Resuscitation 48 (2001) 235–239

European Resuscitation Council Guidelines 2000 forNewly Born Life Support

A statement from the Paediatric Life Support Working Group and approved by the ExecutiveCommittee of the European Resuscitation Council

Barbara Phillips *, David Zideman, Jonathan Wyllie, Sam Richmond,Patrick van Reempts

Royal Li6erpool Children’s Hospital, Eaton Road, Li6erpool L12 2AP, UK

www.elsevier.com/locate/resuscitation

1. Introduction

The European Resuscitation Council (ERC) lastissued guidelines for the resuscitation of the newlyborn infant in 1999 [1]. This was an ‘AdvisoryStatement’ of the International Liaison Committeeon Resuscitation (ILCOR). Following this, theAmerican Heart Association and the NeonatalResuscitation Programme Steering Committee ofthe American Academy of Paediatrics and repre-sentatives of the World Health organisation, to-gether with representatives from ILCOR,undertook a series of evidence based evaluationsof the science of resuscitation which culminated inthe publication of ‘Guidelines 2000 for Cardiopul-monary Resuscitation and Emergency Cardiovas-cular Care’ in August 2000 [2,3]. The PaediatricLife Support Working Party of the European Re-suscitation Council has considered this documentand the supporting scientific literature and pre-sents the ERC Newly Born Guidelines in thispaper. Readers will find few changes to the IL-COR Advisory Statement recommendations as thenew evidence that has emerged since its publica-tion in 1999 has been confirmatory of the ILCORrecommendations.

2. Background to newly born life support

In the following text the masculine includes thefeminine.

The need for resuscitation at birth can be pre-dicted with more readiness than at any other timeof life. The condition of the baby may be consid-ered at risk if he is known to be showing signs offetal distress or is significantly pre-term. Manydelivery units will have a policy that a paediatri-cian should attend any complex delivery includingcaesarian sections, multiple births etc. However,whatever guidelines are used some babies will beborn who unexpectedly require resuscitation. It istherefore important that everyone who is involvedin delivering babies should be trained in resuscita-tion of the newly born.

The frequency with which babies require resus-citation at birth will vary from country to countrybut useful population based information has comefrom a Swedish study. This showed that of nearly100 000 babies studied ten babies per 1000 weigh-ing 2.5 kg or more received mask inflation orintubation. Of these babies eight per 1000 re-sponded to mask inflation and only two per 1000seemed to require intubation at birth [4].

In newly born babies the problem is almostalways initially a respiratory one. The newlyborn is designed to undertake the passagethrough the birth canal, pushed by uterine con-tractions that intermittently interrupt respiration.

* Corresponding author. Tel.: +1-44-151-2284811; fax: +44-151-2525033.

0300-9572/01/$ - see front matter © 2001 European Resuscitation Council. Published by Elsevier Science Ireland Ltd. All rights reserved.PII: S 0 3 0 0 -9572 (00 )00382 -8

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The brain can withstand the lack of oxygen forvery much longer than at any other time of life.The heart continues to function even when there isso little oxygen present that cerebral respiratorydrive has failed. After the initial cessation of nor-mal breathing (primary apnea) a newly born in-fant will start a period of slow, gasping breathsthat are spinally induced. These breaths may besufficient to re-oxygenate the brain, if the airway isopen, and will save some babies even if no resusci-tation is provided. If the gasping breaths are un-successful, the baby is no longer able to generateany respiratory effort (secondary apnea). How-ever, the heart of the newborn baby can keepbeating for 20 min or more on its own, and forquite a time after normal breathing and the reservesystem of gasping, have both ceased to function.Therefore, in resuscitation of the newborn baby itis usually only necessary to inflate the lungs withair or oxygen. The heart and circulation are usu-ally still functioning, albeit less well than normal,and will respond to oxygenation and ventilation.Chest compressions are not often required. Drugsare rarely required and the need for their usesuggests a poor prognosis [5].

Keeping the baby warm is an essential part ofnewborn care. Because of their small size andrelatively large surface area babies get cold veryquickly. Ideally the baby should be born into anenvironment that is warm enough to allow him tomaintain his body temperature within the normalrange without effort. A wet baby rapidly losesheat and an anoxic, small baby can quickly be-come hypothermic. Babies subjected to cold stressin the period immediately after birth have a loweroxygen tension and an increased metabolicacidosis.

