Short, frequent practice (booster training) has been shown to improve neonatal resuscitation outcomes.5 Educational programs and perinatal facilities should develop strategies to ensure that individual and team training is frequent enough to sustain knowledge and skills. If epinephrine is administered via endotracheal tube, a dose of 0.05 to 0.1 mg per kg (1:10,000 solution) is needed.1,2,57, Early volume expansion with crystalloid (10 mL per kg) or red blood cells is indicated for blood loss when the heart rate does not increase with resuscitation.5,6, Use of naloxone is not recommended as part of initial resuscitation of infants with respiratory depression in the delivery room.1,2,5,6, Very rarely, sodium bicarbonate may be useful after resuscitation.6, Term or near term infants with evolving moderate to severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia.57, Intravenous glucose infusion should be started soon after resuscitation to avoid hypoglycemia.5,6, It is recommended to cover preterm infants less than 28 weeks' gestation in polyethylene wrap after birth and place them under a radiant warmer. If the infant's heart rate is less than 100 beats per minute and/or the infant has apnea or gasping respiration, positive pressure ventilation via face mask should be initiated with 21 percent oxygen (room air) or blended oxygen using a self-inflating bag, flow-inflating bag, or T-piece device while monitoring the inflation pressure. Review of the knowledge chunks during this update identified numerous questions and practices for which evidence was weak, uncertain, or absent. When intravenous access is not feasible, the intraosseous route may be considered. It is important to continue PPV and chest compressions while preparing to deliver medications. When epinephrine is required, multiple doses are commonly needed. The following sections are worth special attention. The dosage interval for epinephrine is every 3 to 5 minutes if the heart rate remains less than 60/min, although an intravenous dose may be given as soon as umbilical access is obtained if response to endotracheal epinephrine has been inadequate. Hypoglycemia is common in infants who have received advanced resuscitation and is associated with poorer outcomes.8 These infants should be monitored for hypoglycemia and treated appropriately. Oximetry is used to target the natural range of oxygen saturation levels that occur in term babies. 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. The reduced heart rate that occurs in this situation can be reversed with tactile stimulation. Test your knowledge with our free Neonatal Resuscitation Practice Test provided below in order to prepare you for our official online exam. 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. There should be ongoing evaluation of the baby for normal respiratory transition. Premature animals exposed to brief high tidal volume ventilation (from high PIP) develop lung injury, impaired gas exchange, and decreased lung compliance. This article has been copublished in Pediatrics. Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process. In preterm newly born infants, the routine use of sustained inflations to initiate resuscitation is potentially harmful and should not be performed. 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). One moderate quality RCT found higher rates of hyperthermia with exothermic mattresses. Heart rate assessment is best performed by auscultation. The use of radiant warmers, plastic bags and wraps (with a cap), increased room temperature, and warmed humidified inspired gases can be effective in preventing hypothermia in preterm babies in the delivery room. If skilled health care professionals are available, infants weighing less than 1 kg, 1 to 3 kg, and 3 kg or more can be intubated with 2.5-, 3-, and 3.5-mm endotracheal tubes, respectively. Normal saline (0.9% sodium chloride) is the crystalloid fluid of choice. Birth 1 minute If HR remains <60 bpm, Consider hypovolemia. If the infant's heart rate is less than 60 beats per minute after adequate positive pressure ventilation and chest compressions, intravenous epinephrine at 0.01 to 0.03 mg per kg (1:10,000 solution) is recommended. Optimal PEEP has not been determined, because all human studies used a PEEP level of 5 cm H2O.1822, It is reasonable to initiate PPV at a rate of 40 to 60/min to newly born infants who have ineffective breathing, are apneic, or are persistently bradycardic (heart rate less than 100/min) despite appropriate initial actions (including tactile stimulation).1, To match the natural breathing pattern of both term and preterm newborns, the inspiratory time while delivering PPV should be 1 second or less. Aim for about 30 breaths min-1 with an inflation time of ~one second. 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. One observational study compared neonatal outcomes before (historical cohort) and after implementation of ECG monitoring in the delivery room. In a randomized trial, the use of sodium bicarbonate in the delivery room did not improve survival or neurologic outcome. 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. 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. You have administered epinephrine intravenously. 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. Excessive chest wall movement should be avoided.2,6, In spontaneously breathing preterm infants with respiratory distress, either CPAP or endotracheal intubation with mechanical ventilation may be used.1,5,6, In preterm infants less than 32 weeks' gestation, an initial oxygen concentration of more than 21 percent (30 to 40 percent), but less than 100 percent should be used. 