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URRENT
O
PINION
New concepts in neonatal resuscitation
Peter G. Davis
a,b,c
and Jennifer Anne Dawson
a,b,c
Purpose of review
There has been a substantial increase in the number of studies of neonatal resuscitation and it is timely
to review the accumulating evidence.
Recent findings
There have been major changes in the way that newly born infants are managed in the delivery room.
Colour is no longer recommended as a useful indicator of oxygenation or effectiveness of resuscitation.
Pulse oximetry provides rapid, continuous and accurate information on both oxygenation and heart rate.
Resuscitation of term infants should begin with air, with the provision of blended oxygen to maintain
oxygen saturations similar to those of term infants requiring no resuscitation. Positive end-expiratory
pressure during initial ventilation aids lung aeration and establishment of functional residual capacity.
Respiratory function monitoring allows operators to identify factors adversely affecting ventilation, including
leak around the face mask and airway obstruction. Clamping of the umbilical cord should be delayed for
at least 1min for infants not requiring resuscitation.
Summary
The International Liaison Committee on Resuscitation guidelines on the management of newborn infants
were updated in 2010 and incorporate much of the newly available evidence. The use of intensive care
techniques in the delivery room is promising but requires further evaluation. Monitoring techniques and
interventions need to be adapted for use in developing countries.
Keywords
delivery room, infant/newborn, monitoring, oxygenation, resuscitation
INTRODUCTION
In 2004, Finer and Rich [1] reviewed the topic of
neonatal resuscitation in this journal and noted
that, despite its importance, neonatal resuscitation
remained a poorly studied intervention. They
described a lack of evidence to support the guide-
lines in operation at the time and called for more
prospective research in order to improve care in the
delivery room. Two iterations of the International
Liaison Committee on Resuscitation (ILCOR) guide-
lines for neonatal resuscitation have been released
since, the most recent in2010 [2,3
&&
]. There has been
substantial expansion of the evidence base and it is
timely to review progress in the field.
ROLE OF INTERNATIONAL LIAISON
COMMITTEE ON RESUSCITATION IN
REVIEWING EVIDENCE AND PRODUCING
GUIDELINES
ILCOR is a multinational group that includes repres-
entation from eight international resuscitation
councils: the American Heart Association, European
Resuscitation Council, Heart and Stroke Foundation
of Canada, Resuscitation Council of Asia, Resusci-
tation Council of Southern Africa, the Australia
and New Zealand Council on Resuscitation, and
the InterAmerican Heart Foundation. Every 5 years,
ILCOR rigorously reviews the latest evidence for
resuscitation guidelines. At least two members
of the neonatal subcommittee review guidelines
relevant to the care of newborn infants. Further
discussion and debate among the wider group occur
before a consensus is reached regarding recommen-
dations for practice in resuscitation. These guide-
lines and worksheets used to reviewthe evidence are
available via the Internet (http://www.ilcor.org/en/
a
Division of Neonatal Services, The Royal Womens Hospital, Melbourne,
b
Department of Obstetrics and Gynaecology, The University of Mel-
bourne and
c
Critical Care and Neurosciences, Murdoch Childrens
Research Institute, Melbourne, Victoria, Australia
Correspondence to Professor Peter G. Davis, Newborn Research, The
Royal Womens Hospital, Corner Grattan Street and Flemington Road,
Parkville, Melbourne, VIC 3052, Australia. Tel: +61 3 8345 3763; e-mail:
pgd@unimelb.edu.au
Curr Opin Pediatr 2012, 24:147153
DOI:10.1097/MOP.0b013e3283504e11
1040-8703 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins www.co-pediatrics.com
REVI EW
consensus-2010/worksheets-2010/). Recommenda-
tions are then circulated widely, published in
Resuscitation [4
&&
], Circulation [3
&&
] and Pediatrics
[5
&&
]. The major new recommendations for resusci-
tation in the delivery room in the 2010 guidelines
are summarized in Fig. 1 [3
&&
]. These recommen-
dations encompass many aspects of delivery room
care. They include guidelines regarding initial
and ongoing assessment of the newly born
infant, optimization of the thermal environment,
recognition of the infant who requires assistance to
establish breathing, equipment and techniques to
support breathing and when to stop resuscitative
efforts.
