Nottingham Neonatal Service Clinical Guidelines

Guideline No. B16

Title:

Management of meconium aspiration syndrome

Version:
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3
(Vers 1 May 2008, Vers 2 Nov 12)
February 2014

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February 2017
Nottingham Neonatal Service Clinical Guideline Meeting
Dr Cath Smith, (Stephen Wardle v2 minor changes)
Neonatal Specialist Registrar, Consultant Neonatologist
Nottingham Neonatal Service Staff and Clinical Guideline Meeting,
Midwifery Services
Dr Stephen Wardle, Guideline Coordinator and Consultant Neonatologist
co/ Stephanie Tyrrell, Nottingham Neonatal Service
stephanie.tyrrell@nuh.nhs.uk
Nottingham Neonatal Service, Neonatal Intensive Care Units
Staff of the Nottingham Neonatal Service, Delivery Suites and Postnatal
Wards
Patients of the Nottingham Neonatal Service and newborn infants on the
Postnatal Wards and Labour Suites of the Nottingham University Hospitals
NHS Trust who fit the inclusion criteria of the guideline below
Meconium aspiration syndrome
Prompt evidence based management of meconium aspiration and MAS,
and to reduce morbidity and mortality
The contemporary evidence base has been used to develop this guideline.
References to studies utilised in the preparation of this guideline are given
at its end.

Clinical guidelines are guidelines only. The interpretation and application of clinical
guidelines remain the responsibility of the individual clinician. If in doubt, contact a senior
colleague. Caution is advised when using guidelines after the review date. This guideline has
been registered with the Nottingham University Hospitals NHS Trust.

1.

Introduction

Meconium is formed from 12-16 weeks gestation. It is 75-80% water with the remaining constituents
being intestinal secretions, including bilirubin, cellular debris, blood and mucus.
The frequency of meconium staining of the amniotic fluid increases with increasing gestational age.
The prevalence of true meconium staining is <5% in pre-term infants and, therefore, consideration
should be given to stained liquor representing infection in this group eg. Listeria infection. (See
Therapeutic Guidelines in Neonatal Infection, Guideline C6). The prevalence increases to 10%+ after
38 weeks and 30% at 42 weeks gestation (1). Of the infants presenting with meconium staining of the
amniotic fluid, aspiration (meconium seen below the vocal cords) will occur in 20-30% of infants. 1-9%
of infants will develop meconium aspiration syndrome (MAS) (2). MAS typically occurs when thick,
particulate meconium is present. The mortality associated with MAS and pulmonary hypertension can
be as high as 20% (2). MAS is also associated with neonatal seizures and chronic seizure disorders
(3).

Nottingham Neonatal Service Clinical Guidelines

Guideline No. B16

Passage of meconium in utero is typically thought to be an indicator of fetal stress. It is also associated
with predisposing factors such as breech presentation and gastroschisis. In some infants it may be a
physiological maturational event. Fetal stress may be due to chronic or acute hypoxia, acidaemia or
infection. Inhalation of meconium can occur antenatally, with fetal gasping stimulated by hypoxia, or
during the intra-partum or post-partum stages. Meconium is also thought to affect the umbilical vessels
causing vasoconstriction and fetal hypoperfusion.
It is important to consider the predisposing factors for fetal distress when managing MAS in order to
consider multi-system involvement.
The inhalation of meconium adds to the underlying pathology in a number of ways. Aspirated
meconium causes mechanical obstruction resulting in air trapping and an increased risk of air leak
(pneumothorax, pneumomediastinum). Meconium also causes a chemical pneumonitis and inactivates
surfactant. Although meconium is sterile the processes above predispose to infection. This
combination and the underlying pathology, results in pulmonary vasoconstriction and pulmonary
hypertension. Pulmonary hypertension in these infants can be a significant complication (see the
Hypoxaemic Respiratory Failure Guideline (Guideline B6)).
Chest x-ray will often demonstrate a spectrum of disease from widespread patchy infiltration, +/- small
pleural effusions, to diffuse homogenous opacification. With severe disease a picture similar to CLD
can be seen as the disease progresses.
2.

