Resus 8907 NLS

RESUS 8907 No.
of Pages 36
RESUSCITATION XXX (2021) XXX XXX
Available online at www.sciencedirect.com
Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation
European Resuscitation Council Guidelines 2021:

Newborn resuscitation and support of transition of
infants at birth
John Madar a, *, Charles C. Roehr b,c,d, Sean Ainsworth e, Hege Ersdal f,g,
Colin Morley h,i, Mario Rüdiger j,k, Christiane Skåre l, Tomasz Szczapa m, Arjan te [126_TD$IF]Pas n,
Daniele Trevisanuto o, Berndt Urlesberger p, Dominic Wilkinson q,r,s, Jonathan P. Wyllie t
a
Department of Neonatology, University Hospitals Plymouth, Plymouth, UK
b
Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
c
Department of Paediatrics, Medical Sciences Division, University of Oxford, Oxford, UK
d
Nuffield Department of Population Health, National Perinatal Epidemiology Unit, Medical Sciences Division, University of Oxford, Oxford, UK
e
Directorate of Women’s and Children’s Services, Victoria Hospital, Kirkcaldy, UK
f
Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
g
Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
h
University of Melbourne, Australia
i
Department of Obstetrics, University of Cambridge, UK
j
Department for Neonatology and Pediatric Intensive Care Medicine, Clinic for Pediatrics, University Hospital C.G.Carus, Technische Universität
Dresden, Germany
k
Center for Feto-Neonatal Health, Technische Universität Dresden, Germany
l
Department of Anaesthesiology, Oslo University Hospital, Norway
m
Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznan University of Medical
Sciences, Poznan, Poland
n
Department of Paediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
o
Department of Woman’s and Child’s Health, University Hospital of Padova, Padova, Italy
p
Division of Neonatology, Medical University Graz, Austria
q
Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, UK
r
John Radcliffe Hospital, Oxford, UK
s
Murdoch Children’s Research Institute, Melbourne, Australia
t
James Cook University Hospital, Middlesbrough, UK
Abstract
The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on
Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the
management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors
before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the
newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.
* Corresponding author.
E-mail address: john.madar@nhs.net (J. Madar).
https://doi.org/10.1016/j.resuscitation.2021.02.014
Available online xxx
0300-9572/© 2021 European Resuscitation Council. Published by Elsevier B.V. All rights reserved
Please cite this article in press as: J. Madar, et al., European Resuscitation Council Guidelines 2021: Newborn resuscitation and support
of transition of infants at birth, Resuscitation (2021), https://doi.org/10.1016/j.resuscitation.2021.02.014
RESUS 8907 No. of Pages 36
2 RESUSCITATION XXX (2021) XXX XXX
Vascular access
Introduction and scope The umbilical vein is still favoured as the optimal route of access but,
intraosseous access is an alternative method of emergency access for
drugs/fluids.
[1264_TD$IF]These guidelines are based on the International Liaison Committee on
Adrenaline
Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Where the heart rate has not increased after optimising ventilation
Recommendations (CoSTR) for Neonatal Life Support.1 For the and chest compressions an intravenous dose of adrenaline of
purposes of the ERC Guidelines the ILCOR recommendations were 10 30 micrograms kg 1 is recommended, repeated every 3 5 min in the
supplemented by focused literature reviews undertaken by the ERC absence of a response.
Glucose during resuscitation
NLS guidelines Group for topics not reviewed by 2020 ILCOR CoSTR.
An intravenous dose of 250 mg kg 1 (2.5 mL kg 1 of 10% glucose) is
When appropriate, the guidelines were informed by the expert
suggested in a prolonged resuscitation to reduce the likelihood of
consensus of the ERC guidelines group membership. hypoglycaemia.
These guidelines were drafted and agreed by the Newborn Life Prognosis
Support Writing Group members. The methodology used for guideline Failure to respond despite 10 20 mins of intensive resuscitation is
development is presented in the Executive summary.2 The guidelines associated with high risk of poor outcome. It is appropriate to consider
were posted for public comment in October 2020. The feedback was discussions with the team and family about withdrawal of treatment if there
has been no response despite the provision of all recommended steps of
reviewed by the writing group and the guidelines were updated where
resuscitation and having excluded reversible causes
relevant (see supplemental material). The Guideline was presented to
and approved by the ERC General Assembly on 10th December 2020.
Key messages from these guidelines are summarised in Fig. [1265_TD$IF]2 .
COVID 19 context Concise guideline for clinical practice
The ERC has produced guidance on newborn life support in the Factors before delivery
context of coronavirus disease 2019 (SARS-CoV-2),3 this is based
on an ILCOR CoSTR and systematic review.4,5 Our understanding Transition and the need for assistance after birth
of the risks to infants potentially exposed to SARS-CoV-2 and the Most, but not all, infants adapt well to extra-uterine life but some
risk of virus transmission and infection to those providing care is require help with stabilisation, or resuscitation. Up to 85% breathe
evolving. Please check ERC and national guidelines for the latest spontaneously without intervention; a further 10% respond after
guidance and local policies for both treatment and rescuer drying, stimulation and airway opening manoeuvres; approximately
precautions. 5% receive positive pressure ventilation. Intubation rates vary
between 0.4% and 2%. Fewer than 0.3% of infants receive chest
compressions and only 0.05% receive adrenaline.
Summary of changes since the 2015 guidelines
Management of the umbilical cord Risk factors
Clamping after at least 60 s is recommended, ideally after the lungs are A number of risk factors have been identified as increasing the
aerated. Where delayed cord clamping is not possible cord milking should likelihood of requiring help with stabilisation, or resuscitation (Fig. [1274_TD$IF]1).
be considered in infants >28 weeks gestation.
Infants born through meconium-stained liquor
Staff attending delivery
In non-vigorous infants, recommendations are against immediate
Any infant may develop problems during birth. Local guidelines
laryngoscopy with or without suction after delivery, because this may delay
aeration and ventilation of the lungs. indicating who should attend deliveries should be developed,
Use of the laryngeal mask based on current understanding of best practice and clinical
If facemask ventilation is unsuccessful or if tracheal intubation is audit, and taking into account identified risk factors (Fig. [1275_TD$IF]1 ). As a
unsuccessful or not feasible a laryngeal mask may be considered as an guide,
alternative means of establishing an airway in infants of >34 weeks Personnel competent in newborn life support should be available
gestation (about 2000 g, although some devices have been used
for every delivery.
successfully in infants down to 1500 g).
If intervention is required, there should be personnel available
Inflation pressure
If there is no response to initial inflations despite an open airway then a whose sole responsibility is to care for the infant.
gradual increase in the inflation pressure is suggested. A process should be in place for rapidly mobilising a team with
A starting pressure of 25 cm H2O is suggested for preterm infants <32 sufficient resuscitation skills for any birth.
weeks gestation.
Air/oxygen for preterm resuscitation Equipment and environment
Recommendations are for starting in air at 32 weeks gestation or more, 21-
All equipment must be regularly checked and ready for use.
30% inspired oxygen at 28-31 weeks gestation and 30% inspired oxygen at
<28 weeks gestation.
Where possible, the environment and equipment should be
The concentration should be titrated to achieve saturations of 80% at 5 min prepared in advance of the delivery of the infant. Checklists
of age because there is evidence of poorer outcomes where this is not facilitate these tasks.
achieved. Resuscitation should take place in a warm, well-illuminated,
Chest compressions draught-free area with a flat resuscitation surface and a radiant
If chest compressions are required, the inspired oxygen concentration
heater (if available).
should be increased to 100% and consideration given towards securing the
Equipment to monitor the condition of the infant and to support
airway ideally with a tracheal tube.
ventilation should be immediately available.
RESUSCITATION XXX (2021) XXX XXX 3
Training/education
Recommendations
Newborn resuscitation providers must have relevant current
knowledge, technical and non-technical skills.
Institutions or clinical areas where deliveries may occur should
have structured educational programmes, teaching the knowl-
edge and skills required for newborn resuscitation.
The content and organisation of such training programmes may
vary according to the needs of the providers and the organisation
of the institutions.
Recommended programmes include:
Fig. 1 – Common factors associated with an increased regular practice and drills,
risk of a need for stabilization, or resuscitation at birth. team and leadership training,
multi-modal approaches,
simulation-based training,
feedback on practice from different sources (including feedback
Additional equipment, that might be required in case of more devices),

