1. Neonatal Resuscitation Program™ and Helping Babies Breathe®
The past, present, and future of neonatal resuscitation efforts worldwide
(and lessons learned along the way)
Good afternoon!
On behalf of the American Academy of Pediatrics, I thank you for inviting us to be here with you this week to conduct training sessions in our Helping Babies Breathe program.
We are extremely pleased with how well the program has been received…and the extent of its reach…over these short 18 months since it was launched in June 2010.
Neonatal resuscitation has been a professional…and personal…passion of mine for many years. I am honored to have this opportunity today to talk with you about the past, present and future of neonatal resuscitation efforts worldwide…as well as some of the lessons I personally have learned along the way.
Errol R. Alden, MD, FAAP
AAP Executive Director/CEO
November 2011

2. Objectives
Provide an overview of the AAP’s “Neonatal Resuscitation Program” and “Helping Babies Breathe”
Highlight the importance of working with local authorities
Demonstrate the translation of science into practice
Share lessons learned

3. Neonatal Resuscitation
Of the 130 million babies born each year, about 4 million die in the first 4 weeks of life. A quarter of these deaths are due to asphyxia.
It is estimated that an additional million develop problems such as cerebral palsy and other disabilities.
World Health Report 2005

4. Neonatal Resuscitation
The vast majority of newborn infants do not require intervention from intrauterine to extrauterine life.
Approximately 10% of newborns require some assistance to begin breathing at birth.
About 1% of newborns require extensive resuscitation

5. Inverted Pyramid of Neonatal Resuscitation
136 million babies born
Assessment at Birth and Simple Newborn Care
All infants
Initial Steps: Drying, Warmth, Clearing the Airway, Stimulation
Approx 10 million babies
Approx 6 million babies
Some infants
Positive-Pressure
Ventilation
However, the benefits to be realized are enormous. Recent estimates published in the October supplement to the International Journal of Obstetrics and Gynecology suggest that 16 million babies could be helped – saved from death or possible disability – through universal application of neonatal resuscitation.
Chest
Compressions
< 1.4 million babies
Few infants
Medications
Wall, Lee, Niermeyer et al. IJGO 2009

6. Pathophysiologic Cardio-Pulmonary Consequences of Asphyxia
Dad knew what to do…
The science is there.
Dawes Foetal and Neonatal Physiology. Year Book Medical Publishers Inc; 1968.

7. Some Recommendations for Resuscitation (1850-1950)
Rectal stimulation (stretching of the rectum with a corn cob)
Tobacco smoke blown into the rectum
Immersion into cold water(+ alternating with warm water)
Before NRP there were some novel approaches to Neonatal Resuscitation.

8. Some Recommendations for Resuscitation (1850-1950)
Intragastric oxygen
Rhythmic traction of the tongue
Rubbing, slapping, and pinching
Raising and lowering of the arms, while an assistant compresses the chest O2

9. Consequences of Poor Neonatal Resuscitation
Increased Death
Increased Disability
Emotional & Financial Burden
Direct Community Costs
Loss of Productivity

10. Neonatal Resuscitation Program
mid-1970s: Dr Bloom and Cathy Cropley receive NICHD award to develop an initial simple way to focus neonatal resuscitation teaching
1981: Dr George Peckham, an AHA volunteer and AAP Perinatal Section Chair, advocated for development of a standardized core curriculum
1985: Dr Peckham and Dr Leon Chameides discussed models and outlined the “train the trainer” approach for dissemination
Ron Bloom
The AAP takes up the mantle…
Cathy Cropley

11. Neonatal Resuscitation Program
1986: Dr Peckham and Dr Bill Keenan, AAP Perinatal Section Leaders, began seeking buy-in from neonatology community for such an endeavor
First NRP textbook (1987): based on consensus opinions of leaders in neonatology regarding what was “accepted” practice
First 2-day NRP course occurred in November 1987

12. The Neonatal Resuscitation Program
American Academy of Pediatrics
American Heart Association
The NRP is designed to guide resuscitation of the newborn infant in the critical few minutes during and immediately following birth.

13. NRP: Program Goal To have at least one person
trained in neonatal resuscitation
present at every delivery in the
United States.

