An Advisory Statement From the Pediatric Working Group of the International Liaison Committee on Resuscitation

Temperature

Prevention of heat loss is important for the newly born. Cold stress can increase oxygen consumption and impede effective resuscitation; however, hyperthermia should be avoided.^{25 ,26} Whenever possible, the infant should be delivered in a warm, draft-free area. Rapid drying of the skin, removing wet linen after delivery, placing the infant under a radiant warmer, and wrapping the infant in prewarmed blankets will reduce heat loss. Another strategy for reducing heat loss is placing the newly born skin-to-skin on the mother's chest or abdomen to use her body as a heat source. Several recent animal studies have suggested that selective (cerebral) hypothermia of the asphyxiated infant may protect against subsequent brain injury.^27–29 Although this was felt to be a promising area of research, there was consensus that no recommendation for routine implementation could be made until appropriate controlled studies in humans have been performed.

Standard Precautions

All fluids from patients should be treated as potentially infectious. Personnel should wear gloves and protective shields during procedures that are likely to expose them to droplets of blood or other body fluids. Local standards should be developed, with acknowledgment of individual circumstances and available resources.

Concept of Integrated Assessment

Evaluation of the need to initiate and continue resuscitative efforts should begin immediately after birth and proceed throughout the resuscitation process until vital signs have normalized. The complex of signs (initial cry, respirations, heart rate, color, response to stimulation) should be evaluated simultaneously, with action dictated by the integrated findings (compound and ongoing action) rather than by evaluation of a single vital sign, action on the result, and then evaluation of the next sign (sequential action). The appropriate response to abnormal findings also depends on the time elapsed since birth and how the infant has responded to previous resuscitative interventions. It is recognized that evaluation and intervention for the newly born are often simultaneous processes, especially when more than one trained provider is present. To enhance educational retention, this process is often taught as a sequence of distinct steps.

Response to Stimulation

Most newly born infants will respond to the stimulation of an extrauterine environment with movement of all extremities, strong inspiratory efforts, and a vigorous cry. If these responses are absent or weak, the infant should be stimulated. Appropriate stimulation includes drying the infant with a towel, flicking the bottoms of the feet, or gently rubbing the back. Such tactile stimulation may initiate spontaneous respirations in newly born infants who are experiencing “primary apnea.” If these efforts do not result in prompt onset of effective ventilation, they should be discontinued because the infant is in “secondary” or “terminal apnea” and should be given assisted ventilation.³⁰ By consensus, slapping, shaking, spanking, or holding the newly born upside down is contraindicated and potentially dangerous.⁶

Respiration

After initial respiratory efforts, the newly born infant should be able to establish regular respirations sufficient to improve color and maintain a heart rate >100 beats per minute (bpm). Gasping is an ominous sign and requires intervention. The marked variability of respiratory rate that is characteristic of perinatal transition prevents designation of a specific respiratory rate requiring intervention.

Heart Rate

Heart rate is determined by listening to the precordium with a stethoscope, feeling for pulsations at the base of the umbilical cord, or feeling the brachial or femoral pulse. Palpation of the carotid artery is not recommended in the newly born because of the difficulty of reliably palpating the artery and the potential for causing iatrogenic airway obstruction and/or vagal stimulation of the newly born. Central and peripheral pulses are often difficult to feel in infants and should not be relied on independently if they are absent.^{31 ,32} Heart rate should be consistently >100 bpm in an uncompromised newly born infant. An increasing or decreasing heart rate also can provide evidence of improvement or deterioration.

Color

An uncompromised newly born infant will be able to maintain a pink color without supplemental oxygen. Cyanosis is determined by examining central structures and mucous membranes. Acrocyanosis is usually a normal finding at birth but may indicate other conditions such as cold stress. Acrocyanosis is considered an unreliable indicator of oxygenation.

Positioning

The newly born infant should be placed on his or her back or side with the head in a neutral or slightly extended position. If respiratory efforts are present but not producing effective tidal ventilation, often the airway is obstructed; immediate efforts must be made to reposition the head or clear the airway.

