Gastric lavage for prevention of feeding problems in neonates with meconium-stained amniotic fluid: a randomised controlled trial

Meconium aspiration syndrome: from pathophysiology to treatment

Meconium aspiration syndrome (MAS) is a clinical condition characterized by respiratory distress in neonates born through meconium-stained amniotic fluid (MSAF). Despite advances in obstetric practices and perinatal care, MAS remains an important cause of morbidity and mortality in term and post-term newborns. Since the 1960s, there have been significant changes in the perinatal and postnatal management of infants born through MSAF. Routine endotracheal suctioning is no longer recommended in both vigorous and non-vigorous neonates with MSAF. Supportive care along with new treatments such as surfactant, inhaled nitric oxide, and high-frequency ventilation has significantly improved the outcome of MAS patients. However, determining the most appropriate approach for this condition continues to be a topic of debate. This review offers an updated overview of the epidemiology, etiopathogenesis, diagnosis, management, and prognosis of infants with MAS.

Benefits and harms of gastric suction or lavage at birth for gastrointestinal outcomes: A systematic review and meta-analysis

The benefits of routine gastric suctioning or lavage in neonates remain uncertain, despite the common practice worldwide. To investigate the potential advantages and harms, we conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) examining the effects of these procedures in healthy or meconium-stained neonates at birth. We systematically searched PubMed, Scopus, Embase, Ovid, and the Cochrane Library databases from inception to February 9, 2023. We included only RCTs assessing the outcomes of gastric suction or lavage in neonates at birth. We calculated risk ratio (RR) and weighted mean differences with 95% confidence intervals (CIs) using a random-effects model. The primary outcomes were gastrointestinal symptoms including vomiting, retching, feeding intolerance, and secondary aspiration. The secondary outcomes included time to initiation of breastfeeding and potential adverse procedure-related events. Twelve RCTs with a total of 4,122 neonates were analyzed. All the studies compared neonates who received gastric suction or lavage with those who received usual care. Gastrointestinal symptoms were significantly reduced in neonates receiving gastric suction or gastric lavage compared with the control group (RR, 0.75; 95% CI, 0.63-0.89). Gastric lavage was beneficial for infants with meconium-stained amniotic fluid (RR 0.71; 95% CI, 0.60-0.84), while gastric suction had no significant benefit in reducing gastrointestinal symptoms in infants without meconium-stained amniotic fluid (RR 0.91; 95% CI, 0.61-1.37). Our findings suggest that gastric suction or lavage may reduce gastrointestinal symptoms in neonates; however, these procedures may only benefit infants born with meconium-stained amniotic fluid. Vigorous newborns without meconium-stained amniotic fluid may not benefit from these procedures. Furthermore, gastric suction may lead to adverse outcomes such as apnea and bradycardia. Registration: This study was registered in the PROSPERO International prospective register of systematic reviews in health and social care (CRD42023247780).

Intrapartum care algorithms for liquor abnormalities: oligohydramnios, meconium, blood and purulent discharge

AIM

To construct evidence-based algorithms for the assessment and management of common amniotic fluid abnormalities detected during labour.

POPULATION

Low-risk singleton, term pregnant women in labour.

SETTING

Birth facilities in low- and middle-income countries.

SEARCH STRATEGY

We searched international guidelines published by the American College of Obstetricians and Gynecologists (ACOG), the National Institute for Health and Care Excellence (NICE), the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the Royal College of Obstetricians and Gynaecologists (RCOG), the Society of Obstetrics and Gynaecology (SOGC) and the World Health Organization (WHO). We also searched The Cochrane Library and MEDLINE up to 20 January 2020 using keywords for relevant systematic reviews and randomised trials.

CASE SCENARIOS

We developed evidence-based intrapartum care algorithms for four case scenarios: oligohydramnios; meconium-stained amniotic fluid; bloody amniotic fluid or vaginal bleeding; and purulent amniotic fluid or discharge. These conditions may be associated with fetal and /or maternal morbidity. Differential diagnosis includes uteroplacental insufficiency, fetal growth restriction, fetal distress, abruption, placenta or vasa praevia, uterine rupture and intra-amniotic infection, respectively. Algorithms include how to assess for, diagnose and manage these conditions.

CONCLUSIONS

Four algorithms are presented, to provide a systematic approach and guidance on the clinical management for the following amniotic fluid abnormalities: oligohydramnios; meconium-stained liquor; bloody amniotic fluid or vaginal bleeding; and purulent amniotic fluid or discharge. These algorithms may be beneficial in supporting clinical decision making, particularly in low-resource settings.

