Video laryngoscopy in pediatric and neonatal intubation is now supported by a substantial body of randomised controlled trial evidence. Tracheal intubation in neonates, infants, and children carries risks that differ fundamentally from adult airway management. Smaller airways, higher oxygen consumption, lower apnoeic tolerance, and greater anatomical variability make every paediatric intubation a high-stakes procedure. The question of whether video laryngoscopy improves outcomes in this population has been debated for over a decade. The evidence has now reached a point of clarity. The current evidence on video laryngoscopy pediatric neonatal intubation is consistent across multiple high-quality randomised controlled trials and meta-analyses.
This post reviews the current clinical evidence on video laryngoscopy in pediatric and neonatal intubation, covering neonates in the NICU, infants and children in the PICU and operating room, and paediatric patients in the emergency department. It also addresses the practical and training implications for departments managing these patient groups.
Why paediatric and neonatal intubation carries unique risks
Every neonatal intubation should be considered a critical event. This is not rhetorical. Neonates and young infants have specific developmental airway anatomy and respiratory physiology features, including high airflow resistance, high airway collapsibility, high oxygen consumption with increased metabolism, and low reserve, that contribute to a higher risk of respiratory failure during any airway intervention.
The consequences of a failed or prolonged intubation attempt in a neonate are more immediate and severe than in adults. Oxygen desaturation occurs faster. Bradycardia follows more rapidly. And the anatomical challenges, including a relatively large tongue, anterior larynx, and short trachea, mean that glottic visualisation is harder to achieve with direct laryngoscopy, particularly for less experienced operators.
Multiple intubation attempts increase the risk of severe complications. Achieving high first-pass success is therefore critical in this population, not just a quality metric.
Video laryngoscopy in neonatal intubation: what the evidence shows
The neonatal evidence base has grown substantially since 2020. Several high-quality systematic reviews and meta-analyses now provide a consistent picture. The strongest data on video laryngoscopy pediatric neonatal intubation comes from four recent meta-analyses.
A 2025 meta-analysis by Li et al. published in Frontiers in Pediatrics included nine randomised controlled trials covering 1,059 neonates. Videolaryngoscopy significantly improved the success rate of first-attempt intubation, with a risk ratio of 1.21 (95% CI 1.06 to 1.38). Trial sequential analysis confirmed these findings were not false positives. Subgroup analyses showed that videolaryngoscopy was particularly beneficial for inexperienced clinicians and when used in the neonatal intensive care unit.
A 2024 systematic review and meta-analysis by Kuitunen et al. published in the European Journal of Pediatrics included 13 studies. Seven studies focused on neonates, where the first-attempt success rate was higher in the video laryngoscopy group, with a risk ratio of 1.18 (CI 1.03 to 1.36). Video laryngoscopy did not increase time to intubation and was associated with fewer adverse events than direct laryngoscopy.
A 2024 neonatal meta-analysis published in ScienceDirect covering seven studies and 897 patients found that video laryngoscopy was associated with a higher first intubation success rate (RR 1.18, p = 0.02) and fewer episodes of oxygen desaturation below 90% (RR 0.84, p = 0.008). The reduction in desaturation events is clinically significant because oxygen desaturation in neonates is directly associated with bradycardia and the need for cardiopulmonary resuscitation.
A broader 2025 systematic review covering 17 randomised controlled trials and 1,918 infants and neonates represents the most comprehensive synthesis of this evidence to date. It integrates all available RCTs spanning both earlier and newly available studies, resolving inconsistencies in trial inclusion across prior syntheses and providing a more reliable assessment of outcomes across clinically important subgroups.
Taken together, the neonatal evidence is consistent: video laryngoscopy raises first-attempt success rates, reduces oxygen desaturation events, and provides particular benefit in NICU settings and for less experienced operators.
Video laryngoscopy in pediatric PICU and operating room intubation
The evidence base for older infants and children mirrors the neonatal findings, with some important distinctions.