Management at delivery

A Neonatal Practitioner (SHO/ANNP) should attend the delivery when meconium staining of the liquor
is present. If there is thick meconium and the Neonatal Practitioner is not skilled at intubation senior
help should be summoned as soon as possible. Ask a member of staff to call 2222 and CRASH
CALL THE NEONATAL TEAM.
On delivery of the head, there is no evidence to support routine suction of the infants nose/mouth on
the perineum (4), and therefore, this should not be performed.
In the past compression of the neonatal thorax was advocated to minimise respiratory effort during
transfer to the resuscitaire. There is no evidence to support this and the infant should be handled
normally.
Normal thermal management of the infant should take place. Dry and wrap the baby whilst starting
your assessment.
Document resuscitation in the medical notes. For babies receiving more than just inflation breaths the
resuscitation documentation sheets should be used and filed in the medical notes.

2.1.1

Assessment of the infant

See Appendix A for flow chart summarising management in delivery room

Screaming babies have an open airway

Floppy babies have a look

Nottingham Neonatal Service Clinical Guidelines

Guideline No. B16

At the initial assessment of infants with meconium present at delivery they will fall into 3 main
categories:
a) Vigorous infant, crying
No special measures should be taken. Intubation and suction of the trachea should not be performed
in vigorous infants (5). Dry and wrap the baby and give to mother. There is no need for increased
observation on the postnatal ward.
b) Quiet infant, maintaining airway
Manage with suction and resuscitation, as indicated, following NLS guidelines or the Nottingham
Resuscitation at Birth Guideline (Guideline A5).
Increased observations are not indicated on the postnatal ward unless meconium has been suctioned
from below the vocal cords.
c) Infant not maintaining airway, with inadequate respiratory effort or low heart rate
Under direct vision with a laryngoscope first suction the oropharynx.
Visualize the vocal cords and pass the suction catheter beyond them into the trachea. Do not apply
suction until the tip of the catheter is beyond the vocal cords in order to avoid damage to these. The
catheter should then be withdrawn applying continuous suction.
Low flow suction at 100-120 mmHg can be applied in the following ways:

Black suction catheter (Size 10 French gauge)

Pass uncut 3.5 mm ETT with an introducer, remove the introducer, attach a meconium
aspirator, apply suction, and withdraw the ETT

The NLS Guidelines recommend using uncut endotracheal tubes rather than shouldered Coles tubes
as these may be too short to adequately remove meconium from the lower end of the trachea (6).
Remember that a black suction catheter may be too narrow bore to allow adequate removal of thick,
particulate meconium.
Following suction, reassess the infant:
i) maintaining airway and making respiratory effort support with IPPV via face mask or give facial
oxygen as required. If a good recovery occurs pass a nasogastric tube and aspirate any meconium
from the stomach. Dry and wrap the baby in a clean, dry towel and give to the parents. Infants with
meconium below the vocal cords should have 4 hourly routine observations on the postnatal ward and
the Neonatal SHO should be called if there are any concerns.
ii) not maintaining airway
Visualise the airway again.
Repeated intubation and aspiration is not normally indicated unless the trachea is blocked with
meconium. If there is inadequate respiratory effort or if otherwise indicated and the trachea is not
blocked, commence IPPV, via ETT or face mask, as there is likely to be an urgent need for oxygen.
Continue resuscitation as indicated (see Resuscitation at Birth Guideline A5).

Nottingham Neonatal Service Clinical Guidelines

Guideline No. B16

Infants requiring continued respiratory support, having evidence of encephalopathy or respiratory

distress in the delivery room following resuscitation should be admitted to the Neonatal Unit.
2.

Postnatal ward care

Infants in which meconium is not seen below the vocal cords dont require increased observations on
the postnatal ward.
When meconium is seen below the vocal cords and the infant makes a good recovery and respiratory
distress is not seen in the delivery room the infant can be cared for on the postnatal ward. These
infants require 4 hourly observations of temperature, heart rate, respiratory rate and respiratory effort. If
there are any concerns the Neonatal SHO should be called to assess the infant. These infants are very
likely to require admission to the Neonatal Unit for further assessment and monitoring.
We recommend taking the portable saturations monitor to the baby when making your assessment on
the postnatal ward.
All observations undertaken on the post-natal ward must be recorded on an observation chart which will
then be filed in the babys medical notes.
3.

