The Effect of Stylet Use on Successful Neonatal Endotracheal Intubation: A Systematic Review and Meta-analysis of Randomized Controlled Trials

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BSTRACT

Stylet-assisted endotracheal intubation improves first-attempt success in adults, but its benefit in neonates remains uncertain due to fundamental anatomical differences. This systematic review and meta-analysis evaluated the efficacy and safety of stylet-assisted versus nonstylet endotracheal intubation in neonates. A systematic search of five electronic databases was conducted in December 2025 to identify randomized controlled trials (RCTs) comparing stylet-assisted and nonstylet neonatal endotracheal intubation. The primary outcome was overall intubation success. The secondary outcomes were intubation time and postintubation bleeding. Dichotomous outcomes were pooled as risk ratios (RRs) with 95% confidence intervals (CIs); continuous outcomes as mean differences (MDs). Heterogeneity was quantified using I2 . The review was registered in the International Prospective Register of Systematic Reviews (CRD420250651805). Two RCTs (n = 502; stylet n = 249, no stylet n = 253) met inclusion criteria. Stylet use did not significantly improve intubation success (RR = 1.09; 95% CI = 0.96–1.24; P = 0.18; I2 = 0%). Time to intubation was also comparable (MD = 0.55 s; 95% CI = −4.15–5.25; P = 0.82), though substantial heterogeneity was present ( I2 = 71%). Postintubation bleeding rates did not differ significantly between groups (RR = 0.68; 95% CI = 0.40–1.16; P = 0.16; I2 = 0%). Available randomized evidence does not support the routine use of a stylet during neonatal endotracheal intubation to improve procedural success or safety. Stylet use should be individualized according to clinical context and operator experience. Larger multicenter RCTs, particularly those stratified by gestational age and provider experience, are needed to identify subgroups that may benefit.