The New The New Neonatal Resuscitation Program (NRP) NRP)

GuidelinesGuidelines

Mesfin Woldesenbet, MD, FAAPMesfin Woldesenbet, MD, FAAP

Neonatologist, Medical Director Neonatologist, Medical Director

NICU at Memorial Hermann Southwest HospitalNICU at Memorial Hermann Southwest Hospital

Pediatrix Medical GroupPediatrix Medical Group

Houston, TexasHouston, Texas

April 2013April 2013

IntroductionIntroduction

10% of newborns require some assistance at birth10% of newborns require some assistance at birth

<1% require extensive resuscitation<1% require extensive resuscitation

Crude birth rate ~ 19/1000 population (~134 Crude birth rate ~ 19/1000 population (~134 million)million)

15,120 births/hour15,120 births/hour 252 births/min252 births/min 4.2 births/seconds4.2 births/seconds

~150 babies born per hour~150 babies born per hour USA- 5 babies/hour need extensive USA- 5 babies/hour need extensive

resuscitationresuscitation

The Process of Developing The Process of Developing Guidelines and Education Guidelines and Education

MaterialMaterial

5 Years

Neonatal Resuscitation Program

1st Edition introduced in 1987

1st – 5th Editions Slide and Education format Do not differentiate by job description or

specialty

6th Edition Less didactic More emphasis on simulation and Debriefing Didactic portion taken online with certificate

of passing a test

Neonatal Resuscitation Neonatal Resuscitation ProgramProgram

66thth Edition Edition Rationale for the changes to

procedural guidelines and processes

Evidence behind each step in resuscitation

Rationale for the new educational approach

Implication

2

Steps of resuscitations Steps of resuscitations

1.1. Initial steps- dry, position, assess and Initial steps- dry, position, assess and stimulatestimulate

2.2. VentilationVentilation

3.3. Chest CompressionChest Compression

4.4. Medication or volume expansionMedication or volume expansion

Assessment of efficiency Assessment of efficiency of CPRof CPR

Progression to next step is based onProgression to next step is based on Heart RateHeart Rate RespirationRespiration

The most sensitive indicator remains the heart rateThe most sensitive indicator remains the heart rate Auscultation (best method)Auscultation (best method) Palpation of umbilical cord (underestimate Palpation of umbilical cord (underestimate

heart rate)heart rate) Pulse oximetry (difficult to obtain reading Pulse oximetry (difficult to obtain reading

consistently)consistently)

Do not use color as an indicatorDo not use color as an indicator Will avoid hyperoxiaWill avoid hyperoxia

Initial StepInitial Step

Term, breathing and good muscle tone:Term, breathing and good muscle tone: Dry and place the infant skin-to-skin with Dry and place the infant skin-to-skin with

the mother the mother Continue routine care and ongoing Continue routine care and ongoing

assessmentassessment

This includes the vigorous infant with This includes the vigorous infant with meconium-stained amniotic fluid.meconium-stained amniotic fluid.

Use of the bulb suction is reserved for Use of the bulb suction is reserved for infants whose secretions obstruct breathing infants whose secretions obstruct breathing or the infant requiring PPV.or the infant requiring PPV.

After Initial StepsAfter Initial Steps

HR >100bpm, labored breathing and HR >100bpm, labored breathing and persistent cyanosis:persistent cyanosis: Clear airway.Clear airway. Place pulse ox on infant’s Place pulse ox on infant’s right hand or wristright hand or wrist. . Free flow oxygen if the infant’s O2 sat is below Free flow oxygen if the infant’s O2 sat is below

the time specific target.the time specific target. Consider CPAP for persistent labored Consider CPAP for persistent labored

breathing.breathing.

HR <100bpm or infant is apneic or gasping:HR <100bpm or infant is apneic or gasping: Apply pulse ox. Apply pulse ox. Begin PPV.Begin PPV.

