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. The neonatal epinephrine dose is 0.01 to 0.03 mg per kg (1:10,000 solution) given intravenously (via umbilical venous catheter).1,2,5,6 If there is any delay in securing venous access, epinephrine can be given via endotracheal tube at a higher dose of 0.05 to 0.10 mg per kg (1:10,000 solution), followed by intravenous dosing, if necessary, as soon as access is established.5, Naloxone is not recommended during neonatal resuscitation in the delivery room; infants with respiratory depression should be resuscitated with PPV.1,2,5,6 Volume expansion (using crystalloid or red blood cells) is recommended when blood loss is suspected (e.g., pale skin, poor perfusion, weak pulse) and when the infant's heart rate continues to be low despite effective resuscitation.5,6 Sodium bicarbonate is not recommended during neonatal resuscitation in the delivery room, because it does not improve survival or neurologic outcome.6,39, Approximately 7 to 20 percent of deliveries are complicated by meconium-stained amniotic fluid; these infants have a 2 to 9 percent risk of developing meconium aspiration syndrome.50 Oral and nasopharyngeal suction on the perineum is not recommended, because it has not been shown to reduce the risk of meconium aspiration syndrome.20 In the absence of randomized controlled trials, there is insufficient evidence to recommend changing the current practice of intubation and endotracheal suction in nonvigorous infants (as defined by decreased heart rate, respiratory effort, or muscle tone) born through meconium-stained amniotic fluid.1,2,5 However, if attempted intubation is prolonged or unsuccessful, and bradycardia is present, bag and mask ventilation is advised.5,6 Endotracheal suctioning of vigorous infants is not recommended.1,2,5,6, Withholding resuscitation and offering comfort care is appropriate (with parental consent) in certain infants, such as very premature infants (born at less than 23 weeks' gestation or weighing less than 400 g) and infants with anencephaly or trisomy 13 syndrome.5 If there is no detectable heart rate after 10 minutes of resuscitation, it is appropriate to consider discontinuing resuscitation.5,6, Intravenous glucose infusion should be started soon after resuscitation to avoid hypoglycemia.5,6 In addition, infants born at 36 weeks' gestation or later with evolving moderate to severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia, using studied protocols, within six hours at a facility with capabilities of multidisciplinary care and long-term follow-up.57. In newborns who do not require resuscitation, delaying cord clamping for more than 30 seconds reduces anemia, especially in preterm infants. Neonatal resuscitation teams may therefore benefit from ongoing booster training, briefing, and debriefing. Oximetry and electrocardiography are important adjuncts in babies requiring resuscitation. The reduced heart rate that occurs in this situation can be reversed with tactile stimulation. For neonatal resuscitation providers, it may be reasonable to brief before delivery and debrief after neonatal resuscitation. If heart rate after birth remains at less than 60/min despite adequate ventilation for at least 30 s, initiating chest compressions is reasonable. During 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. NRP courses are moving from the HealthStream platform to RQI. Additional personnel are necessary if risk factors for complicated resuscitation are present. 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. How deep should the catheter be inserted? 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. Intra-arterial epinephrine is not recommended. Evidence for optimal dose, timing, and route of administration of epinephrine during neonatal resuscitation comes largely from extrapolated adult or animal literature. Therefore, identifying a rapid and reliable method to measure the newborn's heart rate is critically important during neonatal resuscitation. The heart rate response to chest compressions and medications should be monitored electrocardiographically. For infants born at less than 28 wk of gestation, cord milking is not recommended. Comprehensive disclosure information for writing group members is listed in Appendix 1(link opens in new window). A team or persons trained in neonatal resuscitation should be promptly available at all deliveries to provide complete resuscitation, including endotracheal intubation and administration of medications. In the resuscitation of an infant, initial oxygen concentration of 21 percent is recommended. Dallas, TX 75231, Customer Service Neonatal Resuscitation: An Update | AAFP The following sections are worth special attention. Many current recommendations are based on weak evidence with a lack of well-designed human studies. The research community needs to address the paucity of educational studies that provide outcomes with a high level of certainty. Endotracheal suctioning may be useful in nonvigorous infants with respiratory depression born through meconium-stained amniotic fluid. It is important to recognize that there are several significant gaps in knowledge relating to neonatal resuscitation. Contact Us, Hours Prevention of hypothermia continues to be an important focus for neonatal resuscitation. 