14. Mead Johnson Nutritionals: Neonatal Resuscitation
Early NRP
Click again to play the video!
Mead Johnson Nutritionals: Neonatal Resuscitation

15. NRP: US Program History
In 24 years:
2.9 million providers have been trained/retrained.
Currently in the United States:
There are more than 27,000 active instructors.
Approximately 130 courses are held each day.
May want to note: that we are only approximately 30,000 providers away from having trained/retrained 3 million providers!

16. Lesson #2: Convince others the mission is their own
After establishing the NRP as an effective tool for teaching neonatal resuscitation in the US, we took on the task of disseminating the message around the world.
Through thousands of hours of volunteer time, the NRP has been established in Laos…Thailand…Turkey…Romania…Brazil…Egypt…and China.
Major key to our success was recognizing that the most effective strategy is to convince others that the mission is their own – rather than a simple implementation of what others have advocated.
These photos were taken during our trip to teach the program in Romania in December That marked the first time the AAP took the program international.
Romania
1991

17. NRP 6th Edition Update Pulse oximetry added
Meconium suctioning recommendations changed
Use of supplemental oxygen during resuscitation
Use of Pulse Oximetry
• Having pulse oximeters available in delivery areas is encouraged and is highly recommended for use whenever supplemental oxygen, positive pressure ventilation or continuous positive airway pressure are considered necessary.
• If chances are high that you’re going to deliver a pre-term infant, the guidelines recommend having an oximeter immediately available for application.
Elimination of Evaluation of Amniotic Fluid in Initial Rapid Assessment
• Results from a randomized controlled study concluded if a baby is crying and breathing well, there is no reason to treat a meconium-stained baby any differently than a baby born through clear fluid, except for continuing to evaluate the baby carefully for evidence of compromise. That evaluation should be able to take place while the baby remains
with the mother.
• Meconium has been removed from the rapid assessment algorithm regarding the four questions to ask when deciding whether or not to begin resuscitation; thus, an active meconium-stained newborn can be kept with his mother.
• If a baby is floppy and bradycardic he should be brought to the resuscitation table to be intubated and meconium-stained baby’s trachea suctioned; however, if the baby has good tone and is breathing well despite the presence of meconium, the baby should
remain with his mother.
Use of Supplemental Oxygen During Neonatal Resuscitation
• In most infants, beginning resuscitation with 100% supplemental oxygen offers no apparent advantage over beginning resuscitation with 21% oxygen.
• Using room air may be associated with slightly lower mortality rates.
• Using 100% oxygen may result in some degree of measurable tissue injury
• The latest available scientific evidence has shown that the concept of increasing a newborn’s oxygen level as fast as possible with 100% supplemental oxygen is probably not the best approach. Rather, starting resuscitation of term babies with room air (ie: no supplemental oxygen) and carefully assessing the amount of oxygen needed for both term and preterm babies will be the recommendation.
• Additional epidemiologic studies suggest that exposure to supplemental oxygen in the delivery room can cause short- and long-term issues; however, further prospective studies are needed to confirm this observation.

18. NRP 6th Edition Update, Continued
Increase time between initiating chest compressions and interrupting compressions to assess heart rate
Induced therapeutic hypothermia
Simulation-based educational methodology
Chest Compressions
• Chest compression to ventilation ratio will remain the same with three chest compressions to one ventilation (3:1).
• If chest compressions are started, whenever possible, performing endotracheal intubation is strongly recommended.
• Use of the two-thumb versus the two-finger technique is preferred. (Studies performed by Dr Myra Wyckoff have shown that using two-thumb technique to deliver compressions results in a greater amount of time that compressions will be performed to correct depth and rate)
• Increase time between initiating chest compressions and interrupting compressions to assess heart rate from 30 seconds to seconds or longer.
Induced Therapeutic Hypothermia
• Use induced therapeutic hypothermia in a tertiary care center when it can be implemented
using well-defined protocols and where appropriate follow-up is available.
Teaching Methodologies for Encouraging Simulation and Debriefing
• A majority of studies demonstrate that the use of simulation-based learning methodologies
enhances learner performance in simulated resuscitations in laboratory and classroom settings and may improve resuscitation quality in real-life clinical situations.
• In the classroom setting, the primary focus of the new NRP will be a realistic active learning environment with hands-on skills practice, case-based resuscitation scenarios and team briefing and debriefing sessions following hands-on training exercises.