Corrective Measures: MR Corrective Measures: MR SOPASOPA

Reapply Reapply MMaskask

RReposition the headeposition the head

SSuction mouth and noseuction mouth and nose

OOpen infant’s mouthpen infant’s mouth

Increase Increase PPressure every few breaths until BBS ressure every few breaths until BBS and chest rise are evident. Do not exceed an and chest rise are evident. Do not exceed an inspiratory pressure > 40cmH2Oinspiratory pressure > 40cmH2O

Use Use AAlternative airway – endotracheal tube or lternative airway – endotracheal tube or laryngeal mask airwaylaryngeal mask airway

Administering OxygenAdministering Oxygen

Every delivery area should have access to an Every delivery area should have access to an air/oxygen blender and pulse oximetry.air/oxygen blender and pulse oximetry.

Resuscitation of term newborns may begin Resuscitation of term newborns may begin with room air if blended oxygen is not with room air if blended oxygen is not available.available.

If baby is bradycardic (<60/min) after 90 If baby is bradycardic (<60/min) after 90 seconds of resuscitation with lower FiO2, seconds of resuscitation with lower FiO2, increase the FiO2 to 100%.increase the FiO2 to 100%.

In preterm infants higher oxygen In preterm infants higher oxygen concentration may achieve target saturation concentration may achieve target saturation more quickly.more quickly.

Oxygen concentration is adjusted according Oxygen concentration is adjusted according to age in minutes and oxygen saturationto age in minutes and oxygen saturation

3rd, 10th, 25th, 50th, 75th, 90th, and 97th 3rd, 10th, 25th, 50th, 75th, 90th, and 97th SpOSpO22 percentiles for all infants with no percentiles for all infants with no

medical intervention after birthmedical intervention after birth

Dawson et al, 2010

3rd, 10th, 25th, 50th, 75th, 90th, and 97th 3rd, 10th, 25th, 50th, 75th, 90th, and 97th SpO2 percentiles for term infants at ≥37 SpO2 percentiles for term infants at ≥37

weeks of gestation with no medical weeks of gestation with no medical intervention after birth.intervention after birth.

Dawson et al, 2010

Third, 10th, 25th, 50th, 75th, 90th, and Third, 10th, 25th, 50th, 75th, 90th, and 97th SpO2 percentiles for term infants 97th SpO2 percentiles for term infants

at 32-36 weeks of gestation with no at 32-36 weeks of gestation with no medical intervention after birth.medical intervention after birth.

Dawson et al, 2010

Third, 10th, 25th, 50th, 75th, 90th, and Third, 10th, 25th, 50th, 75th, 90th, and 97th SpO2 percentiles for term infants 97th SpO2 percentiles for term infants

at≤32 weeks of gestation with no at≤32 weeks of gestation with no medical intervention after birth.medical intervention after birth.

Dawson et al, 2010

Targeted Pre-ductal SPO2 (Term infants)

1 min 60-65%

2 min 65-70%

3 min 70-75%

4 min 75-80%

5 min 80-85%

10 min 85-90%

Use of Supplemental Use of Supplemental OxygenOxygen

Term infant requiring IPPVTerm infant requiring IPPV 100% Oxygen vs. Air 100% Oxygen vs. Air

No advantageNo advantage Increase time to first breathIncrease time to first breath Higher mortalityHigher mortality Potential harm at a cellular level in Potential harm at a cellular level in

asphyxia modelasphyxia model

Infants 32- 37 weeks- insufficient evidenceInfants 32- 37 weeks- insufficient evidence

Use of Supplemental Use of Supplemental OxygenOxygen

Infants <32 weeksInfants <32 weeks Do not reach targeted SpO2 in the first 10 Do not reach targeted SpO2 in the first 10

minutes of lifeminutes of life Use blended oxygen to avoid hypoxia or Use blended oxygen to avoid hypoxia or

hyperoxia hyperoxia 21% or 100% vs. 30% or 90%21% or 100% vs. 30% or 90%

In the absence of a blender, start with room In the absence of a blender, start with room airair

Resuscitation of newborns: Room Resuscitation of newborns: Room air vs. 100% oxygen. Effect on air vs. 100% oxygen. Effect on

Mortality.Mortality.

