2023 American Heart Association and American Academy of Pediatrics Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

This 2023 focused update to the neonatal resuscitation guidelines is based on 4 systematic reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Systematic reviewers and content experts from this task force performed comprehensive reviews of the scientific literature on umbilical cord management in preterm, late preterm, and term newborn infants, and the optimal devices and interfaces used for administering positive-pressure ventilation during resuscitation of newborn infants. These recommendations provide new guidance on the use of intact umbilical cord milking, device selection for administering positive-pressure ventilation, and an additional primary interface for administering positive-pressure ventilation.

2023 American Heart Association and American Academy of Pediatrics Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

This 2023 focused update to the neonatal resuscitation guidelines is based on 4 systematic reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Systematic reviewers and content experts from this task force performed comprehensive reviews of the scientific literature on umbilical cord management in preterm, late preterm, and term newborn infants, and the optimal devices and interfaces used for administering positive-pressure ventilation during resuscitation of newborn infants. These recommendations provide new guidance on the use of intact umbilical cord milking, device selection for administering positive-pressure ventilation, and an additional primary interface for administering positive-pressure ventilation.

Laryngeal mask use during neonatal resuscitation at birth: A United States-based survey of neonatal resuscitation program providers and instructors.

Aim: Neonatal resuscitation guidelines promote the laryngeal mask (LM) interface for positive pressure ventilation (PPV), but little is known about how the LM is used among Neonatal Resuscitation Program (NRP) Providers and Instructors. The study aim was to characterize the training, experience, confidence, and perspectives of NRP Providers and Instructors regarding LM use during neonatal resuscitation at birth. Methods: A voluntary anonymous survey was emailed to all NRP Providers and Instructors. Survey items addressed training, experience, confidence, and barriers for LM use during resuscitation. Associations between respondent characteristics and outcomes of both LM experience and confidence were assessed using logistic regression. Results: Between 11/7/22-12/12/22, there were 5,809 survey respondents: 68% were NRP Providers, 55% were nurses, and 87% worked in a hospital setting. Of these, 12% had ever placed a LM during newborn resuscitation, and 25% felt very or completely confident using a LM. In logistic regression, clinical or simulated hands-on training, NRP Instructor role, professional role, and practice setting were all associated with both LM experience and confidence.The three most frequently identified barriers to LM use were insufficient experience (46%), preference for other interfaces (25%), and failure to consider the LM during resuscitation (21%). One-third (33%) reported that LMs are not available where they resuscitate newborns. Conclusion: Few NRP providers and instructors use the LM during neonatal resuscitation. Strategies to increase LM use include hands-on clinical training, outreach promoting the advantages of the LM compared to other interfaces, and improving availability of the LM in delivery settings.

Recommended Guideline for Uniform Reporting of Neonatal Resuscitation: The Neonatal Utstein Style.

Clinical research on neonatal resuscitation has accelerated over recent decades. However, an important methodologic limitation is that there are no standardized definitions or reporting guidelines for neonatal resuscitation clinical studies. To address this, the International Liaison Committee on Resuscitation Neonatal Life Support Task Force established a working group to develop the first Utstein-style reporting guideline for neonatal resuscitation. The working group modeled this approach on previous Utstein-style guidelines for other populations. This reporting guideline focuses on resuscitation of newborns immediately after birth for respiratory failure, bradycardia, severe bradycardia, or cardiac arrest. We identified 7 relevant domains: setting, patient, antepartum, birth/preresuscitation, resuscitation process, postresuscitation process, and outcomes. Within each domain, relevant data elements were identified as core versus supplemental. Core data elements should be collected and reported for all neonatal resuscitation studies, while supplemental data elements may be collected and reported using standard definitions when possible. The Neonatal Utstein template includes both core and supplemental elements across the 7 domains, and the associated Data Table provides detailed information and reporting standards for each data element. The Neonatal Utstein reporting guideline is anticipated to assist investigators engaged in neonatal resuscitation research by standardizing data definitions. The guideline will facilitate data pooling in meta-analyses, enhancing the strength of neonatal resuscitation treatment recommendations and subsequent guidelines.

Contemporary management of infants born through meconium stained amniotic fluid.

Delivery room management of infants delivered through meconium stained amniotic fluid has evolved over the past four decades. The burden of disease weighs more heavily in low- and middle-resource areas. Current information does not allow for precise prediction of infants that will require resuscitation at delivery versus those that need simple stabilization. Optimal care of newborns requires assessment of risk factors and obstetrical and pediatric team preparation to respond to the needs of the newborn.

