The current guidelines have focused on clinical activities described in the resuscitation algorithm, rather than on the most appropriate devices for each step. High-quality observational studies of large populations may also add to the evidence. Team training remains an important aspect of neonatal resuscitation, including anticipation, preparation, briefing, and debriefing. One moderate quality RCT found higher rates of hyperthermia with exothermic mattresses. In addition, specific recommendations about the training of resuscitation providers and systems of care are provided in their respective guideline Parts.9,10. A brief introduction or short synopsis is provided to put the recommendations into context with important background information and overarching management or treatment concepts. With secondary apnea, the heart rate continues to drop, and blood pressure decreases as well. Very low-quality evidence from 2 nonrandomized studies and 1 randomized trial show that auscultation is not as accurate as ECG for heart rate assessment during newborn stabilization immediately after birth. It is the expert opinion of national medical societies that conditions exist for which it is reasonable to not initiate resuscitation or to discontinue resuscitation once these conditions are identified. Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP. Aim for about 30 breaths min-1 with an inflation time of ~one second. For nonvigorous newborns with meconium-stained fluid, endotracheal suctioning is indicated only if obstruction limits positive pressure ventilation, because suctioning does not improve outcomes. However, the concepts in these guidelines may be applied to newborns during the neonatal period (birth to 28 days). Important aspects of neonatal resuscitation are the hospital policy and planning that ensure necessary equipment and personnel are present before delivery.1 Anticipation and preparation are essential elements for successful resuscitation,18 and this requires timely and accurate communication between the obstetric team and the neonatal resuscitation team. The ILCOR task force review, when comparing PPV with sustained inflation breaths, defined PPV to have an inspiratory time of 1 second or less, based on expert opinion. The decision to continue or discontinue resuscitative efforts should be individualized and should be considered at about 20 minutes after birth. It may be possible to identify conditions in which withholding or discontinuation of resuscitative efforts may be reasonably considered by families and care providers. increase in the newborn's heart rate is the most sensitive indicator of a successful response to resuscitation. None of these studies evaluate outcomes of resuscitation that extends beyond 20 minutes of age, by which time the likelihood of intact survival was very low. In term and late preterm newborns (35 wk or more of gestation) receiving respiratory support at birth, 100% oxygen should not be used because it is associated with excess mortality. We thank Dr. Abhrajit Ganguly for assistance in manuscript preparation. If resuscitation is required, heart rate should be monitored by electrocardiography as early as possible. No studies have examined PEEP vs. no PEEP when positive pressure ventilation is used after birth. The heart rate response to chest compressions and medications should be monitored electrocardiographically. The guidelines form the basis of the AAP/American Heart Association (AHA) Neonatal Resuscitation Program (NRP), 8th edition, which will be available in June 2021. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient In preterm infants younger than 30 weeks' gestation, continuous positive airway pressure instead of intubation reduces bronchopulmonary dysplasia or death with a number needed to treat of 25. It is important to. A rise in heart rate is the most important indicator of effective ventilation and response to resuscitative interventions. Even healthy babies who breathe well after birth benefit from facilitation of normal transition, including appropriate cord management and thermal protection with skin-to-skin care. A prospective study showed that the use of an exhaled carbon dioxide detector is useful to verify endotracheal intubation. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. During an uncomplicated delivery, the newborn transitions from the low oxygen environment of the womb to room air (21% oxygen) and blood oxygen levels rise over several minutes. The heart rate should be verbalized for the team. Nearly 10 percent of the more than 4 million infants born in the United States annually need some assistance to begin breathing at birth, with approximately 1 percent needing extensive resuscitation1,2 and about 0.2 to 0.3 percent developing moderate or severe hypoxic-ischemic encephalopathy.3 Mortality in infants with hypoxic-ischemic encephalopathy ranges from 6 to 30 percent, and significant morbidity, such as cerebral palsy and long-term disabilities, occurs in 20 to 30 percent of survivors.4 The Neonatal Resuscitation Program (NRP), which was initiated in 1987 to identify infants at risk of respiratory depression and provide high-quality resuscitation, underwent major updates in 2006 and 2010.1,57, A 1987 study showed that nearly 78 percent of Canadian hospitals did not have a neonatal resuscitation team, and physicians were called into a significant number of community hospitals (69 percent) for neonatal resuscitation because they were not in-house.8 National guidelines in the United States and Canada recommend that a team or persons trained in neonatal resuscitation be promptly available for every birth.9,10 Actual institutional compliance with this guideline is unknown. Similarly, meta-analysis of 2 quasi-randomized trials showed no difference in moderate-to-severe neurodevelopmental impairment at 1 to 3 years of age. Administer epinephrine, preferably intravenously, if response to chest compressions is poor. All guidelines were reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and AHA Executive Committee. This guideline affirms the previous recommendations. Neonatal Resuscitation Program (NRP): Medications - Tom Wade MD An important point is that ventilation has been shown to be the most effective measure in neonatal resuscitation Teams and individuals who provide neonatal resuscitation are faced with many challenges with respect to the knowledge, skills, and behaviors needed to perform effectively. The recommended route is intravenous, with the intraosseous route being an alternative. Newborn resuscitation and support of transition of infants at birth In preterm birth, there are also potential advantages from delaying cord clamping. If endotracheal epinephrine is given before vascular access is available and response is inadequate, it may be reasonable to give an intravascular* dose as soon as access is obtained, regardless of the interval. Hypothermia after birth is common worldwide, with a higher incidence in babies of lower gestational age and birth weight. Each 2020 AHA Guidelines for CPR and ECC document was submitted for blinded peer review to 5 subject matter experts nominated by the AHA. One large retrospective review found that 0.04% of newborns received volume resuscitation in the delivery room, confirming that it is a relatively uncommon event. Circulation. 