ARTICLE

Delivery Room Management of Meconium-Stained Newborns and Respiratory SupportArpitha Chiruvolu, MD, a, b Kimberly K. Miklis, MSN, NNP-BC, a, b Elena Chen, BA, c Barbara Petrey, MSN, b Sujata Desai, PhDa

BACKGROUND AND OBJECTIVES: Recently, the Neonatal Resuscitation Program (NRP) recommended against routine endotracheal suctioning of meconium-stained nonvigorous newborns but suggested resuscitation with positive pressure ventilation. Our purpose is to study the effects of this change in management.METHODS: In this multicenter cohort study, we compare 130 nonvigorous newborns born during the retrospective 1-year period before the implementation of new NRP guidelines (October 1, 2015, to September 30, 2016) to 101 infants born during the 1-year prospective period after implementation (October 1, 2016, to September 30, 2017).RESULTS: Endotracheal suctioning was performed predominantly in the retrospective group compared with the prospective group (70% vs 2%), indicating the change in practice. A significantly higher proportion of newborns were admitted to the NICU for respiratory issues in the prospective group compared with the retrospective group (40% vs 22%) with an odds ratio (OR) of 2.2 (95% confidence interval [CI]: 1.2–3.9). Similarly, a significantly higher proportion of infants needed oxygen therapy (37% vs 19%) with an OR of 2.5 (95% CI: 1.2–4.5), mechanical ventilation (19% vs 9%) with an OR of 2.6 (95% CI: 1.1–5.8), and surfactant therapy (10% vs 2%) with an OR of 5.8 (95% CI: 1.5–21.8). There were no differences in the incidence of other outcomes, including meconium aspiration syndrome.CONCLUSIONS: The recent NRP guideline change was not associated with an increased incidence of meconium aspiration syndrome but was associated with an increased incidence of NICU admissions for respiratory issues. Also, the need for mechanical ventilation, oxygen, and surfactant therapy increased.

abstract

aDivision of Neonatology, Department of Pediatrics, Baylor University Medical Center, Baylor Scott and White Health, and Pediatrix Medical Group, Dallas, Texas; bDepartment of Women and Infants, Baylor Scott and White Medical Center McKinney, McKinney, Texas; and cDepartment of Medical Education, College of Medicine, Texas A&M University, Bryan, Texas

Dr Chiruvolu conceptualized and designed the study, designed the data collection instruments, collected and analyzed the data, drafted the initial manuscript, and reviewed and revised the manuscript; Ms Miklis and Ms Chen designed the data collection instruments, collected data, and critically reviewed the manuscript for important intellectual content; Ms Petrey coordinated data collection and critically reviewed the manuscript for important intellectual content; Dr Desai conducted the statistical analyses, drafted tables, and critically reviewed the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

DOI: https:// doi. org/ 10. 1542/ peds. 2018- 1485

Accepted for publication Sep 11, 2018

PEDIATRICS Volume 142, number 6, December 2018:e20181485

WHAT’S KNOWN ON THIS SUBJECT: The Neonatal Resuscitation Program’s seventh edition recommended against routine endotracheal suctioning of newborns who are nonvigorous and meconium stained. There are concerns regarding the safety and efficacy of this change in practice because it is not based on large randomized controlled trials.

WHAT THIS STUDY ADDS: Having no routine endotracheal suctioning of newborns who are nonvigorous and meconium stained was not associated with an increased incidence of meconium aspiration syndrome, but it was associated with an increased incidence of NICU respiratory admissions. Also, the need for mechanical ventilation, oxygen, and surfactant therapy increased.

To cite: Chiruvolu A, Miklis KK, Chen E, et al. Delivery Room Management of Meconium-Stained Newborns and Respiratory Support. Pediatrics. 2018;142(6):e20181485

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Meconium-stained amniotic fluid (MSAF) is a major perinatal clinical concern, which occurs in 8% to 15% of all deliveries. Out of the infants born through MSAF, 10% to 20% are nonvigorous and 3% to 5% develop meconium aspiration syndrome (MAS).1, 2 Modern obstetric practices, such as the avoidance of postmaturity, may have for the most part contributed to the reduction in the incidence of MAS.3, 4 Over the years, the Neonatal Resuscitation Program (NRP) has been recommending less aggressive interventions for newborns who are meconium stained after published evidence from large randomized controlled trials.5 – 7 Until recently, nonvigorous newborns born through MSAF were routinely intubated and suctioned below the vocal cords to prevent perinatal aspiration of meconium.8 –10 This recommendation was based on and supported by researchers in several observational studies.11 – 14 The NRP’s seventh edition suggested against routine endotracheal suctioning but recommended resuscitation of these depressed newborns with positive pressure ventilation (PPV) to minimize the delay in initiating ventilation.15 Because this recommendation of not routinely performing endotracheal suctioning in newborns who are nonvigorous and meconium stained is, unlike previous guideline changes, not based on large randomized controlled trials performed in the developed world, there are concerns regarding the safety and efficacy of this delivery room practice change.

