Meconium Stained Newborns: Ethics for Evidence in Resuscitation

Vain, Néstor E.; Musante, Gabriel; Mariani, Gonzalo

doi:10.1016/j.jpeds.2015.01.050

Cited by 12 publications

(8 citation statements)

References 26 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…However, it will be a challenging study to conduct and complete. 28 The best available evidence to date does support the current NRP guidelines, and clinical judgment of the provider will aid in the delivery room management of these infants. It is heartening to note that less aggressive interventions directed toward an infant born through MSAF over the years (►Table 1) is associated with a steady decline in the frequency of ECMO use for MAS and no change in mortality (►Fig.…”

Section: Resultsmentioning

confidence: 96%

See 1 more Smart Citation

Approach to Infants Born Through Meconium Stained Amniotic Fluid: Evolution Based on Evidence?

et al. 2018

View full text Add to dashboard Cite

Meconium-stained amniotic fluid (MSAF) during delivery is a marker of fetal stress. Neonates born through MSAF often need resuscitation and are at risk of meconium aspiration syndrome (MAS), air leaks, hypoxic-ischemic encephalopathy, extracorporeal membrane oxygenation (ECMO), and death. The neonatal resuscitation approach to MSAF has evolved over the last three decades. Previously, nonvigorous neonates soon after delivery were suctioned under the vocal cords with direct visualization technique using a meconium aspirator. The recent neonatal resuscitation program (NRP) recommends against suctioning but favors resuscitation with positive pressure ventilation of nonvigorous neonates with MSAF. This recommendation is aimed to prevent delay in resuscitation and minimize hypoxia-ischemia often associated with MSAF. In this review, we discuss the pathophysiology, evolution and the evidence, randomized control trials, observational studies, and translational research to support these recommendations. The frequency of ECMO use for neonatal respiratory indication of MAS has declined over the years probably secondary to improvements in neonatal intensive care and reduction of postmaturity. Changes in resuscitation practices may have contributed to reduced incidence and severity of MAS. Larger randomized controlled studies are needed among nonvigorous infants with MSAF. However, ethical dilemmas and loss of equipoise pose a challenge to conduct such studies.

show abstract

Section: Resultsmentioning

confidence: 96%

“…This study was not powered adequately to study the reduction in mortality and has been criticized for risk of bias, imprecision and high risk of Type II error but is a bold step in addressing this complex clinical problem. 28…”

Section: Management: Historical Aspectsmentioning

confidence: 99%

Approach to Infants Born Through Meconium Stained Amniotic Fluid: Evolution Based on Evidence?

et al. 2018

View full text Add to dashboard Cite

show abstract

“…1, 15, 21–23 It is not known why only some, or which, neonates exposed to MSAF will develop MAS. 1, 18, 24, 25 Attempts to prevent MAS have included oropharyngeal, 26, 27 nasopharyngeal, 26 and tracheal 28–30 suctioning and amnioinfusion in women who have MSAF, 31, 32 but none of these interventions has proven effective. 33–36 …”

Section: Introductionmentioning

confidence: 99%

Meconium aspiration syndrome: a role for fetal systemic inflammation

Lee

Romero

Lee

et al. 2016

American Journal of Obstetrics and Gynecology

View full text Add to dashboard Cite

Background Meconium aspiration syndrome (MAS) is a leading cause of morbidity and mortality in term infants. Meconium-stained amniotic fluid (MSAF) occurs in approximately one of every seven pregnancies, but only 5% of neonates exposed to MSAF develop MAS. Why some infants exposed to meconium develop MAS while others do not is a fundamental question. Patients with MSAF have a higher frequency of intra-amniotic infection/inflammation than those with clear fluid. We propose that fetal systemic inflammation is a risk factor for the development of MAS in patients with MSAF. Objective To investigate whether intra-amniotic inflammation and funisitis, the histopathologic landmark of a fetal inflammatory response, predispose to MAS. Study Design A prospective cohort study was conducted from 1995 through 2009. Amniotic fluid (AF) samples (n=1,281) were collected at the time of cesarean delivery from women who delivered singleton newborns at term (gestational age ≥38 weeks). Intra-amniotic inflammation was diagnosed if the AF concentration of matrix metalloproteinase-8 (MMP-8) was >23 ng/ml. Funisitis was diagnosed by histologic examination if inflammation was present in the umbilical cord. Results The prevalence of MSAF was 9.2% (118/1,281), and 10.2% (12/118) of neonates exposed to MSAF developed MAS. There were no significant differences in the median gestational age or umbilical cord arterial pH at birth between neonates who developed MAS and those who did not (each p > 0.1). Mothers whose newborns developed MAS had a higher median AF MMP-8 (456.8 ng/ml vs.157.2 ng/ml; p < 0.05). Newborns exposed to intra-amniotic inflammation had a higher rate of MAS than those who were not exposed to intra-amniotic inflammation [13.0% (10/77) vs. 0% (0/32), p = 0.03], as did those exposed to funisitis [31.3% (5/16) vs. 7.3% (6/82), relative risk, 4.3; 95% confidence interval, 1.5–12.3]. Among the 89 newborns for whom both AF and placental histology were available, MAS was more common in patients with both intra-amniotic inflammation and funisitis than in those without intra-amniotic inflammation and funisitis [28.6% (4/14) vs. 0% (0/28), p = 0.009], while the rate of MAS did not show a significant difference between patients with intra-amniotic inflammation alone (without funisitis) and those without intra-amniotic inflammation and funisitis [10.9% (5/46) vs. 0% (0/28)]. Conclusion The combination of intra-amniotic inflammation with fetal systemic inflammation is an important antecedent of MAS. This concept has implications for the understanding of the mechanisms of disease responsible for MAS and for the development of prognostic models and therapeutic interventions for this disorder.

show abstract

“…Perhaps, "deferred" or "retrospective" or "opt-out" consent is one approach to encourage ethical parental participation in a future trial. 25,26 PEEP can be provided with either a T-piece resuscitator as in this study or delivered via a valve connected to a selfinflating bag. Self-inflating bags are widely employed in community settings because of familiarity and readiness for use.…”

Section: Discussionmentioning

confidence: 99%

Positive end-expiratory pressure during resuscitation at birth in very-low birth weight infants: A randomized-controlled pilot trial

Kitsommart

Nakornchai

Yangthara

et al. 2018

Pediatrics & Neonatology

View full text Add to dashboard Cite

Due to the small sample size and potential bias accrued through random allocation of higher birthweight infants to the PEEP-5 group, the results did not confirm differences in outcomes between the groups, despite evidence favoring postnatal ventilation with PEEP. A further randomized, controlled clinical trial with a larger sample size is warranted to determine the utility and safety of PEEP during the resuscitation of premature infants immediately after birth.

show abstract

Meconium Stained Newborns: Ethics for Evidence in Resuscitation

Cited by 12 publications

References 26 publications

Approach to Infants Born Through Meconium Stained Amniotic Fluid: Evolution Based on Evidence?

Approach to Infants Born Through Meconium Stained Amniotic Fluid: Evolution Based on Evidence?

Meconium aspiration syndrome: a role for fetal systemic inflammation

Positive end-expiratory pressure during resuscitation at birth in very-low birth weight infants: A randomized-controlled pilot trial

Contact Info

Product

Resources

About