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. In a randomized controlled simulation study, medical students who underwent booster training retained improved neonatal intubation skills over a 6-week period compared with medical students who did not receive booster training. Exothermic mattresses may be effective in preventing hypothermia in preterm babies. Flush the UVC with normal saline. Peer reviewer feedback was provided for guidelines in draft format and again in final format. PDF Neonatal Resuscitation Algorithm - American Heart Association 1 Exhaled carbon dioxide detection is the recommended method of confirming endotracheal intubation. Birth Antenatal counseling Team briefing and equipment check Neonatal Resuscitation Algorithm. The current guideline, therefore, concludes with a summary of current gaps in neonatal research and some potential strategies to address these gaps. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient A reasonable time frame for this change in goals of care is around 20 min after birth. 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. Blood may be lost from the placenta into the mothers circulation, from the cord, or from the infant. 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 frequency and format of booster training or refresher training that best supports retention of neonatal resuscitation knowledge, technical skills, and behavioral skills, The effects of briefing and debriefing on team performance, Optimal cord management strategies for various populations, including nonvigorous infants and those with congenital heart or lung disease, Optimal management of nonvigorous infants with MSAF, The most effective device(s) and interface(s) for providing PPV, Impact of routine use of the ECG during neonatal resuscitation on resuscitation, Feasibility and effectiveness of new technologies for rapid heart rate measurement (such as electric, ultrasonic, or optical devices), Optimal oxygen management during and after resuscitation, Novel techniques for effective delivery of CPR, such as chest compressions accompanied by sustained inflation, Optimal timing, dosing, dose interval, and delivery routes for epinephrine or other vasoactive drugs, including earlier use in very depressed newly born infants, Indications for volume expansion, as well as optimal dosing, timing, and type of volume, The management of pulseless electric activity, Management of the preterm newborn during and after resuscitation, Management of congenital anomalies of the heart and lungs during and after resuscitation, Resuscitation of newborns in the neonatal unit after the newly born period, Resuscitation of newborns in other settings up to 28 days of age, Optimal dose, route, and timing of surfactant in at-risk newborns, including less-invasive administration techniques, Indications for therapeutic hypothermia in babies with mild HIE and in those born at less than 36 weeks' gestational age, Adjunctive therapies to therapeutic hypothermia, Optimal rewarming strategy for newly born infants with unintentional hypothermia. The baby could attempt to breathe and then endure primary apnea. Because evidence and guidance are evolving with the COVID-19 situation, this interim guidance is maintained separately from the ECC guidelines. A large observational study found that delaying PPV increases risk of death and prolonged hospitalization. NRP 8th Edition Updates - AAP (if you are using the 0.1 mg/kg dose.) ECG (3-lead) displays a reliable heart rate faster than pulse oximetry. The science of neonatal resuscitation applies to newly born infants transitioning from the fluid-filled environment of the womb to the air-filled environment of the birthing room and to newborns in the days after birth. When should i check heart rate after epinephrine? 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. When appropriate, flow diagrams or additional tables are included. 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. 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. 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. Excessive peak inflation pressures are potentially harmful and should be avoided. In term and late preterm newborns (35 wk or more of gestation) receiving respiratory support at birth, the initial use of 21% oxygen is reasonable. If the infant's heart rate is less than 60 beats per minute after effective positive pressure ventilation, then chest compressions should be initiated with continued positive pressure ventilation (3:1 ratio of compressions to ventilation; 90 compressions and 30 breaths per minute). Teams and individuals who provide neonatal resuscitation are faced with many challenges with respect to the knowledge, skills, and behaviors needed to perform effectively. 