Neonatal resuscitation

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Neonatal resuscitation
CPR Infant.png
Specialty neonatology
Frequency10% of newborns who do not readily begin breathing

Neonatal resuscitation, also known as newborn resuscitation, is an emergency procedure focused on supporting approximately 10% of newborn children who do not readily begin breathing, putting them at risk of irreversible organ injury and death. [1] Many of the infants who require this support to start breathing well on their own after assistance. Through positive airway pressure, and in severe cases chest compressions, medical personnel certified in neonatal resuscitation can often stimulate neonates to begin breathing on their own, with attendant normalization of heart rate. [2]

Contents

Face masks that cover the infant's mouth and nose are often used in the resuscitation procedures. Nasal prongs/tubes/masks and laryngeal mask airway devices are also sometimes used. [3]

Uses

Up to 10% of infants are born requiring assistance to begin breathing. After assistance, many of these infants begin to breath on their own and are healthy. Breathing problems at birth is a high priority emergency and interventions such as breathing support and resuscitation is sometimes required. [3]

All infants who are 'gasping', show signs of being apnoeic (suspension of breathing), or have bradycardia with a heart rate lower than 100 beats per minute after birth are recommended to be administered positive pressure ventilation with a 'manual ventilation device' to provide breathing support. [4] Examples of manual ventilation devices include a self-inflating bag or a T-piece. [3]

Complications

About a quarter of all neonatal deaths globally are caused by birth asphyxia. [5] This dangerous condition of oxygen deprivation may begin before birth. For example, if the umbilical cord, which supplies oxygen throughout fetal development, is compressed or tears during delivery. Depending on how quickly and successfully the infant is resuscitated, hypoxic damage can occur to most of the infant's organs (heart, lungs, liver, gut, kidneys). One serious complication is a brain injury known as neonatal hypoxic-ischemic encephalopathy.[ citation needed ]

Training and certification

The most widely known training/certification for neonatal resuscitation is the Neonatal Resuscitation Program (NRP).

Resuscitation guidelines

The International Liaison Committee on Resuscitation (ILCOR) has published Consensus on science and treatment recommendations for neonatal resuscitation. [4] Traditionally, newborn children have been resuscitated using mechanical ventilation with 100% oxygen, but there has since the 1980s increasingly been debated whether newborn infants with asphyxia should be resuscitated with 100% oxygen or normal air, and notably Ola Didrik Saugstad has been a major advocate of using normal air. [7] [8]

In 2020, the International Liaison Committee on Resuscitation (ILCOR) published its 4th and most recent recommendations for newborn life support. The committee reviewed 8 major topics, including anticipation and preparation, initial assessment and intervention, physiologic monitoring and feedback devices, ventilation and oxygenation, circulatory support, drug and fluid administration, prognostication during CPR, and post-resuscitation care. [4]


Initial evaluation of a newborn is done by obtaining an Apgar score, which gives the clinician an approximation of the infant's cardiovascular and neurologic condition at birth. A score of 7–10 at 5 minutes is normal, a score of 4 to 6 at 5 minutes is intermediate, and a score of 0-3 is considered low. It is important to understand that an Apgar score is not a diagnosis, it is merely a clinical finding. [9] If a newborns score is 0–3, then resuscitation efforts are initiated.

Apgar score for newborn infants APGAR score.jpg
Apgar score for newborn infants

Neonatal resuscitation guidelines closely resemble those of the pediatric basic and advanced life support. The main differences in training include an emphasis on positive pressure ventilation (PPV), updated timings on ventilation assistance rates, and some differences in the cardiac arrest chain of survival.

Guidelines for neonatal resuscitation are assessed annually and are developed in collaboration with multiple organizations of numerous experts, including the American Academy of Pediatrics (AAP).