Saugstad et al. 2005RR<1 favors room air

When To Use Pulse When To Use Pulse OximetryOximetry

Resuscitation is anticipatedResuscitation is anticipated

PPV is administered for more than a few PPV is administered for more than a few breathsbreaths

Cyanosis is persistentCyanosis is persistent

Supplementary oxygen is usedSupplementary oxygen is used

The pulse oximeter probe is placed on the The pulse oximeter probe is placed on the infant’s right hand or wrist and then infant’s right hand or wrist and then connected to a pulse oximeter connected to a pulse oximeter

Suctioning of airwaySuctioning of airway

Upper airwayUpper airway Not evidence to support or refuteNot evidence to support or refute Associated with cardio-respiratory Associated with cardio-respiratory

complicationscomplications

Tracheal suctioningTracheal suctioning No evidence to suggest decrease in MASNo evidence to suggest decrease in MAS Decrease in OxygenationDecrease in Oxygenation Increase cerebral blood flow Increase cerebral blood flow Increase intracranial pressureIncrease intracranial pressure

IntubationIntubation

Attempts to complete intubation may now Attempts to complete intubation may now take up to 30 seconds.take up to 30 seconds.

Do not administer free-flow oxygen during Do not administer free-flow oxygen during intubation to an infant who is not breathing. intubation to an infant who is not breathing. It has no benefit.It has no benefit.

None-Vigorous Infants with Meconium stained fluid

Care is in general unchanged Care is in general unchanged

If intubation is difficult and the infant is If intubation is difficult and the infant is bradycardic consider going to the next bradycardic consider going to the next steps of resuscitation (dry, stimulate and steps of resuscitation (dry, stimulate and clear the airway)clear the airway)

The only evidence available for use of The only evidence available for use of tracheal suctioning is the study comparing tracheal suctioning is the study comparing suctioned babies with historical controlssuctioned babies with historical controls

VentilationVentilation

Initial breath in newborns requiring IPPVInitial breath in newborns requiring IPPV Can use short or longer inspiratory timeCan use short or longer inspiratory time Initial Peak pressureInitial Peak pressure

Use to achieve increase heart rate and good Use to achieve increase heart rate and good chest risechest rise

Preterm infants: 20-25 cm H2OPreterm infants: 20-25 cm H2O Term infants: 30-40 cm H2OTerm infants: 30-40 cm H2O

Optimal PEEP Optimal PEEP Increase FRC, oxygenation and lung Increase FRC, oxygenation and lung

compliancecompliance Reduce lung injuryReduce lung injury Avoid High PEEP (8-12)Avoid High PEEP (8-12)

Positive Pressure Positive Pressure VentilationVentilation

A rising heart rate is the best indicator of A rising heart rate is the best indicator of effective PPVeffective PPV

If the heart rate does not show immediate If the heart rate does not show immediate improvement assess breath sounds and improvement assess breath sounds and chest movement.chest movement.

If these indicators are not present in the If these indicators are not present in the first 5-10 attempted breaths of PPV the first 5-10 attempted breaths of PPV the team proceeds to corrective action.team proceeds to corrective action.

Monitoring during/after Monitoring during/after resuscitationresuscitation

Tidal volumeTidal volume No clinical outcome studiesNo clinical outcome studies

Exhaled CO2 detectors to confirm intubationExhaled CO2 detectors to confirm intubation Rapid and accurate than clinical methodsRapid and accurate than clinical methods False NegativeFalse Negative

Cardiac arrestCardiac arrest False PositiveFalse Positive

Contamination with epinephrine, surfactant and Contamination with epinephrine, surfactant and atropineatropine

** Use Exhaled CO2 detection + clinical assessment

CPAPCPAP

CPAP vs. intubation+IPPV CPAP vs. intubation+IPPV Preterm infants >25 weeks Preterm infants >25 weeks

No difference in death or CLDNo difference in death or CLD Decrease use of surfactantDecrease use of surfactant Increase in PneumothoraxIncrease in Pneumothorax

Term infantsTerm infants No evidenceNo evidence

CPAPCPAP

CPAP vs. IPPV with face maskCPAP vs. IPPV with face mask Preterm infantsPreterm infants

Decrease rate of mechanical Decrease rate of mechanical ventilationventilation

Decrease in CLDDecrease in CLD

* May use CPAP or Intubation in the delivery * May use CPAP or Intubation in the delivery room!room!

