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Newborn resuscitation requires anticipation and preparation by providers who train individually and as teams. Most newly born infants do not require immediate cord clamping or resuscitation and can be evaluated and monitored during skin-to-skin contact with their mothers after birth. Inflation and ventilation of the lungs are the priority in newly born infants who need support after birth. A rise in heart rate is the most important indicator of effective ventilation and response to resuscitative interventions. Pulse oximetry is used to guide oxygen therapy and meet oxygen saturation goals. Chest compressions are provided if there is a poor heart rate response to ventilation after appropriate ventilation corrective steps, which preferably include endotracheal intubation. The heart rate response to chest compressions and medications should be monitored electrocardiographically. If the response to chest compressions is poor, it may be reasonable to provide epinephrine, preferably via the intravenous route. Failure to respond to epinephrine in a newborn with history or examination consistent with blood loss may require volume expansion. If all these steps of resuscitation are effectively completed and there is no heart rate response by 20 minutes, redirection of care should be discussed with the team and family. It is estimated that approximately 10% of newly born infants need help to begin breathing at birth,1–3 and approximately 1% need intensive resuscitative measures to restore cardiorespiratory function.4,5 The neonatal mortality rate in the United States and Canada has fallen from almost 20 per 1000 live births6,7 in the 1960s to the current rate of approximately 4 per 1000 live births. The inability of newly born infants to establish and sustain adequate or spontaneous respiration contributes significantly to these early deaths and to the burden of adverse neurodevelopmental outcome among survivors. Effective and timely resuscitation at birth could therefore improve neonatal outcomes further. Successful neonatal resuscitation efforts depend on critical actions that must occur in rapid succession to maximize the chances of survival. The International Liaison Committee on Resuscitation (ILCOR) Formula for Survival emphasizes 3 essential components for good resuscitation outcomes: guidelines based on sound resuscitation science, effective education of resuscitation providers, and implementation of effective and timely resuscitation.8 The 2020 neonatal guidelines contain recommendations, based on the best available resuscitation science, for the most impactful steps to perform in the birthing room and in the neonatal period. In addition, specific recommendations about the training of resuscitation providers and systems of care are provided in their respective guideline Parts.9,10 This guideline is designed for North American healthcare providers who are looking for an up-to-date summary for clinical care, as well as for those who are seeking more in-depth information on resuscitation science and gaps in current knowledge. The science of neonatal resuscitation applies to newly born infants transitioning from the fluid-filled environment of the womb to the air-filled environment of the birthing room and to newborns in the days after birth. In circumstances of altered or impaired transition, effective neonatal resuscitation reduces the risk of mortality and morbidity. Even healthy babies who breathe well after birth benefit from facilitation of normal transition, including appropriate cord management and thermal protection with skin-to-skin care. The 2015 Neonatal Resuscitation Algorithm and the major concepts based on sections of the algorithm continue to be relevant in 2020 (Figure). The following sections are worth special attention. Figure. Neonatal Resuscitation Algorithm. CPAP indicates continuous positive airway pressure; ECG, electrocardiographic; ETT, endotracheal tube; HR, heart rate; IV, intravenous; O2, oxygen; Spo2, oxygen saturation; and UVC, umbilical venous catheter. Positive-pressure ventilation (PPV) remains the main intervention in neonatal resuscitation. While the science and practices surrounding monitoring and other aspects of neonatal resuscitation continue to evolve, the development of skills and practice surrounding PPV should be emphasized. Supplemental oxygen should be used judiciously, guided by pulse oximetry. Prevention of hypothermia continues to be an important focus for neonatal resuscitation. The importance of skin-to-skin care in healthy babies is reinforced as a means of promoting parental bonding, breast feeding, and normothermia. Team training remains an important aspect of neonatal resuscitation, including anticipation, preparation, briefing, and debriefing. Rapid and effective response and performance are critical to good newborn outcomes. Delayed umbilical cord clamping was recommended for both term and preterm neonates in 2015. This guideline affirms the previous recommendations. The 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) recommended against routine endotracheal suctioning for both vigorous and nonvigorous infants born with meconium-stained amniotic fluid (MSAF). This guideline reinforces initial steps and PPV as priorities. It is important to recognize that there are several significant gaps in knowledge relating to neonatal resuscitation. Many current recommendations are based on weak evidence with a lack of well-designed human studies. This is partly due to the challenges of performing large randomized controlled trials (RCTs) in the delivery room. The current guideline, therefore, concludes with a summary of current gaps in neonatal research and some potential strategies to address these gaps. Together with other professional societies, the AHA has provided interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed coronavirus disease 2019 (COVID-19) infection. Because evidence and guidance are evolving