Skip to main content
Skip to main content

AAP Gateway

Advanced Search »

User menu

  • Login
  • Current Policy
  • Topic/Program Collections
  • Submit Manuscript
  • Alerts
  • Subscribe
  • aap.org

Menu

  • AAP Grand Rounds
  • AAP News
  • Hospital Pediatrics
  • NeoReviews
  • Pediatrics
  • Pediatrics in Review
  • Current AAP Policy
  • Journal CME
  • AAP Career Center
  • Pediatric Collections
  • AAP Journals Catalog

Sections

    • Login
    • Current Policy
    • Topic/Program Collections
    • Submit Manuscript
    • Alerts
    • Subscribe
    • aap.org

    Sign up for Insight Alerts highlighting editor-chosen studies with the greatest impact on clinical care.

    New! Video Abstracts -- brief videos summarizing key findings of new articles

    Know what's next when you read AAP Journals, view the new 2018 Catalog.
    Trainees,
    enter the SOPT Essay Contest for a chance to be published in Pediatrics!

    Advertising Disclaimer »

    Tools and Links

    Pediatrics
    November 2010, VOLUME 126 / ISSUE 5
    From the American Academy of Pediatrics
    Special Report

    Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

    John Kattwinkel, Jeffrey M. Perlman, Khalid Aziz, Christopher Colby, Karen Fairchild, John Gallagher, Mary Fran Hazinski, Louis P. Halamek, Praveen Kumar, George Little, Jane E. McGowan, Barbara Nightengale, Mildred M. Ramirez, Steven Ringer, Wendy M. Simon, Gary M. Weiner, Myra Wyckoff, Jeanette Zaichkin
    • Article
    • Figures & Data
    • Info & Metrics
    • Comments
    Loading

    This article has a correction. Please see:

    • Errata - July 01, 2011
    Download PDF
    • cardiopulmonary resuscitation

    The following guidelines are an interpretation of the evidence presented in the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations1). They apply primarily to newly born infants undergoing transition from intrauterine to extrauterine life, but the recommendations are also applicable to neonates who have completed perinatal transition and require resuscitation during the first few weeks to months following birth. Practitioners who resuscitate infants at birth or at any time during the initial hospital admission should consider following these guidelines. For the purposes of these guidelines, the terms newborn and neonate are intended to apply to any infant during the initial hospitalization. The term newly born is intended to apply specifically to an infant at the time of birth.

    Approximately 10% of newborns require some assistance to begin breathing at birth. Less than 1% require extensive resuscitative measures.2,3 Although the vast majority of newly born infants do not require intervention to make the transition from intrauterine to extrauterine life, because of the large total number of births, a sizable number will require some degree of resuscitation.

    Those newly born infants who do not require resuscitation can generally be identified by a rapid assessment of the following 3 characteristics:

    • Term gestation?

    • Crying or breathing?

    • Good muscle tone?

    If the answer to all 3 of these questions is “yes,” the baby does not need resuscitation and should not be separated from the mother. The baby should be dried, placed skin-to-skin with the mother, and covered with dry linen to maintain temperature. Observation of breathing, activity, and color should be ongoing.

    If the answer to any of these assessment questions is “no,” the infant should receive one or more of the following 4 categories of action in sequence:

    1. Initial steps in stabilization (provide warmth, clear airway if necessary, dry, stimulate)

    2. Ventilation

    3. Chest compressions

    4. Administration of epinephrine and/or volume expansion

    Approximately 60 seconds (“the Golden Minute”) are allotted for completing the initial steps, reevaluating, and beginning ventilation if required (see Figure). The decision to progress beyond the initial steps is determined by simultaneous assessment of 2 vital characteristics: respirations (apnea, gasping, or labored or unlabored breathing) and heart rate (whether greater than or less than 100 beats per minute). Assessment of heart rate should be done by intermittently auscultating the precordial pulse. When a pulse is detectable, palpation of the umbilical pulse can also provide a rapid estimate of the pulse and is more accurate than palpation at other sites.4,5

    FIGURE.
    • Download figure
    • Open in new tab
    • Download powerpoint
    FIGURE.

    Newborn Resuscitation Algorithm.

    A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures, but the device takes 1 to 2 minutes to apply, and it may not function during states of very poor cardiac output or perfusion. Once positive pressure ventilation or supplementary oxygen administration is begun, assessment should consist of simultaneous evaluation of 3 vital characteristics: heart rate, respirations, and the state of oxygenation, the latter optimally determined by a pulse oximeter as discussed under “Assessment of Oxygen Need and Administration of Oxygen” below. The most sensitive indicator of a successful response to each step is an increase in heart rate.

    ANTICIPATION OF RESUSCITATION NEED

    Anticipation, adequate preparation, accurate evaluation, and prompt initiation of support are critical for successful neonatal resuscitation. At every delivery there should be at least 1 person whose primary responsibility is the newly born. This person must be capable of initiating resuscitation, including administration of positive-pressure ventilation and chest compressions. Either that person or someone else who is promptly available should have the skills required to perform a complete resuscitation, including endotracheal intubation and administration of medications.6 Several studies have demonstrated that a cesarean section performed under regional anesthesia at 37 to 39 weeks, without antenatally identified risk factors, versus a similar vaginal delivery performed at term, does not increase the risk of the baby requiring endotracheal intubation.7,–,10

    With careful consideration of risk factors, the majority of newborns who will need resuscitation can be identified before birth. If the possible need for resuscitation is anticipated, additional skilled personnel should be recruited and the necessary equipment prepared. Identifiable risk factors and the necessary equipment for resuscitation are listed in the Textbook of Neonatal Resuscitation, 6th Edition (American Academy of Pediatrics, in press).11 If a preterm delivery (<37 weeks of gestation) is expected, special preparations will be required. Preterm babies have immature lungs that may be more difficult to ventilate and are also more vulnerable to injury by positive-pressure ventilation. Preterm babies also have immature blood vessels in the brain that are prone to hemorrhage; thin skin and a large surface area, which contribute to rapid heat loss; increased susceptibility to infection; and increased risk of hypovolemic shock related to small blood volume.

    INITIAL STEPS

    The initial steps of resuscitation are to provide warmth by placing the baby under a radiant heat source, positioning the head in a “sniffing” position to open the airway, clearing the airway if necessary with a bulb syringe or suction catheter, drying the baby, and stimulating breathing. Recent studies have examined several aspects of these initial steps. These studies are summarized below.

    Temperature Control

    Very low-birth-weight (<1500 g) preterm babies are likely to become hypothermic despite the use of traditional techniques for decreasing heat loss.12 For this reason additional warming techniques are recommended (eg, prewarming the delivery room to 26°C,13 covering the baby in plastic wrapping (food or medical grade, heat-resistant plastic) (Class I, LOE A14,15), placing the baby on an exothermic mattress (Class IIb, LOE B16), and placing the baby under radiant heat (Class IIb, LOE C17). The infant's temperature must be monitored closely because of the slight, but described risk of hyperthermia when these techniques are used in combination (Class IIb, LOE B16). Other techniques for maintaining temperature during stabilization of the baby in the delivery room have been used (eg, prewarming the linen, drying and swaddling, placing the baby skin-to-skin with the mother and covering both with a blanket) and are recommended, but they have not been studied specifically (Class IIb, LOE C). All resuscitation procedures, including endotracheal intubation, chest compression, and insertion of intravenous lines, can be performed with these temperature-controlling interventions in place (Class IIb, LOE C).

    Infants born to febrile mothers have been reported to have a higher incidence of perinatal respiratory depression, neonatal seizures, and cerebral palsy and an increased risk of mortality.18,19 Animal studies indicate that hyperthermia during or after ischemia is associated with progression of cerebral injury. Lowering the temperature reduces neuronal damage.20 Hyperthermia should be avoided (Class IIb, LOE C). The goal is to achieve normothermia and avoid iatrogenic hyperthermia.

    Clearing the Airway

    When Amniotic Fluid Is Clear

    There is evidence that suctioning of the nasopharynx can create bradycardia during resuscitation21,22 and that suctioning of the trachea in intubated babies receiving mechanical ventilation in the neonatal intensive care unit (NICU) can be associated with deterioration of pulmonary compliance and oxygenation and reduction in cerebral blood flow velocity when performed routinely (ie, in the absence of obvious nasal or oral secretions).23,24 However, there is also evidence that suctioning in the presence of secretions can decrease respiratory resistance.25 Therefore it is recommended that suctioning immediately following birth (including suctioning with a bulb syringe) should be reserved for babies who have obvious obstruction to spontaneous breathing or who require positive-pressure ventilation (PPV) (Class IIb, LOE C).