Assisted Devices Assisted Devices

T-piece vs. Self-inflating vs. Flow-inflating bagsT-piece vs. Self-inflating vs. Flow-inflating bags No clinical studiesNo clinical studies Mechanical models favor T-piece Mechanical models favor T-piece

resuscitatorresuscitator

Laryngeal Mask AirwayLaryngeal Mask Airway No extensive studyNo extensive study In cases where face mask or intubation failsIn cases where face mask or intubation fails May use in infants >2000g or >34 weeksMay use in infants >2000g or >34 weeks No EvidenceNo Evidence

Meconium stained amniotic fluidMeconium stained amniotic fluid Chest compressionChest compression

Chest CompressionsChest Compressions

Indication: heart rate remains <60 bpm

Use 100% oxygen concentration

Coordinate PPV with chest compressions for 45-60 seconds before reassessing heart rate

Intubation is recommended if chest compressions are required.

Chest CompressionChest Compression

Chest compression and/or VentilationChest compression and/or Ventilation More efficient when combined More efficient when combined

Sustained chest compressionSustained chest compression Deleterious effect on myocardial and cerebral Deleterious effect on myocardial and cerebral

perfusionperfusion

Chest Compression : Ventilation ratioChest Compression : Ventilation ratio 3:13:1, 5:1, 15:2, 30:2, 5:1, 15:2, 30:2

Less minute ventilation as the ratio increasesLess minute ventilation as the ratio increases No human data available No human data available

Chest CompressionChest Compression

2 thumb-encircling hand technique-superior2 thumb-encircling hand technique-superior Diastolic BP, quality chest compression and less Diastolic BP, quality chest compression and less

tiringtiring

Lower sternum than MidsternumLower sternum than Midsternum

Depth: 1/3 AP diameter than deeper Depth: 1/3 AP diameter than deeper compressions compressions

EpinephrineEpinephrine

Indication: Heart rate <60 bpm after at least Indication: Heart rate <60 bpm after at least 45-60 seconds of coordinated PPV and chest 45-60 seconds of coordinated PPV and chest compressions.compressions.

Administration through an umbilical line Administration through an umbilical line remains the preferred route.remains the preferred route.

ETT vs. IV administrationETT vs. IV administration No randomized clinical trialsNo randomized clinical trials Case series and animal studiesCase series and animal studies

ETT less effective than IVETT less effective than IV ETT route has less blood concentration of ETT route has less blood concentration of

epinephrineepinephrine

Epinephrine-Ideal DoseEpinephrine-Ideal Dose

No randomized clinical trialsNo randomized clinical trials IV dose: 0.1-0.3 ml/kgIV dose: 0.1-0.3 ml/kg

Labeled 1 ml syringe and draw minimal dose of Labeled 1 ml syringe and draw minimal dose of 0.1mL/kg.0.1mL/kg.

IV epi >0.3ml/kg- no benefit IV epi >0.3ml/kg- no benefit IV epi >1ml/kgIV epi >1ml/kg

Increased risk of mortalityIncreased risk of mortality Interfere with cerebral perfusion and cardiac Interfere with cerebral perfusion and cardiac

outputoutput ETT epi (ETT epi (ETT Dose has changedETT Dose has changed))

0.5-1ml/kg to achieve adequate blood 0.5-1ml/kg to achieve adequate blood concentrationconcentration

Labeled 3-6 ml syringe and draw up 1mL/kg. Labeled 3-6 ml syringe and draw up 1mL/kg.

