Meconium Aspiration Syndrome Treatment & Management

  • Author: Melinda B Clark, MD; Chief Editor: Ted Rosenkrantz, MD   more...
 
Updated: Mar 30, 2010
 

Medical Care

  • Prevention of meconium aspiration syndrome (MAS)
    • Prevention is paramount.
    • Obstetricians should monitor fetal status in an attempt to identify fetal stress.
    • When meconium is detected, amnioinfusion with warm, sterile saline is theoretically beneficial to dilute the meconium in the amniotic fluid, thereby minimizing the severity of the aspiration. However, current evidence does not support routine amnioinfusion to prevent meconium aspiration syndrome.[4, 5]
    • Current recommendations no longer advise routine intrapartum suctioning for infants born to mothers with meconium staining of the amniotic fluid.{Ref1}[6]
    • When aspiration occurs, intubation and immediate suctioning of the airway can remove much of the aspirated meconium.
    • No clinical trials justify suctioning based on the consistency of meconium. Do not perform the following harmful techniques in an attempt to prevent aspiration of meconium-stained amniotic fluid:
      • Squeezing the chest of the baby
      • Inserting a finger into the mouth of the baby
    • The American Academy of Pediatrics Neonatal Resuscitation Program Steering Committee has promulgated guidelines for management of the baby exposed to meconium. The guidelines are under continuous review and are revised as new evidence-based research becomes available. The current guidelines are as follows:[7]
      • If the baby is not vigorous (defined as depressed respiratory effort, poor muscle tone, and/or heart rate < 100 beats/min): Use direct laryngoscopy, intubate, and suction the trachea immediately after delivery. Suction for no longer than 5 seconds. If no meconium is retrieved, do not repeat intubation and suction. If meconium is retrieved and no bradycardia is present, reintubate and suction. If the heart rate is low, administer positive pressure ventilation and consider suctioning again later.
      • If the baby is vigorous (defined as normal respiratory effort, normal muscle tone, and heart rate >100 beats/min): Do not electively intubate. Clear secretions and meconium from the mouth and nose with a bulb syringe or a large-bore suction catheter.
      • In both cases, the remainder of the initial resuscitation steps should ensue, including drying, stimulating, repositioning, and administering oxygen as necessary.
  • Continued care in the neonatal ICU (NICU)
    • Maintain an optimal thermal environment to minimize oxygen consumption.
    • Minimal handling is necessary because these infants are easily agitated. This can cause right-to-left shunting, leading to hypoxia and acidosis.
    • Sedation is often necessary to decrease agitation.
    • Continue respiratory care. Oxygen therapy via hood or positive pressure is crucial in maintaining adequate arterial oxygenation. Mechanical ventilation is required by approximately 30% of infants with meconium aspiration syndrome.[8] Make concerted efforts to minimize the mean airway pressure and to use as short an inspiratory time as possible. Oxygen saturations should be maintained at 90-95%.
    • Surfactant therapy is now commonly used to replace displaced or inactivated surfactant and as a detergent to remove meconium. Although surfactant use does not appear to affect mortality rates, it may reduce the severity of disease and progression to extracorporeal membrane oxygenation (ECMO).[9] Studies are ongoing to evaluate the potential role of pulmonary lavage with surfactant.
    • Although conventional ventilation commonly is initially used, high-frequency oscillation and jet ventilation are alternative effective therapies. Hyperventilation to induce hypocapnia and compensate for metabolic acidosis is no longer a primary therapy for pulmonary hypertension because hypocarbia may result in decreased cerebral perfusion (PaCO2 < 30 mm Hg). Prolonged alkalosis has been shown to cause neuronal injury in animals and humans, providing another reason to avoid alkalosis in these patients.[10]
    • Ventilator therapy aimed at minimizing mean airway pressure and tidal volume should be used if pulmonary interstitial emphysema or a pneumothorax is present.
    • For treatment of persistent pulmonary hypertension of the newborn (PPHN), inhaled nitric oxide is the pulmonary vasodilator of choice.
    • Pay careful attention to systemic blood volume and blood pressure. Volume expansion, transfusion therapy, and systemic vasopressors are critical in maintaining systemic blood pressure greater than pulmonary blood pressure, thereby decreasing the right-to-left shunt through the patent ductus arteriosus.
    • Ensure adequate oxygen carrying capacity by maintaining the hemoglobin concentration above 13 g/dL.
    • Corticosteroids are not recommended. The evidence supporting the use of steroids in the management of meconium aspiration syndrome is insufficient.[11]
    • ECMO is used if all other therapeutic options have been exhausted. Although effective in treating meconium aspiration syndrome, ECMO is associated with a high incidence of poor neurologic outcomes.
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Surgical Care