The Kuitunen et al. systematic review found that video laryngoscopy improved first-attempt intubation success rates in infants as well as neonates, without increasing time to intubation. The finding that video laryngoscopy did not slow down the procedure is particularly important for departments that have resisted adoption on efficiency grounds.
A 2024 editorial in Translational Pediatrics by Miller, Mallory, and Rotta reviewed the totality of available evidence and concluded directly that video laryngoscopy with high-flow oxygen supplementation should be the standard of care for tracheal intubation of neonates, infants, and children, when readily available. The authors noted that the use of video laryngoscopy in the PICU has increased over time and has been independently associated with a lower occurrence of tracheal intubation adverse events. Benefits also extend to when intubation is performed by advanced practice providers, respiratory therapists, and pediatric emergency medicine physicians.
The 2024 joint guidelines from the European Society of Anaesthesiology and Intensive Care and the British Journal of Anaesthesia on neonatal and infant airway management (Disma N et al., Br J Anaesth, 2024;132(1):124–144) represent the most authoritative European-level guidance on this topic. These guidelines endorse video laryngoscopy as a key tool for neonatal and infant airway management, aligned with the broader trend across adult guidelines including the DAS 2025 guidelines and the ASA 2022 guidelines.
What the evidence shows for the paediatric emergency department
The paediatric emergency department presents the most challenging environment for intubation: unplanned procedures, physiologically unstable patients, variable operator experience, and time pressure. This is where the case for video laryngoscopy is strongest.
A 2024 systematic review by Warinton and Ahmed published in Frontiers in Medicine evaluated videolaryngoscopy versus direct laryngoscopy for intubation of children in emergency departments. The review concluded that videolaryngoscopy offers improved first-pass success rates in paediatric emergency intubation.
A multicenter observational study using data from the National Emergency Airway Registry for Children (NEAR4KIDS), published in the Annals of Emergency Medicine, covered 1,412 tracheal intubation encounters across 11 participating sites. Video-assisted laryngoscopy was associated with increased odds of first-attempt success (OR 2.01, 95% CI 1.48 to 2.73) and decreased odds of severe adverse airway outcomes. The overall first-attempt success rate was 70.0%, and video-assisted laryngoscopy doubled the odds of achieving it.
These findings are particularly relevant for paediatric emergency departments and departments that manage occasional paediatric emergencies alongside adult caseloads. The benefit of video laryngoscopy in the hands of less experienced or infrequent paediatric operators is consistent across studies.
Where video laryngoscopy performs best in paediatric practice
The evidence points to three settings where the benefit of video laryngoscopy is most pronounced.
NICU and PICU intubations. The NICU benefit is driven by two factors: the frequency of less experienced operators performing intubations in these settings, and the physiological vulnerability of the patient population. Subgroup analyses consistently show that video laryngoscopy provides the greatest first-attempt success benefit for non-expert operators.
Emergency intubations. Unplanned intubations in unstable paediatric patients represent the highest-risk scenario in any paediatric setting. The NEAR4KIDS data showing doubled odds of first-attempt success applies directly to this context.
Teaching and training. Video laryngoscopy improves training outcomes in paediatric intubation for the same reason it does in adults: the shared screen allows trainers to guide trainees in real time rather than relying on verbal description. This benefit extends to simulation-based training programmes.
Blade selection for paediatric and neonatal video laryngoscopy
Blade geometry matters in paediatric video laryngoscopy in a way that differs from adult practice. In adults, both hyperangulated and Macintosh-profile blades are well-supported by evidence. In neonates and young infants, the evidence base predominantly covers Macintosh-profile video laryngoscope blades because the anatomical constraints of a neonate’s airway limit the use of highly angulated designs.
For older children and adolescents, the blade selection considerations approach those for adults. Departments managing a mixed paediatric age range should confirm their video laryngoscope system offers appropriate blade sizes and profiles for the full range of patients they intubate.
For a detailed breakdown of how hyperangulated and Macintosh-profile blades compare in difficult airway scenarios, see our analysis of hyperangulated vs Macintosh blade selection. For the role of imaging quality in translating blade design into clinical performance, read why imaging quality matters in intubation success.