Naloxone and Volume Naloxone and Volume Expansion Expansion

NaloxoneNaloxone No difference in clinical outcomeNo difference in clinical outcome Associated with seizures if mother opiate Associated with seizures if mother opiate

addictaddict Concern about short and long-term safetyConcern about short and long-term safety

Volume expansionVolume expansion If chest compression, ventilation and If chest compression, ventilation and

epinephrine failsepinephrine fails Most useful if history of blood lossMost useful if history of blood loss Maybe harmful if no history of blood lossMaybe harmful if no history of blood loss

Use of volume expansion Use of volume expansion during delivery room during delivery room

resuscitation in near-term resuscitation in near-term and term infants.and term infants.

Wycoff et al, 2005

-Received Volume infusion⏏-No Volume infusion* p<.05

Temperature ControlTemperature Control

Large body of evidences Large body of evidences Methods:Methods:

Polythene wraps or BagsPolythene wraps or Bags Exothermic mattressesExothermic mattresses Delivery room temp >26°CDelivery room temp >26°C

Risks associated with hyperthermiaRisks associated with hyperthermia Respiratory depressionRespiratory depression Neonatal SeizureNeonatal Seizure Cerebral PalsyCerebral Palsy Mortality Mortality

Elevated Temperature After Hypoxic-Elevated Temperature After Hypoxic-Ischemic Encephalopathy: Risk Factor Ischemic Encephalopathy: Risk Factor

for Adverse Outcomesfor Adverse Outcomes

Esophageal Temperature

OR (95% CI)

Death or Disability (n=99)

Death (n=99)

Disability (n=65)

Highest 4.0 (1.5-11.2) 6.2 (2.1-17.9) 1.8 (0.4-8.2)

Median 3.2 (0.9-11.2) 5.9 (1.5-22.7) 1.0 (0.2-5.1)

Lowest quartile 1.5 (0.6-3.5) 1.4 (0.6-3.3) 1.1 (0.3-3.5)

Laptook et al. Pediatrics 2008

Induced HypothermiaInduced Hypothermia

Large body of evidenceLarge body of evidence

Term and near-term infantsTerm and near-term infants

Initiated within 6hours of lifeInitiated within 6hours of life

Significant reduction in death and Significant reduction in death and neurodevelopmental disability at 18 months of neurodevelopmental disability at 18 months of lifelife

NNT: 9NNT: 9

Patient recruited based on specific criteriaPatient recruited based on specific criteria Cord or first ABGCord or first ABG Clinical findings (moderate to severe HIE)Clinical findings (moderate to severe HIE)

Improved Pathology scores in Hippocampus Improved Pathology scores in Hippocampus when treated with therapeutic hypothermia when treated with therapeutic hypothermia

and/or 21% oxygen during resuscitation.and/or 21% oxygen during resuscitation.

*P<0.05

Suagstad, 2012

GlucoseGlucose

Hypoglycemia + HIE= brain injuryHypoglycemia + HIE= brain injury Hyperglycemia + HIEHyperglycemia + HIE

No adverse effectNo adverse effect Maybe protectiveMaybe protective

No randomized study to show specific No randomized study to show specific glucose levelglucose level

Cord ClampingCord Clamping

Term: 1 min to no cord pulsationTerm: 1 min to no cord pulsation Improved iron statusImproved iron status

Preterm: 30 seconds to 3 minutesPreterm: 30 seconds to 3 minutes Higher blood pressureHigher blood pressure Low IVHLow IVH Less transfusionLess transfusion

More phototherapyMore phototherapy Insufficient evidenceInsufficient evidence

Non-Initiation of Non-Initiation of ResuscitationResuscitation

Vary according to providers, regions and Vary according to providers, regions and availability of resourcesavailability of resources

Parental role in decision makingParental role in decision making

Categories:Categories: 1- GA, birth weight or congenital anomaly 1- GA, birth weight or congenital anomaly

suggest certain early death or unacceptably high suggest certain early death or unacceptably high morbiditymorbidity

2- High rate of survival and acceptable morbidity2- High rate of survival and acceptable morbidity 3- Uncertain prognosis, borderline survival and 3- Uncertain prognosis, borderline survival and

relatively high morbidity relatively high morbidity

Coordinated approach between Obstetrician, Coordinated approach between Obstetrician, Neonatologist and parents.Neonatologist and parents.