19. Textbook of Neonatal Resuscitation, 6th Edition, 2011
NRP Now
Click slide again when you’re ready to play video!
This video is showing a pulse oximeter probe being attached to a baby's right hand. 
Pulse Oximetry is new to the NRP 6th Edition
An oximeter should be used to confirm the perception of cyanosis (this replaces the "color" assessment on the old algorithm. Rationale for switch is bulleted below).
Studies have shown that clinical assessment of skin color is not very reliable, and varies as a function of skin pigmentation.
Other studies have documented that babies undergoing normal transition may take several minutes after birth to increase their blood oxygen saturation from approximately 60%, which is the normal intrauterine state, to more than 90%, which is the eventual state of air-breathing healthy newborns.
It is not unusual for a newborn to appear slightly cyanotic for the first few minutes after birth.  If the cyanosis persists, you should attach a pulse oximetry probe to determine if the baby's oxygenation is abnormal.  If the levels are low and not increasing, you may need to provide supplemental oxygen. 
Other changes to the 6th edition include meconium suctioning and de-emphasis on using 100% oxygen (this is what the NRP THEN video shows - so may be helpful to tie in here that there are several changes with the 6th Ed). 
Textbook of Neonatal Resuscitation, 6th Edition, 2011

20. NRP Outcomes
Asphyxia decreased in 10 provinces in China after training with NRP. (Huishan et al 2008)
In the first decade, deaths due to birth asphyxia in the US decreased 42%. (Wegman 1991)
Introduction of NRP in 10 hospitals in India reduced overall neonatal mortality by 7 per (Deorari 2000)

21. NRP Outcomes, Continued
Intrauterine hypoxia and birth asphyxia was:
the 10th leading cause of infant death in 1996 – a 72.4% change since 1979.
the 14th leading cause of infant death in 2008 – a 79.5% change since 1979.
Side note: since the annual summary of vital stats only covers the top 10 leading causes, intrauterine hypoxia and birth asphyxia is not listed on the most recent table published in Pediatrics. Thus, the graphic on this slide is for 1996.
Guyer B et al. Annual Summary of Vital Statistics
Pediatrics 1997; 100:90

22. the NRP is the most widely used
NRP: Reach of Program
Although reporting of international NRP courses is voluntary, training has been reported in more than 125 countries and translated into 26 languages.
Of all the educational material produced by the American Academy of Pediatrics,
the NRP is the most widely used
around the world.

23. Lesson #3: Expertise doesn’t necessarily equal ability to teach
Our trip to Laos and Thailand was quite the experience.
Stories:
Switching boxes of program materials
Laos participant offered a true compliment: “This is the first time anyone has ever taught me how to teach neonatal resuscitation.”
Laos & Thailand

24. Lesson #4: Being an expert in your own country doesn’t mean you’re an expert in other countries.
We also found that…in order to effectively export the NRP…we needed to make sure the program was accepted and endorsed by the local experts…and then delivered in their language.

25. Transferability….to more than 125 countries
NRP Reach
Sites of NRP Implementation
Over and over in the ILCOR guidelines process and the international dissemination of NRP it became clear that there was a huge unmet need – a need to train birth attendants in simple livesaving skills in areas of the world where neonatal mortality is the highest.
Transferability….to more than 125 countries

26. Lesson #5: Humor may not translate, but laughter is universal
Some of my favorite memories involve traveling around the world…teaching neonatal resuscitation to our colleagues in other countries.
Our adventures have been both educational and enjoyable...and I learned the importance of being able to see the humor in even the most trying situations.
Take for example our trip to Romania…
Far Side cartoon
Nursing chair
Data: “What numbers would you like to see?”

27. NRP in Developing Countries
While NRP has been embraced internationally, the content and format is routinely altered to meet the needs of the learners in developing countries.

28. NRP in Developing Countries
The challenge has been to develop a curriculum, based on the same rigorous science of NRP, that is culturally effective and meets the needs of those who live in resource limited settings.

29. NRP in Developing Countries
Developing an effective curriculum for limited resource settings would impact Millennium Development Goal #4, which is to reduce by two thirds, the under-five mortality rate.