    When Meconium is Present

    Aspiration of meconium before delivery, during birth, or during resuscitation can cause severe meconium aspiration syndrome (MAS). Historically a variety of techniques have been recommended to reduce the incidence of MAS. Suctioning of the oropharynx before delivery of the shoulders was considered routine until a randomized controlled trial demonstrated it to be of no value.26 Elective and routine endotracheal intubation and direct suctioning of the trachea were initially recommended for all meconium-stained newborns until a randomized controlled trial demonstrated that there was no value in performing this procedure in babies who were vigorous at birth.27 Although depressed infants born to mothers with meconium-stained amniotic fluid (MSAF) are at increased risk to develop MAS,28,29 tracheal suctioning has not been associated with reduction in the incidence of MAS or mortality in these infants.30,31 The only evidence that direct tracheal suctioning of meconium may be of value was based on comparison of suctioned babies with historic controls, and there was apparent selection bias in the group of intubated babies included in those studies.32,–,34

    In the absence of randomized, controlled trials, there is insufficient evidence to recommend a change in the current practice of performing endotracheal suctioning of nonvigorous babies with meconium-stained amniotic fluid (Class IIb, LOE C). However, if attempted intubation is prolonged and unsuccessful, bag-mask ventilation should be considered, particularly if there is persistent bradycardia.

    Assessment of Oxygen Need and Administration of Oxygen

    There is a large body of evidence that blood oxygen levels in uncompromised babies generally do not reach extrauterine values until approximately 10 minutes following birth. Oxyhemoglobin saturation may normally remain in the 70% to 80% range for several minutes following birth, thus resulting in the appearance of cyanosis during that time. Other studies have shown that clinical assessment of skin color is a very poor indicator of oxyhemoglobin saturation during the immediate neonatal period and that lack of cyanosis appears to be a very poor indicator of the state of oxygenation of an uncompromised baby following birth.

    Optimal management of oxygen during neonatal resuscitation becomes particularly important because of the evidence that either insufficient or excessive oxygenation can be harmful to the newborn infant. Hypoxia and ischemia are known to result in injury to multiple organs. Conversely there is growing experimental evidence, as well as evidence from studies of babies receiving resuscitation, that adverse outcomes may result from even brief exposure to excessive oxygen during and following resuscitation.

    Pulse Oximetry

    Numerous studies have defined the percentiles of oxygen saturation as a function of time from birth in uncompromised babies born at term (see table in Figure). This includes saturations measured from both preductal and postductal sites, following both operative and vaginal deliveries, and those occurring at sea level and at altitude.35,–,40

    Newer pulse oximeters, which employ probes designed specifically for neonates, have been shown to provide reliable readings within 1 to 2 minutes following birth.41,–,43 These oximeters are reliable in the large majority of newborns, both term and preterm, and requiring resuscitation or not, as long as there is sufficient cardiac output and skin blood flow for the oximeter to detect a pulse. It is recommended that oximetry be used when resuscitation can be anticipated,2 when positive pressure is administered for more than a few breaths, when cyanosis is persistent, or when supplementary oxygen is administered (Class I, LOE B).

    To appropriately compare oxygen saturations to similar published data, the probe should be attached to a preductal location (ie, the right upper extremity, usually the wrist or medial surface of the palm).43 There is some evidence that attaching the probe to the baby before connecting the probe to the instrument facilitates the most rapid acquisition of signal (Class IIb, LOE C).42

    Administration of Supplementary Oxygen

    Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation initiated with room air versus 100% oxygen showed increased survival when resuscitation was initiated with air.44,45 There are no studies in term infants comparing outcomes when resuscitations are initiated with different concentrations of oxygen other than 100% or room air. One study in preterm infants showed that initiation of resuscitation with a blend of oxygen and air resulted in less hypoxemia or hyperoxemia, as defined by the investigators, than when resuscitation was initiated with either air or 100% oxygen followed by titration with an adjustable blend of air and oxygen.46

    In the absence of studies comparing outcomes of neonatal resuscitation initiated with other oxygen concentrations or targeted at various oxyhemoglobin saturations, it is recommended that the goal in babies being resuscitated at birth, whether born at term or preterm, should be an oxygen saturation value in the interquartile range of preductal saturations (see table in Figure) measured in healthy term babies following vaginal birth at sea level (Class IIb, LOE B). These targets may be achieved by initiating resuscitation with air or a blended oxygen and titrating the oxygen concentration to achieve an Spo2 in the target range as described above using pulse oximetry (Class IIb, LOE C). If blended oxygen is not available, resuscitation should be initiated with air (Class IIb, LOE B). If the baby is bradycardic (HR <60 per minute) after 90 seconds of resuscitation with a lower concentration of oxygen, oxygen concentration should be increased to 100% until recovery of a normal heart rate (Class IIb, LOE B).

    Positive-Pressure Ventilation (PPV)

    If the infant remains apneic or gasping, or if the heart rate remains <100 per minute after administering the initial steps, start PPV.

    Initial Breaths and Assisted Ventilation

    Initial inflations following birth, either spontaneous or assisted, create a functional residual capacity (FRC).47,–,50 The optimal pressure, inflation time, and flow rate required to establish an effective FRC when PPV is administered during resuscitation have not been determined. Evidence from animal studies indicates that preterm lungs are easily injured by large-volume inflations immediately after birth.51,52 Assisted ventilation rates of 40 to 60 breaths per minute are commonly used, but the relative efficacy of various rates has not been investigated.

    The primary measure of adequate initial ventilation is prompt improvement in heart rate.53 Chest wall movement should be assessed if heart rate does not improve. The initial peak inflating pressures needed are variable and unpredictable and should be individualized to achieve an increase in heart rate or movement of the chest with each breath. Inflation pressure should be monitored; an initial inflation pressure of 20 cm H2O may be effective, but ≥30 to 40 cm H2O may be required in some term babies without spontaneous ventilation (Class IIb, LOE C).48,50,54 If circumstances preclude the use of pressure monitoring, the minimal inflation required to achieve an increase in heart rate should be used. There is insufficient evidence to recommend an optimum inflation time. In summary, assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to promptly achieve or maintain a heart rate >100 per minute (Class IIb, LOE C).

    The use of colorimetric CO2 detectors during mask ventilation of small numbers of preterm infants in the intensive care unit and in the delivery room has been reported, and such detectors may help to identify airway obstruction.55,56 However, it is unclear whether the use of CO2 detectors during mask ventilation confers additional benefit above clinical assessment alone (Class IIb, LOE C).

    End-Expiratory Pressure

    Many experts recommend administration of continuous positive airway pressure (CPAP) to infants who are breathing spontaneously, but with difficulty, following birth, although its use has been studied only in infants born preterm. A multicenter randomized clinical trial of newborns at 25 to 28 weeks gestation with signs of respiratory distress showed no significant difference in the outcomes of death or oxygen requirement at 36 weeks postmenstrual age between infants started on CPAP versus those intubated and placed on mechanical ventilation in the delivery room. Starting infants on CPAP reduced the rates of intubation and mechanical ventilation, surfactant use, and duration of ventilation, but increased the rate of pneumothorax.57 Spontaneously breathing preterm infants who have respiratory distress may be supported with CPAP or with intubation and mechanical ventilation (Class IIb, LOE B). The most appropriate choice may be guided by local expertise and preferences. There is no evidence to support or refute the use of CPAP in the delivery room in the term baby with respiratory distress.

    Although positive end–expiratory pressure (PEEP) has been shown to be beneficial and its use is routine during mechanical ventilation of neonates in intensive care units, there have been no studies specifically examining PEEP versus no PEEP when PPV is used during establishment of an FRC following birth. Nevertheless, PEEP is likely to be beneficial and should be used if suitable equipment is available (Class IIb, LOE C). PEEP can easily be given with a flow-inflating bag or T-piece resuscitator, but it cannot be given with a self-inflating bag unless an optional PEEP valve is used. There is, however, some evidence that such valves often deliver inconsistent end-expiratory pressures.58,59

    ASSISTED-VENTILATION DEVICES

    Effective ventilation can be achieved with either a flow-inflating or self-inflating bag or with a T-piece mechanical device designed to regulate pressure.60,–,63 The pop-off valves of self-inflating bags are dependent on the flow rate of incoming gas, and pressures generated may exceed the value specified by the manufacturer. Target inflation pressures and long inspiratory times are more consistently achieved in mechanical models when T-piece devices are used rather than bags,60,61 although the clinical implications of these findings are not clear (Class IIb, LOE C). It is likely that inflation pressures will need to change as compliance improves following birth, but the relationship of pressures to delivered volume and the optimal volume to deliver with each breath as FRC is being established have not been studied. Resuscitators are insensitive to changes in lung compliance, regardless of the device being used (Class IIb, LOE C).64

    Laryngeal Mask Airways

    Laryngeal mask airways that fit over the laryngeal inlet have been shown to be effective for ventilating newborns weighing more than 2000 g or delivered ≥34 weeks gestation (Class IIb, LOE B65,–,67). There are limited data on the use of these devices in small preterm infants, ie, < 2000 g or <34 weeks (Class IIb, LOE C65,–,67). A laryngeal mask should be considered during resuscitation if facemask ventilation is unsuccessful and tracheal intubation is unsuccessful or not feasible (Class IIa, LOE B). The laryngeal mask has not been evaluated in cases of meconium-stained fluid, during chest compressions, or for administration of emergency intratracheal medications.

    Endotracheal Tube Placement

    Endotracheal intubation may be indicated at several points during neonatal resuscitation:

    • Initial endotracheal suctioning of nonvigorous meconium-stained newborns

    • If bag-mask ventilation is ineffective or prolonged

    • When chest compressions are performed

    • For special resuscitation circumstances, such as congenital diaphragmatic hernia or extremely low birth weight

    The timing of endotracheal intubation may also depend on the skill and experience of the available providers.