Discontinuation of Discontinuation of ResuscitationResuscitation

No heart beat for 10 minutesNo heart beat for 10 minutes Death or Severe neurologic disabilityDeath or Severe neurologic disability Evidence: small number of babiesEvidence: small number of babies Decision influenced by:Decision influenced by:

Gestational ageGestational age Etiology of arrestEtiology of arrest Parents previous expressed feelingParents previous expressed feeling

A New Educational A New Educational ApproachApproach

2004-Joint Commission Report: 47 infant 2004-Joint Commission Report: 47 infant deaths and or injuries related to the birth deaths and or injuries related to the birth processprocess

The root cause was related to ineffective The root cause was related to ineffective teamwork and communication.teamwork and communication.

Joint Commission recommendations:Joint Commission recommendations: Team trainingTeam training Clinical drillsClinical drills DebriefingsDebriefings

NRP Response to Joint NRP Response to Joint CommissionCommission

55thth Edition Edition Passive learningPassive learning Poorly prepared Poorly prepared

participantsparticipants Components for content Components for content

and technical skills, not and technical skills, not teamwork and teamwork and communicationcommunication

Instructors and Instructors and participants were not participants were not challenged by the class challenged by the class formatformat

66thth Edition Edition Active learningActive learning Self study and online Self study and online

examination prior to examination prior to class participationclass participation

Skill practice and Skill practice and simulation-based simulation-based scenarios aimed at scenarios aimed at promoting teamwork promoting teamwork and communicationand communication

DebriefingDebriefing

NRP EducationNRP Education

SimulationSimulation As adjunct to traditional trainingAs adjunct to traditional training Enhance performanceEnhance performance Experience obtained from high risk Experience obtained from high risk

organizationsorganizations Airlines, NASA, MilitaryAirlines, NASA, Military

Briefing and de-briefingBriefing and de-briefing Improve knowledge, skill and behaviorImprove knowledge, skill and behavior

Simulation and Simulation and DebriefingDebriefing

Key Behavioral skills targetedKey Behavioral skills targeted1.1. Know your environmentKnow your environment

2.2. Anticipate and planAnticipate and plan

3.3. Assume leadership roleAssume leadership role

4.4. Communicate effectivelyCommunicate effectively

5.5. Delegate workload optimallyDelegate workload optimally

6.6. Allocate attention wiselyAllocate attention wisely

7.7. Use all available informationUse all available information

8.8. Use all available resourcesUse all available resources

9.9. Call for help when needed, and earlyCall for help when needed, and early

10.10.Maintain professional behaviorMaintain professional behavior

SummarySummary

Progression to next step following initial Progression to next step following initial resuscitation depends on heart rate and resuscitation depends on heart rate and respiration.respiration.

Oximetry to be used to assess oxygenationOximetry to be used to assess oxygenation

Term babies- best to start resuscitation with room Term babies- best to start resuscitation with room air than 100% oxygenair than 100% oxygen

Use blender when oxygen is needed and should Use blender when oxygen is needed and should be guided by oximetrybe guided by oximetry

No evidence to support or refute endotracheal No evidence to support or refute endotracheal suctioning in meconium stained fluid, even in suctioning in meconium stained fluid, even in depressed newborndepressed newborn

SummarySummary

Chest compression: ventilation ratio stays Chest compression: ventilation ratio stays 3:13:1

Consider therapeutic hypothermia in term Consider therapeutic hypothermia in term and near-term infants with moderate to and near-term infants with moderate to severe HIEsevere HIE

Consider stopping resuscitation if no Consider stopping resuscitation if no detectable heart rate for 10 minutesdetectable heart rate for 10 minutes