with the COVID-19 situation, this interim guidance is maintained separately from the ECC guidelines. Readers are directed to the AHA website for the most recent guidance.12 The following sections briefly describe the process of evidence review and guideline development. See “Part 2: Evidence Evaluation and Guidelines Development” for more details on this process.11 The Neonatal Life Support Writing Group includes neonatal physicians and nurses with backgrounds in clinical medicine, education, research, and public health. Volunteers with recognized expertise in resuscitation are nominated by the writing group chair and selected by the AHA ECC Committee. The AHA has rigorous conflict of interest policies and procedures to minimize the risk of bias or improper influence during development of the guidelines.13 Before appointment, writing group members and peer reviewers disclosed all commercial relationships and other potential (including intellectual) conflicts. Disclosure information for writing group members is listed in Appendix 1. These 2020 AHA neonatal resuscitation guidelines are based on the extensive evidence evaluation performed in conjunction with the ILCOR and affiliated ILCOR member councils. Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process. Each of these resulted in a description of the literature that facilitated guideline development.14–17 Each AHA writing group reviewed all relevant and current AHA guidelines for CPR and ECC18–20 and all relevant 2020 ILCOR International Consensus on CPR and ECC Science With Treatment Recommendations evidence and recommendations21 to determine if current guidelines should be reaffirmed, revised, or retired, or if new recommendations were needed. The writing groups then drafted, reviewed, and approved recommendations, assigning to each a Level of Evidence (LOE; ie, quality) and Class of Recommendation (COR; ie, strength) (Table).11 This table defines the Classes of Recommendation (COR) and Levels of Evidence (LOE). COR indicates the strength the writing group assigns the recommendation, and the LOE is assigned based on the quality of the scientific evidence. The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information).Classes of RecommendationCOR designations include Class 1, a strong recommendation for which the potential benefit greatly outweighs the risk; Class 2a, a moderate recommendation for which benefit most likely outweighs the risk; Class 2b, a weak recommendation for which it’s unknown whether benefit will outweigh the risk; Class 3: No Benefit, a moderate recommendation signifying that there is equal likelihood of benefit and risk; and Class 3: Harm, a strong recommendation for which the risk outweighs the potential benefit.Suggested phrases for writing Class 1 recommendations includeIs recommendedIs indicated/useful/effective/beneficialShould be performed/administered/otherComparative-effectiveness phrases include treatment/strategy A is recommended/indicated in preference to treatment B, and treatment A should be chosen over treatment B.Suggested phrases for writing Class 2a recommendations includeIs reasonableCan be useful/effective/beneficialComparative-effectiveness phrases include treatment/strategy A is probably recommended/indicated in preference to treatment B, and it is reasonable to choose treatment A over treatment B.For comparative-effectiveness recommendations (COR 1 and 2a; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.Suggested phrases for writing Class 2b recommendations includeMay/might be reasonableMay/might be consideredUsefulness/effectiveness is unknown/unclear/uncertain or not well-establishedSuggested phrases for writing Class 3: No Benefit recommendations (generally, LOE A or B use only) includeIs not recommendedIs not indicated/useful/effective/beneficialShould not be performed/administered/otherSuggested phrases for writing Class 3: Harm recommendations includePotentially harmfulCauses harmAssociated with excess morbidity/mortalityShould not be performed/administered/otherLevels of EvidenceFor LOEs, the method of assessing quality is evolving, including the application of standardized, widely-used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee. LOE designations include Level A, Level B-R, Level B-NR, Level C-LD, and Level C-EO.Those categorized as Level A are derived fromHigh-quality evidence from more than 1 randomized clinical trial, or RCTMeta-analyses of high-quality RCTsOne or more RCTs corroborated by high-quality registry studiesThose categorized as Level B-R (randomized) are derived fromModerate-quality evidence from 1 or more RCTsMeta-analyses of moderate-quality RCTsThose categorized as Level B-NR (nonrandomized) are derived fromModerate-quality evidence from 1 or more well-designed, well-executed nonrandomized studies, observational studies, or registry studiesMeta-analyses of such studiesThose categorized as Level C-LD (limited data) are derived fromRandomized or nonrandomized observational or registry studies with limitations of design or executionMeta-analyses of such studiesPhysiological or mechanistic studies in human subjectsThose categorized as Level C-EO (expert opinion) are derived fromConsensus of expert opinion based on clinical experienceCOR and LOE are determined independently (any COR may be paired with any LOE).A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. Table. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)* Guideline StructureThe 2020 guidelines are organized into “knowledge chunks,” grouped into discrete modules of information on specific topics or management issues.22 Each modular knowledge chunk includes a table of recommendations using standard AHA nomenclature of COR and LOE. A brief introduction or short synopsis is provided to put the recommendations into context with important background information and overarching management or treatment concepts. Recommendation-specific text clarifies the rationale and key study data supporting the recommendations. When appropriate, flow diagrams or additional tables are included. Hyperlinked references are provided to facilitate quick access and review. Document Review and ApprovalEach 2020 AHA Guidelines for CPR and ECC document was submitted for blinded peer review to 5 subject matter experts nominated by the AHA. Before appointment, all peer reviewers were required to disclose relationships with industry and any other potential conflicts of interest, and all disclosures were reviewed by AHA staff. Peer reviewer feedback was provided for guidelines in draft format and again in final format. All guidelines were reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and AHA Executive Committee. Disclosure information for peer reviewers is listed in Appendix 2. References