Further Treatment of Meconium Aspiration Syndrome

For infants admitted to the Neonatal Unit the following general measures should be undertaken.
Arterial access (either peripheral or umbilical) and central venous access should be considered and
obtained early as these infants require close and accurate monitoring of blood pressure as well as
assessment of oxygenation and acid-base balance with arterial blood gases. They may also require
inotropic support and parenteral nutrition. Commence CFM monitoring if is there is an associated
encephalopathic picture.
3.1 General Measures
3.1.1

Maintain a thermoneutral environment

Infants with severe meconium aspiration syndrome have often been subject to hypoxia for a prolonged
period of time. They should therefore be nursed in a thermoneutral environment of 36.0-37.0 C to
minimise secondary reperfusion injury to the neonatal brain. If there is evidence of encephalopathy and
cord/early gases have a pH <7.0 the infant should be considered for entry into the TOBY trial, whilst
this is ongoing, and in the future there may be a role for active cooling in all such cases.
3.1.2 Provide respiratory support
See detailed information in section 3.2 below.
3.1.3

Provide cardiovascular support, avoid hypotension

Adequate cardiovascular support is important in the treatment of persistent pulmonary hypertension

and in preventing further insults to end-organs. The blood pressure should be closely monitored,
preferably with an arterial pressure transducer. Hypotension should be aggressively managed with
inotropes to maintain the systemic blood pressure and reduce right to left shunting.

Nottingham Neonatal Service Clinical Guidelines

Guideline No. B16

Other strategies for improving pulmonary hypertension include maintaining adequate oxygenation.
Oxygen is a potent pulmonary vasodilator. Minimal handling, sedation and paralysis also reduce the
incidence of acute pulmonary hypertensive crises.
3.1.4

Maintain nutrition

Infants with meconium aspiration syndrome may require prolonged ventilatory support preventing
adequate enteral nutrition being provided. Parenteral nutrition should be considered.
3.1.5

Commence antibiotics

Although meconium is a sterile substance the mechanical obstruction in the distal airways predisposes
to infection. Use routine antibiotics in these infants unless otherwise indicated. See the Infection
Guideline (Guideline C1) for further details.
3.1.6

Minimal handling

As in all critically ill infants, handling should be kept to a minimum. This helps to minimise pain and
reduce pulmonary hypertensive crises.

3.2 Respiratory Support and Ventilation

There is a spectrum of respiratory disease which may be seen in meconium aspiration syndrome.
Infants should be managed with adequate respiratory support indicated by the following clinical
assessments:
a) Effort of breathing
b) Oxygen requirement
c) Blood gas indices
Many infants with meconium seen below the vocal cords will have mild respiratory distress, behaving
as a variant of transient tachypnoea of the newborn, with symptoms and signs persisting for 24 to 48
hours. They will typically have normal/near normal blood gas indices and should be managed with
humidified oxygen, if required, via head box (concentration monitored using an oxygen analyser).
Do not use nasal CPAP as this will increase air-trapping and the risk of air leak.
Worsening respiratory distress, or a more severe initial picture reflects mechanical obstruction of the
distal airways with meconium. The ball-valve effect results in increased airway resistance, pulmonary
over-expansion and a significantly increased incidence of pneumothorax and other air leaks. On
examination, the thorax may look hyperinflated with a barrel appearance and increased anteriorposterior diameter. Further evidence of this may be seen on chest radiograph with hyperexpanded
lung fields, along with widespread patchy infiltrations and in 20-30% of cases small pleural effusions
may be seen.
If a pneumothorax is suspected transillumination of the chest with a cold light is a useful tool. Needle
aspiration should be performed in any ventilated baby if pneumothorax is suspected and should not be
delayed for chest x-ray. A chest drain will need to be inserted. In an infant who is not ventilated it may
be possible to manage a small pneumothorax conservatively. See the Pneumothorax Guideline
(Guideline B2) for management and details of how to perform needle aspiration and insert a chest
drain.

Nottingham Neonatal Service Clinical Guidelines

Guideline No. B16

In the early stages of respiratory disease the aim of ventilation is to optimise oxygenation whilst
minimising air-trapping. Use of conventional modes is recommended, aiming to have a short
inspiratory time and longer expiratory times to allow gas removal from the lungs. High frequency
oscillation may further exacerbate gas trapping and for the same reasons high positive end expiratory
pressures should be used with caution.
The effects of air-trapping, and incidence of pneumothorax, can also be minimised by using sedation
and muscle relaxants, such as atracurium. Have a low threshold for commencing sedation and muscle
relaxation as these also have a role in the management of persistent pulmonary hypertension.
In the 24-48 hours following inhalation, meconium causes a chemical pneumonitis.
The airways
become inflamed with an exudative infiltrate and alveolar collapse followed by necrosis of the lung
tissue. The radiological appearances of hyperinflation and air-trapping are no longer seen on chest xray and are replaced by homogenous opacification.
The inflammatory changes and the inactivation of surfactant decreases the compliance of the lungs and
hence the tidal volume. Compensatory tachypnoea in infants who are not muscle relaxed may double
the minute volume. Further effects of mechanical obstruction and inflammation include significant
ventilation-perfusion (V/Q) mismatch. This exacerbates persistent pulmonary hypertension, but will
resolve as the condition improves.

