european resuscitation council guidelines 2021: newborn

European Resuscitation Council Guidelines 2021Newborn resuscitation and support of transition ofinfants at birth

John Madar a Charles C Roehr bcd Sean Ainsworth e Hege Ersdal fg

Colin Morley hi Mario Rudiger jk Christiane Skare l Tomasz Szczapa m Arjan te [1262_TD$DIFF]Pas n

Daniele Trevisanuto o Berndt Urlesberger p Dominic Wilkinson qrs Jonathan P Wyllie t

a Department of Neonatology University Hospitals Plymouth Plymouth UKb Newborn Services John Radcliffe Hospital Oxford University Hospitals Oxford UKc Department of Paediatrics Medical Sciences Division University of Oxford Oxford UKd Nuffield Department of Population Health National Perinatal Epidemiology Unit Medical Sciences Division University of Oxford Oxford UKe Directorate of Womenrsquos and Childrenrsquos Services Victoria Hospital Kirkcaldy UKf Department of Anaesthesiology and Intensive Care Stavanger University Hospital Stavanger Norwayg Faculty of Health Sciences University of Stavanger Stavanger Norwayh University of Melbourne Australiai Department of Obstetrics University of Cambridge UKj Department for Neonatology and Pediatric Intensive Care Medicine Clinic for Pediatrics University Hospital CGCarus Technische Universitat

Dresden Germanyk Center for Feto-Neonatal Health Technische Universitat Dresden Germanyl Department of Anaesthesiology Oslo University Hospital Norwaym Department of Neonatology Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit Poznan University of Medical

Sciences Poznan Polandn Department of Paediatrics Division of Neonatology Leiden University Medical Center Leiden The Netherlandso Department of Womanrsquos and Childrsquos Health University Hospital of Padova Padova Italyp Division of Neonatology Medical University Graz Austriaq Oxford Uehiro Centre for Practical Ethics Faculty of Philosophy University of Oxford UKr John Radcliffe Hospital Oxford UKs Murdoch Childrenrsquos Research Institute Melbourne Australiat James Cook University Hospital Middlesbrough UK

Abstract

The European Resuscitation Council has produced these newborn life support guidelines which are based on the International Liaison Committee on

Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support The guidelines cover the

management of the term and preterm infant The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn factors

before delivery training and education thermal control management of the umbilical cord after birth initial assessment and categorisation of the

newborn infant airwayand breathing and circulation support communicationwith parents considerations when withholding and discontinuing support

Corresponding authorE-mail address johnmadarnhsnet (J Madar)

httpsdoiorg101016jresuscitation202102014

Available online xxx

0300-9572copy 2021 European Resuscitation Council Published by Elsevier BV All rights reserved

R E S U S C I T A T I O N X X X ( 2 0 2 1 ) X X X X X X

RESUS 8907 No of Pages 36

Please cite this article in press as J Madar et al European Resuscitation Council Guidelines 2021 Newborn resuscitation and supportof transition of infants at birth Resuscitation (2021) httpsdoiorg101016jresuscitation202102014

Available online at wwwsciencedirectcom

Resuscitation

journa l homepage wwwe lsev ier com locate resusc i ta t ion

Introduction and scope

[1264_TD$DIFF]Theseguidelinesarebasedon the International LiaisonCommittee onResuscitation (ILCOR) 2020 Consensus on Science and TreatmentRecommendations (CoSTR) for Neonatal Life Support1 For thepurposes of the ERC Guidelines the ILCOR recommendations weresupplemented by focused literature reviews undertaken by the ERCNLS guidelines Group for topics not reviewed by 2020 ILCORCoSTRWhen appropriate the guidelines were informed by the expertconsensus of the ERC guidelines group membership

These guidelines were drafted and agreed by the Newborn LifeSupport Writing Group members The methodology used for guidelinedevelopment is presented in the Executive summary2 The guidelineswere posted for public comment in October 2020 The feedback wasreviewed by the writing group and the guidelines were updated whererelevant (see supplemental material) The Guideline was presented toandapprovedby theERCGeneral Assembly on10thDecember 2020

Key messages from these guidelines are summarised in Fig [1265_TD$DIFF]2

COVID 19 context

The ERC has produced guidance on newborn life support in thecontext of coronavirus disease 2019 (SARS-CoV-2)3 this is basedon an ILCOR CoSTR and systematic review45 Our understandingof the risks to infants potentially exposed to SARS-CoV-2 and therisk of virus transmission and infection to those providing care isevolving Please check ERC and national guidelines for the latestguidance and local policies for both treatment and rescuerprecautions

Summary of changes since the 2015 guidelines

Management of the umbilical cord

Clamping after at least 60 s is recommended ideally after the lungs areaerated Where delayed cord clamping is not possible cord milking shouldbe considered in infants gt28 weeks gestationInfants born through meconium-stained liquor

In non-vigorous infants recommendations are against immediatelaryngoscopy with or without suction after delivery because this may delayaeration and ventilation of the lungsUse of the laryngeal mask

If facemask ventilation is unsuccessful or if tracheal intubation isunsuccessful or not feasible a laryngeal mask may be considered as analternative means of establishing an airway in infants of gt34 weeksgestation (about 2000 g although some devices have been usedsuccessfully in infants down to 1500g)Inflation pressure

If there is no response to initial inflations despite an open airway then agradual increase in the inflation pressure is suggestedA starting pressure of 25 cm H2O is suggested for preterm infants lt32weeks gestationAiroxygen for preterm resuscitation

Recommendations are for starting in air at 32 weeks gestation or more 21-30 inspired oxygen at 28-31 weeks gestation and 30 inspired oxygen atlt28 weeks gestationThe concentration should be titrated to achieve saturations of80at 5 minof age because there is evidence of poorer outcomes where this is notachievedChest compressions

If chest compressions are required the inspired oxygen concentrationshould be increased to 100 and consideration given towards securing theairway ideally with a tracheal tube

Vascular access

The umbilical vein is still favoured as the optimal route of access butintraosseous access is an alternative method of emergency access fordrugsfluidsAdrenaline

Where the heart rate has not increased after optimising ventilationand chest compressions an intravenous dose of adrenaline of10 30micrograms kg 1 is recommended repeated every 3 5 min in theabsence of a responseGlucose during resuscitation

An intravenous dose of 250 mgkg 1 (25 mLkg 1 of 10 glucose) issuggested in a prolonged resuscitation to reduce the likelihood ofhypoglycaemiaPrognosis

Failure to respond despite 10 20mins of intensive resuscitation isassociated with high risk of poor outcome It is appropriate to considerdiscussions with the team and family about withdrawal of treatment if therehas been no response despite the provision of all recommended steps ofresuscitation and having excluded reversible causes

Concise guideline for clinical practice

Factors before delivery

Transition and the need for assistance after birth

Most but not all infants adapt well to extra-uterine life but somerequire help with stabilisation or resuscitation Up to 85 breathespontaneously without intervention a further 10 respond afterdrying stimulation and airway opening manoeuvres approximately5 receive positive pressure ventilation Intubation rates varybetween 04 and 2 Fewer than 03 of infants receive chestcompressions and only 005 receive adrenaline

Risk factors

A number of risk factors have been identified as increasing thelikelihood of requiring help with stabilisation or resuscitation (Fig [1274_TD$DIFF]1)

Staff attending delivery

Any infant may develop problems during birth Local guidelinesindicating who should attend deliveries should be developedbased on current understanding of best practice and clinicalaudit and taking into account identified risk factors (Fig [1275_TD$DIFF]1) As aguide Personnel competent in newborn life support should be available

for every delivery If intervention is required there should be personnel available

whose sole responsibility is to care for the infant A process should be in place for rapidly mobilising a team with

sufficient resuscitation skills for any birth

Equipment and environment

All equipment must be regularly checked and ready for use Where possible the environment and equipment should be

prepared in advance of the delivery of the infant Checklistsfacilitate these tasks

Resuscitation should take place in a warm well-illuminateddraught-free area with a flat resuscitation surface and a radiantheater (if available)

Equipment to monitor the condition of the infant and to supportventilation should be immediately available

2 R E S U S C I T A T I O N X X X ( 2 0 2 1 ) X X X X X X



Additional equipment that might be required in case of moreprolonged resuscitation should be easily accessible

Planned home deliveries

Ideally two trained professionals should be present at all homedeliveries

At least one must be competent in providing mask ventilation andchest compressions to the newborn infant

Recommendations as to who should attend a planned homedelivery vary from country to country but the decision to undergosuch a delivery once agreed with medical and midwifery staffshould not compromise the standard of initial assessmentstabilisation or resuscitation at birth

There will inevitably be some limitations to the extent of theresuscitation of a newborn infant in the home due to the distancefrom healthcare facilities and equipment available and this mustbe made clear to the mother at the time plans for homedelivery aremade

When a birth takes place in a non-designated delivery area aminimum set of equipment of an appropriate size for the newborninfant should be available including13 clean gloves for the attendant and assistants13 means of keeping the infant warm such as heated dry towels

and blankets13 a stethoscope to check the heart rate13 a device for safe assisted lung aeration and subsequent

ventilation such as a self-inflating bag with appropriately sizedfacemask

13 sterile instruments for clamping and then safely cutting theumbilical cord

[1276_TD$DIFF]Unexpected deliveries outside hospital are likely to involveemergency services who should be trained and prepared forsuch events and carry appropriate equipment

Caregivers undertaking home deliveries should have pre-definedplans for difficult situations

[1277_TD$DIFF]Briefing

If there is sufficient time brief the team to clarify responsibilitiescheck equipment and plan the stabilisation or resuscitation

Roles and tasks should be assigned checklists are helpful Prepare the family if it is anticipated that resuscitation might be

required

Trainingeducation

Recommendations

Newborn resuscitation providers must have relevant current

knowledge technical and non-technical skills Institutions or clinical areas where deliveries may occur should

have structured educational programmes teaching the knowl-edge and skills required for newborn resuscitation

The content and organisation of such training programmes mayvary according to the needs of the providers and the organisationof the institutions

Recommended programmes include13 regular practice and drills13 team and leadership training13 multi-modal approaches13 simulation-based training13 feedbackonpractice fromdifferent sources (including feedback

devices)13 objective performance focused debriefings

[1278_TD$DIFF]Ideally training should be repeated more frequently than once peryear

13[1279_TD$DIFF]Updates may include specific tasks simulation andor behav-ioural skills and reflection

Thermal control

Recommendations

Standards

The infants temperature should be regularly monitored after birthand the admission temperature should be recorded as aprognostic and quality indicator

The temperature of newborn infants should be maintainedbetween 365 C and 375 C

Hypothermia (360 C) and hyperthermia (gt380 C) should beavoided In appropriate circumstances therapeutic hypothermiamay be considered after resuscitation (see post-resuscitationcare)

Environment

Protect the infant from draughts Ensure windows are closed andair-conditioning appropriately programmed

Keep the environment in which the infant is looked after (egdelivery room or theatre) warm at 23 25 C

For infants 28 weeks gestation the delivery room or theatretemperature should be gt25 C

Term and near-term infants gt32 weeks gestation

Dry the infant immediately after delivery Cover the head and bodyof the infant apart from the face with a warm and dry towel toprevent further heat loss

If no resuscitation is required place the infant skin-to-skin withmother and cover both with a towel On-going careful observationof mother and infant will be required especially in more pretermand growth restricted infants to ensure they both remainnormothermic

If the infant needs support with transition or when resuscitation isrequired place the infant on a warm surface using a preheatedradiant warmer

Fig 1 ndash Common factors associated with an increasedrisk of a need for stabilization or resuscitation at birth

R E S U S C I T A T I O N X X X ( 2 0 2 1 ) X X X X X X 3



Preterm infants 32 weeks gestation

Completely cover with polyethylene wrapping (apart from face)without drying and use a radiant warmer

If umbilical cord clamping is delayed and a radiant warmer is notaccessible at this point other measures (such as those listedbelow) will be needed to ensure thermal stability while stillattached to the placenta

A combination of further interventions may be required in infants32 weeks including increased room temperature warmblankets head cap and thermal mattress

Skin-to-skin care is feasible in lessmature infants however cautionis required in the more preterm or growth restricted infant in orderto avoid hypothermia

For infants receiving respiratory support use of warmedhumidified respiratory gases should be considered

A quality improvement program including the use of checklists andcontinuous feedback to the team has been shown to significantlyreduce hypothermia at admission in very preterm infants

Out of hospital management

Infants born unexpectedly outside a normal delivery environmentare at higher risk of hypothermia and subsequent pooreroutcomes

They may benefit from placement in a food grade plastic bag afterdrying and then swaddling Alternatively well newborns gt30weeks gestation may be dried and nursed skin-to-skin to maintaintheir temperature whilst they are transferred as long as mothersare normothermic Infants should be covered and protected fromdraughts and watched carefully to avoid hypothermia and ensureairway and breathing are not compromised

Fig 2 ndash NLS infographic




Management of the umbilical cord after birth

The options for managing cord clamping and the rationale should

be discussed with parents before birth Where immediate resuscitation or stabilisation is not required aim

to delay clamping the cord for at least 60 s A longer period may bemore beneficial

Clamping should ideally take place after the lungs are aerated Where adequate thermal care and initial resuscitation interven-

tions can be safely undertaken with the cord intact it may bepossible to delay clamping whilst performing these interventions

Wheredelayedcord clamping is not possible consider cordmilkingin infants gt28 weeks gestation

Initial assessment (Fig 3)

May occur before the umbilical cord is clamped and cut (typicallyperformed in this order) Observe Tone (amp Colour) Assess adequacy of Breathing

Assess the Heart Rate

Take appropriate action to keep the baby warm during these initialsteps

This rapid assessment serves to establish a baseline identify theneed for support andor resuscitation and theappropriateness andduration of delaying umbilical cord clamping

Frequent re-assessment of heart rate and breathing indicateswhether the infant is adequately transitioning or whether furtherinterventions are needed

Tactile stimulation

Initial handling is an opportunity to stimulate the infant duringassessment by Drying the infant Gently [1280_TD$DIFF]stimulating as you dry them for example by rubbing the

soles of the feet or the back of the chest Avoid more aggressivemethods of stimulation

Tone and colour

A very floppy infant is likely to need ventilatory support Colour is a poor means of judging oxygenation Cyanosis can be

difficult torecognisePallormight indicateshockorrarelyhypovolaemia consider blood loss and plan appropriate intervention

Breathing

Is the infant breathing Note the rate depth and symmetryworkeffort of breathing as13 Adequate13 Inadequateabnormal pattern such as gasping or grunting13 Absent

Heart rate

Determine the heart rate with a stethoscope and a saturationmonitorECG (electrocardiogram) for later continuousassessment13 Fast (100 min 1) satisfactory13 Slow (60 100 min 1) intermediate possible hypoxia13 Very slowabsent (lt60 min 1) critical hypoxia likely

If the infant fails to establish spontaneous and effective breathingfollowing assessment and stimulation andor the heart rate does notincrease (andor decreases) if initially fast respiratory support shouldbe started

Classification according to initial assessment

On the basis of the initial assessment the infant can usually be placedinto one of three groups as the following examples illustrate

1

Good toneVigorous breathing or cryingHeart rate fast (100 min 1)

Assessment Satisfactory transition Breathing does not requiresupport Heart rate is acceptable (Fig 4[1251_TD$DIFF]a)

Actions Delay cord clamping Dry wrap in warm towel Keepwithmotheror carer andensuremaintenanceof temperature Consider early skin-to-skin care if stable

2

Reduced toneBreathing inadequately (or apnoeic)Heart rate slow (lt100 min 1)

Assessment Incomplete transition Breathing requires supportslow heart rate may indicate hypoxia (Fig [1281_TD$DIFF]4b)

Actions Delay cord clamping only if you are able to appropriately support

the infant

Fig 3 ndashAssessmentof tonebreathingandheart ratehelpdetermine the need for intervention

Fig 4a ndash Satisfactory transition

Fig 4b ndash Incomplete transition




Dry stimulate wrap in a warm towel Maintain the airway lung inflation and ventilation Continuously assess changes in heart rate and breathing If no improvement in heart rate continue with ventilation Help may be required

3

FloppyPaleBreathing inadequately or apnoeicHeart rate very slow (lt60 min 1) or undetectable

Assessment PoorFailed transition Breathing requires supportheart rate suggestive of significant hypoxia (Fig [1282_TD$DIFF]4c)

Actions Clamp cord immediately and transfer to the resuscitation platform

Delay cord clamping only if you are able to appropriately supportresuscitate the infant

Dry stimulate wrap in warm towel Maintain the airway lung inflation and ventilation Continuously assess heart rate breathing and effect of

ventilation

Continue newborn life support according to response Help is likely to be required

Preterm infants

Same principles apply Consider alternativeadditional methods for thermal care eg

polyethylene wrap Gently support initially with CPAP if breathing Consider continuous rather than intermittent monitoring (pulse

oximetryECG)

Newborn life support

Following initial assessment and intervention continue respiratorysupport if The infant has not established adequate regular breathing or The heart rate is lt100min 1

[1283_TD$DIFF]Ensuring an open airway aerating and ventilating the lungs[1284_TD$DIFF] isusually all that is necessary Without these other interventions will beunsuccessful

Airway

Commence life support if initial assessment shows that the infant hasnot established adequate regular normal breathing or has a heart ratelt100min 1 [1285_TD$DIFF](Fig 5)

Establishing and maintaining an open airway is essential toachieve postnatal transition and spontaneous breathing or for furtherresuscitative actions to be effective[1286_TD$DIFF]

Fig 4c ndash Poorfailed transition




Fig 5 ndash NLS algorithm




Techniques to help open the airway

Place the infant on their back with the head supported in a neutralposition (Fig [1287_TD$DIFF]6a)

In floppy infants pulling the jaw forwards (jaw lift) may beessential in opening andor maintaining the airway and reducingmask leak (Fig [1288_TD$DIFF]6b) When using a facemask two personmethods of airway support are superior and permit true jawthrust to be applied

An oropharyngeal airway may be useful in term infants whenhaving difficulty providing both jaw lift and ventilation or where theupper airway is obstructed for instance in thosewithmicrognathiaHowever oropharyngeal airways should be used with caution ininfants 34 weeks gestation as they may increase airwayobstruction

A nasopharyngeal airway may also be considered where there isdifficulty maintaining an airway and mask support fails to achieveadequate aeration

