***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: In the GRADE approach , r and omized trials start as high- quality evidence and observational studies as low- quality evidence , but both can be rated down if most of the relevant evidence comes from studies that suffer from a high risk of bias . Well-established limitations of r and omized trials include failure to conceal allocation , failure to blind , loss to follow-up , and failure to appropriately consider the intention-to-treat principle . More recently recognized limitations include stopping early for apparent benefit and selective reporting of outcomes according to the results . Key limitations of observational studies include use of inappropriate controls and failure to adequately adjust for prognostic imbalance . Risk of bias may vary across outcomes ( e.g. , loss to follow-up may be far less for all-cause mortality than for quality of life ) , a consideration that many systematic review s ignore . In deciding whether to rate down for risk of bias -- whether for r and omized trials or observational studies -- authors should not take an approach that averages across studies . Rather , for any individual outcome , when there are some studies with a high risk , and some with a low risk of bias , they should consider including only the studies with a lower risk of bias Objectives : Examining the effects of tracheal suctioning on cerebral hemodynamics of normotensive ventilated very low birth weight ( VLBW ) infants with normal cranial ultrasounds ; determining the factor(s ) influencing changes in mean cerebral blood flow velocity ( CBFv ) after suctioning . Methods : Seventy-three VLBW infants had continuous monitoring of mean arterial blood pressure ( MABP ) , PaCO2 , PaO2 and mean CBFv before , during , and after 202 suctioning sessions during the first week of life . Peak ( or nadir ) and relative changes of the four variables for 45 min after suctioning were calculated . Multiple linear regression was used to determine the factor(s ) influencing changes in mean CBFv after suctioning . Result : Birth weight was 928±244 g ; gestational age was 27.0±2.0 weeks . Mean CBFv increased to 31.0±26.4 % after suctioning and remained elevated for 25 min . PaCO2 was highly associated with mean CBFv ( P<0.001 ) , whereas MABP and PaO2 were not . Conclusion : We observed prolonged increases of mean CBFv following suctioning in ventilated VLBW infants that were previously unrecognized . This is concerning since disturbances of CBF may be associated with subsequent brain injury Abstract A numeric scoring system for the assessment of hypoxic ischaemic encephalopathy during the neonatal period was tested . The value of the score in predicting neurodevelopmental outcome at 1 y of age was assessed . Forty‐five infants who developed hypoxic ischaemic encephalopathy after birth were studied prospect ively . In addition to the hypoxic ischaemic encephalopathy score all but two infants had at least one cranial ultrasound examination .  Thirty‐five infants were evaluated at 12 months of age by full neurological examination and the Griffiths Scales of Mental Development . Five infants were assessed at an earlier stage , four who died before 6 months of age and one infant who was hospitalized at the time of the 12 month assessment . Twenty‐three ( 58 % ) of the infants were normal and 17 ( 42 % ) were abnormal , 16 with cerebral palsy and one with developmental delay . The hypoxic ischaemic encephalopathy score was highly predictive for outcome . The best correlation with outcome was the peak score ; a peak score of 15 or higher had a positive predictive value of 92 % and a negative predictive value of 82 % for abnormal outcome , with a sensitivity and specificity of 71 % and 96 % , respectively . For the clinician working in areas where sophisticated technology is unavailable this scoring system will be useful for assessment of infants with hypoxic ischaemic encephalopathy and for prognosis of neurodevelopmental outcome The effect of oro-naso-pharyngeal suction at birth on pulmonary mechanics is described in a r and om assigned controlled study of 40 normal term vaginally born infants . Twenty cases had their oro-naso-pharynx suctioned immediately after birth ( S Group ) , whereas 20 were not suctioned in the neonatal period ( NS Group ) . A computerized pneumotachographic system ( MECVENT ) was used for the assessment