Meconium aspiration syndrome is a clinical condition characterized by respiratory failure occurring in neonates born through meconium-stained amniotic fluid. Worldwide, the incidence has declined in developed countries thanks to improved obstetric practices and perinatal care while challenges persist in developing countries. Despite the improved survival rate over the last decades, long-term morbidity among survivors remains a major concern. Since the 1960s, relevant changes have occurred in the perinatal and postnatal management of such patients but the most appropriate approach is still a matter of debate. This review offers an updated overview of the epidemiology, etiopathogenesis, diagnosis, management and prognosis of infants with meconium aspiration syndrome.

Background: Training programs on resuscitation have been developed using simulation-based learning to build skills, strengthen cognitive strategies, and improve team performance. This is especially important for residency programs where reduced working hours and high numbers of residents can reduce the educational opportunities during the residency, with lower exposure to practical procedures and prolonged length of training. Within this context, gamification has gained popularity in teaching and learning activities. This report describes the implementation of a competition format in the context of newborn resuscitation and participants’ perceptions of the educational experience. Methods: Thirty-one teams of three Italian pediatric residents participated in a 3-day simulation competition on neonatal resuscitation. The event included an introductory lecture, familiarization time, and competition time in a tournament-like structure using high-fidelity simulation stations. Each match was evaluated by experts in neonatal resuscitation and followed by a debriefing. The scenarios and debriefings of simulation station #1 were live broadcasted in the central auditorium where teams not currently competing could observe. At the end of the event, participants received an online survey regarding their perceptions of the educational experience. Results: 81/93 (87%) participants completed the survey. Training before the event mostly included reviewing protocols and textbooks. Low-fidelity manikins were the most available simulation tools at the residency programs. Overall, the participants were satisfied with the event and appreciated the live broadcast of scenarios and debriefings in the auditorium. Most participants felt that the event improved their knowledge and self-confidence and stimulated them to be more involved in high-fidelity simulations. Suggested areas of improvement included more time for familiarization and improved communication between judges and participants during the debriefing. Conclusions: Participants appreciated the simulation competition. They self-perceived the educational impact of the event and felt that it improved their knowledge and self-confidence. Our findings suggest areas of improvements for further editions and may serve as an educational model for other institutions.

Tracheal suctioning in non-vigorous newborn delivered through meconium-stained amniotic fluid (MSAF) is supposed to delay initiation of positive pressure ventilation (PPV), but the magnitude of such delay is unknown. To compare the time of PPV initiation when performing immediate laryngoscopy with intubation and suctioning vs. performing immediate PPV without intubation in a manikin model. Randomized controlled crossover (AB/BA) trial comparing PPV initiation with or without endotracheal suctioning in a manikin model of non-vigorous neonates born through MSAF. Participants were 20 neonatologists and 20 pediatric residents trained in advanced airway management. Timing of PPV initiation was longer with vs. without endotracheal suctioning in both pediatric residents (mean difference 13 s, 95% confidence interval 8 to 18 s; p < 0.0001) and neonatologists (mean difference 12 s, 95% confidence interval 8 to 16 s; p < 0.0001). The difference in timing of PPV initiation was similar between pediatric residents and neonatologists (mean difference − 1 s, 95% confidence interval − 7 to 6 s; p = 0.85). Conclusions : Performing immediate laryngoscopy with intubation and suctioning was associated with longer—but not clinically relevant—time of initiation of PPV compared with immediate PPV without intubation in a manikin model. While suggesting negligible delay in starting PPV, further studies in a clinical setting are warranted. Registration : clinicaltrial.gov NCT04076189. What is Known: • Management of the non-vigorous newborn delivered through meconium-stained amniotic fluid remains still controversial. • Tracheal suctioning in non-vigorous newborn delivered through meconium-stained amniotic fluid is supposed to delay initiation of positive pressure ventilation, but the magnitude of such delay is unknown. What is New: • Performing immediate ventilation without intubation was associated with shorter—but not clinically relevant—time of initiation of ventilation compared to immediate laryngoscopy with intubation and suctioning in a manikin model. • Further studies in a clinical setting are warranted.

