In a randomized trial, the use of sodium bicarbonate in the delivery room did not improve survival or neurologic outcome. It may be reasonable to provide volume expansion with normal saline (0.9% sodium chloride) or blood at 10 to 20 mL/kg. Hyperlinked references are provided to facilitate quick access and review. In a randomized trial, the use of mask CPAP compared with endotracheal intubation and mechanical ventilation in spontaneously breathing preterm infants decreased the risk of bronchopulmonary dysplasia or death, and decreased the use of surfactant, but increased the rate of pneumothorax. For term infants who do not require resuscitation at birth, it may be reasonable to delay cord clamping for longer than 30 seconds. The practice test consists of 10 multiple-choice questions that adhere to the latest ILCOR standards. It may be reasonable to administer further doses of epinephrine every 3 to 5 min, preferably intravascularly,* if the heart rate remains less than 60/ min. Neonatal resuscitation teams may therefore benefit from ongoing booster training, briefing, and debriefing. Before every birth, a standardized risk factors assessment tool should be used to assess perinatal risk and assemble a qualified team on the basis of that risk. It is the expert opinion of national medical societies that conditions exist for which it is reasonable to not initiate resuscitation or to discontinue resuscitation once these conditions are identified. There were only minor changes to the NRP algorithm and recommended practices. A large observational study showed that most nonvigorous newly born infants respond to stimulation and PPV. In small hospitals, a nonphysician neonatal resuscitation team is one way of providing in-house coverage at all hours. Gaps in this domain, whether perceived or real, should be addressed at every stage in our research, educational, and clinical activities. Even healthy babies who breathe well after birth benefit from facilitation of normal transition, including appropriate cord management and thermal protection with skin-to-skin care. Therefore, identifying a rapid and reliable method to measure the newborn's heart rate is critically important during neonatal resuscitation. When chest compressions are initiated, an ECG should be used to confirm heart rate. The suggested ratio is 3 chest compressions synchronized to 1 inflation (with 30 inflations per minute and 90 compressions per minute) using the 2 thumbencircling hands technique for chest compressions. Together with other professional societies, the AHA has provided interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed coronavirus disease 2019 (COVID-19) infection. The intravenous dose of epinephrine is 0.01 to 0.03 mg/kg, followed by a normal saline flush.4 If umbilical venous access has not yet been obtained, epinephrine may be given by the endotracheal route in a dose of 0.05 to 0.1 mg/kg. Once return of spontaneous circulation (ROSC) is achieved, the supplemental oxygen concentration may be decreased to target a physiological level based on pulse oximetry to reduce the risks associated with hyperoxia.1,2. A multicenter randomized trial showed that intrapartum suctioning of meconium does not reduce the risk of meconium aspiration syndrome. Chest compressions are provided if there is a poor heart rate response to ventilation after appropriate ventilation corrective steps, which preferably include endotracheal intubation. In a prospective interventional clinical study, video-based debriefing of neonatal resuscitations was associated with improved preparation and adherence to the initial steps of the Neonatal Resuscitation Algorithm, improved quality of PPV, and improved team function and communication. A randomized study showed similar success in providing effective ventilation using either laryngeal mask airway or endotracheal tube. Suctioning may be considered for suspected airway obstruction. A team or persons trained in neonatal resuscitation should be promptly available to provide resuscitation. If the heart rate remains below 60 beats per minute despite 30 seconds of adequate positive pressure ventilation, chest compressions should be initiated with a two-thumb encircling technique at a 3:1 compression-to-ventilation ratio. For this reason, neonatal resuscitation should begin with PPV rather than with chest compressions.2,3 Delays in initiating ventilatory support in newly born infants increase the risk of death.1, The adequacy of ventilation is measured by a rise in heart rate and, less reliably, chest expansion. This can usually be achieved with a peak inflation pressure of 20 to 25 cm water (H. In newly born infants receiving PPV, it may be reasonable to provide positive end-expiratory pressure (PEEP). If the response to chest compressions is poor, it may be reasonable to provide