Neonatal Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

Ventilation-Induced Lung Injury (VILI) in Neonates: Evidence-Based Concepts and Lung-Protective Strategies

Supportive care with mechanical ventilation continues to be an essential strategy for managing severe neonatal respiratory failure; however, it is well known to cause and accentuate neonatal lung injury. The pathogenesis of ventilator-induced lung injury (VILI) is multifactorial and complex, resulting predominantly from interactions between ventilator-related factors and patient-related factors. Importantly, VILI is a significant risk factor for developing bronchopulmonary dysplasia (BPD), the most common chronic respiratory morbidity of preterm infants that lacks specific therapies, causes life-long morbidities, and imposes psychosocial and economic burdens. Studies of older children and adults suggest that understanding how and why VILI occurs is essential to developing strategies for mitigating VILI and its consequences. This article reviews the preclinical and clinical evidence on the pathogenesis and pathophysiology of VILI in neonates. We also highlight the evidence behind various lung-protective strategies to guide clinicians in preventing and attenuating VILI and, by extension, BPD in neonates. Further, we provide a snapshot of future directions that may help minimize neonatal VILI.

A retrospective cohort study of tracheal intubation for meconium suction in nonvigorous neonates

OBJECTIVES

To study the feasibility of tracheal intubation for meconium suction immediately after birth of nonvigorous neonates born through meconium-stained amniotic fluid (MSAF).

METHODS

A retrospective cohort study was performed on nonvigorous neonates born through MSAF who were admitted to the Department of Neonatology, Zhecheng People's Hospital. The neonates without meconium suction who were admitted from July 1, 2017 to June 30, 2018 were enrolled as the control group. The neonates who underwent meconium suction from July 1, 2018 to June 30, 2019 were enrolled as the suction group. The two groups were compared in terms of the mortality rate and the incidence rates of neonatal meconium aspiration syndrome (MAS), persistent pulmonary hypertension of the newborn, pneumothorax, and pulmonary hemorrhage.

RESULTS

There were 80 neonates in the control group and 71 in the suction group. There were no significant differences between the two groups in the incidence rates of MAS (11% vs 7%), persistent pulmonary hypertension of the newborn (5% vs 4%), pneumothorax (3% vs 1%), and death (0% vs 1%). Compared with the control group, the suction group had a significantly lower proportion of neonates requiring oxygen inhalation (16% vs 33%, P<0.05), noninvasive respiratory support (25% vs 41%, P<0.05) or mechanical ventilation (10% vs 23%, P<0.05) and significantly shorter duration of noninvasive ventilation [(58±24) hours vs (83±41) hours, P<0.05] and length of hospital stay [6(4, 8) days vs 7(5, 10) days, P<0.05].

CONCLUSIONS

Although tracheal intubation for meconium suction immediately after birth may shorten the duration of respiratory support for mild respiratory problems, it cannot reduce the incidence rate of MAS, mortality rate, or the incidence rate of serious complications in nonvigorous infants born through MSAF.

Neonatologists' Resuscitation Decisions at Birth for Extremely Premature Infants. A Belgian Qualitative Study

OBJECTIVE

Deciding whether initiating or withholding resuscitation at birth for extremely preterm infants (EPIs) can be difficult due to uncertainty on outcomes. Clinical uncertainty generates ethical uncertainty. Thus, physicians' attitudes and perspectives on resuscitation of EPIs might influence resuscitation decisions. We aimed at understanding how neonatologists make clinical-ethical decisions for EPI resuscitation and how they perceive these decisions.

METHODS

We performed a qualitative study using a constructivist account of grounded theory. Face-to-face, semi-structured in-depth interviews with neonatologists comprised data collection. For data analysis, we used the Qualitative Analysis Guide of Leuven.

RESULTS

We interviewed 20 neonatologists working in 10 hospitals in Belgium. Participants' decision-making can be described as consensus-based, gestational age-based, contextualized, progressive, and shared. All participants agreed on the importance of using the consensus expressed in guidelines as a guidance for the decision-making, i.e., consensus-based. Consequently, all 20 participants use GA thresholds indicated in the guidelines, i.e., GA-based. However, they use these thresholds differently in their decisions. Few participants rigidly follow established thresholds. The vast majority reported using additional contextual factors as birthweight or parents' wishes in the decision-making, rather than only the EPIs' GA, i.e., contextualized. All participants agreed on the importance of involving the parents in the decision-making, i.e., shared, and indeed parents' wishes were among the most valued factors considered in the decision-making. However, the extent to which parents were involved in the decision-making depended on the infant's GA. Participants described a gray zone in which parents' were viewed as the main decision-makers due to the high clinical uncertainty. This mean that participants tend to follow parents' request even when they disagree with it. Outside the gray zone, physicians were viewed as the main decision-makers. This mean that, although parents' wishes were still considered, counseling was more directive and the final decision was made by the physician.

CONCLUSION

Although an EPI's GA remains the main factor guiding neonatologists' resuscitation decisions, other factors are seriously considered in the decision-making process. All neonatologist participants agreed on the importance of involving parents in the decision-making. However, they involve parents differently depending on the EPI's GA.

Electrocardiogram for heart rate evaluation during preterm resuscitation at birth: a randomized trial

BACKGROUND

Although electrocardiogram (ECG) can detect heart rate (HR) faster compared to pulse oximetry, it remains unknown if routine use of ECG for delivery room (DR) resuscitation reduces the time to stabilization in preterm infants.

METHODS

Neonates <31 weeks' gestation were randomized to either an ECG-displayed or an ECG-blinded HR assessment in the DR. HR, oxygen saturation, resuscitation interventions, and clinical outcomes were compared.

RESULTS

During the study period, 51 neonates were enrolled. The mean gestational age in both groups was 28 ± 2 weeks. The time to stabilization, defined as the time from birth to achieve HR ≥100 b.p.m., as well as oxygen saturation within goal range, was not different between the ECG-displayed and the ECG-blinded groups [360 (269, 435) vs 345 (240, 475) s, p = 1.00]. There was also no difference in the time to HR ≥100 b.p.m. [100 (75, 228) vs 138 (88, 220) s, p = 0.40] or duration of positive pressure ventilation (PPV) [345 (120, 558) vs 196 (150, 273) s, p = 0.36]. Clinical outcomes were also similar between groups.

CONCLUSIONS

Although feasible and safe, the use of ECG in the DR during preterm resuscitation did not reduce time to stabilization.

IMPACT

Although feasible and apparently safe, routine use of the ECG in the DR did not decrease time to HR >100 b.p.m., time to stabilization, or use of resuscitation interventions such as PPV for preterm infants <31 weeks' gestational age. This article adds to the limited randomized controlled trial evidence regarding the impact of routine use of ECG during preterm resuscitation on DR clinical outcomes. Such evidence is important when considering recommendations for routine use of the ECG in the DR worldwide as such a recommendation comes with a significant cost burden.

Therapeutic Hypothermia for Neonatal Encephalopathy in Low- and Middle-Income Countries: A Meta-Analysis

BACKGROUND

Perinatal asphyxia and hypoxic-ischemic encephalopathy (HIE) represent substantial sources of neonatal morbidity and mortality in low- and middle-income countries (LMICs), leading to high rates of adverse long-term neurological outcomes.

METHODS

A systematic review with meta-analysis of randomized controlled trials in LMICs was conducted. PubMed, Scopus, Web of Science, CENTRAL, ClinicalTrials.gov, and Google Scholar were searched from inception to August 20, 2021. The population of the study consisted of neonates with gestational age ≥34 weeks and HIE. The main endpoints were overall mortality and the composite outcome of death or severe disability. The certainty of evidence was evaluated with the GRADE approach.