Airway obstruction

Airway obstruction can be due to inappropriate positioningdecreased airway tone andor laryngeal adduction especially inpreterm infants at birth

Suction is only required if airway obstruction due to mucus vernixmeconium blood clots etc is confirmed through inspection of thepharynx after failure to achieve aeration

Any suctioning should be undertaken under direct vision ideallyusing a laryngoscope and a wide bore catheter

Meconium

Non-vigorous newborn infants delivered through meconium-stained amniotic fluid are at significant risk for requiring advancedresuscitation and a neonatal team competent in advancedresuscitation may be required

Routine suctioning of the airway of non-vigorous infants is likelyto delay initiating ventilation and is not recommended In theabsence of evidence of benefit for suctioning the emphasis

must be on initiating ventilation as soon as possible in apnoeic orineffectively breathing infants born through meconium-stainedamniotic fluid

Should initial attempts at aeration and ventilation be unsuccessfulthenphysical obstructionmaybe the cause In this case inspectionand suction under direct vision be considered Rarely an infantmay require tracheal intubation and tracheal suctioning to relieveairway obstruction

Initial inflations and assisted ventilation

Lung [1289_TD$DIFF]inflation (Fig 7)

If apnoeic gasping or not breathingeffectively aim to start positive

pressure ventilation as soon as possible ideally within 60 s ofbirth

Apply an appropriately fitting facemask connected to a means ofproviding positive pressure ventilation ensuring a good sealbetween mask and face

Give five ldquoinflationsrdquo maintaining the inflation pressure for upto 2 3 s

Provide initial inflation pressures of 30 cm H2O for terminfants commencing with air Start with 25 cm H2O for preterminfants 32 weeks using 21 30 inspired oxygen (see lsquoairoxygenrsquo)

Assessment

Check the heart rate

13 An increase (within 30 s) in heart rate or a stable heart rate ifinitially high confirms adequate ventilationoxygenation

13 A slow or very slow heart rate usually suggests continuedhypoxia and almost always indicates inadequate ventilation

Check for chest movement

Visible chest movement with inflations indicates a patent airwayand delivered volume

Failure of the chest to move may indicate obstruction of theairway or insufficient inflation pressure and delivered volume toaerate the lungs

Ventilation (Fig [1290_TD$DIFF]8)

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 Aim for about 30 breaths min 1 with an inflation time of under 1 s Reduce the inflation pressure if the chest is moving well Reassess heart rate and breathing at least every 30 s Consider a more secure airway (laryngeal masktracheal tube) if

apnoea continues or if mask ventilation is not effective

Fig 6b ndashJaw lift jaw lift enlarges thepharyngeal space

Fig 7 ndash Five 2 3 s inflations are given via facemaskAssess heart rate response and chest movement

Fig 6a ndash Head in a neutral position Face is horizontal(middle picture) neither flexed (left) or extended (right)




Failure to respond

If there is no heart rate response and the chest is not moving withinflations Check if the equipment is working properly Recheck the head-position and jaw liftthrust Recheck mask size position and seal Consider other airway manoeuvres13 2-person mask support if single handed initially13 Inspection of the pharynx and suction under direct vision to

remove obstructing foreign matter if present13 Securing the airway via tracheal intubation or insertion of a

laryngeal mask13 Insertion of an oropharyngealnasopharyngeal airway if unable

to secure the airway with other means Consider a gradual increase in inflation pressure If being used check on a respiratory function monitor that expired

tidal volume is not too low or too high (target about 5 8 mLkg 1)

Then Repeat inflations Continuously assess heart rate and chest movement

If the insertion of a laryngeal mask or tracheal intubation is

considered it must be undertaken by personnel competent in the

procedure with appropriate equipment Otherwise continue with

mask ventilation and call for help

Without adequate lung aeration chest compressions will beineffective therefore where the heart rate remains very slow confirmeffective ventilation through observed chest movement or othermeasures of respiratory function before progressing to chestcompressions

[1291_TD$DIFF]CPAP and PEEPairway adjuncts and assisted ventilation

Continuous positive airway pressure (CPAP) and positive

end expiratory pressure (PEEP)

In spontaneously breathing preterm infants consider CPAP as theinitial method of breathing support after delivery using eithermask or nasal prongs

If equipment permits apply PEEP at minimum of 5 6 cm H2Owhen providing positive pressure ventilation (PPV) to theseinfants

Assisted ventilation devices

Ensure a facemask of appropriate size is used to provide a goodseal between mask and face

Where possible use a T-piece resuscitator (TPR) capable ofproviding either CPAP or PPV with PEEP when providingventilatory support especially in the preterm infant

Nasal prongsof appropriate sizemaybeaviableCPAPalternativeto facemasks

Ifaself-inflatingbagisuseditshouldbeofsufficientvolumetodeliveranadequate inflation Care should be taken not to deliver an excessivevolume The self-inflating bag cannot deliver CPAP effectively

Laryngeal mask

Consider using a laryngeal mask13 In infants of34weeksgestation (about 2000g) althoughsome

devices have been used successfully in infants down to 1500g13 If there are problems with establishing effective ventilation with

a facemask13 Where intubation is not possible or deemed unsafe because

of congenital abnormality a lack of equipment or a lack ofskill

13 Or as an alternative to tracheal intubation as a secondaryairway

Tracheal tube

Tracheal intubation may be considered at several points duringneonatal resuscitation13 When ventilation is ineffective after correction of mask

technique andor the infants head position andor increasinginspiratory pressure with TPR or bag-mask

13 Where ventilation is prolonged to enable a more secure airwayto be established

13 When suctioning the lower airways to remove a presumedtracheal blockage

13 When chest compressions are performed13 In special circumstances (eg congenital diaphragmatic hernia

or to give surfactant) Exhaled CO2 detection should be used when undertaking

intubation to confirm tube placement in the airway A range of differing sized tracheal tubes should be available to

permit placement of the most appropriate size to ensure adequateventilation with minimal leak and trauma to the airway [1292_TD$DIFF]Table 1

Respiratory function monitoring may also help confirm trachealtube position and adequate ventilation through demonstratingadequate expired tidal volume (about 5 8mL kg 1) and minimalleak

The use of a video laryngoscope may aid tube placement If retained the position of the tracheal tube should be confirmed by

radiography

Fig 8 ndash Once inflation breaths have been successfullydelivered ventilate at 30 breaths min 1 Assess heartrate continuously

Table 1 ndash Approximate oral tracheal tube size bygestation (for approximate nasotracheal tube lengthadd 1cm)

Gestationalage (weeks)

Length atlips (cm)

Externaldiameter (mm)

23 24 55 2525 26 60 2527 29 65 2530 32 70 3033 34 75 3035 37 80 3538 40 85 3541 43 90 40




Air[211_TD$DIFF]oxygen

Pulse-oximetry and oxygen blenders should be used during

resuscitation in the delivery room Aim to achieve target oxygen saturation above the 25th percentile

for healthy term infants in the first 5 min after birth (Table 2)

If despite effective ventilation there is no increase in heart rate orsaturations remain low increase the oxygen concentration toachieve adequate preductal oxygen saturations

Check the delivered inspired oxygen concentration and satu-rations frequently (eg every 30 s) and titrate to avoid both hypoxiaand hyperoxia

wean the inspired oxygen if saturations gt95 in preterms

Term and late preterm infants 35 weeks

In infants receiving respiratory support at birth begin with air(21)

Preterm infants lt35 weeks

Resuscitation should be initiated in air or a low inspired oxygenconcentration based on gestational age13 [1293_TD$DIFF]32 weeks 2113 28 31 weeks 21 3013 lt28 weeks 30

In infants lt32 weeks gestation the target should be to avoid anoxygen saturation below 80 andor bradycardia at 5 min of ageBoth are associated with poor outcome

Chest compressions

Assessment of the need for chest compressions (Fig [1294_TD$DIFF]9)

If the heart rate remains very slow (lt60 min 1) or absent after 30 sof good quality ventilation start chest compressions

When starting compressions13 Increase the delivered inspired oxygen to 10013 Call for experienced help if not already summoned

Delivery of chest compressions

[1295_TD$DIFF]Use a synchronous technique providing three compressions toone ventilation at about 15 cycles every 30 s

[1296_TD$DIFF]Use a two-handed technique for compressions if possible Re-evaluate the response every 30 s If the heart rate remains very slow or absent continue ventilation

and chest compressions but ensure that the airway is secured(eg intubate the trachea if competent and not done already)

Titrate the delivered inspired oxygen against oxygen saturation if areliable value is achieved on the pulse oximeter

Consider Vascular access and drugs

Vascular access

During the resuscitation of a compromised infant at birth peripheralvenous access is likely to be difficult and suboptimal for vasopressoradministration

Umbilical venous access

The umbilical vein offers rapid vascular access in newborn

infants and should be considered the primary method duringresuscitation

Ensure a closed system to prevent air embolism during insertionshould the infant gasp and generate sufficient negative pressure

Confirm position in a blood vessel through aspiration of blood priorto administering drugsfluids

Clean rather than sterile access technique may be sufficient in anemergency

The umbilical route may still be achievable some days after birthand should be considered in cases of postnatal collapse

Intraosseous access

Intraosseous (IO) access can be an alternative method ofemergency access for drugsfluids

Support of transitionpost-resuscitation care

If venous access is required following resuscitation peripheralaccess may be adequate unless multiple infusions are required inwhich case central access may be preferred

IO access may be sufficient in the short term if no other site isavailable

Drugs

During active resuscitation

Drugs are rarely required during newborn resuscitation and theevidence for the efficacy of any drug is limited The following maybe considered during resuscitation where despite adequatecontrol of the airway effective ventilation and chest compressionsfor 30 s there is an inadequate response and the HR remainsbelow 60 min 1

Adrenaline13 When effective ventilation and chest compressions have failed

to increase the heart rate above 60 min 1

13 Intravenous or intraosseous is the preferred routeamp At a dose of 10 30 micrograms kg 1 (01 03 mL kg 1 of

110000 adrenaline [1000 micrograms in 10 mL])

Table 2 ndash Approximate target SpO2 in the first 10minfor healthy term infants (derived from Dawsonet al281)

Time after birth (min) Lower SpO2 target ()

2 655 8510 90

Fig 9 ndash Deliver 30 s of good quality ventilation beforereassessment of the heart rate




13 Intra-tracheally if intubated and no other access availableamp At a dose of 50 100 micrograms kg 1

13 Subsequent doses every 3 5min if heart rate remainslt60min 1 Glucose

13 In a prolonged resuscitation to reduce likelihood ofhypoglycaemia

13 Intravenous or intraosseousamp 250 mgkg 1 bolus (25 mLkg 1 of 10 glucose solution)

Volume replacement13 With suspected blood loss or shock unresponsive to other

resuscitative measures13 Intravenous or intraosseous

amp 10 mLkg 1 of group O Rh-negative blood or isotoniccrystalloid

Sodium bicarbonate

13 May be considered in a prolonged unresponsive resuscitationwith adequate ventilation to reverse intracardiac acidosis

13 [1297_TD$DIFF]Intravenous or intraosseousamp 1 2 mmol kg 1 sodium bicarbonate (2 4 mL kg 1 of 42

solution) by slow intravenous injection

In situations of persistent apnoea

Naloxone13 Intramuscular

amp An initial 200 microgram dose may help in thefew infants who despite resuscitation remain apnoeicwith good cardiac output when the mother is knownto have received opiods in labour Effects may betransient so continued monitoring of respiration isimportant

In the absence of an adequate response

Consider other factors which may be impacting on the response toresuscitation and which require addressing such as the presence ofpneumothorax hypovolaemia congenital abnormalities equipmentfailure etc

Post-resuscitation care

Infants who have required resuscitation may later deteriorate Onceadequate ventilation and circulation are established the infant shouldbe cared for in or transferred to an environment in which closemonitoring and anticipatory care can be provided

Glucose

Monitor glucose levels carefully after resuscitation

Have protocolsguidance on the management of unstable glucoselevels

Avoid hyper- and hypoglycaemia Avoid large swings in glucose concentration Consider the use of a glucose infusion to avoid hypoglycaemia

Thermal care

Aim to keep the temperature between 365 C and 375 C Rewarm if the temperature falls below this level and there are no

indications to consider therapeutic hypothermia (see below)

Therapeutic hypothermia

Once resuscitated consider inducing hypothermia to 33 34 C insituations where there is clinical andor biochemical evidence ofsignificant risk of moderate or severe HIE (hypoxic-ischaemicencephalopathy)

Ensure the evidence to justify treatment is clearly documentedinclude cord blood gases and neurological examination

Arrange safe transfer to a facility where monitoring and treatmentcan be continued

Inappropriate application of therapeutic hypothermia withoutconcern about a diagnosis of HIE is likely to be harmful (seetemperature maintenance)

Prognosis (documentation)

Ensure clinical records allow accurate retrospective time-basedevaluation of the clinical state of the infant at birth anyinterventions and the response during the resuscitation tofacilitate any review and the subsequent application of anyprognostic tool

Communication with the parents

Where intervention is anticipated

Whenever possible the decision to attempt resuscitation of an

extremely preterm or clinically complex infant should be taken inclose consultation with the parents and senior paediatricmidwifery and obstetric staff

Discuss the options including the potential need and magnitude ofresuscitation and the prognosis before delivery in order to developan agreed plan for the birth

Record carefully all discussions and decisions in the mothersnotes prior to delivery and in the infants records after birth

For every birth

Where intervention is required it is reasonable formothersfatherspartners to be present during the resuscitation where circum-stances facilities and parental inclination allow

The views of both the team leading the resuscitation and theparents must be taken into account in decisions on parentalattendance

Irrespective of whether the parents are present at the resuscita-tion ensure wherever possible that they are informed of theprogress of the care provided to their infant

Witnessing the resuscitation of their infant may be distressing forparents If possible identify a member of healthcare staff tosupport them to keep them informed as much as possible duringthe resuscitation

Allow parents to hold or even better to have skin-to-skin contactwith their infant as soon as possible after delivery or resuscitationeven if unsuccessful

Provide an explanation of any procedures and why they wererequired as soon as possible after the delivery

Ensure a record is kept of events and any subsequentconversations with parents

Allow for further discussions later to enable parents to reflect andto aid parental understanding of events

Consider what additional support is required for parents followingdelivery and any resuscitation




Withholding and discontinuing resuscitation

Any recommendations must be interpreted in the light of current

nationalregional outcomes When discontinuing withdrawing or withholding resuscitation

care should be focused on the comfort and dignity of the infant andfamily

Such decisions should ideally involve senior paediatric staff

Discontinuing resuscitation

National committees may provide locally appropriate recommen-dations for stopping resuscitation

When the heart rate has been undetectable for longer than 10 minafter delivery review clinical factors (for example gestation of theinfant or presenceabsence of dysmorphic features) effective-ness of resuscitation and the views of other members of theclinical team about continuing resuscitation

If the heart rate of a newborn term infant remains undetectable formore than 20 min after birth despite the provision of allrecommended steps of resuscitation and exclusion of reversiblecauses consider stopping resuscitation

Where there is partial or incomplete heart rate improvementdespite apparently adequate resuscitative efforts the choice ismuch less clear It may be appropriate to take the infant to theintensive care unit and consider withdrawing life-sustainingtreatment if they do not improve

Where life-sustaining treatment is withheld or withdrawn infantsshouldbeprovidedwithappropriatepalliative (comfort focused)care

Withholding resuscitation

Decisions about withholding life-sustaining treatment shouldusually be made only after discussion with parents in the lightof regional or national evidence on outcome if resuscitation andactive (survival focused) treatment is attempted

In situations where there is extremely high (gt90) predictedneonatal mortality and unacceptably high morbidity in survivinginfants attempted resuscitation and active (survival focused)management is usually not appropriate

Resuscitation is nearly always indicated in conditions associatedwith a high (gt50) survival rate and what is deemed to beacceptable morbidity This will include most infants with gestationalage of 24 weeks or above (unless there is evidence of fetalcompromise such as intrauterine infection or hypoxia-ischaemia)and most infants with congenital malformations Resuscitationshould also usually be commenced in situations where there isuncertainty about outcome and there has been no chance to haveprior discussions with parents

In conditions where there is low survival (lt50) and a high rate ofmorbidity and where the anticipated burden of medical treatmentfor the child is high parentalwishes regarding resuscitation shouldbe sought and usually supported

Evidence informing the guidelines


Transition

Survival at birth involves major physiological changes during transitionfrom fetal to newborn life First lung liquid-clearance and aeration need

tooccur afterwhichpulmonarygasexchangecanbeestablished6 Thiscritical event initiates a sequence of inter-dependent cardiopulmonaryadaptations which enable transition to independent life7 Spontaneousbreathingeffort (negativepressure)or lesseffective artificial ventilation(positive pressure) are essential to generate the transpulmonarypressures required to aerate the liquid-filled lung to form and thenmaintain a functional residual capacity89 Most but not all infantstransition smoothly Some infants have problems with transition andwithout timely and adequate support might subsequently needresuscitation Recent large-scale observational studies confirm thatapproximately 85 of infants born at term initiate respirationspontaneously 10 will respond to drying stimulation opening theairway andor applying CPAP or PEEP approximately 5 will breathefollowing positive pressure ventilation Estimates of intubation ratesvary between 04 and 2 lt03 receive chest compressions andapproximately 005 adrenaline10 16

Risk factors

Severalmaternaland fetal pre-and intrapartumfactors increase the riskfor compromised birth or transition and the need for resuscitation In arecent ILCOR evidence update most recent studies confirm previouslyidentified risk factors for needing assistance after birth117 26 There isno universally applicable model to predict risk for resuscitation or needof support during transition and the list of risk factors in theguidelines isnot exhaustive

Elective caesarean delivery at term in the absence of other riskfactors does not increase the risk of needing newborn resuscita-tion182728 Following the review of evidence ILCOR recommendationsareunchangedWhenan infant isdeliveredat termbycaesareandeliveryunder regional anaesthesia a provider capable of performing assistedventilation should be present at the delivery It is not necessary for aprovider skilled in neonatal intubation to be present at that delivery1