TWEETABLE ABSTRACT

Evidence based algorithms for management of common amniotic fluid abnormalities seen during labour.

Design of a prospective multicenter randomized controlled trial evaluating the effects of gastric lavage on coffee-ground emesis in neonates: study protocol

Neonates who swallow a considerable amount of maternal blood may exhibit vomiting and suckling disorder during the first few days of the postnatal period. Some clinicians treat these neonates with gastric lavage (GL) to prevent vomiting and the establishment of enteral feeding empirically, but there was no study assessing the effect of GL for neonates with coffee-ground emesis. We designed a multicenter randomized controlled trial to evaluate the efficacy and safety of GL in neonates with coffee-ground emesis. Vigorous neonates with birth weight ranging from 2500 g to 3999 g and gestational age between 37w0d and 41w6d who presented with coffee-ground emesis on more than twice and diagnosed as false melena, were divided into two groups using computerized randomization. We defined feeding intolerance (FI) as (1) ≥2 vomiting episodes in 4h or ≥3 episodes in 24h and/or (2) feeding failure on at least two occasions because of retching or poor sucking. Primary outcome is percentage of infants who present FI within 24 hours from admission. We also assessed the residual volumes, number of vomiting episodes, percentage of weight reduction at postnatal day 4, rates of body weight gain at 1 month of age, and peak serum total bilirubin value before discharge. To our knowledge, this is the first study to evaluate the safety and efficacy of GL for neonates with coffee-ground emesis. This trial is registered at UMIN Clinical Trials Registry as UMIN000026483.

Effect of Gastric Lavage on Meconium Aspiration Syndrome and Feed Intolerance in Vigorous Infants Born with Meconium Stained Amniotic Fluid - A Randomized Control Trial

OBJECTIVE

To compare the incidence of meconium aspiration syndrome and feed intolerance in infants born through meconium stained amniotic fluid with or without gastric lavage performed at birth.

SETTING

Neonatal unit of a teaching hospital in New Delhi, India.

DESIGN

Parallel group unmasked randomized controlled trial.

PARTICIPANTS

700 vigorous infants of gestational age ≥34 weeks from through meconium stained amniotic fluid.

INTERVENTION

Gastric lavage in the labor room with normal saline at 10 mL per kg body weight (n=350) or no gastric lavage (n=350). Meconiumcrit was measured and expressed as ≤30% and >30%.

OUTCOME MEASURES

Meconium aspiration syndrome, feed intolerance and procedure-related complications during 72 h of observation.

RESULTS

5 (1.4%) infants in lavage group and 8 (2.2%) in no lavage group developed meconium aspiration syndrome (RR 0.63, 95% CI 0.21, 1.89). Feed intolerance was observed in 37 (10.5%) and 53 infants (15.1%) in lavage and no lavage groups, respectively (RR 0.70, 95% CI 0.47, 1.03). None of the infants in either group developed apnea, bradycardia or cyanosis during the procedure.

CONCLUSIONS

Gastric lavage performed in the labor room does not seem to reduce either meconium aspiration syndrome or feed intolerance in vigorous infants born through meconium stained amniotic fluid.

Gastric lavage in babies born through meconium stained amniotic fluid in prevention of early feed intolerance: A randomized controlled trial

OBJECTIVE

To evaluate the efficacy of gastric lavage (GL) in preventing feed intolerance in babies born through Meconium stained amniotic fluid (MSAF).

STUDY DESIGN

In this randomized trial conducted at a tertiary care hospital, neonates born of MSAF after 34 weeks period of gestation requiring routine care were randomly allocated to GL with 10 ml/kg of normal saline. The control group did not receive GL. The subjects were monitored for first 24 hours in predefined time epochs. The primary outcome was incidence of feed intolerance which was defined as vomiting or abdominal distension more than 2 cm from baseline measure. Babies were also monitored for potential adverse events due to GL and total duration of hospital stay.

RESULTS

Baseline parameters were comparable. The incidence of feed intolerance was not significant in the GL group [4.6% vs 9.2%; RR 0.92 (0.29-3)]. There were no adverse events secondary to GL. The duration of hospital stay was comparable between groups.

CONCLUSION

GL in neonates born of MSAF does not reduce feed intolerance.

