Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

vigorous infant born through meconium-stained amniotic fluid, no respiratory distress

1st line – observation

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ACUTE
|
vigorous infant born through meconium-stained amniotic fluid, no respiratory distress
|
without suspected infection
1st line – 

observation

Normal-term infants born through meconium-stained amniotic fluid without a history of maternal group B streptococcal infection or other infections, who are vigorous at birth and manifest no respiratory distress, can be allowed to stay with the mother as a normal newborn after routine delivery room care.[53]

Preventive measures for babies born through meconium-stained amniotic fluid have been investigated. Such interventions include amnioinfusion, oropharyngeal suctioning of the baby at the perineum, tracheal suction, and gastric aspiration. None of these interventions has been shown to reduce the risk of MAS, and their routine use is not recommended.[29][33][34][35][36][37][38][39][40][41] [ Cochrane Clinical Answers logo ]

Treatment with antibiotics is not indicated if no risk factors or laboratory findings suggestive of infection are present (e.g., chorioamnionitis, prolonged rupture of membranes, oligohydramnios, fetal heart rate abnormalities, post-maturity).

1st line – observation plus antibiotics

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ACUTE
|
vigorous infant born through meconium-stained amniotic fluid, no respiratory distress
|
with suspected infection
1st line – 

observation plus antibiotics

Antibiotics are indicated in the presence of risk factors or laboratory findings suggestive of infection (e.g., chorioamnionitis, prolonged rupture of membranes, oligohydramnios, fetal heart rate abnormalities, post-maturity). Broad-spectrum antibiotics used include ampicillin and gentamicin.[54] Treatment with antibiotics should be discontinued if 48-hour blood cultures are negative, unless there is clear evidence of site-specific infection.[54] If blood cultures are positive, antibiotics should be continued for up to 7 days.

Preventive measures for babies born through meconium-stained amniotic fluid have been investigated. Such interventions include amnioinfusion, oropharyngeal suctioning of the baby at the perineum, tracheal suction, and gastric aspiration. None of these interventions has been shown to reduce the risk of MAS, and their routine use is not recommended.[29][33][34][35][36][37][38][39][40][41] [ Cochrane Clinical Answers logo ]

Primary options

ampicillin: 50-100 mg/kg/day intravenously given in divided doses every 6-12 hours depending on age and weight

and

gentamicin: 4-5 mg/kg/day intravenously given in divided doses depending on age and weight

mild MAS

1st line – oxygen therapy plus supportive care

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ACUTE
|
mild MAS
1st line – 

oxygen therapy plus supportive care

Infants with mild respiratory distress, tachypnoea, mild cyanosis, and retractions should be admitted to the neonatal intensive care unit (NICU) for treatment and observation.

Infants should be placed in Isolette, or under an infant warmer, and oxygen saturation should be monitored continuously.

Oxygen should be given by hood or nasal cannula to maintain oxygen saturations at 92% to 97%. Usually, may require FiO₂ <0.40 for a short duration of 48 to 72 hours. As respiratory distress begins to improve, FiO₂ should be decreased by 5% at a time, as tolerated, depending on pulse oximeter reading.

Intravenous fluids (10% dextrose in water) should be started on day 1. On subsequent days, switching to nasogastric or oral feeds, as tolerated, should be considered if the infant's respiratory status improves. If feedings are not adequate, intravenous fluid should be increased (80-90 mL/kg/day, adding NaCl at 2-4 mmol/kg/day [2-4 mEq/kg/day] plus amino acids) to meet the daily requirement. Giving intravenous fluids containing glucose 6 to 8 mg/minute/kg is indicated in those with hypoglycaemia until resolution.

Other measures may include providing partial exchange to lower the haematocrit and improve blood flow in infants with high haemoglobin, or blood transfusion if haemoglobin is low (<130 g/L [<13 g/dL]).