Our neonatal practice covering 4 delivery services in Baylor Scott & White Health North Texas adopted seventh edition NRP guidelines starting October 1, 2016. Our objective in this study is to report the effects of this delivery room management change on newborns who are nonvigorous born through MSAF. We hypothesized that the

current guidelines are safe and not associated with an increased incidence of MAS.

METHODS

Management of Newborns Who Are Nonvigorous and Meconium Stained

Before October 1, 2016, our practice was routine intubation and endotracheal suctioning of the newborns who are nonvigorous, meconium stained, and born with depressed breathing, decreased tone, and/or a heart rate of <100 beats per minute. The resuscitation provider skilled in the procedure performed intubation and endotracheal suctioning for ∼3 to 5 seconds using a meconium aspirator before the newborn took multiple breaths. If no meconium was recovered, no further suctioning was performed. If meconium was recovered, intubation and endotracheal suctioning were repeated, provided there was no significant bradycardia. If the heart rate was <100 beats per minute, PPV was provided to the newborn with the appropriate device. Starting October 1, 2016, the practice was changed to not routinely perform endotracheal suctioning but provide PPV if the newborn who was meconium stained and nonvigorous remained apneic or bradycardic after the initial steps of resuscitation were completed. This included oronasopharyngeal suctioning with a bulb or DeLee catheter if needed. Endotracheal suctioning was reserved only for those depressed newborns with evidence of meconium obstructing the airway. Obstetricians did not perform intrapartum oronasopharyngeal suctioning before the delivery of shoulders during both study periods. Cord clamping was not delayed during both study periods.

Data Collection

With approval from the local institutional review board, our

data were extracted from medical records of mothers and nonvigorous newborns born through MSAF. Deliveries of <35 weeks were excluded because those newborns were directly admitted to the NICU per hospital policy. The retrospective study period was 1 year, from October 1, 2015, to September 30, 2016. The prospective study period was also 1 year, from October 1, 2016, to September 30, 2017. Collected data included maternal demographics, obstetric and fetal complications, mode of delivery, and meconium consistency. Fetal distress diagnosis was based on fetal heart rate tracings (category II and III).16 Meconium was classified as thick if the fluid was of pea soup consistency or opaque and containing particulate material. Neonatal data included gestational age, birth weight, sex, Apgar scores, and other resuscitation variables. Respiratory outcome data included admissions to the NICU, transient tachypnea of the newborn (TTN), respiratory distress syndrome (RDS), pneumothorax, MAS, and hypoxic-ischemic encephalopathy (HIE). The diagnosis of TTN was made if there was a delay in the clearance of lung fluid.17 The diagnosis of RDS was based on a requirement of supplemental oxygen to maintain a Pao2 level of >50 mm Hg or a requirement of supplemental oxygen to maintain a pulse oximeter saturation of >85% within the first 24 hours of life and a chest radiograph consistent with a reticulogranular appearance to the lung fields with or without low lung volumes and air bronchograms within the first 24 hours of life. Pneumothorax was diagnosed if the infant had extrapleural air diagnosed via a chest radiograph or thoracentesis.18 MAS was diagnosed in infants born via MSAF with poor lung compliance and hypoxemia clinically, patchy opacification and hyperinflation radiographically, and in infants whose symptoms could not be otherwise explained.19 The diagnosis

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of pulmonary hypertension was made via an echocardiogram with findings of tricuspid regurgitation, deviation of interventricular septum to the left, and/or the presence of a right to left shunt at the patent foramen ovale and patent ductus arteriosus.20 The diagnosis of HIE was based on metabolic acidosis with a cord pH of <7 or a base deficit of ≥12 mmol/L, an early onset of encephalopathy, and/or multisystem organ dysfunction.21 The need for oxygen, mechanical ventilation (including high frequency), surfactant, inhaled nitric oxide, or hypothermia therapy was documented. Transfers to a higher level of care for extracorporeal membrane oxygenation (ECMO) or home oxygen therapy were reported. Hospital durations of oxygen therapy, mechanical ventilation, and NICU length of stay were collected.

