Interventions to improve neonatal and infant intubation success: a meta-analysis

The aim of this study is to synthesize and evaluate the effectiveness of interventions aimed at improving endotracheal intubation success in neonates and infants. PubMed, Scopus, and Web of Science were searched from inception through July 2025. Randomized studies involving neonatal or infant endotracheal intubation were included regardless of intervention or comparator. Two reviewers independently extracted data and assessed risk of bias. Data were pooled using a random-effects inverse-variance model. Results are reported as risk ratios (RRs) with 95% confidence intervals (CIs). Certainty of evidence was assessed using the GRADE approach. Thirty studies published between 2002 and 2025 were included from 287 screened records. Most intubations were elective and performed in neonatal intensive care units or operating rooms. Video laryngoscopy improved first-attempt success compared with direct laryngoscopy (RR 1.13; 95% CI 1.06-1.20; high-certainty evidence). Pharmacologic interventions, particularly neuromuscular blocking agents and sedatives, generally increased success. Noninvasive respiratory support during intubation improved success (RR 1.18; 95% CI 1.02-1.38; moderate-certainty evidence). Time to successful intubation was similar across most interventions, except for neuromuscular blockade, which shortened intubation duration. Desaturation-related outcomes did not differ. CONCLUSION: Video laryngoscopy improves first-attempt intubation success with high-certainty evidence, and noninvasive respiratory support most likely improves success. These findings support their use during neonatal and infant intubation. WHAT IS KNOWN: • Intubation in neonates and infants carries a high complication risk, making fi rst-attempt successcritical. • Video laryngoscopy and pharmacological premedication each improve intubation conditions but have previouslybeen evaluated in isolation. WHAT IS NEW: • Pooled randomized evidence confi rms with high certainty that video laryngoscopy improves fi rst-attempt success over direct laryngoscopy without prolonging intubation time. • Non-invasive respiratory support during intubation most likely improves fi rst-attempt success and physiologicalsafety.