prolonged resuscitation should be easily accessible. objective, performance focused debriefings.
[1278_TD$IF]Ideally, training should be repeated more frequently than once per

Planned home deliveries year.
Ideally, two trained professionals should be present at all home
[1279_TD$IF]Updates may include specific tasks, simulation and/or behav-
deliveries. ioural skills and reflection.
At least one must be competent in providing mask ventilation and
chest compressions to the newborn infant. Thermal control
Recommendations as to who should attend a planned home
delivery vary from country to country, but the decision to undergo Recommendations
such a delivery, once agreed with medical and midwifery staff,
should not compromise the standard of initial assessment, Standards
stabilisation or resuscitation at birth. The infant's temperature should be regularly monitored after birth
There will inevitably be some limitations to the extent of the and the admission temperature should be recorded as a
resuscitation of a newborn infant in the home, due to the distance prognostic and quality indicator.
from healthcare facilities and equipment available, and this must The temperature of newborn infants should be maintained
be made clear to the mother at the time plans for home delivery are between 36.5 C and 37.5 C.
made. Hypothermia (36.0 C) and hyperthermia (>38.0 C) should be
When a birth takes place in a non-designated delivery area a avoided. In appropriate circumstances, therapeutic hypothermia
minimum set of equipment of an appropriate size for the newborn may be considered after resuscitation (see post-resuscitation
infant should be available, including: care)