In 2020, the ILCOR recommended the following changes to current resuscitation guidelines: [4]

While some guidelines do tend to change, certain elements of neonatal resuscitation have persisted. These include:

Outcomes

Most neonatal deaths (roughly 75%) after resuscitation occur within the first week, but the vast majority occur within 24 hours.[ citation needed ] This statistic is based on a mean Apgar score of 5.9, which is considered intermediate. More data is needed to understand outcomes for more severe patients. Outcomes after resuscitation for neonates vary widely based on many factors. One study in Norway analyzed 15 peer-reviewed published articles and found that high-income countries have a mortality rate as high as 10% while low-income countries have a mortality rate as high as 28%. [10] One major factor that improved survival was how quickly medical responders were able to intervene, noting that the first minutes are critical. [11]

It has been demonstrated that high concentrations of oxygen lead to generation of oxygen free radicals, which have a role in reperfusion injury after asphyxia. [12] Clinical trial evidence suggests that resuscitation using air probably reduces the risk of death [13] and the 2010 ILCOR guidelines recommend the use of normal air rather than 100% oxygen. [14] Another study showed that preterm infants have little or no difference in risk of death or neurodevelopment disability when higher concentrations of oxygen are used compared to lower concentrations but the evidence from clinical trials is still relatively uncertain. [15]

Currently, it is the gold standard to place neonates on a cooling blanket for 72 hours to achieve total body cooling. This is done in order to minimize brain swelling. After cooling is achieved, an MRI is obtained roughly 1 week after hypoxic brain injury in order to classify the severity of brain damage. However, one study found that there was no significant correlation between MRI findings and developmental delay up to 2 years of life. [16]

Related Research Articles

<span class="mw-page-title-main">Asphyxia</span> Severely deficient supply of oxygen

Asphyxia or asphyxiation is a condition of deficient supply of oxygen to the body which arises from abnormal breathing. Asphyxia causes generalized hypoxia, which affects all the tissues and organs, some more rapidly than others. There are many circumstances that can induce asphyxia, all of which are characterized by the inability of a person to acquire sufficient oxygen through breathing for an extended period of time. Asphyxia can cause coma or death.

<span class="mw-page-title-main">Apgar score</span> Scale for newborn viability

The Apgar score is a quick way for health professionals to evaluate the health of all newborns at 1 and 5 minutes after birth and in response to resuscitation. It was originally developed in 1952 by an anesthesiologist at Columbia University, Virginia Apgar, to address the need for a standardized way to evaluate infants shortly after birth.

<span class="mw-page-title-main">Preterm birth</span> Birth at less than a specified gestational age

Preterm birth, also known as premature birth, is the birth of a baby at fewer than 37 weeks gestational age, as opposed to full-term delivery at approximately 40 weeks. Extreme preterm is less than 28 weeks, very early preterm birth is between 28 and 32 weeks, early preterm birth occurs between 32 and 34 weeks, late preterm birth is between 34 and 36 weeks' gestation. These babies are also known as premature babies or colloquially preemies or premmies. Symptoms of preterm labor include uterine contractions which occur more often than every ten minutes and/or the leaking of fluid from the vagina before 37 weeks. Premature infants are at greater risk for cerebral palsy, delays in development, hearing problems and problems with their vision. The earlier a baby is born, the greater these risks will be.

<span class="mw-page-title-main">Patent ductus arteriosus</span> Condition wherein the ductus arteriosus fails to close after birth

Patent ductus arteriosus (PDA) is a medical condition in which the ductus arteriosus fails to close after birth: this allows a portion of oxygenated blood from the left heart to flow back to the lungs through the aorta, which has a higher blood pressure, to the pulmonary artery, which has a lower blood pressure. Symptoms are uncommon at birth and shortly thereafter, but later in the first year of life there is often the onset of an increased work of breathing and failure to gain weight at a normal rate. With time, an uncorrected PDA usually leads to pulmonary hypertension followed by right-sided heart failure.

Fetal distress, also known as non-reassuring fetal status, is a condition during pregnancy or labor in which the fetus shows signs of inadequate oxygenation. Due to its imprecision, the term "fetal distress" has fallen out of use in American obstetrics. The term "non-reassuring fetal status" has largely replaced it. It is characterized by changes in fetal movement, growth, heart rate, and presence of meconium stained fluid.

<span class="mw-page-title-main">Infant respiratory distress syndrome</span> Human disease affecting newborns

Infant respiratory distress syndrome (IRDS), also known as surfactant deficiency disorder (SDD), and previously called hyaline membrane disease (HMD), is a syndrome in premature infants caused by developmental insufficiency of pulmonary surfactant production and structural immaturity in the lungs. It can also be a consequence of neonatal infection and can result from a genetic problem with the production of surfactant-associated proteins.

<span class="mw-page-title-main">Neonatology</span> Medical care of newborns, especially the ill or premature

Neonatology is a subspecialty of pediatrics that consists of the medical care of newborn infants, especially the ill or premature newborn. It is a hospital-based specialty and is usually practised in neonatal intensive care units (NICUs). The principal patients of neonatologists are newborn infants who are ill or require special medical care due to prematurity, low birth weight, intrauterine growth restriction, congenital malformations, sepsis, pulmonary hypoplasia, or birth asphyxia.