epinephrine, preferably via the intravenous route. If a birth is at the lower limit of viability or involves a condition likely to result in early death or severe morbidity, noninitiation or limitation of neonatal resuscitation is reasonable after expert consultation and parental involvement in decision-making. The heart rate response to chest compressions and medications should be monitored electrocardiographically. As mortality and severe morbidities decline with biomedical advancements and improvements in healthcare delivery, there is decreased ability to have adequate power for some clinical questions using traditional individual patient randomized trials. For preterm infants who do not require resuscitation at birth, it is reasonable to delay cord clamping for longer than 30 seconds. Administer epinephrine, preferably intravenously, if response to chest compressions is poor. 5 minutec. Attaches oxygen set at 10-15 lpm. In term and late preterm newborns (35 wk or more of gestation) receiving respiratory support at birth, 100% oxygen should not be used because it is associated with excess mortality. The heart rate should be re-checked after 1 minute of giving compressions and ventilations. A systematic review (low to moderate certainty) of 6 RCTs showed that early skin-to-skin contact promotes normothermia in healthy neonates. Newly born infants born at 36 wk or more estimated gestational age with evolving moderate-to-severe HIE should be offered therapeutic hypothermia under clearly defined protocols. Radiant warmers and other warming adjuncts are suggested for babies who require resuscitation at birth, especially very preterm and very low-birth-weight babies. If the heart rate remains less than 60/min despite these interventions, chest compressions can supply oxygenated blood to the brain until the heart rate rises. Medications are rarely needed in resuscitation of the newly born infant because low heart rate usually results from a very low oxygen level in the fetus or inadequate lung inflation after birth. Intraosseous needles are reasonable, but local complications have been reported. According to the recommendations, suctioning is only necessary if the airway appears obstructed by fluid. In newly born infants who require PPV, it is reasonable to use peak inflation pressure to inflate the lung and achieve a rise in heart rate. Title: Microsoft PowerPoint - CPS GR Final Author: JackieM Created Date: 9/10/2021 9:22:37 PM When blood loss is suspected in a newly born infant who responds poorly to resuscitation (ventilation, chest compressions, and/or epinephrine), it may be reasonable to administer a volume expander without delay. Equipment checklists, role assignments, and team briefings improve resuscitation performance and outcomes. Approximately 10% of infants require help to begin breathing at birth, and 1% need intensive resuscitation. The potential benefit or harm of sustained inflations between 1 and 10 seconds is uncertain.2,29. If the heart rate has not increased to 60/ min or more after optimizing ventilation and chest compressions, it may be reasonable to administer intravascular* epinephrine (0.01 to 0.03 mg/kg). Ventilation should be optimized before starting chest compressions, with endotracheal intubation if possible. The following sections are worth special attention. Newborn resuscitation requires anticipation and preparation by providers who train individually and as teams. Exhaled carbon dioxide detectors can be used to confirm endotracheal tube placement in an infant. If a newborn's heart rate remains less than 60 bpm after PPV and chest compressions, you should NOT Just far enough to get blood return You catheterize the umbilical vein. Nearly 10 percent of the more than 4 million infants born in the United States annually need some assistance to begin breathing at birth, with approximately 1 percent needing extensive resuscitation1,2 and about 0.2 to 0.3 percent developing moderate or severe hypoxic-ischemic encephalopathy.3 Mortality in infants with hypoxic-ischemic encephalopathy ranges from 6 to 30 percent, and significant morbidity, such as cerebral palsy and long-term disabilities, occurs in 20 to 30 percent of survivors.4 The Neonatal Resuscitation Program (NRP), which was initiated in 1987 to identify infants at risk of respiratory depression and provide high-quality resuscitation, underwent major updates in 2006 and 2010.1,57, A 1987 study showed that nearly 78 percent of Canadian hospitals did not have a neonatal resuscitation team, and physicians were called into a significant number of community hospitals (69 percent) for neonatal resuscitation because they were not in-house.8 National guidelines in the United States and Canada recommend that a team or persons trained in neonatal resuscitation be promptly available for every birth.9,10 Actual