RESULTS

Ten studies were included comprising 1,293 neonates. Some concerns of bias were raised due to the nonblinded nature of the intervention. The risk of death was similar between the two groups (risk ratio [RR]: 0.78, 95% confidence interval [CI]: 0.52-1.18). No significant differences were observed in the composite outcome of death or severe disability between the two groups (RR: 0.78, 95% CI: 0.56-1.10, very low quality of evidence). Furthermore, no significant differences were observed in the endpoints of sepsis, shock, acute kidney injury, major arrhythmia, and length of hospital stay. Therapeutic hypothermia was associated with significantly higher risk of thrombocytopenia (RR: 2.13, 95% CI: 1.34-3.38) and clinically significant hemorrhage (RR: 1.57, 95% CI: 1.25-1.97).

CONCLUSION

Therapeutic hypothermia probably results in little to no difference in clinical outcomes among neonates with HIE in LMICs. Further large-scale research targeting proper patient selection is needed to elucidate the utility of therapeutic hypothermia in resource-limited settings.

PROTOCOL REGISTRATION

The protocol of the study has been prospectively registered by Prospero, CRD42021272284.

Decreased moderate admission hypothermia in extremely preterm newborns

BACKGROUND

Admission temperature is inversely correlated with mortality and morbidity risk in extremely preterm newborns (EPNs). As almost all EPNs require advanced resuscitation at birth, we improved a simple and comprehensive management protocol to reduce admission hypothermia. This study reports the changes over the past 15 years in the rate of admission hypothermia in all EPNs. It clarified the distribution of admission temperature and the risk factors for developing admission hypothermia in recent EPNs.

METHODS

This single-center study retrospectively analyzed the EPNs delivered at our institution between January 2006 and December 2020. The comprehensive management protocol, including warming equipment, plastic wrapping, aluminum-polyethylene sheet, and room temperature, was applied to avoid heat loss during resuscitation. On admission, the rectal temperature was measured and defined as moderate (32.0-35.9 °C) or mild (36.0-36.4 °C) hypothermia.

RESULTS

Overall (n = 432), the rate of admission with moderate hypothermia decreased from 48% in 2006 to 8% in 2020. In the recent evaluation of 80 EPNs delivered in 2017-2020, 10 (13%) and 26 (33%) had moderate and mild hypothermia on admission, respectively. Extremely preterm newborns with moderate-to-mild hypothermia had a significantly smaller gestational age and lower birthweight than those without hypothermia. No significant differences in the other perinatal and environmental risk factors were observed between EPNs with and without hypothermia.

CONCLUSIONS

Our comprehensive management protocol reduced the rate of moderate hypothermia on admission in EPNs to only 13%. However, eliminating mild hypothermia remains a challenge and requires continuous improvement, especially in smaller EPNs.

Improving Newborn Resuscitation by Making Every Birth a Learning Event

One third of all neonatal deaths are caused by intrapartum-related events, resulting in neonatal respiratory depression (i.e., failure to breathe at birth). Evidence-based resuscitation with stimulation, airway clearance, and positive pressure ventilation reduces mortality from respiratory depression. Improving adherence to evidence-based resuscitation is vital to preventing neonatal deaths caused by respiratory depression. Standard resuscitation training programs, combined with frequent simulation practice, have not reached their life-saving potential due to ongoing gaps in bedside performance. Complex neonatal resuscitations, such as those involving positive pressure ventilation, are relatively uncommon for any given resuscitation provider, making consistent clinical practice an unrealistic solution for improving performance. This review discusses strategies to allow every birth to act as a learning event within the context of both high- and low-resource settings. We review strategies that involve clinical-decision support during newborn resuscitation, including the visual display of a resuscitation algorithm, peer-to-peer support, expert coaching, and automated guidance. We also review strategies that involve post-event reflection after newborn resuscitation, including delivery room checklists, audits, and debriefing. Strategies that make every birth a learning event have the potential to close performance gaps in newborn resuscitation that remain after training and frequent simulation practice, and they should be prioritized for further development and evaluation.

Impact of early respiratory care for extremely preterm infants

Despite advances in neonatal intensive care, more than half of surviving infants born extremely preterm (EP; < 28 weeks' gestation) develop bronchopulmonary dysplasia (BPD). Prevention of BPD is critical because of its associated mortality and morbidity, including adverse neurodevelopmental outcomes and respiratory health in later childhood and beyond. The respiratory care of EP infants begins before birth, then continues in the delivery room and throughout the primary hospitalization. This chapter will review the evidence for interventions after birth that might improve outcomes for infants born EP, including the timing of umbilical cord clamping, strategies to avoid or minimize exposure to mechanical ventilation, modes of mechanical ventilation and non-invasive respiratory support, oxygen saturation targets, postnatal corticosteroids and other adjunct therapies.

Comparison of Heart Rate Feedback from Dry-Electrode ECG, 3-Lead ECG, and Pulse Oximetry during Newborn Resuscitation

Background: Assessment of heart rate (HR) is essential during newborn resuscitation, and comparison of dry-electrode ECG technology to standard monitoring by 3-lead ECG and Pulse Oximetry (PO) is lacking. Methods: NeoBeat, ECG, and PO were applied to newborns resuscitated at birth. Resuscitations were video recorded, and HR was registered every second. Results: Device placement time from birth was median (quartiles) 6 (4, 18) seconds for NeoBeat versus 138 (97, 181) seconds for ECG and 152 (103, 216) seconds for PO. Time to first HR presentation from birth was 22 (13, 45) seconds for NeoBeat versus 171 (129, 239) seconds for ECG and 270 (185, 357) seconds for PO. Proportion of time with HR feedback from NeoBeat during resuscitation from birth was 85 (69, 93)%, from arrival at the resuscitation table 98 (85, 100)%, and during positive pressure ventilation 100 (95, 100)%. For ECG, these proportions were, 25 (0, 43)%, 28 (0, 56)%, and 33 (0, 66)% and for PO, 0 (0, 16)%, 0 (0, 16)%, and 0 (0, 18)%. All p < 0.0001. Conclusions: NeoBeat was faster to place, presented HR more rapidly, and provided feedback on HR for a larger proportion of time during ongoing resuscitation compared to 3-lead ECG and PO.

Neonatal Resuscitation Research Priorities in Low- and Middle-Income Countries

Several critical physiological changes occur during birth. Optimal and timely resuscitation is essential to avoid morbidity and mortality. The International Liaison Committee on Resuscitation (ILCOR) is a multinational committee that publishes evidence-based consensus and treatment recommendations for resuscitation in various scenarios including that for neonatal resuscitation. The majority of perinatal deaths occur in low- and middle-income countries (LMICs); however, there is limited research output from LMICs to generate evidence-based practice recommendations specific for LMICs. The current review identifies key areas of neonatal resuscitation-related research needed from LMICs to inform evidence-based resuscitation of neonates in LMICs.

Supplemental Oxygen in the Newborn: Historical Perspective and Current Trends

Oxygen is the final electron acceptor in aerobic respiration, and a lack of oxygen can result in bioenergetic failure and cell death. Thus, administration of supplemental concentrations of oxygen to overcome barriers to tissue oxygen delivery (e.g., heart failure, lung disease, ischemia), can rescue dying cells where cellular oxygen content is low. However, the balance of oxygen delivery and oxygen consumption relies on tightly controlled oxygen gradients and compartmentalized redox potential. While therapeutic oxygen delivery can be life-saving, it can disrupt growth and development, impair bioenergetic function, and induce inflammation. Newborns, and premature newborns especially, have features that confer particular susceptibility to hyperoxic injury due to oxidative stress. In this review, we will describe the unique features of newborn redox physiology and antioxidant defenses, the history of therapeutic oxygen use in this population and its role in disease, and clinical trends in the use of therapeutic oxygen and mitigation of neonatal oxidative injury.