    After endotracheal intubation and administration of intermittent positive pressure, a prompt increase in heart rate is the best indicator that the tube is in the tracheobronchial tree and providing effective ventilation.53 Exhaled CO2 detection is effective for confirmation of endotracheal tube placement in infants, including very low-birth-weight infants (Class IIa, LOE B68,–,71). A positive test result (detection of exhaled CO2) in patients with adequate cardiac output confirms placement of the endotracheal tube within the trachea, whereas a negative test result (ie, no CO2 detected) strongly suggests esophageal intubation.68,–,72 Exhaled CO2 detection is the recommended method of confirmation of endotracheal tube placement (Class IIa, LOE B). However, it should be noted that poor or absent pulmonary blood flow may give false-negative results (ie, no CO2 detected despite tube placement in the trachea). A false-negative result may thus lead to unnecessary extubation and reintubation of critically ill infants with poor cardiac output.

    Other clinical indicators of correct endotracheal tube placement are condensation in the endotracheal tube, chest movement, and presence of equal breath sounds bilaterally, but these indicators have not been systematically evaluated in neonates (Class 11b, LOE C).

    Chest Compressions

    Chest compressions are indicated for a heart rate that is <60 per minute despite adequate ventilation with supplementary oxygen for 30 seconds. Because ventilation is the most effective action in neonatal resuscitation and because chest compressions are likely to compete with effective ventilation, rescuers should ensure that assisted ventilation is being delivered optimally before starting chest compressions.

    Compressions should be delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chest (Class IIb, LOE C73,–,75). Two techniques have been described: compression with 2 thumbs with fingers encircling the chest and supporting the back (the 2 thumb–encircling hands technique) or compression with 2 fingers with a second hand supporting the back. Because the 2 thumb–encircling hands technique may generate higher peak systolic and coronary perfusion pressure than the 2-finger technique,76,–,80 the 2 thumb–encircling hands technique is recommended for performing chest compressions in newly born infants (Class IIb, LOE C). The 2-finger technique may be preferable when access to the umbilicus is required during insertion of an umbilical catheter, although it is possible to administer the 2 thumb–encircling hands technique in intubated infants with the rescuer standing at the baby's head, thus permitting adequate access to the umbilicus (Class IIb, LOE C).

    Compressions and ventilations should be coordinated to avoid simultaneous delivery.81 The chest should be permitted to reexpand fully during relaxation, but the rescuer's thumbs should not leave the chest (Class IIb, LOE C). There should be a 3:1 ratio of compressions to ventilations with 90 compressions and 30 breaths to achieve approximately 120 events per minute to maximize ventilation at an achievable rate. Thus each event will be allotted approximately 1/2 second, with exhalation occurring during the first compression after each ventilation (Class IIb, LOE C).

    There is evidence from animals and non-neonatal studies that sustained compressions or a compression ratio of 15:2 or even 30:2 may be more effective when the arrest is of primary cardiac etiology. One study in children suggests that CPR with rescue breathing is preferable to chest compressions alone when the arrest is of noncardiac etiology.82 It is recommended that a 3:1 compression to ventilation ratio be used for neonatal resuscitation where compromise of ventilation is nearly always the primary cause, but rescuers should consider using higher ratios (eg, 15:2) if the arrest is believed to be of cardiac origin (Class IIb, LOE C).

    Respirations, heart rate, and oxygenation should be reassessed periodically, and coordinated chest compressions and ventilations should continue until the spontaneous heart rate is ≥60 per minute (Class IIb, LOE C). However, frequent interruptions of compressions should be avoided, as they will compromise artificial maintenance of systemic perfusion and maintenance of coronary blood flow (Class IIb, LOE C).

    MEDICATIONS

    Drugs are rarely indicated in resuscitation of the newly born infant. Bradycardia in the newborn infant is usually the result of inadequate lung inflation or profound hypoxemia, and establishing adequate ventilation is the most important step toward correcting it. However, if the heart rate remains <60 per minute despite adequate ventilation (usually with endotracheal intubation) with 100% oxygen and chest compressions, administration of epinephrine or volume expansion, or both, may be indicated. Rarely, buffers, a narcotic antagonist, or vasopressors may be useful after resuscitation, but these are not recommended in the delivery room.

    Rate and Dose of Epinephrine Administration

    Epinephrine is recommended to be administered intravenously (Class IIb, LOE C). Past guidelines recommended that initial doses of epinephrine be given through an endotracheal tube because the dose can be administered more quickly than when an intravenous route must be established. However, animal studies that showed a positive effect of endotracheal epinephrine used considerably higher doses than are currently recommended,83,84 and the one animal study that used currently recommended doses via endotracheal tube showed no effect.85 Given the lack of supportive data for endotracheal epinephrine, the IV route should be used as soon as venous access is established (Class IIb, LOE C).

    The recommended IV dose is 0.01 to 0.03 mg/kg per dose. Higher IV doses are not recommended because animal86,87 and pediatric88,89 studies show exaggerated hypertension, decreased myocardial function, and worse neurological function after administration of IV doses in the range of 0.1 mg/kg. If the endotracheal route is used, doses of 0.01 or 0.03 mg/kg will likely be ineffective. Therefore, IV administration of 0.01 to 0.03 mg/kg per dose is the preferred route. While access is being obtained, administration of a higher dose (0.05 to 0.1 mg/kg) through the endotracheal tube may be considered, but the safety and efficacy of this practice have not been evaluated (Class IIb, LOE C). The concentration of epinephrine for either route should be 1:10,000 (0.1 mg/mL).

    VOLUME EXPANSION

    Volume expansion should be considered when blood loss is known or suspected (pale skin, poor perfusion, weak pulse) and the baby's heart rate has not responded adequately to other resuscitative measures (Class IIb, LOE C).90 An isotonic crystalloid solution or blood is recommended for volume expansion in the delivery room (Class IIb, LOE C). The recommended dose is 10 mL/kg, which may need to be repeated. When resuscitating premature infants, care should be taken to avoid giving volume expanders rapidly, because rapid infusions of large volumes have been associated with intraventricular hemorrhage (Class IIb, LOE C).

    POSTRESUSCITATION CARE

    Babies who require resuscitation are at risk for deterioration after their vital signs have returned to normal. Once adequate ventilation and circulation have been established, the infant should be maintained in, or transferred to an environment where close monitoring and anticipatory care can be provided.

    Naloxone

    Administration of naloxone is not recommended as part of initial resuscitative efforts in the delivery room for newborns with respiratory depression. Heart rate and oxygenation should be restored by supporting ventilation.

    Glucose

    Newborns with lower blood glucose levels are at increased risk for brain injury and adverse outcomes after a hypoxic-ischemic insult, although no specific glucose level associated with worse outcome has been identified.91,92 Increased glucose levels after hypoxia or ischemia were not associated with adverse effects in a recent pediatric series93 or in animal studies,94 and they may be protective.95 However, there are no randomized controlled trials that examine this question. Due to the paucity of data, no specific target glucose concentration range can be identified at present. Intravenous glucose infusion should be considered as soon as practical after resuscitation, with the goal of avoiding hypoglycemia (Class IIb, LOE C).

    Induced Therapeutic Hypothermia

    Several randomized controlled multicenter trials of induced hypothermia (33.5°C to 34.5°C) of newborns ≥36 weeks gestational age, with moderate to severe hypoxic-ischemic encephalopathy as defined by strict criteria, showed that those babies who were cooled had significantly lower mortality and less neurodevelopmental disability at 18-month follow-up than babies who were not cooled.96,–,98 The randomized trials produced similar results using different methods of cooling (selective head versus systemic).96,–,100 It is recommended that infants born at ≥36 weeks gestation with evolving moderate to severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia. The treatment should be implemented according to the studied protocols, which currently include commencement within 6 hours following birth, continuation for 72 hours, and slow rewarming over at least 4 hours. Therapeutic hypothermia should be administered under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-up (Class IIa, LOE A). Studies suggest that there may be some associated adverse effects, such as thrombocytopenia and increased need for inotropic support.

    GUIDELINES FOR WITHHOLDING AND DISCONTINUING RESUSCITATION

    For neonates at the margins of viability or those with conditions which predict a high risk of mortality or morbidity, attitudes and practice vary according to region and availability of resources. Studies indicate that parents desire a larger role in decisions to initiate resuscitation and continue life support of severely compromised newborns. Opinions among neonatal providers vary widely regarding the benefits and disadvantages of aggressive therapies in such newborns.

    Withholding Resuscitation

    It is possible to identify conditions associated with high mortality and poor outcome in which withholding resuscitative efforts may be considered reasonable, particularly when there has been the opportunity for parental agreement (Class IIb, LOE C101,102).

    A consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents is an important goal. Noninitiation of resuscitation and discontinuation of life-sustaining treatment during or after resuscitation are ethically equivalent, and clinicians should not hesitate to withdraw support when functional survival is highly unlikely.103 The following guidelines must be interpreted according to current regional outcomes:

    • When gestation, birth weight, or congenital anomalies are associated with almost certain early death and when unacceptably high morbidity is likely among the rare survivors, resuscitation is not indicated. Examples include extreme prematurity (gestational age <23 weeks or birth weight <400 g), anencephaly, and some major chromosomal abnormalities, such as trisomy 13 (Class IIb, LOE C).