institutional compliance with this guideline is unknown. The writing groups then drafted, reviewed, and approved recommendations, assigning to each a Level of Evidence (LOE; ie, quality) and Class of Recommendation (COR; ie, strength) (Table(link opens in new window)).11. PPV may be initiated with air (21% oxygen) in term and late preterm babies, and up to 30% oxygen in preterm babies. How soon after administration of intravenous epinephrine should you pause compressions and assess the baby's heart rate?a. There is a reduction of mortality and no evidence of harm in term infants resuscitated with 21 percent compared with 100 percent oxygen. TALKAD S. RAGHUVEER, MD, AND AUSTIN J. COX, MD. The wet cloth beneath the infant is changed.5 Respiratory effort is assessed to see if the infant has apnea or gasping respiration, and the heart rate is counted by feeling the umbilical cord pulsations or by auscultating the heart for six seconds (e.g., heart rate of six in six seconds is 60 beats per minute [bpm]). monitored. Before appointment, all peer reviewers were required to disclose relationships with industry and any other potential conflicts of interest, and all disclosures were reviewed by AHA staff. Exothermic mattresses have been reported to cause local heat injury and hyperthermia.15, When babies are born in out-of-hospital, resource-limited, or remote settings, it may be reasonable to prevent hypothermia by using a clean food-grade plastic bag13 as an alternative to skin-to-skin contact.8. This series is coordinated by Michael J. Arnold, MD, contributing editor. Pulse oximetry is used to guide oxygen therapy and meet oxygen saturation goals. Administration of epinephrine via a low-lying umbilical venous catheter provides the most rapid and reliable medication delivery. A newly born infant in shock from blood loss may respond poorly to the initial resuscitative efforts of ventilation, chest compressions, and/or epinephrine. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. In animal studies (very low quality), the use of alterative compression-to-inflation ratios to 3:1 (eg, 2:1, 4:1, 5:1, 9:3, 15:2, and continuous chest compressions with asynchronous PPV) are associated with similar times to ROSC and mortality rates. Successful neonatal resuscitation efforts depend on critical actions that must occur in rapid succession to maximize the chances of survival. In preterm infants younger than 30 weeks' gestation, continuous positive airway pressure instead of intubation reduces bronchopulmonary dysplasia or death with a number needed to treat of 25. Many current recommendations are based on weak evidence with a lack of well-designed human studies. Circulation. With the symptoms of The dose of epinephrine is .5-1ml/kg by ETT or .1-.3ml/kg in the concentration of 1:10,000 (0.1mg/ml), which is to be followed by 0.5-1ml flush of normal saline. One moderate quality RCT found higher rates of hyperthermia with exothermic mattresses. In other situations, clamping and cutting of the cord may also be deferred while respiratory, cardiovascular, and thermal transition is evaluated and initial steps are undertaken. For infants born at less than 28 wk of gestation, cord milking is not recommended. Chest compressions should be started if the heart rate remains less than 60/min after at least 30 seconds of adequate PPV.1, Oxygen is essential for organ function; however, excess inspired oxygen during resuscitation may be harmful. Intravenous epinephrine is preferred because plasma epinephrine levels increase much faster than with endotracheal administration. Delayed umbilical cord clamping was recommended for both term and preterm neonates in 2015. We thank Dr. Abhrajit Ganguly for assistance in manuscript preparation. Studies of newly born animals showed that PEEP facilitates lung aeration and accumulation of functional residual capacity, prevents distal airway collapse, increases lung surface area and compliance, decreases expiratory resistance, conserves surfactant, and reduces hyaline membrane formation, alveolar collapse, and the expression of proinflammatory mediators. Recommendation-specific text clarifies the rationale and key study data supporting the recommendations. Endotracheal intubation is indicated in very premature infants; for suctioning of nonvigorous infants born through meconium-stained amniotic fluid; and when bag and mask ventilation is necessary for more than two to three minutes, PPV via face mask does not increase heart rate, or chest compressions are needed. You administer 10 mL/kg of normal saline (based on the newborn's estimated weight). If there is a heart rate response: Continue uninterrupted ventilation until the infant begins to breathe adequately and the heart rate is above 100 min-1. Effective team behaviors, such as anticipation, communication, briefing, equipment