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PEDIATRICS Vol. 105 No. 1 January 2000, pp. 1-7
,
,,
From the Neonatology services at * Thomas Jefferson University,
Philadelphia, Pennsylvania; Providence Alaska Medical Center,
Anchorage, Alaska; § West Jersey Hospital, Voorhees, New Jersey;
Diego Paroissien Hospital, Buenos Aires, Argentina; ¶ Mercer Medical
Center, Trenton, New Jersey; # Fitzgerald Mercy Hospital, Darby,
Pennsylvania; ** Flushing Hospital, Flushing, New York; University
Hospital, Buenos Aires, Argentina; §§ Clinicas Hospital,
Asúncion, Paraguay; || Pennsylvania Hospital, Philadelphia,
Pennsylvania; ¶¶ Desert Samaritan Medical Center, Phoenix, Arizona;
and ## Scott and White Memorial Hospital, Temple, Texas.
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ABSTRACT |
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Top
Abstract
Methods
Results
Discussion
Conclusion
References
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Objective. Disagreement exists concerning the appropriate delivery room management of the airway of vigorous meconium-stained infants. Some suggest a universal approach to intubation and suctioning of the airway in all such neonates, whereas others advocate a selective approach. We performed this investigation: 1) to assess whether intubation and suctioning of apparently vigorous, meconium-stained neonates would reduce the incidence of meconium aspiration syndrome (MAS); and 2) to determine the frequency of complications from delivery room intubation and suctioning of such infants.
Methods. Inclusion criteria included: 1) gestational age
37 weeks; 2) birth through meconium-stained amniotic fluid of any consistency; and 3) apparent vigor immediately after birth. Subjects were randomized to be intubated and suctioned (INT) or to expectant management (EXP). Primary outcome measures included: 1) the incidence of respiratory distress, including MAS, and 2) the incidence of complications from intubation.
Results. A total of 2094 neonates were enrolled from 12 participating centers (1051 INT and 1043 EXP). Meconium-stained amniotic fluid consistency was similar in both groups. Of the 149 (7.1%) infants that subsequently demonstrated respiratory distress, 62 (3.0%) had MAS and 87 (4.2%) had findings attributed to other disorders. There were no significant differences between groups in the occurrence of MAS (INT = 3.2%; EXP = 2.7%) or in the development of other respiratory disorders (INT = 3.8%; EXP = 4.5%). Of 1098 successfully intubated infants, 42 (3.8%) had a total of 51 complications of the procedure. In all cases, the complications were mild and transient in nature.
Conclusions. Compared with expectant management, intubation and suctioning of the apparently vigorous meconium-stained infant does not result in a decreased incidence of MAS or other respiratory disorders. Complications of intubation are infrequent and short-lived.
Key words: meconium aspiration syndrome, newborn infant, intubation.
Approximately 13% of liveborn infants are born through
meconium-stained amniotic fluid (MSAF).1,2 Of the neonates
born through MSAF, 5% to 12% develop the meconium aspiration syndrome
(MAS).1,2 Reports from the mid-1970s suggested that
intratracheal suctioning of meconium-stained infants could prevent
development of MAS and decrease mortality from the disorder.3,4 Although these latter investigations were
only observational studies, after their publication the strategy of
intubation and suctioning the tracheae of all meconium-stained infants
was widely adopted. During the decade after the publication of these
reports, the incidence of MAS and deaths attributable to the disorder
declined significantly.5
In 1988, Linder and colleagues6 reported that the
apparently vigorous meconium-stained infant may not need intratracheal suctioning and that such therapy could be harmful. Despite major design
flaws in the Linder trial,7-10 Cunningham et
al11 proposed a standard of care in which only depressed
meconium-stained neonates needing positive pressure ventilation would
receive intratracheal suctioning in the delivery room. Although some
investigators subsequently reported that such an approach could be
deleterious,12 others found a selective approach generally
to result in good outcomes.13,14 Essentially, however,
there was no well-designed research supporting either universal or
selective intubation of the meconium-stained neonate.
Potential complications of neonatal intubation15 include
bradycardia, perforation of the larynx or pharynx, dislocation of the
vocal cords, hoarseness or stridor, hypoxemia, and apnea. Although
these complications are believed to be rare, no studies have yet
documented their frequency of occurrence.
