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Approximately 800,000 newborns die annually due to birth asphyxia. The resuscitation of asphyxiated term newly born infants often occurs unexpected and is challenging for healthcare providers as it demands experience and knowledge in neonatal resuscitation. Current neonatal resuscitation guidelines often focus on resuscitation of extremely and/or very preterm infants; however, the recommendations for asphyxiated term newborn infants differ in some aspects to those for preterm infants (i.e., respiratory support, supplemental oxygen, and temperature management). Since the update of the neonatal resuscitation guidelines in 2015, several studies examining various resuscitation approaches to improve the outcome of asphyxiated infants have been published. In this review, we discuss current recommendations and recent findings and provide an overview of delivery room management of asphyxiated term newborn infants. [ABSTRACT FROM AUTHOR]

Background: Ventilation is the key intervention to resuscitate non-breathing newborns. Positive end-expiratory pressure (PEEP) may facilitate lung-liquid clearance and help establish functional residual capacity. Objectives: The aim of this study was to describe how mask leak and ventilation rates affect delivered PEEP and tidal volumes during newborn resuscitations using a self-inflating bag with an integrated PEEP valve. Methods: This was an observational study including near-term/term newborns who received bag-mask ventilation (BMV) with a new self-inflating bag with a novel 6 mbar PEEP valve, without external gas flow, between October 1, 2016 and June 30, 2018 in rural Tanzania. Helping Babies Breathe-trained midwives performed most of the resuscitations. Pressures and flow were continuously measured and recorded by resuscitation monitors. Results: In total, 198 newborns with a median gestation of 39 weeks (25th, 75th percentiles 37, 40) and birth weight of 3,100 g (2,580, 3,500) were included. The median delivered PEEP and expired (tidal) volume at different levels of mask leak were 6.0 mbar and 11.3 mL/kg at 0–20% mask leak, 5.5 mbar and 9.3 mL/kg at 20–40%, 5.2 mbar and 7.8 mL/kg at 40–60%, 4.6 mbar and 5.0 mL/kg at 60–80%, and 1.0 mbar and 0.6 mL/kg at 80–100% mask leak. A high ventilation rate (>60/min) nearly halved expired volumes compared to <60/min for 0–60% leak. The BMV rate had a negligible effect on peak inflation pressure (PIP) and PEEP. Conclusions: Mask leak up to 80% did not impair the provision of recommended PEEP or tidal volumes during BMV with a self-inflating bag. High or low ventilation rates did not significantly affect PIP or PEEP. Expired volumes were reduced at ventilation rates >60/min. [ABSTRACT FROM AUTHOR]

Coronavirus disease 2019 (COVID-19), caused by the novel SARS-CoV-2 virus, is rapidly spreading across the world. As the number of infections increases, those of infected pregnant women and children will rise as well. Controversy exists whether COVID-19 can be transmitted in utero and lead to disease in the newborn. As this chance cannot be ruled out, strict instructions for the management of mothers and newborn infants are mandatory. This perspective aims to be a practical support tool for the planning of delivery and neonatal resuscitation of infants born by mothers with suspected or confirmed COVID-19 infection. [ABSTRACT FROM AUTHOR]

Objective: Newborn resuscitation guidelines recommend initial assessment of heart rate (HR) and initiation of positive pressure ventilation (PPV) within 60 s after birth in non-breathing newborns. Pulse oximeter (PO) and electrocardiogram (ECG) are suggested methods for continuous HR monitoring during resuscitation. Our aim was to evaluate compliance with guidelines and the efficacy of PO versus ECG monitoring in real-life newborn resuscitations. Methods: In this prospective observational study, we video recorded resuscitations of newborns ≥34 weeks of gestation receiving PPV at birth. Results: 104 resuscitations were analysed. Median (IQR) time from birth to arrival at the resuscitation bay was 48 (22–68) s (n = 62), to initial HR assessment 70 (47–118) s (n = 61), and to initiation of PPV 78 (42–118) s (n = 62). Initial HR assessment (stethoscope or palpation) and initiation of PPV were achieved within 60 s for 35% of the resuscitated newborns. Time to initial HR assessment and initiating PPV was significantly longer following vaginal deliveries than caesarean sections: 84 (70–139) versus 44 (30–66) s (p < 0.001) and 93 (73–139) versus 38 (30–66) s (p < 0.001). Time from birth and sensor application to provision of a reliable HR signal from PO versus ECG was 348 (217–524) (n = 42) versus 174 (105–277) s (n = 30) (p < 0.001) and 199 (77–352) (n = 65) versus 16 (11–22) s (n = 52) (p < 0.001). Conclusion: Initial HR assessment and initiation of PPV were achieved within 60 s after birth in only 1/3 of newborn resuscitations. When applied for continuous HR monitoring, ECG was superior to PO in time to achieve reliable HR signals in real-life resuscitations. [ABSTRACT FROM AUTHOR]