30. Helping Babies Breathe®
An educational program for birth attendants in first-level health facilities and the community
Strong educational methodology to promote mastery and utilization of bag-mask ventilation
Pictorial materials
Pair learning/teaching with purpose-built simulator
Support for continued practice and learning
Reinforcement of lifesaving fundamentals of care for all babies and development of additional lifesaving skills of bag and mask ventilation:
Cleanliness
Warmth
Early breastfeeding
Catalyst for further development of the perinatal health care system

31. Global Causes of Neonatal Death
The causes of neonatal death globally also remind us that infection and prematurity, play major roles in addition to asphyxia.
Any intervention must address not only asphyxia, but also cleanliness and hygiene as well as warmth and early nutrition for small babies.
A forthcoming meta-analysis of in-facility resuscitation training concluded that death from asphyxia, or intrapartum-related events, could be reduced by 30% in term infants and preterm mortality reduced by 5-10% through neonatal resuscitation. [International Journal of Obstetrics and Gynecology 107 (2008) S47-S64]
UNICEF 2007
Lee, Wall, Cousens et al. Int J Epidemiol (in press) 31

32. Big Target of Helping Babies Breathe
How many babies are dying? Globally, nearly 4 million newborns die each year in the first month of life.
As seen before, about one quarter of these die because they fail to breathe at birth – a simple definition of asphyxia.
In addition to these, there are over 3 million babies who are termed stillbirths .
Among these are some babies who just are not breathing, and who can be helped with simple measures.
Together, each year hundreds of thousands of babies can be helped to breathe at birth.
1 million “stillbirths” due to asphyxia
830,000 neonatal deaths due to asphyxia
Lawn JE et al. IJGO 2009; 107:S5 32

33. Helping Babies Breathe Concept
International Liaison Committee on Resuscitation (ILCOR) Science
Harmonious With NRP & WHO Recommendation, if feasible
Non-Profit, Inclusive
Directed To Resource Limited Conditions - Single Provider
ILCOR (International Liaison Committee on Resuscitation)
Going forward, all of ILCOR will meet once per year. ILCOR’s neonatal delegation, however, will still meet twice per year.

34. Helping Babies Breathe Curricular Concept
Pictorial
Limited Text
Hands On Performance
Frequent Skills Practice
Simplest Steps “Possible”
The Golden Minute

35. Hands on Practice 35

36. Educational Design Adult Learning - TOT, Visual Tool kit Hands on
Performance - OSCE Evidence-Based
Learner to Facilitator - 6:1
Learning in Pairs
TOT = Training of Trainers
OSCE = Objective Structured Clinical Examination

37. Paired Teaching/Learning

38. Neonatal Physiology Hypoxia-apnea, slow heart rate
Breathing for the Baby-rapid reversal
Delays-increase mortality, morbidity

39. Field Testing Educational Approaches Tanzania, Kenya, India, Pakistan
Modified MCQ, Problem-Solving, OSCE
Simulator
India
Implementation Studies
Kenya, India, Bangladesh

40. Educational Field Testing Birth Attendants
Increase Level of Skills Attained
Testing OSCE
Revision of MCQs
Revision of Bag/Mask Instruction
Revision of OSCEs

41. Implementation Field Testing
Knowledge Acquisition improved
Skills Testing – 98% Passed
Resuscitation Required ↑ Stimulation ↓ BMV, Suction
6-12 Hours of Training
Summary from two field studies in Tanzania and Kenya. These are results that are reported to us and I generally do not put them forward as conclusive, only encouraging.
Knowledge Acquisition--significant and consistent improvement in the multiple choice answers
Skills Testing--at the end of the training 98% of all participants passed the Bag and Mask Skills testing and both OSCEs. This is the major step in the educational evaluation.
Resuscitation Required--showed the changes in directly observed resuscitation practice in Tanzania. Somewhat redundant but % of babies requiring resuscitation went down, more early steps were used and less Bag and Mask Ventilation or airway suctioning was used.
Hours of Training--what time these successful courses used to achieve the results.

42. Clinical Outcomes
↓ death at 24 hours among babies not breathing at birth (RR = 0.46) with no change in stillbirths - Tanzania
N=6928/7277 pre/post training
↓ stillbirths (RR = 0.73) with no change in neonatal deaths – India
N=4173/5427 pre/post training
Initial data from field testing; not yet published
Note: different groups with different needs make analysis of the data difficult

43. Helping Babies Breathe Tool Kit
Action Plan
Learner Workbook
Facilitator Flip Chart
Multiple Choice Questions
OSCE
Simulator-Purpose Built
Bag/Mask/Suction/Stethoscope
Objective Structured Clinical Examination (OSCE)

44. Flipchart
Simulator
Workbook 44

45. Routine Care Clearing the airway if meconium present Drying infant
Recognize crying
Keeping warm
Cutting the umbilical cord
Encouraging breastfeeding 45