We performed this investigation: 1) to assess whether intubation and
suctioning of the apparently vigorous meconium-stained neonate would
reduce the incidence of MAS, and 2) to determine the frequency of
complications from delivery room intubation and suctioning of such
infants.
This was a prospective, randomized, controlled trial in which 12 centers enrolled patients between July 1995 and September 1997. The
protocol was adopted for this investigation and approved by the
institutional review boards of the participating sites. This was a no
informed consent protocol. The rationale for this included: 1) wide
acceptance of both proposed management strategies (universal vs
selective intubation) as standards of care; 2) MSAF is frequently not
noted until moments before delivery, obviating the ability to counsel
parents; and 3) inherent difficulties in obtaining valid informed
consent from a mother undergoing the pain of labor. We estimated that
if we were to attempt to obtain informed consent, even during prenatal
visits, at most we would only be able to enroll 70% of eligible
infants. Moreover, the population of enrolled neonates would not be
representative of the entire population of infants born through MSAF.
Potentially, many infants at higher risk for developing MAS would be
excluded (eg, those delivered via emergency cesarean section). The
protocol satisfied the requirements for waiver of informed consent
found in the Combined Federal Regulations developed by the Department of Health and Human Services for the protection of human research subjects (45 Combined Federal Regulations 46.116[d]). Because of the
uniqueness of waiving informed consent, several invited ethicists and
neonatologists were involved in the review process. In addition, the
Steering Committee of the American Academy of Pediatrics/American Heart
Association Neonatal Resuscitation Program wrote a supportive letter
stating investigation was sorely needed and quite ethical to perform
without requiring informed consent.
To incorporate the widespread varieties of clinical practice,
participating sites were chosen in an effort to include both university-affiliated hospitals and predominantly clinical centers. The
inclusion criteria were: 1) meconium presence in the amniotic fluid; 2)
gestational age of Infants were randomized to intubation and intratracheal suctioning
(INT) or to expectant management (EXP). Computer-generated random
numbers were used for assignment to these groups. Group selection was
determined by drawing assignments from a sealed opaque envelope, which
was opened immediately before deliveries complicated by meconium
staining. When a neonate did not meet the criteria for apparent vigor,
the child was excluded from the study and randomization assignment was
discarded. Infants assigned to the INT group were intubated immediately
after birth following the assessment for vigor. A standard meconium
suction device, the Neotech aspirator (Neotech, Inc, Chatsworth, CA)
was connected to the proximal end of the child's endotracheal tube and
attached to wall suction set at 80 to 120 mm Hg negative pressure.
Suction was applied continuously for 1 to 5 seconds and as the
endotracheal tube was withdrawn. If meconium was suctioned from the
trachea, the procedure was repeated until no additional
meconium-stained fluid could be retrieved. Infants randomized to EXP
had routine delivery room care. After initial stabilization and
assessment, EXP infants potentially could manifest signs of respiratory
distress. Therefore, health care providers were allowed to intubate and suction such infants if they believed it was clinically indicated. Extensive antenatal, intrapartum, and postnatal data were collected on
a standardized form that was forwarded to a central facility for entry
into a database. All investigators remained blinded to results until
completion of the trial. An independent data safety and monitoring
committee assessed data one third and two thirds of the way through
enrollment.
Data Analysis
Published data from several sources1,2,5,6,13,14
were used to calculate sample size. We hypothesized that compared with
EXP, intratracheal suctioning of apparently vigorous meconium-stained
neonates would decrease the incidence of MAS from 3% to 1%. To
demonstrate such a difference, at A total of 2094 infants were enrolled in the trial, 1051 in the
intubate group and 1043 in the expectant management group. Of the 12 participating sites, 6 enrolled between 197 and 408 neonates, whereas
the remaining 6 sites cumulatively enrolled a total of 227 infants. Of
the 6 sites that enrolled 197 or more infants, 4 kept data concerning
all meconium-stained infants (both apparently vigorous and those that
were not). Fully 74% of all meconium-stained infants from these 6 sites fit the criteria of being apparently vigorous at the time of
initial evaluation. Selected antenatal and intrapartum characteristics
for the entire population are presented in Table
1. There were no differences between groups in maternal age, maternal gravidity or parity, amount of prenatal care, presence of oligohydramnios, consistency of MSAF, use of
amnioinfusion therapy, application of electronic fetal heart rate (FHR)
monitoring during labor, occurrence of abnormal FHR monitoring, use of
oropharyngeal suctioning, or method of delivery.