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. CPAP, a form of respiratory support, helps newly born infants keep their lungs open. Suction should also be considered if there is evidence of airway obstruction during PPV, Direct laryngoscopy and endotracheal suctioning are not routinely required for babies born through MSAF but can be beneficial in babies who have evidence of airway obstruction while receiving PPV.7. Neonatal resuscitation teams may therefore benefit from ongoing booster training, briefing, and debriefing. TALKAD S. RAGHUVEER, MD, AND AUSTIN J. COX, MD. Early skin-to-skin contact benefits healthy newborns who do not require resuscitation by promoting breastfeeding and temperature stability. Readers are directed to the AHA website for the most recent guidance.12, The following sections briefly describe the process of evidence review and guideline development. 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. A newly born infant in shock from blood loss may respond poorly to the initial resuscitative efforts of ventilation, chest compressions, and/or epinephrine. If the heart rate remains less than 60/min despite 60 seconds of chest compressions and adequate PPV, epinephrine should be administered, ideally via the intravenous route. Excessive peak inflation pressures are potentially harmful and should be avoided. In newborns born before 35 weeks' gestation, oxygen concentrations above 50% are no more effective than lower concentrations. 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. Blood may be lost from the placenta into the mothers circulation, from the cord, or from the infant. Exothermic mattresses may be effective in preventing hypothermia in preterm babies. Effective team behaviors, such as anticipation, communication, briefing, equipment checks, and assignment of roles, result in improved team performance and neonatal outcome. The importance of skin-to-skin care in healthy babies is reinforced as a means of promoting parental bonding, breast feeding, and normothermia. In term and preterm newly born infants, it is reasonable to initiate PPV with an inspiratory time of 1 second or less. The following knowledge gaps require further research: For all these gaps, it is important that we have information on outcomes considered critical or important by both healthcare providers and families of newborn infants. Appropriate and timely support should be provided to all involved. Other recommendations include confirming endotracheal tube placement using an exhaled carbon dioxide detector; using less than 100 percent oxygen and adequate thermal support to resuscitate preterm infants; and using therapeutic hypothermia for infants born at 36 weeks' gestation or later with moderate to severe hypoxic-ischemic encephalopathy. Ventilation should be optimized before starting chest compressions, possibly including endotracheal intubation. Team training remains an important aspect of neonatal resuscitation, including anticipation, preparation, briefing, and debriefing. Very low-quality evidence from 2 nonrandomized studies and 1 randomized trial show that auscultation is not as accurate as ECG for heart rate assessment during newborn stabilization immediately after birth. Higher doses (0.05 to 0.1 mg per kg) of endotracheal epinephrine are needed to achieve an increase in blood epinephrine concentration. 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. This is partly due to the challenges of performing large randomized controlled trials (RCTs) in the delivery room. 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. An improvement in heart rate and establishment of breathing or crying are all signs of effective PPV. The dose of epinephrine can be re-peated after 3-5 minutes if the initial dose is ineffective or can be repeated immediately if initial dose is given by endo-tracheal tube in the absence of an intravenous access. Therefore, identifying a rapid and reliable method to measure the newborn's heart rate is critically important during neonatal resuscitation. If heart rate after birth remains at less than 60/min despite adequate ventilation for at least 30 s, initiating chest compressions is reasonable. During an uncomplicated delivery, the newborn transitions from the low oxygen environment of the womb to room air (21% oxygen) and blood oxygen levels rise over several minutes. The inability of newly born infants to establish and sustain adequate or spontaneous respiration contributes significantly to these early deaths and to the burden of adverse neurodevelopmental outcome among survivors. This series is coordinated by Michael J. Arnold, MD, contributing editor. During resuscitation, a baby is responding to positive-pressure ventilation with a rapidly increasing heart rate. In preterm birth, there are also potential advantages from delaying cord clamping. Many current recommendations are based on weak evidence with a lack of well-designed human studies. While there has been research to study the potential effectiveness of providing longer, sustained inflations, there may be potential harm in providing sustained inflations greater than 10 seconds for preterm newborns. If intravenous access is not feasible, it may be reasonable to use the intraosseous route. CPAP is helpful for preterm infants with breathing difficulty after birth or after resuscitation33 and may reduce the risk of bronchopulmonary dysplasia in very preterm infants when compared with endotracheal ventilation.3436 CPAP is also a less invasive form of respiratory support than intubation and PPV are. However, if heart rate remains less than 60/min after ventilating with 100% oxygen (preferably through an endotracheal tube) and chest compressions, administration of epinephrine is indicated. If resuscitation is required, heart rate should be monitored by electrocardiography as early as possible. It is important to recognize that there are several significant gaps in knowledge relating to neonatal resuscitation. When appropriate, flow diagrams or additional tables are included. 