Major ConceptsThese guidelines apply primarily to the “newly born” baby who is transitioning from the fluid-filled womb to the air-filled room. The “newly born” period extends from birth to the end of resuscitation and stabilization in the delivery area. However, the concepts in these guidelines may be applied to newborns during the neonatal period (birth to 28 days). The primary goal of neonatal care at birth is to facilitate transition. The most important priority for newborn survival is the establishment of adequate lung inflation and ventilation after birth. Consequently, all newly born babies should be attended to by at least 1 person skilled and equipped to provide PPV. Other important goals include establishment and maintenance of cardiovascular and temperature stability as well as the promotion of mother-infant bonding and breast feeding, recognizing that healthy babies transition naturally. The Neonatal Resuscitation Algorithm remains unchanged from 2015 and is the organizing framework for major concepts that reflect the needs of the baby, the family, and the surrounding team of perinatal caregivers. Anticipation and PreparationEvery healthy newly born baby should have a trained and equipped person assigned to facilitate transition. Identification of risk factors for resuscitation may indicate the need for additional personnel and equipment. Effective team behaviors, such as anticipation, communication, briefing, equipment checks, and assignment of roles, result in improved team performance and neonatal outcome. Cord ManagementAfter an uncomplicated term or late preterm birth, it is reasonable to delay cord clamping until after the baby is placed on the mother, dried, and assessed for breathing, tone, and activity. In other situations, clamping and cutting of the cord may also be deferred while respiratory, cardiovascular, and thermal transition is evaluated and initial steps are undertaken. In preterm birth, there are also potential advantages from delaying cord clamping. Initial ActionsWhen possible, healthy term babies should be managed skin-to-skin with their mothers. After birth, the baby should be dried and placed directly skin-to-skin with attention to warm coverings and maintenance of normal temperature. There should be ongoing evaluation of the baby for normal respiratory transition. Radiant warmers and other warming adjuncts are suggested for babies who require resuscitation at birth, especially very preterm and very low-birth-weight babies. Stimulation may be provided to facilitate respiratory effort. Suctioning may be considered for suspected airway obstruction. Assessment of Heart RateHeart rate is assessed initially by auscultation and/or palpation. Oximetry and electrocardiography are important adjuncts in babies requiring resuscitation. Positive-Pressure VentilationPPV remains the primary method for providing support for newborns who are apneic, bradycardic, or demonstrate inadequate respiratory effort. Most babies will respond to this intervention. An improvement in heart rate and establishment of breathing or crying are all signs of effective PPV. Oxygen TherapyPPV may be initiated with air (21% oxygen) in term and late preterm babies, and up to 30% oxygen in preterm babies. Oximetry is used to target the natural range of oxygen saturation levels that occur in term babies. Chest CompressionsIf the heart rate remains less than 60/min despite 30 seconds of adequate PPV, chest compressions should be provided. The suggested ratio is 3 chest compressions synchronized to 1 inflation (with 30 inflations per minute and 90 compressions per minute) using the 2 thumb–encircling hands technique for chest compressions. Vascular AccessWhen vascular access is required in the newly born, the umbilical venous route is preferred. When intravenous access is not feasible, the intraosseous route may be considered. MedicationsIf the heart rate remains less than 60/min despite 60 seconds of chest compressions and adequate PPV, epinephrine should be administered, ideally via the intravenous route. Volume ExpansionWhen blood loss is known or suspected based on history and examination, and there is no response to epinephrine, volume expansion is indicated. Withholding and Discontinuing ResuscitationIt may be possible to identify conditions in which withholding or discontinuation of resuscitative efforts may be reasonably considered by families and care providers. Appropriate and timely support should be provided to all involved. Human Factors and SystemsTeams and individuals who provide neonatal resuscitation are faced with many challenges with respect to the knowledge, skills, and behaviors needed to perform effectively. Neonatal resuscitation teams may therefore benefit from ongoing booster training, briefing, and debriefing. Abbreviations
Anticipation of Resuscitation Need
