Helping Newborns Get a Breathing Tube Safely: What Two New Studies Tell Families About Cameras, Nose Support and Pre-Procedure Medicines

A plain-language look at the Tjurin 2026 meta-analysis and the SUPREMEneo 2026 study of how doctors prepare babies for intubation

When a sick or very small newborn cannot breathe well alone, doctors may place a breathing tube. Research shows that using a camera-equipped instrument makes the first try more likely to work, and gentle breathing help through the nose probably does too. Most babies now get medicine beforehand, though often not the exact combination experts recommend.

Why Placing a Breathing Tube in a Newborn Needs So Much Care

Sometimes a newborn (the medical word is neonate, and neonatal means relating to newborns) needs a soft plastic tube placed into the windpipe so a machine can help with breathing. This procedure is called intubation. Babies have very small airways and very little oxygen in reserve, so if the first attempt does not work or takes too long, the baby's oxygen level can drop and the heart can slow down. That is why neonatal teams spend so much effort planning how to make intubation work smoothly and gently.

Two Studies Looked at the Same Question in Different Ways

Two recent studies approach this question from different angles. The first, by Tjurin and colleagues, is a meta-analysis, which means the researchers collected and combined the results of many earlier studies ^[1]. It gathered 30 randomized trials, in which babies are assigned by chance to one approach or another, from hospitals across Asia, Europe, North America and elsewhere, done in intensive care units, operating rooms and delivery rooms. The second, called SUPREMEneo (a prospective multicentre observational study of premedication before laryngoscopy in neonates), was led by Tauzin and colleagues ^[2]. Rather than testing a new treatment, it watched what doctors actually did in 141 neonatal units: 122 of the 190 French units invited and all 19 Belgian units. Multicentre simply means many hospitals took part. Put simply, the first study asks what works best, and the second asks what is really being done.

How Doctors Came to Use Medicine Before Intubation

Giving medicine before intubation has been a topic of discussion for years. In 2010, the American Academy of Pediatrics published a statement recommending medicine beforehand for planned, non-emergency intubation ^[3]. Researchers have tested different combinations of drugs. One early trial compared atropine and fentanyl with atropine, fentanyl and mivacurium ^[4], and a later trial compared two combinations, one built around propofol and one around atracurium and sufentanil, and looked at how often babies' oxygen levels fell ^[5]. Propofol is a sedative, but one study reported that it can cause a significant drop in blood pressure in premature babies ^[6]. In 2023, the French Society of Neonatology published a statement advising either a fast-acting pain medicine plus a muscle relaxant, or propofol alone as long as the baby's blood pressure and circulation are stable ^[7]. A study of French premature babies had also looked at how often medicine was used for delivery-room intubations ^[8]. What nobody knew was whether units had changed their practice, and how much of the rest of the toolkit rested on solid trials.

A Camera on the Breathing Tube Instrument Helps More Babies on the First Try

The most reliable finding was about equipment. A video laryngoscope has a tiny camera so the doctor can see the airway on a screen. Across 13 trials including 2,029 babies, the video instrument helped doctors place the tube on the first try more often than the standard instrument, and the strength of the evidence was rated high ^[1]. Researchers rate evidence as high, moderate, low or very low: high means we can be quite confident the true effect is close to the result, while very low means the result could easily change with more research. The relative improvement was about 13%. It did not make the procedure quicker, but it made success on the first try more likely. The researchers concluded that video laryngoscopy should be a priority for newborns and infants. Another randomized trial compared the two instruments for urgent intubation of newborns ^[9]. You can read more in our article on video laryngoscopy in neonatal intubation.

Gentle Breathing Help Through the Nose Probably Helps Too

Doctors can also keep giving air or oxygen through small tubes at the nose while they work on the breathing tube. When three trials with 444 babies were combined, this kind of support probably raised the chance of success on the first try, and the evidence was rated moderate ^[1]. In one trial, low oxygen levels happened in about 32% of babies with one kind of nose support, compared with about 57% of babies who received standard care, and they lasted about 10 seconds rather than 20. Another randomized trial studied nasal high-flow therapy, a steady stream of air or oxygen delivered through the nose, during intubation ^[10]. Our article on noninvasive breathing support during intubation explains the details.

Medicines Before the Procedure: Helpful, but Hard to Compare

For medicines, the trials were small and tested many different drugs, so the researchers could not say which medicine is best ^[1]. Still, a few signals stood out. Medicines that relax the muscles seemed to help doctors succeed, and they shortened the procedure by about a minute and a half. Giving any medicine seemed better than intubating an awake baby, although that finding came from only 20 babies, so it should be treated with caution. Side effects other than low oxygen levels were not consistently reported across trials, which means we know less about safety than we would like. International expert guidelines on airway care for newborns and infants offer wider guidance ^[11].

What Doctors Actually Do: Most Babies Get Medicine, but Not Always the Recommended Kind

The SUPREMEneo team followed 673 procedures in 2024, about a year after the French guidance was published ^[2]. Among 396 planned, non-emergency intubations, about 9 in 10 babies received some medicine first (doctors call this premedication). However, fewer than half, about 43%, received one of the combinations that the guideline recommends. For the surfactant procedure, in which a medicine that helps the lungs is given through a thin tube, about 9 in 10 babies also received medicine, and about half got propofol alone. Compared with an earlier French study in which 47% of intubations had medicine, 71% now did, and medicine in the delivery room rose from 5% to 51% ^[8]. This is real progress, even though many units are still working out the best approach.

