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. The primary objective of neonatal resuscitation is effective ventilation; an increase in heart rate indicates effective ventilation. Providing PPV at a rate of 40 to 60 inflations per minute is based on expert opinion. There was no difference in neonatal intubation performance after weekly booster practice for 4 weeks compared with daily booster practice for 4 consecutive days. CPAP, a form of respiratory support, helps newly born infants keep their lungs open. Approximately 10% of newborns require assistance to breathe after birth.13,5,13 Newborn resuscitation requires training, preparation, and teamwork. 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). Depth is correct. Compresses correctly: Rate is correct. There was no difference in Apgar scores or blood gas with naloxone compared with placebo. The heart rate should be verbalized for the team. 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. 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. It may be possible to identify conditions in which withholding or discontinuation of resuscitative efforts may be reasonably considered by families and care providers. 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. Delaying cord clamping for more than 30 seconds is reasonable for term and preterm infants who do not require resuscitation. A 3:1 ratio of compressions to ventilation provided more ventilations than higher ratios in manikin studies. Term newborns with good muscle tone who are breathing or crying should be brought to their mother's chest routinely. 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. Inflation and ventilation of the lungs are the priority in newly born infants who need support after birth. 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. Suctioning may be considered if PPV is required and the airway appears obstructed. The benefit of 100% oxygen compared with 21% oxygen (air) or any other oxygen concentration for ventilation during chest compressions is uncertain. Auscultation of the precordium remains the preferred physical examination method for the initial assessment of the heart rate.9 Pulse oximetry and ECG remain important adjuncts to provide continuous heart rate assessment in babies needing resuscitation. 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 . The heart rate should be re-checked after 1 minute of giving compressions and ventilations. 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. The same study demonstrated that the risk of death or prolonged admission increases 16% for every 30-second delay in initiating PPV. 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. 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. Although this flush volume may . Each of these resulted in a description of the literature that facilitated guideline development.1417, Each AHA writing group reviewed all relevant and current AHA guidelines for CPR and ECC1820 and all relevant 2020 ILCOR International Consensus on CPR and ECC Science With Treatment Recommendations evidence and recommendations21 to determine if current guidelines should be reaffirmed, revised, or retired, or if new recommendations were needed. For nonvigorous newborns with meconium-stained fluid, endotracheal suctioning is indicated only if obstruction limits positive pressure ventilation, because suctioning does not improve outcomes. However, if heart rate remains less than 60/min after ventilating with 100% oxygen (preferably through an endotracheal tube) and chest compressions, administration of epinephrine is indicated. This content is owned by the AAFP. Supplemental oxygen: 100 vs. 21 percent (room air). 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. The heart rate should be re- checked after 1 minute of giving compressions and ventilations. The primary goal of neonatal care at birth is to facilitate transition. 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. No type of routine suctioning is helpful, even for nonvigorous newborns delivered through meconium-stained amniotic fluid. This series is coordinated by Michael J. Arnold, MD, contributing editor. 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. In the resuscitation of an infant, initial oxygen concentration of 21 percent is recommended. The airway is cleared (if necessary), and the infant is dried. Plasma epinephrine concentrations at 1 min after epinephrine administration were not different. Because evidence and guidance are evolving with the COVID-19 situation, this interim guidance is maintained separately from the ECC guidelines. Copyright 2023 American Academy of Family Physicians. Failure to respond to epinephrine in a newborn with history or examination consistent with blood loss may require volume expansion. Hypothermia (temperature less than 36C) should be prevented due to an increased risk of adverse outcomes. For newborns who are breathing, continuous positive airway pressure can help with labored breathing or persistent cyanosis. When should I check heart rate after epinephrine? Randomized controlled studies and observational studies in settings where therapeutic hypothermia is available (with very low certainty of evidence) describe variable rates of survival without moderate-to-severe disability in babies who achieve ROSC after 10 minutes or more despite continued resuscitation. Peer reviewer feedback was provided for guidelines in draft format and again in final format. Epinephrine is indicated if the heart rate remains below 60 beats per minute despite 60 seconds of chest compressions and adequate ventilation. There is no evidence from randomized trials to support the use of volume resuscitation at delivery. 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. Ventilation should be optimized before starting chest compressions, with endotracheal intubation if possible. 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). 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. 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. Immediate, unlimited access to all AFP content, Immediate, unlimited access to this issue's content. 