Use of the RAM Cannula with Early Bubble Continuous Positive Airway Pressure Requires Higher Pressures: Clinical and In vitro Evaluations.

OBJECTIVE: Early bubble continuous positive airway pressure (bCPAP) in the delivery room (DR) reduces early intubation, mechanical ventilation, and bronchopulmonary dysplasia. The RAM cannula, adopted for ease of patient care, is a high resistance nasal interface that, when used with bCPAP, only transmits a portion of set pressures and attenuates the bubble effects. This study aimed to review early bCPAP pressures and bCPAP failure with the RAM cannula interface over a 6-year period. STUDY DESIGN: Retrospective, single-center study of infants delivered <1,250 g from 2013 to 2018 (n = 735) begun on bCPAP in the DR with the RAM cannula. In vitro testing of bCPAP pressure transmission was also performed for multiple nasal interfaces and nasal occlusion percentages. RESULTS: The percentage of infants intubated in the DR decreased over time (59 to 42%), while the average bCPAP pressure increased from 5.3 to 6.8 cmH2O. A total of 355 infants (48%) were admitted to the neonatal intensive care unit (NICU) from the DR on BCPAP. The failure rate for bCPAP in NICU within 72 hours decreased from 45 to 24% as the maximum CPAP increased from 5.8 to 7.6 cmH2O. Pneumothorax rates did not change. CPAP pressure transmission decreased with all sizes of the RAM cannula. CONCLUSION: When utilizing the RAM cannula for bCPAP, higher CPAP levels were associated with decreases in DR intubations and CPAP failure within the first 72 hours. If clinicians choose to use the RAM cannula for bCPAP, they will need higher set pressures to achieve lung inflation and the beneficial oscillatory effect will be diminished. KEY POINTS: · The transmission of the pressure oscillations from bubble CPAP is diminished with the RAM cannula.. · Increasing set CPAP pressures was associated with a decreased delivery room intubation rate and a decreased CPAP failure rate within 72 hours.. · Clinicians using the RAM cannula for bCPAP will need to increase pressures to obtain adequate lung inflation or change to a nasal interface designed for bCPAP..

Tracheal suctioning of meconium at birth for non-vigorous infants: a systematic review and meta-analysis.

CONTEXT: The International Liaison Committee on Resuscitation sought to review the initial management of non-vigorous newborns delivered through meconium stained amniotic fluid (MSAF). OBJECTIVE: To complete a systematic review and meta-analysis comparing endotracheal intubation and suctioning to immediate resuscitation without intubation for non-vigorous infants born at ≥34 weeks gestation delivered through MSAF. DATA SOURCES: Medline, EMBASE, the Cochrane Database of Systematic Reviews, and other registries were searched from 1966 to November 7, 2019. STUDY SELECTION: Studies were selected by pairs of independent reviewers in 2 stages. DATA EXTRACTION: Reviewers extracted data, appraised risk of bias, and assessed Grading of Recommendations Assessment, Development and Evaluation certainty of evidence for each outcome. RESULTS: Four randomized controlled trials (RCTs) included 581 patients and one observational study included 231 patients. No significant differences were observed between the group treated with tracheal suctioning compared with immediate resuscitation for survival at discharge (4 RCTs; risk ratio [RR] = 1.01; 95 % CI, 0.96-1.06; p = 0.69; observational study; no deaths), hypoxic ischemic encephalopathy and meconium aspiration syndrome. LIMITATIONS: The certainty of evidence was low for survival at discharge and very low for all other outcomes. CONCLUSIONS: For non-vigorous newborns delivered through MSAF, there is insufficient evidence to suggest routine immediate direct laryngoscopy with tracheal suctioning. PROSPERO: CRD42019122778. CLINICAL TRIALS REGISTRATION: PROSPERO; CRD42019122778.

Consensus outcome rating for international neonatal resuscitation guidelines.

The International Liaison Committee on Resuscitation uses the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) working group method to evaluate the quality of evidence and the strength of treatment recommendations. This method requires guideline developers to use a numerical rating of the importance of each specified outcome. There are currently no uniform reporting guidelines or outcome measures for neonatal resuscitation science. We describe consensus outcome ratings from a survey of 64 neonatal resuscitation guideline developers representing seven international resuscitation councils. Among 25 specified outcomes, 10 were considered critical for decision-making. The five most critically rated outcomes were death, moderate-severe neurodevelopmental impairment, blindness, cerebral palsy and deafness. These data inform outcome rankings for systematic reviews of neonatal resuscitation science and international guideline development using the GRADE methodology.