The training argument for video laryngoscopy in paediatric settings
One objection raised against video laryngoscopy adoption in paediatric settings is the concern that routine use will erode direct laryngoscopy skills. The evidence does not support this concern.
The shared screen of a video laryngoscope makes direct laryngoscopy teaching more effective, not less. Trainees learning on a Macintosh-profile video laryngoscope blade can observe glottic structures on the monitor while the trainer points out anatomical landmarks in real time. This visual feedback loop is not available with conventional direct laryngoscopy.
For NICU and PICU environments where intubations are performed by a range of providers including neonatologists, intensivists, advanced practice nurses, and respiratory therapists, video laryngoscopy provides a consistent performance floor regardless of operator experience level. The subgroup findings in both the Li et al. and Kuitunen et al. meta-analyses confirm this benefit specifically for inexperienced operators.
What departments should do with this evidence?
The clinical evidence for video laryngoscopy in paediatric and neonatal intubation is now strong enough to guide practice change. Three practical steps follow from the evidence reviewed here.
Step 1: Audit current paediatric video laryngoscope availability. Confirm a device is immediately accessible in your NICU, PICU, and paediatric emergency areas. Equipment that is present only in a central difficult airway kit does not deliver the first-attempt success benefit the evidence shows.
Step 2: Confirm appropriate blade sizes are available. A single adult-sized video laryngoscope does not serve a neonatal population. Verify that your system offers paediatric and neonatal blade sizes and that these are stocked in the relevant clinical areas.
Step 3: Integrate video laryngoscopy into paediatric intubation training. Build video laryngoscopy into your paediatric simulation programme. Use the shared screen as a teaching tool for both direct and video laryngoscopy technique across all operator grades in your NICU and PICU.
Astra-vue’s video laryngoscope systems are available in configurations designed to support both adult and paediatric airway management, with reusable, single-use, and hybrid blade options on a single universal monitor platform. For product specifications and availability, contact our team or explore the full product line.
Frequently asked questions about video laryngoscopy in paediatric and neonatal intubation
Questions about video laryngoscopy pediatric neonatal intubation come from three main clinical groups.
Does video laryngoscopy improve first-attempt success in neonates?
Yes. Multiple meta-analyses now confirm this consistently. The 2025 meta-analysis by Li et al. covering nine RCTs and 1,059 neonates found a risk ratio of 1.21 for first-attempt success with videolaryngoscopy compared to direct laryngoscopy. The benefit was most pronounced for inexperienced clinicians and in NICU settings.
Does video laryngoscopy take longer than direct laryngoscopy in children?
No. The Kuitunen et al. systematic review found no difference in time to intubation between video laryngoscopy and direct laryngoscopy in neonates and infants. This finding is consistent across multiple studies and directly addresses the efficiency objection raised against routine video laryngoscopy adoption.
Is video laryngoscopy recommended in paediatric guidelines?
Yes. The 2024 joint guidelines from the European Society of Anaesthesiology and Intensive Care and the British Journal of Anaesthesia on neonatal and infant airway management endorse video laryngoscopy as a key tool. The ASA 2022 guidelines and DAS 2025 guidelines both support video laryngoscopy strongly in adult practice, and their evidence base extends to paediatric populations.
Does video laryngoscopy benefit less experienced operators more than experts?
Yes. Subgroup analyses in both the Li et al. and Kuitunen et al. meta-analyses show that the first-attempt success benefit is greatest for inexperienced clinicians. Expert operators show smaller but still positive benefit. This finding makes video laryngoscopy particularly valuable in NICU and PICU settings where a range of operator experience levels perform intubations.
What blade size is appropriate for neonatal video laryngoscopy?
Neonatal and infant intubations require appropriately sized paediatric blades. The evidence base for neonatal video laryngoscopy predominantly covers Macintosh-profile blades sized for neonatal anatomy. Highly angulated adult hyperangulated blades are not appropriate for neonatal use. Departments should confirm their video laryngoscope system offers validated paediatric and neonatal blade sizes before adopting it for this patient population.