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. In term and preterm newly born infants, it is reasonable to initiate PPV with an inspiratory time of 1 second or less. Approximately 10% of infants require help to begin breathing at birth, and 1% need intensive resuscitation. The effect of briefing and debriefing on longer-term and critical outcomes remains uncertain. 8. A large multicenter RCT found higher rates of intraventricular hemorrhage with cord milking in preterm babies born at less than 28 weeks gestational age. In a retrospective study, volume infusion was given more often for slow response of bradycardia to resuscitation than for overt hypovolemia. Given the evidence for ECG during initial steps of PPV, expert opinion is that ECG should be used when providing chest compressions. Blood may be lost from the placenta into the mothers circulation, from the cord, or from the infant. Review of the knowledge chunks during this update identified numerous questions and practices for which evidence was weak, uncertain, or absent. 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. A multicenter, case-control study identified 10 perinatal risk factors that predict the need for advanced neonatal resuscitation. 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. If the heart rate remains less than 60/min despite 30 seconds of adequate PPV, chest compressions should be provided. Higher doses (0.05 to 0.1 mg per kg) of endotracheal epinephrine are needed to achieve an increase in blood epinephrine concentration. If the heart rate remains below 60 beats per minute despite 30 seconds of adequate positive pressure ventilation, chest compressions should be initiated with a two-thumb encircling technique at a 3:1 compression-to-ventilation ratio. Table 1. - 14446398 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). 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. Epinephrine is indicated if the heart rate remains below 60 beats per minute despite 60 seconds of chest compressions and adequate ventilation. Copyright 2023 American Academy of Family Physicians. Oximetry and electrocardiography are important adjuncts in babies requiring resuscitation. 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. Epinephrine use in the delivery room for resuscitation of the newborn is associated with significant morbidity and mortality. A reasonable time frame for this change in goals of care is around 20 min after birth. 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. Breakdowns in teamwork and communication can lead to perinatal death and injury.15 Team training in simulated resuscitations improves performance and has the potential to improve outcomes.16,17 Ultimately, being able to perform bag and mask ventilation and work in coordination with a team are important for effective neonatal resuscitation. Copyright 2021 by the American Academy of Family Physicians. Researchers studying these gaps may need to consider innovations in clinical trial design; examples include pragmatic study designs and novel consent processes. However, the concepts in these guidelines may be applied to newborns during the neonatal period (birth to 28 days). 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. For babies requiring vascular access at the time of delivery, the umbilical vein is the recommended route. 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]). You're welcome to take the quiz as many times as you'd like. If skilled health care professionals are available, infants weighing less than 1 kg, 1 to 3 kg, and 3 kg or more can be intubated with 2.5-, 3-, and 3.5-mm endotracheal tubes, respectively. 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. 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. 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. diabetes. There is a reduction of mortality and no evidence of harm in term infants resuscitated with 21 percent compared with 100 percent oxygen. Routine oral, nasal, oropharyngeal, or endotracheal suctioning of newly born babies is not recommended. 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. NRP Advanced may also be appropriate for health care professionals in smaller hospital facilities with fewer per- 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. RQI for NRP. 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. One RCT in resource-limited settings found that plastic coverings reduced the incidence of hypothermia, but they were not directly compared with uninterrupted skin-to-skin care. If it is possible to identify such conditions at or before birth, it is reasonable not to initiate resuscitative efforts. For nonvigorous newborns delivered through MSAF who have evidence of airway obstruction during PPV, intubation and tracheal suction can be beneficial. 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. It is important to. Resuscitation of an infant with respiratory depression (term and preterm) in the delivery room (Figure 1) focuses on airway, breathing, circulation, and medications. A multicenter quality improvement study demonstrated high staff compliance with the use of a neonatal resuscitation bundle that included briefing and an equipment checklist. In a retrospective review, early hypoglycemia was a risk factor for brain injury in infants with acidemia requiring resuscitation. For nonvigorous newborns (presenting with apnea or ineffective breathing effort) delivered through MSAF, routine laryngoscopy with or without tracheal suctioning is not recommended. If heart rate after birth remains at less than 60/min despite adequate ventilation for at least 30 s, initiating chest compressions is reasonable. All Rights Reserved. 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. When vascular access is required in the newly born, the umbilical venous route is preferred. 1. Traditionally, 100 percent oxygen has been used to achieve a rapid increase in tissue oxygen in infants with respiratory depression. PPV may be initiated with air (21% oxygen) in term and late preterm babies, and up to 30% oxygen in preterm babies. One small manikin study (very low quality), compared the 2 thumbencircling hands technique and 2-finger technique during 60 seconds of uninterrupted chest compressions. Establishing ventilation is the most important step to correct low heart rate. Identification of risk factors for resuscitation may indicate the need for additional personnel and equipment. If resuscitation is required, electrocardiography should be used, especially with chest compressions. 