Background: The use of intraosseous (IO) access during resuscitation is widely accepted and promoted in paediatric medicine but features less prominently in neonatal training. Whilst umbilical venous catheterization (UVC) is a reliable method of delivering emergency drugs and fluids, it is not always achievable in a timely manner. IO access warrants exploration as an alternative. Aim: Conduct a systematic review of existing literature to examine the evidence for efficacy and safety of IO devices in neonatal patients, from birth to discharge. Method: A search of PubMed, Ovid, Medline, and Embase was carried out. Abstracts were screened for relevance to focus on neonatal-specific literature and studies which carried out separate analyses for neonates (infants <28 days of age or resident on a neonatal unit). Results: One case series and 12 case reports describe IO device insertion into 41 neonates, delivering a variety of drugs, including adrenaline (epinephrine) and volume resuscitation. Complications range from none to severe. Cadaveric studies show that despite a small margin for error, IO devices can be correctly sited in neonates. Simulation studies suggest that IO devices may be faster and easier to site than UVC, even in experienced hands. Conclusion: IO access should be available on neonatal units and considered for early use in neonates where other access routes have failed. Appropriate training should be available to staff in addition to existing life support and UVC training. Further studies are required to assess the optimal device, position, and whether medication can be delivered IO as effectively as by UVC. If IO devices provide a faster method of delivering adrenaline effectively than UVC, this may lead to changes in neonatal resuscitation practice. [ABSTRACT FROM AUTHOR]

Background: Delaying cord clamping is recommended in order to assure placental transfusion. However, the evidence on cord management in elective cesarean section (CS) is limited. Objective: To compare delayed cord clamping (DCC) with early cord clamping (ECC) with regard to postnatal adaptation in neonates born through elective CS. Methods: All neonates born ≥39 weeks' gestation born through elective CS were assigned to either the DCC or the ECC arm at a 1:1 ratio according to a computer-generated, randomized sequence. The primary outcome was the hematocrit at day 2 of life. Secondary outcomes included: preductal oxygen saturation and heart rate during the first 10 min of life; transcutaneous bilirubin at day 3; and neonatal blood pressures in the first 3 days of life. Additional outcomes included: time to first spontaneous breath; temperature at admission to normal nursery; weight at discharge; and maternal blood losses. Results: Eighty neonates were randomized to the DCC (n = 40) or the ECC (n = 40) arm. The hematocrit at day 2 was significantly higher in the DCC arm than in the ECC arm (mean difference: 6%; 95% CI 3–8; p < 0.0001). The secondary outcome measures were not statistically different between the two arms. No infants needed phototherapy for hyperbilirubinemia during their hospital stay. Conclusions: Delaying cord clamping beyond 60 s increases the hematocrit at day 2 in neonates born through elective CS, without affecting maternal blood losses. Our findings suggest that DCC should be recommended in elective CS, but further studies are warranted to assess long-term outcomes. [ABSTRACT FROM AUTHOR]

As management of respiratory distress syndrome (RDS) advances, clinicians must continually revise their current practice. We report the fourth update of "European Guidelines for the Management of RDS" by a European panel of experienced neonatologists and an expert perinatal obstetrician based on available literature up to the end of 2018. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, need for appropriate maternal transfer to a perinatal centre and timely use of antenatal steroids. Delivery room management has become more evidence-based, and protocols for lung protection including initiation of CPAP and titration of oxygen should be implemented immediately after birth. Surfactant replacement therapy is a crucial part of management of RDS, and newer protocols for its use recommend early administration and avoidance of mechanical ventilation. Methods of maintaining babies on non-invasive respiratory support have been further developed and may cause less distress and reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation using caffeine and, if necessary, postnatal steroids are also important considerations. Protocols for optimising general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome. [ABSTRACT FROM AUTHOR]

