Providing PPV at a rate of 40 to 60 inflations per minute is based on expert opinion. Infants with unintentional hypothermia (temperature less than 36C) immediately after stabilization should be rewarmed to avoid complications associated with low body temperature (including increased mortality, brain injury, hypoglycemia, and respiratory distress). The AHA has rigorous conflict of interest policies and procedures to minimize the risk of bias or improper influence during development of the guidelines.13 Before appointment, writing group members and peer reviewers disclosed all commercial relationships and other potential (including intellectual) conflicts. It is recommended to increase oxygen concentration to 100 percent if the heart rate continues to be less than 60 bpm (despite effective positive pressure ventilation) and the infant needs chest compressions.57, Initial PIP of 20 to 25 cm H2O should be used; if the heart rate does not increase or chest wall movement is not seen, higher pressures can be used. 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. For nonvigorous newborns with meconium-stained fluid, endotracheal suctioning is indicated only if obstruction limits positive pressure ventilation, because suctioning does not improve outcomes. Every healthy newly born baby should have a trained and equipped person assigned to facilitate transition. Naloxone and sodium bicarbonate are rarely needed and are not recommended during neonatal resuscitation. Clinical assessment of heart rate has been found to be both unreliable and inaccurate. We thank Dr. Abhrajit Ganguly for assistance in manuscript preparation. Team briefings promote effective teamwork and communication, and support patient safety.8,1012, During an uncomplicated term or late preterm birth, it may be reasonable to defer cord clamping until after the infant is placed on the mother and assessed for breathing and activity. How soon after administration of intravenous epinephrine should you During resuscitation of term and preterm newborns, the use of electrocardiography (ECG) for the rapid and accurate measurement of the newborns heart rate may be reasonable. A prospective study showed that the use of an exhaled carbon dioxide detector is useful to verify endotracheal intubation. 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. There was no difference in Apgar scores or blood gas with naloxone compared with placebo. 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. 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. Part 11: Neonatal Resuscitation | Circulation With growing enthusiasm for clinical studies in neonatology, elements of the Neonatal Resuscitation Algorithm continue to evolve as new evidence emerges. For babies requiring vascular access at the time of delivery, the umbilical vein is the recommended route. Delaying cord clamping for more than 30 seconds is reasonable for term and preterm infants who do not require resuscitation. You're welcome to take the quiz as many times as you'd like. A newly born infant in shock from blood loss may respond poorly to the initial resuscitative efforts of ventilation, chest compressions, and/or epinephrine. 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. See permissionsforcopyrightquestions and/or permission requests. While vascular access is being obtained, it may be reasonable to administer endotracheal epinephrine at a larger dose (0.05 to 0.1 mg/kg). In newly born infants who are gasping or apneic within 60 s after birth or who are persistently bradycardic (heart rate less than 100/min) despite appropriate initial actions (including tactile stimulation), PPV should be provided without delay. 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. 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. Check the heart rate by counting the beats in 6 seconds and multiply by 10. 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. In the resuscitation of an infant, initial oxygen concentration of 21 percent is recommended. 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. The 2 thumbencircling hands technique achieved greater depth, less fatigue, and less variability with each compression compared with the 2-finger technique. PDF NEONATAL RESUSCITATION - Oregon PPV remains the primary method for providing support for newborns who are apneic, bradycardic, or demonstrate inadequate respiratory effort. For term infants who do not require resuscitation at birth, it may be reasonable to delay cord clamping for longer than 30 seconds. PDF Newborn Resuscitation Initiating Chest Compressions - New York State Intraosseous needles are reasonable, but local complications have been reported. Umbilical venous catheterization has been the accepted standard route in the delivery room for decades. Breathing: Assist breathing with PPV if baby apneic, gasping, or bradycardic. Routine oral, nasal, oropharyngeal, or endotracheal suctioning of newly born babies is not recommended. Early cord clamping (within 30 seconds) may interfere with healthy transition because it leaves fetal blood in the placenta rather than filling the newborns circulating volume. Other important goals include establishment and maintenance of cardiovascular and temperature stability as well as the promotion of mother-infant bonding and breast feeding, recognizing that healthy babies transition naturally. Current resuscitation guidelines recommend that epinephrine should be used if the newborn remains bradycardic with heart rate <60 bpm after 30 s of what appears to be effective ventilation with chest rise, followed by 30 s of coordinated chest compressions and ventilations (1, 8, 9). Positive-Pressure Ventilation (PPV) National Center In newborns born at 35 weeks' gestation or later, resuscitation starting with 21% oxygen reduces short-term mortality. Premature animals exposed to brief high tidal volume ventilation (from high PIP) develop lung injury, impaired gas exchange, and decreased lung compliance. A multicenter quality improvement