of respiratory mechanics ( Dynamic Compliance ( C. Dyn . ) and Total Pulmonary Resistance ( R ) in inspiration and expiration at 10 , 30 and 120 minutes after birth . In both groups the C. Dyn increased during the study period whereas the R decreased , mainly in the initial 30 minutes . No significant differences were observed between S and NS groups for any of the parameters of respiratory mechanics . The results obtained in this study provide no physiological basis to recommend routine airway suction at birth in normal , term , vaginally born infants Adverse changes in cerebral hemodynamics during endotracheal suctioning have been reported in conventionally ventilated newborns , whereas observations on the effect of endotracheal suctioning during high-frequency ventilation have not been reported to date . The present study was design ed to investigate the effect of endotracheal suctioning on cerebral hemodynamics in high-frequency and conventionally ventilated infants . Changes in cerebral concentration of oxygenated ( cO(2)Hb ) and deoxygenated hemoglobin ( cHHb ) and oxidized cytochrome aa3 ( cCyt.aa3 ) were measured by noninvasive near-infrared spectroscopy . In an open prospect i ve study , 26 suctioning periods in 9 high-frequency and in 6 conventionally ventilated newborn infants were investigated . Heart rate , arterial oxygen saturation ( SaO(2 ) ) , mean blood pressure ( MABP ) , and transcutaneous carbon dioxide tension ( TcpCO(2 ) ) were monitored continuously . In both groups , a marked decrease in heart rate , SaO(2 ) and in cO(2)Hb , an increase in cHHb , and a variable pattern in the concentration of total hemoglobin were noted during endotracheal suctioning . During suctioning , no statistically significant differences between the two methods of mechanical ventilation could be observed . We conclude that the mode of ventilation had no significant effect on changes in cerebral hemodynamics during endotracheal suctioning BACKGROUND Wiping of the mouth and nose at birth is an alternative method to oronasopharyngeal suction in delivery-room management of neonates , but whether these methods have equivalent effectiveness is unclear . METHODS For this r and omised equivalency trial , neonates delivered at 35 weeks ' gestation or later at the University of Alabama at Birmingham Hospital , Birmingham , AL , USA , between October , 2010 , and November , 2011 , were eligible . Before birth , neonates were r and omly assigned gentle wiping of the face , mouth ( implemented by the paediatric or obstetric resident ) , and nose with a towel ( wipe group ) or suction with a bulb syringe of the mouth and nostrils ( suction group ) . The primary outcome was the respiratory rate in the first 24 h after birth . We hypothesised that respiratory rates would differ by fewer than 4 breaths per min between groups . Analysis was by intention to treat . This study is registered with Clinical Trials.gov , number NCT01197807 . FINDINGS 506 neonates born at a median of 39 weeks ' gestation ( IQR 38 - 40 ) were r and omised . Three parents withdrew consent and 15 non-vigorous neonates with meconium-stained amniotic fluid were excluded . Among the 488 treated neonates , the mean respiratory rates in the first 24 h were 51 ( SD 8) breaths per min in the wipe group and 50 ( 6 ) breaths per min in the suction group ( difference of means 1 breath per min , 95 % CI -2 to 0 , p<0·001 ) . INTERPRETATION Wiping the nose and mouth has equivalent efficacy to routine use of oronasopharyngeal suction in neonates born at or beyond 35 weeks ' gestation . FUNDING None OBJECTIVE To assess whether endotracheal suctioning of nonvigorous infants born through meconium stained amniotic fluid ( MSAF ) reduces the risk and complications of meconium aspiration syndrome ( MAS ) . STUDY DESIGN Term , nonvigorous babies born through MSAF were r and omized to endotracheal suction and no-suction groups ( n=61 in each ) .  