Consider – antibiotics

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ACUTE
|
mild MAS
Consider – 

antibiotics

Additional treatment recommended for SOME patients in selected patient group

Indicated in the presence of risk factors or laboratory findings suggestive of infection, such as chorioamnionitis, prolonged rupture of membranes, oligohydramnios, fetal heart rate abnormalities, post-maturity.​ Broad-spectrum antibiotics used include ampicillin and gentamicin.[54]

Treatment with antibiotics should be discontinued if 48-hour blood cultures are negative, unless there is clear evidence of site-specific infection.[54] If blood cultures are positive, antibiotics should be continued for up to 7 days.

Primary options

ampicillin: 50-100 mg/kg/day intravenously given in divided doses every 6-12 hours depending on age and weight

and

gentamicin: 4-5 mg/kg/day intravenously given in divided doses depending on age and weight

moderate MAS

1st line – CPAP ventilation

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ACUTE
|
moderate MAS
1st line – 

CPAP ventilation

Patients in this group include infants with moderate respiratory distress who do not respond to oxygen therapy, or infants with moderate respiratory distress at presentation.

In infants with spontaneous breathing and good respiratory effort, continuous positive airway pressure (CPAP) should be started with nasal prongs if FiO₂ needs exceed 0.40 to maintain saturations within normal limits. Starting CPAP is 4 to 6 cm of H₂O. Further increase of CPAP level is determined by presence of atelectasis and work of breathing. CPAP should be avoided in the presence of air leaks and air trapping on CXR. Complications include abdominal distension, air trapping because of underlying ball-valve mechanisms or excessive flow, and distending pressure. These potential complications warrant close monitoring. CPAP reduces the need for mechanical ventilation in infants with MAS who have peripheral oxygen saturations <90% and respiratory distress score >4.[55]

Arterial blood gases should be obtained every 4 to 6 hours, and FiO₂ should be adjusted to maintain oxygen saturations between 92% and 97% or higher, and PaO₂ of 80 to 100 mmHg (10.3 to 13.0 kPa).

Plus – antibiotics plus supportive care

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ACUTE
|
moderate MAS
Plus – 

antibiotics plus supportive care

Treatment recommended for ALL patients in selected patient group

Treatment with intravenous broad-spectrum antibiotics (e.g., ampicillin and gentamicin) is initiated in all patients.

Supportive care includes parenteral nutrition with amino acid solution and intralipid solution to meet caloric requirements.

Primary options

ampicillin: 50-100 mg/kg/day intravenously given in divided doses every 6-12 hours depending on age and weight

and

gentamicin: 4-5 mg/kg/day intravenously given in divided doses depending on age and weight

Consider – vasopressor/inotrope

Back
ACUTE
|
moderate MAS
Consider – 

vasopressor/inotrope

Additional treatment recommended for SOME patients in selected patient group

Infants with MAS are prone to developing hypertension, especially after receiving sedatives. Inotropes such as dopamine, dobutamine, and adrenaline (epinephrine) may be administered to maintain a higher systemic pressure and avoid hypotension from simultaneous administration of sedatives. Due to dopamine’s non-selective systemic and pulmonary vasoconstriction it can often lead to increased pulmonary vascular resistance. Expert consensus therefore now supports the use of dobutamine and/or adrenaline (which is also a vasopressor) to support cardiac function in MAS, particularly when pulmonary hypertension is suspected.[61][62]

Consult a specialist for guidance on suitable inotrope/vasopressor regimens and doses.

Consider – surfactant

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ACUTE
|
moderate MAS
Consider – 

surfactant

Additional treatment recommended for SOME patients in selected patient group

Pulmonary surfactant may be altered or inactivated in babies with MAS. A bolus dose of surfactant may be given through the endotracheal tube. If pneumothorax is present, it should be treated before giving surfactant therapy. Evidence suggests that surfactant administration in infants with moderate to severe MAS decreases the risk of progressive respiratory failure that requires support with extracorporeal membrane oxygenation (ECMO).[56][57][58]

Lung lavage with diluted surfactant in intubated infants in small aliquots may be considered, especially in units where further ECMO support is not available. Lung lavage with diluted surfactant may be beneficial, but further clinical trials are needed to determine long-term outcomes.[59][60] [ Cochrane Clinical Answers logo ] Only an experienced specialist should perform lung lavage, as it is associated with severe desaturations.