SynopsisApproximately 10% of newborns require assistance to breathe after birth.1–3,5,13 Newborn resuscitation requires training, preparation, and teamwork. When the need for resuscitation is not anticipated, delays in assisting a newborn who is not breathing may increase the risk of death.1,5,13 Therefore, every birth should be attended by at least 1 person whose primary responsibility is the newborn and who is trained to begin PPV without delay.2–4 A risk assessment tool that evaluates risk factors present during pregnancy and labor can identify newborns likely to require advanced resuscitation; in these cases, a team with more advanced skills should be mobilized and present at delivery.5,7 In the absence of risk stratification, up to half of babies requiring PPV may not be identified before delivery.6,13 A standardized equipment checklist is a comprehensive list of critical supplies and equipment needed in a given clinical setting. In the birth setting, a standardized checklist should be used before every birth to ensure that supplies and equipment for a complete resuscitation are present and functional.8,9,14,15 A predelivery team briefing should be completed to identify the leader, assign roles and responsibilities, and plan potential interventions. Team briefings promote effective teamwork and communication, and support patient safety.8,10–12 Recommendation-Specific Supportive Text
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Umbilical Cord Management
SynopsisDuring an uncomplicated term or late preterm birth, it may be reasonable to defer cord clamping until after the infant is placed on the mother and assessed for breathing and activity. Early cord clamping (within 30 seconds) may interfere with healthy transition because it leaves fetal blood in the placenta rather than filling the newborn’s circulating volume. Delayed cord clamping is associated with higher hematocrit after birth and better iron levels in infancy.9–21 While developmental outcomes have not been adequately assessed, iron deficiency is associated with impaired motor and cognitive development.24–26 It is reasonable to delay cord clamping (longer than 30 seconds) in preterm babies because it reduces need for blood pressure support and transfusion and may improve survival.1–8 There are insufficient studies in babies requiring PPV before cord clamping to make a recommendation.22 Early cord clamping should be considered for cases when placental transfusion is unlikely to occur, such as maternal hemorrhage or hemodynamic instability, placental abruption, or placenta previa.27 There is no evidence of maternal harm from delayed cord clamping compared with early cord clamping.10–12,28–34 Cord milking is being studied as an alternative to delayed cord clamping but should be avoided in babies less than 28 weeks’ gestational age, because it is associated with brain injury.23 Recommendation-Specific Supportive Text
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Initial ActionsTemperature at Birth
SynopsisTemperature should be measured and recorded after birth and monitored as a measure of quality.1 The temperature of newly born babies should be maintained between 36.5°C and 37.5°C.2 Hypothermia (less than 36°C) should be prevented as it is associated with increased neonatal mortality and morbidity, especially in very preterm (less than 33 weeks) and very low-birth-weight babies (less than 1500 g), who are at increased risk for hypothermia.3–5,7 It is also reasonable to prevent hyperthermia as it may be associated with harm.4,6 Recommendation-Specific Supportive Text
Temperature Management for Newly Born Infants
SynopsisHealthy babies should be skin-to-skin after birth.8 For preterm and low-birth-weight babies or babies requiring resuscitation, warming adjuncts (increased ambient temperature [greater than 23°C], skin-to-skin care, radiant warmers, plastic wraps or bags, hats, blankets, exothermic mattresses, and warmed humidified inspired gases)10,11,14 individually or in combination may reduce the risk of hypothermia. Exothermic mattresses have been reported to cause local heat injury and hyperthermia.15 When babies are born in out-of-hospital, resource-limited, or remote settings, it may be reasonable to prevent hypothermia by using a clean food-grade plastic bag13 as an alternative to skin-to-skin contact.8 Recommendation-Specific Supportive Text
Clearing the Airway and Tactile Stimulation in Newly Born Infants
SynopsisThe immediate care of newly born babies involves an initial assessment of gestation, breathing, and tone. Babies who are breathing well and/or crying are cared for skin-to-skin with their mothers and should not need interventions such as routine tactile stimulation or suctioning, even if the amniotic fluid is meconium stained.7,19 Avoiding unnecessary suctioning helps prevent the risk of induced bradycardia as a result of suctioning of the airway. Recommendation-Specific Supportive Text
SynopsisIf there is ineffective breathing effort or apnea after birth, tactile stimulation may stimulate breathing. Tactile stimulation should be limited to drying an infant and rubbing the back and soles of the feet.21,22 There may be some benefit from repeated tactile stimulation in preterm babies during or after providing PPV, but this requires further study.23 If, at initial assessment, there is visible fluid obstructing the airway or a concern about obstructed breathing, the mouth and nose may be suctioned. Suction should also be considered if there is evidence of airway obstruction during PPV. Recommendation-Specific Supportive Text
SynopsisDirect laryngoscopy and endotracheal suctioning are not routinely required for babies born through MSAF but can be beneficial in babies who have evidence of airway obstruction while receiving PPV.7 Recommendation-Specific Supportive Text
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Assessment of Heart Rate During Neonatal ResuscitationAfter birth, the newborn’s heart rate is used to assess the effectiveness of spontaneous respiratory effort, the need for interventions, and the response to interventions. In addition, accurate, fast, and continuous heart rate assessment is necessary for newborns in whom chest compressions are initiated. Therefore, identifying a rapid and reliable method to measure the newborn’s heart rate is critically important during neonatal resuscitation.