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. 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 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. High oxygen concentrations are recommended during chest compressions based on expert opinion. Rapid evaluation: this evaluation determines if the baby can stay wit the mother for routine care or should be moved to the radiant warmer Airway: The initial steps open the airway and support spontaneous respirations. There are limited data comparing the different approaches to heart rate assessment during neonatal resuscitation on other neonatal outcomes. Another barrier is the difficulty in obtaining antenatal consent for clinical trials in the delivery room. Reassess heart rate and breathing at least every 30 seconds. There are long-standing worldwide recommendations for routine temperature management for the newborn. The heart rate should be re-checked after 1 minute of giving compressions and ventilations. When possible, healthy term babies should be managed skin-to-skin with their mothers. Admission temperature should be routinely recorded. Adaptive trials, comparative effectiveness designs, and those using cluster randomization may be suitable for some questions, such as the best approach for MSAF in nonvigorous infants. 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. Aim for about 30 breaths min-1 with an inflation time of ~one second. It is important to continue PPV and chest compressions while preparing to deliver medications. If the heart rate remains less than 60/min despite 60 seconds of chest compressions and adequate PPV, epinephrine should be administered, ideally via the intravenous route. A prospective study showed that the use of an exhaled carbon dioxide detector is useful to verify endotracheal intubation. 1-800-AHA-USA-1 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. 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. After chest compressions are performed for at least 2 minutes When an alternative airway is inserted Immediately after epinephrine is administered Initiate effective PPV for 30 seconds and reassess the heart rate. Routine suctioning, whether oral, nasal, oropharyngeal, or endotracheal, is not recommended because of a lack of benefit and risk of bradycardia. 5 As soon as the infant is delivered, a timer or clock is started. Watch a recording of Innov8te NRP: An Introduction to the NRP 8th Edition: Three webinars hosted by RQI Partners to discuss changes to the 8 th edition NRP and the new RQI for NRP Posted 2/19/21. In newly born infants who are gasping or apneic within 60 s after birth or who are persistently bradycardic (heart rate less than 100/min) despite appropriate initial actions (including tactile stimulation), PPV should be provided without delay. 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). Team training remains an important aspect of neonatal resuscitation, including anticipation, preparation, briefing, and debriefing. Various combinations of warming strategies (or bundles) may be reasonable to prevent hypothermia in very preterm babies. Early skin-to-skin contact benefits healthy newborns who do not require resuscitation by promoting breastfeeding and temperature stability. Both hands encircling chest Thumbs side by side or overlapping on lower half of . When epinephrine is required, multiple doses are commonly needed. It may be reasonable to administer further doses of epinephrine every 3 to 5 min, preferably intravascularly,* if the heart rate remains less than 60/ min. 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). 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. 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. Wrapping, in addition to radiant heat, improves admission temperature of preterm infants. 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). A combination of chest compressions and ventilation resulted in better outcomes than ventilation or compressions alone in piglet studies. 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. 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. Radiant warmers and other warming adjuncts are suggested for babies who require resuscitation at birth, especially very preterm and very low-birth-weight babies. 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. 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. Gaps in this domain, whether perceived or real, should be addressed at every stage in our research, educational, and clinical activities. For participants who have been trained in neonatal resuscitation, individual or team booster training should occur more frequently than every 2 yr at a frequency that supports retention of knowledge, skills, and behaviors. Preterm and term newborns without good muscle tone or without breathing and crying should be brought to the radiant warmer for resuscitation. 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. Prevention of hyperthermia (temperature greater than 38C) is reasonable due to an increased risk of adverse outcomes. The baby could attempt to breathe and then endure primary apnea. The following sections are worth special attention. There were only minor changes to the NRP algorithm and recommended practices. 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 addition, some conditions are so severe that the burdens of the illness and treatment greatly outweigh the likelihood of survival or a healthy outcome. Premature animals exposed to brief high tidal volume ventilation (from high PIP) develop lung injury, impaired gas exchange, and decreased lung compliance. 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. For infants born at less than 28 wk of gestation, cord milking is not recommended. The importance of skin-to-skin care in healthy babies is reinforced as a means of promoting parental bonding, breast feeding, and normothermia. 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.