2020;142(suppl 2):S524S550. Ventilation should be optimized before starting chest compressions, possibly including endotracheal intubation. Newly born infants born at 36 wk or more estimated gestational age with evolving moderate-to-severe HIE should be offered therapeutic hypothermia under clearly defined protocols. While vascular access is being obtained, it may be reasonable to administer endotracheal epinephrine at a larger dose (0.05 to 0.1 mg/kg). Initiate effective PPV for 30 seconds and reassess the heart rate. Care (Updated May 2019)*, 2020 Advanced Cardiovascular Life Support (ACLS), 2020 Pediatric Advanced Life Support (PALS), 2015 Pediatric Emergency Assessment and Recognition, Conflicts of Interest and Ethics Policies, Advanced Cardiovascular Life Support (ACLS), CPR & First Aid in Youth Sports Training Kit, Resuscitation Quality Improvement Program (RQI), COVID-19 Resources for CPR & Resuscitation, Claiming Your AHA Continuing Education Credits, International Liaison Committee on Resuscitation. As mortality and severe morbidities decline with biomedical advancements and improvements in healthcare delivery, there is decreased ability to have adequate power for some clinical questions using traditional individual patient randomized trials. When the heart rate increases to more than 100 bpm, PPV may be discontinued if there is effective respiratory effort.5 Oxygen is decreased and discontinued once the infant's oxygen saturation meets the targeted levels (Figure 1).5, If there is no heartbeat after 10 minutes of adequate resuscitative efforts, the team can cease further resuscitation.1,5,6 A member of the team should keep the family informed during the resuscitation process. Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process. Dallas, TX 75231, Customer Service For infants born at less than 28 wk of gestation, cord milking is not recommended. The AAP released the 8th edition of the Neonatal Resuscitation Program in June 2021. A team or persons trained in neonatal resuscitation should be promptly available at all deliveries to provide complete resuscitation, including endotracheal intubation and administration of medications. While this research has led to substantial improvements in the Neonatal Resuscitation Algorithm, it has also highlighted that we still have more to learn to optimize resuscitation for both preterm and term infants. ** After completing the initial steps of providing warmth, positioning the infant in the sniffing position, clearing the airway and evaluate the infant's response with the following: Epinephrine (adrenaline) is the only medication recommended by the International Liaison Committee On Resuscitation (ILCOR) during resuscitation in newborns with persistent bradycardia or . Post-resuscitation care. Newly born infants who breathe spontaneously need to establish a functional residual capacity after birth.8 Some newly born infants experience respiratory distress, which manifests as labored breathing or persistent cyanosis. PPV may be initiated with air (21% oxygen) in term and late preterm babies, and up to 30% oxygen in preterm babies. HR below 60/min? Auscultation of the precordium remains the preferred physical examination method for the initial assessment of the heart rate.9 Pulse oximetry and ECG remain important adjuncts to provide continuous heart rate assessment in babies needing resuscitation. Supplemental oxygen: 100 vs. 21 percent (room air). A systematic review (low to moderate certainty) of 6 RCTs showed that early skin-to-skin contact promotes normothermia in healthy neonates. The research community needs to address the paucity of educational studies that provide outcomes with a high level of certainty. Peak inflation pressures of up to 30 cm H2O in term newborns and 20 to 25 cm H2O in preterm newborns are usually sufficient to inflate the lungs.57,9,1114 In some cases, however, higher inflation pressures are required.5,710 Peak inflation pressures or tidal volumes greater than what is required to increase heart rate and achieve chest expansion should be avoided.24,2628, The lungs of sick or preterm infants tend to collapse because of immaturity and surfactant deficiency.15 PEEP provides low-pressure inflation of the lungs during expiration. Review of the knowledge chunks during this update identified numerous questions and practices for which evidence was weak, uncertain, or absent. Saturday: 9 a.m. - 5 p.m. CT Each of these resulted in a description of the literature that facilitated guideline development.1417, Each AHA writing group reviewed all relevant and current AHA guidelines for CPR and ECC1820 and all relevant 2020 ILCOR International Consensus on CPR and ECC Science With Treatment Recommendations evidence and recommendations21 to determine if current guidelines should be reaffirmed, revised, or retired, or if new recommendations were needed. However, it may be reasonable to increase inspired oxygen to 100% if there was no response to PPV with lower concentrations. PEEP has been shown to maintain lung volume during PPV in animal studies, thus improving lung function and oxygenation.16 PEEP may be beneficial during neonatal resuscitation, but the evidence from human studies is limited. IV epinephrine If HR persistently below 60/min Consider hypovolemia Consider pneumothorax HR below 60/min? When appropriate, flow diagrams or additional tables are included. The AHA has rigorous conflict of interest policies and procedures to minimize the risk of bias or improper influence during development of the guidelines.13 Before appointment, writing group members and peer reviewers disclosed all commercial relationships and other potential (including intellectual) conflicts.