It is not always possible to predict the need for stabilisation orresuscitation before an infant is born Interventions may not benecessary but those in attendance at a delivery need to be able toundertake initial resuscitation steps effectively It is essential thatteams can respond rapidly if not present and needed to provideadditional support The experience of the team and their ability torespond in a timely manner can influence outcome29 Units havedifferent guidelines for when teams attend in advance potentiallyleading to widely different outcomes30 A prospective audit of 56Canadian neonatal units found that with the guidelines in force at thattime the need for resuscitation was unanticipated in 76 of cases31

In a series of video recorded resuscitations in 2 Norwegian tertiarylevel units the need for resuscitation was not anticipated in 3232

Approximately 65 of all deliveries in a single Canadian unit wereattended by the resuscitation team only 22 of these infantsrequired IPPV as did another 46 where resuscitation was notanticipated17


The detailed specification of the equipment required to supportstabilisation and resuscitation of the newborn may vary and thoseusing the equipment need to be aware of any limitations Suggestionshave been made on standardising an optimal layout of a resuscitationarea33 but no published evidence has demonstrated improvement inoutcome as a result of specific arrangements The guidelines arebased on international expert opinion134





A systematic review of 8 studies involving 14 637 low risk plannedhome deliveries compared to 30 177 low risk planned hospital birthsconcluded that the risks of neonatal morbidity and mortality weresimilar35 Those attending deliveries at home need to recognise thatdespite risk stratificationandmeasures to avoid theevent infants bornat home may still require resuscitation and they must be prepared forthis possibility34

Briefing and checklists

Briefing with role allocation to improve team functioning and dynamicsis recommended36 although there is a lack of evidence of improvedclinical outcomes37 Likewise use of checklists during briefings (anddebriefings) may help improve team communication and process butagain there is little evidenceof effect onclinical outcome3839 A recentILCOR scoping review on the effect of briefingdebriefing on theoutcome of neonatal resuscitation concluded that briefing or debrief-ing may improve short-term clinical and performance outcomes forinfants and staff but the effects on long-term clinical and performanceoutcomes were uncertain1

The opportunity to brief the family before delivery can significantlyinfluence their expectation and understanding of events decision-making and interactions with health providers Therefore anticipatoryliaison often forms part of national recommendations on practice (seesection parents and family)33

Trainingeducation

Meta-analysis of adult resuscitations showed that attendance by oneor more personnel on an advanced life support course improvesoutcome40 Research on educational methods in neonatal resuscita-tion is evolving but due to study heterogeneity with non-standardisedoutcome measures there is still little evidence on the effect of differenttraining modalities on clinical outcome41 43

For those taking resuscitation courses training or retrainingdistributed over time (spaced learning) may be an alternative totraining provided at one single time point (massed learning) (weakrecommendation very low certainty of evidence)44 Intermittentinfrequent training without interval refreshment leads to skills decay inneonatal resuscitation45 whereas frequent and brief on-site simula-tion-based training has been shown to improve patient 24 h survival ina low-resource setting46 Two observational studies analysing videorecordings of real-time resuscitations against checklists of expectedactions indicated frequent errors in the application of structuredguidelines in newborn resuscitation1547 This suggests that trainingshould be repeated more frequently than once per year however theoptimal interval remains to be established4849

A structured educational programme in neonatal resuscitation wasrecommended in the 2015 ERC guidelines and supported by twosystematic reviews and meta-analyses34 A Cochrane review of 14studies (187 080 deliveries) concluded that there was moderatequality evidence that such training decreased early neonatal mortality(typical RR 088 95 CI 078 100)50 Findings of a meta-analysis of20 trials comparing periods before and after neonatal resuscitationtraining and including 1 653 805 births showed an 18 reduction inperinatal mortality (RR 082 95 CI 074 091) but these findings hadto be downgraded for risk of bias and indirectness43 The optimalcontent or organisation of such training programmes will varyaccording to the needs of the providers and the organisation of theinstitutions

A recent ILCOR systematic review included several studies onteam training in neonatal resuscitation51 55 Team performance andpatient safety appeared to be enhanced by regular practice and drillsthat enabled those likely to be involved to rehearse and improve theirabilities at an individual level and in teams This suggested thatspecific team and leadership training be included as part of AdvancedLife Support training for healthcare providers (weak recommendationvery low certainty of evidence)37

Multi-modal approaches to teaching neonatal resuscitation arethought to be the most beneficial for learning especially whensimulation-based training with emphasis on feedback on practice isincorporated as a teaching method425056 60 Feedback may comefromdifferent sources suchas the facilitator themanikin itself or digitalrecordings (video audio respiratory function monitor etc)3760 62

The role of modalities such as virtual reality tele-education and boardgame simulation in resuscitation training remain to be established Areviewof 12 such neonatal resuscitation-basedgames concluded thatthey had a potential to improve knowledge skills and adherence to theresuscitation algorithm63

Feedback devices providing information on the quality of interven-tion may also be used in real-life settings to improve performance andcompliance with guidelines376465 Debriefing on individual and teamperformance at resuscitations supported by objective data arerecommended after cardiac arrest for both adult and children (weakrecommendation very low certainty of evidence)3766 69 Thisapproach to debrief also applies to neonatal resuscitation537071

Thermal control

Exposed wet newborn infants cannot maintain their body tempera-ture in a room that feels comfortably warm for adults Themechanismsand effects of cold stress and how to avoid these have beenreviewed7273 Heat loss can occur though convection conductionradiation and evaporation meaning unprotected infants will drop theirbody temperature quickly Cold stress lowers the arterial oxygentension and increases the risk of metabolic acidosis Compromisedinfants are particularly vulnerable to cold stress The admissiontemperature of newborn non-asphyxiated infants is a strong predictorof mortality and morbidity at all gestations and in all settings7475

ILCOR recommendations are that it should be recorded as a predictorof outcomes as well as a quality indicator (strong recommendationmoderate-quality evidence)49 Immediate drying and wrapping infantsin a warm towel to avoid exposure to a cold environment will help themmaintain their temperature

Preterm infants are especially vulnerable and hypothermia is alsoassociated with serious morbidities such as intraventricular haemor-rhage need for respiratory support hypoglycaemia and in somestudies late onset sepsis49 In a European cohort study of 5697 infantslt32 weeks gestation admitted for neonatal care an admissiontemperature lt355 C was associated with increased mortality in thefirst 28 days76 For each 1 C decrease in admission temperaturebelow the recommended range an increase in the baseline mortalityby 28 has been reported77

A Cochrane review involving 46 trials and 3850 dyads of infantsgt32 weeks gestation where resuscitation was not requiredconcluded that skin-to-skin care may be effective in maintainingthermal stability (low quality evidence) and also improves maternalbonding and breast feeding rates (low to moderate qualityevidence)78 However most trials were small and unblinded withheterogeneity between groups Skin-to-skin care is feasible in less




mature infants however caution is required in the more preterm orgrowth restricted infant in order to avoid hypothermia In one singlecentre observational study of 55 infants between 28+0 and 32+6

weeks gestation randomised to either skin-to-skin or conventionalthermal care the mean body temperature of the skin-to-skin groupwas 03 C lower 1 h after birth (363 C052 p = 003)79 furtherstudies are ongoing80

Following a recent ILCOR evidence update including aCochrane systematic review of 25 studies including 2433 pretermand low birth weight infants treatment recommendations areunchanged from 201575 It is recommended that newborn temper-atures be kept between 365 C and 375 C in order to reduce themetabolic stress on the infant (strong recommendation very lowquality of evidence)149 For newborn preterm infants of 32 weeksgestation under radiant warmers in the hospital delivery room acombination of interventions is suggested which may include raisingthe environmental temperature to 23 C 25 C use of warmedblankets plastic wrapping without drying cap and thermal mattressto reduce hypothermia on admission to the neonatal intensive careunit (NICU) (weak recommendation very-low quality of evidence)1

For infants lt28 weeks gestation the room temperature shouldideally be above 25 C727381 In the absence of exothermic devicesfood grade plastic wrap and swaddling can be effective in preterminfants727382

It is suggested that hyperthermia (greater than 380 C) shouldbe avoided because it introduces potential associated risks (weakrecommendation very-low quality of evidence)149 Infants born tofebrile mothers have a higher incidence of perinatal respiratorycompromise neonatal seizures early mortality and cerebralpalsy83 85 Animal studies indicate that hyperthermia during orfollowing ischaemia is associated with a progression of cerebralinjury85

Temperature monitoring is key to avoiding cold stress Howeverthere is very little evidence to guide the optimal placement oftemperaturemonitoring probes on the infant in the delivery room In anobservational study of 122 preterm infants between 28 and 36 weeksgestation randomised to different sites for temperature monitoringdorsal thoracic and axillary sited probes measured comparabletemperatures29 There are to date no published studies comparingthe use of rectal temperature probes

Heated humidified gases reduced the incidence of moderatehypothermia inpreterm infants86 Ameta-analysisof twoRCTs involving476 infants lt32 weeks gestation indicated that heated humidifiedinspired gases immediately following delivery reduced the likelihood ofadmission hypothermia in preterm infants by 36 (95 CI 17 50)(high level of evidence)8788 Therewasno significant increase in the riskof hyperthermia or a difference in mortality between humidified and non-humidified groups It is unclear if other outcomes are improved

Quality improvement programs including the use of checklists andcontinuous feed-back to the team have been shown to significantlyreduce hypothermia at admission in very preterm infants8189

Clamping the umbilical cord

There is no universally accepted definition of lsquodelayedrsquo or lsquodeferredrsquocord clampingrsquo (DCC) only that it does not occur immediately after theinfant is born In recent systematic reviewsandmeta-analyses early orimmediate cord clamping (ICC) has been defined as application of theclampwithin 30 s of birth later or delayed cord clampingas applicationof a clamp to the cord greater than 30 s after birth or based on

physiological parameters (such as when cord pulsation has ceased orbreathing has been initiated) without cord milking9091

Physiology of cord clamping

Observational data physiological studies animal models and someclinical studies suggest that ICC currently widely practiced andintroduced primarily to prevent maternal postpartum haemorrhage isnot as innocuous as was once thought9293 ICC significantly reducesventricular preload whilst simultaneously adding to left ventricularafterload794 Effects of this are seen in observational studies with adecrease in cardiac size for 3 4 cardiac cycles95 and bradycardia96

and in experimental animal models97

Differences with gestation

In term infants DCC results in the transfer of approximately 30mLkg 1

of blood from the placenta98 This improves iron status andhaematological indices over the next 3 6 months in all infants andreduces need for transfusion in preterm infants99100 Concerns aboutpolycythaemia and jaundice requiring intervention do not seem to beborneout in randomised trialsConcernsabout the positionof the infantin relation to the introitus also seem unfounded as the effects of uterinecontraction and lung expansion seem to exert a greater impact onumbilical blood flow than gravity101102

In an ILCOR meta-analysis of 23 studies of 3514 eligible infantscomparing ICC versus a delay of at least 30 s in preterm infants lt34weeks gestation the conclusion was that compared to ICC DCC maymarginally improve survival (RR 102 95 CI 0993 104)(certainty of evidence moderate)90 Early cardiovascular stabilitywas improved with less inotropic support (RR 036 95 CI 017 075) and higher lowest mean blood pressure (MD 179 mmHg95 CI 053 305) in the first 12 24 h Infants had betterhaematological indices The peak haematocrit appeared higher at24 hrs (MD 263 95 CI 185 342) and at 7 days (MD 270 95CI 188 352) Infants required fewer blood transfusions (MD 063 95 CI 108 to 017) No effects were seen on any of thecomplications of prematurity such as severe IVH NEC or chroniclung disease nor was there any obvious adverse impact on otherneonatal or maternal outcomes (moderate to high quality evidence)In sub-group analyses of DCC vs ICC there seemed to be analmost linear relationship between survival to discharge andduration of DCC DCC for 1 min RR 100 (95 CI 097 104)DCC for 1 2 min RR 103 (95 CI 100 105) DCC forgt2 min RR107 (95 CI 099 115) None of these results were statisticallysignificant due to the relatively small numbers involved

In term and late preterm infants an ILCOR meta-analysis of 33trials (5236 infants) of DCC vs ICC updated the findings of aprevious 2013 Cochrane study91103 Analysis demonstrated nosignificant effect on mortality (RR 254 95 CI 050 1274 4 trials537 infants) or need for resuscitation (RR 508 95 CI 025 10358 3 trials 329 infants) There were improved earlyhaematological and circulatory parameters (haemoglobin 24 hafter birth (MD 117 g dL 1 95 CI 048 186 9 trials 1352 infants)and 7 days after birth (MD 111 g dL 1 95 CI 040 182 3 trials695 infants) but no impact on longer term anaemia This updatedreview does not suggest clear differences in receipt of phototherapy(RR 128 95 CI 090 182) (all findings low or very low certaintyevidence) The analysis did not provide clear evidence on longerterm neurodevelopmental outcomes

Further study is warrantedmost studies used a temporal definitionfor the timing of cord clamping there are insufficient data to




recommend lsquophysiologicalrsquo cord clamping (ie after the onset ofrespirations)104 although this may confer benefit105 Physiologicalstudies suggest that the hypoxic and bradycardic response observedafter immediate clamping is not seen when clamping occurs after thefirst breaths9697106

The question of resuscitating infants with the intact cord warrantsfurther study in most studies of delayed cord clamping infants whorequired resuscitation at birth were excluded as resuscitation couldonly be undertaken away from the mother Equipment now exists thatallows mother-side resuscitation and initial studies show that delayedcord clamping is feasible in such infants107 109 However it remainsunclear which is the optimum strategy in these infants

Cord milking

Delayed umbilical cord clamping is contra-indicated when placentalblood flow is compromisedbyplacental abruption cordprolapse vasapraevia cord avulsion or maternal haemorrhage Umbilical cordmilking with intact or cut cords has been considered an alternative inthese situations In lsquointact cord milkingrsquo the cord is milked 3 5 timesresulting in a faster blood flow towards the baby than occurs withpassive return due to uterine contraction A term infant can receive upto 50 mL of lsquoplacentalrsquo blood through this action After milking the cordis clamped and cut and the infant can be taken to the resuscitationarea110

lsquoCut cord milkingrsquo involves milking from a length of cord (25 cm)after clamping and cutting The volume of blood is less than from anintact cord but still gives the term infant about 25mL The infant istaken to the resuscitation area immediately and milking occurs duringresuscitation or stabilisation111

In preterm infants born before 34 weeks gestation intact cordmilking shows only transient benefits over ICC including less use ofinotropic support fewer infants needing blood transfusion and higherhaemoglobin and haematocrit on day 1 but not at 7 days There wereno differences in major neonatal morbidities (low to moderate qualityevidence) There was no demonstrable benefit over DCC90 In themeta-analyses therewasnoeffect onmortality (RR099 95CI 095 102) but of particular concern is that one large study of intact cordmilking versus delayed cord clamping was terminated early whenanalysis demonstrated an excess of severe intraventricular haemor-rhage (RD 16 95 CI 6 to 26 p = 0002) in those infants bornbefore 28 weeks allocated to the intact cord milking arm112

In term and late preterm infants there are insufficient data to allowmeta-analysis of umbilical cord milking91

Initial assessment

Initial assessment

The Apgar score was not designed to identify infants in need ofresuscitation113 However individual components of the scorenamely respiratory rate heart rate (HR) and tone if assessed rapidlymay help identify infants likely to need resuscitation

Tactile [1298_TD$DIFF]stimulation

Methods of tactile stimulation vary widely but the optimal methodremains unknown114115 In preterm infants tactile stimulation is oftenomitted115 118 but in a single centre RCT of repetitive stimulationagainst standard stimulation only if deemed necessary in 51 infantsbetween 28 and 32 weeks gestation repetitive stimulation was shownto improve breathing effort and oxygen saturation (SpO2 87633vs81787 p =0007)119 Stimulation ofmore infants at birth (after

introduction of a basic resuscitation training program) was associatedwith an increased 24-h survival in a multi-centre observational study inTanzania including 86624 mainly termnear-term infants120

Tone and colour

Healthy infants are cyanosed at birth but start to become pink withinapproximately 30 s of the onset of effective breathing121 Peripheralcyanosis is common and does not by itself indicate hypoxiaPersistent pallor despite ventilation may indicate significant acidosisor more rarely hypovolaemia with intense cutaneous vascularvasoconstriction A pink upper-part of the body and a blue lower partcan be a sign of right-left shunting over an open duct

Colour is an unreliable marker of oxygenation which is betterassessed using pulse oximetry There are few studies in the newbornIn an observational study involving 27 clinicians making a subjectiveassessment of oxygenation status using videos of preterm infantswhere saturations were known there was a lack of concordance withboth under and over estimation of values122

Breathing

Not crying may be due to apnoea but can also function as a markerof inadequate breathing needing support In an observational studyof 19 977 infants just after birth in a rural hospital setting 11 werenot crying around half of whom were assessed as apnoeic About10 of those assessed as breathing at birth became apnoeic Notcrying but breathing was associated with a 12-fold increase inmorbidity123

The presence or adequacy of breathing effort in preterm infantscan be difficult to assess as breathing can be very subtle and is oftenmissed121124 Breathing perceived as inadequate will prompt anintervention In a retrospective video based observational study of 62preterm infants delivered at lt28 weeks or with birth weight lt1000g80 were assessed as showing signs of breathing but all receivedrespiratory support with CPAP or intubation125

Heart rate

Immediately after birth the heart rate is assessed to evaluate thecondition of the infant and subsequently heart rate is the mostsensitive indicator of a successful response to interventions126 128

There is no published evidence unambiguously defining the thresh-olds for intervention during newborn resuscitation The rates of100 min 1 and 60 min 1 around which interventions are prompted areessentially pragmatic in nature129

In uncompromised breathing term infants where umbilical cordclamping wasdelayed the heart rate is usually above100 min 1128 Inan observational study of 1237 termnear-term infantsresuscitated in a rural setting the initial heart rates at birth weredistributed in a bimodal peak around 60 and 165 min 1 Ventilationincreased heart rate in most bradycardic newborns to a final median of161 min 1 Lower initial and subsequent heart rates were associatedwith poorer outcomes130 In preterm infants lt30 weeks gestation theheart rate does not stabilise until it reaches approximately 120 min 1

and in some stability was only achieved once the heart rate wasgt150min 1131

Auscultation by stethoscope is inexpensive simple and permits areasonably accurate rapid assessment of heart rate In delivery roomstudies of low risk infants heart rate determination was possible within14(10 18) seconds (median(IQR)) and was found to underestimateECG or pulse oximetry (PO) values by between 9(7) and 14(21) min 1 (mean difference (95 CI))132133