Data Analysis

For the purpose of this pre- and postintervention cohort study in which we compared 2 different study periods, a convenience sample size of 100 newborns who were nonvigorous and born through MSAF in each arm was deemed appropriate on the basis of previous studies.22, 23 This sample size was feasible with a 1-year study period for each arm. Continuous data are presented as mean and SD if they are parametrically distributed or median and 25th to 75th interquartile range if they are nonparametric; other variables are presented as counts (percent). Data were compared between the retrospective and prospective cohorts with the use of the 2-tailed Student’s t test or Mann–Whitney U test for continuous variables and Pearson’s χ2 test or Fisher’s exact test for categorical variables. Logistic regression was used to assess the association between major outcomes and changes in delivery room management. The results are

presented as odds ratios (ORs) with 95% confidence intervals (CIs). Data are analyzed by using IBM SPSS version 25 (IBM Corporation, Armonk, NY). Statistical significance is set at a probability value of <.05.

RESULTS

During the retrospective time period, a total of 11 163 mothers delivered at ≥35 weeks’ gestation. MSAF was noted in 1303 (12%) deliveries, yielding 130 (10%) newborns who were nonvigorous. During the prospective time period, a total of 10 717 mothers delivered at ≥35 weeks’ gestation. MSAF was noted in 1282 (12%) deliveries, yielding 101 (8%) newborns who were nonvigorous. Maternal characteristics were similar between the retrospective and prospective groups (Table 1). There were no differences in the modes of delivery, incidences of intrauterine growth restriction, oligohydramnios, chorioamnionitis, placental abruption, or shoulder dystocia. The deliveries associated with fetal distress were significantly higher

in the prospective group compared with the retrospective group (57% vs 43%).

Newborn characteristics such as gestational age, birth weight, and sex were similar between the retrospective and prospective groups (Table 2). The proportion of infants born late preterm (35 to <37 weeks’ gestation) or postterm (>42 weeks’ gestation) was significantly higher in the prospective group compared with the retrospective group (12% vs 2%). The proportion of newborns with 1-minute Apgar scores of <3 and/or 5-minute Apgar scores of <7 were similar between groups. Endotracheal suctioning was performed predominantly in the retrospective group (70% vs 2%) and mask PPV primarily in the prospective group (55% vs 19%), indicating the change in practice.

After adjusting for late preterm, postterm, and deliveries with fetal distress, a significantly higher proportion of infants were admitted to the NICU for respiratory issues (distress or failure) in the prospective group compared with

PEDIATRICS Volume 142, number 6, December 2018 3

TABLE 1 Maternal Characteristics

Retrospective (N = 130) Prospective (N = 101) P

n (%) n (%)

Maternal age, ya 29.1 ± 6.1 28.0 ± 5.6 .16Maternal race .64 White 91 (70) 65 (64) African American 27 (21) 24 (24) Other 12 (9) 12 (12)Hypertensive disorders of pregnancy 28 (22) 25 (25) .64Maternal diabetes 7 (5) 6 (6) .86Intrauterine growth restriction 2 (2) 5 (5) .13Oligohydramnios 7 (5) 4 (4) .61Group B Streptococcus-positive 34 (26) 28 (28) .79Chorioamnionitis 25 (19) 22 (22) .63Rupture of membranes ≥18 h 24 (19) 30 (30) .05Placental abruption 6 (5) 1 (1) .11Fetal distress 56 (43) 58 (57) .03Vaginal delivery 74 (57) 59 (58) .82 Assisted 10 (14) 7 (12) .78Cesarean delivery 56 (43) 42 (42) .88 Emergency 10 (18) 10 (24) .53Thick meconium 66 (51) 61 (60) .15Shoulder dystocia 9 (7) 3 (3) .12

a Data are given as mean ± SD.

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the retrospective group (40% vs 22%) with an OR of 2.2 (95% CI: 1.2–3.9). Similarly, a significantly higher proportion of infants needed oxygen therapy (37% vs 19%) with an OR of 2.5 (95% CI: 1.2–4.5), mechanical ventilation (19% vs 9%) with an OR of 2.6 (95% CI: 1.1–5.8), and surfactant therapy (10% vs 2%) with an OR of 5.8 (95% CI: 1.5–21.8). There were no differences in the incidences of other outcomes, including MAS or HIE (Table 3). Death or positive results for sepsis culture including pneumonia did not occur in either group. Among NICU admissions, the incidences of MAS, HIE, and other respiratory morbidities were similar between groups with a median NICU length of

stay of 6 days (Table 4). Similarly, the incidence of therapy and outcomes among infants diagnosed with MAS did not differ significantly between groups (Table 5).