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 this situation, intravascular means intravenous or intraosseous. Among the most important changes are to not intervene with endotracheal suctioning in vigorous infants born through meconium-stained amniotic fluid (although endotracheal suctioning may be appropriate in nonvigorous infants); to provide positive pressure ventilation with one of three devices when necessary; to begin resuscitation of term infants using room air or blended oxygen; and to have a pulse oximeter readily available in the delivery room. The chest compression technique of using two thumbs, with the fingers encircling the chest and supporting the back, achieved better results in swine models compared with the technique of using two fingers, with a second hand supporting the back. The same study demonstrated that the risk of death or prolonged admission increases 16% for every 30-second delay in initiating PPV. PDF PedsCases Podcast Scripts 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. Textbook of Neonatal Resuscitation | AAP Books | American Academy of The importance of skin-to-skin care in healthy babies is reinforced as a means of promoting parental bonding, breast feeding, and normothermia. 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. Positive-Pressure Ventilation (PPV) 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 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. RQI for NRP. 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. . Immediate, unlimited access to all AFP content, Immediate, unlimited access to this issue's content. Heart rate assessment is best performed by auscultation. Use of ECG for heart rate detection does not replace the need for pulse oximetry to evaluate oxygen saturation or the need for supplemental oxygen. Test your knowledge with our free Neonatal Resuscitation Practice Test provided below in order to prepare you for our official online exam. 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. The very limited observational evidence in human infants does not demonstrate greater efficacy of endotracheal or intravenous epinephrine; however, most babies received at least 1 intravenous dose before ROSC. Volunteers with recognized expertise in resuscitation are nominated by the writing group chair and selected by the AHA ECC Committee. The intravenous dose of epinephrine is 0.01 to 0.03 mg/kg, followed by a normal saline flush.4 If umbilical venous access has not yet been obtained, epinephrine may be given by the endotracheal route in a dose of 0.05 to 0.1 mg/kg. When intravenous access is not feasible, the intraosseous route may be considered. 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 oxygen concentrations are recommended during chest compressions based on expert opinion. An improvement in heart rate and establishment of breathing or crying are all signs of effective PPV. 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). If epinephrine is administered via endotracheal tube, a dose of 0.05 to 0.1 mg per kg (1:10,000 solution) is needed.1,2,57, Early volume expansion with crystalloid (10 mL per kg) or red blood cells is indicated for blood loss when the heart rate does not increase with resuscitation.5,6, Use of naloxone is not recommended as part of initial resuscitation of infants with respiratory depression in the delivery room.1,2,5,6, Very rarely, sodium bicarbonate may be useful after resuscitation.6, Term or near term infants with evolving moderate to severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia.57, Intravenous glucose infusion should be started soon after resuscitation to avoid hypoglycemia.5,6, It is recommended to cover preterm infants less than 28 weeks' gestation in polyethylene wrap after birth and place them under a radiant warmer. The AHA has rigorous conflict of interest policies and procedures to minimize the risk of bias or improper influence during development of the guidelines.13 Before appointment, writing group members and peer reviewers disclosed all commercial relationships and other potential (including intellectual) conflicts. The potential benefit or harm of sustained inflations between 1 and 10 seconds is uncertain.2,29. How soon after administration of intravenous epinephrine should you - 14446398 Before appointment, all peer reviewers were required to disclose relationships with industry and any other potential conflicts of interest, and all disclosures were reviewed by AHA staff. A large observational study showed that most nonvigorous newly born infants respond to stimulation and PPV. Resuscitation of an infant with respiratory depression (term and preterm) in the delivery room (Figure 1) focuses on airway, breathing, circulation, and medications. 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. The 7th edition of the Textbook of Neonatal Resuscitation recommends 0.5-mL to 1-mL flush following IV epinephrine (0.01 to 0.03 mg/kg dose) via a low-lying UVC [6]. Provide chest compressions if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds. minutes, and 80% at 5 minutes of life. See Part 2: Evidence Evaluation and Guidelines Development for more details on this process.11. Recommendation-specific text clarifies the rationale and key study data supporting the recommendations.