We’ve looked at the changes in the paediatric resuscitation guidelines, here we take a closer look at neonatal guidelines.
The neonatal resuscitation algorithm
Supporting transition at birth
There are no major changes for the newborns (just yet), but there is clarification on certain practices since the last 2015 update.
The umbilical cord: Leave it hanging?
We should delay clamping the cord for sixty seconds after the first cry. Researchers are looking at the benefit of beginning resuscitation whilst the cord remains intact. Immediate cord clamping (ICC) significantly reduces ventricular pre-load while adding to left ventricular afterload.
If delayed cord clamping (DCC) is not possible, ‘milking of the cord’ can result in some transient benefits. There may be less need for inotropic support and fewer transfusions but no overall reduction in morbidity or mortality in the premature. There is insufficient data to suggest any benefit in babies 34 weeks to term. Milking of the cord is not recommended below 28 weeks, as one large study was terminated early after babies were found to have a higher risk of intraventricular haemorrhage.
Inflation and ventilation breaths: Increased pressure
When delivering inflation breaths, the resuscitation guidelines recommend slightly increased pressures than before
<32 weeks gestation, 25cm H2O for peak inspiratory pressure
>32 weeks, we should be using 30cm H2O initially slowly titrating up to achieve good chest wall movement.
Set the PEEP at at 5cm H2O for all babies that need assisted ventilation.
Laryngeal Mask Airways
LMAs are better than (in a systematic review of 7 studies, N=794) bag-mask ventilation. Using them reduces the need for intubation and the duration of ventilation, though the evidence was low/moderate quality. The updated guidelines suggest more proactive use of an LMA in babies > 34 weeks and >2kgs.
Oxygen: Start low
- For babies >32/40, the guidelines remain unchanged, start in air, monitor SpO2 and increase as needed. It can take several minutes to reach normal saturation levels.
- For babies born between 28-32 weeks gestation, a small amount of supplemental oxygen (21-30% FiO2) may help with the effort of breathing and reduce mask ventilation time.
- Start babies born before 28 weeks gestation on 30% FiO2.
- Turn the FiO2 immediately up to 100% if you have to start chest compressions.
Thick Meconium: Don’t rush to suction
In the past, if a ‘non-vigorous’ baby (i.e. hasn’t cried yet) was delivered through thick meconium, you were supposed to visualise the cords with a laryngoscope and suction before providing inflation breaths. There wasn’t significant evidence for this, and the thought was that it simply delayed ventilation in an otherwise apnoeic baby.
What about adrenaline dosing?
There are still a few studies looking at the dosing of adrenaline in neonates, but now the recommended dose is 20 micrograms/kg (0.2 mL/kg of 1:10,000 adrenaline (1000 micrograms in 10 mL)). This should be repeated every 3-5 minutes as needed.
Focus on temperature: Aim for 36.5-37.5°C
The admission temperature of all (non-asphyxiated) babies across all settings and gestational ages, is a strong predictive factor for morbidity and mortality.
- Use heated and humidified gases from the outset if you can, for babies born <32 weeks. A meta-analysis of 2 RCTs (N=476) suggested that this reduced the rate of hypothermia on admission by 36%.
- Skin-to-skin care may be enough to keep >32 week babies warm, though a study focusing on 28-32+6 gestation babes suggested that this may be sub-optimal compared to conventional means of warming (a mix of radiant heaters, plastic bags, heated mattresses etc).
For each 1 degree Celsius decrease in admission temperature below the recommended range, an increase in the baseline mortality by 28% has been reported.
Emergency access: You know the drill
Umbilical catheterisation remains the prime means of vascular access. If this is not an option, use intraosseous access to give emergency drugs and volume. Simulation studies suggest that the IO route may be quicker, though not without risk. Adverse events such as osteomyelitis, compartment syndrome and fractures have occurred.
Stopping resuscitation should be considered by the team if there is no response after 20 minutes and reversible (e.g. tension pneumothorax, hypovolaemia, equipment failure) have been discounted.
Selected references
Resuscitation Council UK Guidelines 2021 https://www.resus.org.uk/library/2021-resuscitation-guidelines
Madar J et al European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth (2021). https://doi.org/10.1016/j.resuscitation.2021.02.014
ERC Guidelines 2021: https://cprguidelines.eu/
Wyckoff MH, ET AL. Neonatal Life Support Collaborators. Neonatal Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2020 Nov;156:A156-A187. https://doi.org/10.1016/j.resuscitation.2020.09.015 Epub 2020 Oct 21. PMID: 3309891