DISCUSSION

Our large newborn practice always has a resuscitation provider proficient in intubation to attend deliveries associated with MSAF. Although there was no concern for not providing timely ventilation for these newborns who were depressed and meconium stained, we embraced the recommendations suggested by the NRP’s seventh edition and monitored the effects of the change. In this cohort study

conducted in the developed world setting of a lower incidence of mortality and MAS, we present observations made before and after the change in NRP guidelines in a large group of newborns who were meconium stained and nonvigorous. The change in practice was evident from a significantly higher incidence of endotracheal suctioning in the retrospective group and the application of PPV primarily in the prospective group. The increased NICU respiratory admissions in the prospective group prompt questions of the safety and efficacy of having no routine endotracheal suctioning of newborns who were meconium stained and depressed. Although there was no difference in the incidence of MAS, significantly higher proportions of infants needing mechanical ventilation, oxygen, and surfactant therapy may indicate increased respiratory morbidity in the prospective group.

Intubation is an invasive and stressful procedure with lower Apgar scores and airway complications previously reported in infants who were vigorous and meconium stained.5, 24 Despite avoiding delivery room intubation in the majority of newborns who were nonvigorous and meconium stained in the prospective group of the current study, the proportions of newborns with 1-minute Apgar scores of <3 and/or 5-minute Apgar scores of <7 were similar to the retrospective group in which the majority of newborns were routinely intubated and suctioned. This may indicate that intubation of the newborns who were depressed and nonvigorous is not associated with the same delivery room complications seen in active vigorous newborns born via MSAF. Speculating the reasoning for significant increases in NICU respiratory admissions is beyond the scope of this study, but not clearing the meconium from proximal airways in a few cases may have contributed

CHIRUVOLU et al4

TABLE 2 Newborn Characteristics

Retrospective (N = 130) Prospective (N = 101) P

n (%) n (%)

Gestational age, wka 39.9 ± 1.1 39.9 ± 1.5 .99Birth weight, gramsa 3453.7 ± 549 3397.5 ± 620 .47Boy 64 (49) 62 (61) .07Late preterm 1 (1) 6 (6) .02Postterm 1 (1) 6 (6) .02Small for gestation 14 (11) 12 (12) .79Large for gestation 14 (11) 8 (8) .46Apgar score, nb, min 1 4 (0–7) 4 (0–7) .85 5 8 (0–9) 8 (0–9) .101-min Apgar score <3 32 (25) 21 (21) .595-min Apgar score <7 23 (18) 22 (22) .50PPV 24 (19) 55 (55) <.01Endotracheal suctioning 91 (70) 2 (2) <.01 Meconium recovered 44 (48) 2 (100) .15Cardiopulmonary resuscitation 1 (1) 2 (2) .42

a Data are given as mean ± SD.b Data are given as median (interquartile range).

TABLE 3 Neonatal Therapy and Outcomes

Retrospective (N = 130) Prospective (N = 101) OR (95% CI)a

n (%) n (%)

NICU respiratory admissionsb 29 (22) 40 (40) 2.2 (1.2–3.9)Oxygen therapyb 24 (19) 37 (37) 2.5 (1.2–4.5)Mechanical ventilationb 11 (9) 19 (19) 2.6 (1.1–5.8)Surfactant therapyb 3 (2) 10 (10) 5.8 (1.5–21.8)Inhaled nitric oxide therapy 3 (2) 6 (6) 2.9 (0.71–12)Hypothermia therapy 4 (3) 5 (5) 1.8 (0.55–5.4)MAS 7 (5) 11 (11) 2.3 (0.83–6.2)HIE 5 (4) 6 (6) 1.4 (0.39–4.9)Transfer for ECMO 2 (2) 1 (1) 0.69 (0.06–7.8)

a Adjusted for late preterm, postterm, and deliveries with fetal distress.b P < .05.