Palpation for a pulse at the base of the umbilical cord or (lessreliably) the brachial or femoral arteries is also simple and rapidValues may be considered valid if the heart rate is determined to befast (gt100 min 1) however they are often inaccurate intermittent andaffectedbymovementswitha tendency to significantly underestimatepotentially prompting inappropriate interventions133134

Continuous monitoring provides a more dynamic indication ofheart rate change during resuscitation and is preferable to intermittentcounting A pulse oximeter (ideally connected to the right hand) cangive an accurate heart rate as well as information on oxygenationInitial values may underestimate the ECG a little In a study of 53infants pulse oximeter values were significantly lower than ECG overthe first 2 min (81 (60 109) vs 148 (83 170) min 1 at 90 seconds(plt 0001))135 Later differences of 2(26) min 1 (mean(SD)) wereobserved when compared with ECG136 but the time to obtain reliablevalues may take longer than auscultation137 Findings differ as towhether advantage is gained from connecting the sensor to infant138

or oximeter139 first however signal acquisition canbeachievedwithinabout 15 s once connected Peripheral hypoperfusion signal dropoutmovement arrhythmias and ambient lighting can interfere with POmeasurements Pulse oximetry may significantly underestimatevalues when signal quality is poor140 141142

ECG has been demonstrated to be a practical and rapid means ofaccurately determining the heart rate which may be a few secondsfaster than pulse oximetry and more reliable especially in the first2min after birth141142 Two RCTs reported faster times to HRassessment using ECG compared to PO with a mean(SD) 66(20) vs114(39) seconds and a median(IQR) 24(19 39) vs 48(36 69)seconds both p =0001132143

A recent ILCOR evidence update concluded that the 7 new studiesidentified since 2015 (2 systematic reviews 2 RCTs and 3observational studies) supported the previous recommendations thatin infants requiring resuscitation1 ECG can be used to provide a rapidand accurate estimation of heart rate (weak recommendation lowquality of evidence)49144

It is important to be aware of the limitations of the methods ECGdoes not replace oximetry as whilst ECG may indicate a heart rate inthe absence of output (PEA)145 pulse oximetry has advantages overECG in providing a measure of perfusion and oxygenation Newertechnologies suchasdry electrodesmay improvesignal andmethodssuch as plethysmography and Doppler may permit rapid reliableoutput-based determination of heart rate but clinical validation is stillneeded before they can be recommended141142

Airway

Airway

With flexion and extension the airway can become occluded146 Theevidence on the mechanisms of airway occlusion in the newborn islimited A retrospective analysis of images of the airway of 53 sedatedinfants between 0 and 4 months undergoing cranial MRI indicateshow in extension obstruction might occur through anterior displace-ment of the posterior airway at the level of the tongue147 Therefore aneutral position is favoured to ensure optimal airway patency

Jaw [1299_TD$DIFF]lift

There are no studies of jaw thrustlift in the newborn Studies inchildren demonstrate that anterior displacement of the mandibleenlarges the pharyngeal space through lifting the epiglottis away fromthe posterior pharyngeal wall reversing the narrowing of the laryngeal

inlet148 Two-person manual ventilation techniques are superior tosingle handed airway support146

Oropharyngealnasopharyngeal airway

Although the oropharyngeal airway (OPA) has been shown to beeffective in children149 there is no published evidence demonstratingeffectiveness in helping maintain the patency of the airway at birth In arandomisedstudyof137preterm infantswheregas flowthroughamaskwas measured obstructed inflations were more common in the OPAgroup (complete 81 vs 64 p =003 partial 70 vs 54p =004)150 However by helping lift the tongue and preventing itoccluding the laryngeal opening an OPA may facilitate airway supportwhere difficulty is experienced and manoeuvres like jaw lift fail toimprove ventilation A nasopharyngeal airway (NPA) may helpestablish an airway where there is congenital upper airway abnormali-ty151 and has been used successfully in preterm infants at birth152

Airway obstruction

The cause of airway obstruction is usually unknown It may be due toinappropriate positioning of the head laryngeal adduction or pushinga facemask onto the mouth and nose too hard especially in preterminfants at birth In an animal model of premature birth Crawshaw usedphase contrast X-ray to demonstrate that the larynx and epiglottiswere predominantly closed (adducted) in those with unaerated lungsand unstable breathing patterns making intermittent positivepressure ventilation (IPPV) ineffective unless there was an inspiratorybreath and only opening once the lungs were aerated153 In anobservational study of 56 preterm infants lt32 weeks gestationsignificant mask leak (gt75) andor obstruction to inspiratory flow(75) were identified using respiratory function monitoring in 73 ofinterventionsduring the first 2 minofPPV154 There is noevidence thatnormal lung fluid and secretions cause obstruction and thus no needto aspirate fluid from the oropharynx routinely

Oropharyngeal and nasopharyngeal suction

Oropharyngeal and nasopharyngeal suction has in newborn infantsnot been shown to improve respiratory function and may delay othernecessary manoeuvres and the onset of spontaneous breathingConsequences may include irritation to mucous membraneslaryngospasm apnoea vagal bradycardia hypoxaemia desaturationand impaired cerebral blood flow regulation155 159 A recent ILCORscoping review of 10 studies (8 RCTs1 observational study and 1case study) into the suctioning of clear fluid involving gt1500 mainlytermnear-term infants found no evidence to challenge the currentrecommendations Routine intrapartum oropharyngeal and naso-pharygeal suction for newborn infants with clear or meconium-stainedamniotic fluid is not recommended (very low certainty evidence downgraded for risk of bias indirectness and imprecision)1 Ifsuctioning is attempted it should be undertaken under direct visionideally using a laryngoscope and a wide bore catheter

There have been few studies investigating the effectiveness ofsuction devices for clearing the newborn airway An in vitro study usingsimulated meconium demonstrated the superiority of the Yankauersucker in clearing particulate matter when compared to large bore (12 14F) flexible catheters and bulb devices Most devices could clearnon-particulate matter but the only devices that cleared simulatedparticulatemeconiumwereaYankauer suckeror abulb syringedeviceBulb suction devices are less effective but do not require a separatevacuum source Smaller diameter suction catheters were much lesseffective160 The paediatric Yankauer sucker has the advantage of




single-handeduse andeffectiveness at lower vacuumpressureswhichmay be less likely to damage mucosa A meconium aspirator attachedto a tracheal tube functions in a similar manner and can be used toremove tenacious material from the trachea These devices should beconnected to a suction source not exceeding 150mmHg (20 kPa)161

Meconium

Lightly meconium-stained liquor is common and does not in generalgive rise to much difficulty with transition The less common finding ofvery thick meconium-stained liquor is an indicator of perinatal distressand should alert to the potential need for resuscitation

There is no evidence to support intrapartum suctioning nor routineintubation and suctioning of vigorous infants born through meconium-stained liquor162163 Retrospective registry based studies do notdemonstrate an increase in morbidity following a reduction in deliveryroom intubation for meconium164165 An ILCOR systematic review ofthree RCTs involving 449 infants and one observational study of 231infants demonstrated no benefit from the use of immediatelaryngoscopy with or without tracheal suctioning compared withimmediate resuscitation without laryngoscopy (RR 099 95 CI 093 106 p = 087)1 Parallel meta-analyses including a further RCT with132 infants derived similar conclusions166 168 A post policy changeimpact analysis of the resuscitation of 1138 non-vigorous neonatesborn through meconium-stained amniotic fluid found reduced NICUadmissions and no increase in the incidence of Meconium AspirationSyndrome (MAS) where suctioning was omitted in favour ofimmediate ventilation169

Routine suctioning of non-vigorous infants may result in delaysin initiating ventilation although some newborn infants may stillrequire laryngoscopy with or without tracheal intubation in order toclear a blocked airway or for subsequent ventilation Therefore inapnoeic or ineffectively breathing infants born through meconium-stained amniotic fluid ILCOR treatment recommendations sug-gest against routine immediate direct laryngoscopy andorsuctioning after delivery with the emphasis on initiating ventilationin the first minute of life (weak recommendation low certaintyevidence)1

In infants with respiratory compromise due to meconiumaspiration the routine administration of surfactant or bronchial lavagewith either saline or surfactant is not recommended170171


After initial assessment at birth if breathing efforts are absent orinadequate lung aeration is the priority and must not be delayed Anobservational study in low resource settings suggested thoseresuscitating took around 80 55 s to commence ventilation with a16 (p = 0045) increase in morbiditymortality in apnoeic infants forevery 30 s delay in starting ventilation after birth10 In term infantsrespiratory support should start with air172

Inflation pressure and duration

In newborn infants spontaneous breathing or assisted initial inflationscreate the functional residual capacity (FRC)9173 When assistingventilation the optimum inflation pressure inflation time and flowrequired to establish an effective FRC are subject to technical andbiological variation and have not yet been conclusively determinedDebate continues about the validity of longer inflation breaths withrecent discussion on the merits of sustained inflation (see below)1

Current ERC NLS recommendations on inflation breaths are for a

longer duration although there is a lack of evidence demonstratingadvantage or disadvantage over other recommended approachesOnce an airway is established five initial breaths with inflationpressuresmaintained for up to2 3 saresuggestedandmayhelp lungexpansion49173 175

The evidence for the optimal initial pressure for lung aeration islimited The consensus is that inflation pressures of 30 cm H2O areusually sufficient to inflate the liquid filled lungsof apnoeic term infantsThis value was originally derived from historical studies of limitednumbers of infants173176177 A more recent prospective study of 1237term and near-term infants resuscitated in a rural setting using a bag-mask without PEEP suggests that higher initial pressures maysometimes be required with median peak pressures of 37 cm H2Orequired for successful stabilisation178 In preterm infants criticalreview of the available evidence suggests that previously advocatedinitial inflations pressures of 20 cm H2O are probably to be too low torecruit the lungs effectively175179 181 Therefore it is suggested that astarting pressure of 25 cm H2O would be reasonable Acknowledgingthat smaller airways have greater resistance than larger airwayssome preterm infants may need higher pressures than 25 cm H2O forlung inflation

The time to initiation of spontaneous breathing is reported to beinversely correlated with the peak inflation pressure and the inflationtime174 If the infant has any respiratory effort ventilation is mosteffective when inflation coincides with the inspiratory efforts181

However the tidal volume of positive pressure ventilations may thenexceed that of spontaneous breaths124182 It is acknowledged thatsuch synchronisation is difficult to achieve183

A recent observational study in preterm infants under 32 weekssuggested that the application of a mask to support breathingmight induce apnoea in spontaneously breathing infants184

However the significance of this effect on outcome is currentlyunclear185

Ventilation

There is limited evidence on the optimal rate of ventilation for newbornresuscitation In an observational study of 434 mask ventilated latepreterm and term infants ventilation at a rate of about 30 min 1

achieved adequate tidal volumes without hypocarbia and thefrequency of 30 min 1 with VTE of 10 14 mL kg 1 was associatedwith the highest CO2 clearance186 In an observational study of 215near-termterm infants there was a non-linear relationship betweendelivered tidal volumeandheart rate Theminimumvolumenecessaryto produce an increase in heart rate was 60 (36 80) mL kg 1 A tidalvolumeof 93 mL kg 1 produced themost rapid and largest increase inheart rate127

The delivered tidal volume required to form the FRC may exceedthat of the exhaled TV Foglia et al describe this as being over12 mLkg 1 for a term infant183 Exhaled tidal volumes increase duringthe first positive pressure ventilations as aeration takes placecompliance increases and the FRC is established178 In mostinstances it should be possible to reduce peak pressures once thelungs are aerated to prevent excessive tidal volumes183

There are no published studies clearly determining the optimalinflation time when providing positive pressure ventilation Longerinspiratory times may permit lower pressures183 Observationalstudies on spontaneously breathing newborn infants suggest thatonce lung inflation has been achieved they breathe at a rate between30 and 40 breaths min 1 and regardless of which breathing patternan inspiratory time of 03 04 s is used187




Assessment

The primary response to adequate initial lung inflation is a promptimprovement in heart rate126127 Most newborn infants needingrespiratory support will respond with a rapid increase in heart ratewithin 30 s of lung inflation188 Chest wall movement usually indicatesaerationinflation This may not be so obvious in preterm infants189

Large chest excursions during positive pressure ventilation may be amarker of excessive tidal volumes which should be avoidedContinued ventilation is required if the heart rate increases but theinfant is not breathing adequately

Failure of the heart rate to respond is most likely secondary toinadequate airway control or inadequate ventilation Mask position orseal may be suboptimal182190191 HeadAirway position may be inneed of adjustment146 Inflation pressures may need to be higher toachieve adequate inflationtidal volumes178 In preterm infantsexcessivemaskpressureandglottal closure havebeendemonstratedto be factors8153154192

Using a two-person approach to mask ventilation reduces maskleak in term and preterm infants and is superior to the single handedapproach191193 Published evidence on the incidence of physicalmatter as a cause of obstruction is lacking but it is recognised thatmeconium or other matter (eg blood mucus vernix) may causeairway obstruction194 The use of adjuncts to support the airway isdiscussed elsewhere (see airway and adjuncts)

Sustained inflations (SI)gt 5 s

Animal studies have suggested that a longer SI may be beneficial forestablishing functional residual capacity at birth during transitionfrom a liquid filled to air-filled lung195196 A Cochrane systematicreview of initial inflation gt1 s vs standard inflations 1 s wasupdated in 2020 Eight RCTs enrolling 941 infants met inclusioncriteria for the primary comparison of the use of SI without chestcompressions SIs were of 15 20 s at 20 30 cm H2O No trial usedSIs of 5 s SI was not better than intermittent ventilation forreducing mortality in the delivery room (low quality evidence limitations in study design and imprecision) and during hospital-isation (moderate quality evidence limitations in study design)There was no benefit for SI vs intermittent ventilation for thesecondary outcomes of intubation need for respiratory support orBPD (moderate quality evidence)197

A large multicentre RCT which was not included in this analysisinvestigating effects of SI vs IPPV among extremely preterminfants (23 26 weeks gestational age) concluded that a ventilationstrategy involving 2 SIs of 15 s did not reduce the risk of BPD ordeath at 36 weeks postmenstrual age The study enrolled 460infants out of a planned 600 but was stopped early due to excessearly mortality in the SI group possibly attributable to resuscitationDeath at less than 48 h of age occurred in 16 infants (74) in the SIgroup vs 3 infants (14) in the standard resuscitation group(adjusted risk difference (aRD) 56 [95 CI 21 to 91]p = 0002) but this finding could not be attributed to the SIdirectly198

A recent ILCOR systematic review identified 10 eligible RCTsincluding those above with 1509 newborn infants1 For theprimary outcome of death before discharge no significant benefitor harm was noted from the use of SI gt1 s (actually gt5 s)compared to PPV with inflations of 1 s (low certainty evidencedowngraded for risk of bias and inconsistency) No studies wereidentified reporting on the secondary critical outcomes of long-term neurodevelopmental outcome or death at follow up

Subgroup analysis of different lengths of SI (6 15 s 9 RCTs1300 infants gt15 s 2 RCTs 222 infants) and of differentinspiratory pressures (gt20 mmHg 6 RCTs 803 infants 20mmHg 699 infants) demonstrated no significant benefit or harmfrom SI compared to IPPV of 1 s (downgraded for risk of biasand variously for imprecision and inconsistency)

In subgroup analyses comparing SI gt1 s to inflations of 1 s ininfants atlt28+0 weeks there was low certainty evidence (downgradedfor risk of bias and imprecision) from 5 RCTs enrolling 862 infants ofpotential harm (RR 138 95 CI 100 191) In infants 28+1 31+6

weeks there was very low certainty evidence (downgraded for risk ofbias and very serious imprecision) from 4 RCTs enrolling 175 preterminfants demonstrating no significant benefit or harm (RR 133 95 CI022 820) No SIs werelt5 s There was no published data availablefor more mature infants

Further sub-analyses excluding studies with a high risk of bias (9RCTs 1390 infants RR 124 95CI 092 168) studies with only asingle breath (9 RCTs 1402 infants RR 117 95CI 088 155) andthosewith sustained inflationwithmaskonly (9RCTs1441 infants (RR106 95CI 061 139) demonstrated no difference in outcomebetweenSI andnormal inflations (lowcertaintyevidence downgradedfor risk of bias and imprecision)

ILCOR treatment recommendations suggest that the routineuse of initial SI 5 s cannot be recommended for preterm newborninfants who receive positive pressure ventilation prompted bybradycardia or ineffective respirations at birth (weak recommen-dation low-certainty evidence) but that a sustained inflation mightbe considered in research settings There was insufficientevidence to make any specific recommendation on the durationof inflations in late preterm or term infants It was recognisedthat the total number of infants studied were insufficient tohave confidence in the estimate of effect larger trials beingneeded to determine if there are benefits or harms from sustainedinflation1

There are no randomised trials comparing the use of initial breathsof1 s with breaths of 2 3 s A recent RCT in 60 preterm infantslt34weeks gestation of 2 3 s inflation breaths vs a single 15 SIdemonstrated no difference in minute volume or end tidal CO2

199

Infants receiving the SI made a respiratory effort sooner (median 35(range 02 59) versus median 128 (range 04 119) secondsp = 0001) SI was associated with a shorter duration of ventilation inthe first 48 h (median 17 (range 0 48) versus median 325 (range 0 48) h p = 0025)

PEEP [1300_TD$DIFF]and CPAPairway adjuncts and assisted ventilation

devices

PEEP

Animal studies have shown that immature lungs are easily damagedby large tidal volume inflations immediately after birth200201 andsuggest that maintaining a PEEP immediately after birth may helpreduce lung damage202203 although one study suggests no bene-fit204 PEEP applied immediately after birth improves lung aerationfunctional residual capacity compliance and gas exchange particu-larly oxygenation205206