    • In conditions associated with a high rate of survival and acceptable morbidity, resuscitation is nearly always indicated. This will generally include babies with gestational age ≥25 weeks and those with most congenital malformations (Class IIb, LOE C).

    • In conditions associated with uncertain prognosis in which survival is borderline, the morbidity rate is relatively high, and the anticipated burden to the child is high, parental desires concerning initiation of resuscitation should be supported (Class IIb, LOE C).

    Assessment of morbidity and mortality risks should take into consideration available data, and may be augmented by use of published tools based on data from specific populations. Decisions should also take into account changes in medical practice that may occur over time.

    Mortality and morbidity data by gestational age compiled from data collected by perinatal centers in the US and several other countries may be found on the Neonatal Resuscitation Program (NRP) website (www.aap.org/nrp). A link to a computerized tool to estimate mortality and morbidity from a population of extremely low-birth-weight babies born in a network of regional perinatal centers may be found at that site. However, unless conception occurred via in vitro fertilization, techniques used for obstetric dating are accurate to only ±3 to 4 days if applied in the first trimester and to only ±1 to 2 weeks subsequently. Estimates of fetal weight are accurate to only ±15% to 20%. Even small discrepancies of 1 or 2 weeks between estimated and actual gestational age or a 100- to 200-g difference in birth weight may have implications for survival and long-term morbidity. Also, fetal weight can be misleading if there has been intrauterine growth restriction, and outcomes may be less predictable. These uncertainties underscore the importance of not making firm commitments about withholding or providing resuscitation until you have the opportunity to examine the baby after birth.

    Discontinuing Resuscitative Efforts

    In a newly born baby with no detectable heart rate, it is appropriate to consider stopping resuscitation if the heart rate remains undetectable for 10 minutes (Class IIb, LOE C104,–,106). The decision to continue resuscitation efforts beyond 10 minutes with no heart rate should take into consideration factors such as the presumed etiology of the arrest, the gestation of the baby, the presence or absence of complications, the potential role of therapeutic hypothermia, and the parents' previously expressed feelings about acceptable risk of morbidity.

    STRUCTURE OF EDUCATIONAL PROGRAMS TO TEACH NEONATAL RESUSCITATION

    Studies have demonstrated that use of simulation-based learning methodologies enhances performance in both real-life clinical situations and simulated resuscitations,107,–,110 although a few studies have found no differences when compared to standard or other nonsimulated training.111,112 Also, studies examining briefings or debriefings of resuscitation team performance have generally shown improved knowledge or skills.113,–,118 Interpretation of data is complicated by the heterogeneity and limitations of the studies, including a paucity of data about clinical outcomes. Based on available evidence, it is recommended that the AAP/AHA Neonatal Resuscitation Program adopt simulation, briefing, and debriefing techniques in designing an education program for the acquisition and maintenance of the skills necessary for effective neonatal resuscitation (Class IIb, LOE C).

    DISCLOSURES

    View this table:
    • View inline
    • View popup

    Guidelines Part 15: Neonatal Resuscitation Writing Group Disclosures

    Footnotes

    • The American Heart Association requests that this document be cited as follows: Kattwinkel J, Perlman JM, Aziz K, Colby C, Fairchild K, Gallagher J, Hazinski MF, Halamek LP, Kumar P, Little G, McGowan JE, Nightengale B, Ramirez MM, Ringer S, Simon WM, Weiner GM, Wyckoff M, Zaichkin J. Part 15: neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S909–S919.

    • (Circulation. 2010;122:S909–S919.)

    • Circulation is available at http://circ.ahajournals.org.