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to increased respiratory morbidity. MAS is a complex disease associated with long-term neurodevelopmental morbidity.25 In this study, although therapy and outcomes were similar among infants diagnosed with MAS, the increased durations of oxygen therapy, mechanical ventilation, and NICU lengths of stay in the prospective group may indicate increased severity. The

NRP’s seventh edition clearly states that no routine endotracheal suctioning is a guideline and not a strict recommendation. However, it is not entirely clear which of the nonvigorous newborns need endotracheal suctioning for meconium obstruction. Following these recent NRP guidelines in our practice, fewer infants than needed might have had endotracheal

suctioning performed. Approximately half (48%) of the nonvigorous newborns with endotracheal suctioning had meconium recovered in the retrospective group, whereas only 2% had endotracheal suctioning performed in the prospective group for obstructed airways.

In comparing previous and recent NRP guidelines managing newborns who were meconium stained and nonvigorous in the delivery room, this large multicenter cohort study has several limitations. The significant differences between both groups with regard to deliveries with fetal distress and late preterm or postterm births are a major weakness of this pre- and postintervention cohort study in which we report observational data during different study periods. However, the groups’ differences were adjusted for the major outcomes. There were infants in the retrospective group who received PPV (19%) and infants in the prospective group who had endotracheal suctioning performed (2%). We analyzed them in the study period in which they were born for unbiased estimates of the effects of the guideline change. There was a risk of creating prognostic differences between the groups if we excluded those infants. A confounding of the results by other changes in practice is also a risk of this study design. However, our practice did not change much other than the use of electrocardiography for estimations of heart rate in the event of a prolonged resuscitation in the delivery room. Our practice of having equally skilled resuscitation providers proficient in intubation might not represent every other delivery room setting. Despite these limitations, we believe this study contributes to observations addressing an important consternation of the delivery room care of newborns who are meconium stained and nonvigorous.

PEDIATRICS Volume 142, number 6, December 2018 5

TABLE 4 Therapy and Outcomes Among NICU Admissions

Retrospective (N = 29) Prospective (N = 40) P

n (%) n (%)

Oxygen therapy 24 (83) 37 (93) .27Duration of oxygen therapy, da, b 4.4 ± 4.6 6.4 ± 6.8 .18

3 (0–18) 5 (0–28)Mechanical ventilation 11 (38) 19 (48) .43Duration of mechanical ventilation, da, b 1.3 ± 2.6 2.1 ± 3.9 .37

0 (0–10) 0 (0–17)Surfactant therapy 3 (10) 10 (25) .12Inhaled nitric oxide therapy 3 (10) 6 (15) .57Hypothermia therapy 4 (14) 5(13) .89TTN 17 (59) 21 (53) .75RDS 0 (0) 2(5) .22Pneumothorax 3 (10) 5 (13) .78MAS 7 (24) 11 (28) .75Pulmonary hypertension 3 (10) 6 (15) .57HIE 5 (17) 6 (15) .80Discharged from the hospital on oxygenc 0 (0) 1 (3) .39Length of stay, da, b 7.7 ± 6.3 9.1 ± 11.0 .56

6 (2–27) 6 (1–52)Transfer for ECMO 2 (7) 1 (3) .38

a Data are given as mean ± SD.b Data are given as median (interquartile range).c Sample size corrected for infants transferred out.

TABLE 5 Therapy and Outcomes Among Infants Diagnosed With MAS

Retrospective (N = 7) Prospective (N = 11) P

n (%) n (%)

Duration of oxygen therapy, da, b 6.8 ± 4.6 13.3 ± 8.8 .155 (2–13) 11 (4–28)

Mechanical ventilation 6 (86) 10 (91) .10Duration of mechanical ventilation, da, b 1.4 ± 1.1 5.5 ± 6.0 .16

1 (0–3) 3 (0–17)Surfactant therapy 3 (43) 8 (73) .33Inhaled nitric oxide therapy 2 (29) 5 (46) .64Hypothermia therapy 0 (0) 1 (9) >.99Pneumothorax 0 (0) 1 (9) >.99Pulmonary hypertension 2 (29) 5 (46) .64HIE 0 (0) 1 (9) >.99Discharged from the hospital on oxygenc 0 (0) 1 (10) >.99Length of stay, da, b 7.8 ± 4.4 18.8 ± 19.2 .24

6 (4–15) 9 (5–52)Transfer for ECMO 2 (29) 1 (9) .53

a Data are given as mean ± SD.b Data are given as median (interquartile range). c Sample size corrected for infants transferred out.

