The immediate care of newly born babies involves an initial assessment of gestation, breathing, and tone. Intra-arterial epinephrine is not recommended. Post-resuscitation care. Wait 60 seconds and check the heart rate. 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. 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). Pulse oximetry is used to guide oxygen therapy and meet oxygen saturation goals. RQI for NRP. 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). 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. The same study demonstrated that the risk of death or prolonged admission increases 16% for every 30-second delay in initiating PPV. Various combinations of warming strategies (or bundles) may be reasonable to prevent hypothermia in very preterm babies. Rescuer 2 verbalizes the need for chest compressions. 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. Internal validity might be better addressed by clearly defined primary outcomes, appropriate sample sizes, relevant and timed interventions and controls, and time series analyses in implementation studies. Teams and individuals who provide neonatal resuscitation are faced with many challenges with respect to the knowledge, skills, and behaviors needed to perform effectively. 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). When providing chest compressions to a newborn, it may be reasonable to choose the 2 thumbencircling hands technique over the 2-finger technique, as the 2 thumbencircling hands technique is associated with improved blood pressure and less provider fatigue. The Neonatal Resuscitation Program, which was initiated in 1987 to identify infants at risk of needing resuscitation and provide high-quality resuscitation, underwent major updates in 2006 and 2010. 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. 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. A large observational study found that delaying PPV increases risk of death and prolonged hospitalization. Resuscitation of an infant with respiratory depression (term and preterm) in the delivery room (Figure 1) focuses on airway, breathing, circulation, and medications. Monday - Friday: 7 a.m. 7 p.m. CT All Rights Reserved. Reduce the inflation pressure if the chest is moving well. Copyright 2023 American Academy of Family Physicians. 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. Suctioning may be considered for suspected airway obstruction. Exhaled carbon dioxide detectors can be used to confirm endotracheal tube placement in an infant. Routine oral, nasal, oropharyngeal, or endotracheal suctioning of newly born babies is not recommended. Excessive peak inflation pressures are potentially harmful and should be avoided. 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. High-quality observational studies of large populations may also add to the evidence. If the response to chest compressions is poor, it may be reasonable to provide epinephrine, preferably via the intravenous route. Failure to respond to epinephrine in a newborn with history or examination consistent with blood loss may require volume expansion. Epinephrine is indicated if the heart rate remains below 60 beats per minute despite 60 seconds of chest compressions and adequate ventilation. Before using epinephrine, tell your doctor if any past use of epinephrine injection caused an allergic reaction to get worse. A multicenter randomized trial showed that intrapartum suctioning of meconium does not reduce the risk of meconium aspiration syndrome. When possible, healthy term babies should be managed skin-to-skin with their mothers. Routine suctioning, whether oral, nasal, oropharyngeal, or endotracheal, is not recommended because of a lack of benefit and risk of bradycardia. A rise in heart rate is the most important indicator of effective ventilation and response to resuscitative interventions. In the birth setting, a standardized checklist should be used before every birth to ensure that supplies and equipment for a complete resuscitation are present and functional.8,9,14,15, A predelivery team briefing should be completed to identify the leader, assign roles and responsibilities, and plan potential interventions. 3 minuted. 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. For infants requiring PPV at birth, there is currently insufficient evidence to recommend delayed cord clamping versus early cord clamping. Normal saline (0.9% sodium chloride) is the crystalloid fluid of choice. 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. The heart rate is reassessed,6 and if it continues to be less than 60 bpm, synchronized chest compressions and PPV are initiated in a 3:1 ratio (three compressions and one PPV).5,6 Chest compressions can be done using two thumbs, with fingers encircling the chest and supporting the back (preferred), or using two fingers, with a second hand supporting the back.5,6 Compressions should be delivered to the lower one-third of the sternum to a depth of approximately one-third of the anteroposterior diameter.5,6 The heart rate is reassessed at 45- to 60-second intervals, and chest compressions are stopped once the heart rate exceeds 60 bpm.5,6, Epinephrine is indicated if the infant's heart rate continues to be less than 60 bpm after 30 seconds of adequate PPV with 100 percent oxygen and chest compressions. 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. Preterm and term newborns without good muscle tone or without breathing and crying should be brought to the radiant warmer for resuscitation. 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. When epinephrine is required, multiple doses are commonly needed. 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. This content is owned by the AAFP. 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. Flush the UVC with normal saline. Traditionally, 100 percent oxygen has been used to achieve a rapid increase in tissue oxygen in infants with respiratory depression. 