Medications are rarely needed in resuscitation of the newly born infant because low heart rate usually results from a very low oxygen level in the fetus or inadequate lung inflation after birth. 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. NRP-certified nurses, nurse practitioners, and respiratory therapists have demonstrated the capacity to lead resuscitations.1113 However, it is recommended that an NRP-certified physician be present in the hospital when a high-risk delivery is anticipated.1113 One study provides an outline for physicians interested in developing a neonatal resuscitation team.14. In a retrospective review, early hypoglycemia was a risk factor for brain injury in infants with acidemia requiring resuscitation. Blood may be lost from the placenta into the mothers circulation, from the cord, or from the infant. When do chest compressions stop NRP? When blood loss is suspected in a newly born infant who responds poorly to resuscitation (ventilation, chest compressions, and/or epinephrine), it may be reasonable to administer a volume expander without delay. How deep should the catheter be inserted? NRP Advanced may also be appropriate for health care professionals in smaller hospital facilities with fewer per- PPV remains the primary method for providing support for newborns who are apneic, bradycardic, or demonstrate inadequate respiratory effort. The heart rate response to chest compressions and medications should be monitored electrocardiographically. According to the Textbook of Neonatal Resuscitation, 8th edition, what volume of normal saline flush should you administer? Similarly, meta-analysis of 2 quasi-randomized trials showed no difference in moderate-to-severe neurodevelopmental impairment at 1 to 3 years of age. 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. After chest compressions are performed for at least 2 minutes When an alternative airway is inserted Immediately after epinephrine is administered 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. 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. External validity might be improved by studying the relevant learner or provider populations and by measuring the impact on critical patient and system outcomes rather than limiting study to learner outcomes. Tell your doctor if you have ever had: heart disease or high blood pressure; asthma; Parkinson's disease; depression or mental illness; a thyroid disorder; or. 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. When the need for resuscitation is not anticipated, delays in assisting a newborn who is not breathing may increase the risk of death.1,5,13 Therefore, every birth should be attended by at least 1 person whose primary responsibility is the newborn and who is trained to begin PPV without delay.24, A risk assessment tool that evaluates risk factors present during pregnancy and labor can identify newborns likely to require advanced resuscitation; in these cases, a team with more advanced skills should be mobilized and present at delivery.5,7 In the absence of risk stratification, up to half of babies requiring PPV may not be identified before delivery.6,13, A standardized equipment checklist is a comprehensive list of critical supplies and equipment needed in a given clinical setting. One RCT (low certainty of evidence) suggests improved oxygenation after resuscitation in preterm babies who received repeated tactile stimulation. 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. It may be reasonable to provide volume expansion with normal saline (0.9% sodium chloride) or blood at 10 to 20 mL/kg. A large multicenter RCT found higher rates of intraventricular hemorrhage with cord milking in preterm babies born at less than 28 weeks gestational age. No studies have examined PEEP vs. no PEEP when positive pressure ventilation is used after birth. However, the concepts in these guidelines may be applied to newborns during the neonatal period (birth to 28 days). Your team is caring for a term newborn whose heart rate is 50 bpm after receiving effective ventilation, chest compressions, and intravenous epinephrine administration. A randomized study showed similar success in providing effective ventilation using either laryngeal mask airway or endotracheal tube. 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. Epinephrine can cause increase in heart rate and blood pressure. The newly born period extends from birth to the end of resuscitation and stabilization in the delivery area. Normal saline (0.9% sodium chloride) is the crystalloid fluid of choice. Most changes are related to program administration and course facilitation. In addition, accurate, fast, and continuous heart rate assessment is necessary for newborns in whom chest compressions are initiated. Case series show small numbers of intact survivors after 20 minutes of no detectable heart rate. 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. Ventilation using a flow-inflating bag, self-inflating bag, or T-piece device can be effective. Cord milking in preterm infants should be avoided because of increased risk of intraventricular hemorrhage. The potential benefit or harm of sustained inflations between 1 and 10 seconds is uncertain.2,29. In animal studies (very low quality), the use of alterative compression-to-inflation ratios to 3:1 (eg, 2:1, 4:1, 5:1, 9:3, 15:2, and continuous chest compressions with asynchronous PPV) are associated with similar times to ROSC and mortality rates. Important aspects of neonatal resuscitation are the hospital policy and planning that ensure necessary equipment and personnel are present before delivery.1 Anticipation and preparation are essential elements for successful resuscitation,18 and this requires timely and accurate communication between the obstetric team and the neonatal resuscitation team. Copyright 2023 American Academy of Family Physicians. If the response to chest compressions is poor, it may be reasonable to provide epinephrine, preferably via the intravenous route. 