TABLE 1
METHODS
Top
Abstract
Methods
Results
Discussion
Conclusion
References
37 weeks; and 3) apparent vigor of the child in
the delivery room immediately after birth, defined by a heart rate
>100 beats per minute, as well as presence of spontaneous respirations
and reasonable tone. Reasonable tone was believed to be present if the
child was exhibiting either spontaneous movements or had some degree of
extremity flexion. The degree of vigor was assessed within the first 10 to 15 seconds after delivery. The MSAF could be of any consistency. For
this trial, MSAF consistency was classified in the following manner: 1)
thin MSAF was a watery consistency fluid through which an individual potentially could read newspaper print if the fluid was on the paper;
2) moderate or moderately-thick MSAF was an opaque fluid without
particles; and 3) thick MSAF was fluid of pea soup consistency or
opaque fluid containing particulate material. Additionally, MAS was
defined as respiratory distress in an infant born through MSAF whose
symptoms could not be otherwise explained and who had consistent
radiographic findings (eg, coarse, irregular infiltrates, hyperinflation, and/or segmental or lobar atelectasis). The obstetrical policy at all sites was to suction the oropharynx of each
meconium-stained neonate with either a catheter (attached to wall
suction) or bulb syringe before delivery of the infant's shoulders or
trunk.
= .05 with 90% power, a
minimum of 1029 infants were needed in each group (2058 total). The INT
and EXP groups were analyzed on an intention to treat basis. Univariate
analyses, including 2-group t test, Wilcoxon rank sum test,
two-tailed Fisher's exact test, and the Mantel-Haenszel
2 test, were initially used to compare
the groups. Stepwise logistic regression was subsequently used to
evaluate the effect of various factors on the occurrence of MAS or
other respiratory disorders independent of the potentially confounding
effects of other variables. The logistic regressions were conducted on
SAS Version 6.08,16 and goodness of fit was determined by
the Hosmer-Lemeshow statistic.17
RESULTS
Top
Abstract
Methods
Results
Discussion
Conclusion
References
Antenatal and Intrapartum Population Characteristics
Selected characteristics of the infant population are presented in Table 2. There were no differences between groups in racial background, gender, or 5-minute Apgar scores. The INT group subjects were significantly more likely to have lower 1-minute Apgar scores (P < .0018). A total of 62 meconium-stained infants (3.0%) developed MAS, and an additional 87 (4.2%) were diagnosed with other respiratory disorders including: transient tachypnea of the newborn (n = 52), delayed transition from fetal circulation (n = 16), sepsis or pneumonia (n = 10), persistent pulmonary hypertension of the newborn (n = 3), pulmonary edema (n = 3), pneumothorax (n = 2), hypovolemia (n = 1), and blood aspiration (n = 1). Across sites there was little variation in the frequency of MAS (2.2%-3.5%) or other respiratory disorders (3.4%-5.2%). There were no significant differences between INT and EXP in the incidence of MAS (3.2% vs 2.7%, respectively) or other respiratory disorders (3.8% vs 4.5%, respectively). Additionally, the thicker the MSAF consistency, the more likely the development of either MAS or other respiratory disorders. However, even in the presence of the thickest consistency MSAF, intratracheal suctioning was no better than expectant management in preventing respiratory illness. Moreover, when we put the primary endpoint (development of MAS) into a logistic regression model with other risk factors for the disorder, the results were identical; there were no differences between the intubation and expectant management groups in the incidence of MAS. Two infants required extracorporeal membrane oxygenation, 1 in each group. Five deaths occurred: 2 in the INT group and 3 in the EXP group. Four deaths were caused by respiratory failure, and 1 was attributable to overwhelming infection.
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Of 1051 INT infants, 17 (1.5%) were not intubated for several reasons, most commonly excessively difficult intubation. None of these 17 infants subsequently developed respiratory distress. Of 1043 EXP infants, 64 (6.1%) were intubated after the initial assessment period because they developed clinical symptoms that included respiratory distress, poor respiratory effort, and evidence of meconium blocking the upper airway. These 64 infants were intubated between 1 and 7 minutes of age. Of the 64 infants, 11 (17%) subsequently developed either MAS (n = 4) or other respiratory disorders (n = 7). Of 1098 successfully intubated infants (1034 from the INT group and 64 from the EXP group), 42 (3.8%) had a total of 51 complications of the procedure. Complications included bradycardia (n = 26), hoarseness or stridor (n = 14), laryngospasm (n = 6), apnea (n = 2), bleeding at the vocal cords (n = 2), and cyanosis (n = 1). Most complications were transient, lasting 15 to 60 seconds. Hoarseness or stridor lasted between 2 minutes and 12 hours.