MANAGEMENT OF THE THERMAL
ENVIRONMENT
Warmth is a fundamental requirement of the
newborn infant. An understanding that reducing
thermal stress improves survival of preterm infants
marked the beginning of the modern era of
neonatology. More recently, the dangers of hyper-
thermia have become apparent. Fifty years after the
landmark publicationby Silvermanet al. [6], the best
method of achieving thermoneutrality remains the
subject of ongoing research. The updated Cochrane
review on the topic noted that plastic bags and
wraps reduce heat loss in preterm infants but not
mortality [7
&
]. In a study using historical controls,
Ibrahim and Yoxall [8] found that plastic bags were
less effective for infants below 28 weeks gestation
compared with more mature infants. The same
authors reported a marked fall in rates of hypother-
mia on admission following the use of self-heating
(acetate gel) mattresses [7
&
]. However, the use of gel
mattresses was associated with an increased rate
of hyperthermia (temperature >378C). A small
KEY POINTS
Ventilation remains the key to successful resuscitation.
Heart rate is the most sensitive indicator of a newly
born infants need for, and response to, interventions.
Oximetry provides an objective continuous
measurement of both oxygenation and heart rate.
The concentration of supplemental oxygen in the
delivery room should be titrated against an infants
oxygen saturation.
Progression in the resuscitation algorithm is now guided by simultaneous assessment of
heart rate and respirations. Oximetry should be used for evaluation of oxygenation
because assessment of color is unreliable.
For babies born at term, resuscitation should begin with air rather than 100% oxygen.
Administration of supplementary oxygen should be regulated by blending oxygen and
air, and the concentration guided by oximetry.
The available evidence does not support or refute the routine endotracheal suctioning of
infants born through meconium-stained amniotic fluid, even when the newborn is
depressed.
The chest compression-ventilation ratio should remain at 3:1 for neonates unless the
arrest is known to be of cardiac etiology, in which case a higher ratio should be
considered.
Therapeutic hypothermia should be considered for infants born at term or near-term
with evolving moderate to severe hypoxic-ischemic encephalopathy, with treatment and
follow-up coordinated through a regional perinatal system.
It is appropriate to consider discontinuing resuscitation if there has been no detectable
heart rate for 10 minutes. Many factors contribute to the decision to continue beyond 10
minutes.
Cord clamping should be delayed for at least 1 minute in babies who do not require
resuscitation. Evidence is insufficient to recommend a time for clamping in those who
require resuscitation.
FIGURE 1. The major new recommendations for changes to practice in neonatal resuscitation by International Liaison
Committee on Resuscitation [3
&&
].
Neonatology and perinatology
148 www.co-pediatrics.com Volume 24 Number 2 April 2012
observational trial comparing infants managed
with a polyethylene wrap with those managed
with exothermic mattresses and polyethylene wraps
showed higher rates of hypothermia and hyper-
thermia in infants managed with the mattress.
The authors noted that both groups had an un-
acceptably high rate of hypothermia [9].
Heat loss via the respiratory tract during
stabilization was the focus of a historical cohort
study by te Pas et al. [10
&
]. The authors found that
the provision of heated and humidified gas during
respiratory support was associated with a reduction
in the rate of moderate hypothermia from 53 to
19%.
Economic factors may affect the uptake of these
novel interventions to deliver warmth to newborn
infants. Appropriately powered randomized trials
reporting other important outcomes [mortality,
bronchopulmonary dysplasia (BPD), intraventri-
cular haemorrhage (IVH)] are required before these
techniques are widely applied.
The updated ILCOR guidelines suggest main-
taining delivery room temperatures of at least
268C for infants of less than 28 weeks gestation
[3
&&
]. Careful monitoring of infants temperatures
in order to avoid both hypothermia and hyper-
thermia remains a cornerstone of care of the preterm
infant in the delivery room.
