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NICU guideline identifier

Meconium-stained liquor and meconium aspiration

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Delivery Room management

The Paediatric Resident (SHO, Registrar, or NS-ANP) should be called if there is thick meconium staining or light meconium plus fetal distress.

Intrapartum pharyngeal suction is not indicated1

Oral and pharyngeal suctioning as the head delivers does not alter the chance of developing respiratory distress or symptomatic meconium aspiration syndrome, even in sub-groups with thick meconium, fetal distress or delivered by Caesarean section.2

Routine endotracheal suction is not indicated1

  1. Vigorous babies
    If the baby is apparently vigorous at birth (heart rate >100, spontaneous respiration, reasonable tone), intubation and tracheal suction is not indicated, unless the baby subsequently has poor respiratory effort or early respiratory distress.3
    Intubation of vigorous babies does not improve respiratory outcomes and can result in trauma to the infant as well as inducing apnoea.
  2. Non Vigorous babies
    For babies who are not vigorous (not breathing or crying, low muscle tone) current evidence does not support or refute the value of routine endotracheal suctioning in preventing MAS.1,4
    Emphasis should be made on initiating ventilation rapidly in non-breathing or ineffectively breathing infants.
    If
    tracheal suction is performed:
    - only by a clinician experienced at intubation
    - do not stimulate the baby to breathe prior to suction
    - suction promptly, before giving any respiratory support
    - intubate and suction the ETT using a large bore suction catheter. Do not remove the ETT (unless blocked with particulate meconium)
      as the priority is to obtain a secure airway and provide effective ventilation.
    - do not repeat intubation for suctioning
    If pharyngeal suction is required to remove meconium obstructing the airway, it must be under direct vision e.g. using a laryngoscope.

Further management

  • All infants with meconium stained liquor must be well observed. For most babies this is will be with their mothers.
  • If there is thick meconium or any worrying clinical features, the paediatric resident staff should review the baby at an hour of age.
  • All meconium exposed babies should have AC temperature and respiration recordings for 48 hours with instructions to call the paediatric resident if there is any respiratory distress.

Criteria for admission to NICU

  • Symptomatic meconium aspiration syndrome.
  • Meconium in trachea with significant asphyxia (> 10 minutes to establish spontaneous ventilation or cord pH < 7.2)
    Other significant risk factors for infection.

Management of the Symptomatic Infant

  • Give enough oxygen to maintain SpO2 >95% initially.
  • Capillary or arterial blood gas
  • CXR if significant respiratory distress or tachypnoea persists.
  • Consider CPAP or ventilation
  • Consider antibiotics:
    - if unwell
    - if persistent symptoms
    - if other risk factors for infection
  • Take blood culture if treating with antibiotics.

Complications of Meconium Aspiration

  • Infection: Uncommon unless sepsis was the stimulus to make the infant pass meconium. Consider Listeria, especially if preterm. Meconium is a good culture medium so secondary infection may occur.
  • Pneumothorax: May occur at any stage (MAS is an air-trapping disease). So consider this any time from resuscitation onwards if there is unexpected deterioration or significant disease.
  • Respiratory Failure: Can occur because of respiratory obstruction, inflammation, infection or shunting.
  • Persistent Pulmonary Hypertension (PPHN): Is common in severe MAS and can be very difficult to treat. Early assessment and avoidance of hypoxaemia, hypothermia, hypoglycaemia are important to avert PPHN.


References

  1. Wyllie J, Perlman JM, Kattwinkel J, et al. Part 7: Neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. 2015;95:e169-201
  2. Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates before delivery of their shoulders: multicentre, randomised controlled trial. Vain NE, Szyld EG, et al. Lancet 2004: 364: 597-602
  3. Delivery room management of the apparently vigorous meconium-stained neonate: results of the multicenter, international collaborative trial. Wiswell TE, Gannon CM, Jacob J, et al. Pediatrics 2000; 105:1-7.
  4. ANZCOR Guideline 13.4 Airway Management and Mask Ventilation of the Newborn Infant. ANZCOR April 2016 Page 2.

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Document Control

  • Date last published: 02 May 2016
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Review frequency: 2 years