    REFERENCES

    1. 1.↵
      2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation. In Press
    2. 2.↵
      1. Perlman JM,
      2. Risser R
      . Cardiopulmonary resuscitation in the delivery room: associated clinical events. Arch Pediatr Adolesc Med. 1995;149:20–25
      OpenUrlCrossRefPubMedWeb of Science
    3. 3.↵
      1. Barber CA,
      2. Wyckoff MH
      . Use and efficacy of endotracheal versus intravenous epinephrine during neonatal cardiopulmonary resuscitation in the delivery room. Pediatrics. 2006;118:1028–1034
      OpenUrlAbstract/FREE Full Text
    4. 4.↵
      1. Owen CJ,
      2. Wyllie JP
      . Determination of heart rate in the baby at birth. Resuscitation. 2004;60:213–217
      OpenUrlCrossRefPubMedWeb of Science
    5. 5.↵
      1. Kamlin CO,
      2. Dawson JA,
      3. O'Donnell CP,
      4. Morley CJ,
      5. Donath SM,
      6. Sekhon J,
      7. Davis PG
      . Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room. J Pediatr. 2008;152:756–760
      OpenUrlCrossRefPubMedWeb of Science
    6. 6.↵
      1. Lockwood C,
      2. Lemons J
      Am Academy of Pediatrics, Am College of Obstetricians and Gynecologists. In: Lockwood C, Lemons J eds. Guidelines for Perinatal Care. 6th ed. Elk Grove Village, IL: Am Academy of Pediatrics;2007:205
    7. 7.↵
      1. Annibale DJ,
      2. Hulsey TC,
      3. Wagner CL,
      4. Southgate WM
      . Comparative neonatal morbidity of abdominal and vaginal deliveries after uncomplicated pregnancies. Arch Pediatr Adolesc Med. 1995;149:862–867
      OpenUrlCrossRefPubMedWeb of Science
    8. 8.↵
      1. Atherton N,
      2. Parsons SJ,
      3. Mansfield P
      . Attendance of paediatricians at elective Caesarean sections performed under regional anaesthesia: is it warranted?J Paediatr Child Health. 2006;42:332–336
      OpenUrlCrossRefPubMedWeb of Science
    9. 9.↵
      1. Gordon A,
      2. McKechnie EJ,
      3. Jeffery H
      . Pediatric presence at cesarean section: justified or not?Am J Obstet Gynecol. 2005;193(3 Pt 1):599–605
      OpenUrlCrossRefPubMedWeb of Science
    10. 10.↵
      1. Parsons SJ,
      2. Sonneveld S,
      3. Nolan T
      . Is a paediatrician needed at all Caesarean sections?J Paediatr Child Health. 1998;34:241–244
      OpenUrlCrossRefPubMedWeb of Science
    11. 11.↵
      1. Kattwinkel J
      ed. Textbook of Neonatal Resuscitation. 6th ed. Elk Grove Village: Am Academy of Pediatrics; In Press
    12. 12.↵
      1. Cramer K,
      2. Wiebe N,
      3. Hartling L,
      4. Crumley E,
      5. Vohra S
      . Heat loss prevention: a systematic review of occlusive skin wrap for premature neonates. J Perinatol. 2005;25:763–769
      OpenUrlCrossRefPubMed
    13. 13.↵
      1. Kent AL,
      2. Williams J
      . Increasing ambient operating theatre temperature and wrapping in polyethylene improves admission temperature in premature infants. J Paediatr Child Health. 2008;44:325–331
      OpenUrlCrossRefPubMedWeb of Science
    14. 14.↵
      1. Vohra S,
      2. Frent G,
      3. Campbell V,
      4. Abbott M,
      5. Whyte R
      . Effect of polyethylene occlusive skin wrapping on heat loss in very low birth weight infants at delivery: a randomized trial. J Pediatr. 1999;134:547–551
      OpenUrlCrossRefPubMedWeb of Science
    15. 15.↵
      1. Vohra S,
      2. Roberts RS,
      3. Zhang B,
      4. Janes M,
      5. Schmidt B
      . Heat Loss Prevention (HeLP) in the delivery room: A randomized controlled trial of polyethylene occlusive skin wrapping in very preterm infants. J Pediatr. 2004;145:750–753
      OpenUrlCrossRefPubMedWeb of Science
    16. 16.↵
      1. Singh A,
      2. Duckett J,
      3. Newton T,
      4. Watkinson M
      . Improving neonatal unit admission temperatures in preterm babies: exothermic mattresses, polythene bags or a traditional approach?J Perinatol. 2010;30:45–49
      OpenUrlCrossRefPubMedWeb of Science
    17. 17.↵
      1. Meyer MP,
      2. Bold GT
      . Admission temperatures following radiant warmer or incubator transport for preterm infants <28 weeks: a randomised study. Arch Dis Child Fetal Neonatal Ed. 2007;92:F295–F297
      OpenUrlAbstract/FREE Full Text
    18. 18.↵
      1. Petrova A,
      2. Demissie K,
      3. Rhoads GG,
      4. Smulian JC,
      5. Marcella S,
      6. Ananth CV
      . Association of maternal fever during labor with neonatal and infant morbidity and mortality. Obstet Gynecol. 2001;98:20–27
      OpenUrlCrossRefPubMedWeb of Science
    19. 19.↵
      1. Lieberman E,
      2. Lang J,
      3. Richardson DK,
      4. Frigoletto FD,
      5. Heffner LJ,
      6. Cohen A
      . Intrapartum maternal fever and neonatal outcome. Pediatrics. 2000;105(1 Pt 1):8–13
      OpenUrlAbstract/FREE Full Text
    20. 20.↵
      1. Coimbra C,
      2. Boris-Moller F,
      3. Drake M,
      4. Wieloch T
      . Diminished neuronal damage in the rat brain by late treatment with the antipyretic drug dipyrone or cooling following cerebral ischemia. Acta Neuropathol. 1996;92:447–453
      OpenUrlCrossRefPubMed
    21. 21.↵
      1. Gungor S,
      2. Kurt E,
      3. Teksoz E,
      4. Goktolga U,
      5. Ceyhan T,
      6. Baser I
      . Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section: a prospective randomized controlled trial. Gynecol Obstet Invest. 2006;61:9–14
      OpenUrlCrossRefPubMedWeb of Science
    22. 22.↵
      1. Waltman PA,
      2. Brewer JM,
      3. Rogers BP,
      4. May WL
      . Building evidence for practice: a pilot study of newborn bulb suctioning at birth. J Midwifery Womens Health. 2004;49:32–38
      OpenUrlCrossRefPubMedWeb of Science
    23. 23.↵
      1. Perlman JM,
      2. Volpe JJ
      . Suctioning in the preterm infant: effects on cerebral blood flow velocity, intracranial pressure, and arterial blood pressure. Pediatrics. 1983;72:329–334
      OpenUrlAbstract/FREE Full Text
    24. 24.↵
      1. Simbruner G,
      2. Coradello H,
      3. Fodor M,
      4. Havelec L,
      5. Lubec G,
      6. Pollak A
      . Effect of tracheal suction on oxygenation, circulation, and lung mechanics in newborn infants. Arch Dis Child. 1981;56:326–330
      OpenUrlAbstract/FREE Full Text
    25. 25.↵
      1. Prendiville A,
      2. Thomson A,
      3. Silverman M
      . Effect of tracheobronchial suction on respiratory resistance in intubated preterm babies. Arch Dis Child. 1986;61:1178–1183
      OpenUrlAbstract/FREE Full Text
    26. 26.↵
      1. Vain NE,
      2. Szyld EG,
      3. Prudent LM,
      4. Wiswell TE,
      5. Aguilar AM,
      6. Vivas NI
      . Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates before delivery of their shoulders: multicentre, randomised controlled trial. Lancet. 2004;364:597–602
      OpenUrlCrossRefPubMedWeb of Science
    27. 27.↵
      1. Wiswell TE,
      2. Gannon CM,
      3. Jacob J,
      4. Goldsmith L,
      5. Szyld E,
      6. Weiss K,
      7. Schutzman D,
      8. Cleary GM,
      9. Filipov P,
      10. Kurlat I,
      11. Caballero CL,
      12. Abassi S,
      13. Sprague D,
      14. Oltorf C,
      15. Padula M
      . Delivery room management of the apparently vigorous meconium-stained neonate: results of the multicenter, international collaborative trial. Pediatrics. 2000;105(1 Pt 1):1–7
      OpenUrlAbstract/FREE Full Text
    28. 28.↵
      1. Rossi EM,
      2. Philipson EH,
      3. Williams TG,
      4. Kalhan SC
      . Meconium aspiration syndrome: intrapartum and neonatal attributes. Am J Obstet Gynecol. 1989;161:1106–1110
      OpenUrlPubMedWeb of Science
    29. 29.↵
      1. Usta IM,
      2. Mercer BM,
      3. Sibai BM
      . Risk factors for meconium aspiration syndrome. Obstet Gynecol. 1995;86:230–234
      OpenUrlCrossRefPubMedWeb of Science
    30. 30.↵
      1. Gupta V,
      2. Bhatia BD,
      3. Mishra OP
      . Meconium stained amniotic fluid: antenatal, intrapartum and neonatal attributes. Indian Pediatr. 1996;33:293–297
      OpenUrlPubMed
    31. 31.↵
      1. Al Takroni AM,
      2. Parvathi CK,
      3. Mendis KB,
      4. Hassan S,
      5. Reddy I,
      6. Kudair HA
      . Selective tracheal suctioning to prevent meconium aspiration syndrome. Int J Gynaecol Obstet. 1998;63:259–263
      OpenUrlCrossRefPubMed
    32. 32.↵
      1. Carson BS,
      2. Losey RW,
      3. Bowes WA Jr.,
      4. Simmons MA
      . Combined obstetric and pediatric approach to prevent meconium aspiration syndrome. Am J Obstet Gynecol. 1976;126:712–715
      OpenUrlPubMedWeb of Science
    33. 33.↵
      1. Ting P,
      2. Brady JP
      . Tracheal suction in meconium aspiration. Am J Obstet Gynecol. 1975;122:767–771
      OpenUrlPubMedWeb of Science
    34. 34.↵
      1. Gregory GA,
      2. Gooding CA,
      3. Phibbs RH,
      4. Tooley WH
      . Meconium aspiration in infants—a prospective study. J Pediatr. 1974;85:848–852
      OpenUrlCrossRefPubMedWeb of Science
    35. 35.↵
      1. Toth B,
      2. Becker A,
      3. Seelbach-Gobel B
      . Oxygen saturation in healthy newborn infants immediately after birth measured by pulse oximetry. Arch Gynecol Obstet. 2002;266:105–107
      OpenUrlCrossRefPubMed
    36. 36.↵
      1. Gonzales GF,
      2. Salirrosas A
      . Arterial oxygen saturation in healthy newborns delivered at term in Cerro de Pasco (4340 m) and Lima (150 m). Reprod Biol Endocrinol. 2005;3:46
      OpenUrlCrossRefPubMed
    37. 37.↵
      1. Altuncu E,
      2. Ozek E,
      3. Bilgen H,
      4. Topuzoglu A,
      5. Kavuncuoglu S
      . Percentiles of oxygen saturations in healthy term newborns in the first minutes of life. Eur J Pediatr. 2008;167:687–688
      OpenUrlCrossRefPubMedWeb of Science
    38. 38.↵
      1. Kamlin CO,
      2. O'Donnell CP,
      3. Davis PG,
      4. Morley CJ
      . Oxygen saturation in healthy infants immediately after birth. J Pediatr. 2006;148:585–589
      OpenUrlCrossRefPubMedWeb of Science
    39. 39.↵
      1. Mariani G,
      2. Dik PB,
      3. Ezquer A,
      4. Aguirre A,
      5. Esteban ML,
      6. Perez C,
      7. Fernandez Jonusas S,
      8. Fustinana C
      . Pre-ductal and post-ductal O2 saturation in healthy term neonates after birth. J Pediatr. 2007;150:418–421
      OpenUrlCrossRefPubMedWeb of Science
    40. 40.↵
      1. Rabi Y,
      2. Yee W,
      3. Chen SY,
      4. Singhal N
      . Oxygen saturation trends immediately after birth. J Pediatr. 2006;148:590–594
      OpenUrlCrossRefPubMedWeb of Science
    41. 41.↵
      1. Hay WW Jr.,
      2. Rodden DJ,
      3. Collins SM,
      4. Melara DL,
      5. Hale KA,
      6. Fashaw LM
      . Reliability of conventional and new pulse oximetry in neonatal patients. J Perinatol. 2002;22:360–366
      OpenUrlCrossRefPubMed
    42. 42.↵
      1. O'Donnell CP,
      2. Kamlin CO,
      3. Davis PG,
      4. Morley CJ
      . Feasibility of and delay in obtaining pulse oximetry during neonatal resuscitation. J Pediatr. 2005;147:698–699
      OpenUrlCrossRefPubMedWeb of Science
    43. 43.↵
      1. Dawson JA,
      2. Kamlin CO,
      3. Wong C,
      4. te Pas AB,
      5. O'Donnell CP,
      6. Donath SM,
      7. Davis PG,
      8. Morley CJ
