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The Neonatal Resuscitation Program, which was initiated in 1987 to identify infants at risk of needing resuscitation and provide high-quality resuscitation, underwent major updates in 2006 and 2010. One small manikin study (very low quality), compared the 2 thumbencircling hands technique and 2-finger technique during 60 seconds of uninterrupted chest compressions. Pulse oximetry with oxygen targeting is recommended in this population.3, Most newborns who are apneic or have ineffective breathing at birth will respond to initial steps of newborn resuscitation (positioning to open the airway, clearing secretions, drying, and tactile stimulation) or to effective PPV with a rise in heart rate and improved breathing. Epinephrine is indicated if the heart rate remains below 60 beats per minute despite 60 seconds of chest compressions and adequate ventilation. In resource-limited settings, it may be reasonable to place newly born babies in a clean food-grade plastic bag up to the level of the neck and swaddle them in order to prevent hypothermia. It may be possible to identify conditions in which withholding or discontinuation of resuscitative efforts may be reasonably considered by families and care providers. In newborns who do not require resuscitation, delaying cord clamping for more than 30 seconds reduces anemia, especially in preterm infants. The heart rate should be re-checked after 1 minute of giving compressions and ventilations. 0.5 mL 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). The following knowledge gaps require further research: For all these gaps, it is important that we have information on outcomes considered critical or important by both healthcare providers and families of newborn infants. The very limited observational evidence in human infants does not demonstrate greater efficacy of endotracheal or intravenous epinephrine; however, most babies received at least 1 intravenous dose before ROSC. Before giving PPV, the airway should be cleared by gently suctioning the mouth first and then the nose with a bulb syringe. 5 minutec. Infants with unintentional hypothermia (temperature less than 36C) immediately after stabilization should be rewarmed to avoid complications associated with low body temperature (including increased mortality, brain injury, hypoglycemia, and respiratory distress). In term and preterm newly born infants, it is reasonable to initiate PPV with an inspiratory time of 1 second or less. These 2020 AHA neonatal resuscitation guidelines are based on the extensive evidence evaluation performed in conjunction with the ILCOR and affiliated ILCOR member councils. A large observational study found that delaying PPV increases risk of death and prolonged hospitalization. In this review, we provide the current recommendations for use of epinephrine during neonatal . Effective and timely resuscitation at birth could therefore improve neonatal outcomes further. There should be ongoing evaluation of the baby for normal respiratory transition. No type of routine suctioning is helpful, even for nonvigorous newborns delivered through meconium-stained amniotic fluid. However, it may be reasonable to increase inspired oxygen to 100% if there was no response to PPV with lower concentrations. A systematic review (low to moderate certainty) of 6 RCTs showed that early skin-to-skin contact promotes normothermia in healthy neonates. Multiple clinical and simulation studies examining briefings or debriefings of resuscitation team performance have shown improved knowledge or skills.812. The chest compression technique of using two thumbs, with the fingers encircling the chest and supporting the back, achieved better results in swine models compared with the technique of using two fingers, with a second hand supporting the back. Dallas, TX 75231, Customer Service Historically, the repeat training has occurred every 2 years.69 However, adult, pediatric, and neonatal studies suggest that without practice, CPR knowledge and skills decay within 3 to 12 months1012 after training. With growing enthusiasm for clinical studies in neonatology, elements of the Neonatal Resuscitation Algorithm continue to evolve as new evidence emerges. Epinephrine is indicated if the infant's heart rate continues to be less than 60 bpm after 30 seconds of adequate PPV with 100 percent oxygen and chest compressions. Epinephrine use in the delivery room for resuscitation of the newborn is associated with significant morbidity and mortality. Comprehensive disclosure information for writing group members is listed in Appendix 1(link opens in new window). diabetes. This link is provided for convenience only and is not an endorsement of either the linked-to entity or any product or service. Check the heart rate by counting the beats in 6 seconds and multiply by 10. For infants born at less than 28 wk of gestation, cord milking is not recommended. For nonvigorous newborns delivered through MSAF who have evidence of airway obstruction during PPV, intubation and tracheal suction can be beneficial. Uncrossmatched type O, Rh-negative blood (or crossmatched, if immediately available) is preferred when blood loss is substantial.4,5 An initial volume of 10 mL/kg