<span class="mw-page-title-main">Neonatal intensive care unit</span> Intensive care unit specializing in the care of ill or premature newborn infants

A neonatal intensive care unit (NICU), also known as an intensive care nursery (ICN), is an intensive care unit (ICU) specializing in the care of ill or premature newborn infants. The NICU is divided into several areas, including a critical care area for babies who require close monitoring and intervention, an intermediate care area for infants who are stable but still require specialized care, and a step down unit where babies who are ready to leave the hospital can receive additional care before being discharged.

Perinatal asphyxia is the medical condition resulting from deprivation of oxygen to a newborn infant that lasts long enough during the birth process to cause physical harm, usually to the brain. It remains a serious condition which causes significant mortality and morbidity. It is also the inability to establish and sustain adequate or spontaneous respiration upon delivery of the newborn, an emergency condition that requires adequate and quick resuscitation measures. Perinatal asphyxia is also an oxygen deficit from the 28th week of gestation to the first seven days following delivery. It is also an insult to the fetus or newborn due to lack of oxygen or lack of perfusion to various organs and may be associated with a lack of ventilation. In accordance with WHO, perinatal asphyxia is characterised by: profound metabolic acidosis, with a pH less than 7.20 on umbilical cord arterial blood sample, persistence of an Apgar score of 3 at the 5th minute, clinical neurologic sequelae in the immediate neonatal period, or evidence of multiorgan system dysfunction in the immediate neonatal period. Hypoxic damage can occur to most of the infant's organs, but brain damage is of most concern and perhaps the least likely to quickly or completely heal. In more pronounced cases, an infant will survive, but with damage to the brain manifested as either mental, such as developmental delay or intellectual disability, or physical, such as spasticity.

Fetal viability is the ability of a human fetus to survive outside the uterus. Viability depends upon factors such as birth weight, gestational age, and the availability of advanced medical care. In low-income countries, more than 90% of extremely preterm newborns die due to a lack of said medical care; in high-income countries, the vast majority of these newborns survive.

<span class="mw-page-title-main">Cerebral hypoxia</span> Oxygen shortage of the brain

Cerebral hypoxia is a form of hypoxia, specifically involving the brain; when the brain is completely deprived of oxygen, it is called cerebral anoxia. There are four categories of cerebral hypoxia; they are, in order of increasing severity: diffuse cerebral hypoxia (DCH), focal cerebral ischemia, cerebral infarction, and global cerebral ischemia. Prolonged hypoxia induces neuronal cell death via apoptosis, resulting in a hypoxic brain injury.

Antenatal steroids, also known as antenatal corticosteroids, are medications administered to pregnant women expecting a preterm birth. When administered, these steroids accelerate the maturation of the fetus' lungs, which reduces the likelihood of infant respiratory distress syndrome and infant mortality. The effectiveness of this corticosteroid treatment on humans was first demonstrated in 1972 by Sir Graham Liggins and Ross Howie, during a randomized control trial using betamethasone.

<span class="mw-page-title-main">Bronchopulmonary dysplasia</span> Medical condition

Bronchopulmonary dysplasia is a chronic lung disease which affects premature infants. Premature (preterm) infants who require treatment with supplemental oxygen or require long-term oxygen are at a higher risk. The alveoli that are present tend to not be mature enough to function normally. It is also more common in infants with low birth weight (LBW) and those who receive prolonged mechanical ventilation to treat respiratory distress syndrome. It results in significant morbidity and mortality. The definition of bronchopulmonary dysplasia has continued to evolve primarily due to changes in the population, such as more survivors at earlier gestational ages, and improved neonatal management including surfactant, antenatal glucocorticoid therapy, and less aggressive mechanical ventilation.

<span class="mw-page-title-main">Intrauterine hypoxia</span> Medical condition when the fetus is deprived of sufficient oxygen

Intrauterine hypoxia occurs when the fetus is deprived of an adequate supply of oxygen. It may be due to a variety of reasons such as prolapse or occlusion of the umbilical cord, placental infarction, maternal diabetes and maternal smoking. Intrauterine growth restriction may cause or be the result of hypoxia. Intrauterine hypoxia can cause cellular damage that occurs within the central nervous system. This results in an increased mortality rate, including an increased risk of sudden infant death syndrome (SIDS). Oxygen deprivation in the fetus and neonate have been implicated as either a primary or as a contributing risk factor in numerous neurological and neuropsychiatric disorders such as epilepsy, attention deficit hyperactivity disorder, eating disorders and cerebral palsy.