46. The Golden Minute® Recognizing infant not crying Positioning head
Clearing the airway
Stimulating
Recognizing breathing
Initiating ventilation by 1 minute 46

47. Global Development Alliance for Country-Wide Implementation
American Academy of Pediatrics
US Agency for International Development
Saving Newborn Lives/Save the Children
Eunice Kennedy Shriver National Institute of Child Health and Human Development
Laerdal Global Health
I’d like to welcome a few partners who are at the course today:
From the AAP HBB Task Force – George Little, Rob Clark, Jonathan Spector
From USAID – Troy Jacobs
From NICHD – Linda Wright
These individuals bring a great deal of experience teaching both NRP and HBB around the world.

48. Global Development Alliance
Overall Objective
Reduce newborn mortality due to asphyxia
Guiding Principles
Inclusiveness and collaboration
Country-owned and country-led
Integration with maternal and essential newborn care
Shared goal, results, and recognition
Brand non-exclusivity
To support the implementation of Helping Babies Breathe on a large scale, key organizations involved in the development of HBB have joined together in a Global Development Alliance, with the overall objective to reduce newborn mortality due to asphyxia.
USAID through it implementing partners is supporting training programs at national scale.
NICHD, the National Institute of Child Health and Human Development, is working to improve methods for monitoring and evaluation, and recently received fnding for a large impact evaluation of HBB.
Save the Children serves as a catalyst to build partnerships among stakeholders and strengthen health policy.
Laerdal Medical is working to improve the functionality and availability of both training materials and clinical equipment.
The American Academy of Pediatrics supports advocacy and training with technical expertise and a commitment to ongoing revision and improvement of materials to reflect new science and evaluation by users in the field. 48

49. Global Development Alliance
The GDA continues to grow each day with new partners:
Johnson and Johnson
Latter Day Saints Charities
Soon to be added:
Columbia University Earth Institute Millennium Villages/Cities Project
International Pediatric Association
You’ve already met Rob Clark who represents Latter Day Saints Charities and brings a unique family practice perspective to the partnership. I’d also like to welcome to Jason Sperinck from Johnson and Johnson and Elana Jacobs from Millennium Villages, who are also attending the HBB course.

50. Ongoing Steps Global Development Alliance NICHD Studies
Country-wide Implementation
Facilitator Video
Translations
ENC (Essential Newborn Care) and EMONC (Emergency Obstetric and Neonatal Care)
ENC = Essential Newborn Care
EMONC = Emergency Obstetric and Neonatal Care

51. Fit with Essential Newborn Care
Thermal Protection
Clean Delivery
Cord Management
Early Breast Feeding
Resuscitation As Required

52. Hypothesis From Experience
Improving Skill in Neonatal Resuscitation Spurs Improvements in Other Components of Early Neonatal Care.

53. Helping Babies Breathe
Sustainability
Simple and evidence- based
Low-cost and effective
Easy to integrate with other essential parts of NB care
The program is designed be sustainable and integrated into the health system.
Although HBB can be used alone as a complete resuscitation course, it is easily integrated into Essential Newborn Care as the resuscitation component.
Training can become part of preservice education as well as inservice education.
Learners are encouraged to continue their learning outside the classroom with supervised practice in the clinical setting, self-reflective learning, and case reviews.
Helping Babies Breathe can serve as the keystone for further development of maternal and neonatal care into an integrated system of perinatal care and quality improvement.
This in-charge nurse in a rural health post in Kenya is beaming because at last she sees a way that she can train her staff to help babies breathe and make a difference in her community. She took the baby in her arms and renamed her Gladys. 53

54. Big Hairy Audacious Goal
BHAG
Big Hairy Audacious Goal
To have at least one person
trained in neonatal resuscitation
present at every delivery in the
WORLD

55. Helping Babies Breathe
This video shows the work of Helping Babies Breathe-trained birth attendants in Eldoret, Kenya.

56. Lesson #6: A healthy first cry represents a baby with unlimited potential
Share story re: how quiet things are in the delivery room are until the baby lets out its first cry and the tension quickly lowers.

57. Thank you for taking the time from your busy schedules to attend this Grand Rounds session.
It’s been an honor and a privilege to be here with you today and to have this opportunity to share some of the American Academy of Pediatrics’ efforts to ensure that every baby gets the same start at life…regardless of where he or she is born.
At this time, let’s open the floor to questions and/or comments.