Many current recommendations are based on weak evidence with a lack of well-designed human studies. High-quality observational studies of large populations may also add to the evidence. Early cord clamping (within 30 seconds) may interfere with healthy transition because it leaves fetal blood in the placenta rather than filling the newborns circulating volume. Copyright 2023 American Academy of Family Physicians. In babies who appear to have ineffective respiratory effort after birth, tactile stimulation is reasonable. 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. A multicenter, case-control study identified 10 perinatal risk factors that predict the need for advanced neonatal resuscitation. One observational study compared neonatal outcomes before (historical cohort) and after implementation of ECG monitoring in the delivery room. Neonatal resuscitation teams may therefore benefit from ongoing booster training, briefing, and debriefing. Exhaled carbon dioxide detectors to confirm endotracheal tube placement. Please see updates below from RQI Partners, the company that is providing the NRP Learning Platform TM and RQI for NRP. Neonatal Resuscitation: An Update | AAFP How to do NRP Skills Step by Step - Nurses Educational Opportunities The importance of skin-to-skin care in healthy babies is reinforced as a means of promoting parental bonding, breast feeding, and normothermia. If the heart rate has not increased to 60/ min or more after optimizing ventilation and chest compressions, it may be reasonable to administer intravascular* epinephrine (0.01 to 0.03 mg/kg). For babies requiring vascular access at the time of delivery, the umbilical vein is the recommended route. Medications are rarely needed in resuscitation of the newly born infant because low heart rate usually results from a very low oxygen level in the fetus or inadequate lung inflation after birth. The 2020 guidelines are organized into "knowledge chunks," grouped into discrete modules of information on specific topics or management issues.22 Each modular knowledge chunk includes a table of recommendations using standard AHA nomenclature of COR and LOE. If a birth is at the lower limit of viability or involves a condition likely to result in early death or severe morbidity, noninitiation or limitation of neonatal resuscitation is reasonable after expert consultation and parental involvement in decision-making. Before every birth, a standardized equipment checklist should be used to ensure the presence and function of supplies and equipment necessary for a complete resuscitation. If the baby is bradycardic (HR <60 per minute) after 90 seconds of resuscitation with a lower concentration of oxygen, oxygen concentration should be increased to 100% until recovery of a normal heart rate (Class IIb, LOE B). To start, 21% to 30% oxygen should be used in these newborns, titrating up based on oxygen saturation. How soon after administration of intravenous epinephrine should you Rescuer 2 verbalizes the need for chest compressions. Recommendation-specific text clarifies the rationale and key study data supporting the recommendations. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient The AAP released the 8th edition of the Neonatal Resuscitation Program in June 2021. In the resuscitation of an infant, initial oxygen concentration of 21 percent is recommended. If the neonate's heart rate is less than 60 bpm after optimal ventilation for 30 seconds, the oxygen concentration should be increased to 100% with commencement of chest compressions. 0.5 mL When intravenous access is not feasible, the intraosseous route may be considered. 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. This guideline is designed for North American healthcare providers who are looking for an up-to-date summary for clinical care, as well as for those who are seeking more in-depth information on resuscitation science and gaps in current knowledge. Gaps in this domain, whether perceived or real, should be addressed at every stage in our research, educational, and clinical activities. The frequency and format of booster training or refresher training that best supports retention of neonatal resuscitation knowledge, technical skills, and behavioral skills, The effects of briefing and debriefing on team performance, Optimal cord management strategies for various populations, including nonvigorous infants and those with congenital heart or lung disease, Optimal management of nonvigorous infants with MSAF, The most effective device(s) and interface(s) for providing PPV, Impact of routine use of the ECG during neonatal resuscitation on resuscitation, Feasibility and effectiveness of new technologies for rapid heart rate measurement (such as electric, ultrasonic, or optical devices), Optimal oxygen management during and after resuscitation, Novel techniques for effective delivery of CPR, such as chest compressions accompanied by sustained inflation, Optimal timing, dosing, dose interval, and delivery routes for epinephrine or other vasoactive drugs, including earlier use in very depressed newly born infants, Indications for volume expansion, as well as optimal dosing, timing, and type of volume, The management of pulseless electric activity, Management of the preterm newborn during and after resuscitation, Management of congenital anomalies of the heart and lungs during and after resuscitation, Resuscitation of newborns in the neonatal unit after the newly born period, Resuscitation of newborns in other settings up to 28 days of age, Optimal dose, route, and timing of surfactant in at-risk newborns, including less-invasive administration techniques, Indications for therapeutic hypothermia in babies with mild HIE and in those born at less than 36 weeks' gestational age, Adjunctive therapies to therapeutic hypothermia, Optimal rewarming strategy for newly born infants with unintentional hypothermia. The effect of briefing and debriefing on longer-term and critical outcomes remains uncertain. Optimal PEEP has not been determined, because all human studies used a PEEP level of 5 cm H2O.1822, It is reasonable to initiate PPV at a rate of 40 to 60/min to newly born infants who have ineffective breathing, are apneic, or are persistently bradycardic (heart rate less than 100/min) despite appropriate initial actions (including tactile stimulation).1, To match the natural breathing pattern of both term and preterm newborns, the inspiratory time while delivering PPV should be 1 second or less. Although this flush volume may . *In this situation, intravascular means intravenous or intraosseous. Reassess heart rate and breathing at least every 30 seconds. In preterm newly born infants, the routine use of sustained inflations to initiate resuscitation is potentially harmful and should not be performed. There is a history of acute blood loss around the time of delivery. Newborn resuscitation requires anticipation and preparation by providers who train individually and as teams. The heart rate response to chest compressions and medications should be monitored electrocardiographically. 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. Epinephrine dosing may be repeated every three to five minutes if the heart rate remains less than 60 beats per minute. In a small number of newborns (n=2) with indwelling catheters, the 2 thumbencircling hands technique generated higher systolic and mean blood pressures compared with the 2-finger technique. Identification of risk factors for resuscitation may indicate the need for additional personnel and equipment. This content is owned by the AAFP. 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. 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. 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. Premature animals exposed to brief high tidal volume ventilation (from high PIP) develop lung injury, impaired gas exchange, and decreased lung compliance. Watch a recording of Innov8te NRP: An Introduction to the NRP 8th Edition: Three webinars hosted by RQI Partners to discuss changes to the 8 th edition NRP and the new RQI for NRP Posted 2/19/21. In preterm newborns (less than 35 wk of gestation) receiving respiratory support at birth, it may be reasonable to begin with 21% to 30% oxygen with subsequent oxygen titration based on pulse oximetry. Epinephrine is indicated if the heart rate remains below 60 beats per minute despite 60 seconds of chest compressions and adequate ventilation. Copyright 2021 by the American Academy of Family Physicians. For participants who have been trained in neonatal resuscitation, individual or team booster training should occur more frequently than every 2 yr at a frequency that supports retention of knowledge, skills, and behaviors. One observational study in newly born infants associated high tidal volumes during resuscitation with brain injury. There should be ongoing evaluation of the baby for normal respiratory transition. Naloxone and sodium bicarbonate are rarely needed and are not recommended during neonatal resuscitation. Available for purchase at https://shop.aap.org/textbook-of-neonatal-resuscitation-8th-edition-paperback/ (NOTE: This book features a full text reading experience. Another barrier is the difficulty in obtaining antenatal consent for clinical trials in the delivery room. Higher doses (0.05 to 0.1 mg per kg) of endotracheal epinephrine are needed to achieve an increase in blood epinephrine concentration. The baby could attempt to breathe and then endure primary apnea. One moderate quality RCT found higher rates of hyperthermia with exothermic mattresses.