Why Some Babies Did Not Get Medicine

When medicine was not given for planned intubations, the most common reason, when the reason was recorded, was that the baby did not yet have a vein for the medicine, which was true for about 4 in 10 of these cases ^[2]. In the delivery room, about half of the planned intubations went ahead without medicine, mainly because there was no vein access. Emergencies also made medicine less likely. Practice also differed a great deal from one hospital to another, which suggests that local habits and routines also shape what babies receive.

Did Medicine Make the Procedure Smoother?

The researchers scored how good the conditions were for placing the tube. Poor conditions were found in about 41% of intubations done without medicine, compared with about 25% when guideline-recommended medicine was used and about 19% with other medicine ^[2]. This suggests that medicine of some kind tends to make conditions better. Side effects did occur even with medicine, including a drop in oxygen levels in about 45% of intubations and a slow heart rate in about 12%, and the neonatal team watches for these closely. A little over half of first tries succeeded in this study, whichever approach was used. Because the study only observed what happened, it cannot prove that the medicine caused the better conditions. For example, babies who are in the most urgent situations may be less likely to receive medicine and also harder to intubate, which could affect the comparison.

Reading the Numbers With Care

Neither study is perfect, and it helps to know why. The meta-analysis combined trials that were done in operating rooms, intensive care units and delivery rooms, with doctors ranging from trainees to expert anaesthetists, and for many medicines only one small trial existed ^[1]. The SUPREMEneo study reached 64% of the French units it invited, so units that chose not to take part may have practised differently ^[2]. In addition, smaller or more extremely premature babies are harder to assess, because the scoring system used to judge conditions was developed mainly for babies born at 30 weeks or later. None of this cancels the findings, but it is why the researchers describe the medicine results as a starting point for better trials rather than a final answer.

What This Means for Families and What Researchers Will Do Next

If your baby needs a breathing tube, you can reasonably expect the team to use a camera instrument when available, provide breathing help during the attempt, and plan medicine unless it is a true emergency. You are welcome to ask what the plan is and why. Questions such as whether a video instrument is available, how the baby will be supported with air during the attempt, and which medicine is planned are all reasonable to raise. If a baby cannot receive medicine, for example because a vein has not yet been found, the team can explain why that decision was made in your baby's situation. Researchers say that more studies are still needed on how well the medicines work and how safe they are, in newborns of all sizes ^[2]. Meanwhile the meta-analysis authors say the evidence strongly supports prioritising video laryngoscopy ^[1]. Neither study is a reason for alarm; both show a field working to make a difficult procedure gentler.

References

1. Tjurin W, Kiviranta P, Salmi H, Kuitunen I. Interventions to improve neonatal and infant intubation success: a meta-analysis. Eur J Pediatr. 2026;185(6):450. doi:10.1007/s00431-026-07119-7 ↩
2. Tauzin M, Tribolet S, Goro S, et al. A Prospective, Multicenter, Observational StUdy of PREMEdication Before Laryngoscopy in NEOnates (SUPREMEneo). J Pediatr. 2026;290:114967. doi:10.1016/j.jpeds.2025.114967 ↩
3. Kumar P, Denson SE, Mancuso TJ; Committee on Fetus and Newborn, Section on Anesthesiology and Pain Medicine. Premedication for nonemergency endotracheal intubation in the neonate. Pediatrics. 2010;125(3):608–615. doi:10.1542/peds.2009-2863 ↩
4. Roberts KD, Leone TA, Edwards WH, Rich WD, Finer NN. Premedication for nonemergent neonatal intubations: a randomized, controlled trial comparing atropine and fentanyl to atropine, fentanyl, and mivacurium. Pediatrics. 2006;118(4):1583–1591. doi:10.1542/peds.2006-0590 ↩
5. Durrmeyer X, Breinig S, Claris O, et al. Effect of atropine with propofol vs atropine with atracurium and sufentanil on oxygen desaturation in neonates requiring nonemergency intubation: a randomized clinical trial. JAMA. 2018;319(17):1790. doi:10.1001/jama.2018.3708 ↩
6. Welzing L, Kribs A, Eifinger F, et al. Propofol as an induction agent for endotracheal intubation can cause significant arterial hypotension in preterm neonates. Paediatr Anaesth. 2010;20(7):605–611. doi:10.1111/j.1460-9592.2010.03330.x ↩
7. Durrmeyer X, Walter-Nicolet E, Chollat C, et al. Premedication before laryngoscopy in neonates: evidence-based statement from the French Society of Neonatology (SFN). Front Pediatr. 2023;10:1075184. doi:10.3389/fped.2022.1075184 ↩
8. Walter-Nicolet E, Courtois E, Milesi C, et al. Premedication practices for delivery room intubations in premature infants in France: results from the EPIPAGE 2 cohort study. PLoS One. 2019;14(4):e0215150. doi:10.1371/journal.pone.0215150 ↩
9. Geraghty LE, Dunne EA, Ní Chathasaigh CM, et al. Video versus direct laryngoscopy for urgent intubation of newborn infants. N Engl J Med. 2024;390(20):1885–1894. doi:10.1056/NEJMoa2402785 ↩
10. Hodgson KA, Owen LS, Kamlin COF, et al. Nasal high-flow therapy during neonatal endotracheal intubation. N Engl J Med. 2022;386(17):1627–1637. doi:10.1056/NEJMoa2116735 ↩
11. Disma N, Asai T, Cools E, et al. Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Br J Anaesth. 2024;132(1):124–144. doi:10.1016/j.bja.2023.08.040 ↩