Noninvasive ventilation for preterm infants at birth has been recommended and universally adopted. The umbilical cord is often clamped immediately in order to provide the support the infant needs for stabilization. However, recent scientific data from experimental studies that involve animals in transition and human studies using physiological measurements at birth have increased awareness as to how little we know about how these interventions interact and integrate with the infant's changing physiology. It has become clear that in apneic infants the larynx is closed immediately after birth, which can completely negate the effect of noninvasive ventilation of the lung. For this reason, stimulating and supporting spontaneous breathing could enhance the success of noninvasive ventilation. Animal data also demonstrated that the large swings in blood pressure, blood flow, and oxygenation caused by immediate cord clamping can be avoided by postponing cord clamping until lung aeration has been established. In this review we will focus on these "game changers" that have the potential to completely change the approach used in stabilizing preterm infants at birth. [ABSTRACT FROM AUTHOR]

Background: Neonatal resuscitation (NR) combines a set of life-saving interventions in order to stabilize compromised newborns at birth or when critically ill. Médecins Sans Frontières/Doctors Without Borders (MSF), as an international medical-humanitarian organization working particularly in low-resource settings (LRS), assisted over 250,000 births in obstetric and newborn care aid projects in 2016 and provides thousands of newborn resuscitations annually. The Helping Babies Breathe (HBB) program has been used as formal guidance for basic resuscitation since 2012. However, in some MSF projects with the capacity to provide more advanced NR interventions but a lack of adapted guidance, staff have felt prompted to create their own advanced algorithms, which runs counter to the organization’s aim for standardized protocols in all aspects of its care. Objectives: The aim is to close a significant gap in neonatal care provision in LRS by establishing consensus on a protocol that would guide MSF field teams in their practice of more advanced NR. Methods: An independent committee of international experts was formed and met regularly from June 2016 to agree on the content and design of a new NR algorithm. Results: Consensus was reached on a novel, mid-level NR algorithm in April 2017. The algorithm was accepted for use by MSF Operational Center Paris. Conclusion: This paper contributes to the literature on decision-making in the development of cognitive aids. The authors also highlight how critical gaps in healthcare delivery in LRS can be addressed, even when there is limited evidence to guide the process. [ABSTRACT FROM AUTHOR]

Studies using videotape recordings and respiratory function monitoring have shown that both face mask (FM) application and endotracheal tube (ETT) placement represent a challenge for resuscitators. Hence, there is a strong need for devices that can largely be used independently of individual operator training levels, in order to ensure more reliable support in time-critical situations, such as neonatal resuscitation. The laryngeal mask airway device (LMA) has evolved as a potentially very valuable tool. We conducted a systematic review of studies evaluating the use of the LMA in neonatal resuscitation. An electronic literature search of large medical databases was performed to identify relevant publications on the use of an LMA during neonatal delivery room (DR) resuscitation. Following a rigorous systematic review, we identified a total of 7 randomized controlled trials with results indicating that initial respiratory management of newborn infants with an LMA is feasible for a defined subgroup of infants, but the evidence is still insufficient to recommend the LMA instead of FM ventilation in the DR. There is, in particular, a dearth of evidence of the use of LMA in neonates born before 34 weeks' gestational age or weighing <1,500 g at birth. There were no reports on significant complications following the use of LMA; however, evidence is still limited regarding short- and long-term outcomes. We conclude that the limited currently available evidence suggests that the use of the LMA is a feasible and safe alternative to mask ventilation of late preterm and term infants in the DR. The potential use of LMA resuscitation, in particular for low-gestation and low-birth-weight infants, needs further study. [ABSTRACT FROM AUTHOR]

