium-exposed neonates was suggested on the basis of extremely low-certainty evidence. In 2015, after publication and analysis of new (although limited) randomized trial data, the NLS Task Force changed the treatment recommendation to  eliminate routine tracheal intubation and suctioning for nonvigorous meconium-stained infants.1,9,10 Additional studies have been published since 2015, prompting the NLS Task Force to complete a new SysRev with meta-analysis.37

Population, Intervention, Comparator, Outcome, Study Design, and Time Frame

  • Population: Nonvigorous infants born at 34 weeks’ or greater gestation delivered through meconiumstained amniotic fluid (of any consistency) at the start of resuscitation (nonvigorous defined as heart rate less than 100/min, decreased muscle tone,  and/or depressed breathing at delivery)

  • Intervention: Immediate laryngoscopy with or without intubation and suctioning

  • Comparator: Immediate resuscitation without direct laryngoscopy at the start of resuscitation

  • Outcome21:

    • Primary

      • Survival to hospital discharge (critical)

    • Secondary

      • Neurodevelopmental impairment (critical)

      • MAS (critical)

      • Other respiratory outcomes (continuous positive airway pressure or mechanical ventilation, treatment of pulmonary hypertension with inhaled nitric oxide, oral medications or extracorporeal membrane oxygenation) (important)

      • Delivery room interventions (CPR/medications, intubation for PPV) (important)

      • Length of hospitalization (important)

  • Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, and cohort studies) were included in the review.

  • Time frame: All years and languages were included if there was an English abstract; unpublished studies (eg, conference abstracts, trial protocols) and animal studies were excluded. The literature search was updated to May 2019.

A Priori Subgroups to Be Examined

Consistency of meconium (thin versus thick), gestational age categories (late preterm [34 weeks to 36 weeks and 6 days], term [37 weeks to 41 weeks and 6 days],
postterm [42 weeks or greater]), presence or absence of fetal bradycardia, route of delivery (spontaneous vaginal, instrumented vaginal, cesarean delivery), direct
laryngoscopy with versus without suctioning.
International Prospective Register of Systematic Reviews (PROSPERO) Registration: CRD42019122778


Consensus on Science

The SysRev identified 4 eligible studies that included 680 newborn infants.37 Data from 3 RCTs involving 449 newborns38–40 and 1 observational study involving 231 newborn infants41 were included.

A draft CoSTR document based on the SysRev was posted on the website for a 2-week public commenting period. During this period, the draft CoSTR was viewed over 5600 times and 65 comments were provided; most comments were very positive. However, there were concerns about clarity, which the task force subsequently addressed. Suggestions made were used to modify the wording of the treatment recommendations, justification and evidence-to-decision framework highlights, and the knowledge gaps to improve clarity. Although these treatment recommendations do not preclude the use of carefully considered clinical judgment for individual cases, the NLS Task Force cannot use unpublished, personal observations to inform an international consensus on science or to guide treatment recommendations.

For the critical primary outcome of survival to discharge, we identified low-certainty evidence (downgraded for inconsistency and imprecision) from 3 RCTs38–40 involving 449 nonvigorous newborns delivered through meconium-stained amniotic fluid which showed no benefit from the use of immediate laryngoscopy with or without tracheal suctioning when compared with immediate resuscitation without laryngoscopy (relative risk [RR], 0.99; 95% CI, 0.93–1.06; P=0.87); absolute risk reduction, –0.9%; (95% CI, –6.4% to 5.5%), or 9 fewer patients/1000 survived to discharge with the intervention (95% CI, 64 fewer to 55 more patients per 1000 survived to discharge with the intervention). For complete data, see
Table 1.


Table 1.-    Meta-analysis of RCTs of Immediate Laryngoscopy With or Without Tracheal Suctioning Versus Immediate Resuscitation Without Laryngoscopy for Nonvigorous Infants Born at 34 Weeks’ or Greater Gestation and Delivered Through Meconium-Stained Amniotic Fluid .

For the remainder of the outcomes of interest (eg, neurodevelopmental impairment (NDI), hypoxic-ischemic encephalopathy (HIE), MAS, use of mechanical ventilation, use of respiratory support excluding mechanical ventilation, endotracheal intubation for PPV in the delivery room, chest compressions in the delivery
room, use of epinephrine in the delivery room, treatment of pulmonary hypertension, and length of hospitalization), evidence of very low certainty (downgraded for risk of bias, indirectness, and imprecision) showed no benefit from the use of immediate laryngoscopy with or without tracheal suctioning compared with immediate resuscitation without laryngoscopy for nonvigorous newborns delivered through meconium-stained amniotic fluid (
Table 1).

The neurodevelopmental assessment from the single study that reported this outcome was performed at an early and nonstandard time, hence the results are poorly predictive of longer-term outcomes. Therefore, the task force concluded that the effect on NDI of immediate laryngoscopy with or without suctioning remains uncertain.
In 2015, the treatment recommendation indicated that there was insufficient human evidence to continue to suggest routine suctioning of meconium in nonvigorous babies born through meconium-stained amniotic fluid.1,9,10 This new 2020 recommendation is more direct in its suggestion against this practice.

Treatment Recommendations

  • For nonvigorous newborn infants delivered through meconium-stained amniotic fluid, we suggest against routine immediate direct laryngoscopy with or without tracheal suctioning compared with immediate resuscitation without direct laryngoscopy (weak recommendation,  low-certainty evidence).

  • Meconium-stained amniotic fluid remains a significant risk factor for receiving advanced resuscitation in the delivery room. Rarely, an infant may require intubation and tracheal suctioning to relieve airway obstruction.

Justification and Evidence-to-Decision Framework Highlights

The task force recognizes that, although the direction of the treatment recommendation has not changed, several studies published after 2015 provide additional
evidence to support the recommendation. These studies contributed new evidence, but the certainty of the findings remains low or very low because it is difficult to perform unbiased studies of this clinical question.
Finally, even combining the data from all studies does not provide sufficient power for certainty as the optimal information size is still not achieved. The NLS Task Force considered that the procedure of laryngoscopy and suctioning with or without tracheal intubation is invasive and has potential to harm, particularly if initiation of ventilation is delayed. This, together with the evidence of no benefit of routine tracheal suctioning, led the task force to suggest against routine practice of these interventions. It is possible that the infant born through meconium-stained fluid will require intubation for resuscitation. Therefore, trained personnel and equipment for intubation should be readily available for births where meconium-stained amniotic fluid is present. If meconium is obstructing the trachea, suctioning by using an endotracheal tube with a meconium aspirator may be effective in relieving the obstruction.42,43

See Supplement Appendix A-1 for the evidence-todecision table for this SysRev.


Knowledge Gaps

Priorities for research include the following :

  • Additional RCTs are needed that focus on nonvigorous infants in a variety of populations, such as where the incidence of MAS is low, and in settings with various levels of healthcare resources.

  • Do risks or benefits of intubation with tracheal suctioning vary with any subgroup (gestational age, thickness of meconium, operator experience)?

  • Long-term outcomes are needed in future studies.  These include neurodevelopmental, behavioral, or educational assessment, which for future studies should be at or beyond 18 months of age and completed with a validated tool.