Stepwise logistic regression revealed an association between several
factors and subsequent occurrence of respiratory distress (Fig
1). Infants delivered via cesarean
section were significantly more likely to develop MAS compared with
vaginally delivered infants (odds ratio [OR]: 1.89; 95% confidence
interval [CI]: 1.10,3.22). Among infants delivered via cesarean
section, there was no difference in the occurrence of respiratory
disorders between those electively delivered compared with those
delivered operatively for fetal distress. Infants whose mothers had <5
prenatal visits were significantly more likely to develop MAS compared with infants whose mothers had 5 prenatal visits (OR: 6.56; CI: 3.91,11.00). The occurrence of MAS increased significantly with increasing consistency of MSAF. Infants born through moderately thick
MSAF were significantly more likely to develop MAS compared with those
born through thin consistency MSAF (OR: 2.79; CI: 1.11,7.03). Neonates
born through thick MSAF were significantly more likely to develop MAS
compared with those born through either thin consistency MSAF (OR:
9.85; CI: 4.39,22.08) or moderately thick MSAF (OR: 3.93; CI:
1.88,6.65). When oropharyngeal suctioning was not performed before
delivery of the shoulders, neonates were significantly more likely to
develop MAS (OR: 3.35; CI: 1.55,7.27). The incidence of MAS in infants
who did not have oropharyngeal suctioning was 8 of 94 (8.5%) compared
with 54 of 2000 (2.7%) of infants who had such suctioning
(P = .013). Among infants who had oropharyngeal suctioning, there were no differences in the occurrence of respiratory illnesses between those suctioned with a catheter and those suctioned with a bulb syringe. Among the 1098 infants who were successfully intubated, 373 (34.0%) were noted to have meconium present in the
trachea. These infants were significantly more likely to develop MAS
compared with those who did not have meconium present in the trachea
(OR: 3.49; CI: 1.78,6.84). Of the 1649 infants whose mothers had
electronic FHR monitoring performed, when abnormalities in FHR were
noted the infants were more likely to developed MAS (OR: 1.92; CI:
1.10,3.34). Amnioinfusion was performed in the mothers of 138 (6.6%)
meconium-stained infants, virtually only in the presence of
thick-consistency MSAF. However, use of amnioinfusion did not result in
any decrease in the incidence of MAS or other respiratory disorders.
The meconium-stained neonates with 1-minute (OR: 10.03; CI 5.97,16.86)
or 5-minute (OR: 21.35; CI: 8.65,53.04) Apgar scores of <7 were
significantly more likely to develop MAS, as were those born in the
presence of oligohydramnios (OR: 4.26; CI: 1.62, 11.18). Male infants
were significantly more likely than female infants to have MAS (OR:
2.48; CI: 1.42,4.34).
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We similarly used stepwise logistic regression to assess whether any of
the aforementioned factors were independent predictors of other causes
of respiratory distress (Fig 2).
We found the following factors to be independently significantly
related to the development of other respiratory disorders: cesarean
delivery (OR: 3.78; CI: 2.45,5.84); <5 prenatal visits (OR: 2.11; CI:
1.26,3.53); moderately thick versus thin consistency of MSAF (OR: 2.71;
CI: 1.40,5.26); thick versus thin MSAF (OR: 5.65; CI: 3.08,10.34); thick versus moderately thick MSAF (OR: 2.08; CI: 1.27,3.42); not
performing oropharyngeal suctioning (OR: 2.61; CI: 1.27,4.13); meconium
presence in the trachea (OR: 5.49; CI: 2.96,10.54); no use of FHR
monitoring (OR: 2.76; CI: 1.77,4.28); abnormal FHR monitoring when
performed (OR: 4.69; CI: 2.57,8.56); 1-minute (OR: 8.10; CI:
5.18,12.64) or 5-minute (OR: 17.70; CI: 7.34,42.62) Apgar score of 
6;
and oligohydramnios (OR: 2.92; CI: 1.13,7.59). Although the frequency
of other respiratory disorders was increased among male neonates, this
was not an independently significant risk factor (OR: 1.49; CI:
.96,2.31). The incidence of other respiratory disorders was 9 of 94 (9.6%) in infants who did not have oropharyngeal suctioning compared
with 78 of 2000 (3.9%) of infants who had such suctioning
(P = .007).