Length of Resuscitation for Severely Depressed Newborns.

OBJECTIVE: Current guidelines for neonatal resuscitation suggest it may be reasonable to stop resuscitation after 10 minutes in infants born with no detectable heartbeat. This study describes the length of resuscitation provided in a cohort of profoundly compromised newborn infants. STUDY DESIGN: Chart review of a regional hospital system database of newborn infants from 2010 to 2017 with a documented 10-minute Apgar score of 0 or 1. RESULTS: From a total birth population of 49,876 infants, 172 newborns were identified. Of these, 133 infants did not receive resuscitation and died while receiving comfort care. In the 39 resuscitated infants, 15 (38%) achieved return of spontaneous circulation (ROSC) at an average of 20 minutes; 32 of these 39 newborns (82%) died within 24 hours. Average time to ROSC for survivors was 17.8 minutes. Death or severe neurologic disability at 15 to 24 months of age was present in 92% (36/39) of resuscitated infants. CONCLUSION: Prolonged resuscitation of newborns is rare. In this cohort, 92% died or had severe neurodevelopmental disability. Infants with ROSC received 20 minutes of resuscitation. Infants with ROSC typically did not survive beyond 24 hours unless they survived to discharge. To increase the number of infants with ROSC, continuing resuscitation beyond 10 minutes may be reasonable.

Multicenter retrospective comparison of spontaneous intestinal perforation outcomes between primary peritoneal drain and primary laparotomy.

PURPOSE: The purpose of our study was to compare outcomes of infants with spontaneous intestinal perforation (SIP) treated with primary peritoneal drain versus primary laparotomy. METHODS: We performed a multi-institution retrospective review of infants with diagnosis of SIP from 2012 to 2016. Clinical characteristics and outcomes were compared between infants treated with primary peritoneal drain vs infants treated with laparotomy. RESULTS: We identified 171 patients treated for SIP (drain n = 110 vs. laparotomy n = 61). There were no differences in maternal or prenatal characteristics. There were no clinically significant differences in vital signs, white blood cell or platelet measures, up to 48 h after intervention. Patients who were treated primarily with a drain were more premature (24.9 vs. 27.2 weeks, p < 0.001) and had lower median birth weight (710 g vs. 896 g, p < 0.001). No significant differences were found in complications, time to full feeds, length of stay (LOS) or mortality between the groups. Primary laparotomy group had more procedures (median number 1 vs. 2, p = 0.002). There were 32 (29%) primary drain failures whereby a laparotomy was ultimately needed. CONCLUSIONS: SIP treated with primary drain is successful in the majority of patients with no significant differences in outcomes when compared to laparotomy with stoma. THE LEVEL OF EVIDENCE: III.

Comparison of Bubble CPAP Devices Using RAM Cannula for Extubation Failure in Very Low Birth Weight Infants: Randomized and Cohort Studies.

INTRODUCTION: Bubble continuous positive airway pressure (bCPAP) generates a variable pressure due to bubble size and frequency, and these pressure oscillations may contribute to lung recruitment and gas exchange. Single-outlet bCPAP devices generate larger pressure fluctuation than bCPAP devices with diffusers, but clinical efficacy is unclear. Our hypothesis was that a single-outlet bCPAP device (B&B Bubbler©) would decrease extubation failure and improve oxygenation compared with a bCPAP device with a diffuser (BabiPlus©). METHODS: Bench testing of bCPAP devices with the RAM© cannula determined pressure averages, fluctuations, and CPAP transmission at prongs. The B&B Bubbler© and the BabiPlus© devices were compared for oxygenation and bCPAP failure within 72 h of extubation in a randomized trial in infants less than 1,250 g (n = 43). Additionally, a cohort study with infants extubated to BabiPlus© (n = 128), B&B Bubbler© (n = 119), and noninvasive positive pressure ventilation (NIPPV) (n = 107) were compared. RESULTS: Small differences in pressure fluctuations between bCPAP devices are attenuated by the RAM© cannula. Pressures at RAM© prongs are 62% of set pressure. The bCPAP extubation failure rate (35%) and oxygenation were similar between the bCPAP devices. bCPAP success was associated with lower FiO2 at extubation and decreased need for additional FiO2 in both groups. In the setting of the RAM© cannula, there were no differences in extubation failure rate for infants extubated to bCPAP or NIPPV. CONCLUSIONS: There were no clinical differences at extubation between the B&B Bubbler© and BabiPlus© devices. Oxygenation may predict bCPAP failure. The use of the RAM© cannula as a bCPAP interface should be more closely examined.