study demonstrated high staff compliance with the use of a neonatal resuscitation bundle that included briefing and an equipment checklist. Metrics. The frequency and format of booster training or refresher training that best supports retention of neonatal resuscitation knowledge, technical skills, and behavioral skills, The effects of briefing and debriefing on team performance, Optimal cord management strategies for various populations, including nonvigorous infants and those with congenital heart or lung disease, Optimal management of nonvigorous infants with MSAF, The most effective device(s) and interface(s) for providing PPV, Impact of routine use of the ECG during neonatal resuscitation on resuscitation, Feasibility and effectiveness of new technologies for rapid heart rate measurement (such as electric, ultrasonic, or optical devices), Optimal oxygen management during and after resuscitation, Novel techniques for effective delivery of CPR, such as chest compressions accompanied by sustained inflation, Optimal timing, dosing, dose interval, and delivery routes for epinephrine or other vasoactive drugs, including earlier use in very depressed newly born infants, Indications for volume expansion, as well as optimal dosing, timing, and type of volume, The management of pulseless electric activity, Management of the preterm newborn during and after resuscitation, Management of congenital anomalies of the heart and lungs during and after resuscitation, Resuscitation of newborns in the neonatal unit after the newly born period, Resuscitation of newborns in other settings up to 28 days of age, Optimal dose, route, and timing of surfactant in at-risk newborns, including less-invasive administration techniques, Indications for therapeutic hypothermia in babies with mild HIE and in those born at less than 36 weeks' gestational age, Adjunctive therapies to therapeutic hypothermia, Optimal rewarming strategy for newly born infants with unintentional hypothermia. This content is owned by the AAFP. In a small number of newborns (n=2) with indwelling catheters, the 2 thumbencircling hands technique generated higher systolic and mean blood pressures compared with the 2-finger technique. A team or persons trained in neonatal resuscitation should be promptly available to provide resuscitation. Team debrieng. For nonvigorous newborns delivered through MSAF who have evidence of airway obstruction during PPV, intubation and tracheal suction can be beneficial. Review of the knowledge chunks during this update identified numerous questions and practices for which evidence was weak, uncertain, or absent. Positive end-expiratory pressure of up to 5 cm of water may be used to maintain lung volumes based on low-quality evidence of reduced mortality in preterm infants. Administer epinephrine, preferably intravenously, if response to chest compressions is poor. Updates to neonatal, pediatric resuscitation guidelines based on new Copyright 2021 by the American Academy of Family Physicians. 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. The current guideline, therefore, concludes with a summary of current gaps in neonatal research and some potential strategies to address these gaps. Epinephrine (adrenaline) is the only medication recommended by the International Liaison Committee On Resuscitation (ILCOR) during resuscitation in newborns with persistent bradycardia or . Given the evidence for ECG during initial steps of PPV, expert opinion is that ECG should be used when providing chest compressions. Expert neonatal and bioethical committees have agreed that, in certain clinical conditions, it is reasonable not to initiate or to discontinue life-sustaining efforts while continuing to provide supportive care for babies and families.1,2,4, If the heart rate remains undetectable and all steps of resuscitation have been completed, it may be reasonable to redirect goals of care. Limited observational studies suggest that tactile stimulation may improve respiratory effort. The heart rate should be re-checked after 1 minute of giving compressions and ventilations. Traditionally, 100 percent oxygen has been used to achieve a rapid increase in tissue oxygen in infants with respiratory depression. The decision to continue or discontinue resuscitative efforts should be individualized and should be considered at about 20 minutes after birth. Normal saline (0.9% sodium chloride) is the crystalloid fluid of choice. 7272 Greenville Ave. - 14446398 One observational study describes the initial pattern of breathing in term and preterm newly born infants to have an inspiratory time of around 0.3 seconds. Author disclosure: No relevant financial affiliations. Peer reviewer feedback was provided for guidelines in draft format and again in final format. In preterm infants, delaying clamping reduces the need for vasopressors or transfusions. The very limited observational evidence in human infants does not demonstrate greater efficacy of endotracheal or intravenous epinephrine; however, most babies received at least 1 intravenous dose before ROSC. Once the infant is brought to the warmer, the head is kept in the sniffing position to open the airway. The baby could attempt to breathe and then endure primary apnea. When possible, healthy term babies should be managed skin-to-skin with their mothers. PPV may be initiated with air (21% oxygen) in term and late preterm babies, and up to 30% oxygen in preterm babies. 