Background: Surfactant is a well-established therapy for preterm neonates affected by respiratory distress syndrome (RDS). The goals of different methods of surfactant administration are to reduce the duration of mechanical ventilation and the severity of bronchopulmonary dysplasia (BPD); however, the optimal administration method remains unknown. This study compares the effectiveness of the INtubate-RECruit-SURfactant-Extubate (IN-REC-SUR-E) technique with the less-invasive surfactant administration (LISA) technique, in increasing BPD-free survival of preterm infants. This is an international unblinded multicenter randomized controlled study in which preterm infants will be randomized into two groups to receive IN-REC-SUR-E or LISA surfactant administration. Methods: In this study, 382 infants born at 24⁺⁰–27⁺⁶ weeks’ gestation, not intubated in the delivery room and failing nasal continuous positive airway pressure (nCPAP) or nasal intermittent positive pressure ventilation (NIPPV) during the first 24 h of life, will be randomized 1:1 to receive IN-REC-SUR-E or LISA surfactant administration. The primary outcome is a composite outcome of death or BPD at 36 weeks’ postmenstrual age. The secondary outcomes are BPD at 36 weeks’ postmenstrual age; death; pulse oximetry/fraction of inspired oxygen; severe intraventricular hemorrhage; pneumothorax; duration of respiratory support and oxygen therapy; pulmonary hemorrhage; patent ductus arteriosus undergoing treatment; percentage of infants receiving more doses of surfactant; periventricular leukomalacia, severe retinopathy of prematurity, necrotizing enterocolitis, sepsis; total in-hospital stay; systemic postnatal steroids; neurodevelopmental outcomes; and respiratory function testing at 24 months of age. Randomization will be centrally provided using both stratification and permuted blocks with random block sizes and block order. Stratification factors will include center and gestational age (24⁺⁰ to 25⁺⁶ weeks or 26⁺⁰ to 27⁺⁶ weeks). Analyses will be conducted in both intention-to-treat and per-protocol populations, utilizing a log-binomial regression model that corrects for stratification factors to estimate the adjusted relative risk (RR). Discussion: This trial is designed to provide robust data on the best method of surfactant administration in spontaneously breathing preterm infants born at 24⁺⁰–27⁺⁶ weeks’ gestation affected by RDS and failing nCPAP or NIPPV during the first 24 h of life, comparing IN-REC-SUR-E to LISA technique, in increasing BPD-free survival at 36 weeks’ postmenstrual age of life. Trial registration: ClinicalTrials.gov NCT05711966. Registered on February 3, 2023.

Background: Surfactant is a well-established therapy for preterm neonates affected by respiratory distress syndrome (RDS). Goals of different methods of surfactant administration are to reduce duration of mechanical ventilation and the severity of bronchopulmonary dysplasia (BPD), however the optimal administration method remains unknown. This study compares the effectiveness of the INtubate-RECruit-SURfactant-Extubate (IN-REC-SUR-E) technique with the less invasive surfactant administration (LISA) technique, in increasing BPD-free survival of preterm infants. This is an international unblinded multicenter randomized controlled study in which preterm infants will be randomized into two groups to receive IN-REC-SUR-E or LISA surfactant administration. Methods: In this study 382 infants born at 24⁺⁰-27⁺⁶ weeks’ gestation, not intubated in the delivery room and failing nasal continuous positive airway pressure (nCPAP) or nasal intermittent positive pressure ventilation (NIPPV) during the first 24 h of life, will be randomized 1:1 to receive IN-REC-SUR-E or LISA surfactant administration. The primary outcome is a composite outcome of death or BPD at 36 weeks’ postmenstrual age. Secondary outcomes are: BPD at 36 weeks’ postmenstrual age; death; pulse oximetry/fraction of inspired oxygen; severe intraventricular haemorrhage; pneumothorax; duration of respiratory support and oxygen therapy; pulmonary hemorrhage; patent ductus arteriosus undergoing treatment; percentage of infants receiving more doses of surfactant; periventricular leukomalacia, severe retinopathy of prematurity, necrotizing enterocolitis, sepsis; total in-hospital stay; systemic postnatal steroids; neurodevelopmental outcomes and respiratory function testing at 24 months of age. Randomization will be centrally provided using both stratification and permuted blocks with random block sizes and block order. Stratification factors will include centre and gestational age (24⁺⁰ to 25⁺⁶ weeks or 26⁺⁰ to 27⁺⁶ weeks). Analyses will be conducted in both intention-to-treat and per-protocol populations, utilizing a log-binomial regression model that corrects for stratification factors to estimate the adjusted relative risk (RR). Discussion: This trial is designed to provide robust data on the best method of surfactant administration in spontaneously breathing preterm infants born at 24⁺⁰-27⁺⁶ weeks' gestation affected by RDS and failing nCPAP or NIPPV during the first 24 hours of life, comparing IN-REC-SUR-E to LISA technique, in increasing BPD-free survival at 36 weeks' postmenstrual age of life. Trial registration: ClinicalTrials.gov identifier NCT05711966