      . Oxygen saturation and heart rate during delivery room resuscitation of infants <30 weeks' gestation with air or 100% oxygen. Arch Dis Child Fetal Neonatal Ed. 2009;94:F87–F91
      OpenUrlAbstract/FREE Full Text
    44. 44.↵
      1. Davis PG,
      2. Tan A,
      3. O'Donnell CP,
      4. Schulze A
      . Resuscitation of newborn infants with 100% oxygen or air: a systematic review and meta-analysis. Lancet. 2004;364:1329–1333
      OpenUrlCrossRefPubMedWeb of Science
    45. 45.↵
      1. Rabi Y,
      2. Rabi D,
      3. Yee W
      . Room air resuscitation of the depressed newborn: a systematic review and meta-analysis. Resuscitation. 2007;72:353–363
      OpenUrlCrossRefPubMedWeb of Science
    46. 46.↵
      1. Escrig R,
      2. Arruza L,
      3. Izquierdo I,
      4. Villar G,
      5. Saenz P,
      6. Gimeno A,
      7. Moro M,
      8. Vento M
      . Achievement of targeted saturation values in extremely low gestational age neonates resuscitated with low or high oxygen concentrations: a prospective, randomized trial. Pediatrics. 2008;121:875–881
      OpenUrlAbstract/FREE Full Text
    47. 47.↵
      1. Karlberg P,
      2. Koch G
      . Respiratory studies in newborn infants. III. Development of mechanics of breathing during the first week of life. A longitudinal study. Acta Paediatr. 1962;(Suppl 135):121–129
    48. 48.↵
      1. Vyas H,
      2. Milner AD,
      3. Hopkin IE,
      4. Boon AW
      . Physiologic responses to prolonged and slow-rise inflation in the resuscitation of the asphyxiated newborn infant. J Pediatr. 1981;99:635–639
      OpenUrlCrossRefPubMedWeb of Science
    49. 49.↵
      1. Vyas H,
      2. Field D,
      3. Milner AD,
      4. Hopkin IE
      . Determinants of the first inspiratory volume and functional residual capacity at birth. Pediatr Pulmonol. 1986;2:189–193
      OpenUrlPubMedWeb of Science
    50. 50.↵
      1. Boon AW,
      2. Milner AD,
      3. Hopkin IE
      . Lung expansion, tidal exchange, and formation of the functional residual capacity during resuscitation of asphyxiated neonates. J Pediatr. 1979;95:1031–1036
      OpenUrlCrossRefPubMedWeb of Science
    51. 51.↵
      1. Hillman NH,
      2. Moss TJ,
      3. Kallapur SG,
      4. Bachurski C,
      5. Pillow JJ,
      6. Polglase GR,
      7. Nitsos I,
      8. Kramer BW,
      9. Jobe AH
      . Brief, large tidal volume ventilation initiates lung injury and a systemic response in fetal sheep. Am J Respir Crit Care Med. 2007;176:575–581
      OpenUrlCrossRefPubMedWeb of Science
    52. 52.↵
      1. Polglase GR,
      2. Hooper SB,
      3. Gill AW,
      4. Allison BJ,
      5. McLean CJ,
      6. Nitsos I,
      7. Pillow JJ,
      8. Kluckow M
      . Cardiovascular and pulmonary consequences of airway recruitment in preterm lambs. J Appl Physiol. 2009;106:1347–1355
      OpenUrlAbstract/FREE Full Text
    53. 53.↵
      1. Dawes GS
      . Foetal and Neonatal Physiology. A Comparative Study of the Changes at Birth. Chicago: Year Book Medical Publishers, Inc; 1968
    54. 54.↵
      1. Lindner W,
      2. Vossbeck S,
      3. Hummler H,
      4. Pohlandt F
      . Delivery room management of extremely low birth weight infants: spontaneous breathing or intubation?Pediatrics. 1999;103(5 Pt 1):961–967
      OpenUrlAbstract/FREE Full Text
    55. 55.↵
      1. Leone TA,
      2. Lange A,
      3. Rich W,
      4. Finer NN
      . Disposable colorimetric carbon dioxide detector use as an indicator of a patent airway during noninvasive mask ventilation. Pediatrics. 2006;118:e202–204
      OpenUrlAbstract/FREE Full Text
    56. 56.↵
      1. Finer NN,
      2. Rich W,
      3. Wang C,
      4. Leone T
      . Airway obstruction during mask ventilation of very low birth weight infants during neonatal resuscitation. Pediatrics. 2009;123:865–869
      OpenUrlAbstract/FREE Full Text
    57. 57.↵
      1. Morley CJ,
      2. Davis PG,
      3. Doyle LW,
      4. Brion LP,
      5. Hascoet JM,
      6. Carlin JB
      . Nasal CPAP or intubation at birth for very preterm infants. N Engl J Med. 2008;358:700–708
      OpenUrlCrossRefPubMedWeb of Science
    58. 58.↵
      1. Kelm M,
      2. Proquitte H,
      3. Schmalisch G,
      4. Roehr CC
      . Reliability of two common PEEP-generating devices used in neonatal resuscitation. Klin Padiatr. 2009;221:415–418
      OpenUrlCrossRefPubMedWeb of Science
    59. 59.↵
      1. Morley CJ,
      2. Dawson JA,
      3. Stewart MJ,
      4. Hussain F,
      5. Davis PG
      . The effect of a PEEP valve on a Laerdal neonatal self-inflating resuscitation bag. J Paediatr Child Health. 46(1–2):51–56, 2010
      OpenUrlCrossRefPubMedWeb of Science
    60. 60.↵
      1. Oddie S,
      2. Wyllie J,
      3. Scally A
      . Use of self-inflating bags for neonatal resuscitation. Resuscitation. 2005;67:109–112
      OpenUrlCrossRefPubMedWeb of Science
    61. 61.↵
      1. Hussey SG,
      2. Ryan CA,
      3. Murphy BP
      . Comparison of three manual ventilation devices using an intubated mannequin. Arch Dis Child Fetal Neonatal Ed. 2004;89:F490–493
      OpenUrlAbstract/FREE Full Text
    62. 62.↵
      1. Finer NN,
      2. Rich W,
      3. Craft A,
      4. Henderson C
      . Comparison of methods of bag and mask ventilation for neonatal resuscitation. Resuscitation. 2001;49:299–305
      OpenUrlCrossRefPubMedWeb of Science
    63. 63.↵
      1. Bennett S,
      2. Finer NN,
      3. Rich W,
      4. Vaucher Y
      . A comparison of three neonatal resuscitation devices. Resuscitation. 2005;67:113–118
      OpenUrlCrossRefPubMedWeb of Science
    64. 64.↵
      1. Kattwinkel J,
      2. Stewart C,
      3. Walsh B,
      4. Gurka M,
      5. Paget-Brown A
      . Responding to compliance changes in a lung model during manual ventilation: perhaps volume, rather than pressure, should be displayed. Pediatrics. 2009;123:e465–470
      OpenUrlAbstract/FREE Full Text
    65. 65.↵
      1. Trevisanuto D,
      2. Micaglio M,
      3. Pitton M,
      4. Magarotto M,
      5. Piva D,
      6. Zanardo V
      . Laryngeal mask airway: is the management of neonates requiring positive pressure ventilation at birth changing?Resuscitation. 2004;62:151–157
      OpenUrlCrossRefPubMedWeb of Science
    66. 66.↵
      1. Gandini D,
      2. Brimacombe JR
      . Neonatal resuscitation with the laryngeal mask airway in normal and low birth weight infants. Anesth Analg. 1999;89:642–643
      OpenUrlCrossRefPubMedWeb of Science
    67. 67.↵
      1. Esmail N,
      2. Saleh M,
      3. et al
      . Laryngeal mask airway versus endotracheal intubation for Apgar score improvement in neonatal resuscitation. Egyptian Journal of Anesthesiology. 2002;18:115–121
      OpenUrl
    68. 68.↵
      1. Hosono S,
      2. Inami I,
      3. Fujita H,
      4. Minato M,
      5. Takahashi S,
      6. Mugishima H
      . A role of end-tidal CO monitoring for assessment of tracheal intubations in very low birth weight infants during neonatal resuscitation at birth. J Perinat Med. 2009;37:79–84
      OpenUrlCrossRefPubMedWeb of Science
    69. 69.↵
      1. Repetto JE,
      2. Donohue P-CP,
      3. Baker SF,
      4. Kelly L,
      5. Nogee LM
      . Use of capnography in the delivery room for assessment of endotracheal tube placement. J Perinatol. 2001;21:284–287
      OpenUrlCrossRefPubMed
    70. 70.↵
      1. Roberts WA,
      2. Maniscalco WM,
      3. Cohen AR,
      4. Litman RS,
      5. Chhibber A
      . The use of capnography for recognition of esophageal intubation in the neonatal intensive care unit. Pediatr Pulmonol. 1995;19:262–268
      OpenUrlPubMedWeb of Science
    71. 71.↵
      1. Aziz HF,
      2. Martin JB,
      3. Moore JJ
      . The pediatric disposable end-tidal carbon dioxide detector role in endotracheal intubation in newborns. J Perinatol. 1999;19:110–113
      OpenUrlCrossRefPubMed
    72. 72.↵
      1. Garey DM,
      2. Ward R,
      3. Rich W,
      4. Heldt G,
      5. Leone T,
      6. Finer NN
      . Tidal volume threshold for colorimetric carbon dioxide detectors available for use in neonates. Pediatrics. 2008;121:e1524–1527
      OpenUrlAbstract/FREE Full Text
    73. 73.↵
      1. Orlowski JP
      . Optimum position for external cardiac compression in infants and young children. Ann Emerg Med. 1986;15:667–673
      OpenUrlCrossRefPubMedWeb of Science
    74. 74.↵
      1. Phillips GW,
      2. Zideman DA
      . Relation of infant heart to sternum: its significance in cardiopulmonary resuscitation. Lancet. 1986;1:1024–1025
      OpenUrlCrossRefPubMedWeb of Science
    75. 75.↵
      1. Braga MS,
      2. Dominguez TE,
      3. Pollock AN,
      4. Niles D,
      5. Meyer A,
      6. Myklebust H,
      7. Nysaether J,
      8. Nadkarni V
      . Estimation of optimal CPR chest compression depth in children by using computer tomography. Pediatrics. 2009;124:e69–e74
      OpenUrlAbstract/FREE Full Text
    76. 76.↵
      1. Menegazzi JJ,
      2. Auble TE,
      3. Nicklas KA,
      4. Hosack GM,
      5. Rack L,
      6. Goode JS
      . Two-thumb versus two-finger chest compression during CRP in a swine infant model of cardiac arrest. Ann Emerg Med. 1993;22:240–243
      OpenUrlCrossRefPubMedWeb of Science
    77. 77.↵
      1. Houri PK,
      2. Frank LR,
      3. Menegazzi JJ,
      4. Taylor R
      . A randomized, controlled trial of two-thumb vs two-finger chest compression in a swine infant model of cardiac arrest. Prehosp Emerg Care. 1997;1:65–67
      OpenUrlCrossRefPubMed
    78. 78.↵
      1. Udassi JP,
      2. Udassi S,
      3. Theriaque DW,
      4. Shuster JJ,
      5. Zaritsky AL,
      6. Haque IU
      . Effect of alternative chest compression techniques in infant and child on rescuer performance. Pediatr Crit Care Med. 2009;10:328–333
      OpenUrlCrossRefPubMedWeb of Science
    79. 79.↵
      1. David R
      . Closed chest cardiac massage in the newborn infant. Pediatrics. 1988;81:552–554
      OpenUrlAbstract/FREE Full Text
    80. 80.↵
      1. Thaler MM,
      2. Stobie GH
      . An improved technique of external caridac compression in infants and young children. N Engl J Med. 1963;269:606–610
      OpenUrlPubMedWeb of Science
    81. 81.↵
      1. Berkowitz ID,
      2. Chantarojanasiri T,
      3. Koehler RC,
      4. Schleien CL,
      5. Dean JM,
      6. Michael JR,
      7. Rogers MC,
      8. Traystman RJ
      . Blood flow during cardiopulmonary resuscitation with simultaneous compression and ventilation in infant pigs. Pediatr Res. 1989;26:558–564
      OpenUrlCrossRefPubMedWeb of Science
    82. 82.↵
      1. Kitamura T,
      2. Iwami T,
      3. Kawamura T,
      4. Nagao K,
      5. Tanaka H,
      6. Nadkarni VM,
      7. Berg RA,
      8. Hiraide A
      . Conventional and chest-compression-only cardiopulmonary resuscitation by bystanders for children who have out-of-hospital cardiac arrests: a prospective, nationwide, population-based cohort study. Lancet. 2010;375:1347–1354
      OpenUrlCrossRefPubMedWeb of Science
    83. 83.↵
      1. Mielke LL,
      2. Frank C,
      3. Lanzinger MJ,
      4. Wilhelm MG,
      5. Entholzner EK,
      6. Hargasser SR,
      7. Hipp RF