Respiratory support after delayed cord clamping: a prospective cohort study of at-risk births at ≥35+0 weeks gestation

OBJECTIVE

To identify risk factors associated with delivery room respiratory support in at-risk infants who are initially vigorous and received delayed cord clamping (DCC).

DESIGN

Prospective cohort study.

SETTING

Two perinatal centres in Melbourne, Australia.

PATIENTS

At-risk infants born at ≥35⁺⁰ weeks gestation with a paediatric doctor in attendance who were initially vigorous and received DCC for >60 s.

MAIN OUTCOME MEASURES

Delivery room respiratory support defined as facemask positive pressure ventilation, continuous positive airway pressure and/or supplemental oxygen within 10 min of birth.

RESULTS

Two hundred and ninety-eight infants born at a median (IQR) gestational age of 39⁺³ (38⁺²-40⁺²) weeks were included. Cord clamping occurred at a median (IQR) of 128 (123-145) s. Forty-four (15%) infants received respiratory support at a median of 214 (IQR 156-326) s after birth. Neonatal unit admission for respiratory distress occurred in 32% of infants receiving delivery room respiratory support vs 1% of infants who did not receive delivery room respiratory support (p<0.001). Risk factors independently associated with delivery room respiratory support were average heart rate (HR) at 90-120 s after birth (determined using three-lead ECG), mode of birth and time to establish regular cries. Decision tree analysis identified that infants at highest risk had an average HR of <165 beats per minute at 90-120 s after birth following caesarean section (risk of 39%). Infants with an average HR of ≥165 beats per minute at 90-120 s after birth were at low risk (5%).

CONCLUSIONS

We present a clinical decision pathway for at-risk infants who may benefit from close observation following DCC. Our findings provide a novel perspective of HR beyond the traditional threshold of 100 beats per minute.

Higher versus Lower Oxygen Concentration during Respiratory Support in the Delivery Room in Extremely Preterm Infants: A Pilot Feasibility Study

Background: Optimal starting oxygen concentration for delivery room resuscitation of extremely preterm infants (<29 weeks) remains unknown, with recommendations of 21–30% based on uncertain evidence. Individual patient randomized trials designed to answer this question have been hampered by poor enrolment. Hypothesis: It is feasible to compare 30% vs. 60% starting oxygen for delivery room resuscitation of extremely preterm infants using a change in local hospital policy and deferred consent approach. Study design: Prospective, single-center, feasibility study, with each starting oxygen concentration used for two months for all eligible infants. Population: Infants born at 23 + 0–28 + 6 weeks’ gestation who received delivery room resuscitation. Study interventions: Initial oxygen at 30% or 60%, increasing by 10–20% every minute for heart rate < 100 bpm, or increase to 100% for chest compressions. Primary outcome: Feasibility, defined by (i) achieving difference in cumulative supplied oxygen concentration between groups, and (ii) post-intervention rate consent >50%. Results: Thirty-four infants were born during a 4-month period; consent was obtained in 63%. Thirty (n = 12, 30% group; n = 18, 60% group) were analyzed, including limited data from eight who died or were transferred before parents could be approached. Median cumulative oxygen concentrations were significantly different between the two groups in the first 5 min. Conclusion: Randomized control trial of 30% or 60% oxygen at the initiation of resuscitation of extremely preterm neonates with deferred consent is feasible. Trial registration: Clinicaltrials.gov NCT03706586

Ventilation With or Without Endotracheal Tube Leak in Prolonged Neonatal Asphyxia

Background Severe and prolonged asphyxia can result in either intrauterine fetal death and stillbirth or multiorgan failure in surviving neonates. Establishing effective ventilation is the primary aim of resuscitation in newborns with asphyxia. The objective of this study was to compare the outcome of resuscitation by applying an endotracheal tube (ETT) with less, an ETT with moderate, and an ETT with high leakage during mechanical ventilation in swine neonates after prolonged perinatal asphyxia. Materials and methods A prospective, randomized controlled laboratory study was performed. Thirty Landrace/large white pigs, aged one to four days and weighted 1.754±218 gr, were randomly allocated into three groups depending on the ETT size: Group C (less leak: ETT no 4.0, n=10); Group A (high leak: ETT no 3.0, n=10); and Group B (moderate leak: ETT no 3.5, n=10). Mechanical asphyxia was performed until their heart rate was less than 60 bpm or their mean arterial pressure was below 15 mmHg. All animals with return of spontaneous circulation (ROSC) were monitored for four hours for their hemodynamic parameters, arterial oxygen saturation, and lactate acid levels. Results We demonstrate that 70% of the surviving animals were ventilated with an ETT with a leak (no. 3.5 and 3). A statistically significant difference was noted in PO₂ (p=0.032) between Group B (126.4±53.4 mmHg) compared to Group A (72.28±29.18 mmHg) and Group C (94.28±20.46 mmHg) as well as in the right atrial pressure (p<0.001) between Group C (4.5 mmHg) vs Groups A (2 mmHg) and B (2 mmHg) during ROSC time. Lactate levels were statistically significantly lower (p=0.035) in Group C (mean=0.92 ± 0.07mmol/L) as compared to Group A (mean=1.13 ± 0.1 mmol/L) and Group B (mean= 1.08 ± 0.07 mmol /L; p = 0.034) at 4h post-ROSC. Conclusion We provide preliminary evidence that ventilation with ETT with moderate leakage improves survival after 2h of ROSC, along with oxygenation and hemodynamic parameters, in a porcine model of neonatal asphyxia and resuscitation, compared to less leakage ETT.

SaferBirths bundle of care protocol: a stepped-wedge cluster implementation project in 30 public health-facilities in five regions, Tanzania

Background

The burden of stillbirth, neonatal and maternal deaths are unacceptably high in low- and middle-income countries, especially around the time of birth. There are scarce resources and/or support implementation of evidence-based training programs. SaferBirths Bundle of Care is a well-proven package of innovative tools coupled with data-driven on-the-job training aimed at reducing perinatal and maternal deaths. The aim of this project is to determine the effect of scaling up the bundle on improving quality of intrapartum care and perinatal survival.

Methods

The project will follow a stepped-wedge cluster implementation design with well-established infrastructures for data collection, management, and analysis in 30 public health facilities in regions in Tanzania. Healthcare workers from selected health facilities will be trained in basic neonatal resuscitation, essential newborn care and essential maternal care. Foetal heart rate monitors (Moyo), neonatal heart rate monitors (NeoBeat) and skills trainers (NeoNatalie Live) will be introduced in the health facilities to facilitate timely identification of foetal distress during labour and improve neonatal resuscitation, respectively. Heart rate signal-data will be automatically collected by Moyo and NeoBeat, and newborn resuscitation training by NeoNatalie Live.

Given an average of 4000 baby-mother pairs per year per health facility giving an estimate of 240,000 baby-mother pairs for a 2-years duration, 25% reduction in perinatal mortality at a two-sided significance level of 5%, intracluster correlation coefficient (ICC) to be 0.0013, the study power stands at 0.99.

Discussion

Previous reports from small-scale Safer Births Bundle implementation studies show satisfactory uptake of interventions with significant improvements in quality of care and lives saved. Better equipped and trained birth attendants are more confident and skilled in providing care. Additionally, local data-driven feedback has shown to drive continuous quality of care improvement initiatives, which is essential to increase perinatal and maternal survival. Strengths of this research project include integration of innovative tools with existing national guidelines, local data-driven decision-making and training. Limitations include the stepwise cluster implementation design that may lead to contamination of the intervention, and/or inability to address the shortage of healthcare workers and medical supplies beyond the project scope.

Trial registration

Name of Trial Registry: ISRCTN Registry.