Delay cord clamp for at least 1 minute in Delay cord clamp for at least 1 minute in those who does not require resuscitation those who does not require resuscitation

ImplicationImplication

Old habit vs. New informationOld habit vs. New information

More time vs. Efficiency vs. CostMore time vs. Efficiency vs. Cost Education or DebriefingEducation or Debriefing Pulse oximeterPulse oximeter

Shared responsibility vs. Neonatal TeamShared responsibility vs. Neonatal Team

Conditions where Oxygen is neededConditions where Oxygen is needed PPHNPPHN

Meconium Stained Amniotic FluidMeconium Stained Amniotic Fluid

Lack or need for more evidenceLack or need for more evidence

ImplicationImplication

Legal Implication (especially in depressed Legal Implication (especially in depressed newborns) newborns) All hospital need to have oxygen blender in the DRAll hospital need to have oxygen blender in the DR

Use room air Use room air Self inflating bag without reservoir (40% O2)Self inflating bag without reservoir (40% O2)

CO2 detectorsCO2 detectors Correct BMV taught to providers not skilled in Correct BMV taught to providers not skilled in

intubationintubation HypothermiaHypothermia

Preventable condition in a court settingPreventable condition in a court setting Therapeutic Hypothermia within 6hrs of lifeTherapeutic Hypothermia within 6hrs of life Preference of IV route to give epinephrinePreference of IV route to give epinephrine

States law credentialing nurses to put a UVCStates law credentialing nurses to put a UVC

Do we need a new Apgar score?Do we need a new Apgar score?

0 1 2

Heart Rate 0 <100 >100

Respiration 0 Weak, irregular Good cry

Reaction 0 Slight Good

Color Blue/pale All pink, limb blue

Body pink

Tone Limp Some movement Active movement, well flexed limbs

Virginia Apgar

ReferenceReference

1- Carson et al. American J Obstet Gynecol. 1976:126:712-7151- Carson et al. American J Obstet Gynecol. 1976:126:712-715 2- Ting et al. American J Obstet Gynecol. 1975;122:767-7712- Ting et al. American J Obstet Gynecol. 1975;122:767-771 3- Gregory et al. J Pediatr. 1974;85:848-8523- Gregory et al. J Pediatr. 1974;85:848-852 4- O’Donnell et al. J Pediatr. 2005;147:698-6994- O’Donnell et al. J Pediatr. 2005;147:698-699 5- Davis et al. Lancet. 2004;364:1329-13335- Davis et al. Lancet. 2004;364:1329-1333 6- Rabi et al. Resuscitation. 2007;72:353-3636- Rabi et al. Resuscitation. 2007;72:353-363 7- Escrig et al. Pediatrics. 2008;121:875-8817- Escrig et al. Pediatrics. 2008;121:875-881 8- Wycoff et al. Pediatrics 2005;115:950-9558- Wycoff et al. Pediatrics 2005;115:950-955 9- Finer et al. Pediatrics 1999;104:428-4349- Finer et al. Pediatrics 1999;104:428-434 10- Wycoff and Berg Seminars Fetal and Neonatal Med 2008;13:410-10- Wycoff and Berg Seminars Fetal and Neonatal Med 2008;13:410-

415415 11- Perlman et al. Pediatrics 2010;126:e1319-e134411- Perlman et al. Pediatrics 2010;126:e1319-e1344 12-Perlman et al. Circulation;122(suppl 2):S516-S53812-Perlman et al. Circulation;122(suppl 2):S516-S538 13-AAP News, October 2011 14-Dawson et al. Pediatrics 2010; 125 (6),e1340-e1347 15-Suagstad et al. Pediatrics Research 2012;71:247-52 16-Wycoff et al. Pediatrics. 2005, Apr;115(4):950-5.Pediatrics. 2005, Apr;115(4):950-5. 17-Laptook et al. Pediatrics 2008, Sept;122 (3):491-499 18-Saugstad et al. Biol Neon 2005

Do Not Attempt Do Not Attempt This!This!

Questions / Comments

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