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. Appropriate resuscitation must be available for each of the more than 4 million infants born annually in the United States. Naloxone and sodium bicarbonate are rarely needed and are not recommended during neonatal resuscitation. TALKAD S. RAGHUVEER, MD, AND AUSTIN J. COX, MD. Compresses correctly: Rate is correct. Epinephrine should be administered intravenously at 0.01 to 0.03 mg per kg or by endotracheal tube at 0.05 to 0.1 mg per kg. 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. Limited observational studies suggest that tactile stimulation may improve respiratory effort. When appropriate, flow diagrams or additional tables are included. The most important priority for newborn survival is the establishment of adequate lung inflation and ventilation after birth. 1-800-242-8721 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. Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process. Nearly 10 percent of the more than 4 million infants born in the United States annually need some assistance to begin breathing at birth, with approximately 1 percent needing extensive resuscitation1,2 and about 0.2 to 0.3 percent developing moderate or severe hypoxic-ischemic encephalopathy.3 Mortality in infants with hypoxic-ischemic encephalopathy ranges from 6 to 30 percent, and significant morbidity, such as cerebral palsy and long-term disabilities, occurs in 20 to 30 percent of survivors.4 The Neonatal Resuscitation Program (NRP), which was initiated in 1987 to identify infants at risk of respiratory depression and provide high-quality resuscitation, underwent major updates in 2006 and 2010.1,57, A 1987 study showed that nearly 78 percent of Canadian hospitals did not have a neonatal resuscitation team, and physicians were called into a significant number of community hospitals (69 percent) for neonatal resuscitation because they were not in-house.8 National guidelines in the United States and Canada recommend that a team or persons trained in neonatal resuscitation be promptly available for every birth.9,10 Actual institutional compliance with this guideline is unknown. 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. It may be reasonable to use higher concentrations of oxygen during chest compressions. Hypothermia (temperature less than 36C) should be prevented due to an increased risk of adverse outcomes. 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. One large retrospective review found that 0.04% of newborns received volume resuscitation in the delivery room, confirming that it is a relatively uncommon event. These guidelines apply primarily to the newly born baby who is transitioning from the fluid-filled womb to the air-filled room. ECG provides the most rapid and accurate measurement of the newborns heart rate at birth and during resuscitation. 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. If you have a certificate code, then you can manually verify a certificate by entering the code here. Tactile stimulation is reasonable in newborns with ineffective respiratory effort, but should be limited to drying the infant and rubbing the back and the soles of the feet. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient 3 minuted. Noninitiation of resuscitation and discontinuation of life-sustaining treatment during or after resuscitation should be considered ethically equivalent. For every 30 seconds that ventilation is delayed, the risk of prolonged admission or death increases by 16%. According to the Textbook of Neonatal Resuscitation, 8th edition algorithm, at what point during resuscitation is a cardiac monitor recommended to assess the baby's heart rate? HR below 60/min? For term and preterm infants who require resuscitation at birth, there is insufficient evidence to recommend early cord clamping versus delayed cord clamping. Epinephrine dosing may be repeated every three to five minutes if the heart rate remains less than 60 beats per minute. To start, 21% to 30% oxygen should be used in these newborns, titrating up based on oxygen saturation. The impact of therapeutic hypothermia on infants less than 36 weeks gestational age with HIE is unclear and is a subject of ongoing research trials. Traditionally, 100 percent oxygen has been used to achieve a rapid increase in tissue oxygen in infants with respiratory depression. In preterm infants, delaying clamping reduces the need for vasopressors or transfusions. Oximetry and electrocardiography are important adjuncts in babies requiring resuscitation. 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. 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. 5 As soon as the infant is delivered, a timer or clock is started. 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%. The updated guidelines also provide indications for chest compressions and for the use of intravenous epinephrine, which is the preferred route of administration, and recommend not to use sodium bicarbonate or naloxone during resuscitation. Preterm and term newborns without good muscle tone or without breathing and crying should be brought to the radiant warmer for resuscitation. 