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). Please contact the American Heart Association at ECCEditorial@heart.org or 1-214-706-1886 to request a long description of . In newborns who do not require resuscitation, delaying cord clamping for more than 30 seconds reduces anemia, especially in preterm infants. minutes, and 80% at 5 minutes of life. It is important to recognize that there are several significant gaps in knowledge relating to neonatal resuscitation. When ECG heart rate is greater than 60/min, a palpable pulse and/or audible heart rate rules out pulseless electric activity.1721, The vast majority of newborns breathe spontaneously within 30 to 60 seconds after birth, sometimes after drying and tactile stimulation.1 Newborns who do not breathe within the first 60 seconds after birth or are persistently bradycardic (heart rate less than 100/min) despite appropriate initial actions (including tactile stimulation) may receive PPV at a rate of 40 to 60/min.2,3 The order of resuscitative procedures in newborns differs from pediatric and adult resuscitation algorithms. Positive-pressure ventilation (PPV) remains the main intervention in neonatal resuscitation. 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. The reduced heart rate that occurs in this situation can be reversed with tactile stimulation. 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. Oximetry and electrocardiography are important adjuncts in babies requiring resuscitation. Test your knowledge with our free Neonatal Resuscitation Practice Test provided below in order to prepare you for our official online exam. 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. Heart rate is assessed initially by auscultation and/or palpation. Approximately 10% of newborns require assistance to breathe after birth.13,5,13 Newborn resuscitation requires training, preparation, and teamwork. 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. This guideline is designed for North American healthcare providers who are looking for an up-to-date summary for clinical care, as well as for those who are seeking more in-depth information on resuscitation science and gaps in current knowledge. The decision to continue or discontinue resuscitative efforts should be individualized and should be considered at about 20 minutes after birth. 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. Most changes are related to program administration and course facilitation. Tactile stimulation should be limited to drying an infant and rubbing the back and soles of the feet.21,22 There may be some benefit from repeated tactile stimulation in preterm babies during or after providing PPV, but this requires further study.23 If, at initial assessment, there is visible fluid obstructing the airway or a concern about obstructed breathing, the mouth and nose may be suctioned. The heart rate response to chest compressions and medications should be monitored electrocardiographically. 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. See Part 2: Evidence Evaluation and Guidelines Development for more details on this process.11. Premature animals exposed to brief high tidal volume ventilation (from high PIP) develop lung injury, impaired gas exchange, and decreased lung compliance. When should I check heart rate after epinephrine? Epinephrine use in the delivery room for resuscitation of the newborn is associated with significant morbidity and mortality. After birth, the baby should be dried and placed directly skin-to-skin with attention to warm coverings and maintenance of normal temperature. In the delivery room setting, the primary method of vascular access is umbilical venous catheterization. In preterm infants, delaying clamping reduces the need for vasopressors or transfusions. One small manikin study (very low quality), compared the 2 thumbencircling hands technique and 2-finger technique during 60 seconds of uninterrupted chest compressions. Delayed umbilical cord clamping was recommended for both term and preterm neonates in 2015. 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. Therapeutic hypothermia is recommended in infants born at 36 weeks' gestation or later with evolving moderate to severe hypoxic-ischemic encephalopathy. The 2020 guidelines are organized into "knowledge chunks," grouped into discrete modules of information on specific topics or management issues.22 Each modular knowledge chunk includes a table of recommendations using standard AHA nomenclature of COR and LOE. 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. If the infant needs PPV, the recommended approach is to monitor the inflation pressure and to initiate PPV using a peak inspiratory pressure (PIP) of 20 cm H2O for the first few breaths; however, a PIP of 30 to 40 cm H2O (in some term infants) may be required at a rate of 40 to 60 breaths per minute.5,6 The best measure of adequate ventilation is prompt improvement in heart rate.24 Auscultation of the precordium is the primary means of assessing heart rate, but for infants requiring respiratory support, pulse oximetry is recommended.5,6 However, if the heart rate does not increase with mask PPV and there is no chest rise, ventilation should be optimized by implementing the following six steps: (1) adjust the mask to ensure a good seal; (2) reposition the airway by adjusting the position of the head; (3) suction the secretions in the mouth and nose; (4) open the mouth slightly and move the jaw forward; (5) increase the PIP enough to move the chest; and (6) consider an alternate airway (endotracheal intubation or laryngeal mask airway).5 PIP may be decreased when the heart rate increases to more than 60 bpm, and PPV may be discontinued once the heart rate is more than 100 bpm and there is spontaneous breathing. In addition, accurate, fast, and continuous heart rate assessment is necessary for newborns in whom chest compressions are initiated. The most important priority for newborn survival is the establishment of adequate lung inflation and ventilation after birth. Physicians who provide obstetric care should be aware of maternal-fetal risk factors1 and should assess the risk of respiratory depression with each delivery.19 The obstetric team should inform the neonatal resuscitation team of the risk status for each delivery and continue to focus on obstetric care. For nonvigorous newborns delivered through MSAF who have evidence of airway obstruction during PPV, intubation and tracheal suction can be beneficial. There is a history of acute blood loss around the time of delivery. monitored. After an uncomplicated term or late preterm birth, it is reasonable to delay cord clamping until after the baby is placed on the mother, dried, and assessed for breathing, tone, and activity. 