Risk of MAS , complications of MAS and endotracheal suction , mortality , duration of neonatal intensive care unit stay , and neurodevelopmental outcome at 9 months were assessed . RESULTS Maternal age , consistency of meconium , mode of delivery , birth weight , sex , and Apgar scores were similar in the groups . In total , 39 ( 32 % ) neonates developed MAS and 18 ( 14.8 % ) of them died . There were no significant differences in MAS , its severity and complications , mortality , and neurodevelopmental outcome for the 2 groups . One infant had a complication of endotracheal suctioning , which was mild and transient . CONCLUSIONS The current practice of routine endotracheal suctioning for nonvigorous neonates born through MSAF should be further evaluated . TRIAL REGISTRATION Clinical Trial Registry of India : CTRI/2013/03/003469 The purpose of the study was to examine the effects of bulb suctioning on healthy , term newborns and the feasibility of conducting a large-scale study of this practice . In a r and omized , controlled two-group design pilot study , 10 newborns received oronasopharyngeal bulb suctioning at birth and 10 did not . Differences in Apgar scores , heart rates , and oxygen saturation levels were determined . Infants were r and omized to groups before delivery . The participants were 20 term , healthy newborns of uncomplicated pregnancies .  Apgar scores , heart rates , and oxygen saturation levels in the first 20 minutes of life were the main outcome variables . There were no statistically significant differences in Apgar scores between groups . Apgar scores at 5 and 10 minutes were 9 or 10 for all newborns . Newborns receiving bulb suctioning showed a statistically significant , lower heart rate ( P=.042 ) during the first 20 minutes and a significantly higher SpO2 level ( P=.005 ) by 15 minutes of age . Although statistically significant , these findings were not considered clinical ly significant because values remained within normal parameters BACKGROUND Meconium aspiration syndrome ( MAS ) is a life-threatening respiratory disorder in infants born through meconium-stained amniotic fluid ( MSAF ) . Although anecdotal data concerning the efficacy of intrapartum oropharyngeal and nasopharyngeal suctioning of MSAF are conflicting , the procedure is widely used . We aim ed to assess the effectiveness of intrapartum suctioning for the prevention of MAS . METHODS We design ed a r and omised controlled trial in 11 hospitals in Argentina and one in the USA . 2514 patients with MSAF of any consistency , gestational age at least 37 weeks , and cephalic presentation were r and omly assigned to suctioning of the oropharynx and nasopharynx ( including the hypopharynx ) before delivery of the shoulders ( n=1263 ) , or no suctioning before delivery ( n=1251 ) . Postnatal delivery-room management followed Neonatal Resuscitation Program guidelines . The primary outcome was incidence of MAS . Clinicians diagnosing the syndrome and design ating other study outcomes were masked to group assignment . An informed consent waiver was used . Analysis was by intention to treat . FINDINGS 18 infants in the suction group and 15 in the no suction group did not meet entry criteria after r and om assignment . 87 in the suction group were not suctioned , and 26 in the no suction group were suctioned . No significant difference between treatment groups was seen in the incidence of MAS ( 52 [ 4 % ] suction vs 47 [ 4 % ] no suction ; relative risk 0.9 , 95 % CI 0.6 - 1.3 ) , need for mechanical ventilation for MAS ( 24 [ 2 % ] vs 18 [ 1 % ] ; 0.8 , 0.4 - 1.4 ) , mortality ( 9 [ 1 % ] vs 4 [ 0.3 % ] ; 0.4 , 0.1 - 1.5 ) , or in the duration of ventilation , oxygen treatment , and hospital care . INTERPRETATION Routine intrapartum oropharyngeal and nasopharyngeal suctioning of term-gestation infants born through MSAF does not prevent MAS . Consideration should be given to revision of present recommendations Abstract Oronasopharyngeal suction ( ONPS ) with a suction bulb at birth is a traditional practice in the initial management of healthy infants in Iran and many other countries . The purpose of this study was to compare the effects of oronasopharyngeal suction ( ONPS ) with those of no suction in normal , term newborns delivered vaginally . A total of 170 healthy term infants of first and single uncomplicated pregnancies , with clear amniotic fluid , vaginal delivery and cephalic presentation , enrolled in the trial during labour . Newborns were r and omised into one of the two groups , according to the use of the ONPS procedure . Arterial oxygen saturation ( SaO2 ) levels , heart rates , blood gases of umbilical cord and Apgar scores were determined . The mean SaO2 values over the first and fifth min of 
    Output:
    
The currently available evidence does not support or refute the benefits or harms of routine oro/nasopharyngeal suction over no suction .