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. The temperature of newly born babies should be maintained between 36.5C and 37.5C after birth through admission and stabilization. When anticipating a high-risk birth, a preresuscitation team briefing should be completed to identify potential interventions and assign roles and responsibilities. Several animal studies found that ventilation with high volumes caused lung injury, impaired gas exchange, and reduced lung compliance in immature animals. Endotracheal suctioning may be useful in nonvigorous infants with respiratory depression born through meconium-stained amniotic fluid. The guidelines form the basis of the AAP/American Heart Association (AHA) Neonatal Resuscitation Program (NRP), 8th edition, which will be available in June 2021. Cord milking in preterm infants should be avoided because of increased risk of intraventricular hemorrhage. IV epinephrine If HR persistently below 60/min Consider hypovolemia Consider pneumothorax HR below 60/min? Higher doses (0.05 to 0.1 mg per kg) of endotracheal epinephrine are needed to achieve an increase in blood epinephrine concentration. Hypothermia after birth is common worldwide, with a higher incidence in babies of lower gestational age and birth weight. Contact Us, Hours Chest compressions are provided if there is a poor heart rate response to ventilation after appropriate ventilation corrective steps, which preferably include endotracheal intubation. Endotracheal suctioning for apparent airway obstruction with MSAF is based on expert opinion. The ILCOR task force review, when comparing PPV with sustained inflation breaths, defined PPV to have an inspiratory time of 1 second or less, based on expert opinion. Establishing ventilation is the most important step to correct low heart rate. 3 minuted. No type of routine suctioning is helpful, even for nonvigorous newborns delivered through meconium-stained amniotic fluid. 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. One observational study compared neonatal outcomes before (historical cohort) and after implementation of ECG monitoring in the delivery room. Delayed cord clamping is associated with higher hematocrit after birth and better iron levels in infancy.921 While developmental outcomes have not been adequately assessed, iron deficiency is associated with impaired motor and cognitive development.2426 It is reasonable to delay cord clamping (longer than 30 seconds) in preterm babies because it reduces need for blood pressure support and transfusion and may improve survival.18, There are insufficient studies in babies requiring PPV before cord clamping to make a recommendation.22 Early cord clamping should be considered for cases when placental transfusion is unlikely to occur, such as maternal hemorrhage or hemodynamic instability, placental abruption, or placenta previa.27 There is no evidence of maternal harm from delayed cord clamping compared with early cord clamping.1012,2834 Cord milking is being studied as an alternative to delayed cord clamping but should be avoided in babies less than 28 weeks gestational age, because it is associated with brain injury.23, Temperature should be measured and recorded after birth and monitored as a measure of quality.1 The temperature of newly born babies should be maintained between 36.5C and 37.5C.2 Hypothermia (less than 36C) should be prevented as it is associated with increased neonatal mortality and morbidity, especially in very preterm (less than 33 weeks) and very low-birthweight babies (less than 1500 g), who are at increased risk for hypothermia.35,7 It is also reasonable to prevent hyperthermia as it may be associated with harm.4,6, Healthy babies should be skin-to-skin after birth.8 For preterm and low-birth-weight babies or babies requiring resuscitation, warming adjuncts (increased ambient temperature [greater than 23C], skin-to-skin care, radiant warmers, plastic wraps or bags, hats, blankets, exothermic mattresses, and warmed humidified inspired gases)10,11,14 individually or in combination may reduce the risk of hypothermia. (if you are using the 0.1 mg/kg dose.) If there is ineffective breathing effort or apnea after birth, tactile stimulation may stimulate breathing. Evaluate respirations The three signs of effective resuscitation are: Heart rate Respirations Assessment of oxygenation (O2 Sat based on age in minutes) Baby can take up to ten minutes to reach an oxygen saturation of 90-95%. Although current guidelines recommend using 100% oxygen while providing chest compressions, no studies have confirmed a benefit of using 100% oxygen compared to any other oxygen concentration, including air (21%). 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. ECG (3-lead) displays a reliable heart rate faster than pulse oximetry. It is recommended to begin resuscitation with 21 percent oxygen, and increase the concentration of oxygen (using an air/oxygen blender) if oxygen saturation is low57 (see Figure 1). There are limited data comparing the different approaches to heart rate assessment during neonatal resuscitation on other neonatal outcomes. 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. Noninitiation of resuscitation and discontinuation of life-sustaining treatment during or after resuscitation should be considered ethically equivalent. Compared with term infants receiving early cord clamping, term infants receiving delayed cord clamping had increased hemoglobin concentration within the first 24 hours and increased ferritin concentration in the first 3 to 6 months in meta-analyses of 12 and 6 RCTs. Flush the UVC with normal saline. When appropriate, flow diagrams or additional tables are included. These 2020 AHA neonatal resuscitation guidelines are based on the extensive evidence evaluation performed in conjunction with the ILCOR and affiliated ILCOR member councils. However, it may be reasonable to increase inspired oxygen to 100% if there was no response to PPV with lower concentrations. If resuscitation is required, heart rate should be monitored by electrocardiography as early as possible. If a baby does not begin breathing . A multicenter, case-control study identified 10 perinatal risk factors that predict the need for advanced neonatal resuscitation. "Epinephrine is indicated when the heart rate remains below 60 beats per minute after you have given 30 seconds of effective assisted ventilation (preferably after endotracheal intubation) and at least another 45 to 60 seconds of coordinated chest compressions and effective ventilation." (p 219)