Suctioning

Healthy, vigorous newly born infants generally do not require suctioning after delivery. If necessary, secretions should be cleared with a suction device (bulb syringe, suction catheter). Aggressive pharyngeal suction can cause laryngeal spasm and vagal bradycardia³³ and delay the onset of spontaneous breathing. In the absence of meconium or blood, mechanical suction with a catheter should be limited to a depth of 5 cm from the lips and a duration of 5 seconds. Negative pressure of the suction apparatus should not exceed 100 mm Hg (13.3 kPa).

Clearing the Airway of Meconium

When the amniotic fluid is contaminated with meconium, the mouth, pharynx, and nose should be suctioned as soon as the head is delivered (intrapartum suctioning).³⁴ If the fluid contains meconium and the infant has absent or depressed respirations or decreased muscle tone, direct laryngoscopy should be conducted immediately after birth for suctioning of residual meconium from the hypopharynx (under direct vision) and intubation/suction of the trachea.^{35 ,36} Drying and stimulation generally should be delayed in such infants. Tracheal suctioning can be accomplished by applying suction directly to a tracheal tube as it is withdrawn from the airway. Intubation and suctioning during tracheal tube withdrawal can be repeated until meconium is no longer recovered, providing the infant's heart rate remains at >60 bpm. If the infant's respiration is severely depressed, tracheal reintubation for positive-pressure ventilation may be necessary even though some meconium remains in the airway. There is evidence that tracheal suctioning of the vigorous infant with meconium-stained fluid does not improve outcome and may cause complications.^{37 ,38}

Free-Flow Oxygen

The traditional treatment for central cyanosis is administration of 100% oxygen, either by passive delivery via an oxygen mask or by positive pressure delivered via a resuscitation bag. Although there is some in vitro evidence, a valid biochemical rationale, and preliminary clinical evidence³⁹ to support resuscitation with lower oxygen concentrations, current clinical data are insufficient to justify adopting this as a routine practice.^{40 ,41}Conversely, in settings where availability of oxygen is limited (eg, the developing world), it is reasonable to consider resuscitation with room air. There is some evidence that infants born at high altitude (ie, low ambient Pao ₂) have more difficulty establishing normal oxygenation and pulmonary blood flow than infants born at sea level.⁴² However, the first priority should be to ensure adequate inflation of the fluid-filled lungs, followed by attention to the desired concentration of inspired oxygen.

Assisted Ventilation

Effectiveness of Ventilation

Effectiveness of ventilation is judged by watching adequacy of chest rise and improvement in vital signs. Critical adjustments to improve effectiveness include improving the seal between mask and face, ensuring patency of the airway (clearing airway of material, adjusting head position, opening the mouth), increasing inflation pressure on the bag, and optimizing the position of the tracheal tube.

Mouth-to-Mouth/Nose and Mouth-to-Mask Ventilation

The best method for initially assisting ventilation is with a bag-valve–mask apparatus.^43–45 However, for BLS at birth, when equipment is not available, mouth-to-mouth/nose ventilation is effective. Consensus continues to support initial attempts at ventilation via both the infant's mouth and nose, with creation of a functional seal to ensure adequate chest rise and ventilation. To decrease the risk of infection to the rescuer, maternal blood and other body fluids should first be wiped from the face of the infant. New devices for delivery of mouth-to-mask or barrier resuscitation for the newly born are under development.^{46 ,47}

Bag-Valve–Mask Ventilation

Laryngeal Mask Airway Ventilation

Masks that fit over the laryngeal inlet have been developed and have been shown to be effective for ventilating newly born full-term infants.⁴⁸ However, these masks have not been evaluated in small, preterm infants, and relative effectiveness for the suctioning of meconium has not been reported.

