Is the McGrath video laryngoscope the best device for neonatal intubation?

Is the McGrath the Best Video Laryngoscope for Neonatal Intubation?

The McGrath MAC is among the most effective video laryngoscopes for neonatal intubation, but it is not definitively superior to other devices like the C-MAC, and no single device can be declared "the best" based on current evidence.

Evidence from Guidelines and Research

The 2017 ICU intubation guidelines 1 state that "no head to head comparison between available VLs is sufficiently powerful and definitive to favor one particular device over another" 1. While these guidelines note that the McGrath Mac "appears to be the best validated VL" with demonstrated superiority over direct laryngoscopy in terms of laryngoscopy quality, intubation success, and performance in difficult airways 1, they explicitly acknowledge that the McGrath Mac does not reduce potentially lethal complications in intensive care intubation 1.

Importantly, a meta-analysis cited in these guidelines found that "the meta-analysis does not reveal any one studied VL to be better than the others" 1 when comparing various video laryngoscopes including McGrath Mac, C-MAC, and GlideScope.

Recent Neonatal-Specific Evidence

The most recent and highest-quality neonatal evidence comes from 2025-2026 studies:

The 2026 comparative trial 2 directly comparing C-MAC, McGrath MAC, and Miller direct laryngoscopy in 90 neonates found:

• C-MAC provided the shortest total intubation time (27 seconds vs 29 seconds for McGrath; P=0.01)
• C-MAC achieved better glottic visualization with superior Cormack-Lehane grades and POGO scores
• First-attempt success rates were comparable: 93.3% (C-MAC), 90.0% (McGrath), 86.7% (Miller)

The 2026 McGrath-specific trial 3 in 124 infants showed:

• McGrath VL achieved 86.9% first-attempt success vs 74.6% with direct laryngoscopy (P=0.026)
• Particularly beneficial for less experienced anesthesia trainees
• Zero esophageal intubations with McGrath vs 3 with direct laryngoscopy

The 2021 head-to-head comparison 4 of C-MAC Miller vs McGrath MAC in 140 neonates/infants revealed:

• Similar intubation times and success rates between devices
• C-MAC provided superior glottic views (better POGO scores and Cormack-Lehane grades)
• Two failed McGrath intubations were successfully completed with C-MAC

Clinical Recommendations

For neonatal intubation, choose your video laryngoscope based on:

1. Operator experience level:

   • Less experienced clinicians: McGrath MAC or C-MAC both significantly improve success rates 5, 6, 3
   • Experienced operators: Benefits may be smaller, though video laryngoscopy still recommended 6

2. Available resources and training:

   • The 2025 AHA/AAP guidelines 5 and ILCOR consensus 6 recommend video laryngoscopy "where resources and training allow" (conditional recommendation, moderate-certainty evidence)
   • Always have a traditional laryngoscope available as backup 6

3. Specific device considerations:

   • C-MAC: Provides best glottic visualization and slightly faster intubation times 2, 4
   • McGrath MAC: Excellent first-attempt success rates, particularly user-friendly for trainees 3
   • Both devices show 100% or near-100% overall success rates in experienced hands 4

Important Caveats

• Video laryngoscopy likely reduces airway trauma (moderate-certainty evidence) 7
• The 2023 Cochrane review 7 found video laryngoscopy may increase first-attempt success and may result in fewer intubation attempts, but evidence certainty remains low to moderate
• Cost and availability remain barriers to universal implementation 6
• The technique differs from traditional direct laryngoscopy—operators must avoid screen fixation and use appropriate stylet shaping 8

Bottom line: Both McGrath MAC and C-MAC are excellent choices for neonatal intubation, with C-MAC showing marginal advantages in visualization speed, but McGrath MAC demonstrating comparable clinical outcomes and particular benefit for novice operators. The "best" device is the one your team is trained on and has readily available.