Current Concepts in the Management of Meconium Aspiration Syndrome

In developing countries, meconium aspiration syndrome (MAS) is an important cause of morbidity and mortality among neonates. The concepts of pathophysiology and management of meconium stained amniotic fluid (MSAF) and meconium aspiration syndrome have undergone tremendous change in recent years. Routine intranatal and postnatal endotracheal suctioning of meconium in vigorous infants is no longer recommended. Recent studies have challenged its role even in non-vigorous infants. Supportive therapy like oxygen supplementation, mechanical ventilation and intravenous fluids are the cornerstone in the management of meconium aspiration syndrome. Availability of surfactant, inhaled nitric oxide, high frequency ventilators and extracorporeal membrane oxygenation has made it possible to salvage more infants with meconium aspiration syndrome. In this review the authors have discussed the current concepts in the pathophysiology and management of MAS. Drugs in trials and future therapeutic targets are also discussed briefly.

Status of gastric lavage in neonates born with meconium stained amniotic fluid: a randomized controlled trial

Background

Neonates born with meconium stained amniotic fluid (MSAF) can develop feed intolerance during first few days of post -natal period. A randomized controlled trial was conducted with the objectives of to find out the incidence of feed intolerance in vigorous neonates with MSAF who received gastric lavage (GL) as compared to those in whom it was not performed.

Methods

This was a randomized controlled trial on 500 neonates satisfying the inclusion criteria, 230 were allocated to GL and 270 to no lavage group through computer generated random numbers.

Results

No significant difference in the incidence of vomiting was found between GL and no lavage group (8.7 % vs 11.5 %, p = 0.305). Feed intolerance had no relationship with gestational age, gender, birth weight and mode of delivery. No neonates of GL group developed any complications related to the procedure.

Conclusion

Thus, it may be concluded that gastric lavage is not required in neonates born with MSAF.

Effect of gastric lavage on feeding in neonates born through meconium-stained liquor: a systematic review

OBJECTIVE

To evaluate the efficacy and safety of gastric lavage (GL) in neonates born through meconium-stained liquor (MSL).

DESIGN

A systematic review of randomised controlled trials by searching databases MEDLINE (from 1966), EMBASE (from1980), CINAHL, Cochrane Central Register of Controlled Trials, Google Scholar and proceedings of Pediatric Academic Society meetings (2002-2014).

SETTING

Delivery room/Neonatal ward.

PATIENTS

Neonates with gestation >34 weeks and birth weight ≥1800 g born through MSL.

INTERVENTIONS

Prophylactic GL versus no intervention before first feed.

MAIN OUTCOME MEASURE

Feeding intolerance, defined as inability to initiate/upgrade feeds due to problems such as retching, vomiting, regurgitation and gastric residuals.

RESULTS

A total of six studies (GL: 918, no GL: 966) were included in the review. Meta-analysis using fixed-effects model showed decreased incidence of feed intolerance following GL ((81/918 (8.8%) vs 114/966 (11.8%); risk ratio (RR): 0.71 (95% CI 0.55 to 0.93)). However, the results were not significant when random-effects model was used (RR: 0.78 (95% CI 0.55 to 1.09)). No significant adverse effects of GL were reported.

CONCLUSIONS

Routine GL immediately after birth may improve feed tolerance in neonates born through MSL. However, the evidence is limited, with probable small-study bias and high risk of bias in a number of the included studies. Well-designed studies with adequate sample size are essential to confirm these findings.

Utility of gastric lavage in vigorous neonates delivered with meconium stained liquor: a randomized controlled trial

Objective. To determine the incidence of feed intolerance in vigorous babies with meconium stained liquor (MSL) who received prophylactic gastric lavage as compared to those who were not subjected to this procedure. Design. Randomized controlled trial. Setting. Tertiary care teaching hospital. Participants/Intervention. 330 vigorous babies delivered with MSL and satisfying the predefined inclusion criteria were randomized either to receive gastric lavage (group A, n = 165) or to not receive gastric lavage (group B, n = 153). Clinical monitoring was subsequently performed and recorded in prestructured proforma. Results. There was no significant statistical difference (P > 0.05) in incidence of feed intolerance in “lavage” and “no lavage” groups. Secondary Outcome. There was no evidence of secondary respiratory distress in either group. None of the patients in the lavage group exhibited adverse effects owing to the procedure. Conclusions. There is no role of prophylactic gastric lavage in neonates born with MSL.