Trial registration number: ISRCTN30541755.

Date of Registration: 12/10/2020.

Type of registration: Prospectively Registered.

Outcomes of delivery room resuscitation of bradycardic preterm infants: A retrospective cohort study of randomised trials of high vs low initial oxygen concentration and an individual patient data analysis

OBJECTIVE

To determine whether hospital mortality (primary outcome) is associated with duration of bradycardia without chest compressions during delivery room (DR) resuscitation in a retrospective cohort study of randomized controlled trials (RCTs) in preterm infants assigned low versus high initial oxygen concentration.

METHODS

Medline and EMBASE were searched from 01/01/1990 to 12/01/2020. RCTs of low vs high initial oxygen concentration which recorded serial heart rate (HR) and oxygen saturation (SpO2) during resuscitation of infants <32 weeks gestational age were eligible. Individual patient level data were requested from the authors. Newborns receiving chest compressions in the DR and those with no recorded HR in the first 2 min after birth were excluded. Prolonged bradycardia (PB) was defined as HR < 100 bpm for ≥2 min. Individual patient data analysis and pooled data analysis were conducted.

RESULTS

Data were collected from 720 infants in 8 RCTs. Neonates with PB had higher odds of hospital death before [OR 3.8 (95% CI 1.5, 9.3)] and after [OR 1.7 (1.2, 2.5)] adjusting for potential confounders. Bradycardia occurred in 58% infants, while 38% had PB. Infants with bradycardia were more premature and had lower birth weights. The incidence of bradycardia in infants resuscitated with low (≤30%) and high (≥60%) oxygen was similar. Neonates with both, PB and SpO2 < 80% at 5 min after birth had higher odds of hospital mortality. [OR 18.6 (4.3, 79.7)].

CONCLUSION

In preterm infants who did not receive chest compressions in the DR, prolonged bradycardia is associated with hospital mortality.

Proposing a care practice bundle for neonatal encephalopathy during therapeutic hypothermia

Neonates with neonatal encephalopathy (NE) often present with multi-organ dysfunction that requires multidisciplinary specialized management. Care of the neonate with NE is thus complex with interaction between the brain and various organ systems. Illness severity during the first days of birth, and not only during the initial hypoxia-ischemia event, is a significant predictor of adverse outcomes in neonates with NE treated with therapeutic hypothermia (TH). We thus propose a care practice bundle dedicated to support the injured neonatal brain that is based on the current best evidence for each organ system. The impact of using such bundle on outcomes in NE remains to be demonstrated.

Neonatologists' decision-making for resuscitation and non-resuscitation of extremely preterm infants: ethical principles, challenges, and strategies-a qualitative study

Background

Deciding whether to resuscitate extremely preterm infants (EPIs) is clinically and ethically problematic. The aim of the study was to understand neonatologists’ clinical–ethical decision-making for resuscitation of EPIs.

Methods

We conducted a qualitative study in Belgium, following a constructivist account of the Grounded Theory. We conducted 20 in-depth, face-to-face, semi-structured interviews with neonatologists. Data analysis followed the qualitative analysis guide of Leuven.

Results

The main principles guiding participants’ decision-making were EPIs’ best interest and respect for parents’ autonomy. Participants agreed that justice as resource allocation should not be considered in resuscitation decision-making. The main ethical challenge for participants was dealing with the conflict between EPIs’ best interest and respect for parents’ autonomy. This conflict was most prominent when parents and clinicians disagreed about births within the gray zone (24–25 weeks). Participants’ coping strategies included setting limits on extent of EPI care provided and rigidly following established guidelines. However, these strategies were not always feasible or successful. Although rare, these situations often led to long-lasting moral distress.

Conclusions

Participants’ clinical–ethical reasoning for resuscitation of EPIs can be mainly characterized as an attempt to balance EPIs’ best interest and respect for parents’ autonomy. This approach could explain why neonatologists considered conflicts between these principles as their main ethical challenge and why lack of resolution increases the risk of moral distress. Therefore, more research is needed to better understand moral distress in EPI resuscitation decisions.

Clinical Trial Registration: The study received ethical approval from the ethics committee of UZ/KU Leuven (S62867). Confidentiality of personal information and anonymity was guaranteed in accordance with the General Data Protection Regulation of 25 May 2018.

Randomized trial of oxygen weaning strategies following chest compressions during neonatal resuscitation

BACKGROUND

The Neonatal Resuscitation Program (NRP) recommends using 100% O2 during chest compressions and adjusting FiO2 based on SpO2 after return of spontaneous circulation (ROSC). The optimal strategy for adjusting FiO2 is not known.

METHODS

Twenty-five near-term lambs asphyxiated by umbilical cord occlusion to cardiac arrest were resuscitated per NRP. Following ROSC, lambs were randomized to gradual decrease versus abrupt wean to 21% O2 followed by FiO2 titration to achieve NRP SpO2 targets. Carotid blood flow and blood gases were monitored.

RESULTS

Three minutes after ROSC, PaO2 was 229 ± 32 mmHg in gradual wean group compared to 57 ± 13 following abrupt wean to 21% O2 (p < 0.001). PaO2 remained high in the gradual wean group at 10 min after ROSC (110 ± 10 vs. 67 ± 12, p < 0.01) despite similar FiO2 (~0.3) in both groups. Cerebral O2 delivery (C-DO2) was higher above physiological range following ROSC with gradual wean (p < 0.05). Lower blood oxidized/reduced glutathione ratio (suggesting less oxidative stress) was observed with abrupt wean.

CONCLUSION

Weaning FiO2 abruptly to 0.21 with adjustment based on SpO2 prevents surge in PaO2 and C-DO2 and minimizes oxidative stress compared to gradual weaning from 100% O2 following ROSC. Clinical trials with neurodevelopmental outcomes comparing post-ROSC FiO2 weaning strategies are warranted.

IMPACT

In a lamb model of perinatal asphyxial cardiac arrest, abrupt weaning of inspired oxygen to 21% prevents excessive oxygen delivery to the brain and oxidative stress compared to gradual weaning from 100% oxygen following return of spontaneous circulation. Clinical studies assessing neurodevelopmental outcomes comparing abrupt and gradual weaning of inspired oxygen after recovery from neonatal asphyxial arrest are warranted.

Back rubs or foot flicks for neonatal stimulation at birth in a low-resource setting: A randomized controlled trial

BACKGROUND

Approximately 15% of infants require stimulation in low-resource settings, but data on effectiveness of different stimulation approaches are limited. We aimed to compare two recommended approaches of stimulation (back rubs vs. foot flicks) in reducing the need for face-mask ventilation in newly born infants who were not crying immediately after birth in a low-resource setting.

METHODS

A single center, open-label, randomized, superiority trial was conducted at St. Kizito Hospital in Matany (Uganda) between November 2019 and May 2020. Newly born infants with expected birthweight > 1500 grams who were not crying immediately after birth were randomly assigned to stimulation using back rubs or foot flicks. The primary outcome measure was the success rate of the stimulation, defined as the achievement of an effective crying preventing the need for face-mask ventilation.

RESULTS

Success of stimulation was achieved in 76/93 neonates (82%) using back rubs and 68/93 neonates (73%) using foot flicks (risk ratio 1.12, 95% confidence interval 0.96-1.31). No procedure-associated complications arose during the study. Time to first cry was not statistically different between the two arms (mean difference -11 seconds, 95% confidence interval -39 to 18).

CONCLUSIONS

In newly born infants who were not crying immediately after birth, this trial did not provide a conclusive message in favor of back rubs or foot flicks. Nonetheless, we could not exclude a possible benefit of back rubs in avoiding the need for positive pressure ventilation and, possibly, further advanced resuscitative maneuvers.

