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COMMENTARY |
Department of Pediatrics and Division of Neonatal-Perinatal Medicine
St Louis University School of Medicine
St Louis, MO 63104
Abbreviations: MSAF, meconium-stained amniotic fluid • NRP, Neonatal Resuscitation Program
Approximately 8% to 15% of all infants are born with evidence of meconium-stained amniotic fluid (MSAF).1 Many of these infants rapidly initiate a good respiratory response and are otherwise vigorous. Other infants present with a variety of types of distress from a simple delay in the initiation of respiration to signs of prolonged hypoxemia. The method to best care for these children has been the subject of considerable discussion, especially between obstetricians and pediatricians.
The Neonatal Resuscitation Program (NRP) is a very successful system of instruction taught to >1.5 million providers in >70 countries since its introduction in 1987.2 Although simply an approach to teaching neonatal resuscitation, the recommendations contained in the textbook are widely used in hospitals and often cited in litigation.
Beginning with a 1963 teaching movie by Dr Stanley James at Infants Hospital in New York and stimulated by publications of Gregory et al3 and Ting and Brady,4 tracheal suction for the removal of meconium has been widely recommended for all infants born with MSAF. Although not randomized trials, these two publications demonstrated a reduction in mortality and morbidity associated with tracheal clearing of meconium immediately after birth. A 1990 analysis showed a gradual reduction of the incidence of meconium aspiration syndrome and related mortality between 1973 and 1987.5
Despite apparent progress, questions have persisted about the role of tracheal suction when MSAF occurs, especially in infants who are vigorous at birth. Linder et al6 and Liu and Harrington7 compared vigorous term infants with MSAF assigned to tracheal suction or routine care. Routine tracheal suction showed no clear benefit and was even associated with an increase in minor respiratory difficulty. In 2000, a large, randomized, controlled study by Wiswell et al8 examined infants with MSAF with >37 weeks’ gestation, heart rates >100, and spontaneous breathing and displaying reasonable muscle tone within 10 to 15 seconds of delivery. The incidence of meconium aspiration syndrome in the group assigned to tracheal suction was almost identical to the incidence in the group assigned to routine care without tracheal suction (3.2% vs 2.7%, respectively).
In preparation for the 4th edition of the Textbook of Neonatal Resuscitation, the NRP Steering Committee, representing the American Academy of Pediatrics and American Heart Association, considered the evolving recommendations from the International Liaison Committee on Resuscitation9 as well as initiated a vigorous process of evidence review. Particular foci of the review included the use of oxygen, fluids for volume expansion, medications for resuscitation, and the management of the infant born through MSAF. The best evidence available for this review ranged from randomized, controlled trials to expert opinion or consensus. Fortunately, the major changes in recommendations relating to the vigorous child with MSAF were based on the randomized, controlled trials cited earlier.
Raupp and Reynolds,10 in their letter to the editor in the current issue of Pediatrics, urge a change in the way in which the Textbook of Neonatal Resuscitation addresses the management of the distressed infant born through MSAF. They express their concerns about the lack of precision in the recommendations for balancing the needs for tracheal clearing of possible or probable meconium in the trachea and ventilation of the depressed infant. As many as 2.5% to 4% of term infants may present with MSAF and less-than-adequate "vigor."11 The recommendations contained in the 4th edition of the Textbook of Neonatal Resuscitation detail tracheal suctioning until clear or "until the infant’s heart rate indicates that resuscitation must proceed without delay."2 This statement leaves us with a series of questions cited by Raupp and Reynolds that, at the bedside, require multiple clinical judgments to be made under trying circumstances.
An incomplete list of possible variables that require rapid assessment and action includes the extent of perinatal depression, etiologies of the depression, responses in the first few moments, the possibilities that tracheal suction will reduce morbidity and mortality, and the current skill of the providers. As unsettling as nonspecific directions in the NRP might be, the authors of the text might have been wise to emphasize clinical judgment in the albeit stressful situation for which few data exist and expert opinion cannot easily resolve.
The proper first response to the angst represented by the letter of Raupp and Reynolds might be to define collectively the course of investigation that would begin to address these heuristic ambiguities and clinical uncertainties associated with the resuscitation of the depressed infant born through MSAF. Clinical judgment will always be required in the care of sick children; informed clinical judgment is the progress for which we hope.
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FOOTNOTES |
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Address correspondence to William J. Keenan, MD, Departments of Pediatrics and Neonatal-Perinatal Medicine, St Louis University School of Medicine, 1465 S Grand Blvd, St Louis, MO 63104. E-mail: keenanwj{at}slu.edu
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