Background: A sustained inflation (SI) at birth in preterm babies may be ineffective unless the infants breathe. Gain in lung volume is associated with breathing during delivery room non-invasive management. Objective: To describe the breathing patterns of preterm infants during an SI and correlate to a calculated gain in lung volume. Methods: Retrospective observational study. Data collected from a respiratory function monitor during SI (25 cmH2O for 15 s then PEEP at 5 cmH2O) through a face mask in preterm infants (gestational age [GA] ≤ 31 weeks). Spontaneous breaths, inspiratory time (TI), inspiratory/expiratory tidal volume (Vti/Vte), and gain in lung volume were determined. Results: 30 SIs in 20 infants (mean GA 27 weeks; birth weight 825 g) were analysed and stratified in 2 groups according to spontaneous breathing: SIs without spontaneous breaths (apnoea: n = 11) and SIs with spontaneous breaths (breathing: n = 19). Mean GA was lower in the apnoea group versus the breathing group (25 vs. 27+5 weeks; p = 0.01). Mean birth weight was lower in the apnoea group versus the breathing group (683 vs. 860 g; p = ns). In the breathing group, the mean number of spontaneous breaths was 4 with a mean TI of 0.52 min, the mean Vti/kg was 5.9 mL/kg, and the mean Vt e was 2.7 mL/kg. The calculated mean gain in lung volume was 7.5 mL/kg in the apnoea group and 17.8 mL/kg in the breathing group (p = 0.039). Conclusions: Actively breathing infants during an SI at birth showed a gain in lung volume higher than apnoeic infants. Spontaneous breathing during SI seems to be related to GA. [ABSTRACT FROM AUTHOR]

Background: The laryngeal mask airway (LMA) has been used in adult and pediatric populations for decades. While the familiarity of its use in the neonatal population is increasing, there are few data investigating this. Objective: The objective of this study was to determine the feasibility of LMA placement in neonates by investigating the time and number of attempts required for successful placement and physiologic stability during the placement of the device. Methods: This study is one component of a national, multicenter, randomized controlled trial investigating surfactant administration through an LMA in neonates. Videotape of LMA placement was reviewed to determine the total procedure time and the number of attempts required to successfully place the device. Heart rate and oxygen saturation (SaO 2 ) were analyzed as change from baseline, in order to examine physiologic stability during device placement. Results: Videotape and physiologic data were analyzed for 36 infants. Gestational age ranged from 29 3/7 to 35 4/7 weeks (mean 33 ± 1.7) with the birth weight ranging from 1,290 to 3,180 g (mean 2,006 ± 482). Average total procedure time was 88 s (±136) with 64% of the procedures successfully completed in <35 s. Successful placement was achieved on the first attempt in 69% of the cases. Compared to baseline, heart rate increased by an average of 1 bpm (±4.5) and SaO 2 decreased an average of 6% (±7). Conclusions: Successful placement was achieved in the majority of patients in <35 s and required only one attempt. Physiologic parameters were maintained close to baseline, measured by minimal fluctuation in heart rate and SaO 2 during the procedure. Placement of the LMA is feasible in neonates. [ABSTRACT FROM AUTHOR]

Advances in the management of respiratory distress syndrome (RDS) ensure that clinicians must continue to revise current practice. We report the third update of the European Guidelines for the Management of RDS by a European panel of expert neonatologists including input from an expert perinatal obstetrician based on available literature up to the beginning of 2016. Optimizing the outcome for babies with RDS includes consideration of when to use antenatal steroids, and good obstetric practice includes methods of predicting the risk of preterm delivery and also consideration of whether transfer to a perinatal centre is necessary and safe. Methods for optimal delivery room management have become more evidence based, and protocols for lung protection, including initiation of continuous positive airway pressure and titration of oxygen, should be implemented from soon after birth. Surfactant replacement therapy is a crucial part of the management of RDS, and newer protocols for surfactant administration are aimed at avoiding exposure to mechanical ventilation, and there is more evidence of differences among various surfactants in clinical use. Newer methods of maintaining babies on non-invasive respiratory support have been developed and offer potential for greater comfort and less chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease although minimizing the time spent on mechanical ventilation using caffeine and if necessary postnatal steroids are also important considerations. Protocols for optimizing the general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome. [ABSTRACT FROM AUTHOR]