Primary options

beractant intratracheal: 100-150 mg/kg endotracheal bolus

2nd line – conventional mechanical ventilation

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ACUTE
|
moderate MAS
2nd line – 

conventional mechanical ventilation

Infants who continue to exhibit respiratory distress should be intubated and mechanically ventilated. Intubation criteria include FiO₂ >0.60, increased work of breathing or apnoea, and deteriorating ABG values showing low PaO₂ (<50 mmHg, PaCO₂ 70 mmHg, dropping pH to <7.25). Once the infant is intubated and stabilised, blood gases and CXR should be obtained to reassess the condition.

In mechanically ventilated patients, sedation is preferable to muscle paralysis, although evidence-based recommendations to support this are lacking. Sedation decreases the agitation and frequent desaturation seen in these infants.

Plus – antibiotics plus supportive care

Back
ACUTE
|
moderate MAS
Plus – 

antibiotics plus supportive care

Treatment recommended for ALL patients in selected patient group

Treatment with intravenous broad-spectrum antibiotics (e.g., ampicillin and gentamicin) is initiated in all patients.

Supportive care includes parenteral nutrition with amino acid solution and intralipid solution to meet caloric requirements.

Primary options

ampicillin: 50-100 mg/kg/day intravenously given in divided doses every 6-12 hours depending on age and weight

and

gentamicin: 4-5 mg/kg/day intravenously given in divided doses depending on age and weight

Consider – vasopressor/inotrope

Back
ACUTE
|
moderate MAS
Consider – 

vasopressor/inotrope

Additional treatment recommended for SOME patients in selected patient group

Infants with MAS are prone to developing hypertension, especially after receiving sedatives. Inotropes such as dopamine, dobutamine, and adrenaline (epinephrine) may be administered to maintain a higher systemic pressure and avoid hypotension from simultaneous administration of sedatives. Due to dopamine’s non-selective systemic and pulmonary vasoconstriction it can often lead to increased pulmonary vascular resistance. Expert consensus therefore now supports the use of dobutamine and/or adrenaline (which is also a vasopressor) to support cardiac function in MAS, particularly when pulmonary hypertension is suspected.[61][62]

Consult a specialist for guidance on suitable inotrope/vasopressor regimens and doses.

3rd line – conventional or high-frequency ventilation plus inhaled nitric oxide (iNO)

Back
ACUTE
|
moderate MAS
3rd line – 

conventional or high-frequency ventilation plus inhaled nitric oxide (iNO)

Infants who are refractory to mechanical ventilation with high oxygen inspiration and surfactant treatment invariably have concomitant persistent pulmonary hypertension (PPHN). iNO should be given with a starting concentration of 20 ppm, along with conventional or high-frequency ventilation, if dual pulse oximetry or echocardiography demonstrates right-to-left shunt and oxygen index is >25.[63][64] Echocardiographic evaluation is recommended before initiating iNO therapy to rule out cardiac disease and to assess pulmonary artery pressure and ventricular function. About 60% of infants with PPHN respond to iNO therapy.[63]

Once FiO₂ can be weaned to 0.60, then iNO should be weaned gradually. Methaemoglobin should be monitored.

In patients who are difficult to wean from iNO, sildenafil (a phosphodiesterase-5 inhibitor) can be added;[68][69] however, it should be used cautiously (i.e., when the benefit-risk profile is acceptable) with appropriate cardiac evaluation, and high doses and long-term use should be avoided due to an increased risk of mortality in paediatric patients. Revatio (sildenafil): drug safety communication - FDA clarifies warning about pediatric use for pulmonary arterial hypertension Opens in new window

In mechanically ventilated patients, sedation is preferable to muscle paralysis, although evidence-based recommendations to support this are lacking. Sedation decreases the agitation and frequent desaturation seen in these infants.

