NEONATAL OUTCOMES OF SUCTIONING IN INFANTS BORN THROUGH MECONIUM-STAINED LIQUOR: A PROSPECTIVE COHORT STUDY

Abstract

Objective:  In non-vigorous neonates born with meconium-stained amniotic fluid (MSAF) routine ET at birth will be associated with reduced numbers of meconium aspiration syndrome (MAS) and 28 day neonatal mortality compared with standard non-invasive neonatal resuscitation.
Study Design:  A prospective cohort study.
Place and Duration of Study: Department of Obstetrics & Gynaecology (in close collaboration with the Neonatal Intensive Care Unit (NICU)) at Shifa International Hospital, Islamabad, Pakistan between November 11, 2025, and May 11, 2026.
Methodology: Non-probability consecutive sampling technique was used by enrolling 312 of non-vigorous singleton neonates, born of meconium stained amniotic fluid from ≥ 34 weeks of gestation. Twenty-one newborn resuscitation operators in the delivery room (OR) were enrolled, and classified into 2 parallel cohort groups: ET suction group (n = 156) and non-ET suction group (n = 156) according to the delivery room resuscitative strategy used by the attending neonatal team. In the ET suction group, immediate direct laryngoscopy and mechanical clearance of the endotracheal tube were performed under negative pressure (≤ 100 mmHg) before starting positive pressure ventilation. Routine intubation was not performed in the non-ET suction group, and gentle oropharyngeal/nasopharyngeal (O/N) aspiration with bulb syringe or suction catheter (< or equal to 100 mmHg) was performed followed by start of the Neonatal Resuscitation Program (NRP) standard NRP updates. Clinical incidence of MAS, neonatal mortality rates (NMR) at 28-day, were primary outcomes. Clinical parameters, APGAR score and duration of hospitalization were obtained. The collected data was analysed using SPSS version 25.0.
Results: Maternal and neonatal demographic characteristics were similar between the two cohorts (P > 0·05). Primary outcome of development of MAS was found in 64 infants (41.0%) of ET suction group versus 48 infants (30.8%) of non-ET suction group, which was statistically higher respiratory risk for ET suction group (Relative Risk [RR] = 1.33; 95% Confidence Interval [CI]: 1.01 – 1.76; P = 0.05). For the secondary outcome of 28-day neonatal mortality, 12 neonates (7.7%) and 8 neonates (5.1%) in ET suction and non-ET suction groups respectively experienced death but this did not result in a significant difference (RR = 1.50; 95% CI: 0.63 to 3.56; P = 0.355). However, there was a significant difference in mean 5-minute APGAR scores (7.2 \pm 1.1 vs 6.8 \pm 1.3, P = 0.004) and mean length of NICU stay (6.4 \pm 2.8 days vs 4.9 \pm 2.1 days, P < 0.001) in favor of the non-ET suction cohort.
Conclusion: Routine endotracheal suctioning at delivery does not lead to a decrease in MAS or early neonatal mortality in non-vigorous babies born via MSAF. It rather relates to a much greater clinical incidence of MAS, low 5 minute Apgar score and longer NICU hospitalization. Immediate, non-invasive airway stabilization algorithms should be preferred to routine, invasive mechanical clearing algorithms in resuscitation protocols.