checks, and assignment of roles, result in improved team performance and neonatal outcome. IV epinephrine If HR persistently below 60/min Consider hypovolemia Consider pneumothorax HR below 60/min? During resuscitation, a baby is responding to positive-pressure ventilation with a rapidly increasing heart rate. Use of CPAP for resuscitating term infants has not been studied. There is a history of acute blood loss around the time of delivery. In newly born babies receiving resuscitation, if there is no heart rate and all the steps of resuscitation have been performed, cessation of resuscitation efforts should be discussed with the team and the family. Aim for about 30 breaths min-1 with an inflation time of ~one second. On the basis of animal research, the progression from primary apnea to secondary apnea in newborns results in the cessation of respiratory activity before the onset of cardiac failure.4 This cycle of events differs from that of asphyxiated adults, who experience concurrent respiratory and cardiac failure. Positive pressure ventilation should be delivered without delay to infants who are apneic, gasping, or have a heart rate below 100 beats per minute within the first 60 seconds of life despite initial resuscitation. Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP. In a case series, endotracheal epinephrine (0.01 mg per kg) was less effective than intravenous epinephrine. The American Heart Association requests that this document be cited as follows: Aziz K, Lee HC, Escobedo MB, Hoover AV, Kamath-Rayne BD, Kapadia VS, Magid DJ, Niermeyer S, Schmolzer GM, Szyld E, Weiner GM, Wyckoff MH, Yamada NK, Zaichkin J. Part 2: Evidence Evaluation and Guidelines Development, Part 3: Adult Basic and Advanced Life Support, Part 4: Pediatric Basic and Advanced Life Support, Part 9: COVID-19 Interim Guidance for Healthcare Providers, Part 10: COVID-19 Interim Guidance for EMS, 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Consequently, all newly born babies should be attended to by at least 1 person skilled and equipped to provide PPV. If the heart rate is less than 60 bpm, begin chest compressions. Review of the knowledge chunks during this update identified numerous questions and practices for which evidence was weak, uncertain, or absent. NRP Advanced may also be appropriate for health care professionals in smaller hospital facilities with fewer per- When blood loss is known or suspected based on history and examination, and there is no response to epinephrine, volume expansion is indicated. PPV remains the primary method for providing support for newborns who are apneic, bradycardic, or demonstrate inadequate respiratory effort. These 2020 AHA neonatal resuscitation guidelines are based on the extensive evidence evaluation performed in conjunction with the ILCOR and affiliated ILCOR member councils. Positive pressure ventilation should be provided at 40 to 60 inflations per minute with peak inflation pressures up to 30 cm of water in term newborns and 20 to 25 cm of water in preterm infants. RCTs and observational studies of warming adjuncts, alone and in combination, demonstrate reduced rates of hypothermia in very preterm and very low-birth-weight babies. In a randomized controlled simulation study, medical students who underwent booster training retained improved neonatal intubation skills over a 6-week period compared with medical students who did not receive booster training. In a retrospective study, volume infusion was given more often for slow response of bradycardia to resuscitation than for overt hypovolemia. A prospective study showed that the use of an exhaled carbon dioxide detector is useful to verify endotracheal intubation. Available for purchase at https://shop.aap.org/textbook-of-neonatal-resuscitation-8th-edition-paperback/ (NOTE: This book features a full text reading experience. Newborn temperature should be maintained between 97.7F and 99.5F (36.5C and 37.5C), because mortality and morbidity increase with hypothermia, especially in preterm and low birth weight infants. There was no difference in Apgar scores or blood gas with naloxone compared with placebo. Appropriate and timely support should be provided to all involved. If a baby does not begin breathing . One RCT in resource-limited settings found that plastic coverings reduced the incidence of hypothermia, but they were not directly compared with uninterrupted skin-to-skin care. A meta-analysis of 3 RCTs (low certainty of evidence) and a further single RCT suggest that nonvigorous newborns delivered through MSAF have the same outcomes (survival, need for respiratory support, or neurodevelopment) whether they are suctioned before or after the initiation of PPV. Ventilation using a flow-inflating bag, self-inflating bag, or T-piece device can be effective. Unauthorized use