Neonatal Resuscitation Program™ and Helping Babies Breathe®

The past, present, and future of neonatal resuscitation efforts worldwide

(and lessons learned along the way)

Errol R. Alden, MD, FAAPAAP Executive Director/CEO

November 2011

Objectives• Provide an overview of the AAP’s

“Neonatal Resuscitation Program” and “Helping Babies Breathe”

• Highlight the importance of working with local authorities

• Demonstrate the translation of science into practice

• Share lessons learned

Neonatal Resuscitation

• Of the 130 million babies born each year, about 4 million die in the first 4 weeks of life. A quarter of these deaths are due to asphyxia.

• It is estimated that an additional million develop problems such as cerebral palsy and other disabilities.

World Health Report 2005

Neonatal Resuscitation

• The vast majority of newborn infants do not require intervention from intrauterine to extrauterine life.

• Approximately 10% of newborns require some assistance to begin breathing at birth.

• About 1% of newborns require extensive resuscitation

Inverted Pyramidof Neonatal Resuscitation

Medications

ChestCompressions

Positive-Pressure Ventilation

Initial Steps: Drying, Warmth, Clearing the Airway, Stimulation

Assessment at Birth and Simple Newborn Care

All infantsAll infants

Some infantsSome infants

Few infantsFew infants

Wall, Lee, Niermeyer et al. IJGO 2009

136 million babies born

Approx 10 million babies

Approx 6 million babies

< 1.4 million babies

Dawes Foetal and Neonatal Physiology. Year Book Medical Publishers Inc; 1968.

Pathophysiologic Cardio-Pulmonary Consequences of Asphyxia

Some Recommendations for Resuscitation (1850-1950)

•Rectal stimulation (stretching of the rectum with a corn cob)

•Tobacco smoke blown into the rectum

•Immersion into cold water(+ alternating with warm water)

Some Recommendations for Resuscitation (1850-1950)

•Intragastric oxygen

•Rhythmic traction of the tongue

•Rubbing, slapping, and pinching

•Raising and lowering of the arms, while an assistant compresses the chest

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Consequences of Poor Neonatal Resuscitation

• Increased Death

• Increased Disability

• Emotional & Financial Burden

• Direct Community Costs

• Loss of Productivity

Neonatal Resuscitation Program• mid-1970s: Dr Bloom and Cathy

Cropley receive NICHD award to develop an initial simple way to focus neonatal resuscitation teaching

• 1981: Dr George Peckham, an AHA volunteer and AAP Perinatal Section Chair, advocated for development of a standardized core curriculum

• 1985: Dr Peckham and Dr Leon Chameides discussed models and outlined the “train the trainer” approach for dissemination

Ron Bloom

Cathy Cropley

Neonatal Resuscitation Program• 1986: Dr Peckham and Dr

Bill Keenan, AAP Perinatal Section Leaders, began seeking buy-in from neonatology community for such an endeavor

• First NRP textbook (1987): based on consensus opinions of leaders in neonatology regarding what was “accepted” practice

• First 2-day NRP course occurred in November 1987

The Neonatal Resuscitation Program

American Academy of PediatricsAmerican Heart Association

The NRP is designed to guide resuscitation of the

newborn infant in the critical few minutes during and immediately following

birth.

NRP: Program Goal

To have at least one person

trained in neonatal resuscitation

present at every delivery in the

United States.

Early NRP

Mead Johnson Nutritionals: Neonatal Resuscitation

NRP: US Program HistoryIn 24 years:• 2.9 million providers have been trained/retrained.

Currently in the United States:• There are more than 27,000 active instructors.

• Approximately 130 courses are held each day.

Lesson #2: Convince others the mission is their own

Romania1991

NRP 6th Edition Update• Pulse oximetry

added

• Meconium suctioning recommendations changed

• Use of supplemental oxygen during resuscitation

NRP 6th Edition Update, Continued

• Increase time between initiating chest compressions and interrupting compressions to assess heart rate

• Induced therapeutic hypothermia

• Simulation-based educational methodology

NRP Now

Textbook of Neonatal Resuscitation, 6th Edition, 2011

NRP Outcomes

• Asphyxia decreased in 10 provinces in China after training with NRP. (Huishan et al 2008)

• In the first decade, deaths due to birth asphyxia in the US decreased 42%. (Wegman 1991)

• Introduction of NRP in 10 hospitals in India reduced overall neonatal mortality by 7 per 1000. (Deorari 2000)

NRP Outcomes, Continued

Guyer B et al. Annual Summary of Vital Statistics - 1996 Pediatrics 1997; 100:90

NRP: Reach of Program

Although reporting of international NRP courses is voluntary, training has been reported in more than 125 countries and translated into 26 languages.

Of all the educational material produced by the American Academy of Pediatrics,

the NRP is the most widely usedaround the world.

Lesson #3: Expertise doesn’t necessarily equal ability to teach

Laos & Thailand

Lesson #4: Being an expert in your own country doesn’t mean you’re an expert in other countries.

