Neonatal Resuscitation

Putri Maharani T Marsubrin

Neonatology Division, Department of Child Health
Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital
 Interventions in term or near term newborn in the
delivery room
INTERVENTION FREQUENCY
130 mill Assess baby’s response to birth 100/100 B
110 mill
Dry, keep baby warm, position correctly A
Breathes spontaneously within 10 – 30 s S
15/100 I
20 mill Stimulate to breathe by drying
C
Clear airways – if needed

4 – 6 mill Establish effective bag & mask ventilation 3 – 5 /100

Start with air
1 – 2 mill
Endotracheal intubation 1 – 2 /100 A
<0.13 mill Provide chest < 1/1000 D
compressions with oxygen
<0.13 mill V
Adrenaline
6/10000 A
N
0.01 mill
1/12000
Volume expansion C
E
Suagstad OD D
 ILCOR/AHA 2005Four
- 2015
Categories

A • Initial steps of stabilisation (assess the airways, positioning,

Airways stimulating, dry and provide warmth)

B • Ventilation (including bag – mask or bag – tube ventilation)

Breathing

• Chest compressions
C
Circulation
• Medications or volume expansion
D
Drugs
ILCOR changes 2010 - 2015
1. Support of transition, not automatically = 𝑟𝑒𝑠𝑢𝑠𝑐𝑖𝑡𝑎𝑡𝑖𝑜𝑛
2. Cord clamping
For uncompromised infants, a delay of cord clamping > 1 min only preterm
(2015)?
3. Body temperature
For non-asphyxiated infants 36.5 – 37.5oC
4. Maintenance of temperature
< 32 wk 36.5 – 37.5oC maintained by warmed humidified resp gases, increased
room temperature (< 28 wk > 25oC, plastic wrapping, cap, thermal mettress)
Changes 2010 - 2015
5. Optimal assesment of heart rate
Suggest use of ECG in resuscitation
6. Meconium stained amniotic fluid – non vigorous infant
Intubation only for suspected tracheal obstruction
7. Air/oxygen
Term infants start with 21%, preterm 21 – 30%
8. Continuous Positive Airways Pressure (CPAP)
CPAP rather than intubation for spontaneously breathing preterm infants
9. Hypothermia therapy in low income setting
Cooling with ice packs
 2015

2010
 2015
2010
A: Airways
Stabilisation and suctioning
• A vigorous newborn who starts to breath within 10 – 15 seconds does not need
suctioning routinely
• Deep suctioning should be avoided especially the first 5 min of life.
• It may induce apnea, bradycardia and bronchospasm
• If suctioning, always suction the mouth before through the nose to minimize risk
of aspiration

ILCOR 2010
2015: no change
Initial breaths and pressure
• Initiation of intermittent possitive – pressure ventilation at birth can be
accomplished with either shorter or longer inspiratory times
• Initial peak inflating pressures needed are variable
• Start with 20 cmH20 may be effective but in term infants 30 – 40 cm H20
may be needed

ILCOR 2010
2015: no change
CPAP and IPPV
• Treatment recommendation
• For spontaneously breathing preterm infants with respiratory distress
requiring respiratory support in the delivery room, we suggest initial
use of CPAP rather than intubation and IPPV
Weak recommendation, moderate-quality evidence

ILCOR 2015
Ventilation strategies in the delivery room
• Treatment recommendation
• We suggest against the routine use of initial sustained inflation
(greater than 5 seconds duration) for preterm infants without
spontaneous respirations immediately after birth, but an SI may be
considered in individual clinical circumstances or research settings
Weak recommendation, low – quality evidence

ILCOR 2015
Resuscitation/stabilization in the delivery
room
• Term and near term babies in need of resuscitation start with FiO2 0.21%
• 29-31 weeks GA start with FiO2 0.21-0.30
• <29 weeks GA start with FiO2 0.30 or more

• Oxygenation for ELBWI < 28 weeks GA beyond the delivery room

• Oxygen targets 91-95% increase ROP in need of therapy
• Oxygen targets 85-89% increases mortality and NEC
• Long term follow up: no differences between the arms regarding Death/disability,
blindness, hearing loss
• Recommendations? Target SpO2 at 90-95%?
C: Circulation
• Chest compressions 3:1
• 30 ventilations
• 90 compressions
• Pause for ventilation
• Give oxygen

• 15:2 an option if cardiac origin

ILCOR 2010
Chest compressions
• Depth of compressions and coefficient of variation (COV) utilising a 3:1 compression to
ventilation ratio for 2 min using the two-thumb compared with the two-finger technique
•