      . Plasma catecholamine levels following tracheal and intravenous epinephrine administration in swine. Resuscitation. 1998;36:187–192
      OpenUrlCrossRefPubMedWeb of Science
    84. 84.↵
      1. Roberts JR,
      2. Greenberg MI,
      3. Knaub MA,
      4. Kendrick ZV,
      5. Baskin SI
      . Blood levels following intravenous and endotracheal epinephrine administration. JACEP. 1979;8:53–56
      OpenUrlPubMedWeb of Science
    85. 85.↵
      1. Hornchen U,
      2. Schuttler J,
      3. Stoeckel H,
      4. Eichelkraut W,
      5. Hahn N
      . Endobronchial instillation of epinephrine during cardiopulmonary resuscitation. Crit Care Med. 1987;15:1037–1039
      OpenUrlCrossRefPubMedWeb of Science
    86. 86.↵
      1. Berg RA,
      2. Otto CW,
      3. Kern KB,
      4. Hilwig RW,
      5. Sanders AB,
      6. Henry CP,
      7. Ewy GA
      . A randomized, blinded trial of high-dose epinephrine versus standard-dose epinephrine in a swine model of pediatric asphyxial cardiac arrest. Crit Care Med. 1996;24:1695–1700
      OpenUrlCrossRefPubMedWeb of Science
    87. 87.↵
      1. Burchfield DJ,
      2. Preziosi MP,
      3. Lucas VW,
      4. Fan J
      . Effects of graded doses of epinephrine during asphxia-induced bradycardia in newborn lambs. Resuscitation. 1993;25:235–244
      OpenUrlCrossRefPubMedWeb of Science
    88. 88.↵
      1. Perondi MB,
      2. Reis AG,
      3. Paiva EF,
      4. Nadkarni VM,
      5. Berg RA
      . A comparison of high-dose and standard-dose epinephrine in children with cardiac arrest. N Engl J Med. 2004;350:1722–1730
      OpenUrlCrossRefPubMedWeb of Science
    89. 89.↵
      1. Patterson MD,
      2. Boenning DA,
      3. Klein BL,
      4. Fuchs S,
      5. Smith KM,
      6. Hegenbarth MA,
      7. Carlson DW,
      8. Krug SE,
      9. Harris EM
      . The use of high-dose epinephrine for patients with out-of-hospital cardiopulmonary arrest refractory to prehospital interventions. Pediatr Emerg Care. 2005;21:227–237
      OpenUrlCrossRefPubMedWeb of Science
    90. 90.↵
      1. Wyckoff MH,
      2. Perlman JM,
      3. Laptook AR
      . Use of volume expansion during delivery room resuscitation in near-term and term infants. Pediatrics. 2005;115:950–955
      OpenUrlAbstract/FREE Full Text
    91. 91.↵
      1. Salhab WA,
      2. Wyckoff MH,
      3. Laptook AR,
      4. Perlman JM
      . Initial hypoglycemia and neonatal brain injury in term infants with severe fetal acidemia. Pediatrics. 2004;114:361–366
      OpenUrlAbstract/FREE Full Text
    92. 92.↵
      1. Ondoa-Onama C,
      2. Tumwine JK
      . Immediate outcome of babies with low Apgar score in Mulago Hospital, Uganda. East Afr Med J. 2003;80:22–29
      OpenUrlPubMed
    93. 93.↵
      1. Klein GW,
      2. Hojsak JM,
      3. Schmeidler J,
      4. Rapaport R
      . Hyperglycemia and outcome in the pediatric intensive care unit. J Pediatr. 2008;153:379–384
      OpenUrlCrossRefPubMedWeb of Science
    94. 94.↵
      1. LeBlanc MH,
      2. Huang M,
      3. Patel D,
      4. Smith EE,
      5. Devidas M
      . Glucose given after hypoxic ischemia does not affect brain injury in piglets. Stroke. 25:1443–1447, 1994; discussion 1448
      OpenUrlAbstract/FREE Full Text
    95. 95.↵
      1. Hattori H,
      2. Wasterlain CG
      . Posthypoxic glucose supplement reduces hypoxic-ischemic brain damage in the neonatal rat. Ann Neurol. 1990;28:122–128
      OpenUrlCrossRefPubMedWeb of Science
    96. 96.↵
      1. Gluckman PD,
      2. Wyatt JS,
      3. Azzopardi D,
      4. Ballard R,
      5. Edwards AD,
      6. Ferriero DM,
      7. Polin RA,
      8. Robertson CM,
      9. Thoresen M,
      10. Whitelaw A,
      11. Gunn AJ
      . Selective head cooling with mild systemic hypothermia after neonatal encephalopathy: multicentre randomised trial. Lancet. 2005;365:663–670
      OpenUrlCrossRefPubMedWeb of Science
    97. 97.↵
      1. Shankaran S,
      2. Laptook AR,
      3. Ehrenkranz RA,
      4. Tyson JE,
      5. McDonald SA,
      6. Donovan EF,
      7. Fanaroff AA,
      8. Poole WK,
      9. Wright LL,
      10. Higgins RD,
      11. Finer NN,
      12. Carlo WA,
      13. Duara S,
      14. Oh W,
      15. Cotten CM,
      16. Stevenson DK,
      17. Stoll BJ,
      18. Lemons JA,
      19. Guillet R,
      20. Jobe AH
      . Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy. N Engl J Med. 2005;353:1574–1584
      OpenUrlCrossRefPubMedWeb of Science
    98. 98.↵
      1. Azzopardi DV,
      2. Strohm B,
      3. Edwards AD,
      4. Dyet L,
      5. Halliday HL,
      6. Juszczak E,
      7. Kapellou O,
      8. Levene M,
      9. Marlow N,
      10. Porter E,
      11. Thoresen M,
      12. Whitelaw A,
      13. Brocklehurst P
      . Moderate hypothermia to treat perinatal asphyxial encephalopathy. N Engl J Med. 2009;361:1349–1358
      OpenUrlCrossRefPubMedWeb of Science
    99. 99.↵
      1. Eicher DJ,
      2. Wagner CL,
      3. Katikaneni LP,
      4. Hulsey TC,
      5. Bass WT,
      6. Kaufman DA,
      7. Horgan MJ,
      8. Languani S,
      9. Bhatia JJ,
      10. Givelichian LM,
      11. Sankaran K,
      12. Yager JY
      . Moderate hypothermia in neonatal encephalopathy: safety outcomes. Pediatr Neurol. 2005;32:18–24
      OpenUrlCrossRefPubMedWeb of Science
    100. 100.↵
      1. Lin ZL,
      2. Yu HM,
      3. Lin J,
      4. Chen SQ,
      5. Liang ZQ,
      6. Zhang ZY
      . Mild hypothermia via selective head cooling as neuroprotective therapy in term neonates with perinatal asphyxia: an experience from a single neonatal intensive care unit. J Perinatol. 2006;26:180–184
      OpenUrlCrossRefPubMedWeb of Science
    101. 101.↵
      1. Field DJ,
      2. Dorling JS,
      3. Manktelow BN,
      4. Draper ES
      . Survival of extremely premature babies in a geographically defined population: prospective cohort study of 1994–9 compared with 2000–5. BMJ. 2008;336:1221–1223
      OpenUrlAbstract/FREE Full Text
    102. 102.↵
      1. Tyson JE,
      2. Parikh NA,
      3. Langer J,
      4. Green C,
      5. Higgins RD
      . Intensive care for extreme prematurity–moving beyond gestational age. N Engl J Med. 2008;358:1672–1681
      OpenUrlCrossRefPubMedWeb of Science
    103. 103.↵
      1. Paris JJ
      . What standards apply to resuscitation at the borderline of gestational age?J Perinatol. 2005;25:683–684
      OpenUrlCrossRefPubMed
    104. 104.↵
      1. Jain L,
      2. Ferre C,
      3. Vidyasagar D,
      4. Nath S,
      5. Sheftel D
      . Cardiopulmonary resuscitation of apparently stillborn infants: survival and long-term outcome. J Pediatr. 1991;118:778–782
      OpenUrlCrossRefPubMedWeb of Science
    105. 105.↵
      1. Casalaz DM,
      2. Marlow N,
      3. Speidel BD
      . Outcome of resuscitation following unexpected apparent stillbirth. Arch Dis Child Fetal Neonatal Ed. 1998;78:F112–F115
      OpenUrlCrossRefPubMed
    106. 106.↵
      1. Laptook AR,
      2. Shankaran S,
      3. Ambalavanan N,
      4. Carlo WA,
      5. McDonald SA,
      6. Higgins RD,
      7. Das A
      . Outcome of term infants using apgar scores at 10 minutes following hypoxic-ischemic encephalopathy. Pediatrics. 2009;124:1619–1626
      OpenUrlAbstract/FREE Full Text
    107. 107.↵
      1. Knudson MM,
      2. Khaw L,
      3. Bullard MK,
      4. Dicker R,
      5. Cohen MJ,
      6. Staudenmayer K,
      7. Sadjadi J,
      8. Howard S,
      9. Gaba D,
      10. Krummel T
      . Trauma training in simulation: translating skills from SIM time to real time. J Trauma. 64:255–263, 2008; discussion 263–254
      OpenUrlCrossRefPubMedWeb of Science
    108. 108.↵
      1. Wayne DB,
      2. Didwania A,
      3. Feinglass J,
      4. Fudala MJ,
      5. Barsuk JH,
      6. McGaghie WC
      . Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study. Chest. 2008;133:56–61
      OpenUrlCrossRefPubMedWeb of Science
    109. 109.↵
      1. Kory PD,
      2. Eisen LA,
      3. Adachi M,
      4. Ribaudo VA,
      5. Rosenthal ME,
      6. Mayo PH
      . Initial airway management skills of senior residents: simulation training compared with traditional training. Chest. 2007;132:1927–1931
      OpenUrlCrossRefPubMedWeb of Science
    110. 110.↵
      1. Schwid HA,
      2. Rooke GA,
      3. Michalowski P,
      4. Ross BK
      . Screen-based anesthesia simulation with debriefing improves performance in a mannequin-based anesthesia simulator. Teach Learn Med. 2001;13:92–96
      OpenUrlCrossRefPubMedWeb of Science
    111. 111.↵
      1. Shapiro MJ,
      2. Morey JC,
      3. Small SD,
      4. Langford V,
      5. Kaylor CJ,
      6. Jagminas L,
      7. Suner S,
      8. Salisbury ML,
      9. Simon R,
      10. Jay GD
      . Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum?Qual Saf Health Care. 2004;13:417–421
      OpenUrlAbstract/FREE Full Text
    112. 112.↵
      1. Cherry RA,
      2. Williams J,
      3. George J,
      4. Ali J
      . The effectiveness of a human patient simulator in the ATLS shock skills station. J Surg Res. 2007;139:229–235
      OpenUrlCrossRefPubMedWeb of Science
    113. 113.↵
      1. Savoldelli GL,
      2. Naik VN,
      3. Park J,
      4. Joo HS,
      5. Chow R,
      6. Hamstra SJ
      . Value of debriefing during simulated crisis management: oral versus video-assisted oral feedback. Anesthesiology. 2006;105:279–285
      OpenUrlCrossRefPubMedWeb of Science
    114. 114.↵
      1. Edelson DP,
      2. Litzinger B,
      3. Arora V,
      4. Walsh D,
      5. Kim S,
      6. Lauderdale DS,
      7. Vanden Hoek TL,
      8. Becker LB,
      9. Abella BS
      . Improving in-hospital cardiac arrest process and outcomes with performance debriefing. Arch Intern Med. 2008;168:1063–1069
      OpenUrlCrossRefPubMedWeb of Science
    115. 115.↵
      1. DeVita MA,
      2. Schaefer J,
      3. Lutz J,
      4. Wang H,
      5. Dongilli T
      . Improving medical emergency team (MET) performance using a novel curriculum and a computerized human patient simulator. Qual Saf Health Care. 2005;14:326–331
      OpenUrlAbstract/FREE Full Text
    116. 116.↵
      1. Wayne DB,
      2. Butter J,
      3. Siddall VJ,
      4. Fudala MJ,
      5. Linquist LA,
      6. Feinglass J,
      7. Wade LD,
      8. McGaghie WC
      . Simulation-based training of internal medicine residents in advanced cardiac life support protocols: a randomized trial. Teach Learn Med. 2005;17:210–216
      OpenUrlPubMedWeb of Science
    117. 117.↵
      1. Clay AS,
      2. Que L,
      3. Petrusa ER,
      4. Sebastian M,
      5. Govert J
      . Debriefing in the intensive care unit: a feedback tool to facilitate bedside teaching. Crit Care Med. 2007;35:738–754
      OpenUrlCrossRefPubMedWeb of Science
    118. 118.↵
      1. Blum RH,
      2. Raemer DB,
      3. Carroll JS,
      4. Dufresne RL,
      5. Cooper JB
      . A method for measuring the effectiveness of simulation-based team training for improving communication skills. Anesth Analg. 2005;100:1375–1380
      OpenUrlCrossRefPubMedWeb of Science
    • Copyright © 2010 American Heart Association, Inc.
    View Abstract
    Next