PEEP is more reliably be delivered by pressure limiting deviceswhich use continuous gas flow like TPR devices A recent review ofthe evidence undertaken by ILCOR identified two randomized trialsand one quasi-randomized trial (very low quality evidence)comparing ventilation with TPR vs SIB and reported similar rates




of death and chronic lung disease1 There was no difference in SpO2

at 5 min after birth in 80 infants lt29 weeks gestation (61 [13 72] versus 55 [42 67] p = 027)207 No difference wasidentified in achieving HR gt100 min 1 in 1027 infants 26 weeks (1(05 16) vs 1 (05 18) p = 0068 (min(IQR))208 There werereductions in the magnitude of some interventions with TPR 86(17) vs 134(26) were intubated in the delivery room (OR 058(04 08) 95 CI p = 0002) The maximum positive inspiratorypressure was 26(2) cm H2O TPR vs 28(5) cm H2O SIB (plt 0001)mean (SD)

In a quasi-randomised study of 90 infants of 34 (37) (mean (SD))weeks gestation the duration of PPV in delivery room was significantlyless with TPR (median (IQR) 30 s (30 60) vs 60 s (30 90)(plt0001))209 A higher proportion were intubated in the SIB group(34 vs 15 p =004) In one large multicentre observational study of1962 infants between 23 and 33 weeks gestation improved survivaland less BPD was seen when PEEP was used at birth (OR= 13895 CI 106 180)210

All term and preterm infants who remain apnoeic despiteadequate initial steps must receive positive pressure ventilationILCOR treatment recommendations are unchanged from 2015suggesting PEEP should be used for the initial ventilation forpremature newborn infants during delivery room resuscitation (weakrecommendations low-quality evidence)1 It is suggested thatpositive end expiratory pressure (PEEP) of approximately 5 6 cmH2O to begin with should be administered to preterm newborninfants receiving PPV No clear recommendations on the level ofPEEP can be made for term infants because of a lack ofevidence49144

CPAP

A Cochrane systematic review of CPAP applied within the first 15 minof life in preterm infants lt32 weeks identified 7 RCTs involving 3123infants and concluded that CPAP reduced the need for additionalbreathing assistance but with insufficient evidence to evaluateprophylactic CPAP compared to oxygen therapy and other supportivecare211 Evidence was downgraded to low quality because ofconsiderable heterogeneity imprecision and lack of blinding In 3 ofthe studies involving 2354 infants comparing CPAP with assistedventilation prophylactic nasal CPAP in very preterm infants reducedthe need for mechanical ventilation and surfactant and also reducedthe incidence of BPD and death or BPD (evidence downgraded due toimprecision)

Another systematic review included 4 RCTs 3 of which wereincluded in the Cochraneanalysis and one additional study212 Pooledanalysis showed a significant benefit for the combined outcome ofdeath or bronchopulmonary dysplasia or both at 36 weeks correctedgestation for infants treated with nasal CPAP (RR 091 95 CI084 099 RD 004 95 CI 007 to 000) NNT 25 Following areview of the evidence ILCOR recommendations are unchanged from2015 that for spontaneously breathing preterm newborn infants withrespiratory distress requiring respiratory support in the delivery roomit is suggested thatCPAPshould beused initially rather than intubationand IPPV (weak recommendation moderate certainly of evi-dence)149144 There are few data to guide the appropriate use ofCPAP in term infants at birth213214 Caution is prompted byretrospective cohort studies which suggest that delivery room CPAPmay be associated with an increased incidence of pneumothorax intermnear term infants215 217


Effective ventilation in the newborn can be achieved with a flow-inflating bag (FIB) a self-inflating bag (SIB) or with a pressure limitedTPR207208218 220 Anattribute of aTPR device is its ability to deliver aconsistent measure of PEEP or CPAP when compared to standardSIBs and this may be a factor contributing to any observed differencein outcomes between the devices (see section on PEEP)

Whilst the TPR appears to confer benefit it cannot be used in allcircumstances Unlike the TPR the self-inflating bag can be used inthe absence of a positive pressure gas supply However the blow-offvalves of SIB are flow-dependent and pressures generated mayexceed the value specified by the manufacturer usually 30 40 cmH2O if the bag is compressed vigorously221222 More training isrequired to provide an appropriate peak and end pressure using FIBscompared with self-inflating bags In an observational manikin-basedstudy of 50 clinicians technical difficulties with the FIB impairedperformance when compared to an SIB223

A qualitative review identified 30 studies comparing TPR againstother neonatal manual ventilation devices and noted that the majorityof studies were manikin based with 2 infant based studies154207

Users of the TPR could provide PIPs closest to the target PIP withleast variation when compared to SIB and FIB224 228 Similarly TPRusers provided a PEEP closer to the predetermined PEEP value withpotentially less volutrauma with the TPR as tidal volumes are smallerand less variable in comparison to the SIB225 228 TPR provided amore consistent inspiratory time than SIB independent of experienceProlonged inflation could be more reliably provided by the TPR229

Limitations of the TPR device were identified Resuscitation is adynamic process where the resuscitator needs to adapt to theresponse or non-response of the newborn TPR users were not asgood at detecting changes in compliance as users of the SIB andFIB230 PEEP valves could be inadvertently screwed down leading toexcess PEEP231 TPR users needed more time to change the inflatingpressures during resuscitation compared to users of the SIB or FIBMask leak can be greater with the TPR than with SIB227228 andchanges to TPR gas flow rate had significant effects on PIP PEEP232

235 and mask leak232 The TPR can require more training to set upproperly but once in use provided more consistent ventilation than theSIB even with inexperienced operators236The SIB cannot deliverCPAP and may not be able to achieve a consistent end expiratorypressure even with a PEEP valve224 226237 240 The performance ofvarious TPRs and self-inflating bags may differ considerably241 Anewer upright design of SIB and revised mask confers advantages inuse including improved delivery of PEEP188242 244

In addition to the 1107 infants in the two RCTs included in the 2015analysis207208 a recent ILCOR scoping review of TPR vs SIB forventilation1245 reported a substantial number of additional patients inone further RCT (n =90)209 and one large observational study(n = 1962)210 Studies differed regarding the investigated populations(two studies included term and preterm infants208209 two studieswere in preterm infants only)207210 The findings of these studies areoutlined in the section on PEEP and suggest improved survival andless need for intubation and BPD with TPR use compared to SIBparticularly in preterm infants

The ILCOR task force concluded that whilst the direction ofevidence is shifting towards support for the use of TPR devices until afurther systematic review is conducted recommendations wouldremain unchanged1 The 2015 consensus on science stated that theuse of the TPR showed marginally but not statistically significant




benefits for the clinical outcome of achieving spontaneousbreathing49

Facemask versus nasal prong

A problem when using a facemask for newborn ventilation is apotentially large and variable leak and loss of inflating gas volumearising from suboptimal selection of mask size and poor technique Inmanikin studies using a T-piece and different masks 50 volunteeroperators had variable mask leak up to 80 with improvement afterwritten instruction and demonstration of alternative mask holdtechniques190191 Using flow monitoring recordings of the airwaymanagement of 56 newborn preterm infantsSchmoumllzer demonstratedvariable degrees of either obstruction (75) andor leak (gt75)during first 2 min of support in 73 of cases154

Nasopharyngeal tubes have been suggested as an alternativeAn observational study investigating respiratory function foundthat when using a single nasopharyngeal tube it took longer beforePPV was given leak was increased and obstruction occurredmore frequently inadequate tidal volumes were delivered moreoften and SpO2 was lower in the first minutes during PPV246

However two randomised trials in preterm infants of lt31 weeksgestation involving 507 infants did not find any difference inintubation rates in the delivery room between facemask and singlenasal prong152247

Laryngeal mask

The laryngeal mask (LM) may be used in ventilation of the newbornparticularly if facemask ventilation or tracheal intubation isunsuccessful or not feasible49 A recent systematic review of seventrials (794 infants) showed that the laryngeal mask was moreeffective than bag-mask in terms of shorter resuscitation andventilation times and less need for tracheal intubation (low- tomoderate-quality evidence)248 Of note bag-mask was effective inmore than 80 of enrolled infants Efficacy of the laryngeal maskwas comparable to that offered by tracheal intubation (very low tolow quality evidence) suggesting that it is a valid alternative airwaydevice when attempts at tracheal intubation are unsuccessful duringresuscitation or where those involved lack the skills or equipment tointubate safely

As available studies included infants with birth weight gt1500 g or34 or more weeks gestation evidence supporting laryngeal mask usein more premature infants is lacking248249 The laryngeal mask hasnot been evaluated in the setting of meconium-stained fluid duringchest compressions or for the administration of emergency intra-tracheal medications

Tracheal tube placement

The use and timing of tracheal intubation will depend on the skill andexperience of the available resuscitators Formulae may be unreliablein determining tracheal tube lengths250251 Appropriate tube lengthsfor oral intubation derived from observational data based on gestationare shown in Table 1[1301_TD$DIFF]252 Nasotracheal tube length was found to beapproximately 1 cm more than the oral length253 Uncuffed tubes aretypically used There is no published evidence to support the routineuse of cuffed tubes during neonatal resuscitation Efficacy has beendemonstrated in infants lt3 kg during perioperative respiratorysupport254

The diameter of the narrowest part of the airway and varies withgestational age and size of the infant whereas the external diameter ofthe tube (of the same internal diameter) may vary depending on

manufacturer255 A range of differing sized tubes should be availableto permit placement of that most appropriate to ensure adequateventilation with only a small leak of gas around the tracheal tube andwithout trauma to the airway A narrow diameter tube in a large airwaymay be confirmed in the correct position but fail to provide adequateventilation because of low lung compliance and excessive leak Thetube diameter may be estimated as 110 of the gestational age256

Tracheal tube placement should be confirmed by exhaled CO2

detection (see below) the length inserted assessed visually duringintubation and the tip position confirmed clinically and ideallyradiographically Markings on the tips of tracheal tubes to aid tubeplacement distal to the vocal cords vary considerably betweenmanufacturers257 Within institutions users will likely gain familiaritywith specific types Tube position may alter during the securingprocess252 A systematic review of published literature on methods ofconfirming correct tube placement concluded that objective assess-ments of tube position werebetter validated than subjective ones suchas visual assessment of chest movement258 Following trachealintubation and IPPV a prompt increase in heart rate and observationof expired CO2 are good indications that the tube is in the trachea258

End tidal CO2 and respiratory function monitoring

Detection of exhaled CO2 in addition to clinical assessment isrecommended to confirm correct placement of a tracheal tube inneonates with spontaneous circulation49 Even in VLBW in-fants259260 detecting evidence of exhaled CO2 confirms trachealintubation in neonates with a cardiac output more rapidly and moreaccurately than clinical assessment alone260261 However studieshave excluded infants in need of extensive resuscitation Failure todetect exhaled CO2 strongly suggests tube misplacement most likelyoesophageal intubation or tube dislodgement259261 False negativeend tidal carbon dioxide (ETCO2) readings have been reported duringcardiac arrest259 and in VLBW infants despite models suggestingeffectiveness with low tidal volumes262 Poor or absent pulmonaryblood flow or tracheal obstruction may prevent detection of exhaledCO2 despite correct tracheal tube placement There is a lack ofevidence in the neonate as to the effect of drugs on exhaled CO2

monitoring however studies in adults suggest drugs such asadrenaline and bicarbonate may affect end-tidal CO2 determina-tion263 Insufficient inflating pressure to recruit an adequate FRC andgenerate sufficient expiratory flow might also be a factor The inabilityto detect exhaled CO2 despite correct placement may lead to adecision to extubate Where CO2 detection is unreliable tube positionshould be confirmed by direct laryngoscopy

Both qualitative (colorimetric) and quantitative (waveform) meth-ods have been successfully used after delivery264 Studies in adultssuggest that waveform capnography may be more sensitive thancolorimetry in detecting exhaled CO2 however due to lack of data onthe validity of waveform capnography in neonates caution must beexercised when considering its use263265266

Flow monitoring is useful for confirming tracheal tube position In arandomised controlled trial a flow sensor confirmed appropriate tubeplacement faster and more reliably than capnography267

Respiratory flowvolume monitoring268 and end tidal CO2269270

may be used in non-intubated patients The effectiveness ofquantitative capnography in confirming mask ventilation has beendemonstrated but may not provide reliable ETCO2 values270 The useof exhaled CO2 detectors to assess ventilation with other interfaces(eg nasal airways laryngeal masks) during positive pressureventilation in the delivery room has not been reported




Video-laryngoscopy

A systematic review of studies of video-laryngoscopy in newborninfants concluded by suggesting that video-laryngoscopy increasesthe success of intubation in the first attempt but does not decreasethe time to intubation or the number of attempts for intubation(moderate to very low-certainty evidence) However includedstudies were conducted with trainees performing the intubationsand highlight the potential usefulness of video-laryngoscopy as ateaching tool Well-designed adequately powered RCTs arenecessary to confirm efficacy and address safety and cost-effectiveness of video-laryngoscopy for neonatal endotrachealintubation by trainees and those proficient in direct laryngoscopy271

The effectiveness in the context of resuscitation at birth has notbeen fully evaluated

Airoxygen

Term infants and late preterm infants 35 weeks

A recent ILCOR CoSTR suggests that for term and late pretermnewborns (35 weeks gestation) receiving respiratory support at birthsupport should start with 21 oxygen (weak recommendation lowcertainty evidence)1 It recommends against starting with 100inspired oxygen (strong recommendation low certainty evidence) Asystematic review and meta-analysis of 5 RCTs and 5 quasi RCTsincluded 2164 patients demonstrated a 27 relative reduction in short-term mortality when initial room air was used compared with 100oxygen forneonates35weeksgestation receiving respiratorysupportat birth (RR=073 95CI057 094)172 Nodifferenceswerenoted inneurodevelopmental impairment or hypoxic-ischaemic encephalopa-thy (low to very low certainty evidence) Use of low concentrations ofinspired oxygen may result in suboptimal oxygenation where there issignificant lung disease272 and in term infants a high inspired oxygenmay be associated with a delay in onset of spontaneous breathing273

Therefore oxygen should be titrated to achieve adequate preductalsaturations If increased oxygen concentrations are used they shouldbe weaned as soon as possible274 276


In an ILCOR systematic review and meta-analysis of 10 RCTs and 4cohort studies including 5697 infants comparing initial low with highinspired oxygen for preterm infants lt35 weeks gestation whoreceived respiratory support at birth there were no statisticallysignificant benefits or harms from starting with lower compared tohigher inspired oxygen in short or long term mortality (n = 968RR= 083 (95 CI 050 137)) neurodevelopmental impairment orother key preterm morbidities277 It is suggested that low (21 30)rather than a higher initial concentration (60 100) be used (weakrecommendation very low certainty evidence) The range selectedreflects the low oxygen range used in clinical trials Oxygenconcentration should be titrated using pulse oximetry (weakrecommendation low certainty evidence)1

In contrast to term infants in preterm infants the use ofsupplemental oxygen to reach adequate oxygenation increasesbreathing efforts In an animal experimental study278 and one RCT in52 preterm infantslt30 weeks gestation279 initiating stabilisation withhigher oxygen concentrations (100 vs 30) led to increasedbreathing effort improved oxygenation and a shorter duration ofmask ventilation Minute volumes were significantly higher at 100(14634 11268mL kg 1 min 1) compared to 30 (7443 5219mL kg 1 min 1) p = 0014

A recent European consensus statement recommended theuse ofan initial inspired oxygen concentration of 30 for newborns lt28weeks gestation of 21 30 for 28 31 weeks gestation and of 21for gt32 weeks gestation280

Target oxygen saturation

The target range recommended for both term and preterm infantsare similar and based upon time based values for preductalsaturations in normal term infants in air281 Consensus recom-mendations suggest aiming for values approximating to theinterquartile range282 or using the 25th centile as the lowerthreshold value49 (Fig [1302_TD$DIFF][676_TD$DIFF]10)

A systematic reviewof 8RCTswith 768preterm infantslt32weeksinvolving low (30) vs higher (60) initial oxygen concentrationsconcluded that failure to reach a minimum SpO2 of 80 at 5 min wasassociated with a two-fold risk of death (OR 457 95 CI 162 1398plt005) and had an association with lower heart rate (meandifference 837 95 CI 1573 to 101 plt005) and a higherrisk of severe intraventricular haemorrhage (OR 204 95 CI 101 411 plt005)283 It remained unclear whether this was because ofthe severity of illness or the amount of oxygen administered duringstabilisation

Available data suggest nearly all preterm newborns lt32 weeksgestation will receive oxygen supplementation in the first 5 min afterdelivery in order to achieve commonly recommended oxygensaturation targets276281283 However it may be difficult to titratethe oxygen concentration in the first minutes and preterm infantslt32weeks gestation may spend a significant time outside the intendedtarget range284285 In an individual patient analysis of the 706 preterminfants enrolled in the RCTs only 12 reached the threshold SpO2 of80 at 5min after birth283

Titration of oxygen

It is important to select the appropriate initial oxygen concentrationwith careful and timely titration of inspired oxygen against timesensitive threshold saturation levels in order to avoid extremes ofhypoxia and hyperoxia and avoid bradycardia A recent reviewsuggested that oxygen delivery should be reviewed and titrated asnecessary every 30 s to achieve this286

An important technical aspect of the titration of supplementaloxygen when using a TPR device is that it takes a median 19 s (IQR 0 57) to achieve the desired oxygen concentration at the distal end of

Fig 10 ndash Oxygen saturations in healthy infants at birthwithoutmedical intervention (3rd 10th 25th 50th 75th90th 97th centiles) Reproducedwith permission fromDawson 2010




the TPR287 Although the cause of this delay is unclear mask leakcontributes significantly A good mask seal can lead to a longer delaywith a resulting lag between adjustment and response

Circulatory support

Circulatory support with chest compressions is effective only if thelungs have been successfully inflated and oxygen can be delivered tothe heart Ventilation may be compromised by compressions so it isvital to ensure that satisfactory ventilation is occurring beforecommencing chest compressions288

The most effective traditional technique for providing chestcompressions is with two thumbs over the lower third of the sternumwith the fingers encircling the chest and supporting the back289 292

This technique generates higher blood pressures and coronary arteryperfusion with less fatigue than the alternative two-finger tech-nique293294 In a manikin study overlapping the thumbs on thesternum was more effective than adjacent positioning but more likelyto cause fatigue295 The sternum is compressed to a depth ofapproximately one-third of the anterior-posterior diameter of the chestallowing the chest wall to return to its relaxed position betweencompressions296 300 Delivering compressions from lsquoover the headrsquoappears as effective as the lateral position301