Whilst supporting infants with mechanical ventilation regular chest x-rays may be required. Arterial
blood gases should be frequently reviewed and the use of transcutaneous PaCO2 and PaO2 monitoring,
in addition to routine saturation monitoring, is encouraged. Good oxygenation, PaO2 > 10 KPa, should
be achieved whilst the paCO2 and pH should be maintained in the normal range, 4-6 KPa and >7.35
respectively, to avoid exacerbation of pulmonary hypertension. (See Hypoxaemic Respiratory Failure
Guideline, Guideline B6).

3.2.1 Surfactant
As previously discussed meconium in the airways causes inactivation of surfactant. This is an ongoing
process and results in alveolar collapse and hence V/Q mismatch.
In a recent Cochrane Review, it was concluded that surfactant administration in MAS may reduce the
severity of respiratory illness and decrease the number of infants with progressive respiratory failure
requiring support with ECMO. There is no evidence that surfactant therapy reduces mortality (7).
Surfactant should be prescribed at a dose of 200mg/kg. A second dose is often required after 4 hours.
Subsequent doses may also be indicated and further administration should be discussed with the
Neonatal Consultant on duty.

3.2.2 Lavage
The use of bronchial lavage with saline has been shown to be dangerous and should not be performed
(8). Currently, there is no evidence to support the use of surfactant lavage.

3.2.3

Nitric Oxide

Inhaled nitric oxide is a potent pulmonary vasodilator. The results available to date provide
support for the use of inhaled NO in doses of 10 - 80 ppm in the near-term, hypoxic,

Nottingham Neonatal Service Clinical Guidelines

Guideline No. B16

mechanically ventilated neonate with an OI => 25 or a paO2 < 100 mmHg (13.3 KPa) in an FiO2
= 1 (9).
The use of nitric oxide in the management of meconium aspiration syndrome is therefore
recommended up to a maximal dose of 40 ppm. The oxygenation index (OI) is a measure of
the severity of hypoxic ischaemic failure. If the OI is greater than 25 and conventional
ventilatory support, blood pressure and perfusion have been optimized inhaled nitric oxide
therapy should be commenced.
Oxygenation Index (OI)
OI

= MAP (cm of water) FiO2 (%) x 100

PaO2 mm of Hg

(1 KPa = 7.5 mm Hg.)

Please consult the Inhaled Nitric Oxide Guideline (Guideline B10) for further information.

3.2.4

Extra-corporeal Membranous Oxygenation (ECMO)

The use of ECMO has been shown to be an effective policy in mature infants with severe but potentially
reversible respiratory failure. Its use in this category of infants, such as those with MAS, results in
significantly improved survival without increased risk of severe disability amongst survivors (10).
Referral for ECMO should be discussed with the Consultant on-call when the oxygenation index is 30.
Please refer to the Hypoxaemic Respiratory Failure Guideline (Guideline B6).
3.3
Additional Therapies
3.3.1 Physiotherapy
Physiotherapy is not indicated in the treatment of meconium aspiration syndrome. It may be used in
the management of further complications after the first few days.

3.3.2 Steroids
There is insufficient evidence to support the use of corticosteroids in the management of MAS (11).
4.

Audit Points

Attendance and management at delivery of infants with meconium stained amniotic fluid.
5.

Monitoring Plan

The Management of meconium aspiration syndrome guideline will be monitored in conjunction

with the NUH Maternity Services Clinical and Operational Monitoring Plan.

6.

Allied Guidelines

Guideline A5
Guideline B2
Guideline B6
Guideline B9
Guideline B10
Guideline C1

Resuscitation at Birth
Pneumothorax Recognition and Management
Hypoxaemic Respiratory Failure
High Frequency Oscillatory Ventilation
Guideline for the use of inhaled nitric oxide
Therapeutic Guidelines for Neonatal Infection

Nottingham Neonatal Service Clinical Guidelines

6.

