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. 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. It is reasonable to perform all resuscitation procedures, including endotracheal intubation, chest compressions, and insertion of intravenous lines with temperature-controlling interventions in place. 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. 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. Hypothermia (temperature less than 36C) should be prevented due to an increased risk of adverse outcomes. Admission temperature should be routinely recorded. Target Oxygen Saturation Table Initial oxygen concentration for PPV 1 min 60%-65% 2 min 65%-70% 3 min 70%-75% 4 min 75%-80% 5 min 80%-85% 10 min 85%-95% 35 weeks' GA 21% oxygen Ninety percent of infants transition safely, and it is up to the physician to assess risk factors, identify the nearly 10 percent of infants who need resuscitation, and respond appropriately. A large observational study showed that most nonvigorous newly born infants respond to stimulation and PPV. Intravenous epinephrine is preferred because. 1. A new Resuscitation Quality Improvement (RQI) program for NRP focused on PPV will be . 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. 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). With growing enthusiasm for clinical studies in neonatology, elements of the Neonatal Resuscitation Algorithm continue to evolve as new evidence emerges. 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. For term infants who do not require resuscitation at birth, it may be reasonable to delay cord clamping for longer than 30 seconds. Newly born infants who receive prolonged PPV or advanced resuscitation (eg, intubation, chest compressions epinephrine) should be closely monitored after stabilization in a neonatal intensive care unit or a monitored triage area because these infants are at risk for further deterioration. Multiple clinical and simulation studies examining briefings or debriefings of resuscitation team performance have shown improved knowledge or skills.812. The suggested ratio is 3 chest compressions synchronized to 1 inflation (with 30 inflations per minute and 90 compressions per minute) using the 2 thumbencircling hands technique for chest compressions. Epinephrine is indicated if the heart rate remains below 60 beats per minute despite 60 seconds of chest compressions and adequate ventilation. Exhaled carbon dioxide detectors to confirm endotracheal tube placement. In preterm birth, there are also potential advantages from delaying cord clamping. Part 5: neonatal resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. One small manikin study (very low quality), compared the 2 thumbencircling hands technique and 2-finger technique during 60 seconds of uninterrupted chest compressions. 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. Use of CPAP for resuscitating term infants has not been studied. The newly born period extends from birth to the end of resuscitation and stabilization in the delivery area. Please contact the American Heart Association at ECCEditorial@heart.org or 1-214-706-1886 to request a long description of . The 2020 guidelines are organized into "knowledge chunks," grouped into discrete modules of information on specific topics or management issues.22 Each modular knowledge chunk includes a table of recommendations using standard AHA nomenclature of COR and LOE. Before giving PPV, the airway should be cleared by gently suctioning the mouth first and then the nose with a bulb syringe. Peak inflation pressures of up to 30 cm H2O in term newborns and 20 to 25 cm H2O in preterm newborns are usually sufficient to inflate the lungs.57,9,1114 In some cases, however, higher inflation pressures are required.5,710 Peak inflation pressures or tidal volumes greater than what is required to increase heart rate and achieve chest expansion should be avoided.24,2628, The lungs of sick or preterm infants tend to collapse because of immaturity and surfactant deficiency.15 PEEP provides low-pressure inflation of the lungs during expiration. Clinical assessment of heart rate has been found to be both unreliable and inaccurate. 1 minuteb. With secondary apnea, the heart rate continues to drop, and blood pressure decreases as well. History and physical examination findings suggestive of blood loss include a pale appearance, weak pulses, and persistent bradycardia (heart rate less than 60/min). For neonatal resuscitation providers, it may be reasonable to brief before delivery and debrief after neonatal resuscitation. This article has been copublished in Pediatrics. However, it may be reasonable to increase inspired oxygen to 100% if there was no response to PPV with lower concentrations. Reassess heart rate and breathing at least every 30 seconds. For this reason, neonatal resuscitation should begin with PPV rather than with chest compressions.2,3 Delays in initiating ventilatory support in newly born infants increase the risk of death.1, The adequacy of ventilation is measured by a rise in heart rate and, less reliably, chest expansion. If the heart rate remains less than 60/min despite these interventions, chest compressions can supply oxygenated blood to the brain until the heart rate rises. 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. 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. Oximetry is used to target the natural range of oxygen saturation levels that occur in term babies. 