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. Most babies will respond to this intervention. 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. A large observational study showed that most nonvigorous newly born infants respond to stimulation and PPV. 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. 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. Currently, epinephrine is the only vasoactive drug recommended by the International Liaison Committee on Resuscitation (ILCOR) for neonates who remain severely bradycardic (heart rate <. Before giving PPV, the airway should be cleared by gently suctioning the mouth first and then the nose with a bulb syringe. Initiate effective PPV for 30 seconds and reassess the heart rate. Positive-pressure ventilation should be started in newborns who are gasping, apneic, or with a heart rate below 100 beats per minute by 60 seconds of life. 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. 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. Hypothermia (temperature less than 36C) should be prevented due to an increased risk of adverse outcomes. If the baby is apneic or has a heart rate less than 100 bpm Begin the initial steps Warm, dry and stimulate for 30 seconds (Heart rate is 50/min.) One observational study in newly born infants associated high tidal volumes during resuscitation with brain injury. On the other hand, overestimation of heart rate when a newborn is bradycardic may delay necessary interventions. No studies have examined PEEP vs. no PEEP when positive pressure ventilation is used after birth. Newly born infants who receive prolonged PPV or advanced resuscitation (intubation, chest compressions, or epinephrine) should be maintained in or transferred to an environment where close monitoring can be provided. 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. Three out of seven (43%) and 12/15 (80%) lambs achieved ROSC after the rst dose of epinephrine with 1-mL and 2.5-mL ush respectively (p = 0.08). 1 Exhaled carbon dioxide detection is the recommended method of confirming endotracheal intubation. If there is ineffective breathing effort or apnea after birth, tactile stimulation may stimulate breathing. 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. If resuscitation is required, electrocardiography should be used, especially with chest compressions. Early skin-to-skin contact benefits healthy newborns who do not require resuscitation by promoting breastfeeding and temperature stability. However, it may be reasonable to increase inspired oxygen to 100% if there was no response to PPV with lower concentrations. Pulse oximetry with oxygen targeting is recommended in this population.3, Most newborns who are apneic or have ineffective breathing at birth will respond to initial steps of newborn resuscitation (positioning to open the airway, clearing secretions, drying, and tactile stimulation) or to effective PPV with a rise in heart rate and improved breathing. The American Heart Association released minor updates to neonatal resuscitation recommendations with only minor changes to the previous algorithm (Figure 1). 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. The potential benefit or harm of sustained inflations between 1 and 10 seconds is uncertain.2,29. The research community needs to address the paucity of educational studies that provide outcomes with a high level of certainty. Another barrier is the difficulty in obtaining antenatal consent for clinical trials in the delivery room. Before every birth, a standardized equipment checklist should be used to ensure the presence and function of supplies and equipment necessary for a complete resuscitation. Every birth should be attended by at least 1 person who can perform the initial steps of newborn resuscitation and initiate PPV, and whose only responsibility is the care of the newborn. 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. This series is coordinated by Michael J. Arnold, MD, contributing editor. Newer methods of chest compression, using a sustained inflation that maintains lung inflation while providing chest compressions, are under investigation and cannot be recommended at this time outside research protocols.12,13. Attaches oxygen set at 10-15 lpm. Consequently, all newly born babies should be attended to by at least 1 person skilled and equipped to provide PPV. 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. Comprehensive disclosure information for peer reviewers is listed in Appendix 2(link opens in new window). Target Oxygen Saturation Table Initial oxygen concentration for PPV 1 min 60%-65% 2 min 65%-70% 3 min 70%-75% 4 min 75%-80% 5 min 80%-85% 10 min 85%-95% 35 weeks' GA 21% oxygen PPV remains the primary method for providing support for newborns who are apneic, bradycardic, or demonstrate inadequate respiratory effort. There should be ongoing evaluation of the baby for normal respiratory transition. 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. How soon after administration of intravenous epinephrine should you pause compressions and assess the baby's heart rate?a. Review of the knowledge chunks during this update identified numerous questions and practices for which evidence was weak, uncertain, or absent.
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