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Should we reconsider awake neonatal intubation? A review of the evidence and treatment strategies

Tracheal intubation is a frequent and routine neonatal procedure that is often performed without anaesthesia or premedication (1). The concept of painful or uncomfortable procedures performed in a child without analgesia or anaesthesia provokes strong opinions in both the medical and nonmedical literature (2±6). While this issue remains highly emotive, what evidence is there to show that awake intubation in premature and term neonates is detrimental in terms of physical and physiological consequences? Is there evidence to show that neonates have the ability to perceive the noxious stimulus of laryngoscopy as pain? If this evidence exists, what strategies are available to ensure safety and avoid the potential unwanted physical and physiological effects of awake intubation?