Ola Didrik Saugstad is a Norwegian pediatrician, neonatologist and neuroscientist noted for his research on resuscitation of newborn children and his contribution to reduce child mortality. He is a Research Professor at Oslo University Hospital and Professor of Neonatology at Northwestern University's Feinberg School of Medicine in Chicago. He is Professor Emeritus of Pediatrics at the University of Oslo and was Director of the Department of Pediatric Research at Oslo University Hospital from 1991 to 2017.

<span class="mw-page-title-main">Neonatal nursing</span>

Neonatal nursing is a sub-specialty of nursing care for newborn infants up to 28 days after birth. The term neonatal comes from neo, "new", and natal, "pertaining to birth or origin". Neonatal nursing requires a high degree of skill, dedication and emotional strength as they care for newborn infants with a range of problems. These problems vary between prematurity, birth defects, infection, cardiac malformations and surgical issues. Neonatal nurses are a vital part of the neonatal care team and are required to know basic newborn resuscitation, be able to control the newborn's temperature and know how to initiate cardiopulmonary and pulse oximetry monitoring. Most neonatal nurses care for infants from the time of birth until they are discharged from the hospital.

Neonatal encephalopathy (NE), previously known as neonatal hypoxic-ischemic encephalopathy, is defined as a encephalopathy syndrome with signs and symptoms of abnormal neurological function, in the first few days of life in an infant born after 35 weeks of gestation. In this condition there is difficulty initiating and maintaining respirations, a subnormal level of consciousness, and associated depression of tone, reflexes, and possibly seizures. Hypoxia refers to deficiency of oxygen, Ischemia refers to restriction in blood flow to the brain. The result is “encephalopathy” which refers to damaged brain cells. Encephalopathy is a nonspecific response of the brain to injury which may occur via multiple methods, but is commonly caused by birth asphyxia, leading to cerebral hypoxia.

Mild total body hypothermia, induced by cooling a baby to 33-34°C for three days after birth, is nowadays a standardized treatment after moderate to severe hypoxic ischemic encephalopathy in full-term and near to fullterm neonates. It has recently been proven to be the only medical intervention which reduces brain damage, and improves an infant's chance of survival and reduced disability.

Neonatal sepsis is a type of neonatal infection and specifically refers to the presence in a newborn baby of a bacterial blood stream infection (BSI) in the setting of fever. Older textbooks may refer to neonatal sepsis as "sepsis neonatorum". Criteria with regards to hemodynamic compromise or respiratory failure are not useful clinically because these symptoms often do not arise in neonates until death is imminent and unpreventable. Neonatal sepsis is divided into two categories: early-onset sepsis (EOS) and late-onset sepsis (LOS). EOS refers to sepsis presenting in the first 7 days of life, with LOS referring to presentation of sepsis after 7 days. Neonatal sepsis is the single most common cause of neonatal death in hospital as well as community in developing country.

The Bloxsom air lock was an incubator used in the treatment of respiratory distress among newly born infants in the 1950s. The device attempted to mimic the rhythm of uterine contractions, which were thought to have a role in stimulating fetal breathing. The device was developed by Dr. Allan Bloxsom, a pediatrician at St. Joseph Hospital and Baylor College of Medicine in Houston, Texas. At its peak, the device was utilized in more than 700 hospitals.

