Table 1 lists evidence and recommendations for interventions during neonatal resuscitation.1,2,57,2043, Intrapartum suctioning is not recommended with clear or meconium-stained amniotic fluid.1,2,5,6, Endotracheal suctioning of vigorous* infants is not recommended.1,2,5,6, Endotracheal suctioning of nonvigorous infants born through meconium-stained amniotic fluid may be useful.1,2,5, A self-inflating bag, flow-inflating bag, or T-piece device can be used to deliver positive pressure ventilation.1,6, Auscultation should be the primary means of assessing heart rate, and in infants needing respiratory support, the goal should be to check the heart rate by auscultation and by pulse oximetry.6, Initial PIP of 20 cm H2O may be effective, but a PIP of 30 to 40 cm H2O may be necessary in some infants to achieve or maintain a heart rate of more than 100 bpm.5, Ventilation rates of 40 to 60 breaths per minute are recommended.5,6, Use of an exhaled carbon dioxide detector in term and preterm infants is recommended to confirm endotracheal tube placement.5,6, Laryngeal mask airway should be considered if bag and mask ventilation is unsuccessful, and if endotracheal intubation is unsuccessful or not feasible.5,6, No evidence exists to support or refute the use of mask CPAP in term infants.2,5, PEEP should be used if suitable equipment is available, such as a flow-inflating bag or T-piece device.5, Delivery rooms should have a pulse oximeter readily available.57, A pulse oximeter is recommended when supplemental oxygen, positive pressure ventilation, or CPAP is used.57, Supplemental oxygen should be administered using an air/oxygen blender.57. It is important to continue PPV and chest compressions while preparing to deliver medications. Outside the delivery room, or if intravenous access is not feasible, the intraosseous route may be a reasonable alternative, determined by the local availability of equipment, training, and experience. Given the evidence for ECG during initial steps of PPV, expert opinion is that ECG should be used when providing chest compressions. Another barrier is the difficulty in obtaining antenatal consent for clinical trials in the delivery room. 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. For infants with a heart rate of 60 to < 100 beats/minute who have apnea, gasping, or ineffective respirations, positive pressure ventilation (PPV) using a mask is indicated. Intravenous epinephrine is preferred because. The heart rate should be re-checked after 1 minute of giving compressions and ventilations. Attaches oxygen set at 10-15 lpm. 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. The same study demonstrated that the risk of death or prolonged admission increases 16% for every 30-second delay in initiating PPV. Copyright 2023 American Academy of Family Physicians. Team training remains an important aspect of neonatal resuscitation, including anticipation, preparation, briefing, and debriefing. Neonatal resuscitation program Your team is resuscitating a newborn whose heart rate remains less than 60 bpm despite effective PPV and 60 seconds of chest compressions. We thank Dr. Abhrajit Ganguly for assistance in manuscript preparation. In the resuscitation of an infant, initial oxygen concentration of 21 percent is recommended. 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. The airway is cleared (if necessary), and the infant is dried. Neonatal resuscitation teams may therefore benefit from ongoing booster training, briefing, and debriefing. This is partly due to the challenges of performing large randomized controlled trials (RCTs) in the delivery room. It may be reasonable to administer a volume expander to newly born infants with suspected hypovolemia, based on history and physical examination, who remain bradycardic (heart rate less than 60/min) despite ventilation, chest compressions, and epinephrine. If the heart rate is less than 60 bpm, begin chest compressions. 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. 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. Intravenous epinephrine is preferred because plasma epinephrine levels increase much faster than with endotracheal administration. 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. Appropriate and timely support should be provided to all involved. 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. Copyright 2021 by the American Academy of Family Physicians. One observational study compared neonatal outcomes before (historical cohort) and after implementation of ECG monitoring in the delivery room. After birth, the baby should be dried and placed directly skin-to-skin with attention to warm coverings and maintenance of normal temperature. For term and preterm infants who require resuscitation at birth, there is insufficient evidence to recommend early cord clamping versus delayed cord clamping. The current guideline, therefore, concludes with a summary of current gaps in neonatal research and some potential strategies to address these gaps. 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. One RCT (low certainty of evidence) suggests improved oxygenation after resuscitation in preterm babies who received repeated tactile stimulation. A prospective study showed that the use of an exhaled carbon dioxide detector is useful to verify endotracheal intubation. No type of routine suctioning is helpful, even for nonvigorous newborns delivered through meconium-stained amniotic fluid. 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. 1 minuteb. Recommendation-specific text clarifies the rationale and key study data supporting the recommendations. Several animal studies found that ventilation with high volumes caused lung injury, impaired gas exchange, and reduced lung compliance in immature animals. Most RCTs in well-resourced settings would routinely manage at-risk babies under a radiant warmer. 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. Routine oral, nasal, oropharyngeal, or endotracheal suctioning of newly born babies is not recommended. A laboring woman received a narcotic medication for pain relief 1 hour before delivery.The baby does not have spontaneous respirations and does not improve with stimulation.Your first priority is to. Consider pneumothorax. Plasma epinephrine concentrations at 1 min after epinephrine administration were not different. 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 addition, some conditions are so severe that the burdens of the illness and treatment greatly outweigh the likelihood of survival or a healthy outcome. A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide. Ventilation should be optimized before starting chest compressions, possibly including endotracheal intubation. 