SynopsisAuscultation of the precordium remains the preferred physical examination method for the initial assessment of the heart rate.9 Pulse oximetry and ECG remain important adjuncts to provide continuous heart rate assessment in babies needing resuscitation. ECG provides the most rapid and accurate measurement of the newborn’s heart rate at birth and during resuscitation. Clinical assessment of heart rate by auscultation or palpation may be unreliable and inaccurate.1–4 Compared to ECG, pulse oximetry is both slower in detecting the heart rate and tends to be inaccurate during the first few minutes after birth.5,6,10–12 Underestimation of heart rate can lead to potentially unnecessary interventions. On the other hand, overestimation of heart rate when a newborn is bradycardic may delay necessary interventions. There are limited data comparing the different approaches to heart rate assessment during neonatal resuscitation on other neonatal outcomes. Use of ECG for heart rate detection does not replace the need for pulse oximetry to evaluate oxygen saturation or the need for supplemental oxygen. Recommendation-Specific Supportive Text
SynopsisWhen chest compressions are initiated, an ECG should be used to confirm heart rate. When ECG heart rate is greater than 60/min, a palpable pulse and/or audible heart rate rules out pulseless electric activity.17–21 Recommendation-Specific Supportive Text
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Ventilatory Support After Birth: PPV and Continuous Positive Airway PressureInitial Breaths (When and How to Provide PPV)The vast majority of newborns breathe spontaneously within 30 to 60 seconds after birth, sometimes after drying and tactile stimulation.1 Newborns who do not breathe within the first 60 seconds after birth or are persistently bradycardic (heart rate less than 100/min) despite appropriate initial actions (including tactile stimulation) may receive PPV at a rate of 40 to 60/min.2,3 The order of resuscitative procedures in newborns differs from pediatric and adult resuscitation algorithms. On the basis of animal research, the progression from primary apnea to secondary apnea in newborns results in the cessation of respiratory activity before the onset of cardiac failure.4 This cycle of events differs from that of asphyxiated adults, who experience concurrent respiratory and cardiac failure. For this reason, neonatal resuscitation should begin with PPV rather than with chest compressions.2,3 Delays in initiating ventilatory support in newly born infants increase the risk of death.1
SynopsisThe adequacy of ventilation is measured by a rise in heart rate and, less reliably, chest expansion. Peak inflation pressures of up to 30 cm H2O in term newborns and 20 to 25 cm H2O in preterm newborns are usually sufficient to inflate the lungs.5–7,9,11–14 In some cases, however, higher inflation pressures are required.5,7–10 Peak inflation pressures or tidal volumes greater than what is required to increase heart rate and achieve chest expansion should be avoided.24,26–28 The lungs of sick or preterm infants tend to collapse because of immaturity and surfactant deficiency.15 PEEP provides low-pressure inflation of the lungs during expiration. PEEP has been shown to maintain lung volume during PPV in animal studies, thus improving lung function and oxygenation.16 PEEP may be beneficial during neonatal resuscitation, but the evidence from human studies is limited. Optimal PEEP has not been determined, because all human studies used a PEEP level of 5 cm H2O.18–22 Recommendation-Specific Supportive Text
SynopsisIt is reasonable to initiate PPV at a rate of 40 to 60/min to newly born infants who have ineffective breathing, are apneic, or are persistently bradycardic (heart rate less than 100/min) despite appropriate initial actions (including tactile stimulation).1 To match the natural breathing pattern of both term and preterm newborns, the inspiratory time while delivering PPV should be 1 second or less. While there has been research to study the potential effectiveness of providing longer, sustained inflations, there may be potential harm in providing sustained inflations greater than 10 seconds for preterm newborns. The potential benefit or harm of sustained inflations between 1 and 10 seconds is uncertain.2,29 Recommendation-Specific Supportive Text
Continuous Positive Airway Pressure Administration
SynopsisNewly born infants who breathe spontaneously need to establish a functional residual capacity after birth.8 Some newly born infants experience respiratory distress, which manifests as labored breathing or persistent cyanosis. CPAP, a form of respiratory support, helps newly born infants keep their lungs open. CPAP is helpful for preterm infants with breathing difficulty after birth or after resuscitation33 and may reduce the risk of bronchopulmonary dysplasia in very preterm infants when compared with endotracheal ventilation.34–36 CPAP is also a less invasive form of respiratory support than intubation and PPV are. Recommendation-Specific Supportive Text
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Oxygen Administration
SynopsisDuring an uncomplicated delivery, the newborn transitions from the low oxygen environment of the womb to room air (21% oxygen) and blood oxygen levels rise over several minutes. During resuscitation, supplemental oxygen may be provided to prevent harm from inadequate oxygen supply to tissues (hypoxemia).4 However, overexposure to oxygen (hyperoxia) may be associated with harm.5 Term and late preterm newborns have lower short-term mortality when respiratory support during resuscitation is started with 21% oxygen (air) versus 100% oxygen.1 No difference was found in neurodevelopmental outcome of survivors.1 During resuscitation, pulse oximetry may be used to monitor oxygen saturation levels found in healthy term infants after vaginal birth at sea level.3 In more preterm newborns, there were no differences in mortality or other important outcomes when respiratory support was started with low (50% or less) versus high (greater than 50%) oxygen concentrations.2 Given the potential for harm from hyperoxia, it may be reasonable to start with 21% to 30% oxygen. Pulse oximetry with oxygen targeting is recommended in this population.3 Recommendation-Specific Supportive Text
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Chest CompressionsCPR Timing
SynopsisMost newborns who are apneic or have ineffective breathing at birth will respond to initial steps of newborn resuscitation (positioning to open the airway, clearing secretions, drying, and tactile stimulation) or to effective PPV with a rise in heart rate and improved breathing. If the heart rate remains less than 60/min despite these interventions, chest compressions can supply oxygenated blood to the brain until the heart rate rises. Ventilation should be optimized before starting chest compressions, with endotracheal intubation if possible. Chest compressions should be started if the heart rate remains less than 60/min after at least 30 seconds of adequate PPV.1 Oxygen is essential for organ function; however, excess inspired oxygen during resuscitation may be harmful. Although current guidelines recommend using 100% oxygen while providing chest compressions, no studies have confirmed a benefit of using 100% oxygen compared to any other oxygen concentration, including air (21%). However, it may be reasonable to increase inspired oxygen to 100% if there was no response to PPV with lower concentrations. Once return of spontaneous circulation (ROSC) is achieved, the supplemental oxygen concentration may be decreased to target a physiological level based on pulse oximetry to reduce the risks associated with hyperoxia.1,2 Recommendation-Specific Supportive Text
Compression-to-Ventilation Ratio and Techniques (Newborn)
SynopsisChest compressions are a rare event in full-term newborns (approximately 0.1%) but are provided more frequently to preterm newborns.11 When providing chest compressions to a newborn, it may be reasonable to deliver 3 compressions before or after each inflation: providing 30 inflations and 90 compressions per minute (3:1 ratio for 120 total events per minute). Alternative compression-to-ventilation ratios to 3:1, as well as asynchronous PPV (administration of inflations to a patient that are not coordinated with chest compressions), are routinely utilized outside the newborn period, but the preferred method in the newly born is 3:1 in synchrony. Newer methods of chest compression, using a sustained inflation that maintains lung inflation while providing chest compressions, are under investigation and cannot be recommended at this time outside research protocols.12,13 When providing chest compressions to a newborn, the 2 thumb–encircling hands technique may have benefit over the 2-finger technique with respect to blood pressure generation and provider fatigue. When providing chest compressions with the 2 thumb–encircling hands technique, the hands encircle the chest while the thumbs depress the sternum.1,2 The 2 thumb–encircling hands technique can be performed from the side of the infant or from above the head of the newborn.1 Performing chest compressions with the 2 thumb–encircling hands technique from above the head facilitates placement of an umbilical venous catheter. Recommendation-Specific Supportive Text
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Intravascular Access
SynopsisBabies who have failed to respond to PPV and chest compressions require vascular access to infuse epinephrine and/or volume expanders. In the delivery room setting, the primary method of vascular access is umbilical venous catheterization. Outside the delivery room, or if intravenous access is not feasible, the intraosseous route may be a reasonable alternative, determined by the local availability of equipment, training, and experience. Recommendation-Specific Supportive Text
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Medications (Epinephrine) IN Neonatal Resuscitation
SynopsisMedications are rarely needed in resuscitation of the newly born infant because low heart rate usually results from a very low oxygen level in the fetus or inadequate lung inflation after birth. Establishing ventilation is the most important step to correct low heart rate. However, if heart rate remains less than 60/min after ventilating with 100% oxygen (preferably through an endotracheal tube) and chest compressions, administration of epinephrine is indicated. Administration of epinephrine via a low-lying umbilical venous catheter provides the most rapid and reliable medication delivery. The intravenous dose of epinephrine is 0.01 to 0.03 mg/kg, followed by a normal saline flush.4 If umbilical venous access has not yet been obtained, epinephrine may be given by the endotracheal route in a dose of 0.05 to 0.1 mg/kg. The dosage interval for epinephrine is every 3 to 5 minutes if the heart rate remains less than 60/min, although an intravenous dose may be given as soon as umbilical access is obtained if response to endotracheal epinephrine has been inadequate. Recommendation-Specific Supportive Text
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Volume Replacement