A recent ILCOR review of the evidence identified 19 studiespublished since2015 includingone systematic reviewand18RCTsallof which were manikin studies302 No evidence was found to altertreatment recommendations from 2015 in suggesting that chestcompressions in the newborn should be delivered by the two thumbhand encircling the chest method as the preferred option (weakrecommendation very low certainty evidence)1 However newertechniques one using two thumbs at an angle of 90 to the chest andthe other a lsquoknocking fingerrsquo technique have been reported inmanikins Further studies are required to determine if they have anyclear advantage over the standard two thumb technique1303

A recent evidence update was undertaken by ILCOR to identify themost effective compression to ventilation ratio for neonatal resuscita-tion1 13 trials published since 2015 were found to be relevant Fourneonatal manikin studies comparing alternative compression toventilation ratios or asynchronous ventilation strategies found noadvantage over traditional synchronised 31 techniques A number ofanimal trials compared the delivery of cardiac compressions during asustained inflation with traditional 31 compression to ventilation Noconsistently clear advantages were identified Some trials areongoing

ILCORfoundnoevidence tochange the2015recommendations fora31 compression to ventilation ratio (weak recommendation very lowquality evidence) aiming to achieve a total of approximately 90compressions and 30 ventilations per minute149144 Compressionsandventilationsshouldbecoordinated toavoidsimultaneousdelivery304

There are theoretical advantages to allowing a relaxation phase that isslightly longer than the compression phase however the quality of thecompressions and breaths are probably more important than the rate305

A 31 compression to ventilation ratio is used at all times forresuscitation at birth where compromise of gas exchange is nearlyalways the primary cause of cardiovascular collapse Rescuers mayconsider using higher ratios (eg 152) if the arrest is believed to be ofcardiac origin more likely in a witnessed postnatal collapse than atbirthWhen chest compressions are indicated by a persistent veryslowabsent heart rate it would appear reasonable to increase thesupplementary inspired oxygen to 100 However there are no

human studies to support this and animal studies demonstrate noadvantage to 100 inspired oxygen during CPR306 312

Unless using continuous monitoring such as pulse oximetry orECG check the heart rate after no longer than 30 s and periodicallythereafter Whilst chest compressions may be discontinued when thespontaneous heart rate is faster than 60min 1 a continued increasein rate is necessary to truly demonstrate improvement It is not until theheart rate exceeds 120 min 1 that it becomes stable130131

Exhaled carbon dioxide monitoring and pulse oximetry have beenreported to be useful in determining the return of spontaneouscirculation313 316 however current evidence does not support theuseof any single feedbackdevice in a clinical settingandextrapolationof their use from adult and paediatric settings have for a variety ofreasons been proven error prone in neonates49144265

Vascular access

Umbilical vein catheterisation (UVC) and intraosseous (IO)

access

In a systematic review no evidence was identified comparing theumbilical venous route or use of intravenous (IV) cannulas againstthe IO route in the newborn for drug administration in any setting1

No case series or case reports on IO administration in the deliveryroom setting were identified Consensus suggests UVC as theprimary method of vascular access If umbilical venous access is notfeasible or delivery occurs in another setting the IO route issuggested as a reasonable alternative (weak recommendation verylow certainty of evidence)

A systematic review on the use of IO in neonates in any situationidentified one case series and 12 case reports of IO device insertioninto 41 neonates delivering several drugs including adrenaline andvolume317 However whilst the IO route has been demonstrated to bea practical alternative to the UVC significant adverse events includetibial fractures osteomyelitis and extravasation of fluid andmedications resulting in compartment syndrome and amputation1

The actual route and methodusedmay dependon local availabilityof equipment training and experience1 There is limited evidence onthe effective use of IO devices immediately after birth or the optimalsite or type of device318 although simulation studies undertaken in adelivery room setting suggest that the IO route can be faster to insertand use than UVC319

Peripheral access

No studies were identified reviewing the use of peripheral IVcannulation in infants requiring resuscitation at birth A retrospectiveanalysis of 6170 newborn preterm infants requiring iv access in asingle centre showed that peripheral iv cannulation is feasible andsuccessful in most cases at first attempt320

Drugs

Drugs are rarely indicated in resuscitation of the newborn infant1112

Bradycardia is usually caused by profound hypoxia and the key toresuscitation is aerating the fluid filled lungs and establishingadequate ventilation However if the heart rate remains less than60 min 1 despite apparently effective ventilation and chest com-pressions it is reasonable to consider the use of drugs

Knowledge of the use of drugs in newborn resuscitation is largelylimited to retrospective studies as well as extrapolation from animalsand adult humans321




Adrenaline

A recent systematic review identified 2 observational studiesinvolving 97 newborn infants comparing doses and routes ofadministration of adrenaline322 There were no differences betweenIV and endotracheal adrenaline for the primary outcome of death athospital discharge (RR = 103 [95 CI 062 171]) or for failure toachieve return of spontaneous circulation time to return ofspontaneous circulation (1 study 50 infants) or proportionreceiving additional adrenaline (2 studies 97 infants) There wereno differences in outcomes between 2 endotracheal doses (1study) No human infant studies were found addressing IV dose ordosing interval (very low certainty evidence) Despite the lack ofnewborn human data it is reasonable to use adrenaline wheneffective ventilation and chest compressions have failed to increasethe heart rate above 60 min 1 ILCOR treatment recommendationssuggest that if adrenaline is used an initial dose of 10 30 micro-grams kg 1 (01 03 mL kg 1 of 110000 adrenaline [1 mg in10 mL)) should be administered intravenously (weak recommen-dation very low certainty evidence) If intravascular access is notyet available endotracheal adrenaline at a larger dose of 50 100 micrograms kg 1 (05 10 mL kg 1 of 110000 adrenaline[1 mg in 10 mL]) is suggested (weak recommendation very lowcertainty evidence) but should not delay attempts at establishingvenous access (weak recommendation very low certainty evi-dence) If the heart rate remains less than 60 min 1 further doses preferably intravascularly every 3 5 min are suggested (weakrecommendation very low certainty evidence) If the response totracheal adrenaline is inadequate it is suggested an intravenousdose is given as soon as venous access is established regardlessof the interval between doses (weak recommendation very lowcertainty evidence)1

Glucose

Hypoglycaemia is an important additional risk factor for perinatalbrain injury323 Endogenous glycogen stores are rapidly depletedduring prolonged hypoxia In one study infants with birth asphyxiahad prior to administration of glucose in the delivery roomsignificantly lower blood glucose (1906 mmolL vs 32 03mmolL)324 therefore in protracted resuscitation it is reasonable touse glucose by giving a 250 mg kg 1 bolus (25 mL kg 1 of 10glucose) After successful resuscitation formal steps to prevent bothhypoglycaemia and hyperglycaemia should be instituted (see post-resuscitation care)

Volume replacement

A recent ILCOR evidence update1 identified no further human studiesand a single animal RCT which supported the 2010 CoSTRrecommendations34274 Early volume replacement is indicated fornewborn infants with blood loss who are not responding toresuscitation Therefore if there has been suspected blood loss orthe infant appears to be in shock (pale poor perfusion weak pulse)and has not responded adequately to other resuscitative measuresthen consider giving volume replacement with crystalloid or red cellsBlood loss causing acute hypovolaemia in the newborn infant is a rareevent There is little to support the use of volume replacement in theabsence of blood loss when the infant is unresponsive to ventilationchest compressions and adrenaline However because blood lossmay be occult and distinguishing normovolaemic infants with shockdue toasphyxia from thosewhoarehypovolaemic canbeproblematica trial of volume administration may be considered1

In the absence of suitable blood (ie group O Rh-negative blood)isotonic crystalloid rather than albumin is the solution of choice forrestoring intravascular volume Give a bolus of 10 mL kg 1 initially Ifsuccessful it may need to be repeated to maintain an improvementWhen resuscitating preterm infants volume is rarely needed and hasbeen associated with intraventricular and pulmonary haemorrhageswhen large volumes are infused rapidly325

Sodium bicarbonate

If effective spontaneous cardiac output is not restored despiteadequate ventilation and adequate chest compressions reversingintracardiac acidosis may improve myocardial function and achievea spontaneous circulation There are insufficient data to recommendroutine use of bicarbonate in resuscitation of the newborn Thehyperosmolarity and carbon dioxide-generating properties ofsodium bicarbonate may impair myocardial and cerebralfunction326

A recent review of the evidence1 concluded that there were noreasons to change the 2010 recommendations34274 Use of sodiumbicarbonate is not recommended during brief cardiopulmonary resusci-tationUse howevermaybeconsideredduringprolongedcardiacarrestunresponsive to other therapy when it should be given only afteradequate ventilation is established and chest compressions are beingdeliveredAdoseof1 2mmol kg 1sodiumbicarbonate(2 4mLkg 1of42 solution) may be given by slow intravenous injection

Naloxone

There is no strong evidence that naloxone confers any clinicallyimportant benefits to newborn infants with respiratory depression dueto hypoxia327328 Current recommendations do not support use ofnaloxone during resuscitation with the preference being to concen-trate on providing effective respiratory support

Use is best reserved for those infants whose cardiac output hasbeen restored but who remain apnoeic despite resuscitation andwhere the mother has received opioid analgesia in labour An initialintramuscular 200 microgram dose irrespective of weight provides apragmatic delivery room approach suitable for most infants An IMdoseprovides steady plasma concentrations for about 24 h329 Infantswhose breathing is suppressed by opioids may show a reboundtachypnoea after naloxone is given330


Hypo and hyperglycaemia

Perinatal hypoxia interferes with metabolic adaptation and mainte-nance of cerebral energy supply in several ways Significantly lowerblood glucose levels in the delivery room promote ketogenesis324

Hypoglycaemia is common a quarter of infants with moderate tosevere HIE reported to a national cooling registry had a blood glucoseless than 26 mmolL331

Animal studies suggest hypoxic cerebral injury is worsened by bothhypoglycaemia and hyperglycaemia332 334 In human infants withhypoxic ischaemic encephalopathy an abnormal early postnatalglycaemic profile (ie hypoglycaemia hyperglycaemia or labile bloodglucose) is associated with distinct patterns of brain injury on MRIcompared to normoglycaemia324 Hyperglycaemia and a labile bloodglucose were also associated with amplitude-integrated electroen-cephalographyevidenceofworseglobalbrain functionandseizures335

Both hypoglycaemia and hypoglycaemia were associated withpoorer neurological outcomes in the CoolCap study336 and there is a




clear association between initial hypoglycaemia and poorer neuro-logical outcome in infants with perinatal hypoxia337338

A recent ILCOR review of the evidence on the post resuscitationmanagement of glucose identified no systematic reviews or RCTsspecifically addressing the management of blood glucose in the firstfew hours after birth1 13 non randomised trials or observationalstudieswere identified published since 2015 investigating whether themaintenance of normoglycaemia during or immediately after resusci-tation improved outcome

The update suggests that infants who require significantresuscitation should be monitored and treated to maintain glucosein the normal range Protocols for blood glucose management shouldbeused that avoid both hypoandhyperglycaemia andalsoavoid largeswings in blood glucose level The evidence update suggests thatresearch to determine the optimal protocols for glycaemic manage-ment for pretermand term infants in the aftermath of resuscitation andthe optimal target range should be a high priority Overall no changehas been made to the previous recommendation that intravenousglucose infusion should be considered soon after resuscitation withthe goal of avoiding hypoglycaemia (low certainty evidence)339

Rewarming

If therapeutic hypothermia is not indicated hypothermia after birthshould be corrected because of evidence of poor outcomes7677

Infants should be maintained within the normal range of temperatureA recent ILCORevidence review identifiednosystematic reviewsor

RCTs published since the previous guidelines1 Two retrospectiveobservational studies involving 182340 and 98341 patients wereidentified which investigated whether in hypothermic infants (36 Con admission) rapid or slow rewarming changed outcome The findingsof both studies were that the rate of rewarming (after adjustment forconfounders) did not affect the critical and important outcomesHowever one study suggested that rapid rewarming reduces risk forrespiratorydistresssyndrome340 Theconclusionwas that therewasnonew evidence to alter the 2015 ILCOR consensus that a recommenda-tion for either rapid (05 Ch or greater) or slow rewarming (05 Ch orless) of unintentionally hypothermic newborn infants (temperature lessthan 36 C) at hospital admission would be speculative274339342

Induced hypothermia

This topic has not been reviewed as part of the most recent ILCORprocess A Cochrane review including 11 randomised controlled trialscomprising 1505 term and late preterm infants calculated thattherapeutic hypothermia resulted in a statistically significant andclinically important reduction in the combined outcome of mortality ormajor neurodevelopmental disability to 18 months of age (typical RR075 (95CI068 083) typicalRD 015 (95CI 020 010)) andconcluded that newborn infants at term or near-term with evolvingmoderate to severe hypoxic-ischaemic encephalopathy should beoffered therapeutic hypothermia343 Cooling should be initiated andconducted under clearly defined evidence-based protocols withtreatment in neonatal intensive care facilities and with the capabilitiesfor multidisciplinary care Treatment should commence within 6h ofbirth target a temperature between 335 C and 345 C continue for72h after birth and re-warm over at least 4 h A four way clinical trial of364 infants randomised to receive longer (120h) or deeper (32 C)cooling found no evidence of benefit of longer cooling or lowertemperatures344 Animaldatastronglysuggests that theeffectivenessofcooling is related to early intervention Hypothermia initiated at 6 24hafter birth may have benefit but there is uncertainty in its

effectiveness345 Such therapy is at the discretion of the treating teamon an individualised basis Current evidence is insufficient torecommend routine therapeutic hypothermia for infants with mildencephalopathy346

Prognostic tools

This subject was not reviewed through the ILCOR process Nosystematic or scoping reviews have been identified

The APGAR score was proposed as a ldquosimple common clear

classification or grading of newborn infantsrdquo to be used ldquoas a basis for

discussion and comparison of the results of obstetric practices types

of maternal pain relief and the effects of resuscitationrdquo (ouremphasis)113 Although widely used in clinical practice and forresearch purposes the applicability has been questioned due to largeinter- and intra-observer variations In a retrospective study involving42 infants between 23 and 40 weeks gestation OrsquoDonnell found asignificant discrepancy (average 24 points) between observersretrospectively scoring the APGAR from videos of the deliveriescompared to the scores applied by those attending the delivery347

A lack of correlation with outcome is partly explained by a lack ofagreement on how to score infants receiving medical interventions orbeing born preterm Variations in the APGAR score have beenproposed attempting to correct for maturity and the interventionsundertaken such as theSpecified Expandedand Combined versions(which incorporates elements of both) These might have greaterprecision in predicting outcome in preterm and term infants whencompared to the conventional score but are not used widely348349


The principles governing the need for good communication withparents are derived from clinical consensus and enshrined inpublished European and UK guidance350351

Mortality and morbidity for newborns varies according to regionethnicity and to availability of resources352 354 Social science studiesindicate that parents wish to be involved in decisions to resuscitate or todiscontinue life support in severely compromised infants355356 Localsurvival and outcome data are important in appropriate counselling ofparents The institutional approach to management (for example at theborder of viability) affects the subsequent results in surviving infants357

European guidelines are supportive of family presence duringcardiopulmonary resuscitation358 Healthcare professionals areincreasingly offering family members the opportunity to remainpresent during resuscitation and this is more likely if this takes placewithin the delivery room Parentsrsquo wishes to be present duringresuscitation should be supported where possible1359360

There is insufficient evidence to indicate an interventional effect onpatient or family outcome Being present during the resuscitation oftheir baby seems to be a positive experience for some parents butconcerns about an effect upon performance exist in professionals andfamily members (weak recommendation very low certainty ofevidence)1360

In a single centre review of management of birth at the bedsideparents who were interviewed were supportive but some foundwitnessing resuscitation difficult361 Clinicians involved felt the closeproximity improved communication but interviews suggested supportand training in dealing with such situations might be required forstaff362 In a retrospective questionnaire based survey of cliniciansrsquoworkload during resuscitation the presence of parents appeared to bebeneficial in reducing perceived workload363




Qualitative evidence emphases the need for support during and afterany resuscitation without which the birth may be a negative experiencewithpost traumatic consequences364365Thereshouldbeanopportunityfor the parents to reflect ask questions about details of the resuscitationandbe informedabout thesupport servicesavailable359 Itmaybehelpfulto offer any parental witness of a resuscitation the opportunity to discusswhat they have seen at a later date364365

Decisions to discontinue or withhold resuscitation should ideallyinvolve senior paediatric staff

Discontinuing or withholding treatment


Failure to achieve return of spontaneous circulation in newborn infantsafter 10 20min of intensive resuscitation is associatedwithahigh riskof mortality and a high risk of severe neurodevelopmental impairmentamong survivors There is no evidence that any specific duration ofresuscitation universally predicts mortality or severe neurodevelop-mental impairment

When the heart rate has been undetectable for longer than 10 minoutcomes are not universally poor366 368 For the composite outcomeof survival without neurodevelopmental impairment a recent ILCORsystematic review identified low certainty evidence (downgraded forrisk of bias and inconsistency) from 13 studies involving 277 infantsreporting neurodevelopmental outcomes Among all 277 infants 69died before last follow up 18 survived with moderate to severeneurodevelopmental impairment and 11 were judged to havesurvived withoutmoderate or severe neurodevelopmental impairment(2 lost to follow up)1 It can be helpful to consider clinical factorseffectiveness of resuscitation and the views of other members of theclinical team about continuing resuscitation369

If despite provision of all the recommended steps of resuscitationand excluding reversible causes a newborn infant requires ongoingcardiopulmonary resuscitation for a prolonged period it would beappropriate to discontinue resuscitative efforts A reasonable timeframe to consider this is around 20 min after birth (weak recommen-dation very low certainty evidence)1

The decision to cease resuscitation is a clinical decision but it isimportant where possible to give the family updates during theresuscitation and advance warning that there is a high chance thebaby will not survive In extremely preterm infants prolongedresuscitation is associated with lower survival rates and highermorbidity the decision should be individualised370371


In situations where there is extremely high predicted mortality andsevere morbidity in surviving infants withholding resuscitation may bereasonable particularly when there has been the opportunity for priordiscussion with parents372 379 Examples from the publishedliterature include extreme prematurity (gestational age less than22 weeks andor birth weight less than 350 g)380 and anomalies suchas anencephaly and bilateral renal agenesis