prohibited. The same study demonstrated that the risk of death or prolonged admission increases 16% for every 30-second delay in initiating PPV. Volunteers with recognized expertise in resuscitation are nominated by the writing group chair and selected by the AHA ECC Committee. A large multicenter RCT found higher rates of intraventricular hemorrhage with cord milking in preterm babies born at less than 28 weeks gestational age. If resuscitation is required, electrocardiography should be used, especially with chest compressions. See Part 2: Evidence Evaluation and Guidelines Development for more details on this process.11. The goal should be to achieve oxygen saturation targets shown in Figure 1.5,6, When chest compressions are indicated, it is recommended to use a 3:1 ratio of compressions to ventilation.57, Chest compressions in infants should be delivered by using two thumbs, with the fingers encircling the chest and supporting the back, and should be centered over the lower one-third of the sternum.5,6, If the infant's heart rate is less than 60 bpm after adequate ventilation and chest compressions, epinephrine at 0.01 to 0.03 mg per kg (1:10,000 solution) should be given intravenously. ECG provides the most rapid and accurate measurement of the newborns heart rate at birth and during resuscitation. In resource-limited settings, it may be reasonable to place newly born babies in a clean food-grade plastic bag up to the level of the neck and swaddle them in order to prevent hypothermia. In term infants, delaying clamping increases hematocrit and iron levels without increasing rates of phototherapy for hyperbilirubinemia, neonatal intensive care, or mortality. Evidence suggests that warming can be done rapidly (0.5C/h) or slowly (less than 0.5C/h) with no significant difference in outcomes.1519 Caution should be taken to avoid overheating. The newly born period extends from birth to the end of resuscitation and stabilization in the delivery area. ECG (3-lead) displays a reliable heart rate faster than pulse oximetry. In the resuscitation of an infant, initial oxygen concentration of 21 percent is recommended. Care (Updated May 2019)*, 2020 Advanced Cardiovascular Life Support (ACLS), 2020 Pediatric Advanced Life Support (PALS), 2015 Pediatric Emergency Assessment and Recognition, Conflicts of Interest and Ethics Policies, Advanced Cardiovascular Life Support (ACLS), CPR & First Aid in Youth Sports Training Kit, Resuscitation Quality Improvement Program (RQI), COVID-19 Resources for CPR & Resuscitation, Claiming Your AHA Continuing Education Credits, International Liaison Committee on Resuscitation. *Red Dress DHHS, Go Red AHA ; National Wear Red Day is a registered trademark. Epinephrine use in the delivery room for resuscitation of the newborn is associated with significant morbidity and mortality. This is partly due to the challenges of performing large randomized controlled trials (RCTs) in the delivery room. Effective and timely resuscitation at birth could therefore improve neonatal outcomes further. If it is possible to identify such conditions at or before birth, it is reasonable not to initiate resuscitative efforts. Randomized trials have shown that infants born at 36 weeks' gestation or later with moderate to severe hypoxic-ischemic encephalopathy who were cooled to 92.3F (33.5C) within six hours after birth had significantly lower mortality and less disability at 18 months compared with those not cooled. High-quality observational studies of large populations may also add to the evidence. When vascular access is required in the newly born, the umbilical venous route is preferred. An improvement in heart rate and establishment of breathing or crying are all signs of effective PPV. Rate is 40 - 60/min. Similarly, meta-analysis of 2 quasi-randomized trials showed no difference in moderate-to-severe neurodevelopmental impairment at 1 to 3 years of age. Adaptive trials, comparative effectiveness designs, and those using cluster randomization may be suitable for some questions, such as the best approach for MSAF in nonvigorous infants. Peak inflation pressures of up to 30 cm H2O in term newborns and 20 to 25 cm H2O in preterm newborns are usually sufficient to inflate the lungs.57,9,1114 In some cases, however, higher inflation pressures are required.5,710 Peak inflation pressures or tidal volumes greater than what is required to increase heart rate and achieve chest expansion should be avoided.24,2628, The lungs of sick or preterm infants tend to collapse because of immaturity and surfactant deficiency.15 PEEP provides low-pressure inflation of the lungs during expiration. Rapid and effective response and performance are critical to good newborn outcomes. A 3:1 ratio of compressions to ventilation provided more ventilations than higher ratios in manikin studies. Newly born infants with abnormal glucose levels (both low and high) are at increased risk for brain injury and adverse outcomes after a hypoxic-ischemic insult. There was no difference in neonatal intubation performance after weekly booster practice for 4 weeks compared with daily booster practice for 4 consecutive days. When attempts at endotracheal intubation are unsuccessful, laryngeal mask airway (size 1) is an alternative for providing PPV in infants weighing more than 2 kg or in infants greater than 34 weeks' gestation.5,6,26, Neonatal resuscitation aims to restore tissue oxygen delivery before irreversible damage occurs. 