CLINICAL TRIALS REGISTRATION

clinicalTrial.gov: NCT04056091.

Trends in respiratory management of transferred very preterm infants in the last two decades

BACKGROUND

Among infants needing urgent transfer after birth, very preterm infants are a high-risk sub-group requiring special attention. This study aimed to assess trends in early respiratory management in a large series of very preterm infants undergoing postnatal transfer.

METHODS

Trends in patient characteristics and early respiratory management were assessed in 798 very preterm infants who were transferred by the Eastern Veneto Neonatal Emergency Transport Service in 2000-2019. Trends were analyzed using joinpoint regression analysis and summarized as annual percentage changes (APCs).

RESULTS

Proportion of neonates with birth weight less than 1 kg decreased from 33% to 16% (APC -3.82%). Use of nasal-continuous-positive-airway pressure increased (at call: APC 15.39%; during transfer: APC 15.60%), while use of self-inflating bag (at call: APC -12.09%), oxygen therapy (at call: APC -13.00%; during transfer: APC -23.77%) and mechanical ventilation (at call: APC -2.71%; during transfer: APC -2.99%) decreased. Use of oxygen concentrations at 21% increased (at call: APC 6.26%; during transfer: APC 7.14%), while oxygen concentrations above 40% decreased (at call: APC -5.73%; at transfer APC -8.89%). Surfactant administration at call increased (APC 3%-10%), while surfactant administration when arriving at referring hospital remained around 7-11% (APC 2.55%).

CONCLUSION

Relevant trends toward "gentle" approaches in early respiratory management of very preterm infants undergoing postnatal transfer occurred during the last twenty years. In addition, the proportion of transferred extremely low birth weight infants halved. Clinicians and stakeholders should consider such information when allocating assets to both hospitals and transfer services and planning regional perinatal programs.

Optimizing initial neonatal resuscitation to reduce neonatal encephalopathy around the world

One million two hundred thousand neonatal lives are lost each year due to intrapartum-related events; 99% of these deaths occur in low- and lower middle-income countries. Neonates exposed to intrapartum-related events present with failure to breathe at birth. Quick and effective delivery room management of these neonates is critical in the prevention of brain injury. Given the prominent role of lung aeration in the cardiopulmonary transition at birth, the mainstay of neonatal resuscitation is effective ventilation. Basic neonatal resuscitation focuses on simple stimulation, airway positioning and clearing, and bag-mask ventilation. Although principles for basic neonatal resuscitation remain the same for high- and low-resource settings, guidelines may differ based on available human and material resources. Formal training in basic resuscitation reduces intrapartum-related neonatal mortality in low-resource settings. However, there remain opportunities to improve provider performance for increased impact with other strategies such as regular practice and continuous quality improvement.

Predicting the risk of respiratory distress in newborns with congenital pulmonary malformations

OBJECTIVES

Most children with prenatally diagnosed congenital pulmonary malformations (CPM) are asymptomatic at birth. We aimed to develop a parsimonious prognostic model for predicting the risk of neonatal respiratory distress (NRD) in preterm and term infants with CPM, based on the prenatal attributes of the malformation.

METHODS

MALFPULM is a prospective population-based nationally representative cohort including 436 pregnant women. The main predictive variable was the CPM volume ratio (CVR) measured at diagnosis (CVR first) and the highest CVR measured (CVR max). Separate models were estimated for preterm and term infants and were validated by bootstrapping.

RESULTS

In total, 67 of the 383 neonates studied (17%) had NRD. For infants born at term (>37 weeks, N=351), the most parsimonious model included CVR max as the only predictive variable (ROC area: 0.70±0.04, negative predictive value: 0.91). The probability of NRD increased linearly with increasing CVR max and remained below 10% for CVR max<0.4. In preterm infants (N=32), both CVR max and gestational age were important predictors of the risk of NRD (ROC area: 0.85±0.07). Models based on CVR first had a similar predictive ability.

CONCLUSIONS

Predictive models based exclusively on CVR measurements had a high negative predictive value in infants born at term. Our study results could contribute to the individualised general risk assessment to guide decisions about the need for newborns with prenatally diagnosed CPM to be delivered at specialised centers.

Devices for Administering Ventilation at Birth: A Systematic Review

CONTEXT

Positive pressure ventilation (PPV) is the most important intervention during neonatal resuscitation.

OBJECTIVE

To compare T-piece resuscitators (TPRs), self-inflating bags (SIBs), and flow-inflating bags for newborns receiving PPV during delivery room resuscitation.

DATA SOURCES

Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, and trial registries (inception to December 2020).

STUDY SELECTION

Randomized, quasi-randomized, interrupted time series, controlled before-and-after, and cohort studies were included without language restrictions.

DATA EXTRACTION

Two researchers independently extracted data, assessed the risk of bias, and evaluated the certainty of evidence. The primary outcome was in-hospital mortality. When appropriate, data were pooled by using fixed-effect models.

RESULTS

Meta-analysis of 4 randomized controlled trials (1247 patients) revealed no significant difference between TPR and SIB for in-hospital mortality (risk ratio 0.74; 95% confidence interval [CI] 0.40 to 1.34). Resuscitation with a TPR resulted in a shorter duration of PPV (mean difference -19.8 seconds; 95% CI -27.7 to -12.0 seconds) and lower risk of bronchopulmonary dysplasia (risk ratio 0.64; 95% CI 0.43 to 0.95; number needed to treat 32). No differences in clinically relevant outcomes were found in 2 randomized controlled trials used to compare SIBs with and without positive end-expiratory pressure valves. No studies used to evaluate flow-inflating bags were found.

LIMITATIONS

Certainty of evidence was very low or low for most outcomes.

CONCLUSIONS

Resuscitation with a TPR compared with an SIB reduces the duration of PPV and risk of bronchopulmonary dysplasia. A strong recommendation cannot be made because of the low certainty of evidence. There is insufficient evidence to determine the effectiveness of positive end-expiratory pressure valves when used with SIBs.

Tracheal suction at birth in non-vigorous neonates born through meconium-stained amniotic fluid

BACKGROUND

Neonates born through meconium-stained amniotic fluid (MSAF) are at risk of developing meconium aspiration syndrome (MAS). Neonates who are non-vigorous due to intrapartum asphyxia are at higher risk of developing MAS. Clearance of meconium from the airways below the vocal cords by tracheal suction before initiating other steps of resuscitation may reduce the risk of development of MAS. However, conducting tracheal suction may not only be ineffective, it may also delay effective resuscitation, thus prolonging and worsening the hypoxic-ischaemic insult.  OBJECTIVES: To evaluate the efficacy of tracheal suctioning at birth in preventing meconium aspiration syndrome and other complications among non-vigorous neonates born through meconium-stained amniotic fluid.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search Cochrane Central Register of Controlled Trials (CENTRAL 2020, Issue 11) in the Cochrane Library; Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R) (1946 to 25 November 2020) for randomised controlled trials (RCTs) and quasi-randomised trials. We also searched clinical trials databases and the reference lists of retrieved articles for RCTs and quasi-randomised trials (up to November 2020).