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Of the infants with MAS, 30 (48%) needed support with either mechanical ventilation (n = 24) or continuous positive airway pressure (n = 6) compared with 13 (15%) of those with other respiratory disorders (P < .0001). The need for increasing levels of respiratory support was significantly related to MSAF consistency but not to other variables (Table 3). We assessed the relationship between the level of experience and training of the clinicians performing intubation and suctioning to the occurrence of MAS. Of the 1098 intubation procedures, 176 (16.0%) were performed by pediatric residents, 147 (13.4%) by neonatology fellows, 467 (42.5%) by attending neonatologists, 305 (27.8%) by neonatal nurse practitioners, and the remaining 3 (.3%) were performed by an obstetrician, a respiratory therapist, and an anesthesiologist, respectively. There were no significant differences in the occurrence of MAS or other respiratory distress based on the differing levels of experience and training.
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DISCUSSION |
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Top
Abstract
Methods
Results
Discussion
Conclusion
References
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In this trial, we found routine suctioning of the apparently
vigorous meconium-stained infant to be no better than expectant management in preventing MAS or other respiratory disorders.
Additionally, we found the infrequent complications of routine
intubation and suctioning to be minor and short-lived. MAS is a common
cause of respiratory distress in newborn infants around the
world.1,2 Historically, as many as 62% of infants born
through MSAF subsequently suffered respiratory distress.18
Although intratracheal suctioning of the meconium-stained neonate was
proposed initially in 1960,19 it was not until the
mid-1970s that direct tracheal suctioning was reported to be effective
in preventing MAS.3,4 Although the latter reports only
represented anecdotal experience, not prospective, randomized,
controlled trials, after their publication there was widespread
acceptance of the practice of intubating and suctioning the tracheae of
all meconium-stained infants. In the subsequent decade, the incidence of MAS and deaths attributable to the disorder significantly
declined.5 In 1988, Linder and colleagues6
suggested that nondepressed meconium-stained infants would not benefit
from intratracheal suctioning. A number of issues were raised
concerning their trial.7-10 They did not randomize all
enrolled subjects. They excluded all infants delivered via cesarean
section or vaginally with instrument assistance. There was a remarkably
high incidence of meconium-stained infants with 1-minute Apgar scores
of 9 (>90%), as well as a remarkably low frequency of MAS (.7%).
Nevertheless, based on the results of the Linder trial, selective
intubation was proposed as a standard of care.11 Several
authors13,14 retrospectively reviewed delivery room
management in their own institutions and concluded that a selective
approach was justified. However, others12,20 concluded
that universal intubation and suctioning was the best strategy to
prevent morbidity and mortality.
We were not surprised to find a high rate of respiratory disorders other than MAS to occur among infants born through MSAF. Fleischer et al21 and Yoder14 similarly described non-MAS respiratory illnesses to be more common among infants born through MSAF compared with those delivered through clear amniotic fluid. Because we found risk factors for these other disorders to be virtually identical to those for MAS, we speculate that many of the illnesses were not distinctly different entities but were actually part of the overall spectrum of MAS. The range of roentgenographic findings among infants with MAS are diverse,22,23 varying from consolidation or diffuse, patchy infiltrates to a hypovascular or even a virtually normal appearance. There is often no association between the degree of radiographic abnormalities and the severity of MAS.22,23 We believe that when clinicians do not appreciate classic roentgenographic MAS features (ie, diffuse, patchy infiltrates) in sick neonates born through MSAF, they occasionally mistakenly attribute the respiratory distress to disorders other than MAS.
Lower 1-minute Apgar scores among INT infants likely represented the consequence of the intubation procedure itself. Several neonates assigned to EXP also had low 1-minute scores after having initially fulfilled the enrollment criteria for apparent vigor within 10 to 15 seconds of birth. Most of the latter infants had clinical symptoms that investigators believed necessitated intubation and suctioning. Meconium-stained infants delivered operatively were at greater risk for respiratory distress compared with those delivered vaginally. Infants of mothers with few prenatal visits were also at greater risk for respiratory disorders. The current work supports the important role of oropharyngeal suctioning before delivery of an infant's shoulders in preventing MAS or other respiratory problems, a strategy first addressed by Carson and colleagues.24 Oropharyngeal suctioning with a bulb syringe and a catheter attached to wall suction were equally effective. The presence of abnormal FHR monitoring indicated a greater risk for adverse pulmonary outcomes.