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. Approximately 10% of infants require help to begin breathing at birth, and 1% need intensive resuscitation. Review of the knowledge chunks during this update identified numerous questions and practices for which evidence was weak, uncertain, or absent. While the science and practices surrounding monitoring and other aspects of neonatal resuscitation continue to evolve, the development of skills and practice surrounding PPV should be emphasized. Hypothermia at birth is associated with increased mortality in preterm infants. If the baby is bradycardic (HR <60 per minute) after 90 seconds of resuscitation with a lower concentration of oxygen, oxygen concentration should be increased to 100% until recovery of a normal heart rate (Class IIb, LOE B). The benefit of 100% oxygen compared with 21% oxygen (air) or any other oxygen concentration for ventilation during chest compressions is uncertain. 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. The wet cloth beneath the infant is changed.5 Respiratory effort is assessed to see if the infant has apnea or gasping respiration, and the heart rate is counted by feeling the umbilical cord pulsations or by auscultating the heart for six seconds (e.g., heart rate of six in six seconds is 60 beats per minute [bpm]). Check the heart rate by counting the beats in 6 seconds and multiply by 10. 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. When anticipating a high-risk birth, a preresuscitation team briefing should be completed to identify potential interventions and assign roles and responsibilities. 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. Providing PPV at a rate of 40 to 60 inflations per minute is based on expert opinion. The airway is cleared (if necessary), and the infant is dried. Ventilation should be optimized before starting chest compressions, with endotracheal intubation if possible. National Center 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. 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 Copyright 2011 by the American Academy of Family Physicians. Epinephrine (adrenaline) is the only medication recommended by the International Liaison Committee On Resuscitation (ILCOR) during resuscitation in newborns with persistent bradycardia or . 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. Together with other professional societies, the AHA has provided interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed coronavirus disease 2019 (COVID-19) infection. After 30 seconds, Rescuer 2 evaluates heart rate. Coordinate chest compressions with ventilations at a ratio of 3:1 and a rate of 120 events per minute to achieve approximately 90 compressions and 30 breaths per minute. 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 . There is no evidence from randomized trials to support the use of volume resuscitation at delivery. Compared with preterm infants receiving early cord clamping, those receiving delayed cord clamping were less likely to receive medications for hypotension in a meta-analysis of 6 RCTs. 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. The current guideline, therefore, concludes with a summary of current gaps in neonatal research and some potential strategies to address these gaps. June 2021 The NRP 8th Edition introduces a new educational methodology to better meet the needs of health care professionals who manage the newly born baby. 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. 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. doi: 10.1161/ CIR.0000000000000902. NRP courses are moving from the HealthStream platform to RQI. There should be ongoing evaluation of the baby for normal respiratory transition. In newborns who do not require resuscitation, delaying cord clamping for more than 30 seconds reduces anemia, especially in preterm infants. 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. In this review, we provide the current recommendations for use of epinephrine during neonatal . If it is possible to identify such conditions at or before birth, it is reasonable not to initiate resuscitative efforts. 8 Assessment of Heart Rate During Neonatal Resuscitation 9 Ventilatory Support After Birth: PPV And Continuous Positive Airway Pressure 10 Oxygen Administration 11 Chest Compressions 12 Intravascular Access 13 Medications Epinephrine in Neonatal Resuscitation 14 Volume Replacement 15 Postresuscitation Care Admission temperature should be routinely recorded. The practice test consists of 10 multiple-choice questions that adhere to the latest ILCOR standards. A multicenter, case-control study identified 10 perinatal risk factors that predict the need for advanced neonatal resuscitation. The International Liaison Committee on Resuscitation (ILCOR) Formula for Survival emphasizes 3 essential components for good resuscitation outcomes: guidelines based on sound resuscitation science, effective education of resuscitation providers, and implementation of effective and timely resuscitation.8 The 2020 neonatal guidelines contain recommendations, based on the best available resuscitation science, for the most impactful steps to perform in the birthing room and in the neonatal period. In a case series, endotracheal epinephrine (0.01 mg per kg) was less effective than intravenous epinephrine. CPAP, a form of respiratory support, helps newly born infants keep their lungs open. See Part 2: Evidence Evaluation and Guidelines Development for more details on this process.11. High oxygen concentrations are recommended during chest compressions based on expert opinion. 2023 American Heart Association, Inc. All rights reserved. For nonvigorous newborns with meconium-stained fluid, endotracheal suctioning is indicated only if obstruction limits positive pressure ventilation, because suctioning does not improve outcomes. All Rights Reserved. There was no difference in neonatal intubation performance after weekly booster practice for 4 weeks compared with daily booster practice for 4 consecutive days. The suggested ratio is 3 chest compressions synchronized to 1 inflation (with 30 inflations per minute and 90 compressions per minute) using the 2 thumbencircling hands technique for chest compressions.