1. Department of Pediatric Research Rikshospitalet, University of Oslo
Resucitation of newborn infants
Ola Didrik Saugstad
Department of Pediatric Research
Rikshospitalet, University of Oslo
NORWAY

2. 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

3. Newborn Resuscitation
Guidelines

4. 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

5. 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)

6. 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

7. 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

8. 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

9. 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

10. 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 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

11. Newborn Resuscitation
Physiology

14. Secondary energy failure – an opportunity for treatment

15. 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

20. Newborn Resuscitation
Clinical sequences

22. Resair 2
Median (5-95percentile)

23. Resair 2
Median (5-95percentile)

24. Resair 2

25. Oxygen saturation% during first minutes of life

26. SaO2 during resuscitation related to 1 min heart rate
Min 1’HR > ’min HR < ’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

29. Newborn Resuscitation
How to carry out?

30. 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!

31. 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

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

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

35. Bag and mask the most important tool in newborn resuscitation

36. Expiratory tidal exchange
Milner A, et al

37. 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

38. 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

39. 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 …”

40. Heart rate < 60 per min %
seconds
Resair 2 – Pediatrics, 1998

41. Chest compression 19%
But needed in only 1-2% …
RESAIR 2

42. 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)

43. RESAIR 2 Room air vs 100% oxygen
Saugstad, Rootwelt, Aalen on behalf of the Resair 2 Study Group et al Pediatrics, 1998; 102:e1

44. Median time (min) to first cry
Saugstad et al Ramji et al 2003
21% O
100% O p
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

45. .............. 0 1 2 3 Odds Ratio Favoring 21% Favoring 100%
Odds Ratio :
Favoring 21% Favoring 100%
Ramji et al
Saugstad et al
1737 newborn in 5 studies randomized to 21 or 100% O2
21% % O2
Total %
Spain %
Vento et al
Neonatal mortality
Ramji et al
0.58 (95% CI )
Typical estimate

46. 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%

47. 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 \

48. Is the highest Apgar score always best?
Virginia Apgar
0_________ __________ _____
Heart rate < >100
Respiration weak, irregular good cry
Reaction slight good
Colour blue or pale body pink limbs blue all pink
Tone limp some movement active movements
limbs well flexed

49. Drugs needed for Newborn Resuscitation

50. 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

51. 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]

52. 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.

53. Neonatal Resuscitation Ethics
There are circumstances in which non-initiation or discontinuation of resuscitation in the delivery room may be appropriate…
AHA-AAP 2000

54. 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

55. 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

56. Documentation Written documentation of Personal involved
All procedures including drugs
Timing

57. 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

58. 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

59. 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.

60. 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

61. 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

62. 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

63. 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.