Delayed umbilical cord clamping was recommended for both term and preterm neonates in 2015. When blood loss is known or suspected based on history and examination, and there is no response to epinephrine, volume expansion is indicated. When vascular access is required in the newly born, the umbilical venous route is preferred. 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. One moderate quality RCT found higher rates of hyperthermia with exothermic mattresses. Suctioning may be considered if PPV is required and the airway appears obstructed. Review of the knowledge chunks during this update identified numerous questions and practices for which evidence was weak, uncertain, or absent. 2020;142(suppl 2):S524S550. All Rights Reserved. Hypothermia after birth is common worldwide, with a higher incidence in babies of lower gestational age and birth weight. Exhaled carbon dioxide detectors to confirm endotracheal tube placement. Once return of spontaneous circulation (ROSC) is achieved, the supplemental oxygen concentration may be decreased to target a physiological level based on pulse oximetry to reduce the risks associated with hyperoxia.1,2. Therapeutic hypothermia is provided under defined protocols similar to those used in published clinical trials and in facilities capable of multidisciplinary care and longitudinal follow-up. The American Heart Association is a qualified 501(c)(3) tax-exempt organization. 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. 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. These situations benefit from expert consultation, parental involvement in decision-making, and, if indicated, a palliative care plan.1,2,46. Your team is caring for a term newborn whose heart rate is 50 bpm after receiving effective ventilation, chest compressions, and intravenous epinephrine administration. Newly born infants who breathe spontaneously need to establish a functional residual capacity after birth.8 Some newly born infants experience respiratory distress, which manifests as labored breathing or persistent cyanosis. Contact Us, Hours 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. 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. When the heart rate increases to more than 100 bpm, PPV may be discontinued if there is effective respiratory effort.5 Oxygen is decreased and discontinued once the infant's oxygen saturation meets the targeted levels (Figure 1).5, If there is no heartbeat after 10 minutes of adequate resuscitative efforts, the team can cease further resuscitation.1,5,6 A member of the team should keep the family informed during the resuscitation process. 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. For newly born infants who are unintentionally hypothermic (temperature less than 36C) after resuscitation, it may be reasonable to rewarm either rapidly (0.5C/h) or slowly (less than 0.5C/h). Epinephrine is indicated if the heart rate remains below 60 beats per minute despite 60 seconds of chest compressions and adequate ventilation. The 2 thumbencircling hands technique achieved greater depth, less fatigue, and less variability with each compression compared with the 2-finger technique. Hypothermia (temperature less than 36C) should be prevented due to an increased risk of adverse outcomes. 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. Approximately 10% of newborns require assistance to breathe after birth.13,5,13 Newborn resuscitation requires training, preparation, and teamwork. Teams and individuals who provide neonatal resuscitation are faced with many challenges with respect to the knowledge, skills, and behaviors needed to perform effectively. Clinical assessment of heart rate has been found to be both unreliable and inaccurate. doi: 10.1161/ CIR.0000000000000902. Ventilation using a flow-inflating bag, self-inflating bag, or T-piece device can be effective. None of these studies evaluate outcomes of resuscitation that extends beyond 20 minutes of age, by which time the likelihood of intact survival was very low. 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. Inflation and ventilation of the lungs are the priority in newly born infants who need support after birth. 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. 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. Oximetry is used to target the natural range of oxygen saturation levels that occur in term babies. Initiate effective PPV for 30 seconds and reassess the heart rate. 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). Reduce the inflation pressure if the chest is moving well. Gaps in this domain, whether perceived or real, should be addressed at every stage in our research, educational, and clinical activities. 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. Supplemental oxygen should be used judiciously, guided by pulse oximetry. 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. In a retrospective review, early hypoglycemia was a risk factor for brain injury in infants with acidemia requiring resuscitation. Consequently, all newly born babies should be attended to by at least 1 person skilled and equipped to provide PPV. In addition, specific recommendations about the training of resuscitation providers and systems of care are provided in their respective guideline Parts.9,10. Babies who are breathing well and/or crying are cared for skin-to-skin with their mothers and should not need interventions such as routine tactile stimulation or suctioning, even if the amniotic fluid is meconium stained.7,19 Avoiding unnecessary suctioning helps prevent the risk of induced bradycardia as a result of suctioning of the airway. 