The lungs of the newborn baby have never beeninflated and are filled with lung fluid. At the onsetof normal labour the fetal lung switches fromsecreting to absorbing fluid. A small amount offluid, perhaps 35 ml or so in a term baby, isexpelled from the airways during the passagethrough the birth canal but more than 100 ml israpidly reabsorbed into the blood stream and thelymphatics within a few mins of birth.

Babies who are delivered by Caesarian sectionprior to the onset of labour are at a disadvantagein this respect and this may go some way toexplaining why they have a higher incidence ofrespiratory problems. A healthy baby can generate

a very high negative inspiratory pressure withinthe chest (greater than −100 cm H2O) to draw airinto the lungs. Intrathoracic pressure is often fur-ther raised by crying, which helps to drive lungfluid into the lymphatics during the first fewbreaths. In this way fluid is rapidly removed fromthe lungs and a normal resting (residual) lungvolume is achieved.

Babies who need resuscitation at birth need helpin achieving a resting (residual) lung volume. Arelatively long inflation time is needed to ade-quately inflate the lung of a newborn baby usingpositive pressure inflation. A pressure of 40 cm ofwater sustained for half a second can be effective,but an inflation pressure of 30 cm of water appliedfor 2–3 s and repeated half a dozen times willadequately aerate the lungs of most babies at birth[6].

3. Sequence of actions

In the following text the masculine includes thefeminine.

1. At deli7ery collect the baby in a clean, warmtowel.

2. Clamp the cordThe cord can usually be clamped about a min

after delivery, the baby being kept at approxi-mately the same level as the mother’s uterus untilthis time. Very early clamping, and clampingwhile the baby is held above the level of theplacenta can cause hypovolaemia.

3. Dry the baby and wrap in a clean, warm towel.

4. Assess the baby ’s condition by checking:

� Colour — look at the colour of the trunk, lipsand tongue;� Tone — check whether the baby is well flexedwith good tone or is hypotonic;� Breathing — look for the rate and depth ofrespiration. Breathing may be irregular to startwith but should soon become regular;� Heart rate — listen for the heart rate with astethoscope or feel for a pulse at the base of theumbilical cord. Even in a healthy baby the corddoes not always pulsate so if you cannot feel

B. Phillips et al. / Resuscitation 48 (2001) 235–239 237

pulsation of the cord check with a stethoscopebefore assuming that there is no effective heartbeat.� These four features should be reassessed regu-larly during any subsequent resuscitation.� A baby who is breathing regularly, with a fastheart rate (100 beats/min or more), who is cen-trally pink and who has good tone needs nofurther intervention and should be given to themother.� A baby who is not breathing adequately, whohas a slow heart rate or one who is blue or whiteor floppy requires intervention and resuscitationstarting with opening of the airway.

5. Opening the airway� Hold the head in the neutral position. In new-born babies the occiput is prominent, so the neckflexes if the baby is placed on its back. To correctthis, place the baby’s head in the neutral positionwith the neck neither extended nor flexed. Thisposition can be stabilised by placing a small padunder the baby’s shoulders.� Lift the chin or perform a jaw thrust manoeuvre.Care must be taken to avoid damage to the softtissues under the chin.� Positioning the head and performing a jawthrust are most easily accomplished by a twohanded approach, placing one hand on each sideof the head, fixing the neutral position and per-forming jaw thrust.

6. Clear the airway� Remove any blood, vernix, meconium, mucus orvomit if present. The removal of debris requiresgentle direct examination and suction using alaryngoscope and a soft suction catheter ratherthan blind suction. Stimulation in the region of theposterior pharynx and larynx should be kept to aminimum because it can produce vagal bradycar-dia. Do not apply suction unless it is necessary.� Meconium aspirationThe vigorous baby with possible meconium aspira-tion does not require suctioning of the trachea.The baby with absent or depressed respirationsand (heavy) meconium aspiration should have di-rect laryngosocopy and tracheal intubation andsuctioning, using the tracheal tube as the suctioncatheter [7].

