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. In babies who appear to have ineffective respiratory effort after birth, tactile stimulation is reasonable. 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. Delaying cord clamping for more than 30 seconds is reasonable for term and preterm infants who do not require resuscitation. Both hands encircling chest Thumbs side by side or overlapping on lower half of . A combination of chest compressions and ventilation resulted in better outcomes than ventilation or compressions alone in piglet studies. For term infants who do not require resuscitation at birth, it may be reasonable to delay cord clamping for longer than 30 seconds. 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. In a meta-analysis of 8 RCTs involving 1344 term and late preterm infants with moderate-to-severe encephalopathy and evidence of intrapartum asphyxia, therapeutic hypothermia resulted in a significant reduction in the combined outcome of mortality or major neurodevelopmental disability to 18 months of age (odds ratio 0.75; 95% CI, 0.680.83). When chest compressions are initiated, an ECG should be used to confirm heart rate. 3 minuted. Establishing ventilation is the most important step to correct low heart rate. After birth, the baby should be dried and placed directly skin-to-skin with attention to warm coverings and maintenance of normal temperature. A team or persons trained in neonatal resuscitation should be promptly available to provide resuscitation. Peer reviewer feedback was provided for guidelines in draft format and again in final format. With growing enthusiasm for clinical studies in neonatology, elements of the Neonatal Resuscitation Algorithm continue to evolve as new evidence emerges. 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. A multicenter, case-control study identified 10 perinatal risk factors that predict the need for advanced neonatal resuscitation. The American Heart Association released minor updates to neonatal resuscitation recommendations with only minor changes to the previous algorithm (Figure 1). Hypothermia (temperature less than 36C) should be prevented due to an increased risk of adverse outcomes. When vascular access is required in the newly born, the umbilical venous route is preferred. 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. It is important to recognize that there are several significant gaps in knowledge relating to neonatal resuscitation. Historically, the repeat training has occurred every 2 years.69 However, adult, pediatric, and neonatal studies suggest that without practice, CPR knowledge and skills decay within 3 to 12 months1012 after training. 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. 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. When providing chest compressions in a newborn, it may be reasonable to repeatedly deliver 3 compressions followed by an inflation (3:1 ratio). However, the concepts in these guidelines may be applied to newborns during the neonatal period (birth to 28 days). Recommendation-specific text clarifies the rationale and key study data supporting the recommendations. See Part 2: Evidence Evaluation and Guidelines Development for more details on this process.11. There should be ongoing evaluation of the baby for normal respiratory transition. 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. In preterm birth, there are also potential advantages from delaying cord clamping. Early skin-to-skin contact benefits healthy newborns who do not require resuscitation by promoting breastfeeding and temperature stability. When appropriate, flow diagrams or additional tables are included. A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide. 5 minutec. 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. Review of the knowledge chunks during this update identified numerous questions and practices for which evidence was weak, uncertain, or absent. 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. 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. 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. For infants requiring PPV at birth, there is currently insufficient evidence to recommend delayed cord clamping versus early cord clamping. The heart rate should be verbalized for the team. Case series in preterm infants have found that most preterm infants can be resuscitated using PPV inflation pressures in the range of 20 to 25 cm H. An observational study including 1962 infants between 23 and 33 weeks gestational age reported lower rates of mortality and chronic lung disease when giving PPV with PEEP versus no PEEP. In preterm infants, delaying clamping reduces the need for vasopressors or transfusions. 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. 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. Please see updates below from RQI Partners, the company that is providing the NRP Learning Platform TM and RQI for NRP. 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? A large multicenter RCT found higher rates of intraventricular hemorrhage with cord milking in preterm babies born at less than 28 weeks gestational age. 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. Radiant warmers and other warming adjuncts are suggested for babies who require resuscitation at birth, especially very preterm and very low-birth-weight babies. CPAP, a form of respiratory support, helps newly born infants keep their lungs open. 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. Once the heart rate increases to more than 60 bpm, chest compressions are stopped. Plasma epinephrine concentrations at 1 min after epinephrine administration were not different. HR below 60/min? 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. A 3:1 ratio of compressions to ventilation provided more ventilations than higher ratios in manikin studies. Because evidence and guidance are evolving with the COVID-19 situation, this interim guidance is maintained separately from the ECC guidelines. Every healthy newly born baby should have a trained and equipped person assigned to facilitate transition. See permissionsforcopyrightquestions and/or permission requests. Effective team behaviors, such as anticipation, communication, briefing, equipment checks, and assignment of roles, result in improved team performance and neonatal outcome. When intravenous access is not feasible, the intraosseous route may be considered. The potential benefit or harm of sustained inflations between 1 and 10 seconds is uncertain.2,29. It is important to. Preterm infants less than 32 weeks' gestation are more likely to develop hyperoxemia with the initial use of 100 percent oxygen, and develop hypoxemia with 21 percent oxygen compared with an initial concentration of 30 or 90 percent oxygen. Several animal studies found that ventilation with high volumes caused lung injury, impaired gas exchange, and reduced lung compliance in immature animals. Wrapping, in addition to radiant heat, improves admission temperature of preterm infants. 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). The 2 thumbencircling hands technique achieved greater depth, less fatigue, and less variability with each compression compared with the 2-finger technique. Copyright 2023 American Academy of Family Physicians. Median time to ROSC and cumulative epinephrine dose required were not different. 7272 Greenville Ave. 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. 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. The guidelines form the basis of the AAP/American Heart Association (AHA) Neonatal Resuscitation Program (NRP), 8th edition, which will be available in June 2021. The current guidelines have focused on clinical activities described in the resuscitation algorithm, rather than on the most appropriate devices for each step. 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. Higher doses (0.05 to 0.1 mg per kg) of endotracheal epinephrine are needed to achieve an increase in blood epinephrine concentration. 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. Supplemental oxygen: 100 vs. 21 percent (room air). ECG (3-lead) displays a reliable heart rate faster than pulse oximetry. Endotracheal suctioning may be useful in nonvigorous infants with respiratory depression born through meconium-stained amniotic fluid. 5 As soon as the infant is delivered, a timer or clock is started. 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. minutes, and 80% at 5 minutes of life. If the neonate's heart rate is less than 60 bpm after optimal ventilation for 30 seconds, the oxygen concentration should be increased to 100% with commencement of chest compressions. There are limited data comparing the different approaches to heart rate assessment during neonatal resuscitation on other neonatal outcomes. If the heart rate remains less than 60/min despite 30 seconds of adequate PPV, chest compressions should be provided. Once the neonatal resuscitation team is summoned to the delivery room, it is important to obtain a pertinent history; assign roles to each team member; check that all equipment is available and functional,1 including a pulse oximeter and an air/oxygen blender6; optimize room temperature for the infant; and turn on the warmer, light, oxygen, and suction.