Resucitation of newborn infants
Ola Didrik Saugstad
Department of Pediatric Research
Rikshospitalet, University of Oslo
NORWAY
Facts
•6-10 out of 130 mill newborns
need intervention at birth
•4 mill birth asphyxia
•1 mill die and a similar number
develop sequels due to birth
asphyxia (CP, Epilepsia)
•Most newborn infants
are born outside
hospitals without
health personel
attending
Newborn Resuscitation
Guidelines
Is newborn resuscitation
evidence based?
AHA and AAP in their last guidelines (2000)
summarised the literature and tried to determine
what is and what is not evidence based
If a procedure is not evidence based
evidenced based information should be collected
before the procedure in case is changed
Resuscitation of Newborn Infants
WHO: Basic Newborn Resuscitation
(WHO, Geneva 1998)
ILCOR: An Advisory Statement From the
Pediatric Working Group of the International
Liason Committee on Resuscitation.
(Pediatrics, April 1999)
AHA/AAP: International Guidelines for Neonatal
Resuscitation. (Pediatrics September 2000)
WHO guidelines
Anticipate
• Be prepared for every birth by having skill to
resuscitate and by knowing the institutions policy on
resuscitation
• Review the risk factors for birth asphyxia
• Clearly decide on the responsibilities of each health
care provider during resuscitation
• Remember that the mother is also at risk of
complications
WHO Guidelines
Risk factors for birth asphyxia
maternal illness
sexually transmitted diseases
malaria
eclampsia
maternal bleeding
maternal sedation
fever during labour
traumatic delivery
prolapsed cord
mec stained amniot fluid
congenital anomaly
prolonged labour
breech/other abn presnt
PROM
WHO Guidelines 1998
Prepare for birth
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
two clean towels for thermal protection and small)
a suction device ( mucus extractor)
a radiant heater (if available
a draught-free delivery room > 25oC
clean delivery kit for cord care, gloves
two infant masks (normal)
a blanket
a clock
an additional set of equipment in reserve for multiple births or in
case of failure of the first set
inform mother
open the airway - clear the airway by suctioning first the mouth
and then the nose
ventilate with appropriate mask (size 1 for a normal weight and 0
for a small newborn)
observe the rise of the chest
ventilate 40 (30-60) breaths/min
stop an look for spontaneous breathing after about 1 min
AHA/AAP 2000
Recommendations resulting from
collaboration among
–AHA Pediatric Subcommittee
–ILCOR Pediatric Working Group
–AAP Neonatal Resuscitation Program
Textbook and video is available
www.aap.org
Newborn Resuscitation
AHA/AAP Guidelines
Summary of changes from 1992
• Meconium -stained amniotic fluid: endotracheal suctioning
of the depressed - not the vigorous child
• Hyperthermia should be avoided
• 100% oxygen is still recommended, however if
supplemental oxygen is unavailable room air should be
used
• Chest compression: Initiated if heart rate is absent or
remains < 60 bpm despite adequate ventilation for 30 sec
• Medications: Epinephrine 0.01-0.03 mg/kg if heart rate <
60 bpm in spite of 30 seconds adequate ventilation and
chest compression
• Volume: Isotonic crystalloid solution or 0-neg blood
Newborn Resuscitation
Physiology
Secondary energy failure – an opportunity for treatment
Perinatal asphyxia – some basic facts
•Primary to 2nd apnea lasts 8-10 min.
Auto resuscitation possible
•Secondary apnea about 10 min
asphyxia. Auto resuscitation not
possible
•pCO2  10 mm Hg (1.3 kPa) /min
•Serum potassium 15 mmol/L after 10 min
•Base deficit  2/5 mmol/L/min in 8% O2
 2/3 mmol/L/min in 6% O2
Newborn Resuscitation
Clinical sequences
Resair 2
Time to first breath
(1.0-43.5)
minutes after birth
3
2
(0.25-27.5)
1'Hr > 80
1' Hr < 80
1' Hr < 60
(0.25-5.0)
1
0
1'Hr > 80
1' Hr < 80
1' Hr < 60
Median (5-95percentile)
Resair 2
Development in Apgar Scores
10
Apgar score
(4-9)
8
(3-9)
1' Apgar score
5' Apgar score
10' Apgar score
6
(1-7)
4
2
0
1'
5'
Minutes
10'
Median (5-95percentile)
Resair 2
heart rate beats per min
Heart rate related to 1 min Apgar score
150
Apgar 1 min >6
Apgar 1 min < 7
Apgar 1 min < 4
130
110
90
70
50
0
1
2
3
Min after birth
4
5
Oxygen saturation% during first minutes of life
Sauturation %
100
Asphyxia
Controls
75
50
25
0
0 1 2 3 4 5 6 7 8 9 10
minutes after birth
R Rao, S Ramji: Indian Pediatrics 2001;38:762-766
SaO2 during resuscitation related to 1 min heart rate
Min 1’HR >80
1’min HR <80
1’min HR < 60
1
70 (39-82)
60 (40-75)
45 (40-99)
3
85 (41-94)
85 (60-93)
76 (60-94)
5
90 (72-96)
90 (69-95)
80 (60-93)
10
93 (70-97)
90 (80-97)
90 (74-9)
Median , 5-95 percentiles
Development in Base Deficit
BD mmol/L
30
<4
>6
20
10
0
0
10
30
min after birth
60
Newborn Resuscitation
How to carry out?
