Video laryngoscopy versus direct laryngoscopy for pediatric emergency tracheal intubation: a systematic review and meta-analysis

Aim To compare video laryngoscopy with direct laryngoscopy for pediatric intubation during cardiac arrest and peri-arrest scenarios. Methods This systematic review (PROSPERO CRD420251081694) searched MEDLINE, Embase, and Cochrane from inception to May 1, 2026. Two authors independently screened studies; data were extracted by one and independently verified by a second reviewer. Eligible studies compared video versus direct laryngoscopy in pediatric acute care; emergency department, intensive care, and prehospital settings. Risk of bias was assessed using ROBINS-I and RoB2. Critical outcomes were survival to hospital discharge, first-pass intubation success, overall intubation success, and severe tracheal intubation–associated events. Additional data included study design, setting, age, operator type, and device. Meta-analyses used random-effects Mantel–Haenszel models reporting risk ratios (RR) with 95% confidence intervals. Certainty of evidence was assessed using GRADE. Results Eighteen studies (17 observational, 1 RCT). First-pass success was higher with video laryngoscopy (72.2% vs 69.0%; RR 1.11, 95% CI 1.06–1.16; very low certainty). Severe adverse events were less frequent with video laryngoscopy (7.7% vs 11.8%; RR 0.76, 95% CI 0.62–0.93; very low certainty). Overall success (RR 1.00, 95% CI 0.99–1.01) and desaturation (RR 0.88, 95% CI 0.77–1.01) were similar. No studies reported survival outcomes or data specific to cardiac arrest. Conclusion Among children undergoing emergency tracheal intubation, video laryngoscopy may be associated with improved first-pass success and fewer adverse events, although the certainty of evidence is very low and causal inferences are limited. No data were available for survival outcomes and cardiac arrest.