SELECTION CRITERIA

We included studies enrolling non-vigorous neonates born through MSAF, if the intervention being tested included tracheal suction at the time of birth with an intent to clear the trachea of meconium before regular breathing efforts began. Tracheal suction could be performed with an endotracheal tube or a wide-gauge suction catheter. Neonates in the control group should have been resuscitated at birth with no effort made to clear the trachea of meconium.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data, consulting with a third review author about any disagreements. We used standard Cochrane methodological procedures, including assessment of risk of bias for all studies. Our primary outcomes were: MAS; all-cause neonatal mortality; and incidence of hypoxic-ischaemic encephalopathy (HIE). Secondary outcomes included: need for mechanical ventilation; incidence of pulmonary air leaks; culture-positive sepsis; and persistent pulmonary hypertension. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included four studies (enrolling 581 neonates) in the review. All four studies were conducted in tertiary care hospitals in India. Three of the four studies included neonates born at and beyond term gestation, whereas one included neonates born at and beyond 34 weeks of gestation. Due to the nature of the intervention, it was not possible to blind the healthcare personnel conducting the intervention. Tracheal suction compared to no suction in non-vigorous neonates born through MSAF In non-vigorous infants, no differences were noted in the risks of MAS (RR 1.00, 95% CI 0.80 to 1.25; RD 0.00, 95% CI -0.07 to 0.08; 4 studies, 581 neonates) or all-cause neonatal mortality (RR 1.24, 95% CI 0.76 to 2.02; RD 0.02, 95% CI -0.03 to 0.07; 4 studies, 575 neonates) with or without tracheal suctioning. No differences were reported in the risk of any severity HIE (RR 1.05, 95% CI 0.68 to 1.63; 1 study, 175 neonates) or moderate to severe HIE (RR 0.68, 95% CI 0.43 to 1.09; 1 study, 152 neonates) among non-vigorous neonates born through MSAF. We are also uncertain as to the effect of tracheal suction on other outcomes such as incidence of mechanical ventilation (RR 0.99, 95% CI 0.68 to 1.44; RD 0.00, 95% CI -0.06 to 0.06; 4 studies, 581 neonates), pulmonary air leaks (RR 1.22, 95% CI 0.38 to 3.93; RD 0.00, 95% CI -0.02 to 0.03; 3 studies, 449 neonates), persistent pulmonary hypertension (RR 1.29, 95% CI 0.60 to 2.77; RD 0.02, 95% CI -0.03 to 0.06; 3 studies, 406 neonates) and culture-positive sepsis (RR 1.32, 95% CI 0.48 to 3.57; RD 0.01, 95% CI -0.03 to 0.05; 3 studies, 406 neonates). All reported outcomes were judged as providing very low certainty evidence.

AUTHORS' CONCLUSIONS

We are uncertain about the effect of tracheal suction on the incidence of MAS and its complications among non-vigorous neonates born through MSAF. One study awaits classification and could not be included in the review. More research from well-conducted large trials is needed to conclusively answer the review question.

Effect of a Larger Flush Volume on Bioavailability and Efficacy of Umbilical Venous Epinephrine during Neonatal Resuscitation in Ovine Asphyxial Arrest

The 7th edition of the Textbook of Neonatal Resuscitation recommends administration of epinephrine via an umbilical venous catheter (UVC) inserted 2-4 cm below the skin, followed by a 0.5-mL to 1-mL flush for severe bradycardia despite effective ventilation and chest compressions (CC). This volume of flush may not be adequate to push epinephrine to the right atrium in the absence of intrinsic cardiac activity during CC. The objective of our study was to evaluate the effect of 1-mL and 2.5-mL flush volumes after UVC epinephrine administration on the incidence and time to achieve return of spontaneous circulation (ROSC) in a near-term ovine model of perinatal asphyxia induced cardiac arrest. After 5 min of asystole, lambs were resuscitated per Neonatal Resuscitation Program (NRP) guidelines. During resuscitation, lambs received epinephrine through a UVC followed by 1-mL or 2.5-mL normal saline flush. Hemodynamics and plasma epinephrine concentrations were monitored. Three out of seven (43%) and 12/15 (80%) lambs achieved ROSC after the first dose of epinephrine with 1-mL and 2.5-mL flush respectively (p = 0.08). Median time to ROSC and cumulative epinephrine dose required were not different. Plasma epinephrine concentrations at 1 min after epinephrine administration were not different. From our pilot study, higher flush volume after first dose of epinephrine may be of benefit during neonatal resuscitation. More translational and clinical trials are needed.

Successful Postnatal Cardiopulmonary Resuscitation Due to Defibrillation

An asphyxiated term neonate required postnatal resuscitation. After six minutes of cardio-pulmonary resuscitation (CPR) and two doses of epinephrine, spontaneous circulation returned, but was shortly followed by ventricular fibrillation. CPR and administration of magnesium, calcium gluconate, and sodium bicarbonate did not improve the neonate’s condition. A counter shock of five Joule was delivered and the cardiac rhythm immediately converted to sinus rhythm. The neonate was transferred to the neonatal intensive care unit and received post-resuscitation care. Due to prolonged QTc and subsequently suspected long-QT syndrome propranolol treatment was initiated. The neonate was discharged home on day 14 without neurological sequelae.

Inhaled Nitric Oxide at Birth Reduces Pulmonary Vascular Resistance and Improves Oxygenation in Preterm Lambs

Resuscitation with 21% O₂ may not achieve target oxygenation in preterm infants and in neonates with persistent pulmonary hypertension of the newborn (PPHN). Inhaled nitric oxide (iNO) at birth can reduce pulmonary vascular resistance (PVR) and improve PaO₂. We studied the effect of iNO on oxygenation and changes in PVR in preterm lambs with and without PPHN during resuscitation and stabilization at birth. Preterm lambs with and without PPHN (induced by antenatal ductal ligation) were delivered at 134 d gestation (term is 147–150 d). Lambs without PPHN were ventilated with 21% O₂, titrated O₂ to maintain target oxygenation or 21% O₂ + iNO (20 ppm) at birth for 30 min. Preterm lambs with PPHN were ventilated with 50% O₂, titrated O₂ or 50% O₂ + iNO. Resuscitation with 21% O₂ in preterm lambs and 50%O₂ in PPHN lambs did not achieve target oxygenation. Inhaled NO significantly decreased PVR in all lambs and increased PaO₂ in preterm lambs ventilated with 21% O₂ similar to that achieved by titrated O₂ (41 ± 9% at 30 min). Inhaled NO increased PaO₂ to 45 ± 13, 45 ± 20 and 76 ± 11 mmHg with 50% O₂, titrated O₂ up to 100% and 50% O₂ + iNO, respectively, in PPHN lambs. We concluded that iNO at birth reduces PVR and FiO₂ required to achieve target PaO₂.

Heart rate detection properties of dry-electrode ECG compared to conventional 3-lead gel-electrode ECG in newborns

Objective

To compare the accuracy of heart rate detection properties of a novel, wireless, dry-electrode electrocardiogram (ECG) device, NeoBeat®, to that of a conventional 3-lead gel-electrode ECG monitor (PropaqM®) in newborns.

Results

The study population had a mean gestational age of 39 weeks and 2 days (1.5 weeks) and birth weight 3528 g (668 g). There were 950 heart rate notations from each device, but heart rate was absent from the reference monitor in 14 of these data points, leaving 936 data pairs to compare. The mean (SD) difference when comparing NeoBeat to the reference monitor was -0.25 (9.91) beats per minute (bpm) (p = 0.44). There was a deviation of more than 10 bpm in 7.4% of the data pairs, which primarily (78%) was attributed to ECG signal disturbance, and secondly (22%) due to algorithm differences between the devices. Excluding these outliers, the correlation was equally consistent (r² = 0.96) in the full range of heart rate captured measurements with a mean difference of − 0.16 (3.09) bpm. The mean difference was less than 1 bpm regardless of whether outliers were included or not.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-021-05576-x.

