In preterm birth, there are also potential advantages from delaying cord clamping. 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. Intra-arterial epinephrine is not recommended. When providing chest compressions in a newborn, it may be reasonable to repeatedly deliver 3 compressions followed by an inflation (3:1 ratio). CPAP indicates continuous positive airway pressure; ECG, electrocardiographic; ETT, endotracheal tube; HR, heart rate; IV, intravenous; O2, oxygen; Spo2, oxygen saturation; and UVC, umbilical venous catheter. All guidelines were reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and AHA Executive Committee. For babies requiring vascular access at the time of delivery, the umbilical vein is the recommended route. Failure to respond to epinephrine in a newborn with history or examination consistent with blood loss may require volume expansion. 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. For term infants who do not require resuscitation at birth, it may be reasonable to delay cord clamping for longer than 30 seconds. In addition, accurate, fast, and continuous heart rate assessment is necessary for newborns in whom chest compressions are initiated. A combination of chest compressions and ventilation resulted in better outcomes than ventilation or compressions alone in piglet studies. The American Heart Association is a qualified 501(c)(3) tax-exempt organization. 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. What is true about a pneumothorax in the newborn? Exhaled carbon dioxide detectors to confirm endotracheal tube placement. 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. 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. 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. Several animal studies found that ventilation with high volumes caused lung injury, impaired gas exchange, and reduced lung compliance in immature animals. 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. In addition, specific recommendations about the training of resuscitation providers and systems of care are provided in their respective guideline Parts.9,10. The reduced heart rate that occurs in this situation can be reversed with tactile stimulation. Immediate, unlimited access to all AFP content, Immediate, unlimited access to this issue's content. 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. Available for purchase at https://shop.aap.org/textbook-of-neonatal-resuscitation-8th-edition-paperback/ (NOTE: This book features a full text reading experience. 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. All Rights Reserved. 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. 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). Recommendation-specific text clarifies the rationale and key study data supporting the recommendations. Depth is correct. 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. 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. 2020;142(suppl 2):S524S550. Positive-pressure ventilation (PPV) remains the main intervention in neonatal resuscitation. 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. 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? Before using epinephrine, tell your doctor if any past use of epinephrine injection caused an allergic reaction to get worse. We thank Dr. Abhrajit Ganguly for assistance in manuscript preparation. Recent clinical trials have shown that infants resuscitated with 21 percent oxygen compared with 100 percent oxygen had significantly lower mortality (at one week and one month) and were able to establish regular respiration in a shorter time; the rates of encephalopathy and cerebral palsy were similar in the two groups.4549 The 2010 NRP guidelines recommend starting resuscitation of term infants with 21 percent oxygen or blended oxygen and increasing the concentration of oxygen (using an air/oxygen blender) if oxygen saturation (measured using a pulse oximeter) is lower than recommended targets (Figure 1).5 Oxygen concentration should be increased to 100 percent if the heart rate is less than 60 bpm despite effective ventilation, and when chest compressions are necessary.57, If the infant's heart rate is less than 60 bpm, the delivery of PPV is optimized and applied for 30 seconds. This article has been copublished in Pediatrics. monitored. 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. Hypothermia after birth is common worldwide, with a higher incidence in babies of lower gestational age and birth weight. 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. High-quality observational studies of large populations may also add to the evidence. Various combinations of warming strategies (or bundles) may be reasonable to prevent hypothermia in very preterm babies. When blood loss is known or suspected based on history and examination, and there is no response to epinephrine, volume expansion is indicated. In term infants, delaying clamping increases hematocrit and iron levels without increasing rates of phototherapy for hyperbilirubinemia, neonatal intensive care, or mortality. Attaches oxygen set at 10-15 lpm. There is a history of acute blood loss around the time of delivery. 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. Currently, epinephrine is the only vasoactive drug recommended by the International Liaison Committee on Resuscitation (ILCOR) for neonates who remain severely bradycardic (heart rate <. The research community needs to address the paucity of educational studies that provide outcomes with a high level of certainty. 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. 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. 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. 7. In a retrospective study, volume infusion was given more often for slow response of bradycardia to resuscitation than for overt hypovolemia. Routine oral, nasal, oropharyngeal, or endotracheal suctioning of newly born babies is not recommended. Author disclosure: No relevant financial affiliations. ** 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: When do chest compressions stop NRP? 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. Rate is 40 - 60/min. 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. How soon after administration of intravenous epinephrine should you pause compressions and assess the baby's heart rate?a. - 14446398 ECG (3-lead) displays a reliable heart rate faster than pulse oximetry. The decision to continue or discontinue resuscitative efforts should be individualized and should be considered at about 20 minutes after birth. 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. 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. 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. 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]). 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. In small hospitals, a nonphysician neonatal resuscitation team is one way of providing in-house coverage at all hours. 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. Intravenous epinephrine is preferred because. The most important priority for newborn survival is the establishment of adequate lung inflation and ventilation after birth. Hypothermia at birth is associated with increased mortality in preterm infants. In a randomized trial, the use of sodium bicarbonate in the delivery room did not improve survival or neurologic outcome. Providing PPV at a rate of 40 to 60 inflations per minute is based on expert opinion. Birth 1 minute If HR remains <60 bpm, Consider hypovolemia. Traditionally, 100 percent oxygen has been used to achieve a rapid increase in tissue oxygen in infants with respiratory depression. 1-800-AHA-USA-1 All Rights Reserved. This guideline affirms the previous recommendations. There were only minor changes to the NRP algorithm and recommended practices. This content is owned by the AAFP. Hand position is correct. 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. This content is owned by the AAFP. *Red Dress DHHS, Go Red AHA ; National Wear Red Day is a registered trademark. 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. Neonatal resuscitation teams may therefore benefit from ongoing booster training, briefing, and debriefing. Exhaled carbon dioxide detectors can be used to confirm endotracheal tube placement in an infant. 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). National Center Teams and individuals who provide neonatal resuscitation are faced with many challenges with respect to the knowledge, skills, and behaviors needed to perform effectively. 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. 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. 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. "Epinephrine is indicated when the heart rate remains below 60 beats per minute after you have given 30 seconds of effective assisted ventilation (preferably after endotracheal intubation) and at least another 45 to 60 seconds of coordinated chest compressions and effective ventilation." (p 219) The importance of skin-to-skin care in healthy babies is reinforced as a means of promoting parental bonding, breast feeding, and normothermia. 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. Both hands encircling chest Thumbs side by side or overlapping on lower half of . These guidelines apply primarily to the newly born baby who is transitioning from the fluid-filled womb to the air-filled room. IV epinephrine If HR persistently below 60/min Consider hypovolemia Consider pneumothorax HR below 60/min? 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. 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.