DEFERRED OR DELAYED CORD
CLAMPING
Recent studies have assessed whether delaying
the clamping and cutting of the umbilical cord
until the cord stops pulsating may improve
outcomes. Strategies for increasing placental trans-
fusioninclude positioning the infant belowthe level
of the placenta, use of oxytocin and milking blood
in the cord towards the infant [11,12]. Randomized
controlled trials (RCTs) have demonstrated benefits
of this approach, including improved postnatal
iron status [13]. A nonsignificant increase in hyper-
bilirubinaemia needing phototherapy was seen
when cord clamping was delayed. In infants less
than 37 weeks gestation, delayed cord clamping
seems to be associated with reduced need for blood
transfusion and less intraventricular haemorrhage
[14]. However, in preterm infants or infants who
require assistance withbreathing inthe first minutes
after birth, delaying cord clamping may delay
resuscitation. In this group of infants, the potential
benefits of increased placental transfer are less
well defined. Appropriately powered randomized
trials are required to resolve uncertainty regarding
delayed cord clamping in infants requiring
resuscitation.
OXYGEN MONITORING AND THERAPY
The past decade has seen remarkable changes in our
attitudes to the use of oxygen in the delivery room.
There has been a recognition that newborn infants
are susceptible to oxidative stress and 100% oxygen
can be harmful to both preterm and term infants
[15
&&
]. Updated meta-analyses confirm a reduction
in the risk of neonatal mortality and a trend towards
a reduction in the risk of severe hypoxic ischaemic
encephalopathy innewborns resuscitated inair [16].
In addition, it has been shown that clinical assess-
ment of colour as a measure of oxygenation is
imprecise and inaccurate [17]. The debate has
shifted to questions of how best to titrate oxygen
delivery to an infants requirements using new
generation pulse oximeters. In order to obtain rapid,
reliable data, the monitor should be turned on, the
sensor applied to the right wrist or hand and then
connected to the monitor [18]. Masimo pulse
oximeters provide oxygen saturation (S
p
O
2
) and
heart rate (HR) data within 60s after delivery [18].
Clinicians need to be aware of the performance
characteristics of pulse oximeters in local use.
The Ohmeda Biox 3700 (GE Healthcare, UK) and
Nellcor N395 (Covidien, Boulder, CO, USA) were
found to be significantly slower than the Masimo
Radical-7 SET (Masimo Corp., CA, USA) in display-
ing reliable oxygen saturation readings, but Nellcor
Oximax monitors had similar performance [19].
Use of supplemental oxygen in very low birth
weight babies was addressed in a series of recent
trials. In a small observational study with historical
controls, Stola et al. [20] demonstrated that lowering
the concentration of oxygen used for resuscitation
was associated with fewer babies with a P
a
O
2
more
than 80mmHg on admission to the nursery as well
as a lower F
i
O
2
at 24h. Other studies found that
starting resuscitation with air was associated with
a failure to reach predefined saturation targets
but no differences in HR or in-hospital outcomes
[21,22
&
,23]. A randomized comparison of starting
oxygen concentrations of 30 versus 90% and adjust-
ment according to saturations and HR showed that
similar, acceptable saturations and HRs could be
achieved using lower oxygen concentrations [24].
There were trends to increased rates of BPD and
retinopathy of prematurity in infants in the high-
oxygen group. Until larger trials are conducted,
a starting point of 2130% oxygen for preterm
infants seems reasonable. However, if the response
to resuscitation is suboptimal, higher concen-
trations of inspired oxygen should be used.
Kattwinkel [25] introduced the concept of
targeting normoxia throughout neonatal resusci-
tation. A reference range of oxygen saturations
measured in terminfants receiving no interventions
New concepts in neonatal resuscitation Davis and Dawson
1040-8703 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins www.co-pediatrics.com 149
suggests that median saturations rise steadily from
around 60 at 1min of age to above 90 by 5min
[26
&&
]. However, 10% of normal infants have
saturations in the 30s at 1min, rising to the 70s
by 5min and mid-80s by 10min. It is important to
note that the use of a pulse oximeter to determine
the appropriate level of respiratory support and
whether to provide oxygen is not based on the
highest-quality evidence. At present, this reference
range represents our best guess at optimal oxygen
saturation targets. Experts and national bodies have
chosen different centiles as triggers to commence
oxygen therapy [5
&&
,2730]. Whether the 10th or
25th centile (or indeed another centile) is preferable
remains to be established. It is clear that high
saturations (>95%) may be associated with very
high arterial oxygen levels and hyperoxic stress
and should be avoided.