Central versus Low-Lying Umbilical Venous Catheters: A Multicenter Study of Practices and Complications.

OBJECTIVES: Conventional neonatology practice is to place umbilical venous catheters (UVCs) in central position and to limit the use of low-lying catheters. Our objectives were to describe the practices and complications associated with UVCs and to evaluate the type of infusates used with either UVC position. STUDY DESIGN: A retrospective chart review was performed at four neonatal intensive care units to identify neonates who underwent UVC placement over a 2-year period. Infant demographics, UVC position, catheter days, fluid and medication characteristics, and specific complications were extracted. RESULTS: A total of 2,011 neonates who underwent UVC placement were identified during the 2-year period. Of these, 641 UVCs (31.9%) were identified in the low-lying position. Centrally positioned UVCs were associated with lower gestational age and were left in situ for a longer duration than low-lying UVCs. Infusions of hyperosmolar solutions and vasopressors were significantly higher in central UVCs, though they were used in a significant number of low-lying UVCs. Complications, while not statistically different, were three times higher in low-lying UVCs. CONCLUSION: Despite conventional teaching, low-lying UVCs were used in nearly one-third of infants in this cohort. Parenteral nutrition, antibiotics, and vasopressors were infused through central and low-lying UVCs. There was no statistically significant difference in complication rates between UVC positions.

The multiple negative randomized controlled trials in perinatology--why?

Many of the multicenter trials in perinatal medicine have been negative in that they have shown no benefit for the intervention relative to the control. Although a negative trial can improve patient care by the avoidance of an unnecessary treatment, most trials are designed with the intent of the intervention improving outcomes. We selectively reviewed a number of recent trials in order to identify why the trials were negative. In general, the preliminary information on which the trials were based, which was a small trial or a meta-analysis of multiple small trials, was not robust or predictive. The weak preliminary information together with limited numbers of patients, problematic primary outcomes and a poor understanding of the biology of neonatal diseases has limited the ability to reliably design trials with positive outcomes.

Promoting the uptake and use of evidence: an overview of the problem.

Application of evidence-based practice principles in neonatology requires that the use of proved therapies is monitored and evaluated. Although studies of neonatal center practice variation are appearing in the literature, careful, population-based assessments of the use of proved therapies are lacking. Few center comparison studies focus on proved therapies or explore the patient-independent reasons for practice variation. For a specific proved neonatal therapy, the ideal studies would carefully determine the number of eligible patients and the proportion who receive the therapy and then evaluate the characteristics of hospitals, clinicians, parents, and other decision makers among users and non-users. This information may allow for targeted interventions to disseminate evidence to both clinicians and parents, train clinicians critically to appraise the evidence, address identified barriers, and train clinicians to recognize and deal with the inevitable uncertainties associated with changing practice. The authors suggest that studies designed to evaluate the net benefit of proposed new therapies include a plan for evaluating the extent of incorporation of the therapy into practice if and when the therapy is shown to be beneficial. Studies should also rigorously evaluate alternative methods of disseminating the primary study's findings and identify the characteristics of clinicians, patients, and parents associated with practice change.

Effects of high PCO2 on ventilated preterm lamb lungs.

High PCO(2) levels attenuate reperfusion injury and ventilation-induced injury in isolated and perfused lungs. We asked whether premature lambs could tolerate 6 h of ventilation with a PCO(2) >80 mm Hg and whether the high PCO(2) modulated the ventilator-induced injury. Preterm surfactant-treated lambs were ventilated for 30 min with a high tidal volume (V(T)) to induce lung injury. The lambs then were ventilated for 5.5 h with a V(T) of 6-9 mL/kg to achieve a PCO(2) of 40-50 mm Hg in the control group. CO(2) was added to the ventilator circuit of a high PCO(2) group to maintain an average PCO(2) of 95 +/- 5 mm Hg. The high PCO(2) lambs had heart rates, blood pressures, plasma cortisol values, and oxygenation equivalent to the control lambs. The lungs of the high PCO(2) group had significantly higher gas volumes and had less lung injury by histopathology. Indicators of inflammation (white blood cells, hydrogen peroxide production, and IL-1beta and IL-8 cytokine mRNA expression in cells from the alveolar wash) qualitatively indicated less injury in the high PCO(2) group, although the differences were not significant. Preterm lambs tolerated a very high PCO(2) without physiologic compromise for 6 h. The high PCO(2) may attenuate ventilator-induced lung injury in the preterm.