References

  1. "Neonatal Resuscitation - Pediatrics". Merck Manuals Professional Edition. Retrieved 2019-11-13.
  2. Johnson, Peter A.; Schmölzer, Georg M. (23 February 2020). "Heart Rate Assessment during Neonatal Resuscitation". Healthcare. 8 (1): 43. doi: 10.3390/healthcare8010043 . PMC   7151423 . PMID   32102255.
  3. 1 2 3 Ni Chathasaigh, Caitriona M; Davis, Peter G; O'Donnell, Colm PF; McCarthy, Lisa K (2023-10-03). Cochrane Neonatal Group (ed.). "Nasal interfaces for neonatal resuscitation". Cochrane Database of Systematic Reviews. 2023 (10). doi:10.1002/14651858.CD009102.pub2. PMC   10546484 . PMID   37787113.
  4. 1 2 3 4 5 6 7 8 9 Wyckoff, Myra H.; Wyllie, Jonathan; Aziz, Khalid; de Almeida, Maria Fernanda; Fabres, Jorge; Fawke, Joe; Guinsburg, Ruth; Hosono, Shigeharu; Isayama, Tetsuya; Kapadia, Vishal S.; Kim, Han-Suk; Liley, Helen G.; McKinlay, Christopher J.D.; Mildenhall, Lindsay; Perlman, Jeffrey M. (2020-10-20). "Neonatal Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations". Circulation. 142 (16_suppl_1). doi: 10.1161/CIR.0000000000000895 . ISSN   0009-7322.
  5. Guidelines on basic newborn resuscitation. Geneva: World Health Organization. 2012. ISBN   9789241503693.
  6. Heartbeat, Project (2019-03-13). "Who Can Benefit from a Neonatal Resuscitation Program? | NRP Training". Project Heartbeat. Retrieved 2021-11-11.
  7. Saugstad, OD; Rootwelt, T; Aalen, O (1998). "Resuscitation of asphyxiated newborn infants with room air or oxygen: an international controlled trial: the Resair 2 study". Pediatrics . 102 (1): e1. doi:10.1542/peds.102.1.e1. PMID   9651453.
  8. Davis, PG; Tan, A; O'Donnell, CPF; Schulze, A (2004). "Resuscitation of newborn infants with 100% oxygen or air: a systematic review and meta-analysis". The Lancet . 364 (9442): 1329–1333. doi:10.1016/S0140-6736(04)17189-4. PMID   15474135. S2CID   24825982.
  9. "Neonatal Resuscitation - Pediatrics". Merck Manuals Professional Edition. Retrieved 2021-11-09.
  10. Boldingh, Anne Marthe; Solevåg, Anne Lee; Nakstad, Britt (2018-05-28). "Outcomes following neonatal cardiopulmonary resuscitation". Tidsskrift for den Norske Legeforening. 138 (9). doi: 10.4045/tidsskr.17.0358 . ISSN   0029-2001. PMID   29808658.
  11. Shikuku, Duncan N.; Milimo, Benson; Ayebare, Elizabeth; Gisore, Peter; Nalwadda, Gorrette (2018-05-15). "Practice and outcomes of neonatal resuscitation for newborns with birth asphyxia at Kakamega County General Hospital, Kenya: a direct observation study". BMC Pediatrics. 18 (1): 167. doi: 10.1186/s12887-018-1127-6 . ISSN   1471-2431. PMC   5953400 . PMID   29764391.
  12. Kutzsche, S; Ilves, P; Kirkeby, OJ; Saugstad, OD (2001). "Hydrogen peroxide production in leukocytes during cerebral hypoxia and reoxygenation with 100% or 21% oxygen in newborn piglets". Pediatric Research . 49 (6): 834–842. doi: 10.1203/00006450-200106000-00020 . PMID   11385146.
  13. Tan, A; Schulze, A; O'Donnell, CP; Davis, PG (18 April 2005). "Air versus oxygen for resuscitation of infants at birth". The Cochrane Database of Systematic Reviews. 2005 (2): CD002273. doi:10.1002/14651858.CD002273.pub3. PMC   7017642 . PMID   15846632.
  14. ILCOR Neonatal Resuscitation Guidelines 2010
  15. Lui, K; Jones, LJ; Foster, JP; Davis, PG; Ching, SK; Oei, JL; Osborn, DA (4 May 2018). "Lower versus higher oxygen concentrations titrated to target oxygen saturations during resuscitation of preterm infants at birth". The Cochrane Database of Systematic Reviews. 5 (5): CD010239. doi:10.1002/14651858.CD010239.pub2. PMC   6494481 . PMID   29726010.
  16. Rusli, Emilia Rosniza Mohammed; Ismail, Juriza; Wei, Wong Saw; Ishak, Shareena; Jaafar, Rohana; Zaki, Faizah Mohd (2019). "Neonatal hypoxic encephalopathy: Correlation between post-cooling brain MRI findings and 2 years neurodevelopmental outcome". The Indian Journal of Radiology & Imaging. 29 (4): 350–355. doi: 10.4103/ijri.IJRI_62_19 . ISSN   0971-3026. PMC   6958878 . PMID   31949335.