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. In term infants, delaying clamping increases hematocrit and iron levels without increasing rates of phototherapy for hyperbilirubinemia, neonatal intensive care, or mortality. NRP Advanced is suited for health care professionals who serve as members of the resuscitation team in the delivery room or in other settings where complex neonatal resuscitation is required. Case series show small numbers of intact survivors after 20 minutes of no detectable heart rate. The heart rate should be re-checked after 1 minute of giving compressions and ventilations. Heart rate assessment is best performed by auscultation. 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. Term newborns with good muscle tone who are breathing or crying should be brought to their mother's chest routinely. 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. When the need for resuscitation is not anticipated, delays in assisting a newborn who is not breathing may increase the risk of death.1,5,13 Therefore, every birth should be attended by at least 1 person whose primary responsibility is the newborn and who is trained to begin PPV without delay.24, A risk assessment tool that evaluates risk factors present during pregnancy and labor can identify newborns likely to require advanced resuscitation; in these cases, a team with more advanced skills should be mobilized and present at delivery.5,7 In the absence of risk stratification, up to half of babies requiring PPV may not be identified before delivery.6,13, A standardized equipment checklist is a comprehensive list of critical supplies and equipment needed in a given clinical setting. Similarly, meta-analysis of 2 quasi-randomized trials showed no difference in moderate-to-severe neurodevelopmental impairment at 1 to 3 years of age. The usefulness of positive end-expiratory pressure during PPV for term infant resuscitation has not been studied.6 A recent study showed that use of mask continuous positive airway pressure for resuscitation and treatment of respiratory distress syndrome in spontaneously breathing preterm infants reduced the need for intubation and subsequent mechanical ventilation without increasing the risk of bronchopulmonary dysplasia or death.29 In a preterm infant needing PPV, a PIP of 20 to 25 cm H2O may be adequate to increase heart rate while avoiding a higher PIP to prevent injury to preterm lungs, and positive end-expiratory pressure may be beneficial if suitable equipment is available.6. One large retrospective review found that 0.04% of newborns received volume resuscitation in the delivery room, confirming that it is a relatively uncommon event. When appropriate, flow diagrams or additional tables are included. 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. Monday - Friday: 7 a.m. 7 p.m. CT 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. Several animal studies found that ventilation with high volumes caused lung injury, impaired gas exchange, and reduced lung compliance in immature animals. The 2015 Neonatal Resuscitation Algorithm and the major concepts based on sections of the algorithm continue to be relevant in 2020 (Figure(link opens in new window)(link opens in new window)). 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. 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. Expert neonatal and bioethical committees have agreed that, in certain clinical conditions, it is reasonable not to initiate or to discontinue life-sustaining efforts while continuing to provide supportive care for babies and families.1,2,4, If the heart rate remains undetectable and all steps of resuscitation have been completed, it may be reasonable to redirect goals of care. Rescuer 2 verbalizes the need for chest compressions. The AAP released the 8th edition of the Neonatal Resuscitation Program in June 2021. 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. A brief introduction or short synopsis is provided to put the recommendations into context with important background information and overarching management or treatment concepts. The recommended route is intravenous, with the intraosseous route being an alternative. 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. For term and preterm infants who require resuscitation at birth, there is insufficient evidence to recommend early cord clamping versus delayed cord clamping. The American Heart Association is a qualified 501(c)(3) tax-exempt organization. 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. For infants born at less than 28 wk of gestation, cord milking is not recommended. 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]. Birth Antenatal counseling Team briefing and equipment check Neonatal Resuscitation Algorithm. 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. The decision to continue or discontinue resuscitative efforts should be individualized and should be considered at about 20 minutes after birth. 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. Comprehensive disclosure information for writing group members is listed in Appendix 1(link opens in new window). Randomized trials have shown that infants born at 36 weeks' gestation or later with moderate to severe hypoxic-ischemic encephalopathy who were cooled to 92.3F (33.5C) within six hours after birth had significantly lower mortality and less disability at 18 months compared with those not cooled. 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. Naloxone and sodium bicarbonate are rarely needed and are not recommended during neonatal resuscitation. In addition, accurate, fast, and continuous heart rate assessment is necessary for newborns in whom chest compressions are initiated. Epinephrine (adrenaline) is the only medication recommended by the International Liaison Committee On Resuscitation (ILCOR) during resuscitation in newborns with persistent bradycardia or . Copyright 2023 American Academy of Family Physicians. 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.