7272 Greenville Ave. The benefit of 100% oxygen compared with 21% oxygen (air) or any other oxygen concentration for ventilation during chest compressions is uncertain. Newly born infants who receive prolonged PPV or advanced resuscitation (eg, intubation, chest compressions epinephrine) should be closely monitored after stabilization in a neonatal intensive care unit or a monitored triage area because these infants are at risk for further deterioration. Ninety percent of infants transition safely, and it is up to the physician to assess risk factors, identify the nearly 10 percent of infants who need resuscitation, and respond appropriately. The Neonatal Resuscitation Algorithm remains unchanged from 2015 and is the organizing framework for major concepts that reflect the needs of the baby, the family, and the surrounding team of perinatal caregivers. Clinical assessment of heart rate by auscultation or palpation may be unreliable and inaccurate.14 Compared to ECG, pulse oximetry is both slower in detecting the heart rate and tends to be inaccurate during the first few minutes after birth.5,6,1012 Underestimation of heart rate can lead to potentially unnecessary interventions. A randomized trial showed that endotracheal suctioning of vigorous. During resuscitation, supplemental oxygen may be provided to prevent harm from inadequate oxygen supply to tissues (hypoxemia).4 However, overexposure to oxygen (hyperoxia) may be associated with harm.5, Term and late preterm newborns have lower shortterm mortality when respiratory support during resuscitation is started with 21% oxygen (air) versus 100% oxygen.1 No difference was found in neurodevelopmental outcome of survivors.1 During resuscitation, pulse oximetry may be used to monitor oxygen saturation levels found in healthy term infants after vaginal birth at sea level.3, In more preterm newborns, there were no differences in mortality or other important outcomes when respiratory support was started with low (50% or less) versus high (greater than 50%) oxygen concentrations.2 Given the potential for harm from hyperoxia, it may be reasonable to start with 21% to 30% oxygen. Placing healthy newborn infants who do not require resuscitation skin-to-skin after birth can be effective in improving breastfeeding, temperature control and blood glucose stability. Team training remains an important aspect of neonatal resuscitation, including anticipation, preparation, briefing, and debriefing. The exhaled carbon dioxide detector changes from purple to yellow with endotracheal intubation, and a negative result suggests esophageal intubation.5,6,25 Clinical indicators of endotracheal intubation, such as condensation in the tube, chest wall movement, or presence of bilateral equal breath sounds, have not been well studied. Newly born infants who breathe spontaneously need to establish a functional residual capacity after birth.8 Some newly born infants experience respiratory distress, which manifests as labored breathing or persistent cyanosis. For babies requiring vascular access at the time of delivery, the umbilical vein is the recommended route. The updated guidelines also provide indications for chest compressions and for the use of intravenous epinephrine, which is the preferred route of administration, and recommend not to use sodium bicarbonate or naloxone during resuscitation. There are limited data comparing the different approaches to heart rate assessment during neonatal resuscitation on other neonatal outcomes. The primary goal of neonatal care at birth is to facilitate transition. Infants 36 weeks or greater estimated gestational age who receive advanced resuscitation should be examined for evidence of HIE to determine if they meet criteria for therapeutic hypothermia. The importance of skin-to-skin care in healthy babies is reinforced as a means of promoting parental bonding, breast feeding, and normothermia. The effect of briefing and debriefing on longer-term and critical outcomes remains uncertain. Historically, the repeat training has occurred every 2 years.69 However, adult, pediatric, and neonatal studies suggest that without practice, CPR knowledge and skills decay within 3 to 12 months1012 after training.