  • Although primary management of air block syndromes (pneumothorax or pneumopericardium) is achieved by thoracic drainage tubes inserted by a neonatologist, a pediatric surgical consultation may be necessary in severe cases. Therapy with fibrin glue has been shown to be effective in patients with a persistent air leak.[12]
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Consultations

  • Evaluation with a pediatric cardiologist is necessary for echocardiographic assessment. This imaging technique ensures normal cardiac structure and assesses the severity of pulmonary hypertension and right-to-left shunting.
  • Evaluation with a pediatric neurologist is helpful in the presence of neonatal encephalopathy or seizure activity.
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Diet

  • Perinatal distress and severe respiratory distress preclude feeding.
  • Intravenous fluid therapy begins with adequate dextrose infusion to prevent hypoglycemia.
  • Intravenous fluids should be provided at mildly restricted rates (60-70 mL/kg/d).
  • Progressively add electrolytes, protein, lipids, and vitamins to ensure adequate nutrition and prevent essential amino acid and essential fatty acid deficiencies.
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Contributor Information and Disclosures
Author

Melinda B Clark, MD  Assistant Professor of Pediatrics, Department of Pediatrics, Albany Medical College

Melinda B Clark, MD is a member of the following medical societies: Alpha Omega Alpha, Ambulatory Pediatric Association, American Academy of Pediatrics, and Medical Society of the State of New York

Disclosure: Nothing to disclose.

Coauthor(s)

David A Clark, MD  Chairman, Professor, Department of Pediatrics, Albany Medical College

David A Clark, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Pediatric Society, Christian Medical & Dental Society, Medical Society of the State of New York, New York Academy of Sciences, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Specialty Editor Board

Steven M Donn, MD  Professor of Pediatrics, University of Michigan Medical School; Director, Division of Neonatal-Perinatal Medicine, Department of Pediatrics, CS Mott Children's Hospital, University of Michigan Health System

Steven M Donn, MD is a member of the following medical societies: American Pediatric Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Brian S Carter, MD, FAAP  Professor of Pediatrics (Neonatology), Vanderbilt University School of Medicine; Director, Neonatal Follow-up Program, Monroe Carell Jr Children's Hospital at Vanderbilt

Brian S Carter, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Society for Bioethics and Humanities, American Society of Law, Medicine & Ethics, National Hospice and Palliative Care Organization, Society for Pediatric Research, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Carol L Wagner, MD  Professor of Pediatrics, Medical University of South Carolina

Carol L Wagner, MD is a member of the following medical societies: American Academy of Pediatrics, American Chemical Society, American Medical Women's Association, American Public Health Association, American Society for Bone and Mineral Research, American Society for Clinical Nutrition, Massachusetts Medical Society, National Perinatal Association, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD  Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine

Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research

Disclosure: Nothing to disclose.

References

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Air trapping and hyperexpansion from airway obstruction.
Acute atelectasis.
Pneumomediastinum from gas trapping and air leak.
Left pneumothorax with depressed diaphragm and minimal mediastinal shift because of noncompliant lungs.
Diffuse chemical pneumonitis from constituents of meconium.
 
 
 
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