Videolaryngoscopy versus direct laryngoscopy for paediatric tracheal intubation: a systematic review with meta-analysis and trial sequential analysis.

Background Paediatric tracheal intubation presents unique challenges owing to anatomical and physiological characteristics. Multiple intubation attempts increase the risk of severe complications; therefore, achieving high first-pass success is critical. Videolaryngoscopy (VL) represents an alternative to direct laryngoscopy (DL), but its comparative efficacy, safety, and clinical impact in paediatric practice remain under investigation. Methods This systematic review and meta-analysis evaluated VL vs DL for paediatric tracheal intubation, focusing on first-attempt success rate, glottic visualisation, intubation time, and critical events. Eight databases were searched. RCTs comparing VL and DL in paediatric patients (<16 yr) were included. Results Of 22 221 screened articles, 53 RCTs (4887 patients) met inclusion criteria. VL and DL showed comparable first-attempt tracheal intubation success rates, without a statistically significant difference (risk ratio: 1.03, 95% confidence interval [95% CI]: 0.99-1.07, P=0.18). Certainty of evidence was rated as high by the Grading of Recommendations Assessment, Development, and Evaluation criteria. Intubation time was slightly longer with VL (mean difference: +3 s, 95% CI: 0.1-5.4). VL improved glottic visualisation across all paediatric age groups (Percentage of Glottic Opening score, mean difference: 9.8%, 95% CI: 3.2-16.4, P<0.01) and reduced oesophageal intubation in children under 1 yr of age (risk ratio: 0.16, 95% CI: 0.06-0.40, P<0.01). Conclusions In paediatric patients with mostly normal airways, no significant differences were observed between VL and DL in achieving first-attempt tracheal intubation success. VL improved glottic visualisation, and, in patients under 1 yr of age, reduced oesophageal intubation with low certainty of evidence. Trial sequential analysis indicates that the available data remain underpowered to confirm a definitive effect.Systematic Review Protocol PROSPERO (CRD42024498524).