Neonatal resuscitation guidelines: Updated for 2015

The neonatal resuscitation section of the 2015 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care includes a number of new and modified recommendations.

Speaking to Contemporary Pediatrics, Myra H Wyckoff, MD, professor of pediatrics, University of Texas Southwestern Medical School, Dallas, summarized the most important changes and the background for their implementation. These updates pertain to umbilical cord management; suctioning of nonvigorous infants born through meconium-stained amniotic fluid; assessment of heart rate; and administration of oxygen to preterm newborns.

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The most critical message, Wyckoff says, is that the neonatal resuscitation guidelines remain focused on providing effective ventilation to stabilize a newborn. “The most important step is to achieve effective ventilation to inflate the lung and start the child breathing, because that is what will bring up the heart rate and stabilize the baby. In the 2015 guidelines, the steps for achieving effective ventilation and adequate breathing have not changed,” Wyckoff added.

Wyckoff served on the Neonatal Resuscitation Task Force of the International Liaison Committee on Resuscitation (ILCOR) that reviewed the science on which the guideline updates are based. She also recently completed her term as co-chair of the AAP Neonatal Resuscitation Program steering committee, was chair of the neonatal resuscitation guidelines writing group for the AAP and AHA, and is now co-chair of the ILCOR Neonatal Resuscitation Task Force for the next 5-year cycle.

NEXT: Umbilical cord management

Umbilical cord management

Wyckoff says that the 2015 guidelines contain a strong statement supporting the use of delayed cord clamping for at least 30 seconds in vigorous preterm and term infants who do not require resuscitation at birth. The new recommendation is based on data from multiple-albeit small-randomized, controlled trials showing this practice was associated with benefits of decreased intraventricular hemorrhage, higher blood pressure and blood volume, decreased need for transfusion after birth, and less necrotizing enterocolitis. The only downside identified was a slight increase in bilirubin level.

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“The new recommendation is concordant with statements from the AAP and the American College of Obstetricians and Gynecologists,” Wyckoff says, adding that, “It is important to note that the 2015 guidelines do not recommend delayed cord clamping for infants who require resuscitation at the time of birth. Such children were excluded from the randomized clinical trials assessing delayed cord clamping, and more study is needed to determine the benefits and safety of delayed cord clamping in that population.”

Suctioning nonvigorous infants exposed to meconium-stained amniotic fluid

Although the 2010 guideline recommendation for nonvigorous infants exposed to meconium-stained amniotic fluid was to perform immediate intubation for tracheal suctioning to clear potential meconium from the airway, the 2015 recommendation is to place the baby under the radiant warmer and begin the initial steps of resuscitation. Positive pressure ventilation (PPV) should be started if the infant is still not breathing or the heart rate is less than 100 beats per minute. Then, if the airway appears obstructed, the baby can be intubated and the airway suctioned.

“Only a minority of nonvigorous infants exposed to meconium-stained amniotic fluid will need to be intubated,” Wyckoff says. She explained that the previous recommendation for immediate intubation and suctioning was based on historical practice. A review of the literature, however, which included a recent small randomized, controlled trial, failed to identify significant evidence of benefit from that practice. “In addition, because intubation is being done less often now than in the past, we had concern that today’s workforce was less skilled in performing intubation, and, consequently, that attempts at immediate intubation might delay provision of effective ventilation.”

NEXT: Assessing heart rate

Assessment of heart rate

Another major change in the 2015 guideline is a recommendation for delivery rooms to have access to 3-lead electrocardiography (ECG) for use in determining heart rate. The basis for this practice derives from recent evidence demonstrating that 3-lead ECG provides heart rate information faster and more accurately than auscultation, palpation, or pulse oximetry.

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“The statements pertaining to 3-lead ECG in the 2015 guideline do not mandate its use, but rather are encouraging delivery rooms to establish a plan for accessing it in the context of infants needing resuscitation, and there are a variety of options for accomplishing that,” says Wyckoff. “Consideration for use of ECG is not dissimilar to that used 10 years ago to introduce pulse oximetry. In the 2005 guideline, use of pulse oximetry was suggested as potentially useful based on emerging evidence, but in 2010, it was recommended as being mandatory.”

The emphasis on access to ECG varies along the neonatal resuscitation algorithm, so ECG may be considered as the preferred method for determining heart rate at the step where PPV is being initiated. Further down in the algorithm where CPR becomes needed, however, use of 3-lead ECG is recommended.

Administration of oxygen to preterm infants

Results from a meta-analysis including 7 small randomized, controlled trials published since 2010 supported a change in recommendations about the initial oxygen concentration for resuscitation of preterm newborns less than 35 weeks’ gestation. According to the 2015 guidelines, oxygen should be started at 21% to 30% and then titrated to meet the preductal saturation range achieved in healthy term babies.

“The 2005 guideline recommended starting at a high oxygen concentration of 100%, and in 2010 that was changed to a suggestion to start with room air or blended oxygen and to titrate the oxygen concentration to meet goal saturations. For the 2015 guidelines, there were more studies available that suggested that initiation of resuscitation with low concentration of room air to 30% limits the risk of oxygen toxicity compared to higher starting concentrations,” Wyckoff explained.

The ILCOR Neonatal Resuscitation Task Force also reviewed the question of whether preterm babies would benefit from sustained inflation (>5 sec) at the time of birth and decided there was insufficient evidence on which to make a recommendation.

“At the time of our review, we did not find convincing evidence to show a benefit of sustained inflation. Therefore, the guidelines recommend against its routine use,” says Wyckoff. “However, we think more studies would be valuable and are not against performing sustained inflation in the setting of carefully designed research protocols.”

FOR MORE INFORMATION

The neonatal resuscitation section of the 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations can be accessed online at: http://pediatrics.aappublications.org/content/136/Supplement_2/S196

Or

http://circ.ahajournals.org/content/132/16_suppl_1/S204.full.pdf+html

The ILCOR scientific evidence evaluation, which provided the science for the recommendations, is available online at: http://circ.ahajournals.org/content/132/18_suppl_2/S368.full.pdf+html

Ms Krader has 30 years’ experience as a medical writer. She has worked as both a hospital pharmacist and a clinical researcher/writer for the pharmaceutical industry and is presently a freelance writer in Deerfield, Illinois. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.