POSITIVE END-EXPIRATORY PRESSURE
IN THE DELIVERY ROOM
Although the use of positive end-expiratory pressure
(PEEP) during intermittent positive pressure venti-
lation has been standard practice in neonatal
intensive care units for many decades, its use in
the delivery room has been a matter of personal
preference. Until recently, the most commonly used
ventilation devices, self-inflating bags, generally
did not provide PEEP. Clearance of lung liquid
and aeration of the lungs is critical to the transition
from in-utero to postnatal life and depends on
a transpulmonary pressure gradient [31]. Phase-
contrast imaging and plethysmography of a preterm
rabbit model demonstrate that, without PEEP,
gas only enters the distal airways during inflation
[32]. These airways collapse in expiration and estab-
lishment of functional residual capacity (FRC) is
delayed. When PEEP is applied, airways are kept
open throughout the respiratory cycle and FRC is
steadily accumulated.
The delivery of PEEP is not without adverse
effects. Although PEEP improved oxygenation in a
lamb model of resuscitation, pulmonary blood flow
is reduced when levels of 810cmH
2
O are applied
[33]. Jobe et al. [34] point out that PEEP is not a
panacea for preventing lung injury and that a better
understanding of how and where the preterm
infants lungs are injured is required in order to
develop better lung protective strategies in the
delivery room.
Investigation of PEEP in the resuscitation of
human neonates is at an early stage. A small RCT
in extremely preterm infants comparing a T-piece
which delivered PEEP with a self-inflating bag
did not demonstrate important differences in
short-term outcomes [35]. Other larger trials are
underway.
The range of resuscitation devices which
provide PEEP includes the T-piece resuscitator,
flow-inflating (anaesthesia) bags and self-inflating
bags fitted with PEEP valves. The T-piece provides
the most accurate and consistent level of PEEP [36].
PEEP valves fitted to a Laerdal self-inflating bag
provide a PEEP level that falls quickly, particularly
at rates below 40 inflations per min [37]. Operators
need to be careful when using the T-piece. The PEEP
valve is flowsensitive, and at lowflows (5l/min) half
a rotation of the PEEP dial can double the delivered
PEEP [38]. Review of a single centres experience
with the T-piece revealed several instances of
inadvertent administration of PEEP levels as high
as 15cmH
2
O [39].
SUSTAINED INFLATIONS IN THE DELIVERY
ROOM
It has been suggested that sustained inflations
facilitate lung liquid clearance, assist in uniform
lung aeration and aid in the establishment of
FRC. Although noting the publication of three
RCTs [4042], current ILCOR guidelines do not
recommend the use of sustained inflations for either
term or preterm infants. Multiple variables regard-
ing the interfaces and pressure-generating devices
made it difficult to determine the effect of the
initial sustained inflation on establishing FRC [30].
In a lamb model, sustained inflations improved
lung compliance, pulmonary blood flow, oxygen-
ation and cerebral oxygen delivery [43]. In venti-
lated preterm rabbits, the benefits of PEEP and
a sustained inflation were additive and improved
FRCformation and uniformity of lung aeration [44].
Sustained inflations should therefore be regarded as
a promising intervention and further randomized
trials in term and preterm infants are indicated.
Comparison of various resuscitation devices
shows that the T-piece provides more accurate
and consistent delivery of the inflation than flow-
inflating or self-inflating bags [45,46]. The charac-
teristics of the optimal strategy in terms of duration,
pressure and number of inflations remain to be
determined.
CHOOSING A MANUAL VENTILATION
DEVICE FOR USE IN THE DELIVERY ROOM
National and international surveys show that
several devices are commonly used to provide
positive pressure ventilation in the delivery room
[4752]. These include the T-piece neonatal
resuscitator, flow-inflating (anaesthesia) bags and
Neonatology and perinatology
150 www.co-pediatrics.com Volume 24 Number 2 April 2012
self-inflating bags. Current ILCOR guidelines do
not indicate superiority of any one device [3
&&
].