Plus – antibiotics plus supportive care

Back
ACUTE
|
moderate MAS
Plus – 

antibiotics plus supportive care

Treatment recommended for ALL patients in selected patient group

Treatment with intravenous broad-spectrum antibiotics (e.g., ampicillin and gentamicin) is indicated in all patients.

Supportive care includes giving intravenous fluids. Infants with severe MAS may need initial fluid bolus (10 mL/kg). However, it subsequently should be restricted to 70 to 80 mL/kg/day, unless infant is asphyxiated, in which case it should be restricted even further (60 mL/kg/day). Sodium can be initiated at 1 to 2 mmol/kg/day (1-2 mEq/kg/day) on the first day.

Primary options

ampicillin: 50-100 mg/kg/day intravenously given in divided doses every 6-12 hours depending on age and weight

and

gentamicin: 4-5 mg/kg/day intravenously given in divided doses depending on age and weight

Consider – vasopressor/inotrope

Back
ACUTE
|
moderate MAS
Consider – 

vasopressor/inotrope

Additional treatment recommended for SOME patients in selected patient group

Infants with MAS are prone to developing hypertension, especially after receiving sedatives. Inotropes such as dopamine, dobutamine, and adrenaline (epinephrine) may be administered to maintain a higher systemic pressure and avoid hypotension from simultaneous administration of sedatives. Due to dopamine’s non-selective systemic and pulmonary vasoconstriction it can often lead to increased pulmonary vascular resistance. Expert consensus therefore now supports the use of dobutamine and/or adrenaline (which is also a vasopressor) to support cardiac function in MAS, particularly when pulmonary hypertension is suspected.[61][62]

Consult a specialist for guidance on suitable inotrope/vasopressor regimens and doses.

severe MAS

1st line – high-frequency mechanical ventilation plus inhaled nitric oxide (iNO)

Back
ACUTE
|
severe MAS
1st line – 

high-frequency mechanical ventilation plus inhaled nitric oxide (iNO)

Patients in this group include infants who are refractory to mechanical ventilation with high oxygen inspiration and surfactant treatment or with severe respiratory distress at presentation. These infants are best managed at a level III neonatal intensive care unit (NICU; or IV, if no extracorporeal membrane oxygenation available at level III) under the care of a neonatologist.

Treatment consists of high-frequency ventilation plus iNO. Echocardiographic evaluation is recommended before initiating iNO therapy to rule out cardiac disease and to assess pulmonary artery pressure and ventricular function.

iNO should be given with starting concentration of 20 ppm, along with conventional or high-frequency ventilation, if dual pulse oximetry or echocardiography demonstrates right-to-left shunt and oxygen index is >25.[63][64]

Once FiO₂ can be weaned to 0.60, then iNO should be weaned gradually. Methaemoglobin should be monitored.

In patients who are difficult to wean from iNO, sildenafil (a phosphodiesterase-5 inhibitor) can be added;[68][69] however, it should be used cautiously (i.e., when the benefit-risk profile is acceptable) with appropriate cardiac evaluation, and high doses and long-term use should be avoided due to an increased risk of mortality in paediatric patients. Revatio (sildenafil): drug safety communication - FDA clarifies warning about pediatric use for pulmonary arterial hypertension Opens in new window

In mechanically ventilated patients, sedation is preferable to muscle paralysis, although evidence-based recommendations to support this are lacking. Sedation decreases the agitation and frequent desaturation seen in these infants.

