Our practice has a resuscitation team, including a neonatal provider proficient in intubation, to attend deliveries associated with MSAF. The determination of a newborn being vigorous or nonvigorous was made soon after birth by the resuscitation team during both retrospective and prospective time periods. During the prospective time period, when the newborn appeared nonvigorous, the newborn was handed over by the obstetric provider to the neonatal provider, and routine initial steps of resuscitation were performed on the warmer. The label of nonvigorous was given before initial stimulation was performed. We do not believe that the prospective nonvigorous cohort in our study was sicker than the retrospective cohort given the fact that only 55% needed positive pressure ventilation. The rest of them responded to routine initial steps of resuscitation, such as drying and stimulation. The 1- and 5-minute Apgar scores and the proportion of newborns with a 1-minute Apgar score of <3 and/or a 5-minute Apgar score of <7 were similar between both retrospective and prospective groups. We agree that other practices may be different from ours; hence, the incidence of MAS needs to be monitored with different denominators, such as all the term newborns or all the term newborns born through MSAF. However, because the major revision was in the management of newborns who were nonvigorous, it was important to report the change with the denominator being all the newborns who were nonvigorous and meconium stained. There was a risk of diluting the effect of the change with the denominator being all newborns born through MSAF because we know the majority of newborns who are meconium stained are vigorous (∼90%); however, newborns who are nonvigorous are at a higher risk for respiratory issues, including MAS.

As for now, we respectfully follow NRP suggestions while we await more published evidence. In addition, we will continue to monitor our practice over a longer period of time, and we plan to present the respiratory data after adjustment of risk factors on all term newborns born through MSAF.

We thank the NRP Steering Committee for the comprehensive response and appreciate their kind comments toward our article.1  Although we respect the AHA NRP for transparency, we do agree with the excellent commentary by Wiswell2  that there was no compelling evidence that harm outweighed the benefit of endotracheal suctioning in newborns who were nonvigorous and meconium stained to recommend revision of decades of routine practice.3  We strongly believe that a large RCT is needed to have a definitive answer to the question concerning optimal management of newborns born through MSAF who are nonvigorous.

1
Chiruvolu
A
,
Miklis
KK
,
Chen
E
,
Petrey
B
,
Desai
S
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Delivery room management of meconium-stained newborns and respiratory support
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2018
;
142
(
6
):
e20181485
2
Wiswell
TE
.
Appropriate management of the nonvigorous meconium-stained neonate: an unanswered question
.
Pediatrics
.
2018
;
142
(
6
):
e20183052
3
Wyckoff
MH
,
Aziz
K
,
Escobedo
MB
, et al
.
Part 13: neonatal resuscitation: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care (reprint)
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2015
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Competing Interests

CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose.