Highlights of the New Neonatal ResuscitationProgram Guidelines
Jeffrey M. Perlman, MB, ChB*
*Division of Newborn Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY, and
New York Presbyterian Hospital, Komansky Centre for Children’s Health, New York, NY.
Practice Gap
Scientific recommendations and treatment guidelines for neonatal
resuscitation need to be applied to clinical practice.
Abstract
In 2015, the neonatal guidelines for resuscitation were published with several
new treatment guidelines. Many of these are highlighted in this review. They
included changes in the algorithm, timing of cord clamping in the preterm
infant, optimizing detection of heart rate after birth, maintaining the
premature infant temperature in the delivery room, initiating oxygen use
during resuscitation, and using sustained inflation to establish functional
residual capacity. In the term infant, changes included management of the
nonbreathing infant delivered in the presence of meconium-stained amniotic
fluid and consideration for when to continue/discontinue resuscitation in infants
with an Apgar score of 0 after 10 minutes of resuscitation.
Objectives After completing this article, readers should be able to:
1. Understand the GRADE process for evaluating the science and significance
of the recommendations.
2. Understand the rationale behind delayed cord clamping in the premature
infant.
3. Understand the starting concentration of supplemental oxygen in the
premature infant needing resuscitation.
4. Understand the importance of avoiding moderate hypothermia after birth
and the methods of achieving this goal.
5. Understand the suggestive approach to managing the term
depressed infant delivered in the presence of meconium-stained
amniotic fluidAUTHOR DISCLOSURE Dr Perlman hasdisclosed no financial relationships relevant tothis article. This commentary does contain adiscussion of an unapproved/investigativeuse of a commercial product/device.
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INTRODUCTION
The neonatal guidelines for resuscitation were recently
published and reflected a summary of the evidence pre-
sented in the 2015 International Consensus on Cardiopul-
monary Resuscitation and Emergency Cardiovascular Care
Science with Treatment Recommendations. (1)(2) This
review of the guidelines will highlight some of the newer
and potentially controversial issues brought about by new
evidence. Importantly, some of the new recommendations
are based on “Grading of Recommendations, Assessment,
Development and Evaluation” (GRADE), a new system
for evaluating the quality of evidence and strength of the
recommendations (Table 1). (3)(4) In this review, the GRADE
process will be briefly described, and the following new/
controversial issues will be highlighted: the algorithm,
timing of cord clamping in the preterm infant, optimizing
detection of heart rate after birth, maintaining the tem-
perature of the premature infant in the delivery room,
initiating oxygen use during resuscitation, and using sus-
tained inflation to establish functional residual capacity
(FRC). This article also will include a discussion of the man-
agement approach to the nonbreathing term infant deliv-
ered in the presence of meconium-stained amniotic fluid
(MSAF) and consideration for when to continue/discontinue
TABLE 1. Topics Reviewed for the 2015 ILCOR Process
Optimal assessment of heart rate
Delayed cord clamping in preterm infants requiring resuscitation
Umbilical cord milking
Temperature maintenance in the delivery room
Maintaining infant temperature during delivery room resuscitation
Warming of hypothermic newborns
Infants born to mothers who are hypothermic or hyperthermic in labor
Continuous positive airway pressure and intermittent positive pressure ventilation
Sustained inflations
Outcomes for PEEP versus no PEEP in the delivery room
T-piece resuscitator and self-inflating bag
Intubation and tracheal suctioning in nonvigorous infants born through MSAF vs no intubation for tracheal suctioning
Oxygen concentration for resuscitating premature newborns
Two thumb vs two finger for chest compression
Chest compression ratio
Oxygen delivery during CPR (neonatal)
Laryngeal mask airway
Newborn infants who receive positive pressure ventilation for resuscitation, and use of a device to assess respiratory function
Use of feedback CPR devices for neonatal cardiac arrest
Limited resource-induced hypothermia
Delivery room assessment <25 weeks and prognostic score
Apgar score of 0 for ‡10 minutes
Predicting death or disability of newborns >34 weeks based on Apgar and/or absence of breathing
Resuscitation training frequency
Neonatal resuscitation instructors
CPR¼cardiopulmonary resuscitation; ILCOR¼International Liaison Committee on Resuscitation; MSAF=meconium-stained amniotic fluid; PEEP¼positiveend-expiratory pressure.
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resuscitation in infants with an Apgar score of 0 after 10
minutes of resuscitation.
USING GRADE TO DEVELOP RECOMMENDATIONS
GRADE is an emerging consensus process that rates quality
of evidence and strength of recommendations along with
values and preferences. (3)(4) In brief, GRADE classifies
quality of evidence as: high quality (where one has high
confidence in the estimate of effect as reported in a synthesis
of the literature); moderate quality (moderate confidence,
but there may be differences from a further elucidated
truth); low quality (where one has low confidence in the
estimate of the effect, which may be substantially different
from the true effect); and very low quality (it is possible that
the estimate of effect is substantially different from the true
effect). The quality of a body of evidence involves consid-
eration of 5 unique domains, including risk of bias for each
outcome as reported across relevant studies (methodolog-
ical quality), as well as the directness of evidence (such
as, was the population studied the same as that for which
the guideline will be used), heterogeneity of the results of
individual studies, precision of effect estimates, and risk of
publication bias. Randomized studies start off as high quality
Figure. Neonatal resuscitation algorithm.CPAP=continuous positive airway pressure,ECG=electrocardiography, ET=endotrachealintubation, HR=heart rate, IV=intravenous,PPV=positive pressure ventilation,SpO2=peripheral capillary oxygen saturation.
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but may be downgraded for methodological quality, whereas
observational or cohort studies start off as low quality and can
be further downgraded or upgraded depending on method-
ological quality or positive outcome effect.
Guideline users have to determine how much they can
trust that a recommendation will produce more favorable
rather than unfavorable consequences. The strength of a
recommendation reflects a gradient in guidance, with a
clearer expectation for adherence with strong recommen-
dations and lesser insistence on weak recommendations.
In addition, the effect may be in favor of or against the
recommendation. According to GRADE, several factorsmay
influence the strength of a recommendation, including the
risk-benefit balance, quality of evidence, patient values and
preferences, and finally, costs and resource utilization. If
confidence in these values and preferences is high and
variability is low, it is more likely that the recommendation
will be strong (and vice versa). Recommendations, whether
strong or weak, have different implications for patients,
health care professionals, or health care management.
BACKGROUND
Approximately 85% of infants born at term will initiate
spontaneous respirations within 10 to 30 seconds of birth,
an additional 10% will respond during drying and stim-
ulation, approximately 3% will initiate respirations after
positive pressure ventilation (PPV), 2% will undergo intu-
bation to support respiratory function, and 0.1%will require
chest compressions and/or epinephrine to achieve this
transition. (5)(6)(7) Although the vast majority of newborn
infants do not require intervention to make these transi-
tional changes, the large number of births worldwidemeans
that many infants require some assistance to achieve car-
diorespiratory stability each year.
NEONATAL ALGORITHM
There was considerable debate with regard to modifying the
International Liaison Committee on Resuscitation (ILCOR)
algorithm. First, the 30-second time rule was considered
unreasonable, and not evidence-based; however, there was
strong consensus that a reminder to assess and intervene if
necessary, within 60 seconds after birth, should be retained
to avoid critical delays in initiating resuscitation. This is
based on the fact that more than 95% of newly born in-
fants will start breathing spontaneously or in response to
stimulation within approximately 30 seconds. (5) If apnea
persists, PPV should be initiated within 60 seconds.
Second, given the importance of moderate hypothermia
(temperature <36°C) as a predictor of mortality, and evi-
dence from multiple studies that it can be avoided (as
described later in this article) with simple intervention
strategies, the ILCOR algorithm contains a running line
reminding providers to maintain thermoregulation through-
out the immediate newborn period (Figure). The algorithm
contained in the neonatal guidelines does not include this
important reminder.
DELAYED CORD CLAMPING IN PRETERM INFANTSREQUIRING RESUSCITATION
For many years, the umbilical cord of the preterm neonate
was generally cut soon after birth, so that the newborn can
be transferred immediately to the neonatal team. However,
there is evidence that a delay of clamping by 30 to 60
seconds after birth results in a smoother transition, partic-
ularly if the newborn begins breathing before the cord is
cut. (2) The ILCOR scientific review indicates that delay is
associated with increased placental transfusion, increased
cardiac output, more stable and higher neonatal blood
pressure, less intraventricular hemorrhage (IVH) of any
grade, less need for transfusion after birth, and less necro-
tizing enterocolitis. (2) However, there was no evidence of
decreased mortality or decreased incidence of severe IVH.
The only negative consequence appears to be an increased
level of bilirubin associated with more need for photother-
apy. Despite drawing evidence from randomized controlled
trials, the small sample size inmost trials and the associated
imprecision limit the quality of evidence for all outcomes
of interest. Based on the latter, ILCOR suggests delaying
umbilical cord clamping for preterm infants not requiring
immediate resuscitation after birth (weak recommendation).
The neonatal guidelines translated this scientific state-
ment as follows: “DCC [delayed cord clamping] for longer
than 30 seconds is reasonable for both term and preterm
infants who do not require resuscitation at birth. However,
there is insufficient evidence to recommend an approach
to cord clamping for preterm infants who do receive resus-
citation immediately after birth.” Notably, both ILCOR and
the neonatal guidelines do not specify a maximum time to
delay in cord clamping. (1)(2)
DETERMINATION OF HEART RATE
Neonatal resuscitation success has typically been deter-
mined by detecting an increase in heart rate through aus-
cultation. Heart rate also determines the need for changing
interventions and escalating care. However, recent evidence
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demonstrates that auscultation of heart rate is inaccurate,
and pulse oximetry takes several minutes to achieve a signal
and also may be inaccurate during the early minutes after
birth. The ILCOR scientific review identified several non-
randomized studies (deemed very-low-quality evidence)
showing a benefit of electrocardiography (ECG) compared
with oximetry for a fast and accurate measurement of heart
rate in infants requiring resuscitation. (8)(9)(10) In addi-
tion, clinical assessment was found to be both unreliable and
inaccurate. Among healthy newborns, providers frequently
could not palpate the umbilical pulse and underestimated
the newborn’s heart rate by auscultation or palpation. (11)
Although the mean differences between the series of heart
rates measured by ECG and pulse oximetry were small,
pulse oximetry tended to underestimate the newborn’s heart
rate and would have led to potentially unnecessary inter-
ventions. (8)(9)(10)(11) In particular, during the first 2
minutes after birth, pulse oximetry frequently displayed
the newborn’s heart rate below either 60 or 100 beats per
minute, whereas a simultaneous ECG showed the heart rate
higher than 100 beats per minute. (10)
ILCOR suggests that an ECG can be used to provide a
rapid and accurate estimation of heart rate (weak recom-
mendation, very-low-quality evidence). Importantly, ECG
should not replace the role of auscultation for the assess-
ment of heart rate, as well as pulse oximetry to evaluate
oxygenation. Moreover, each hospital will need to define
the patient populations that may require ECG placement
and develop methods for rapid application of the leads.
TEMPERATURE MAINTENANCE IN THE PREMATUREINFANT
It has been known for more than a century that preterm
newborns who become hypothermic after birth have a
higher mortality than those who remain normothermic.
(12)(13)(14) The premature neonate is especially vulnerable
and there appears to be a dose-related effect. Thus, in a large
study involving more than 5,000 premature infants less
than 1,500 g, there was an associated 28% increase in
mortality for every 1 degree decrease in temperature below
36.5°C. (14) Hypothermia is also associated with serious
morbidities, such as increased risk of IVH, respiratory
issues, hypoglycemia, and late-onset sepsis. (2)
The ILCOR treatment recommendation states: “Admis-
sion temperature of newly born nonasphyxiated infants is a
strong predictor of mortality and morbidity at all gestations.
It should be recorded as a predictor of outcomes as well
as a quality indicator” (this was a strong recommendation
based on moderate-quality evidence). Hence, the running
timelinewas added to the algorithm to emphasize this point.
It is recommended that the temperature of newly born
nonasphyxiated infants be maintained between 36.5°C and
37.5°C after birth through admission and stabilization. In
making this strong statement, ILCOR places a higher val-
ue on the strong association of inadvertent hypothermia with
mortality, the apparent dose effect, and the single direction
of the evidence. Most studies reviewed measured axillary
temperature but some older studies used rectal temperature.
The relative benefits of one over the other were not as-
sessed. However, ILCOR suggests that axillary temperature
should be used in the delivery room, but that on admission,
the measurement site should be left to individual local
practice.
INTERVENTIONS TO MAINTAIN NEWBORNTEMPERATURE IN THE DELIVERY ROOM THROUGHADMISSION TO A NEONATAL INTENSIVE AREA INTHE PREMATURE INFANT
Various strategies have been suggested to maintain a pre-
term infant’s temperature; it is unknown which of these
strategies is most effective. The scientific evidence indicates
that the use of radiant warmers and plastic wrap with a cap
has significantly improved but not eliminated the risk of
hypothermia in preterm infants in the delivery room. (15)
(16)(17) Other strategies have been introduced, including
thermal mattresses, increased room temperature, and the
use of warmed humidified resuscitation gases. (18)(19)(20)
(21)(22) Various combinations of these strategies may be
reasonable to prevent hypothermia in infants born at less
than 32 weeks of gestation. (23)(24)(25)
The ILCOR treatment recommendation focuses on pre-
term infants of less than 32weeks of gestation in the delivery
room and suggests “using a combination of interventions,
which may include environmental temperature 23°C to
25°C, warm blankets, plastic wrapping without drying,
cap, and thermal mattress to reduce hypothermia (temper-
ature <36.0°C) on admission to NICU.” This is a weak
recommendation, based on very-low-quality evidence. In
addition, it was pointed out that hyperthermia (>38.0°C)
should be avoided because of potential associated risks.
However no study showed any harm from hyperthermia.
Practical ConsiderationsMany of the studies used multiple strategies, so it is not
possible to identify a specific intervention that is effective in
maintaining infant temperature. Each unit should develop
specific strategies to avoid moderate hypothermia.
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OXYGEN CONCENTRATION FOR PREMATURENEWBORNS
The fact that high oxygen concentrations can be toxic to the
newly born lungs has long been recognized by ILCOR. The
original studies examined only air versus 100% oxygen and
led to a recommendation that blended oxygen be used to
titrate the concentration to achieve a targeted oxygen satu-
ration. It is uncertain whether the preterm newborn should
be started in a high (50%–100%) or low (21%–30%) oxygen
concentration while a pulse oximeter is being attached.
Review of the science revealed the following salientfindings:
initiating resuscitation of preterm newborns (<35 weeks of
gestation) with high oxygen (‡65%) or low oxygen (21%–
30%) showed no improvement in survival to hospital dis-
charge with the use of high oxygen. (26)(27)(28)(29)(30)
Similarly, in the subset of studies that evaluated these out-
comes, no benefit was seen in preventing bronchopulmo-
nary dysplasia, IVH, or retinopathy of prematurity. In all
studies, irrespective of whether air or high oxygen (includ-
ing 100%) was used to initiate resuscitation, most infants
were receiving approximately 30% oxygen by the time of
stabilization. (27)(29)(30) ILCOR recommends against ini-
tiating resuscitation of preterm newborns (<35 weeks of
gestation) with high-supplemental oxygen concentrations
(65%–100%). Rather, it recommends initiating with a low
oxygen concentration (21%–30%) (strong recommendation,
moderate-quality evidence). In making this recommenda-
tion, ILCOR places value on not exposing pretermnewborns
to additional oxygen without proven benefit for outcomes.
The neonatal guidelines state more clearly that resuscita-
tion of preterm newborns of less than 35 weeks of gestation
should be initiated with low oxygen (21%–30%), and the oxy-
gen concentration should be titrated to achieve preductal
oxygen saturation approximating the interquartile range mea-
sured in healthy term infants after vaginal birth at sea level.
Practical ConsiderationsThere is much debate among physicians as to the appro-
priate saturation targets to follow in the first 5 to 10 minutes
after birth. This issue is further complicated by the fact that
the oximeter may underestimate heart rate during the first 2
minutes after birth, (10) raising serious questions regarding
reliability of saturation values during this critical period.
RESPIRATORY SUPPORT IN THE PREMATURE INFANT
Establishing Functional Residual CapacityThemost effective method for establishing FRC in the fluid-
filled lung of a newborn who does not breathe spontaneously
has been debated for many decades. In the 1980s, Vyas et al
(31) suggested a technique for administering a sustained
inflation of up to 5 seconds in duration. Both standard
PPV with or without positive end-expiratory pressure (PEEP)
and inflation breaths up to 3 seconds in duration are the initial
strategies currently advocated to initiate ventilation (Neonatal
Resuscitation Program, European Resuscitation Council). (1)
(32) Several recent animal studies have suggested that a
longer sustained inflation (up to 30 seconds) may be bene-
ficial for establishing FRC during transition from fluid-filled
to air-filled lungs after birth. (33)(34) Three randomized
studies demonstrated a benefit of sustained inflation (up to
15 seconds) for reducing the need for mechanical ventilation,
but no benefit was found for reduction of mortality, bron-
chopulmonary dysplasia, or air leak (very-low-quality evi-
dence, downgraded for variability of interventions). (35)(36)
(37) Importantly, a recent randomized study showed an
increase in pneumothorax and pulmonary interstitial emphy-
sema (Table 2). (37) The ILCOR treatment recommendation
is against the routine use of initial sustained inflation (>5
seconds’ duration) for preterm infants without spontaneous
respirations immediately after birth. It is suggested that
sustained inflation may be considered in individual clinical
circumstances or research settings (weak recommendation,
low-quality evidence). In making this recommendation and
in the absence of long-term benefits, ILCOR places a higher
value on the negative aspect involving lack of clarity as to how
to administer sustained inflation and the duration of the
breath compared with the positive findings of a reduced need
for intubation at 72 hours. In addition, the methods used to
deliver sustained inflation varied among studies. It was
stressed that different devices varied in their ability to gen-
erate pharyngeal pressures. Moreover, recent experimental
data suggest that an unintended glottis closure may be
associated with sustained inflation.
Intubation and Tracheal Suctioning in NonvigorousInfants Born Through Meconium-Stained Amniotic FluidFor many years, it has been recommended that newborns
with MSAF should receive tracheal suctioning using an
endotracheal tube as a suction device. Approximately 15
years ago, as a result of a multicenter randomized clinical
trial, the recommendation was restricted to infants who
appeared to have respiratory compromise at birth (ie, were
“nonvigorous”). ILCOR revisited this issue with regard to
the risks/benefits of routine suctioning, and analyzed the
data for the critical outcomes ofmortality and/or meconium
aspiration syndrome (MAS). Since the last ILCOR review
(2010), 1 randomized study involving 122 infants showed
no benefit to suctioning versus no suctioning in either
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reducing mortality and/or MAS (low-quality evidence,
downgraded for risk of bias and imprecision). (38) Older
evidence was re-reviewed and the following findings were
noted: three nonrandomized very-low-quality evidence stud-
ies showed a higher incidence of MAS in depressed in-
fants who had tracheal intubation for suctioning (26%)
compared with vigorous infants who did not undergo in-
tubation (0.3%) (downgraded for indirectness). (39)(40)(41)
Six very-low-quality observational studies demonstrated im-
proved survival and lower incidence of MAS when infants
(including depressed and/or vigorous infants) born through
MSAF were intubated for tracheal suctioning (downgraded
for indirectness and inconsistency). (42)(43)(44)(45)(46)
(47) Six very-low-quality observational studies demonstrated
no improvement in survival and/or incidence of MAS
(including depressed and/or vigorous infants) when infants
born through MSAF underwent intubation for tracheal
suctioning (downgraded for indirectness). (48)(49)(50)(51)
(52)(53)
Based on this re-review of the data, the ILCOR treatment
recommendation stated the following: “There is insuffi-
cient published human evidence to suggest routine tracheal
intubation for suctioning of meconium in nonvigorous
infants born through MSAF as opposed to no tracheal intu-
bation for suctioning.” In making this suggestion, ILCOR
places a value on both harm avoidance (delays in provid-
ing bag-mask ventilation, potential harm of the procedure)
and the unclear benefits of routine tracheal intubation and
suctioning.
The neonatal guidelines state: “If an infant born through
MSAFpresents with poor tone and inadequate breathing ef-
forts, the initial steps of resuscitation should be completed
under the radiant warmer. PPV should be initiated if the
infant is not breathing or the heart rate is less than 100 beats
per minute. Routine suctioning of nonvigorous infants is
more likely to result in delays in initiating ventilation, es-
pecially where the provider is unable to promptly intubate
the infant or suction attempts are repeated.” In the absence
of evidence of benefit for suctioning, the emphasis should
be on initiating ventilation within the first minute after birth
in nonbreathing or ineffectively breathing infants.
Practical ConsiderationsThis change in the ILCOR treatment recommendation is
based on 1 low-quality randomized study that showed no
difference in outcomes (death and/or MAS), regardless of
whether the infant underwent suctioning. In keeping with
the low-quality evidence, it is important to restate that this
is a suggestion and not a recommendation. It is also impor-
tant to recognize that many cases of MAS described in the
literature occur in the context of associated clinical events,
chorioamnionitis, and/or fetal heart rate abnormalities.
Clearly, under clinical circumstances that increase the
potential for aspiration, the provider should anticipate and
be prepared for the possibility that immediate intubation
may be indicated, rather than waiting for signs of obstruc-
tion. The spirit of the ILCOR treatment recommendation
recognized that a provider at delivery may not be skilled in
intubation. Under such circumstances, delay in providing
bag-mask ventilation versus potential harm of attempting
intubation would favor the former approach while addi-
tional assistance is sought.
APGAR SCORE OF 0 FOR 10 MINUTES OR LONGER
Controversy exists as to how long after attempting resus-
citation after birth, when a heart rate cannot be detected,
should the provider continue or discontinue resuscitation
efforts. The Apgar score of 0 has typically been the criterion
used as the marker, because it indicates no detectable signs
of life. The current recommendation for duration of resus-
citative efforts is 10 minutes after birth. This guideline was
revisited because the therapeutic hypothermia (TH) trials
showed an increasing number of intact survivors with an
TABLE 2. Occurrence of Air Leaks in Infants Exposed to Normal InflationPressures and Sustained Inflation of 15 seconds
OUTCOME CONTROL GROUP (N [ 143) SLI GROUP (N [ 148) UNADJUSTED ODDS RATIO (95% CI) P
Respiratory distress syndrome 134 (94%) 133 (90%) 0.60 (0.25–1.41) .23
Pneumothorax 2 (1%) 9 (6%) 4.57 (0.97–21.50) .06
Interstitial emphysema 2 (1%) 7 (5%) 3.50 (0.72–17.10) .09
Relative risk 4.01 (95% confidence interval [CI] 1.38–11.73); P ¼ .01 (when combining pneumothorax and interstitial emphysema).Adapted from Lista et al. (37)
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Apgar score of 0 after birth. The ILCOR science review
indicates that 106 (82%) of 129 infants of gestational age of
greater than or equal to 36 weeks, and an Apgar score of 0 at
10 minutes after birth, either died or exhibited moderate
to severe neurodevelopmental impairment at 22 months
of age or later (very-low-quality evidence, downgraded for
risk of bias, inconsistency, indirectness, and imprecision).
(54)(55)(56)(57)(58)(59) Results from 3 of these studies,
which included nested observational series in randomized
clinical trials of TH and series of infants who received TH,
showed that this adverse outcome occurred in 68 (76%) of
90 infants with an Apgar score of 0 at 10 minutes. Among
the 56 cooled infants in these studies, 15 (27%) survived
without major/moderate disabilities. (56)(57)(59) The cur-
rent ILCOR treatment recommendation states that an
Apgar score of 0 at 10 minutes is a strong predictor of
mortality andmorbidity in late-preterm and term infants. It
is suggested that in infants with an Apgar score of 0 after 10
minutes of resuscitation, if the heart rate remains undetect-
able, it may be reasonable to stop resuscitation; however,
the decision to continue or discontinue resuscitative efforts
should be individualized. Variables to be considered may
include whether the resuscitation was considered to be
optimal, availability of advanced neonatal care such as TH,
specific circumstances before delivery, and the family’s
wishes (weak recommendation, very-low-quality evidence.)
Importantly, the number of infants with no heart rate at 10
minutes who died in the delivery room is unknown.
Practical ConsiderationsThere is a subtle but important distinction in the current
recommendation. This refers to the Apgar score of 0 after 10
minutes of resuscitation, which is distinct from 0 at 10
minutes. In addition, it states that consideration should be
given as to whether the resuscitation was optimal. Examples
of optimization would include intubation before initiating
chest compressions and administering intravenous rather
than endotracheal epinephrine if indicated. (60)
CONCLUSIONS
This brief review highlights several of the new neonatal
guideline recommendations that should enhance manage-
ment options for the compromised infant immediately
after delivery. There are many gaps in current manage-
ment, which demands ongoing research to further opti-
mize care.
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American Board of PediatricsNeonatal–Perinatal ContentSpecifications• Know the rationale, risks, and benefits of delayed cordclamping.
• Understand the significance, limitations, and causes of low Apgarscores, including the relationship between Apgar scores and lateroutcomes in preterm and full-term infants.
• Know the current recommendations regarding suctioningmeconium from the airway during and following delivery.
• Know indications for and proper administration of supplementaloxygen immediately after birth.
• Know the causes, metabolic consequences, and treatment ofinfants with hypothermia.
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measures a lower heart rate at birth compared with
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37. Lista G, Boni L, Scopesi F, et al; SLI Trial Investigators. Sustainedlung inflation at birth for preterm infants: a randomized clinicaltrial. Pediatrics. 2015;135(2):e457–e464
38. Chettri S, Adhisivam B, Bhat BV. Endotracheal suction fornonvigorous neonates born through meconium stained amnioticfluid: a randomized controlled trial. J Pediatr. 2015;166(5):1208–1213.e1
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54. Casalaz DM, Marlow N, Speidel BD. Outcome of resuscitationfollowing unexpected apparent stillbirth. Arch Dis Child FetalNeonatal Ed. 1998;78(2):F112–F115
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NeoReviews QuizThere are two ways to access the journal CME quizzes:
1. Individual CME quizzes are available via a handy blue CME link in the Table of Contents of any issue.
2. To access all CME articles, click “Journal CME” from Gateway’s orange main menu or go directly to: http://www.
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NOTE: Learners can takeNeoReviews quizzes andclaim credit online onlyat: http://Neoreviews.org.
To successfully complete2016 NeoReviews articlesfor AMA PRA Category 1CreditTM, learners mustdemonstrate a minimumperformance level of 60%or higher on thisassessment, whichmeasures achievement ofthe educational purposeand/or objectives of thisactivity. If you score lessthan 60% on theassessment, you will begiven additionalopportunities to answerquestions until an overall60% or greater score isachieved.
This journal-based CMEactivity is availablethrough Dec. 31, 2018,however, credit will berecorded in the year inwhich the learnercompletes the quiz.
1. Your hospital team is in the process of implementing the new Neonatal ResuscitationProgram (NRP) guidelines. Which of the following statements correctly describes theGrading of Recommendations, Assessment, Development and Evaluation (GRADE) processthat informs guideline development?
A. The GRADE process classifies articles as either “include” or “exclude” based on themerits of the study.
B. Randomized studies start off as high-quality evidence, but may be downgradeddue to methodological quality.
C. The strength of studies considered for inclusion is determined by the study typeand precision of effect, but does not take into account whether the populationstudied is the same as that for which the guideline will be used.
D. Although assessing the strength of the studies is part of the GRADE process ofreview, the final recommendations do not have any language to indicate whether itis a strong or weak recommendation.
E. Observational studies can only be included in the process if there are no ran-domized trials that are relevant to the question at hand.
2. You are at the delivery of a 31-week-gestational-age infant. You are discussing themanagement of cord clamping with the obstetric and pediatric teams. The plan is toclamp and cut the cord 60 seconds after delivery. Which of the following statementscorrectly describes the relationship of delayed cord clamping (DCC) and potentialeffects?
A. Most of the literature on the subject suggests that DCC is most beneficial when theinfant does not cry until after cord clamping.
B. DCC is associated with increased placental transfusion, increased cardiac output,and increase in low-grade intraventricular hemorrhage, with decreased risk of high-grade intraventricular hemorrhage.
C. The current recommendation from ILCOR is a strong recommendation to delayumbilical cord clamping for all preterm infants.
D. The new guidelines state that DCC for longer than 30 seconds is reasonable forboth term and preterm infants who do not require resuscitation at birth.
E. The ILCOR and NRP recommendation for maximum time until cord clamping is 120seconds.
3. You are at the delivery of a termmale infant. The infant is apneic and is receiving warming,drying, and stimulation after being brought to the radiant warmer. Which of the followingis an appropriate method to assess heart rate?
A. In this case, there is no reason to assess heart rate until the apnea is re-solved, because the resuscitation steps will be the same regardless of heartrate.
B. Auscultation of the heart rate at the chest should be the main method ofassessment unless the infant eventually undergoes intubation.
C. Electrocardiographymay provide a faster andmore accuratemeasurement of heartrate than oximetry in infants requiring resuscitation.
D. Pulse oximetry should only be applied to the infant 2minutes after delivery or later.E. Palpation of the umbilical cord should be the main method of assessment unless it
has been cut too short for this purpose.
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4. The resuscitation team is briefing before the cesarean delivery for a mother who is at 28weeks’ gestation. Which of the following plans for setting the initial oxygen concentrationfor starting resuscitation is consistent with the new NRP guidelines?
A. 21%–30%.B. 30%–40%.C. 50%–60%.D. 70%–100%.E. The new guidelines do not specify a specific range, but recommend somewhere
above 21% and below 100%.
5. The labor and delivery unit calls for a pediatrics team for meconium-stained amniotic fluidin a term infant with no other specified maternal risk factors. Which of the followingregarding planning for this delivery is consistent with the new NRP guidelines regardingthis issue?
A. There is no need for a pediatrics team to attend this delivery.B. The decision for intubation versus no intubation for tracheal suctioning should be
based on the thickness of the meconium-stained fluid.C. The decision for intubation versus no intubation for tracheal suctioning should be
based on whether the infant is vigorous at birth or not.D. If the infant presents with poor tone and inadequate breathing efforts, the initial
steps for resuscitation can be completed under the radiant warmer and positivepressure ventilation provided if the infant is not breathing or heart rate is less than100 beats per minute.
E. The infant should undergo intubation at least once for tracheal suctioning andfurther attempts determined by the consistency of the suctioned fluid.
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DOI: 10.1542/neo.17-8-e4352016;17;e435NeoReviews
Jeffrey M. PerlmanHighlights of the New Neonatal Resuscitation Program Guidelines
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Referenceshttp://neoreviews.aappublications.org/content/17/8/e435#BIBLThis article cites 57 articles, 23 of which you can access for free at:
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DOI: 10.1542/neo.17-8-e4352016;17;e435NeoReviews
Jeffrey M. PerlmanHighlights of the New Neonatal Resuscitation Program Guidelines
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