Plus – antibiotics plus supportive care

Back
ACUTE
|
severe MAS
Plus – 

antibiotics plus supportive care

Treatment recommended for ALL patients in selected patient group

Treatment with intravenous broad-spectrum antibiotics (e.g., ampicillin and gentamicin) is initiated in all patients.

Supportive care includes parenteral nutrition with amino acid solution and intralipid solution to meet caloric requirements.

Primary options

ampicillin: 50-100 mg/kg/day intravenously given in divided doses every 6-12 hours depending on age and weight

and

gentamicin: 4-5 mg/kg/day intravenously given in divided doses depending on age and weight

Plus – vasopressor/inotrope

Back
ACUTE
|
severe MAS
Plus – 

vasopressor/inotrope

Treatment recommended for ALL patients in selected patient group

Inotropes such as dobutamine can be used in infants with MAS and PPHN to maintain higher systemic pressure and avoid hypotension from simultaneous administration of sedatives. Adrenaline (epinephrine) may also be used for its combined inotrope and vasopressor properties. Arterial blood pressure must be maintained in suprasystemic pressure to overcome a right-to-left shunt at the ductal level secondary to PPHN.

Consult a consultant for guidance on suitable inotrope/vasopressor regimens and doses.

Consider – surfactant

Back
ACUTE
|
severe MAS
Consider – 

surfactant

Additional treatment recommended for SOME patients in selected patient group

Pulmonary surfactant may be altered or inactivated in babies with MAS. A bolus dose of surfactant may be given through the endotracheal tube. If pneumothorax is present, it should be treated before giving surfactant therapy. Evidence suggests that surfactant administration in infants with moderate to severe MAS decreases the risk of progressive respiratory failure that requires support with extracorporeal membrane oxygenation (ECMO).[56][57][58]

Lung lavage with diluted surfactant in intubated infants in small aliquots may be considered, especially in units where further ECMO support is not available. Lung lavage with diluted surfactant may be beneficial, but further clinical trials are needed to determine long-term outcomes.[59][60] [ Cochrane Clinical Answers logo ] Only an experienced specialist should perform lung lavage, as it is associated with severe desaturations.

Primary options

beractant intratracheal: 100-150 mg/kg endotracheal bolus

2nd line – extracorporeal membrane oxygenation (ECMO)

Back
ACUTE
|
severe MAS
2nd line – 

extracorporeal membrane oxygenation (ECMO)

If there is no response to iNO therapy along with high-frequency ventilation, infants should be placed on ECMO. Indications include alveolar-arterial oxygen gradient >610 mmHg and oxygen index ≥40.[65][66]

In mechanically ventilated patients, sedation is preferable to muscle paralysis, although evidence-based recommendations to support this are lacking. Sedation decreases the agitation and frequent desaturation seen in these infants.

Plus – antibiotics plus supportive care

Back
ACUTE
|
severe MAS
Plus – 

antibiotics plus supportive care

Treatment recommended for ALL patients in selected patient group

Treatment with intravenous broad-spectrum antibiotics (e.g., ampicillin and gentamicin) is indicated in all patients.

Supportive care includes parenteral nutrition with amino acid solution and intralipid solution to meet caloric requirements.

Primary options

ampicillin: 50-100 mg/kg/day intravenously given in divided doses every 6-12 hours depending on age and weight

and

gentamicin: 4-5 mg/kg/day intravenously given in divided doses depending on age and weight

Plus – vasopressor/inotrope

Back
ACUTE
|
severe MAS
Plus – 

vasopressor/inotrope

Treatment recommended for ALL patients in selected patient group

Inotropes such as dobutamine can be used in infants with MAS and PPHN to maintain higher systemic pressure and avoid hypotension from simultaneously giving sedatives. Adrenaline (epinephrine) may also be used for its combined inotrope and vasopressor properties. Arterial blood pressure must be maintained in suprasystemic pressure to overcome a right-to-left shunt at the ductal level secondary to PPHN.

Consult a consultant for guidance on suitable inotrope/vasopressor regimens and doses.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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