Resuscitation with an Intact Cord Enhances Pulmonary Vasodilation and Ventilation with Reduction in Systemic Oxygen Exposure and Oxygen Load in an Asphyxiated Preterm Ovine Model

(1) Background: Optimal initial oxygen (O₂) concentration in preterm neonates is controversial. Our objectives were to compare the effect of delayed cord clamping with ventilation (DCCV) to early cord clamping followed by ventilation (ECCV) on O₂ exposure, gas exchange, and hemodynamics in an asphyxiated preterm ovine model. (2) Methods: Asphyxiated preterm lambs (127-128 d) with heart rate <90 bpm were randomly assigned to DCCV or ECCV. In DCCV, positive pressure ventilation (PPV) was initiated with 30-60% O₂ and titrated based on preductal saturations (SpO₂) with an intact cord for 5 min, followed by clamping. In ECCV, the cord was clamped, and PPV was initiated. (3) Results: Fifteen asphyxiated preterm lambs were randomized to DCCV (N = 7) or ECCV (N = 8). The inspired O₂ (40 ± 20% vs. 60 ± 20%, p < 0.05) and oxygen load (520 (IQR 414-530) vs. 775 (IQR 623-868), p-0.03) in the DCCV group were significantly lower than ECCV. Arterial oxygenation and carbon dioxide (PaCO₂) levels were significantly lower and peak pulmonary blood flow was higher with DCCV. (4) Conclusion: In asphyxiated preterm lambs, resuscitation with an intact cord decreased O₂ exposure load improved ventilation with an increase in peak pulmonary blood flow in the first 5 min.

Continuous chest compressions with asynchronous ventilation improve survival in a neonatal swine model of asphyxial cardiac arrest

BACKGROUND

Guidelines for neonatal resuscitation recommend a 3:1 compression to ventilation ratio. However, this recommendation is based on expert opinion and consensus rather than strong scientific evidence. Our primary aim was to assess whether continuous chest compressions with asynchronous ventilations would increase return of spontaneous circulation (ROSC) rate and survival compared to the 3:1 chest compression to ventilation ratio.

METHODS

This was a prospective, randomized, laboratory study. Twenty male Landrace-Large White pigs, aged 1-4 days with an average weight 1.650 ± 228.3 g were asphyxiated and left untreated until heart rate was less than 60 bpm or mean arterial pressure was below 15 mmHg. Animals were then randomly assigned to receive either continuous chest compressions with asynchronous ventilations (n = 10), or standard (3:1) chest compression to ventilation ratio (n = 10). Heart rate and arterial pressure were assessed every 30 s during cardiopulmonary resuscitation (CPR) until ROSC or asystole. All animals with ROSC were monitored for 4 h.

RESULTS

Coronary perfusion pressure (CPP) at 30 s of CPR was significantly higher in the experimental group (45.7 ± 16.9 vs. 21.8 ± 6 mmHg, p < 0.001) and remained significantly elevated throughout the experiment. End-tidal carbon dioxide (ETCO₂) was also significantly higher in the experimental group throughout the experiment (23.4 ± 5.6 vs. 14.7 ± 5.9 mmHg, p < 0.001). ROSC was observed in six (60%) animals treated with 3:1 compression to ventilation ratio and nine (90%) animals treated with continuous chest compressions and asynchronous ventilation (p = 0.30). Time to ROSC was significantly lower in the experimental group (30 (30-30) vs. 60 (60-60) sec, p = 0.021). Of note, 7 (77.8%) animals in the experimental group and 1 (16.7%) animal in the control group achieved ROSC after 30 s (0.02). At 4 h, 2 (20%) animals survived in the control group compared to 7 (70%) animals in the experimental group (p = 0.022).

CONCLUSION

Continuous chest compressions with asynchronous ventilations significantly improved CPP, ETCO₂, time to ROSC, ROSC at 30 s and survival in a porcine model of neonatal resuscitation.

A critical review of the 2020 International Liaison Committee on Resuscitation treatment recommendations for resuscitating the newly born infant

The 2020 recommendations from the International Liaison Committee on Resuscitation are an improved version of the 2015 version. The algorithm and 15 procedures are unchanged from 2015, but there are six procedures with new or changed recommendations. One new recommendation is briefing/debriefing following neonatal resuscitation. Procedures with changed suggestions/recommendations are as follows: suctioning of non-vigorous infants delivered through meconium-stained amniotic fluid, sustained inflation of preterm infants, optimising epinephrine (adrenaline), vascular access and discontinuing resuscitative efforts. CONCLUSION: In this review, we summarise the present recommendations and offer additional comments and views regarding heart rate detection, cord clamping, oxygenation and thermal control.

Meconium Aspiration Syndrome: A Narrative Review

Meconium aspiration syndrome is a clinical condition characterized by respiratory failure occurring in neonates born through meconium-stained amniotic fluid. Worldwide, the incidence has declined in developed countries thanks to improved obstetric practices and perinatal care while challenges persist in developing countries. Despite the improved survival rate over the last decades, long-term morbidity among survivors remains a major concern. Since the 1960s, relevant changes have occurred in the perinatal and postnatal management of such patients but the most appropriate approach is still a matter of debate. This review offers an updated overview of the epidemiology, etiopathogenesis, diagnosis, management and prognosis of infants with meconium aspiration syndrome.

Effects of therapeutic hypothermia on death among asphyxiated neonates with hypoxic-ischemic encephalopathy: A systematic review and meta-analysis of randomized control trials

Background

Hypoxic perinatal brain injury is caused by lack of oxygen to baby’s brain and can lead to death or permanent brain damage. However, the effectiveness of therapeutic hypothermia in birth asphyxiated infants with encephalopathy is uncertain. This systematic review and meta-analysis was aimed to estimate the pooled relative risk of mortality among birth asphyxiated neonates with hypoxic-ischemic encephalopathy in a global context.

Methods

We used the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines to search randomized control trials from electronic databases (PubMed, Cochrane library, Google Scholar, MEDLINE, Embase, Scopus, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and meta register of Current Controlled Trials (mCRT)). The authors extracted the author’s name, year of publication, country, method of cooling, the severity of encephalopathy, the sample size in the hypothermic, and non-hypothermic groups, and the number of deaths in the intervention and control groups. A weighted inverse variance fixed-effects model was used to estimate the pooled relative risk of mortality. The subgroup analysis was done by economic classification of countries, methods of cooling, and cooling devices. Publication bias was assessed with a funnel plot and Eggers test. A sensitivity analysis was also done.

Results

A total of 28 randomized control trials with a total sample of 35, 92 (1832 hypothermic 1760 non-hypothermic) patients with hypoxic-ischemic encephalopathy were used for the analysis. The pooled relative risk of mortality after implementation of therapeutic hypothermia was found to be 0.74 (95%CI; 0.67, 0.80; I² = 0.0%; p<0.996). The subgroup analysis revealed that the pooled relative risk of mortality in low, low middle, upper-middle and high income countries was 0.32 (95%CI; -0.95, 1.60; I² = 0.0%; p<0.813), 0.5 (95%CI; 0.14, 0.86; I² = 0.0%; p<0.998), 0.62 (95%CI; 0.41–0.83; I² = 0.0%; p<0.634) and 0.76 (95%CI; 0.69–0.83; I² = 0.0%; p<0.975) respectively. The relative risk of mortality was the same in selective head cooling and whole-body cooling method which was 0.74. Regarding the cooling device, the pooled relative risk of mortality is the same between the cooling cap and cooling blanket (0.74). However, it is slightly lower (0.73) in a cold gel pack.

Conclusions

Therapeutic hypothermia reduces the risk of death in neonates with moderate to severe hypoxic-ischemic encephalopathy. Both selective head cooling and whole-body cooling method are effective in reducing the mortality of infants with this condition. Moreover, low income countries benefit the most from the therapy. Therefore, health professionals should consider offering therapeutic hypothermia as part of routine clinical care to newborns with hypoxic-ischemic encephalopathy especially in low-income countries.

Is Chest Compression Superimposed with Sustained Inflation during Cardiopulmonary Resuscitation an Alternative to 3:1 Compression to Ventilation Ratio in Newborn Infants?

Approximately 0.1% for term and 10-15% of preterm infants receive chest compression (CC) in the delivery room, with high incidence of mortality and neurologic impairment. The poor prognosis associated with receiving CC in the delivery room has raised concerns as to whether specifically-tailored cardiopulmonary resuscitation methods are needed. The current neonatal resuscitation guidelines recommend a 3:1 compression:ventilation ratio; however, the most effective approach to deliver chest compression is unknown. We recently demonstrated that providing continuous chest compression superimposed with a high distending pressure or sustained inflation significantly reduced time to return of spontaneous circulation and mortality while improving respiratory and cardiovascular parameters in asphyxiated piglet and newborn infants. This review summarizes the current available evidence of continuous chest compression superimposed with a sustained inflation.

Ultrasound for Endotracheal Tube Tip Position in Term and Preterm Infants

BACKGROUND AND OBJECTIVE

Placing an endotracheal tube (ETT) in neonates is challenging and currently requires timely radiographic confirmation of correct tip placement. The objective was to establish the reliability of ultrasound (US) for assessing ETT position in the neonatal intensive care unit (NICU), time needed to do so, and patients' tolerance.

METHODS

A prospective study on 71 newborns admitted to our NICU whose ETT placement was evaluated with US (ETT-echo) and confirmed on chest X-rays (CXR). Data were collected by 3 operators (2 neonatologists and a resident in pediatrics). The right pulmonary artery (RPA) was used as a landmark for US. The distance between the tip of the ETT and the upper margin of the RPA was measured using US and compared with the distance between the tube's tip and the carina on the CXR.

RESULTS

Seventy-one intubated newborns were included in the study (n = 34 < 1,000 g, n = 18 1,000-2,000 g, n = 19 > 2,000 g). Statistical analysis (Bland-Altman plot and Lin's concordance correlation coefficient) showed an excellent consistency between ETT positions identified on US and chest X-ray. The 2 measures (ETT-echo and CXR) were extremely concordant both in the whole sample and in the subgroups. Minimal changes in patients' vital signs were infrequently observed during US, confirming the tolerability of ETT-echo. The mean time to perform US was 3.2 min (range 1-13).

CONCLUSIONS

ETT-echo seems to be a rapid, tolerable, and highly reliable method worth further investigating for future routine use in neonatology with a view to reducing radiation exposure.

Return of Spontaneous Circulation Depends on Cardiac Rhythm During Neonatal Cardiac Arrest in Asphyxiated Newborn Animals

Objective: Pulseless electrical activity (PEA) occurs in asphyxiated newborn piglets and infants. We aimed to examine whether different cardiac rhythms (asystole, bradycardia, PEA) affects the resuscitation outcomes during continuous chest compressions (CC) during sustained inflations (CC+SI). Design: This study is a secondary analysis of four previous randomized controlled animal trials that compared CC+SI with different CC rate (90 or 120/min), SI duration (20 or 60 s), peak inflation pressure (10, 20, or 30 cmH₂O), and oxygen concentration (18, 21, or 100%). Setting and Subjects: Sixty-six newborn mixed breed piglets (1-3 days of age, weight 1.7-2.4 kg) were obtained on the day of experimentation from the University Swine Research Technology Center. Interventions: In all four studies, piglets were randomized into intervention or sham. Piglets randomized to "intervention" underwent both hypoxia and asphyxia, whereas, piglets randomized to "sham" received the same surgical protocol, stabilization, and equivalent experimental periods without hypoxia and asphyxia. Measurements: To compare differences in asphyxiation time, time to return of spontaneous circulation (ROSC), hemodynamics, and survival rate in newborn piglets with asystole, bradycardia or PEA. Main Results: Piglets with PEA (n = 29) and asystole (n = 13) had a significantly longer asphyxiation time and time to ROSC vs. bradycardia (n = 24). Survival rates were similar between all groups. Compared to their baseline, mean arterial pressure and carotid blood flow were significantly lower 4 h after resuscitation in all groups, while being significantly higher in the bradycardia group. Conclusion: This study indicates that cardiac rhythm before resuscitation influences the time to ROSC and hemodynamic recovery after ROSC.

Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for pediatric life support is based on the most extensive evidence evaluation ever performed by the Pediatric Life Support Task Force. Three types of evidence evaluation were used in this review: systematic reviews, scoping reviews, and evidence updates. Per agreement with the evidence evaluation recommendations of the International Liaison Committee on Resuscitation, only systematic reviews could result in a new or revised treatment recommendation. Systematic reviews performed for this 2020 CoSTR for pediatric life support included the topics of sequencing of airway-breaths-compressions versus compressions-airway-breaths in the delivery of pediatric basic life support, the initial timing and dose intervals for epinephrine administration during resuscitation, and the targets for oxygen and carbon dioxide levels in pediatric patients after return of spontaneous circulation. The most controversial topics included the initial timing and dose intervals of epinephrine administration (new treatment recommendations were made) and the administration of fluid for infants and children with septic shock (this latter topic was evaluated by evidence update). All evidence reviews identified the paucity of pediatric data and the need for more research involving resuscitation of infants and children.

Part 2: Evidence Evaluation and Guidelines Development: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

The 2020 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care is based on the extensive evidence evaluation performed in conjunction with the International Liaison Committee on Resuscitation. The Adult Basic and Advanced Life Support, Pediatric Basic and Advanced Life Support, Neonatal Life Support, Resuscitation Education Science, and Systems of Care Writing Groups drafted, reviewed, and approved recommendations, assigning to each recommendation a Class of Recommendation (ie, strength) and Level of Evidence (ie, quality). The 2020 Guidelines are organized in knowledge chunks that are grouped into discrete modules of information on specific topics or management issues. The 2020 Guidelines underwent blinded peer review by subject matter experts and were also reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. The AHA has rigorous conflict-of-interest policies and procedures to minimize the risk of bias or improper influence during development of the guidelines. Anyone involved in any part of the guideline development process disclosed all commercial relationships and other potential conflicts of interest.

Asphyxiated Female and Male Newborn Piglets Have Similar Outcomes With Different Cardiopulmonary Resuscitation Interventions

Background: Male newborns have a greater risk of poor cardiovascular and respiratory outcomes compared to females. The mechanisms associated with the "male disadvantage" remains unclear. We have previously shown no difference between male and female newborn piglets during hypoxia, asphyxia, resuscitation, and post-resuscitation recovery. However, it is unknown if there are differences in resuscitation outcomes between males and females during different cardiopulmonary resuscitation techniques. Intervention and Measurements: Secondary analysis of 184 term newborn mixed breed duroc piglets (1-3 days of age, weighing 2.0 (0.2) kg) from seven different studies, which were exposed to 30-50 min of normocapnic hypoxia followed by asphyxia until asystole. This was followed by cardiopulmonary resuscitation. For the analysis, piglets were divided into male and female groups, as well as resuscitation technique groups (sustained inflation, 3:1 compression-to-ventilation ratio, or asynchronous ventilations during chest compressions). Cardiac function, carotid blood flow, and cerebral oxygenation were continuously recorded throughout the experiment. Main results: Regardless of resuscitation technique, there was no significant difference between males and females in the number achieving return of spontaneous circulation (ROSC) [95/123 (77%) vs. 48/61 (79%)], the time to achieve ROSC [112 (80-185) s vs. 110 (77-186) s], and the 4-h survival rate [81/95 (85%) vs. 40/48 (83%)]. Levels of the injury markers interleukin (IL)-1ß, IL-6, IL-8, and tumor necrosis factor-α in frontoparietal cortex tissue homogenates were similar between males and females. Conclusions: Regardless of resuscitation technique, there was no significant effect of sex on resuscitation outcome, survival, and hemodynamic recovery in asphyxiated newborn piglets.