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. Prevention of hypothermia continues to be an important focus for neonatal resuscitation. There are limited data comparing the different approaches to heart rate assessment during neonatal resuscitation on other neonatal outcomes. 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. A multicenter, case-control study identified 10 perinatal risk factors that predict the need for advanced neonatal resuscitation. Every birth should be attended by one person who is assigned, trained, and equipped to initiate resuscitation and deliver positive pressure ventilation. Naloxone and sodium bicarbonate are rarely needed and are not recommended during neonatal resuscitation. 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. 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. 7. If the heart rate remains less than 60/min despite 30 seconds of adequate PPV, chest compressions should be provided. 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. Plasma epinephrine concentrations at 1 min after epinephrine administration were not different. The initiation of chest compressions in newborn babies with a heart rate less than 60/min is based on expert opinion because there are no clinical or physiological human studies addressing this question. 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 Umbilical venous catheterization has been the accepted standard route in the delivery room for decades. 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. 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. 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. The American Heart Association released minor updates to neonatal resuscitation recommendations with only minor changes to the previous algorithm (Figure 1). Both hands encircling chest Thumbs side by side or overlapping on lower half of . For term infants who do not require resuscitation at birth, it may be reasonable to delay cord clamping for longer than 30 seconds. In term and preterm newly born infants, it is reasonable to initiate PPV with an inspiratory time of 1 second or less. Volunteers with recognized expertise in resuscitation are nominated by the writing group chair and selected by the AHA ECC Committee. 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. 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. Care (Updated May 2019)*, 2020 Advanced Cardiovascular Life Support (ACLS), 2020 Pediatric Advanced Life Support (PALS), 2015 Pediatric Emergency Assessment and Recognition, Conflicts of Interest and Ethics Policies, Advanced Cardiovascular Life Support (ACLS), CPR & First Aid in Youth Sports Training Kit, Resuscitation Quality Improvement Program (RQI), COVID-19 Resources for CPR & Resuscitation, Claiming Your AHA Continuing Education Credits, International Liaison Committee on Resuscitation. Limited observational studies suggest that tactile stimulation may improve respiratory effort. 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. With the symptoms of The dose of epinephrine is .5-1ml/kg by ETT or .1-.3ml/kg in the concentration of 1:10,000 (0.1mg/ml), which is to be followed by 0.5-1ml flush of normal saline. This content is owned by the AAFP. The studies were too heterogeneous to be amenable to meta-analysis. 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. 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. After chest compressions are performed for at least 2 minutes When an alternative airway is inserted Immediately after epinephrine is administered Check the heart rate by counting the beats in 6 seconds and multiply by 10. 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. Aim for about 30 breaths min-1 with an inflation time of ~one second. There are long-standing worldwide recommendations for routine temperature management for the newborn. This article has been copublished in Pediatrics. For infants requiring PPV at birth, there is currently insufficient evidence to recommend delayed cord clamping versus early cord clamping. 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. Newly born infants born at 36 wk or more estimated gestational age with evolving moderate-to-severe HIE should be offered therapeutic hypothermia under clearly defined protocols. Reassess heart rate and breathing at least every 30 seconds. In small hospitals, a nonphysician neonatal resuscitation team is one way of providing in-house coverage at all hours. In resource-limited settings, it may be reasonable to place newly born babies in a clean food-grade plastic bag up to the level of the neck and swaddle them in order to prevent hypothermia. CPAP, a form of respiratory support, helps newly born infants keep their lungs open. If resuscitation is required, electrocardiography should be used, especially with chest compressions. In one RCT and one observational study, there were no reports of technical difficulties with ECG monitoring during neonatal resuscitation, supporting its feasibility as a tool for monitoring heart rate during neonatal resuscitation. 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. One RCT (low certainty of evidence) suggests improved oxygenation after resuscitation in preterm babies who received repeated tactile stimulation. 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. This can usually be achieved with a peak inflation pressure of 20 to 25 cm water (H. In newly born infants receiving PPV, it may be reasonable to provide positive end-expiratory pressure (PEEP).