Tracheal Intubation for Ventilation

Indications for Chest Compressions

The heart rate, the change of heart rate, and the time elapsed after initiation of resuscitative measures should all be considered in deciding when chest compressions should be initiated. Establishment of adequate ventilation will restore vital signs in the vast majority of newly born infants. Because chest compressions may diminish the effectiveness of ventilation, they should not be initiated until effective ventilation has been established. Guidelines for initiation of chest compressions are

• Absent heart rate at any time

• Heart rate <60 bpm despite adequate assisted ventilation for 30 seconds

It is common practice to give compressions if the heart rate is 60 to 100 bpm and the heart rate is not rising. However, the ILCOR working group agrees that ventilation should be the priority in resuscitation of the newly born. Chest compressions are likely to compete with effective ventilation. Because no scientific data suggest an evidence-based resolution of these different council recommendations, the working group recommends a heart rate guideline of 60 bpm based on construct validity (ease of teaching and skill retention).

Compression Technique

Compressions should be delivered on the lower third of the sternum.^{53 ,54} Consensus supports recommendation of a relative rather than absolute depth of compression (eg, compress to approximately one third of the anterior-posterior diameter of the chest rather than 2 to 3 cm) to generate a palpable pulse. Acceptable techniques are 1) two thumbs on the sternum, superimposed or adjacent to each other according to the size of the infant, with fingers surrounding the thorax, and 2) two fingers placed on the sternum at right angles to the chest.^55–57 Data suggest that the two-thumb technique may offer some advantages in generating peak systolic and coronary perfusion pressure and in provider preference over the two-finger technique without introducing additional complications.^55–60 The two-finger technique may be preferable for a single rescuer. Compressions and ventilations should be coordinated to avoid simultaneous delivery. There should be a 3:1 ratio of compressions to ventilations, with 90 compressions and 30 breaths to achieve approximately 120 “events” per minute. Thus, each event will be allotted approximately 0.5 seconds, with exhalation occurring during the first compression after each ventilation. Reassessment of the heart rate should continue approximately every 60 seconds, and chest compressions should continue until the spontaneous heart rate is >60 bpm.

Indications for Medication Administration

Drugs are rarely indicated in resuscitation of the newly born infant.⁶¹ Administration of epinephrine is not recommended unless the heart rate remains <60 bpm after a minimum of 30 seconds of adequate ventilation and chest compression.⁶² Volume expansion should be considered when there has been suspected blood loss and/or the infant appears to be in shock (pale, poor perfusion, weak pulse) and has not responded adequately to other resuscitative measures. If the mother has received a narcotic drug and the infant's respiratory drive is considered inadequate, naloxone may be indicated after vital signs have been established. However, support with artificial ventilation should be the priority. Naloxone should not be administered to newly born infants whose mothers are suspected of having recently abused narcotic drugs; naloxone may precipitate abrupt withdrawal signs in such infants. There are insufficient data to recommend routine use of bicarbonate in resuscitation of the newly born, as well as theoretical concerns that its hyperosmolarity and CO₂-generating properties may be detrimental to myocardial and/or cerebral function.^63–65 If used, it should be given only after adequate ventilation and circulation are ensured. Further use of bicarbonate in persistent metabolic acidosis should be directed by arterial blood gas levels, among other evaluations.

Routes of Medication Administration

Epinephrine and naloxone may be given via the endotracheal route, which is generally the most rapidly accessible site of administration. There are concerns that the endotracheal route may not result in as effective a level of epinephrine as does the intravenous (IV) route^66–69; however, the data are insufficient to recommend a higher dose via the endotracheal route. The umbilical vein is the most rapidly accessible route for volume expanders and may also be used for epinephrine, naloxone, and/or bicarbonate. Naloxone may be given intramuscularly but only after adequate assisted ventilation has been delivered and the infant is judged to have adequate peripheral circulation. The umbilical artery is not generally recommended for administration of resuscitation drugs, because it is often not rapidly accessible and there are concerns that complications may result if vasoactive or hypertonic drugs (eg, epinephrine or bicarbonate) are given into an artery. Intraosseous lines are not commonly used in newly born infants because of the more readily accessible umbilical vein, the fragility of small bones, and the small intraosseous space in a premature infant.

Types and Doses of Medications