NRP Reach

Transferability….to more than 125 countries

Sites of NRP Implementation

Lesson #5: Humor may not translate, but laughter is universal

NRP in Developing Countries

• While NRP has been embraced

internationally, the content and

format is routinely altered to

meet the needs of the learners in

developing countries.

NRP in Developing Countries

• The challenge has been to

develop a curriculum, based on

the same rigorous science of

NRP, that is culturally effective

and meets the needs of those

who live in resource limited

settings.

NRP in Developing Countries

• Developing an effective

curriculum for limited resource

settings would impact

Millennium Development Goal

#4, which is to reduce by two

thirds, the under-five mortality

rate.

Helping Babies Breathe®

Global Causes of Neonatal Death

UNICEF 2007Lee, Wall, Cousens et al. Int J Epidemiol (in press)

Big Target of Helping Babies Breathe

Lawn JE et al. IJGO 2009; 107:S5

1 million “stillbirths” due to asphyxia

830,000 neonatal deaths due to asphyxia

Helping Babies Breathe Concept

• International Liaison Committee on Resuscitation (ILCOR) Science

• Harmonious With NRP & WHO Recommendation, if feasible

• Non-Profit, Inclusive

• Directed To Resource Limited Conditions - Single Provider

Helping Babies Breathe Curricular Concept

• Pictorial

• Limited Text

• Hands On Performance

• Frequent Skills Practice

• Simplest Steps “Possible”

• The Golden Minute

Hands on Practice

Educational Design

• Adult Learning - TOT, Visual Tool kit Hands on

• Performance - OSCE Evidence-Based

• Learner to Facilitator - 6:1

• Learning in Pairs

Paired Teaching/Learning

Neonatal Physiology

• Hypoxia-apnea, slow heart rate

• Breathing for the Baby-rapid reversal

• Delays-increase mortality, morbidity

Field Testing• Educational Approaches

Tanzania, Kenya, India, Pakistan

• Modified MCQ, Problem-Solving, OSCE

Tanzania, Kenya, India, Pakistan

• Simulator

India

• Implementation Studies

Kenya, India, Bangladesh

Educational Field TestingBirth Attendants

• Increase Level of Skills Attained

• Testing OSCE

• Revision of MCQs

• Revision of Bag/Mask Instruction

• Revision of OSCEs

Implementation Field Testing

• Knowledge Acquisition improved

• Skills Testing – 98% Passed

• Resuscitation Required ↑ Stimulation ↓ BMV, Suction

• 6-12 Hours of Training

• ↓ death at 24 hours among babies not breathing at birth (RR = 0.46) with no change in stillbirths - Tanzania

– N=6928/7277 pre/post training

• ↓ stillbirths (RR = 0.73) with no change in neonatal deaths – India

– N=4173/5427 pre/post training

Clinical Outcomes

Helping Babies Breathe Tool Kit

• Action Plan

• Learner Workbook

• Facilitator Flip Chart

• Multiple Choice Questions

• OSCE

• Simulator-Purpose Built

• Bag/Mask/Suction/Stethoscope

Flipchart

Workbook

Simulator

Routine Care• Clearing the airway if

meconium present

• Drying infant

• Recognize crying

• Keeping warm

• Cutting the umbilical cord

• Encouraging breastfeeding

The Golden Minute®

• Recognizing infant not crying

• Positioning head

• Clearing the airway

• Stimulating

• Recognizing breathing

• Initiating ventilation by 1 minute

Global Development Alliance for Country-Wide Implementation

• American Academy of Pediatrics

• US Agency for International Development

• Saving Newborn Lives/Save the Children

• Eunice Kennedy Shriver National Institute of Child Health and Human Development

• Laerdal Global Health

Global Development Alliance

Overall Objective•Reduce newborn mortality due to asphyxia

Guiding Principles

•Inclusiveness and collaboration

•Country-owned and country-led

•Integration with maternal and essential newborn care

•Shared goal, results, and recognition

•Brand non-exclusivity

Global Development Alliance

The GDA continues to grow each day with new partners:

• Johnson and Johnson

• Latter Day Saints Charities

Soon to be added:

• Columbia University Earth Institute Millennium Villages/Cities Project

• International Pediatric Association

Ongoing Steps

• Global Development Alliance

• NICHD Studies

• Country-wide Implementation

• Facilitator Video

• Translations

• ENC (Essential Newborn Care) and EMONC (Emergency Obstetric and Neonatal Care)

Fit with Essential Newborn Care

• Thermal Protection

• Clean Delivery

• Cord Management

• Early Breast Feeding

• Resuscitation As Required

Hypothesis From Experience

Improving Skill in Neonatal

Resuscitation Spurs Improvements

in Other Components of Early

Neonatal Care.

Helping Babies Breathe

Sustainability

• Simple and evidence-based

• Low-cost and effective

• Easy to integrate with other essential parts of NB care

BHAGBig Hairy Audacious Goal

To have at least one person

trained in neonatal resuscitation

present at every delivery in the

WORLD

Helping Babies Breathe

Lesson #6: A healthy first cry represents a baby with unlimited potential