Mannequin studies have been used to test these
devices. A T-piece provides more reliable and
constant peak inspiratory pressure (PIP) and tidal
volume than a self-inflating bag [53]. In a preterm
lamb model, experienced neonatologists using a
self-inflating bag delivered erratic and potentially
damaging tidal volumes and peak pressures [54]. In
spite of the apparent stability offered by the T-piece,
when operators are distracted or inexperienced,
widely variable mean airway pressures and tidal
volumes are delivered [55].
MONITORING RESPIRATORY FUNCTION IN
THE DELIVERY ROOM
Vento et al. [56] suggest that bringing intensive
care technology to the delivery room may improve
neonatal outcomes. Modern neonatal ventilators
display inspiratory and expiratory flow and volume.
Volume-targeted ventilation is widely practised,
and there is evidence that its use reduces rates of
pneumothorax, BPD and severe IVH or periventric-
ular leukomalacia in the NICU [57].
There is growing recognition that it is the
volume of gas delivered, rather than pressures
achieved, that is important when ventilating infants
in the delivery room. Low tidal volumes will lead to
failure to ventilate adequately, whereas as few as
six high tidal volume inflations have been shown
to damage preterm neonatal lamb lungs [58].
Operators should not be reassured that delivery of
a stable PIP means that a constant tidal volume is
being given. Schmolzer [59] showed that, in the
delivery room, tidal volumes ranging from less than
1 to more than 20ml/kg were delivered using a set
pressure of 30cmH
2
O.
Hot wire anemometers are used to measure
flow towards and away from an infant. Flow and
its integral volume can be displayed continuously
and may provide valuable information to clinicians
in the delivery room. Leaks around the face
mask and airway obstruction are common during
resuscitation and may lead to low, ineffective
tidal volumes [60]. Respiratory function monitoring
allows operators to detect and correct these
problems. The technique is also useful for detecting
malposition of an endotracheal tube and avoiding
dangerously high tidal volumes [61].
Although promising, respiratory function
monitoring requires further evaluation before it
can become widely practised. Limited availability
of monitors and their cost are currently major
barriers. Perhaps more importantly, it needs to be
demonstrated that, for operators of varying levels of
experience, the usefulness of the information pro-
vided outweighs the additional complexity imposed
on an already stressful situation.
RESUSCITATION IN DEVELOPING
COUNTRIES
Much of the research on neonatal resuscitation is
conducted in and applies to developed countries.
Little et al. [62
&
] remind us that the majority of the
burden of illness and therefore the largest potential
gains are to be found in the developing world. They
suggest that simple measures could prevent 244000
neonatal deaths from asphyxia globally. Essential
Newborn Care training in universal precautions,
routine neonatal care, resuscitation, thermoregula-
tion, breastfeeding and kangaroo care almost halved
7-day mortality in 18 low-risk Zambian centres [63].
Research into devices which meet the specific needs
of developing countries has started to occur [64,65],
but much more needs to be done in order to meet
the United Nations Millennium Development Goal
of reducing the child mortality rate by two-thirds by
2015 [66].
CONCLUSION
Accumulating evidence suggests limiting oxygen
exposure in the delivery room. This can be achieved
by monitoring oxygen saturations and titrating
delivery of oxygen to achieve saturations in the
range seen in term infants not requiring assistance.
The same technology can also be used to continu-
ously display HR, which remains the best indicator
of response to resuscitative efforts. Delivery of
effective ventilation remains the most important
intervention in the delivery room. The use of PEEP
and sustained inflations is promising but requires
further refinement and evaluation. The upsurge in
research in the delivery room has provided a more
substantial evidence base underpinning neonatal
resuscitation. However, more remains to be done,
particularly with respect to improving delivery
room care in the developing world.
Acknowledgements
J.A.D. is a recipient of a National Health and Medical
Research Council (NHMRC) Post Doctoral Fellowship.
P.G.D. is a recipient of an NHMRC Practitioner Fellow-
ship. P.G.D. holds an Australian National Health and
Medical Research Council Program Grant No. 384100.
J.A.D. is supported by the Victorian Governments
Operational Infrastructure Support Program.
Conflicts of interest
There are no conflicts of interest.
New concepts in neonatal resuscitation Davis and Dawson
1040-8703 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins www.co-pediatrics.com 151
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Papers of particular interest, published within the annual period of review, have
been highlighted as:
&
of special interest
&&
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