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Although done on the basis of anecdotal evidence, over the decades the newborns who were nonvigorous and born through MSAF were routinely intubated and suctioned to prevent perinatal aspiration of meconium.2 With the recent guideline change of no routine endotracheal suctioning, the NRP placed a greater value on avoiding harm caused by delaying the initiation of ventilation.15 This change in delivery room management of newborns who are meconium stained and nonvigorous is based on the nonavailability of sufficient evidence to continue recommending routine endotracheal suctioning and underpowered randomized clinical trials failing to show any benefit.22, 23 However, the authors of these trials acknowledge the need for larger studies to validate the findings. Moreover, generalizability of these results was questioned because

of relatively high incidences of mortality and MAS in these studies.26 Performing a large randomized controlled trial in newborns who are nonvigorous and meconium stained may be ethically and logistically challenging, 27 but we provide enough evidence for the need to conduct larger studies.

CONCLUSIONS

The recent NRP guideline change in the delivery room management of newborns who are nonvigorous and born through MSAF avoided a large number of intubations in the delivery room and was not associated with an increased incidence of MAS. However, this change was associated with a higher incidence of NICU respiratory admissions and increased needs for mechanical ventilation, oxygen, and surfactant therapy. Additional large randomized

controlled trials are needed to look into the safety and efficacy of this practice change.

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CHIRUVOLU et al6

Address correspondence to Arpitha Chiruvolu, MD, Division of Neonatology, Baylor University Medical Center at Dallas, 3500 Gaston Ave, 3 Hoblitzelle, Dallas, TX 75246. E-mail: arpitha.chiruvolu@bswhealth.org

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2018 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

COMPANION PAPER: A companion to this article can be found online at www. pediatrics. org/ cgi/ doi/ 10. 1542/ peds. 2018- 3052.

ABBREVIATIONS

CI:  confidence intervalECMO:  extracorporeal membrane

oxygenationHIE:  hypoxic-ischemic

encephalopathyMAS:  meconium aspiration

syndromeMSAF:  meconium-stained

amniotic fluidNRP:  Neonatal Resuscitation

ProgramOR:  odds ratioPPV:  positive pressure

ventilationRDS:  respiratory distress

syndromeTTN:  transient tachypnea of the

newborn

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9. American Heart Association; American Academy of Pediatrics. 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: neonatal resuscitation guidelines. Pediatrics. 2006;117(5). Available at: www. pediatrics. org/ cgi/ content/ full/ 117/ 5/ e1029

10. Kattwinkel J, Perlman JM, Aziz K, et al; American Heart Association. Neonatal resuscitation: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care [published correction appears in Pediatrics. 2011;128(1):176]. Pediatrics. 2010;126(5). Available at: www. pediatrics. org/ cgi/ content/ full/ 126/ 5/ e1400

11. Burke-Strickland M, Edwards NB. Meconium aspiration in the newborn. Minn Med. 1973;56(12): 1031–1035

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16. American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 106: intrapartum fetal heart rate monitoring: nomenclature, interpretation and general management principles. Obstet Gynecol. 2009;114(1): 192–202

17. Guglani L, Lakshminrusimha S, Ryan RM. Transient tachypnea of the newborn. Pediatr Rev. 2008;29(11):e59–e65

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20. Bendapudi P, Rao GG, Greenough A. Diagnosis and management of persistent pulmonary hypertension

of the newborn. Paediatr Respir Rev. 2015;16(3):157–161

21. Shankaran S. Therapeutic hypothermia for neonatal encephalopathy. Curr Opin Pediatr. 2015;27(2):152–157

22. Chettri S, Adhisivam B, Bhat BV. Endotracheal suction for nonvigorous neonates born through meconium stained amniotic fluid: a randomized controlled trial. J Pediatr. 2015;166(5):1208–1213.e1

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24. Linder N, Aranda JV, Tsur M, et al. Need for endotracheal intubation and suction in meconium-stained neonates. J Pediatr. 1988;112(4):613–615

25. Beligere N, Rao R. Neurodevelopmental outcome of infants with meconium aspiration syndrome: report of a study and literature review. J Perinatol. 2008;28(suppl 3):S93–S101

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DOI: 10.1542/peds.2018-1485 originally published online November 1, 2018; 2018;142;Pediatrics 

Arpitha Chiruvolu, Kimberly K. Miklis, Elena Chen, Barbara Petrey and Sujata DesaiSupport

Delivery Room Management of Meconium-Stained Newborns and Respiratory

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DOI: 10.1542/peds.2018-1485 originally published online November 1, 2018; 2018;142;Pediatrics 

Arpitha Chiruvolu, Kimberly K. Miklis, Elena Chen, Barbara Petrey and Sujata DesaiSupport

Delivery Room Management of Meconium-Stained Newborns and Respiratory

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by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397. the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2018has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

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