Use of amnioinfusion did not prevent MAS in infants born through MSAF. Although initial reports from the late 1980s and early 1990s indicated that amnioinfusion for thick-consistency MSAF would prevent MAS,25 several recent reports have not found this therapy to be of benefit.26 The current investigation confirms the direct relationship between MSAF consistency and occurrence of respiratory distress, as well as the level of respiratory support needed. The presence of oligohydramnios, as well as 1- or 5-minute Apgar scores of <7, are similarly associated with an increased risk for subsequent respiratory distress. This is the first report of a greater propensity for MAS in male compared with female infants.
The current investigation was performed without informed consent being
obtained from the infants' parent(s). Our assumption that informed
consent could not be obtained from 30% of eligible infants was
confirmed by the recent work of Liu.27 In an abstract, he
described results from a trial assessing the need for intubation in 356 neonates born through thin-consistency meconium. Liu was only able to
obtain informed consent from 47% of the parents of eligible infants.
The goal of informing and obtaining consent from patients or their
surrogates in research studies is of indisputable importance. However,
this goal is often difficult to achieve in many situations, such as in
an emergency department when a critically-ill patient first arrives or
before the occurrence of an unexpected event like MSAF noted at the
time of cesarean delivery. Under the usual rules of evidence in
medicine, mandatory interventions should be those for which there is
credible evidence that the benefits outweigh the risks. However,
throughout medicine (including neonatology) unproven therapies are
broadly prescribed in clinical practice without independent monitoring,
without consent, and with little effort to inform the patients (or
surrogates) of what is known and not known about the
therapy.28 The best attempts to assess the validity of
certain therapies may be impossible under the usual rules for obtaining
informed consent.29 Ironically, some institutional review
boards may not permit research without informed consent, yet in the
same institution widespread clinical application of unproven therapies
is practiced. Under such constraints, potentially answerable questions
may never be answered. Suboptimal or even harmful therapies may be
adopted and used widely.
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CONCLUSION |
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Top
Abstract
Methods
Results
Discussion
Conclusion
References
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We conclude that intratracheal suctioning of apparently vigorous meconium-stained infants does not result in a decreased incidence of respiratory distress compared with expectant management. The complication rate of intubation is relatively low and complications are minor and transient in nature. Until proven otherwise, endotracheal intubation and suctioning should still be performed in infants born through MSAF if they are not vigorous, if they need positive pressure ventilation, or if they develop symptoms of respiratory distress subsequent to initial assessment.
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ACKNOWLEDGMENTS |
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This investigation was supported by grants from: the Steering Committee of the American Heart Association/American Academy of Pediatrics Neonatal Resuscitation Program; and the American Pediatric Society/Society for Pediatric Research Multicenter Trials Initiative.
We thank Dr Arnold Heyman (Neotech, Inc, Chatsworth, CA) who supplied the meconium aspirators for this investigation, Lynn Lynam, RN, PhD (Ohmeda, Inc, Columbia, MD) who provided vacuum regulators for several international sites to standardize negative wall-suction pressure, Drs Louis D. Pollack and Jon E. Tyson for their suggestions and encouragement, and the members of the obstetrical and neonatology services, as well as the delivery room staffs, at the participating hospitals. Without their cooperation and recognition of the need to study this important issue, this investigation could never have been accomplished. We also thank the following individuals: Nancy Vecchione; William Holt, RN; Adriana Aguilar, MD; Paul Foschiatti MD; Patricia Nemer, MD; Cynthia Villasis, MD; Raj Sharma, MD; Richard Rothchild, MD; Ramon Mir, MD; Fabiana Oliveira, MD; Sharon Hulman, RN; Chris Catts, RN; Giselle Yecco, RN; and Diane Rose, RN.
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FOOTNOTES |
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The results from this trial were presented in part at the Annual Meeting of the American Academy of Pediatrics; October 16, 1998; San Francisco, CA. A summary of that presentation was published in the October 1998 issue of the newsletter NRP Instructor Update.
Received for publication Feb 11, 1999; accepted Apr 26, 1999.