Withholding resuscitation and discontinuation of life-sustainingtreatment during or following resuscitation are considered by many tobe ethically equivalent and clinicians should not be hesitant towithdraw treatment when it would not be in the best interests of theinfant381

A consistent and coordinated approach to individual cases by theobstetric and neonatal teams and the parents is an important goal Inconditionswhere there is lowsurvival (lt50)anda relatively high rate

of morbidity and where the anticipated burden to the child is highparental wishes regarding resuscitation should be sought andsupported351

Conflict of interest

CR declares speaker honorarium from Chiesi and funding from theNational Institute for Health Research JM declares occasional adviceto Laerdal Medical and Brayden on Newborn ResuscitationEquipment HE declares research funding for Safer Births projectfrom Laerdal foundation Governmental World Bank Global Financ-ing Facility and Laerdal Global Health CM declares honorarium fromDraumlger andChiesi andhis role of consultant for Fisher andPaykel andLaerdal TS declares educational funding from GE and Chiesi CSResearch declares funding from Government and ZOLL foundationATP is science advisor for CONCORD neonatal he is patent holder ofthe Concord resuscitation table MR declares his role of consultant forsurfactant study Chiesi JW declares NIH grant as co-applicant forldquoBaby-OSCARrdquo project

Appendix A Supplementary data

Supplementary data associated with this article can be found in theonline version at httpsdoiorg101016jresuscitation202102014

R E F E R E N C E S

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2 PerkinsGDGraesner JT SemeraroF et al EuropeanResuscitationCouncil Guidelines 2021 executive summary Resuscitation2021161

3 Nolan JP Monsieurs KG Bossaert L et al European ResuscitationCouncil COVID-19 guidelines executive summary Resuscitation202015345 55 doihttpdxdoiorg101016jresuscitation202006001

4 Perkins GD Morley PT Nolan JP et al International LiaisonCommittee on Resuscitation COVID-19 consensus on sciencetreatment recommendations and task force insights Resuscitation2020151145 7 doihttpdxdoiorg101016jresuscitation202004035

5 Couper K Taylor-Phillips S Grove A et al COVID-19 in cardiacarrest and infection risk to rescuers a systematic reviewResuscitation 202015159 66 doihttpdxdoiorg101016jresuscitation202004022

6 te Pas AB Davis PG Hooper SB Morley CJ From liquid to airbreathing after birth J Pediatr 2008152607 11 doihttpdxdoiorg101016jjpeds200710041

7 Hooper SB Polglase GR Roehr CC Cardiopulmonary changes withaeration of the newborn lung Paediatr Respir Rev 201516147 50doihttpdxdoiorg101016jprrv201503003

8 Dekker J vanKaamAHRoehrCC et al Stimulating andmaintainingspontaneous breathing during transition of preterm infants PediatrRes 2019 doihttpdxdoiorg101038s41390-019-0468-7

9 Hooper SB Siew ML Kitchen MJ te Pas AB Establishing functionalresidual capacity in the non-breathing infant Semin Fetal NeonatalMed 201318336 43 doihttpdxdoiorg101016jsiny201308011




10 ErsdalHLMdumaESvensenEPerlmanJMEarly initiationof basicresuscitation interventions including face mask ventilation mayreduce birth asphyxia related mortality in low-income countries aprospective descriptive observational study Resuscitation201283869 73 doihttpdxdoiorg101016jresuscitation201112011

11 Perlman JM Risser R Cardiopulmonary resuscitation in the deliveryroom associated clinical events Arch Pediatr Adolesc Med199514920 5

12 Barber CA Wyckoff MH Use and efficacy of endotracheal versusintravenous epinephrine during neonatal cardiopulmonaryresuscitation in the delivery room Pediatrics 200611891028 34doihttpdxdoiorg101542peds2006-0416

13 Halling C Sparks JE Christie L Wyckoff MH Efficacy of intravenousand endotracheal epinephrine during neonatal cardiopulmonaryresuscitation in the delivery room J Pediatr 2017185232 6 doihttpdxdoiorg101016jjpeds201702024

14 Bjorland PA Oymar K Ersdal HL Rettedal SI Incidence of newbornresuscitative interventions at birth and short-term outcomes aregional population-based study BMJ Paediatr Open 20193e000592 doihttpdxdoiorg101136bmjpo-2019-000592

15 Skare C Boldingh AM Kramer-Johansen J et al Videoperformance-debriefings and ventilation-refreshers improve qualityof neonatal resuscitation Resuscitation 2018132140 6 doihttpdxdoiorg101016jresuscitation201807013

16 Niles DE Cines C Insley E et al Incidence and characteristics ofpositive pressure ventilation delivered to newborns in a US tertiaryacademic hospital Resuscitation 2017115102 9 doihttpdxdoiorg101016jresuscitation201703035

17 Aziz K Chadwick M Baker M Andrews W Ante- and intra-partumfactors that predict increased need for neonatal resuscitationResuscitation 200879444 52 doihttpdxdoiorg101016jresuscitation200808004

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20 Lee J Lee JHA clinical scoring system to predict the need for extensiveresuscitation at birth in very low birth weight infants BMC Pediatr201919197 doihttpdxdoiorg101186s12887-019-1573-9

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25 Berhan Y Haileamlak A The risks of planned vaginal breech deliveryversus planned caesarean section for term breech birth a meta-analysis including observational studies BJOG 201612349 57doihttpdxdoiorg1011111471-052813524

26 Foo XY Greer RM Kumar S Impact of maternal body mass index onintrapartum and neonatal outcomes in Brisbane Australia 2007 to2013 Birth 201643358 65 doihttpdxdoiorg101111birt12246

27 Parsons SJ Sonneveld S Nolan T Is a paediatrician needed at allCaesarean sections J Paediatr Child Health 199834241 4

28 Gordon A McKechnie EJ Jeffery H Pediatric presence at cesareansection justified or not Am J Obstet Gynecol 2005193599 605doihttpdxdoiorg101016jajog200506013

29 Bensouda B Boucher J Mandel R Lachapelle J Ali N 247 in houseattending staff coverage improves neonatal short-term outcomes aretrospective study Resuscitation 201812225 8 doihttpdxdoiorg101016jresuscitation201711045

30 Tu JH Profit J Melsop K et al Relationship of hospital staff coverageand delivery room resuscitation practices to birth asphyxia Am JPerinatol 201734259 63 doihttpdxdoiorg101055s-0036-1586505

31 Mitchell A Niday P Boulton J Chance G Dulberg C A prospectiveclinical audit of neonatal resuscitation practices in Canada AdvNeonatal Care 20022316 26 doihttpdxdoiorg101053adnc200236831

32 SkareCBoldinghAMNakstadB et al Ventilation fraction during thefirst 30s of neonatal resuscitation Resuscitation 201610725 30doihttpdxdoiorg101016jresuscitation201607231

33 Sawyer T Lee HC Aziz K Anticipation and preparation for everydelivery room resuscitation Semin Fetal Neonatal Med 201823312 20 doihttpdxdoiorg101016jsiny201806004

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36 Halamek LP Cady RAH Sterling MR Using briefing simulation anddebriefing to improve human and system performance SeminPerinatol 201943151178 doihttpdxdoiorg101053jsemperi201908007

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38 Bennett SC Finer N Halamek LP et al Implementing delivery roomchecklists and communication standards in a multi-neonatal ICUquality improvement collaborative Jt Comm J Qual Patient Saf201642369 76 doihttpdxdoiorg101016s1553-7250(16)42052-0

39 Katheria A Rich W Finer N Development of a strategic processusing checklists to facilitate team preparation and improvecommunication during neonatal resuscitation Resuscitation2013841552 7 doihttpdxdoiorg101016jresuscitation201306012

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42 Rakshasbhuvankar AA Patole SK Benefits of simulation basedtraining for neonatal resuscitation education a systematic reviewResuscitation 2014851320 3 doihttpdxdoiorg101016jresuscitation201407005

43 Patel A KhatibMNKurheKBhargavaSBangA Impact of neonatalresuscitation trainings on neonatal and perinatal mortality asystematic review and meta-analysis BMJ Paediatr Open 20171e000183 doihttpdxdoiorg101136bmjpo-2017-000183Yeung J Djarv T Hsieh MJ et al Spaced learning versus massedlearning in resuscitation a systematic review Resuscitation




44 202015661 71 doihttpdxdoiorg101016jresuscitation202008132

45 Mosley CM Shaw BN A longitudinal cohort study to investigate theretention of knowledge and skills following attendance on theNewborn Life support course Arch Dis Child 201398582 6 doihttpdxdoiorg101136archdischild-2012-303263

46 Mduma E Ersdal H Svensen E Kidanto H Auestad B Perlman JFrequent brief on-site simulation training and reduction in 24-hneonatal mortality an educational intervention studyResuscitation 2015931 7 doihttpdxdoiorg101016jresuscitation201504019

47 Yamada NK Yaeger KA Halamek LP Analysis and classification oferrors made by teams during neonatal resuscitation Resuscitation201596109 13 doihttpdxdoiorg101016jresuscitation201507048

48 Finn JC Bhanji F Lockey A et al Part 8 Education implementationand teams 2015 International Consensus on CardiopulmonaryResuscitation and Emergency Cardiovascular Care Science withTreatment Recommendations Resuscitation 201595e203 24doihttpdxdoiorg101016jresuscitation201507046

49 Wyllie J Perlman JM Kattwinkel J et al Part 7 Neonatalresuscitation 2015 International Consensus on CardiopulmonaryResuscitation and Emergency Cardiovascular Care Science withTreatment Recommendations Resuscitation 201595e169 201doihttpdxdoiorg101016jresuscitation201507045

50 Dempsey E Pammi M Ryan AC Barrington KJ Standardised formalresuscitation trainingprogrammes for reducingmortality andmorbidityin newborn infants Cochrane Database Syst Rev 20159CD009106doihttpdxdoiorg10100214651858CD009106pub2

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58 Levett-Jones T Lapkin S A systematic review of the effectiveness ofsimulation debriefing in health professional education Nurse EducToday 201434e58 63 doihttpdxdoiorg101016jnedt201309020

59 Garden AL Le Fevre DM Waddington HL Weller JM Debriefingafter simulation-based non-technical skill training in healthcare asystematic review of effective practice Anaesth Intensive Care201543300 8 doihttpdxdoiorg1011770310057X1504300303

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Database Syst Rev 201611CD003519 doihttpdxdoiorg10100214651858CD003519pub4

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81 Manani M Jegatheesan P DeSandre G Song D Showalter LGovindaswami B Elimination of admission hypothermia in pretermvery low-birth-weight infants by standardization of delivery roommanagement Perm J 2013178 13 doihttpdxdoiorg107812TPP12-130

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magnetic resonance imaging data PLoS One 201611e0151789doihttpdxdoiorg101371journalpone0151789

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birth a manikin study Neonatology 201199266 71 doihttpdxdoiorg101159000318663

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saturation in healthy term neonates after birth J Pediatr2007150418 21 doihttpdxdoiorg101016jjpeds200612015

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Dis Child Fetal Neonatal Ed 2018103F446 54 doihttpdxdoiorg101136archdischild-2016-312366

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295 Lim JS Cho Y Ryu S et al Comparison of overlapping (OP) andadjacent thumb positions (AP) for cardiac compressions using theencircling method in infants Emergency Medicine 201330139 42doihttpdxdoiorg101136emermed-2011-200978

296 Christman C Hemway RJ Wyckoff MH Perlman JM The two-thumbis superior to the two-finger method for administering chestcompressions in a manikin model of neonatal resuscitation Arch DisChild Fetal Neonatal Ed 201196F99 F101 doihttpdxdoiorg101136adc2009180406

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298 Saini SSGuptaNKumarPBhalla AKKaurHA comparison of two-fingers technique and two-thumbs encircling hands technique ofchest compression in neonates J Perinatol 201232690 4 doihttpdxdoiorg101038jp2011167

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303 Rodriguez-RuizE Martinez-Puga A Carballo-Fazanes A Abelairas-Gomez C Rodriguez-Nunez A Two new chest compressionmethods might challenge the standard in a simulated infant modelEur J Pediatr 20191781529 35 doihttpdxdoiorg101007s00431-019-03452-2

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319 Schwindt EM Hoffmann F Deindl P Waldhoer TJ Schwindt JCDuration to establish an emergency vascular access and how toaccelerate it a simulation-based studyperformed in real-life neonatalresuscitation rooms Pediatr Crit Care Med 201819468 76 doihttpdxdoiorg101097PCC0000000000001508

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The ethics of resuscitation and end-of-life decisions Resuscitation201595302 11 doihttpdxdoiorg101016jresuscitation201507033

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366 Shah P Anvekar A McMichael J Rao S Outcomes of infants withApgar score of zero at 10 min the West Australian experience Arch


367 Zhang Y Zhu J Liu Z et al Intravenous versus intraosseousadrenaline administration in out-of-hospital cardiac arrest aretrospective cohort study Resuscitation 2020149209 16 doihttpdxdoiorg101016jresuscitation202001009

368 Zhong YJ Claveau M Yoon EW et al Neonates with a 10-min Apgarscore of zero outcomes by gestational age Resuscitation201914377 84 doihttpdxdoiorg101016jresuscitation201907036

369 Torke AM Bledsoe P Wocial LD Bosslet GT Helft PR CEASE aguide for clinicians on how to stop resuscitation efforts Ann AmThorac Soc 201512440 5 doihttpdxdoiorg101513AnnalsATS201412-552PS

370 Foglia EE Weiner G de Almeida MFB et al Duration ofresuscitation at birth mortality and neurodevelopment asystematic review Pediatrics 2020146 doihttpdxdoiorg101542peds2020-1449

371 Haines M Wright IM Bajuk B et al Population-based study showsthat resuscitating apparently stillborn extremely preterm babies isassociated with poor outcomes Acta Paediatr 20161051305 11doihttpdxdoiorg101111apa13503

372 Mactier H Bates SE Johnston T et al Perinatal management ofextreme preterm birth before 27 weeks of gestation a framework forpractice Arch Dis Child Fetal Neonatal Ed 2020105232 9 doihttpdxdoiorg101136archdischild-2019-318402

373 Costeloe KL Hennessy EM Haider S Stacey F Marlow N DraperES Short term outcomes after extreme preterm birth in Englandcomparison of two birth cohorts in 1995 and 2006 (the EPICurestudies) BMJ 2012345e7976 doihttpdxdoiorg101136bmje7976

374 Marlow N Bennett C Draper ES Hennessy EM Morgan ASCosteloe KL Perinatal outcomes for extremely preterm babies inrelation to place of birth in England the EPICure 2 study Arch DisChild Fetal Neonatal Ed 201499F181 8 doihttpdxdoiorg101136archdischild-2013-305555

375 Bottoms SF Paul RH Mercer BM et al Obstetric determinants ofneonatal survival antenatal predictors of neonatal survival andmorbidity in extremely low birth weight infants Am J Obstet Gynecol1999180665 9 httpwwwncbinlmnihgovpubmed10076145

376 Manktelow BN Seaton SE Field DJ Draper ES Population-based estimates of in-unit survival for very preterm infantsPediatrics 2013131e425 32 doihttpdxdoiorg101542peds2012-2189

377 Medlock S Ravelli AC Tamminga P Mol BW Abu-Hanna APrediction of mortality in very premature infants a systematic reviewof prediction models PLoS One 20116e23441 doihttpdxdoiorg101371journalpone0023441

378 Tyson JE Parikh NA Langer J Green C Higgins RD Intensive carefor extreme prematurity moving beyond gestational age N Engl JMed 20083581672 81 doihttpdxdoiorg101056NEJMoa073059 [doi]

379 Swamy R Mohapatra S Bythell M Embleton ND Survival in infantslive born at less than 24 weeksrsquo gestation the hidden morbidity ofnon-survivors Arch Dis Child Fetal Neonatal Ed 201095F293 4doihttpdxdoiorg101136adc2009171629

380 Brumbaugh JE Hansen NI Bell EF et al Outcomes of extremelypreterm infants with birth weight less than 400g JAMA Pediatr2019173434 45 doihttpdxdoiorg101001jamapediatrics20190180

381 Wilkinson D Savulescu J A costly separation betweenwithdrawing and withholding treatment in intensive care Bioethics201428127 37 doihttpdxdoiorg101111j1467-8519201201981x




Reply to Francesco Montorsi Giorgio Gandaglia Christoph Wuumlrnschimmel Markus Graefen Alberto Briganti and Hartwig Hula

References

8907pdf

European Resuscitation Council Guidelines 2021 Newborn resuscitation and support of transition of infants at birth


COVID 19 context




Risk factors




Briefing

Trainingeducation

Recommendations

Thermal control

Recommendations

Standards

Environment


Preterm infants ample32 weeks gestation



Initial assessment (Fig3)

Tactile stimulation

Tone and colour

Breathing

Heart rate


Preterm infants


Airway


Airway obstruction

Meconium


Lung inflation (Fig7)

Assessment

Ventilation (Fig8)

Failure to respond

CPAP and PEEPairway adjuncts and assisted ventilation

Continuous positive airway pressure (CPAP) and positive end expiratory pressure (PEEP)


Laryngeal mask

Tracheal tube

Airoxygen

Term and late preterm infants ampge35 weeks


Chest compressions

Assessment of the need for chest compressions (Fig9)


Vascular access


Intraosseous access


Drugs





Glucose

Thermal care





For every birth






Transition

Risk factors





Trainingeducation

Thermal control




Cord milking

Initial assessment

Initial assessment

Tactile stimulation

Tone and colour

Breathing

Heart rate

Airway

Airway

Jaw lift


Airway obstruction


Meconium



Ventilation

Assessment

Sustained inflations (SI)ampx202fgtampx202f5ampx202fs

PEEP and CPAPairway adjuncts and assisted ventilation devices

PEEP

CPAP



Laryngeal mask



Video-laryngoscopy

Airoxygen

Term infants and late preterm infants ampge35 weeks



Titration of oxygen

Circulatory support

Vascular access

Umbilical vein catheterisation (UVC) and intraosseous (IO) access

Peripheral access

Drugs

Adrenaline

Glucose

Volume replacement

Sodium bicarbonate

Naloxone



Rewarming

Induced hypothermia

Prognostic tools







References


[1264_TD$DIFF]Theseguidelinesarebasedon the International LiaisonCommittee onResuscitation (ILCOR) 2020 Consensus on Science and TreatmentRecommendations (CoSTR) for Neonatal Life Support1 For thepurposes of the ERC Guidelines the ILCOR recommendations weresupplemented by focused literature reviews undertaken by the ERCNLS guidelines Group for topics not reviewed by 2020 ILCORCoSTRWhen appropriate the guidelines were informed by the expertconsensus of the ERC guidelines group membership

