Department of Pediatric Research Rikshospitalet, University of Oslo 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 maternal illness traumatic delivery Risk factors for birth asphyxia maternal illness traumatic delivery sexually transmitted diseases prolapsed cord malaria mec stained amniot fluid eclampsia congenital anomaly maternal bleeding prolonged labour maternal sedation breech/other abn presnt fever during labour 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

Recommendations resulting from collaboration among 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

Primary to 2nd apnea lasts 8-10 min. Auto resuscitation possible 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 Median (5-95percentile)

Resair 2 Median (5-95percentile)

Resair 2

Oxygen saturation% during first minutes of life

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

Newborn Resuscitation How to carry out?

Neonatal Resuscitation AAP/AHA 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

Facts About Newborn Resuscitation The most important is to get air into the lungs Facts About Newborn Resuscitation

Bag and mask HR < 60 HR 60-100 HR >100 Ventilate for 30 seconds: Rate: 40-60 /min Pressure: Visible rise and fall of chest HR < 60 HR 60-100 HR >100 Continue ventilation Initiate chest compression Consider intubation Continue ventilation Consider intubation HR > 100 bpm: Check for spontaneous respirations

Bag and mask the most important tool in newborn resuscitation

Expiratory tidal exchange 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 % 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 Ramji et al 2003 21% O2 1.6 2.0 100% O2 2.0 3.0 p 0.005 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% 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 21% 100% O2 Total % 8 13 Spain % 0.5 3.5 Vento et al Neonatal mortality Ramji et al 0.58 (95% CI 0.43-0.80) Typical estimate

0 1 2 odds ratio Neonat mortality Term Preterm Apgar 1min < 4 All infants A 5% reduction in mortality indicates approx 200,000 saved lives worldwide A 3% reduction in mortality indicates approx 6000 saved lives in both North America and Western Europe 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 Inflammation in brain, myocardium and lungs Increases neuronal damage? Poorer neurological outcome \

Is the highest Apgar score always best? Virginia Apgar 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

Neonatal Resuscitation Meconium 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.