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. There was no difference in Apgar scores or blood gas with naloxone compared with placebo. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. 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. 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. 7. Evidence for optimal dose, timing, and route of administration of epinephrine during neonatal resuscitation comes largely from extrapolated adult or animal literature. Gaps in this domain, whether perceived or real, should be addressed at every stage in our research, educational, and clinical activities. During 1-800-AHA-USA-1 If all these steps of resuscitation are effectively completed and there is no heart rate response by 20 minutes, redirection of care should be discussed with the team and family. Part 5: neonatal resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. For newborns who are breathing, continuous positive airway pressure can help with labored breathing or persistent cyanosis. A team or persons trained in neonatal resuscitation should be promptly available to provide resuscitation. However, it may be reasonable to increase inspired oxygen to 100% if there was no response to PPV with lower concentrations. When providing chest compressions to a newborn, the 2 thumbencircling hands technique may have benefit over the 2-finger technique with respect to blood pressure generation and provider fatigue. See Part 2: Evidence Evaluation and Guidelines Development for more details on this process.11. In preterm infants, delaying clamping reduces the need for vasopressors or transfusions. If a baby does not begin breathing . IV epinephrine every 3-5 minutes. The usefulness of positive end-expiratory pressure during PPV for term infant resuscitation has not been studied.6 A recent study showed that use of mask continuous positive airway pressure for resuscitation and treatment of respiratory distress syndrome in spontaneously breathing preterm infants reduced the need for intubation and subsequent mechanical ventilation without increasing the risk of bronchopulmonary dysplasia or death.29 In a preterm infant needing PPV, a PIP of 20 to 25 cm H2O may be adequate to increase heart rate while avoiding a higher PIP to prevent injury to preterm lungs, and positive end-expiratory pressure may be beneficial if suitable equipment is available.6. Prevention of hyperthermia (temperature greater than 38C) is reasonable due to an increased risk of adverse outcomes. ** After completing the initial steps of providing warmth, positioning the infant in the sniffing position, clearing the airway and evaluate the infant's response with the following: Monday - Friday: 7 a.m. 7 p.m. CT See permissionsforcopyrightquestions and/or permission requests. The dose of epinephrine can be re-peated after 3-5 minutes if the initial dose is ineffective or can be repeated immediately if initial dose is given by endo-tracheal tube in the absence of an . Babies who have failed to respond to PPV and chest compressions require vascular access to infuse epinephrine and/or volume expanders. Epinephrine (adrenaline) is the only medication recommended by the International Liaison Committee On Resuscitation (ILCOR) during resuscitation in newborns with persistent bradycardia or . 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. In addition, some conditions are so severe that the burdens of the illness and treatment greatly outweigh the likelihood of survival or a healthy outcome. The American Heart Association released minor updates to neonatal resuscitation recommendations with only minor changes to the previous algorithm (Figure 1). For spontaneously breathing preterm infants who require respiratory support immediately after delivery, it is reasonable to use CPAP rather than intubation. 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. Researchers studying these gaps may need to consider innovations in clinical trial design; examples include pragmatic study designs and novel consent processes. 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. 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. When the heart rate increases to more than 100 bpm, PPV may be discontinued if there is effective respiratory effort.5 Oxygen is decreased and discontinued once the infant's oxygen saturation meets the targeted levels (Figure 1).5, If there is no heartbeat after 10 minutes of adequate resuscitative efforts, the team can cease further resuscitation.1,5,6 A member of the team should keep the family informed during the resuscitation process. There are limited data comparing the different approaches to heart rate assessment during neonatal resuscitation on other neonatal outcomes. If the infant's heart rate is less than 60 beats per minute after effective positive pressure ventilation, then chest compressions should be initiated with continued positive pressure ventilation (3:1 ratio of compressions to ventilation; 90 compressions and 30 breaths per minute). 