Guideline No. B16

Summary Box and Levels of Evidence

Summary
Intubation and tracheal suction should not be performed in vigorous
Infants (5)
Surfactant administration in MAS may reduce the severity of respiratory
illness and decrease the number of infants with progressive respiratory
failure requiring support with ECMO but does not reduce mortality, no
evidence for surfactant lavage (6)
Use of iNO reduces the need for ECMO in severe respiratory failure but
does not reduce mortality (8)
Use of ECMO significantly improves survival without increasing the risk of
severe disability (9)
Use of steroids is not indicated in MAS (10)
Suction of the oropharynx before delivery of the shoulders is not
indicated (4)
No evidence for saline lavage (7)
Physiotherapy is not indicated in the first few days after meconium
aspiration

Level of Evidence
A
A

A
A
A
B
C
D

7.

References

1)
2)
3)

Wiswell, TE. Handling the meconium-stained infant. Semin Neonat. 2001 Jun; 6(3): 225-31.
Clark, DA. Meconium Aspiration Syndrome. Emedicine May 2004.
Fleischer, A., Anyaegbunam, A., Guidetti, D., Randolph, G., Merkatz, IR. A persistent clinical
problem: profile of the term infant with significant respiratory complications. Obstet Gynecol.
1992; 79:185-90.
Vain, NE., Szyld, EG., Prudent, LM., et al. Oropharyngeal and nasopharyngeal suctioning of
meconium-stained neonates before delivery of their shoulders: multicentre, randomized
controlled trial. Lancet. 2004 Aug 14; 364(9434):597-602.
Endotracheal intubation at birth for preventing morbidity and mortality in vigorous, meconiumstained infants born at term. The Cochrane Database of Systematic Reviews. 2001, Issue 1
Newborn Life Support Manual. 2nd Edition, Resuscitation Council UK. Page 45.
Surfactant for meconium aspiration syndrome in full term infants. Soll, RF., Dargaville, P. The
Cochrane Database of Systematic Reviews. 2000, Issue 2.
Linder, N., Aranda, JV., Tsur, M., et al. Need for endotracheal intubation and suction in
meconium stained neonates. J Pediatr 1988; 112:613-15.
Finer NN, Barrington KJ. Nitric oxide for respiratory failure in infants born at or near term. The
Cochrane Database of Systematic Reviews 2001, Issue 4.
Elbourne D, Field D, Mugford M. Extracorporeal membrane oxygenation for severe respiratory
failure in newborn infants. The Cochrane Database of Systematic Reviews 2002, Issue 1
Steroid therapy for meconium aspiration syndrome in newborn infants. Ward, M., Sinn, J. The
Cochrane Database of Systematic Reviews 2006, Issue 1.

4)

5)
6)
7)
8)
9)
10)
11)

Nottingham Neonatal Service Clinical Guidelines

Guideline No. B16

Appendix A.
Flow Chart for the management of meconium present at delivery
Meconium staining of the amniotic fluid
Transfer the infant to the resuscitaire
Dry and wrap
Make assessment

Vigorous, crying
infant

Quiet infant,
maintaining airway

Infant with inadequate

respiratory effort or low
heart rate

No special measures

Place airway in the neutral position

Give to parents

Using direct laryngoscopy suction any

meconium from the oropharynx

No observations on
postnatal ward unless
otherwise indicated

No meconium

Reassess the infant:

If indicated commence
resuscitation following NLS
Guidelines

If not indicated dry and

wrap and give to parents

Using direct laryngoscopy visualise the

vocal cords

Meconium on or
below the cords
Intubate with either: 10G black suction catheter. DO NOT APPLY
SUCTION UNTIL BEYOND THE CORDS.
3.0-3.5 ETT and meconium aspirator with suction
attached
Withdraw the ETT/suction catheter whilst applying
continuous suction

REASSESS
Support with IPPV and/or facial
oxygen as required
Dry and wrap infant and give to
parents
Pass nasogastric tube and
aspirate stomach
4hrly observations on postnatal
ward

Visualise airway under direct vision, repeat suction if

trachea blocked
Intubate and commence IPPV
If unable to intubate commence mask ventilation and
call for senior help
If indicated continue resuscitation following NLS
Guidance
Pass nasogastric tube and aspirate the stomach
Transfer to Neonatal Intensive Care