These guidelines were drafted and agreed by the Newborn LifeSupport Writing Group members The methodology used for guidelinedevelopment is presented in the Executive summary2 The guidelineswere posted for public comment in October 2020 The feedback wasreviewed by the writing group and the guidelines were updated whererelevant (see supplemental material) The Guideline was presented toandapprovedby theERCGeneral Assembly on10thDecember 2020

Key messages from these guidelines are summarised in Fig [1265_TD$DIFF]2

COVID 19 context

The ERC has produced guidance on newborn life support in thecontext of coronavirus disease 2019 (SARS-CoV-2)3 this is basedon an ILCOR CoSTR and systematic review45 Our understandingof the risks to infants potentially exposed to SARS-CoV-2 and therisk of virus transmission and infection to those providing care isevolving Please check ERC and national guidelines for the latestguidance and local policies for both treatment and rescuerprecautions

Summary of changes since the 2015 guidelines

Management of the umbilical cord

Clamping after at least 60 s is recommended ideally after the lungs areaerated Where delayed cord clamping is not possible cord milking shouldbe considered in infants gt28 weeks gestationInfants born through meconium-stained liquor

In non-vigorous infants recommendations are against immediatelaryngoscopy with or without suction after delivery because this may delayaeration and ventilation of the lungsUse of the laryngeal mask

If facemask ventilation is unsuccessful or if tracheal intubation isunsuccessful or not feasible a laryngeal mask may be considered as analternative means of establishing an airway in infants of gt34 weeksgestation (about 2000 g although some devices have been usedsuccessfully in infants down to 1500g)Inflation pressure

If there is no response to initial inflations despite an open airway then agradual increase in the inflation pressure is suggestedA starting pressure of 25 cm H2O is suggested for preterm infants lt32weeks gestationAiroxygen for preterm resuscitation

Recommendations are for starting in air at 32 weeks gestation or more 21-30 inspired oxygen at 28-31 weeks gestation and 30 inspired oxygen atlt28 weeks gestationThe concentration should be titrated to achieve saturations of80at 5 minof age because there is evidence of poorer outcomes where this is notachievedChest compressions

If chest compressions are required the inspired oxygen concentrationshould be increased to 100 and consideration given towards securing theairway ideally with a tracheal tube

Vascular access

The umbilical vein is still favoured as the optimal route of access butintraosseous access is an alternative method of emergency access fordrugsfluidsAdrenaline

Where the heart rate has not increased after optimising ventilationand chest compressions an intravenous dose of adrenaline of10 30micrograms kg 1 is recommended repeated every 3 5 min in theabsence of a responseGlucose during resuscitation

An intravenous dose of 250 mgkg 1 (25 mLkg 1 of 10 glucose) issuggested in a prolonged resuscitation to reduce the likelihood ofhypoglycaemiaPrognosis

Failure to respond despite 10 20mins of intensive resuscitation isassociated with high risk of poor outcome It is appropriate to considerdiscussions with the team and family about withdrawal of treatment if therehas been no response despite the provision of all recommended steps ofresuscitation and having excluded reversible causes




Most but not all infants adapt well to extra-uterine life but somerequire help with stabilisation or resuscitation Up to 85 breathespontaneously without intervention a further 10 respond afterdrying stimulation and airway opening manoeuvres approximately5 receive positive pressure ventilation Intubation rates varybetween 04 and 2 Fewer than 03 of infants receive chestcompressions and only 005 receive adrenaline

Risk factors

A number of risk factors have been identified as increasing thelikelihood of requiring help with stabilisation or resuscitation (Fig [1274_TD$DIFF]1)


Any infant may develop problems during birth Local guidelinesindicating who should attend deliveries should be developedbased on current understanding of best practice and clinicalaudit and taking into account identified risk factors (Fig [1275_TD$DIFF]1) As aguide Personnel competent in newborn life support should be available

for every delivery If intervention is required there should be personnel available

whose sole responsibility is to care for the infant A process should be in place for rapidly mobilising a team with

sufficient resuscitation skills for any birth


All equipment must be regularly checked and ready for use Where possible the environment and equipment should be

prepared in advance of the delivery of the infant Checklistsfacilitate these tasks

Resuscitation should take place in a warm well-illuminateddraught-free area with a flat resuscitation surface and a radiantheater (if available)

Equipment to monitor the condition of the infant and to supportventilation should be immediately available



















required

Trainingeducation

Recommendations









Thermal control

Recommendations

Standards




Environment







































Tactile stimulation



Tone and colour



Breathing


Heart rate





1




2




the infant








3






ventilation


Preterm infants



oximetryECG)




Airway
















Airway obstruction




Meconium












Assessment

















Failure to respond






















Laryngeal mask






Tracheal tube











radiography




Length atlips (cm)


23 24 55 2525 26 60 2527 29 65 2530 32 70 3033 34 75 3035 37 80 3538 40 85 3541 43 90 40
















Chest compressions










Vascular access









Intraosseous access





Drugs









2 655 8510 90












Sodium bicarbonate











Glucose




Thermal care
















For every birth































Transition



Risk factors

















Trainingeducation








Thermal control

































Cord milking





Initial assessment

Initial assessment





Tone and colour



Breathing



Heart rate















Airway

Airway







Airway obstruction









Meconium
















Ventilation








Assessment















199



devices

PEEP










CPAP




















Laryngeal mask



















Video-laryngoscopy



Airoxygen












Titration of oxygen








Circulatory support












Vascular access


access





Peripheral access


Drugs







Adrenaline


Glucose


Volume replacement



Sodium bicarbonate



Naloxone















Rewarming




Induced hypothermia



Prognostic tools

































R E F E R E N C E S














































































































































































































































































































































































































































References

8907pdf



COVID 19 context




Risk factors




Briefing

Trainingeducation

Recommendations

Thermal control

Recommendations

Standards

Environment






Tactile stimulation

Tone and colour

Breathing

Heart rate


Preterm infants


Airway


Airway obstruction

Meconium



Assessment

Ventilation (Fig8)

Failure to respond




Laryngeal mask

Tracheal tube

Airoxygen



Chest compressions



Vascular access


Intraosseous access


Drugs





Glucose

Thermal care





For every birth






Transition

Risk factors





Trainingeducation

Thermal control




Cord milking

Initial assessment

Initial assessment

Tactile stimulation

Tone and colour

Breathing

Heart rate

Airway

Airway

Jaw lift


Airway obstruction


Meconium



Ventilation

Assessment



PEEP

CPAP



Laryngeal mask



Video-laryngoscopy

Airoxygen




Titration of oxygen

Circulatory support

Vascular access


Peripheral access

Drugs

Adrenaline

Glucose

Volume replacement

Sodium bicarbonate

Naloxone



Rewarming

Induced hypothermia

Prognostic tools







References
















required

Trainingeducation

Recommendations









Thermal control

Recommendations

Standards




Environment







































Tactile stimulation



Tone and colour



Breathing


Heart rate





1




2




the infant








3






ventilation


Preterm infants



oximetryECG)




Airway
















Airway obstruction




Meconium












Assessment

















Failure to respond






















Laryngeal mask






Tracheal tube











radiography




Length atlips (cm)


23 24 55 2525 26 60 2527 29 65 2530 32 70 3033 34 75 3035 37 80 3538 40 85 3541 43 90 40
















Chest compressions










Vascular access









Intraosseous access





Drugs









2 655 8510 90












Sodium bicarbonate











Glucose




Thermal care
















For every birth































Transition



Risk factors

















Trainingeducation








Thermal control

































Cord milking





Initial assessment

Initial assessment





Tone and colour



Breathing



Heart rate















Airway

Airway







Airway obstruction









Meconium
















Ventilation








Assessment















199



devices

PEEP










CPAP




















Laryngeal mask



















Video-laryngoscopy



Airoxygen












Titration of oxygen








Circulatory support












Vascular access


access





Peripheral access


Drugs







Adrenaline


Glucose


Volume replacement



Sodium bicarbonate



Naloxone















Rewarming




Induced hypothermia



Prognostic tools

































R E F E R E N C E S














































































































































































































































































































































































































































References

8907pdf



COVID 19 context




Risk factors




Briefing

Trainingeducation

Recommendations

Thermal control

Recommendations

Standards

Environment






Tactile stimulation

Tone and colour

Breathing

Heart rate


Preterm infants


Airway


Airway obstruction

Meconium



Assessment

Ventilation (Fig8)

Failure to respond




Laryngeal mask

Tracheal tube

Airoxygen



Chest compressions



Vascular access


Intraosseous access


Drugs





Glucose

Thermal care





For every birth






Transition

Risk factors





Trainingeducation

Thermal control




Cord milking

Initial assessment

Initial assessment

Tactile stimulation

Tone and colour

Breathing

Heart rate

Airway

Airway

Jaw lift


Airway obstruction


Meconium



Ventilation

Assessment



PEEP

CPAP



Laryngeal mask



Video-laryngoscopy

Airoxygen




Titration of oxygen

Circulatory support

Vascular access


Peripheral access

Drugs

Adrenaline

Glucose

Volume replacement

Sodium bicarbonate

Naloxone



Rewarming

Induced hypothermia

Prognostic tools







References




























Tactile stimulation



Tone and colour



Breathing


Heart rate





1




2




the infant








3






ventilation


Preterm infants



oximetryECG)




Airway
















Airway obstruction




Meconium












Assessment

















Failure to respond






















Laryngeal mask






Tracheal tube











radiography




Length atlips (cm)


23 24 55 2525 26 60 2527 29 65 2530 32 70 3033 34 75 3035 37 80 3538 40 85 3541 43 90 40
















Chest compressions










Vascular access









Intraosseous access





Drugs









2 655 8510 90












Sodium bicarbonate











Glucose




Thermal care
















For every birth































Transition



Risk factors

















Trainingeducation








Thermal control

































Cord milking





Initial assessment

Initial assessment





Tone and colour



Breathing



Heart rate















Airway

Airway







Airway obstruction









Meconium
















Ventilation








Assessment















199



devices

PEEP










CPAP




















Laryngeal mask



















Video-laryngoscopy



Airoxygen












Titration of oxygen








Circulatory support












Vascular access


access





Peripheral access


Drugs







Adrenaline


Glucose


Volume replacement



Sodium bicarbonate



Naloxone















Rewarming




Induced hypothermia



Prognostic tools

































R E F E R E N C E S














































































































































































































































































































































































































































References

8907pdf



COVID 19 context




Risk factors




Briefing

Trainingeducation

Recommendations

Thermal control

Recommendations

Standards

Environment






Tactile stimulation

Tone and colour

Breathing

Heart rate


Preterm infants


Airway


Airway obstruction

Meconium



Assessment

Ventilation (Fig8)

Failure to respond




Laryngeal mask

Tracheal tube

Airoxygen



Chest compressions



Vascular access


Intraosseous access


Drugs





Glucose

Thermal care





For every birth






Transition

Risk factors





Trainingeducation

Thermal control




Cord milking

Initial assessment

Initial assessment

Tactile stimulation

Tone and colour

Breathing

Heart rate

Airway

Airway

Jaw lift


Airway obstruction


Meconium



Ventilation

Assessment



PEEP

CPAP



Laryngeal mask



Video-laryngoscopy

Airoxygen




Titration of oxygen

Circulatory support

Vascular access


Peripheral access

Drugs

Adrenaline

Glucose

Volume replacement

Sodium bicarbonate

Naloxone



Rewarming

Induced hypothermia

Prognostic tools







References


3






ventilation


Preterm infants



oximetryECG)




Airway
















Airway obstruction




Meconium












Assessment

















Failure to respond






















Laryngeal mask






Tracheal tube











radiography




Length atlips (cm)


23 24 55 2525 26 60 2527 29 65 2530 32 70 3033 34 75 3035 37 80 3538 40 85 3541 43 90 40
















Chest compressions










Vascular access









Intraosseous access





Drugs









2 655 8510 90












Sodium bicarbonate











Glucose




Thermal care
















For every birth































Transition



Risk factors

















Trainingeducation








Thermal control

































Cord milking





Initial assessment

Initial assessment





Tone and colour



Breathing



Heart rate















Airway

Airway







Airway obstruction









Meconium
















Ventilation








Assessment















199



devices

PEEP










CPAP




















Laryngeal mask



















Video-laryngoscopy



Airoxygen












Titration of oxygen








Circulatory support












Vascular access


access





Peripheral access


Drugs







Adrenaline


Glucose


Volume replacement



Sodium bicarbonate



Naloxone















Rewarming




Induced hypothermia



Prognostic tools

































R E F E R E N C E S














































































































































































































































































































































































































































References

8907pdf



COVID 19 context




Risk factors




Briefing

Trainingeducation

Recommendations

Thermal control

Recommendations

Standards

Environment






Tactile stimulation

Tone and colour

Breathing

Heart rate


Preterm infants


Airway


Airway obstruction

Meconium



Assessment

Ventilation (Fig8)

Failure to respond




Laryngeal mask

Tracheal tube

Airoxygen



Chest compressions



Vascular access


Intraosseous access


Drugs





Glucose

Thermal care





For every birth






Transition

Risk factors





Trainingeducation

Thermal control




Cord milking

Initial assessment

Initial assessment

Tactile stimulation

Tone and colour

Breathing

Heart rate

Airway

Airway

Jaw lift


Airway obstruction


Meconium



Ventilation

Assessment



PEEP

CPAP



Laryngeal mask



Video-laryngoscopy

Airoxygen




Titration of oxygen

Circulatory support

Vascular access


Peripheral access

Drugs

Adrenaline

Glucose

Volume replacement

Sodium bicarbonate

Naloxone



Rewarming

Induced hypothermia

Prognostic tools







References










Airway obstruction




Meconium












Assessment

















Failure to respond






















Laryngeal mask






Tracheal tube











radiography




Length atlips (cm)


23 24 55 2525 26 60 2527 29 65 2530 32 70 3033 34 75 3035 37 80 3538 40 85 3541 43 90 40
















Chest compressions










Vascular access









Intraosseous access





Drugs









2 655 8510 90












Sodium bicarbonate











Glucose




Thermal care
















For every birth































Transition



Risk factors

















Trainingeducation








Thermal control

































Cord milking





Initial assessment

Initial assessment





Tone and colour



Breathing



Heart rate















Airway

Airway







Airway obstruction









Meconium
















Ventilation








Assessment















199



devices

PEEP










CPAP




















Laryngeal mask



















Video-laryngoscopy



Airoxygen












Titration of oxygen








Circulatory support












Vascular access


access





Peripheral access


Drugs







Adrenaline


Glucose


Volume replacement



Sodium bicarbonate



Naloxone















Rewarming




Induced hypothermia



Prognostic tools

































R E F E R E N C E S














































































































































































































































































































































































































































References

8907pdf



COVID 19 context




Risk factors




Briefing

Trainingeducation

Recommendations

Thermal control

Recommendations

Standards

Environment






Tactile stimulation

Tone and colour

Breathing

Heart rate


Preterm infants


Airway


Airway obstruction

Meconium



Assessment

Ventilation (Fig8)

Failure to respond




Laryngeal mask

Tracheal tube

Airoxygen



Chest compressions



Vascular access


Intraosseous access


Drugs





Glucose

Thermal care





For every birth






Transition

Risk factors





Trainingeducation

Thermal control




Cord milking

Initial assessment

Initial assessment

Tactile stimulation

Tone and colour

Breathing

Heart rate

Airway

Airway

Jaw lift


Airway obstruction


Meconium



Ventilation

Assessment



PEEP

CPAP



Laryngeal mask



Video-laryngoscopy

Airoxygen




Titration of oxygen

Circulatory support

Vascular access


Peripheral access

Drugs

Adrenaline

Glucose

Volume replacement

Sodium bicarbonate

Naloxone



Rewarming

Induced hypothermia

Prognostic tools







References

Failure to respond






















Laryngeal mask






Tracheal tube











radiography




Length atlips (cm)


23 24 55 2525 26 60 2527 29 65 2530 32 70 3033 34 75 3035 37 80 3538 40 85 3541 43 90 40
















Chest compressions










Vascular access









Intraosseous access





Drugs









2 655 8510 90












Sodium bicarbonate











Glucose




Thermal care
















For every birth































Transition



Risk factors

















Trainingeducation








Thermal control

































Cord milking





Initial assessment

Initial assessment





Tone and colour



Breathing



Heart rate















Airway

Airway







Airway obstruction









Meconium
















Ventilation








Assessment















199



devices

PEEP










CPAP




















Laryngeal mask



















Video-laryngoscopy



Airoxygen












Titration of oxygen








Circulatory support












Vascular access


access





Peripheral access


Drugs







Adrenaline


Glucose


Volume replacement



Sodium bicarbonate



Naloxone















Rewarming




Induced hypothermia



Prognostic tools

































R E F E R E N C E S














































































































































































































































































































































































































































References

8907pdf



COVID 19 context




Risk factors




Briefing

Trainingeducation

Recommendations

Thermal control

Recommendations

Standards

Environment






Tactile stimulation

Tone and colour

Breathing

Heart rate


Preterm infants


Airway


Airway obstruction

Meconium



Assessment

Ventilation (Fig8)

Failure to respond




Laryngeal mask

Tracheal tube

Airoxygen



Chest compressions



Vascular access


Intraosseous access


Drugs





Glucose

Thermal care





For every birth






Transition

Risk factors





Trainingeducation

Thermal control




Cord milking

Initial assessment

Initial assessment

Tactile stimulation

Tone and colour

Breathing

Heart rate

Airway

Airway

Jaw lift


Airway obstruction


Meconium



Ventilation

Assessment



PEEP

CPAP



Laryngeal mask



Video-laryngoscopy

Airoxygen




Titration of oxygen

Circulatory support

Vascular access


Peripheral access

Drugs

Adrenaline

Glucose

Volume replacement

Sodium bicarbonate

Naloxone



Rewarming

Induced hypothermia

Prognostic tools







References

european resuscitation council guidelines 2021: newborn

Documents