0.5 mL 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. After birth, the baby should be dried and placed directly skin-to-skin with attention to warm coverings and maintenance of normal temperature. In newborns who do not require resuscitation, delaying cord clamping for more than 30 seconds reduces anemia, especially in preterm infants. Finally, we wish to reinforce the importance of addressing the values and preferences of our key stakeholders, the families and teams who are involved in the process of resuscitation. This guideline affirms the previous recommendations. 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%. Routine oral, nasal, oropharyngeal, or endotracheal suctioning of newly born babies is not recommended. Metrics. A rise in heart rate is the most important indicator of effective ventilation and response to resuscitative interventions. A multicenter randomized trial showed that intrapartum suctioning of meconium does not reduce the risk of meconium aspiration syndrome. *In this situation, intravascular means intravenous or intraosseous. 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. Attaches oxygen set at 10-15 lpm. 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. For newly born infants who are unintentionally hypothermic (temperature less than 36C) after resuscitation, it may be reasonable to rewarm either rapidly (0.5C/h) or slowly (less than 0.5C/h). 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). Table 1. 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. doi: 10.1161/ CIR.0000000000000902. Available for purchase at https://shop.aap.org/textbook-of-neonatal-resuscitation-8th-edition-paperback/ (NOTE: This book features a full text reading experience. Copyright 2011 by the American Academy of Family Physicians. 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. Before giving PPV, the airway should be cleared by gently suctioning the mouth first and then the nose with a bulb syringe. In babies who appear to have ineffective respiratory effort after birth, tactile stimulation is reasonable. Use of ECG for heart rate detection does not replace the need for pulse oximetry to evaluate oxygen saturation or the need for supplemental oxygen. 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. For every 30 seconds that ventilation is delayed, the risk of prolonged admission or death increases by 16%. The practice test consists of 10 multiple-choice questions that adhere to the latest ILCOR standards. For neonatal resuscitation providers, it may be reasonable to brief before delivery and debrief after neonatal resuscitation. 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. On the other hand, overestimation of heart rate when a newborn is bradycardic may delay necessary interventions. 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. Alternative compression-to-ventilation ratios to 3:1, as well as asynchronous PPV (administration of inflations to a patient that are not coordinated with chest compressions), are routinely utilized outside the newborn period, but the preferred method in the newly born is 3:1 in synchrony. Chest compressions are provided if there is a poor heart rate response to ventilation after appropriate ventilation corrective steps, which preferably include endotracheal intubation. Reassess heart rate and breathing at least every 30 seconds. The airway is cleared (if necessary), and the infant is dried. Randomized controlled studies and observational studies in settings where therapeutic hypothermia is available (with very low certainty of evidence) describe variable rates of survival without moderate-to-severe disability in babies who achieve ROSC after 10 minutes or more despite continued resuscitation. A new Resuscitation Quality Improvement (RQI) program for NRP focused on PPV will be . If you have a certificate code, then you can manually verify a certificate by entering the code here. Two observational studies found an association between hyperthermia and increased morbidity and mortality in very preterm (moderate quality) and very low-birth-weight neonates (very low quality). Copyright 2023 American Academy of Family Physicians. None of these studies evaluate outcomes of resuscitation that extends beyond 20 minutes of age, by which time the likelihood of intact survival was very low. 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. Umbilical venous catheterization is the recommended vascular access, although it has not been studied. If the infant's heart rate is less than 100 bpm, PPV via face mask (not mask continuous positive airway pressure) is initiated at a rate of 40 to 60 breaths per minute to achieve and maintain a heart rate of more than 100 bpm.1,2,57 PPV can be administered via flow-inflating bag, self-inflating bag, or T-piece device.1,6 There is no major advantage of using one ventilatory device over another.23 Thus, each institution should standardize its equipment and train the neonatal resuscitation team appropriately. When providing chest compressions with the 2 thumbencircling hands technique, the hands encircle the chest while the thumbs depress the sternum.1,2 The 2 thumbencircling hands technique can be performed from the side of the infant or from above the head of the newborn.1 Performing chest compressions with the 2 thumbencircling hands technique from above the head facilitates placement of an umbilical venous catheter. Reduce the inflation pressure if the chest is moving well. Team debrieng. 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. Hyperlinked references are provided to facilitate quick access and review.