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. In one RCT and one observational study, there were no reports of technical difficulties with ECG monitoring during neonatal resuscitation, supporting its feasibility as a tool for monitoring heart rate during neonatal resuscitation. Term newborns with good muscle tone who are breathing or crying should be brought to their mother's chest routinely. Successful neonatal resuscitation efforts depend on critical actions that must occur in rapid succession to maximize the chances of survival. In addition, accurate, fast, and continuous heart rate assessment is necessary for newborns in whom chest compressions are initiated. Comprehensive disclosure information for peer reviewers is listed in Appendix 2(link opens in new window). If the heart rate is less than 100 bpm and/or the infant has apnea or gasping respiration, positive pressure ventilation (PPV) via face mask is initiated with 21 percent oxygen (room air) or blended oxygen, and the pulse oximeter probe is applied to the right hand/wrist to monitor heart rate and oxygen saturation.5,6 The heart rate is reassessed after 30 seconds, and if it is less than 100 bpm, PPV is optimized to ensure adequate ventilation, and heart rate is checked again in 30 seconds.57 If the heart rate is less than 60 bpm after 30 seconds of effective PPV, chest compressions are started with continued PPV with 100 percent oxygen (3:1 ratio of compressions to ventilation; 90 compressions and 30 breaths per minute) for 45 to 60 seconds.57 If the heart rate continues to be less than 60 bpm despite adequate ventilation and chest compressions, epinephrine is administered via umbilical venous catheter (or less optimally via endotracheal tube).57, Depending on the skill of the resuscitator, the infant can be intubated and PPV delivered via endotracheal tube if chest compressions are needed or if bag and mask ventilation is prolonged or ineffective (with no chest rise).5 Heart rate, respiratory effort, and color are reassessed and verbalized every 30 seconds as PPV and chest compressions are performed. National Center 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. Most babies will respond to this intervention. The temperature of newly born babies should be maintained between 36.5C and 37.5C after birth through admission and stabilization. 2020;142(suppl 2):S524S550. When do chest compressions stop NRP? For nonvigorous newborns (presenting with apnea or ineffective breathing effort) delivered through MSAF, routine laryngoscopy with or without tracheal suctioning is not recommended. Variables to be considered may include whether the resuscitation was considered optimal, availability of advanced neonatal care (such as therapeutic hypothermia), specific circumstances before delivery, and wishes expressed by the family.3,6, Some babies are so sick or immature at birth that survival is unlikely, even if neonatal resuscitation and intensive care are provided. Identification of risk factors for resuscitation may indicate the need for additional personnel and equipment. Wrapping, in addition to radiant heat, improves admission temperature of preterm infants. 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. 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. 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. Animal studies in newborn mammals show that heart rate decreases during asphyxia. 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. Supplemental oxygen: 100 vs. 21 percent (room air). 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. NRP courses are moving from the HealthStream platform to RQI. Hyperthermia should be avoided.1,2,6, Delivery room temperature should be set at at least 78.8F (26C) for infants less than 28 weeks' gestation.6. Every birth should be attended by one person who is assigned, trained, and equipped to initiate resuscitation and deliver positive pressure ventilation. 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. Currently, epinephrine is the only vasoactive drug recommended by the International Liaison Committee on Resuscitation (ILCOR) for neonates who remain severely bradycardic (heart rate <. History and physical examination findings suggestive of blood loss include a pale appearance, weak pulses, and persistent bradycardia (heart rate less than 60/min). 7272 Greenville Ave. Your team is caring for a term newborn whose heart rate is 50 bpm after receiving effective ventilation, chest compressions, and intravenous epinephrine administration. Chest compressions are a rare event in full-term newborns (approximately 0.1%) but are provided more frequently to preterm newborns.11When providing chest compressions to a newborn, it may be reasonable to deliver 3 compressions before or after each inflation: providing 30 inflations and 90 compressions per minute (3:1 ratio for 120 total events per minute). Suctioning may be considered for suspected airway obstruction. Before giving PPV, the airway should be cleared by gently suctioning the mouth first and then the nose with a bulb syringe. See permissionsforcopyrightquestions and/or permission requests. Preterm and term newborns without good muscle tone or without breathing and crying should be brought to the radiant warmer for resuscitation. Copyright 2011 by the American Academy of Family Physicians. NRP Advanced may also be appropriate for health care professionals in smaller hospital facilities with fewer per- After birth, the newborn's heart rate is used to assess the effectiveness of spontaneous respiratory effort, the need for interventions, and the response to interventions. Establishing ventilation is the most important step to correct low heart rate. A large observational study found that delaying PPV increases risk of death and prolonged hospitalization. An important point is that ventilation has been shown to be the most effective measure in neonatal resuscitation Two randomized trials and 1 quasi-randomized trial (very low quality) including 312 infants compared PPV with a T-piece (with PEEP) versus a self-inflating bag (no PEEP) and reported similar rates of death and chronic lung disease. Exhaled carbon dioxide detectors can be used to confirm endotracheal tube placement in an infant. Most changes are related to program administration and course facilitation. If there is ineffective breathing effort or apnea after birth, tactile stimulation may stimulate breathing. Unauthorized use prohibited. Copyright 2023 American Academy of Family Physicians. TALKAD S. RAGHUVEER, MD, AND AUSTIN J. COX, MD. 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. This series is coordinated by Michael J. Arnold, MD, contributing editor. (if you are using the 0.1 mg/kg dose.) 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. Therefore, identifying a rapid and reliable method to measure the newborn's heart rate is critically important during neonatal resuscitation. It is reasonable to perform all resuscitation procedures, including endotracheal intubation, chest compressions, and insertion of intravenous lines with temperature-controlling interventions in place. 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. In preterm birth, there are also potential advantages from delaying cord clamping. *Red Dress DHHS, Go Red AHA ; National Wear Red Day is a registered trademark. Appropriate resuscitation must be available for each of the more than 4 million infants born annually in the United States. 1 Exhaled carbon dioxide detection is the recommended method of confirming endotracheal intubation. 8. Delaying cord clamping for more than 30 seconds is reasonable for term and preterm infants who do not require resuscitation.
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