|Year : 2013 | Volume
| Issue : 3 | Page : 118-120
Is oronasopharyngeal suctioning necessary in neonatal resuscitation?
Fahad Al Hazzani
Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
|Date of Web Publication||18-Oct-2013|
Fahad Al Hazzani
Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Al Hazzani F. Is oronasopharyngeal suctioning necessary in neonatal resuscitation?. J Clin Neonatol 2013;2:118-20
| Context|| |
The 2010 American Academy of Pediatrics Neonatal Resuscitation Program and American Heart Association guidelines recommend clearing the airways in neonates born through clear amniotic fluid (i.e., not meconium-stained) with either a bulb syringe or suction catheter only if airway obstruction is evident or positive pressure ventilation (PPV) is required. The option of wiping of the mouth and nose has been cited as an alternative method to routine use of suction in the Neonatal Resuscitation Program (NRP) guidelines since 2006. These methods have not, however, been compared directly in trials. Wiping alone might be sufficient to clear the airways and could provide some stimulation to initiate respiration without the potential adverse effects associated with suction.
| Materials and Methods|| |
This was a randomized, equivalency trial to compare hospital outcomes in neonates after wiping or suction. It was designed to test the hypothesis that respiratory rates would not differ significantly in the first 24 h after birth between those who underwent wiping of the mouth and nose and those who underwent oronasopharyngeal suction immediately after birth.
Neonates born in the University of Alabama at Birmingham Hospital, Birmingham, AL, USA, between October 2010 and November 2011 at or after 35 completed weeks of gestation were eligible for study enrolment.
- Known major congenital anomalies.
- Decision to institute comfort care.
- Anticipated advanced resuscitation.
- Non-vigorous neonates with meconium-stained amniotic fluid.
- Previous enrolment in other delivery room intervention studies.
- An obstetric resident managed low-risk deliveries and the pediatric resident managed deliveries that involved high-risk conditions (e.g., meconium-stained amniotic fluid).
- Neonates underwent gentle wiping externally over the face, mouth (at the discretion of the obstetric or pediatric resident), and nose with a towel (wipe group) or suction in the mouth and nostrils with a bulb syringe, as per NRP guidelines (suction group).
- Wiping or suction was applied immediately after the umbilical cord was cut and for as long as a neonate remained in the resuscitation area.
- In the wipe group, if copious secretions were seen coming from the mouth, the baby's head was turned to the side to facilitate clearance.
- Delivery nurses documented the randomized intervention, whether it was applied, any forms of advanced resuscitation used, and whether neonates were transferred to the neonatal intensive care unit or the postnatal nursery after delivery.
- Nurses in the postnatal nursery and neonatal intensive care unit were asked to use the hospital's standard method of counting the number of respirations per 60 s within the 1 st h and at 8, 16, and 24 h thereafter, with a leeway of 4 h on each of these three timings.
- Oxygen saturation was checked on the feet of neonates by pulse oximetry before discharge home.
- Mean respiratory rate in the first 24 h after birth.
- Use at birth of advanced resuscitation by intubation, PPV, chest compression, emergent medications, or a combination of these methods.
- One minute and 5 min Apgar scores.
- Admission to the neonatal intensive care unit.
- Tachypnea, defined as a respiratory rate higher than 60 breaths per min, at any time in the first 24 h.
- Oxygen saturation before discharge home.
- Randomization was based on a computer- generated random block sequence and 1:1 parallel allocation.
- Group allocations were stored centrally in sequentially numbered sealed envelopes.
- At the time of consent being given, the next envelope was delivered to the mother's bedside by a research assistant, but remained sealed until delivery, when it was opened by a delivery nurse.
Masking of the intervention allocation from the medical personnel within the resuscitation area was not practically possible. Therefore, only the nurses who recorded data for the outcomes after intervention were masked to the randomization and per treatment statuses of neonates.
| Results|| |
- Five hundred and six neonates born at a median of 39 weeks' gestation were randomized.
- Three parents withdrew consent and 15 non-vigorous neonates with meconium-stained amniotic fluid were excluded.
- Among the infants, 488 (96%) received a study intervention and 117 (24%) protocol deviations occurred, including 98 crossovers.
- Baseline characteristics for the two groups were similar.
- The mean respiratory rates in the first 24 h after birth (primary outcome) did not differ between groups in the intention-to-treat analysis (wipe group 51 (standard deviation (SD) 8) breaths per min vs suction group 50 (6) breaths per min) and were within the predefined range for equivalence in both groups (difference of means 1 breath per min, 95% confidence interval (CI) 2-0, P < 0.001).
- The respiratory rates were similar at every time point.
- Secondary outcomes did not differ between groups in the intention-to-treat analysis or the per treatment and per protocol analyses.
| Commentary|| |
Current NRP guidelines states that routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born with clear or meconium-stained amniotic fluid is no longer recommended.  It is also recommended that suctioning immediately following birth (including suctioning with a bulb syringe) should be reserved for babies who have obvious obstruction to spontaneous breathing or who require PPV. 
The use of routine suction increases healthcare costs and equipment might not be available. Therefore, clearing the airway by wiping with a towel is an appealing intervention that can be used anywhere and at no cost. Nevertheless, suction and wiping have not been directly compared.
In this randomized, equivalency trial; it was shown that wiping the mouth and nose of neonates at birth has equal efficacy to suction with regards to respiratory rate and various other clinical outcomes in the first 24 h after birth. In this trial, there was a high proportion of crossovers (20%), particularly from the wipe group to the suction group, which could have biased the study findings.
Overall, however, the main finding of this study is of major importance for resource-limited countries and it support the NRP recommendations for clearing of airway secretions at birth.
John Kelleher, Ramachandra Bhat, Ariel A. Salas, et al. Oronasopharyngeal suction versus wiping of the mouth and nose at birth: A randomised equivalency trial. Lancet 2013;382:326-30.
| References|| |
|1.||Kelleher J, Bhat R, Salas AA, Addis D, Mills EC, Mallick H, et al. Oronasopharyngeal suction versus wiping of the mouth and nose at birth: A randomised equivalency trial. Lancet 2013;382:326-30. |
|2.||Perlman JM, Wyllie J, Kattwinkel J, Atkins DL, Chameides L, Goldsmith JP. Part 11: Neonatal resuscitation: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2010;81(suppl 1): e260- 87. |
|3.||Kattwinkel J, Perlman JM, Aziz K, Colby C, Fairchild K, Gallagher J. Part 15: Neonatal resuscitation: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122 (18 suppl 3):S909- 19. |