Use of suctioning devices such as a bulb syringe is poorly studied in the newborn and infant population. There is minimal literature to identify indications, safe procedures, evaluation, and proper storage and cleaning of these devices for the newborn or infant.

In this special topics series, three articles are presented that discuss clinical situations where suctioning or airway clearance occurs. In Airway Clearance for the Term Newborn, Adams et al. observed suctioning practices of newborns at birth. Overuse of airway clearance procedures was noted despite national guidelines not supportive of routine suctioning of the baby who is breathing, crying, and has good muscle tone. In a retrospective review of airway clearance procedures for moderate to late preterm newborns in a NICU, Harbin, Adams, and O'Neal found airway clearance procedures were common. However, with limited published evidence, protocols are not available to guide the specific procedure steps. In Nasal Airway Clearance for Bronchiolitis, Norris, O'Neal, Adams, and Wyatt provide evidence that noninvasive nasal airway clearance is a supportive measure that is appropriate for the hospitalized infant with acute bronchiolitis.

Nurses in labor and delivery, well-baby nursery, postpartum, NICU, and pediatric settings are responsible for assessing the respiratory status and implementing measures to improve respiratory function of the newborn and infant. Making accurate assessments and safe implementation of airway clearance procedures require a sound knowledge base, validation of clinical skills, evidence-based clinical guidelines published by professional organizations, and specific, clinical agency protocols for each type of airway clearance procedure.

The American Academy of Pediatrics (AAP) and the American Heart Association (AHA) support simple drying of the term newborn, wiping away excess fluids from the mouth and nose, proper positioning of the airway, and provision of a warm environment for babies with spontaneous respirations, adequate crying, and good muscle tone instead of routine suctioning at birth (AAP & AHA, 2016). Although this resource discusses preterm respiratory care at birth, there is a lack of clinical guidelines for airway clearance of the preterm infant in the NICU setting. For the hospitalized infant with acute bronchiolitis, AAP (Ralston et al., 2014) recommends noninvasive nasal airway clearance. Although these evidence-based standards provide general guidelines, they lack specificity in certain areas. For example, AAP recommends gentle suctioning of the term newborn when "copious" secretions or a "blocked" airway is present. However, the guidelines do not objectively define these findings and therefore variation in practice may occur. There is a fair amount of literature related to the intubated preterm newborn, yet minimal literature on use of other devices used in this population. The AAP recommends supportive care for the infant with nasal airway clearance combined with saline, yet the amount of saline per event is not specified.

To improve the science of newborn and infant respiration, rigorously designed research is needed. Once these studies provide sound evidence, specific, clinical agency protocols can be developed for each type of airway clearance procedure. Ideally, these protocols will include a comprehensive list of indications for airway clearance for a specific population; step-by-step procedures with guidelines for each type of device; evaluation of the procedure and documentation of complications or resolution of the indication for suctioning; proper storage of the device to ensure infection control; effective cleaning methods; and patient teaching on home use of the device if necessary. These steps will provide safe, effective airway clearance with strong evidence to support the practice.

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