Reprint requests to (T.E.W.) Discovery Laboratories, Inc, 350 S Main St, Suite 307, Doylestown, PA 18901. E-mail: twiswell{at}discoverylabs.com
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ABBREVIATIONS |
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MSAF, meconium-stained amniotic fluid; MAS, meconium aspiration syndrome; INT, intubated and suctioned; EXP, expectant management; FHR, fetal heart rate; OR, odds ratio; CI, 95% confidence interval.
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REFERENCES |
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Methods
Results
Discussion
Conclusion
References
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 H. S. Marshall, M. S. Gold, R. Gent, P. J. Quinn, L. Piotto, M. F. Clarke, and D. M. Roberton Ultrasound Examination of Extensive Limb Swelling Reactions After Diphtheria-Tetanus-Acellular Pertussis or Reduced-Antigen Content Diphtheria-Tetanus-Acellular Pertussis Immunization in Preschool-Aged Children Pediatrics, October 1, 2006; 118(4): 1501 - 1509. [Abstract] [Full Text] [PDF]
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 C. Barber, P. Karimi, and J. M. Anderson Educational Perspectives: Changes in The Neonatal Resuscitation Program NeoReviews, September 1, 2006; 7(9): e449 - e453. [Full Text] [PDF]
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C P F O'Donnell, A T Gibson, and P G Davis Pinching, electrocution, ravens' beaks, and positive pressure ventilation: a brief history of neonatal resuscitation. Arch. Dis. Child. Fetal Neonatal Ed., September 1, 2006; 91(5): F369 - F373. [Abstract] [Full Text] [PDF]
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L McKechnie and A B Gill Consent for neonatal research. Arch. Dis. Child. Fetal Neonatal Ed., September 1, 2006; 91(5): F374 - F376. [Abstract] [Full Text] [PDF]
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M. W. Wilson, B. G. Haik, and C. Rodriguez-Galindo Socioeconomic Impact of Modern Multidisciplinary Management of Retinoblastoma Pediatrics, August 1, 2006; 118(2): e331 - e336. [Abstract] [Full Text] [PDF]
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 C. E. Hunt and F. R. Hauck Sudden infant death syndrome. Can. Med. Assoc. J., June 20, 2006; 174(13): 1861 - 1869. [Abstract] [Full Text] [PDF]
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P. A. Dargaville, B. Copnell, and for the Australian and New Zealand Neonatal Networ The Epidemiology of Meconium Aspiration Syndrome: Incidence, Risk Factors, Therapies, and Outcome Pediatrics, May 1, 2006; 117(5): 1712 - 1721. [Abstract] [Full Text] [PDF]
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American Heart Association, American Academy of Pe 2005 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) of Pediatric and Neonatal Patients: Neonatal Resuscitation Guidelines Pediatrics, May 1, 2006; 117(5): e1029 - e1038. [Full Text] [PDF]
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The International Liaison Committee on Resuscitati The International Liaison Committee on Resuscitation (ILCOR) Consensus on Science With Treatment Recommendations for Pediatric and Neonatal Patients: Neonatal Resuscitation Pediatrics, May 1, 2006; 117(5): e978 - e988. [Full Text] [PDF]
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M. C. Nelson and P. Gordon-Larsen Physical Activity and Sedentary Behavior Patterns Are Associated With Selected Adolescent Health Risk Behaviors Pediatrics, April 1, 2006; 117(4): 1281 - 1290. [Abstract] [Full Text] [PDF]
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 S. Misra, A. Lee, and K. Gensel Chronic Constipation in Overweight Children JPEN J Parenter Enteral Nutr, March 1, 2006; 30(2): 81 - 84. [Abstract] [Full Text] [PDF]
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D Cattarelli, M Spandrio, A Gasparoni, R Bottino, C Offer, and G Chirico A randomised, double blind, placebo controlled trial of the effect of theophylline in prevention of vasomotor nephropathy in very preterm neonates with respiratory distress syndrome Arch. Dis. Child. Fetal Neonatal Ed., March 1, 2006; 91(2): F80 - F84. [Abstract] [Full Text] [PDF]
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F. R. Moya, S. K. Sinha, and R. D'Agostino Surfactant Trials Pediatrics, January 1, 2006; 117(1): 245 - 247. [Full Text] [PDF]
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 Part 13: Neonatal Resuscitation Guidelines Circulation, December 13, 2005; 112(24_suppl): IV-188 - IV-195. [Full Text] [PDF]
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