7A. If the infant is now breathing regularly, withgood chest mo7ement and is pink� Keep the infant warm and continue support-ive care and regular re-assessment

7B. If the infant is not breathing, is breathingirregularly or shallowly or is blue� Provide five inflation breaths with 100% oxygen,if available, at 30–35 cm H2O pressure, eachsustained for 2–3 s with either– a pressure limited device with a blow off valveand an over-ride for higher pressure if necessary– a pressure bag-valve-mask device (a minimumbag volume of 450–500 ml may be necessary)– mouth to mouth and nose ventilation (if noequipment is available) Providers must be aware,however that this method carries a risk to theprovider of infection from blood and birth canalmaterials. In areas of high HIV infection prevalencethis risk may be substantial. If the method is used,the provider should wipe obvious material from thebaby’s mouth and avoid swallowing or inhalingmaterial.– watch for chest expansion

8A. If the infant ’s chest is expanding with theinflation breaths:� Continue with ventilations at 40–60 breaths permin and reassess the heart rate by auscultating theprecordium or feeling for a pulse at the base of theumbilical cord.

8B. If the infant ’s chest is not expanding with theinflation breaths :� Re-position the airway: try a jaw thrust manoeu-vre if this has not been used or perhaps an oropha-ryngeal airway if this has not been used and attemptthe inflation breaths again. Consider using twopeople to control the airway and deliver breaths.

9B. If the infant ’s heart rate is more than 60 beatsper min and rising :� Continue with ventilation at a rate of 40–60breaths per min and continue to monitor colour,tone, breathing and heart rate.

9B. If the infant ’s heart rate is less than 60 beatsper min :� Start chest compressions using the followingmethod:– Locate the sternum and place both thumbsflat side by side on the lower sternum Placethem so that the thumbs are just below an

B. Phillips et al. / Resuscitation 48 (2001) 235–239238

imaginary line joining the infant’s nipples. Therest of both hands should be spread with thefingers together to encircle the lower part of theinfant’s rib cage with the tips of the fingers sup-porting the infant’s back.– Press down on the lower sternum with thetwo thumbs to depress it about one third of thedepth of the infant’s chest.– Release the pressure, then repeat at a rate ofabout 120 times a min (with interspersed ventila-tions the actual number of compressions per minwill be less than 90).� If there is only one provider, the two-fingermethod of chest compressions will have to beused– Locate the sternum and place the tips of twofingers, just below an imaginary line joining theinfant’s nipples.– With the tips of two fingers, press down onthe sternum to depress it approximately onethird of the depth of the infant’s chest.– Release the pressure, then repeat at a rate ofabout 120 times a min (with interspersed ventila-tions the actual number of compressions per minwill be less than 90).

10. Co-ordinate chest compressions and 7entila-tionsThey should be in a ratio of 3:1 with about 90compressions and 30 breaths per min. The actualnumber of events may be less than this becausethe interspersed breaths must be sufficient to ex-pand the lungs. The quality of ventilations andcompressions is more important than attainingthe exact number each minute.

11A. If the heart rate is rising after 30 s of chestcompression and 7entilationChest compressions may be stopped once thespontaneous heart rate is over 60 beats per minand rising. Continue ventilations until the infantis breathing adequately and is pink.

11B. If the heart rate is not rising after 30 s ofcompression and 7entilationAdminister epinephrine 0.1–0.3 ml/kg of a1:10 000 solution via– A venous catheter inserted into the umbilicalvein.– A tracheal tube into the trachea.– The intraosseous route. The intraosseous routeis not normally used in newborn resuscitation

because the umbilical vein is more accessible andthe newborn’s small bones are fragile. This routecan be used if umbilical or other direct venousaccess is not readily attainable.Continue chest compressions and ventilationsand consider the following further actions:� Establish a definitive airway.

Attempt tracheal intubation and verify the posi-tion of the tracheal tube.

� Establish vascular access.Gain access to the circulation by:Umbilical venous accessIntraosseous access� Give epinephrine every 3 min by direct vascu-lar access or via the tracheal route.� Consider giving bicarbonate to correct a severeacidosis: 1–2 mmol/kg as a 4.2% solution ofsodium bicarbonate intravenously.� Drugs should not be given until good lung in-flation and chest compressions have been estab-lished.� Correct reversible causes:

Hypovolaemia (give 10 ml/kg of crystalloid orblood),Hypothermia,Hypoglycaemia,Tension pneumothorax.

References

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[5] Sims DG, Heal CA, Bartle SM. The use of adrenalineand atropine in neonatal resuscitation. Arch Dis Child1994;70:F3–F10.

[6] Vyas H, Milner AD, Hopkin IE, Boon AW. Physiologic

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[7] Wiswell TE, Gannon CM, Jacob J, et al. Delivery roommanagement of the apparently vigorous meconium-stained neonate: results of the multicenter internationalcollaborative trial. Pediatrics 2000;105:1–7.

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