AAP/AHA
Neonatal Resuscitation
The following questions should be answered after
every birth:
• Is the amniotic fluid clear of
meconium?
• Is the baby breathing or crying?
• Is there a good muscle tone?
• Is the color pink?
• Was the baby born at term?
If the answer is no to any of these consider resuscitation
Be prepared: every newborn baby might need resuscitation!
Neonatal Resuscitation
AHA/AAP (2000)
Four Categories
• Basic steps including rapid assessments
and initial steps of stabilisation
• Ventilation, including bag-mask or bag tube ventilation
• Chest compression
• Administration of medications or fluids
The most important is to get air into the lungs
Facts About Newborn Resuscitation
Bag and mask
Ventilate for 30 seconds:
Rate:
40-60 /min
Pressure: Visible rise and fall of chest
HR < 60
HR 60-100
Continue ventilation
Initiate chest compression
Consider intubation
Continue ventilation
Consider intubation
HR >100
HR > 100 bpm:
Check for spontaneous
respirations
Bag and mask the most important tool in newborn resuscitation
Expiratory tidal exchange
18
mL
16
14
12
10
face mask
intubation
8
6
4
2
0
1st breath
3rd breath
Milner A, et al
Ventilation
Even a few (6) blows with a too high tidal
volume (35-40 mL/kg) before surfactant
destroys the lungs of premature lambs
A too high or a too low tidal volume triggers
inflammatory changes in the lungs leading
to influx of phagocytes, proinflammatory
cytokines increase
Neonatal Resuscitation
Chest compressions - indication
Chest compressions should be performed
if the heart rate is < 60 beats/minute,
despite adequate ventilation with 100%
oxygen for 30 seconds. [ILCOR 1999
Advisory Statement],AHA- AAP 2000
Chest compression
If:
HR < 60 after 30 seconds ventilation and stimulation
• Thumb technique: Place your thumbs side by side or, on a small baby,
one over the other, immediately above xyphoid. The other fingers provide
support needed for the back
• Pressure so that you depress the sternum to a depth of approximately
1/3 of the anterior/posterior diameter of the chest. Then release.
• The downward stroke should be somewhat shorter than duration of the release.
• Your thumbs should remain in contact with the chest at all times
• 90 compressions + 30 breaths per min
”One and two and three and breath, and one and two and three and breath …”
Heart rate < 60 per min
%
9
8
7
6
5
4
3
2
1
0
60
90
180
300
seconds
Resair 2 – Pediatrics, 1998
Chest compression 19%
But needed in only 1-2% …
RESAIR 2
Neonatal Resuscitation
Room air vs. 100% Oxygen
If assisted ventilation is required, 100%
oxygen should be delivered by positive
pressure ventilation … If supplemental
oxygen is not available, resuscitation of
the newly born infant should be initiated
with positive pressure ventilation and
room air.
AAP/AHA 2000:
Not sufficient data to change present guidelines
(grandfather principle)
RESAIR 2
Room air vs 100% oxygen
Saugstad, Rootwelt, Aalen on behalf of the Resair 2 Study Group et al Pediatrics, 1998; 102:e1
Median time (min) to first cry
Saugstad et al 1998
21% O2
100% O2
p
1.6
2.0
0.005
Ramji et al 2003
2.0
3.0
0.008
•Duration of ventilation significantly shorter ( 2 min)
in room air group. Saugstad et al, 1998, Vento et al, 2001
•Oxygen resuscitated received 350 ml more O2 than
room air resuscitated. Vento et al, 2003
0
1
2
3
Odds Ratio
.
Favoring 21% .. Favoring 100%
.
.
Ramji et al
.
.
.
.
.
.
Saugstad et al
.
1737 newborn in 5 studies
.
.
randomized to 21 or 100% O2
.
.
Vento et al
.
.
.
Neonatal mortality 21% 100% O2
.
.
Total
% 8
13
.
Ramji et al
.
.
Spain
% 0.5
3.5
.
.
. 0.58 (95% CI 0.43-0.80)
.
Typical estimate
:
0
1
2 odds ratio
Neonat mortality
Term
A 5% reduction in mortality
indicates approx 200,000 saved
lives worldwide
Preterm
Apgar 1min < 4
A 3% reduction in mortality
indicates approx 6000 saved
lives in both North America
and Western Europe
All infants
Favoring 21%
Favoring 100%
Adverse effects of resuscitation with 100% O2
Clinical data
•Prolonges time to first breath
•Prolonges duration of positive pressure ventilation
•Elevates oxidative stress (at least 4 weeks)
•Increases neonatal mortality
3% in industrialised, 5% in developing countries
• Associated with acute lymphatic leukemia
Experimental data
\ lungs
• Inflammation in brain, myocardium and
•Increases neuronal damage?