over 5 to 10 minutes may be reasonable and may be repeated if there is inadequate response. Team briefings promote effective teamwork and communication, and support patient safety.8,1012, During an uncomplicated term or late preterm birth, it may be reasonable to defer cord clamping until after the infant is placed on the mother and assessed for breathing and activity. The AHA has rigorous conflict of interest policies and procedures to minimize the risk of bias or improper influence during development of the guidelines.13 Before appointment, writing group members and peer reviewers disclosed all commercial relationships and other potential (including intellectual) conflicts. When providing chest compressions to a newborn, the 2 thumbencircling hands technique may have benefit over the 2-finger technique with respect to blood pressure generation and provider fatigue. 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. Briefing has been defined as a discussion about an event that is yet to happen to prepare those who will be involved and thereby reduce the risk of failure or harm.4 Debriefing has been defined as a discussion of actions and thought processes after an event to promote reflective learning and improve clinical performance5 or a facilitated discussion of a clinical event focused on learning and performance improvement.6 Briefing and debriefing have been recommended for neonatal resuscitation training since 20107 and have been shown to improve a variety of educational and clinical outcomes in neonatal, pediatric, and adult simulation-based and clinical studies. A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide. Establishing ventilation is the most important step to correct low heart rate. External validity might be improved by studying the relevant learner or provider populations and by measuring the impact on critical patient and system outcomes rather than limiting study to learner outcomes. Flush the UVC with normal saline. Table 1 lists evidence and recommendations for interventions during neonatal resuscitation.1,2,57,2043, Intrapartum suctioning is not recommended with clear or meconium-stained amniotic fluid.1,2,5,6, Endotracheal suctioning of vigorous* infants is not recommended.1,2,5,6, Endotracheal suctioning of nonvigorous infants born through meconium-stained amniotic fluid may be useful.1,2,5, A self-inflating bag, flow-inflating bag, or T-piece device can be used to deliver positive pressure ventilation.1,6, Auscultation should be the primary means of assessing heart rate, and in infants needing respiratory support, the goal should be to check the heart rate by auscultation and by pulse oximetry.6, Initial PIP of 20 cm H2O may be effective, but a PIP of 30 to 40 cm H2O may be necessary in some infants to achieve or maintain a heart rate of more than 100 bpm.5, Ventilation rates of 40 to 60 breaths per minute are recommended.5,6, Use of an exhaled carbon dioxide detector in term and preterm infants is recommended to confirm endotracheal tube placement.5,6, Laryngeal mask airway should be considered if bag and mask ventilation is unsuccessful, and if endotracheal intubation is unsuccessful or not feasible.5,6, No evidence exists to support or refute the use of mask CPAP in term infants.2,5, PEEP should be used if suitable equipment is available, such as a flow-inflating bag or T-piece device.5, Delivery rooms should have a pulse oximeter readily available.57, A pulse oximeter is recommended when supplemental oxygen, positive pressure ventilation, or CPAP is used.57, Supplemental oxygen should be administered using an air/oxygen blender.57. For preterm infants who do not require resuscitation at birth, it is reasonable to delay cord clamping for longer than 30 seconds. Researchers studying these gaps may need to consider innovations in clinical trial design; examples include pragmatic study designs and novel consent processes. Chest compressions are a rare event in full-term newborns (approximately 0.1%) but are provided more frequently to preterm newborns.11When providing chest compressions to a newborn, it may be reasonable to deliver 3 compressions before or after each inflation: providing 30 inflations and 90 compressions per minute (3:1 ratio for 120 total events per minute). *Red Dress DHHS, Go Red AHA ; National Wear Red Day is a registered trademark. A meta-analysis (very low quality) of 8 animal studies (n=323 animals) that compared air with 100% oxygen during chest compressions showed equivocal results. Contact Us, Hours When feasible, well-designed multicenter randomized clinical trials are still optimal to generate the highest-quality evidence. If the heart rate is less than 60 bpm, begin chest compressions. Heart rate is assessed initially by auscultation and/or palpation. If the heart rate remains less than 60/min despite these interventions, chest compressions can supply oxygenated blood to the brain until the heart rate rises. Providing PPV at a rate of 40 to 60 inflations per minute is based on expert opinion. The suggested ratio is 3 chest compressions synchronized to 1 inflation (with 30 inflations per minute and 90 compressions per minute) using the 2 thumbencircling hands technique for chest compressions. Compresses correctly: Rate is correct.