Elsevier

The Lancet

Volume 382, Issue 9889, 27 July–2 August 2013, Pages 326-330
The Lancet

Articles
Oronasopharyngeal suction versus wiping of the mouth and nose at birth: a randomised equivalency trial

https://doi.org/10.1016/S0140-6736(13)60775-8Get rights and content

Summary

Background

Wiping of the mouth and nose at birth is an alternative method to oronasopharyngeal suction in delivery-room management of neonates, but whether these methods have equivalent effectiveness is unclear.

Methods

For this randomised equivalency trial, neonates delivered at 35 weeks' gestation or later at the University of Alabama at Birmingham Hospital, Birmingham, AL, USA, between October, 2010, and November, 2011, were eligible. Before birth, neonates were randomly assigned gentle wiping of the face, mouth (implemented by the paediatric or obstetric resident), and nose with a towel (wipe group) or suction with a bulb syringe of the mouth and nostrils (suction group). The primary outcome was the respiratory rate in the first 24 h after birth. We hypothesised that respiratory rates would differ by fewer than 4 breaths per min between groups. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT01197807.

Findings

506 neonates born at a median of 39 weeks' gestation (IQR 38–40) were randomised. Three parents withdrew consent and 15 non-vigorous neonates with meconium-stained amniotic fluid were excluded. Among the 488 treated neonates, the mean respiratory rates in the first 24 h were 51 (SD 8) breaths per min in the wipe group and 50 (6) breaths per min in the suction group (difference of means 1 breath per min, 95% CI −2 to 0, p<0·001).

Interpretation

Wiping the nose and mouth has equivalent efficacy to routine use of oronasopharyngeal suction in neonates born at or beyond 35 weeks' gestation.

Funding

None.

Introduction

Clearing the airways of secretions in neonates facilitates the transition from intrauterine to postnatal life by the prevention of aspiration of material into the lungs. A degree of stimulation necessary to initiate respiration is also provided.1 Oronasopharyngeal suction of airway secretions in neonates after delivery is a common practice worldwide. However, this method can cause adverse effects, including bradycardia and apnoea.2

The Essential Newborn Care practice guidelines from WHO recommend use of suction in neonates at delivery.3 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 (ie, not meconium-stained) with either a bulb syringe or suction catheter only if airway obstruction is evident or positive-pressure ventilation is required.4 The International Liaison Committee on Resuscitation 2010 consensus group on neonatal resuscitation emphasises that routine use of suction in the mouth and nose is not necessary in neonates born with clear or meconium-stained amniotic fluid.5 Two large randomised, controlled trials showed that post-partum6 and intrapartum7 use of suction did not reduce or prevent meconium aspiration. Additionally, four smaller randomised, controlled trials showed no benefits with routine use of suction at delivery. 8, 9, 10, 11

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 guidelines since 2006.1 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. We did a randomised trial to compare hospital outcomes in neonates after wiping or suction. Respiratory rate is an objective indicator of respiratory illness in neonates. Thus, we tested 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.

Section snippets

Patients

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. Gestational age was based on best obstetric estimate. Exclusion criteria were as follows: known major congenital anomalies, decision to institute comfort care, anticipated advanced resuscitation, non-vigorous neonates with meconium-stained amniotic fluid, and previous enrolment in other

Results

2164 women were screened for eligibility (figure 1). Some women were unable to give consent because no researchers were available (ie, out of consent hours on certain nights and holidays) or labour was too advanced. 506 neonates were randomised, of whom 488 (96%) received a study intervention (figure 1). 117 (24%) protocol deviations occurred, including 98 crossovers (figure 1). Other reasons for protocol deviations were loss of randomisation cards (n=15) and bulb syringes being accidentally

Discussion

In this randomised equivalency trial, we showed 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. More neonates in the wipe group were admitted to the neonatal intensive-care unit than were those in the suction group (45 [18%] vs 30 [12%]). This finding was close to significance (p=0·07), but should be interpreted with caution as the study was not powered to assess

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