•Poorer neurological outcome
Is the highest Apgar score always best?
Saturation %
100
Asphyxia
Controls
75
50
25
0
Virginia Apgar
0 1 2 3 4 5 6 7 8 9 10
minutes after birth
R Rao, S Ramji: Indian Pediatrics 2001;38:762-766
0_________
1__________
2_____
Heart rate
0
<100
>100
Respiration
0
weak, irregular
good cry
Reaction
0
slight
good
Colour
blue or pale body pink limbs blue all pink
Tone
limp
some movement
active movements
limbs well flexed
Drugs needed for
Newborn Resuscitation
Neonatal Resuscitation
Epinephrine dose
The recommended IV or endotracheal
dose of epinephrine is 0.1 to 0.3 mL/kg
of a 1:10,000 solution (0.01 to 0.03
mg/kg) repeated every 3 to 5 minutes
as indicated.
Higher doses have been associated with increased risk
of intracranial hemorrhage and myocardial damage.
No different dose for premature infants
Neonatal Resuscitation
Volume expansion
Volume expansion may be accomplished with
(1) isotonic crystalloid such as normal saline
or Ringer’s lactate or (2) O-negative blood.
[Class IIb, level 7 evidence]
Neonatal Resuscitation
Cerebral Hypothermia
Cerebral hypothermia cannot presently be
recommended for newly born infants who
have experienced severe perinatal
asphyxia.
Hyperthermia appears to be injurious and
should be avoided.
Neonatal Resuscitation
Ethics
There are circumstances in which non-initiation
or discontinuation of resuscitation in the
delivery room may be appropriate…
AHA-AAP 2000
Neonatal Resuscitation
Ethics
Non-initiation of resuscitation in the delivery
room may be appropriate in infants with:
• confirmed gestation < 23 weeks
• birthweight < 400 grams
• anencephaly
• confirmed trisomy 13 or 18 may be
appropriate.
Current data support that resuscitation of these
newborns is very unlikely to result in survival
or survival without severe disability.
AHA/AAP 2000
Neonatal Resuscitation
Ethics
In cases of uncertain prognosis, including
uncertain gestational age, a trial of therapy,
non-initiation, or discontinuation of
resuscitation remain options following
assessment of the baby. Ongoing evaluation
and discussion with the parents and the health
care team should guide continuation vs.
withdrawal of support.
AHA/AAP 2000
Documentation
Written documentation of
• Personal involved
• All procedures including drugs
• Timing
Post resuscitation care
infants (especially preterm) who required
resuscitation are at increased risk for all of the
general post-resuscitation complications,
especially:
•
•
•
•
•
•
Heat loss
Develop RDS due to immature lungs
Intracranial hemorrhage due to a fragile
germinal matrix
Hypoglycemia
Necrotizing enterocolitis
Oxygen injury
Resuscitation of Preterm Infants
No specific guidelines. No clinical trials
WHO: principles are the same for preterm and
term
ILCOR: No specific recommendations
AHA/AAP: ”Prematurity pointers”
Avoid rapid boluses of volume expanders or
hyperosmolar solutions.
Avoid heat loss.
Handle with care in order to prevent ICH
AHA-AAP 2000
Neonatal Resuscitation
Meconium
• Direct endotracheal suctioning may not be
necessary in the apparently vigorous infant
with meconium-stained fluid.
• Direct endotracheal suctioning, using the
endotracheal tube as a suction catheter, should
be performed if the neonate is depressed.
Newborn Resuscitation
Some conclusions
• preparation and teaching in the bottom of successful
resuscitation
• ventilation is the primary goal
• oxygenation can in most cases be obtained by room air
- more studies are needed
• Chest compression and drugs are rarely needed
• ethics should carefully be considered
• each step should be assessed scientifically - more
research
WHO Guidelines
Resuscitation practises not effective or even harmful
• routine aspiration of babies mouth and nose
• routine aspiration of stomach
• stimulation by slapping or flicking the soles of its feet
• postural drainage or slapping the back
• squeezing the chest to remove secretions
• routine giving sodium bicarbonate to newborns who
are not breathing
WHO Guidelines
Care after successful resuscitation
• do not separate mother and newborn- skin-to
skin
• examine the newborn (body temp, count
breaths, observe indrawing and grunting,
malformations, etc)
• record the resuscitation and the problems, if
any
• clean the equipment and prepare for the next
birth
Neonatal Resuscitation
Confirmation of ETI
Expired CO2 detection can be useful
in the secondary confirmation of
endotracheal intubation in the
newly born, particularly when
clinical assessment is equivocal.
In newborns, data are limited and the frequent circumstances of
inadequate pulmonary expansion, decreased pulmonary blood flow
and small tidal volumes make extrapolation from other age groups
especially hazardous.