     

    Advertising Disclaimer »

    View this article with LENS
    Next
    Email

    Thank you for your interest in spreading the word on Pediatrics.

    NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

    Enter multiple addresses on separate lines or separate them with commas.
    Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
    (Your Name) has sent you a message from Pediatrics
    (Your Name) thought you would like to see the Pediatrics web site.

    Alerts
    Sign In to Email Alerts with your Email Address
    Citation Tools
    Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
    John Kattwinkel, Jeffrey M. Perlman, Khalid Aziz, Christopher Colby, Karen Fairchild, John Gallagher, Mary Fran Hazinski, Louis P. Halamek, Praveen Kumar, George Little, Jane E. McGowan, Barbara Nightengale, Mildred M. Ramirez, Steven Ringer, Wendy M. Simon, Gary M. Weiner, Myra Wyckoff, Jeanette Zaichkin
    Pediatrics Nov 2010, 126 (5) e1400-e1413; DOI: 10.1542/peds.2010-2972E

    Citation Manager Formats

    • BibTeX
    • Bookends
    • EasyBib
    • EndNote (tagged)
    • EndNote 8 (xml)
    • Medlars
    • Mendeley
    • Papers
    • RefWorks Tagged
    • Ref Manager
    • RIS
    • Zotero
    Share
    Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
    John Kattwinkel, Jeffrey M. Perlman, Khalid Aziz, Christopher Colby, Karen Fairchild, John Gallagher, Mary Fran Hazinski, Louis P. Halamek, Praveen Kumar, George Little, Jane E. McGowan, Barbara Nightengale, Mildred M. Ramirez, Steven Ringer, Wendy M. Simon, Gary M. Weiner, Myra Wyckoff, Jeanette Zaichkin
    Pediatrics Nov 2010, 126 (5) e1400-e1413; DOI: 10.1542/peds.2010-2972E
    del.icio.us logo Digg logo Reddit logo Technorati logo Twitter logo CiteULike logo Connotea logo Facebook logo Google logo Mendeley logo
    Print
    PDF
    Insight Alerts
    • Table of Contents
    • Current Policy
    • Early Release
    • Current Issue
    • Past Issues
    • Editorial Board
    • Editorial Policies
    • Overview
    • Open Access
    • Pediatric Collections
    • Video Abstracts
    • Author Guidelines
    • Reviewer Guidelines
    • Submit My Manuscript

    Subjects

    • Critical Care
      • Critical Care
    Back to top

                

    Copyright (c) 2018 by American Academy of Pediatrics

    International Access »           

    Terms of Use
    Privacy Statement
    FAQ

    AAP Pediatrics