Two- Two-finger P Value

thumb
Depth (mm) 29+5.4 23.7+5.8 0.0009

• We suggest
Variability that
(COV) chest compressions
6.1+2.9 in the
9.8+3.1 0.00002
newborn should be delivered by the 2-thumb,
hands encircling-the-chest method as preferred option
Weak recommendation, very-low quality evidence
• We suggest that chest compressions should be delivered over the lower third of the
sternum
Weak recommendation, very low-quality evidence

ILCOR 2015
Assist ventilation devices
Treatment recommendations
• We suggest the laryngeal mask may be used as an alternative to tracheal
intubation during resuscitation of the late-preterm and term newborn (> 34
weeks) if ventilation via the face mask is unsuccessful
Weak recommendation, low-quality evidence

• In the unusual situation where intubation is not feasible after failed PPV, the
laryngeal mask is recommended for resuscitation of the late-preterm and term
newborn (>34 weeks)
Strong recommendation, good clinical practice

ILCOR 2015
Oxygen concentration for resuscitating premature
newborns
Treatment recommendations
• We recommend against initiating resuscitation of preterm newborns (< 35
weeks of gestation) with high supplementary oxygen concentrations (65% -
100%)

• We recommend initiating resuscitation with a low-oxygen concentration

(21% - 30%)
Strong recommendation, moderate-quality evidence

ILCOR 2015
Intubation and tracheal suctioning in nonvigorous infants born thugh
MSAF versus no intubation for tracheal suctioning

Treatment reccomendation
• The available evidence does not support or refute the routine endotracheal
suctioning of depreesed infants born thouh MSAF

ILCOR 2010
• There is insufficients published human evidence to suggest routine tracheal
intubation for suctioning of meconium in non-vigorous infants born through
MSAF as opposed to no tracheal intubation for suctioning

ILCOR 2015 No grading To suction or not is a clinical decision!

 When to give surfactant in RDS. U.S.
Levels of Evidence
Polin RA, Carlo WA. AAP Pediatrics 2014;133 (1):156-63.

Recommendation LOE LOE Grade of Reccomendation

Preterm infants born at < 30 wk of gestation who need mechanical ventilation 1 Strong recommendation
because of severe RDS should be given surfactant after initial stabilization

Using CPAP immediately after birth with subsequent selective surfactant 1 Strong recommendation
administration should be considered as an alternative route intubation with
prophylactic or early surfactant administration in preterm infants
Rescue surfactant may be considered for infants with hypoxic respiratory failure
attributable to scondary surfactant deficiency (eg. Meconium aspiration
syndrome or sepsis/pneumonia)
D: Drugs
Adrenaline/epinephrine
• If adequate ventilation and chest compressions have failed to
increase heart rate to > 60 bpm, then it is reasonable to use
adrenaline despite the lack of human neonatal data

• 6:10 000 newborns

ILCOR 2010
• 0.1-0.3 mL/kg 1:10 000 adrenaline solution
• 1st dose at earliest at 4-5 min of life

Wyckoff et all 2006 No new recommendations in 2015

Post resuscitation management induced
hypothermia
• We suggest that newly born infants at term or near-
term with evolving moderate-to-severe HIE in low
income countires and/or settings with limited
resources may be treated with therapeutic
hypothermia
Weak recommendation, low quality evidence

ILCOR 2015
Therapeutic hypothermia
• The recommendation is that hypothermia could be induced passively or by
ice packs
• It is known that overcooling can be harmful, and therefore, this
recommendation is of concern

• ILCOR 2015 suggests that treatment should be carried out in neonatal care
facilities with capabilities for multidisciplinary care and the availability of
adequate resources.
• It is vital that basic antenatal and neonatal care is optimized before
diverting resources to added therapies such as cooling
Discontinuing resuscitation
• Treatment recommendation
• There is insufficient evidence to support the prospective use of any delivery
room prognostic score presently described over estimated GA assessment
alone in preterm infants of < 25 weeks of gestation
• No score has been shown to improve the ability of estimate the likelihood
of survival through either 30 days or in the first 18 to 22 months after birth

No grading
ILCOR 2015
Apgar score of 0 for 10 min or longer -
prognosis
• Treatment recommendation
• In a newly born baby with no detectable heart rate, it is appropriate to consider stopping
resuscitation if the heart rate remains undetectable for 10 minutes

ILCOR
• An Apgar score of 0 at 10 2010
minutes is a strong predictor of mortality and morbidity in late-
preterm and term infants.
• We suggest that, in babies with an Apgar score of 0 after 10 minutes of resuscitation, if
the HR remains undetectable, it may be reasonable to stop resuscitation; however the
decision to continue or discontinue resuscitative efforts should be individualized
• Weak recommendation, very low quality evidence

ILCOR 2015
IDAI

This neonatal resuscitation

guideline can be adjusted
to local policy
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