SynopsisA newly born infant in shock from blood loss may respond poorly to the initial resuscitative efforts of ventilation, chest compressions, and/or epinephrine. History and physical examination findings suggestive of blood loss include a pale appearance, weak pulses, and persistent bradycardia (heart rate less than 60/min). Blood may be lost from the placenta into the mother’s circulation, from the cord, or from the infant. When blood loss is suspected in a newly born infant who responds poorly to resuscitation (ventilation, chest compressions, and/or epinephrine), it may be reasonable to administer a volume expander without delay. Normal saline (0.9% sodium chloride) is the crystalloid fluid of choice. Uncrossmatched type O, Rh-negative blood (or crossmatched, if immediately available) is preferred when blood loss is substantial.4,5 An initial volume of 10 mL/kg over 5 to 10 minutes may be reasonable and may be repeated if there is inadequate response. The recommended route is intravenous, with the intraosseous route being an alternative. Recommendation-Specific Supportive Text
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Postresuscitation Care
SynopsisNewly born infants who receive prolonged PPV or advanced resuscitation (eg, intubation, chest compressions ± epinephrine) should be closely monitored after stabilization in a neonatal intensive care unit or a monitored triage area because these infants are at risk for further deterioration. Infants 36 weeks’ or greater estimated gestational age who receive advanced resuscitation should be examined for evidence of HIE to determine if they meet criteria for therapeutic hypothermia. Therapeutic hypothermia is provided under defined protocols similar to those used in published clinical trials and in facilities capable of multidisciplinary care and longitudinal follow-up. The impact of therapeutic hypothermia on infants less than 36 weeks’ gestational age with HIE is unclear and is a subject of ongoing research trials. Hypoglycemia is common in infants who have received advanced resuscitation and is associated with poorer outcomes.8 These infants should be monitored for hypoglycemia and treated appropriately. Infants with unintentional hypothermia (temperature less than 36°C) immediately after stabilization should be rewarmed to avoid complications associated with low body temperature (including increased mortality, brain injury, hypoglycemia, and respiratory distress). Evidence suggests that warming can be done rapidly (0.5°C/h) or slowly (less than 0.5°C/h) with no significant difference in outcomes.15–19 Caution should be taken to avoid overheating. Recommendation-Specific Supportive Text
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Withholding and Discontinuing Resuscitation
SynopsisExpert neonatal and bioethical committees have agreed that, in certain clinical conditions, it is reasonable not to initiate or to discontinue life-sustaining efforts while continuing to provide supportive care for babies and families.1,2,4 If the heart rate remains undetectable and all steps of resuscitation have been completed, it may be reasonable to redirect goals of care. Case series show small numbers of intact survivors after 20 minutes of no detectable heart rate. The decision to continue or discontinue resuscitative efforts should be individualized and should be considered at about 20 minutes after birth. Variables to be considered may include whether the resuscitation was considered optimal, availability of advanced neonatal care (such as therapeutic hypothermia), specific circumstances before delivery, and wishes expressed by the family.3,6 Some babies are so sick or immature at birth that survival is unlikely, even if neonatal resuscitation and intensive care are provided. In addition, some conditions are so severe that the burdens of the illness and treatment greatly outweigh the likelihood of survival or a healthy outcome. If it is possible to identify such conditions at or before birth, it is reasonable not to initiate resuscitative efforts. These situations benefit from expert consultation, parental involvement in decision-making, and, if indicated, a palliative care plan.1,2,4–6 Recommendation-Specific Supportive Text
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Human and System PerformanceTraining Frequency
SynopsisTo perform neonatal resuscitation effectively, individual providers and teams need training in the required knowledge, skills, and behaviors. Historically, the repeat training has occurred every 2 years.6–9 However, adult, pediatric, and neonatal studies suggest that without practice, CPR knowledge and skills decay within 3 to 12 months10–12 after training. Short, frequent practice (booster training) has been shown to improve neonatal resuscitation outcomes.5 Educational programs and perinatal facilities should develop strategies to ensure that individual and team training is frequent enough to sustain knowledge and skills. Recommendation-Specific Supportive Text
In a randomized controlled simulation study, pediatric and family practice residents who underwent booster training 9 months after an initial Neonatal Resuscitation Program course demonstrated better procedural skills and teamwork behaviors at a follow-up assessment at 16 months compared with residents who did not receive booster training.2 In a prospective cohort study, physicians and nurses trained in Helping Babies Breathe demonstrated a rapid loss of resuscitation skills by 1 month after training. Subjects who received monthly practice sessions were more likely to pass an objective structured clinical evaluation than those who practiced less frequently.3 In a prospective observational study, implementation of weekly, brief Helping Babies Breathe simulation training after a 1-day Helping Babies Breathe training course resulted in increased frequency of stimulation of newborns, decrease in bag-mask ventilation, and decreased neonatal mortality at 24 hours.4 References
Briefing and Debriefing
SynopsisBriefing has been defined as “a discussion about an event that is yet to happen to prepare those who will be involved and thereby reduce the risk of failure or harm.”4Debriefing has been defined as “a discussion of actions and thought processes after an event to promote reflective learning and improve clinical performance”5 or “a facilitated discussion of a clinical event focused on learning and performance improvement.”6 Briefing and debriefing have been recommended for neonatal resuscitation training since 20107 and have been shown to improve a variety of educational and clinical outcomes in neonatal, pediatric, and adult simulation-based and clinical studies. The effect of briefing and debriefing on longer-term and critical outcomes remains uncertain. Recommendation-Specific Supportive TextMultiple clinical and simulation studies examining briefings or debriefings of resuscitation team performance have shown improved knowledge or skills.8–12
In 2 pre–quality improvement/post–quality improvement initiatives, use of a team briefing, debriefing, and predelivery checklist was associated with an improvement in team communication in the delivery room and short-term clinical outcomes, such as decreased frequency of intubation in the delivery room and increased frequency of normothermia on admission to the neonatal intensive care unit. There was no significant effect on other in-hospital clinical outcomes such as bronchopulmonary dysplasia, necrotizing enterocolitis, retinopathy of prematurity, intraventricular hemorrhage, or length of stay.2,3 References
Knowledge GapsNeonatal resuscitation science has advanced significantly over the past 3 decades, with contributions by many researchers in laboratories, in the delivery room, and in other clinical settings. While this research has led to substantial improvements in the Neonatal Resuscitation Algorithm, it has also highlighted that we still have more to learn to optimize resuscitation for both preterm and term infants. With growing enthusiasm for clinical studies in neonatology, elements of the Neonatal Resuscitation Algorithm continue to evolve as new evidence emerges. The current guidelines have focused on clinical activities described in the resuscitation algorithm, rather than on the most appropriate devices for each step. Reviews in 2021 and later will address choice of devices and aids, including those required for ventilation (T-piece, self-inflating bag, flow-inflating bag), ventilation interface (face mask, laryngeal mask), suction (bulb syringe, meconium aspirator), monitoring (respiratory function monitors, heart rate monitoring, near infrared spectroscopy), feedback, and documentation. Review of the knowledge chunks during this update identified numerous questions and practices for which evidence was weak, uncertain, or absent. The following knowledge gaps require further research: Resuscitation Preparedness
During and Just After Delivery
Early Resuscitation
Advanced Resuscitation
Specific Populations
Postresuscitation Care
For all these gaps, it is important that we have information on outcomes considered critical or important by both healthcare providers and families of newborn infants. The research community needs to address the paucity of educational studies that provide outcomes with a high level of certainty. Internal validity might be better addressed by clearly defined primary outcomes, appropriate sample sizes, relevant and timed interventions and controls, and time series analyses in implementation studies. External validity might be improved by studying the relevant learner or provider populations and by measuring the impact on critical patient and system outcomes rather than limiting study to learner outcomes. Researchers studying these gaps may need to consider innovations in clinical trial design; examples include pragmatic study designs and novel consent processes. As mortality and severe morbidities decline with biomedical advancements and improvements in healthcare delivery, there is decreased ability to have adequate power for some clinical questions using traditional individual patient randomized trials. Another barrier is the difficulty in obtaining antenatal consent for clinical trials in the delivery room. Adaptive trials, comparative effectiveness designs, and those using cluster randomization may be suitable for some questions, such as the best approach for MSAF in nonvigorous infants. High-quality observational studies of large populations may also add to the evidence. When feasible, well-designed multicenter randomized clinical trials are still optimal to generate the highest-quality evidence. Finally, we wish to reinforce the importance of addressing the values and preferences of our key stakeholders, the families and teams who are involved in the process of resuscitation. Gaps in this domain, whether perceived or real, should be addressed at every stage in our research, educational, and clinical activities. Article InformationThe American Heart Association requests that this document be cited as follows: Aziz K, Lee HC, Escobedo MB, Hoover AV, Kamath-Rayne BD, Kapadia VS, Magid DJ, Niermeyer S, Schmölzer GM, Szyld E, Weiner GM, Wyckoff MH, Yamada NK, Zaichkin J. Part 5: neonatal resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(suppl 2):S524–S550. doi: 10.1161/CIR.0000000000000902 This article has been copublished in Pediatrics. AcknowledgmentWe thank Dr Abhrajit Ganguly for assistance in manuscript preparation.
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When coordinating PPV with chest compressions How long does it take to complete a cycle of 3 compressions and 1 breath NRP?
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