clean gloves for the attendant and assistants,
means of keeping the infant warm, such as heated dry towels Environment
and blankets, Protect the infant from draughts. Ensure windows are closed and
a stethoscope to check the heart rate, air-conditioning appropriately programmed.
a device for safe assisted lung aeration and subsequent Keep the environment in which the infant is looked after (e.g.
ventilation such as a self-inflating bag with appropriately sized delivery room or theatre) warm at 23 25 C.
facemask, For infants 28 weeks gestation the delivery room or theatre
sterile instruments for clamping and then safely cutting the temperature should be >25 C.
umbilical cord.
[1276_TD$IF]Unexpected deliveries outside hospital are likely to involve Term and near-term infants >32 weeks gestation
emergency services who should be trained and prepared for Dry the infant immediately after delivery. Cover the head and body
such events and carry appropriate equipment. of the infant, apart from the face, with a warm and dry towel to
Caregivers undertaking home deliveries should have pre-defined prevent further heat loss.
plans for difficult situations. If no resuscitation is required place the infant skin-to-skin with
mother and cover both with a towel. On-going careful observation
[127_TD$IF]Briefing of mother and infant will be required especially in more preterm
If there is sufficient time, brief the team to clarify responsibilities, and growth restricted infants to ensure they both remain
check equipment and plan the stabilisation, or resuscitation. normothermic.
Roles and tasks should be assigned checklists are helpful. If the infant needs support with transition or when resuscitation is
Prepare the family if it is anticipated that resuscitation might be required, place the infant on a warm surface using a preheated
required. radiant warmer.
Fig. 2 – NLS infographic.
Preterm infants 32 weeks gestation A quality improvement program including the use of checklists and
Completely cover with polyethylene wrapping (apart from face) continuous feedback to the team has been shown to significantly
without drying and use a radiant warmer. reduce hypothermia at admission in very preterm infants.
If umbilical cord clamping is delayed and a radiant warmer is not
accessible at this point, other measures (such as those listed Out of hospital management
below) will be needed to ensure thermal stability while still Infants born unexpectedly outside a normal delivery environment
attached to the placenta. are at higher risk of hypothermia and subsequent poorer
A combination of further interventions may be required in infants outcomes.
32 weeks including increased room temperature, warm They may benefit from placement in a food grade plastic bag after
blankets, head cap and thermal mattress. drying and then swaddling. Alternatively, well newborns >30
Skin-to-skin care is feasible in less mature infants however caution weeks gestation may be dried and nursed skin-to-skin to maintain
is required in the more preterm or growth restricted infant in order their temperature whilst they are transferred as long as mothers
to avoid hypothermia. are normothermic. Infants should be covered and protected from
For infants receiving respiratory support, use of warmed draughts and watched carefully to avoid hypothermia and ensure
humidified respiratory gases should be considered. airway and breathing are not compromised.
Management of the umbilical cord after birth Heart rate

Determine the heart rate with a stethoscope and a saturation
The options for managing cord clamping and the rationale should monitor ECG (electrocardiogram) for later continuous
be discussed with parents before birth. assessment.
Where immediate resuscitation or stabilisation is not required, aim
Fast (100 min 1) satisfactory
to delay clamping the cord for at least 60 s. A longer period may be Slow (60 100 min 1) intermediate, possible hypoxia
more beneficial. Very slow/absent (<60 min 1) critical, hypoxia likely
Clamping should ideally take place after the lungs are aerated.
Where adequate thermal care and initial resuscitation interven- If the infant fails to establish spontaneous and effective breathing
tions can be safely undertaken with the cord intact it may be following assessment and stimulation, and/or the heart rate does not
possible to delay clamping whilst performing these interventions. increase (and/or decreases) if initially fast, respiratory support should
Where delayed cord clamping is not possible consider cord milking be started.
in infants >28 weeks gestation.
Initial assessment (Fig. 3) Classification according to initial assessment
On the basis of the initial assessment, the infant can usually be placed
into one of three groups as the following examples illustrate.
1.
Fig. 3 – Assessment of tone, breathing and heart rate help

determine the need for intervention.
Fig. 4a – Satisfactory transition.
May occur before the umbilical cord is clamped and cut (typically
performed in this order): Good tone
Observe Tone (& Colour) Vigorous breathing or crying
Assess adequacy of Breathing Heart rate fast (100 min 1)
Assess the Heart Rate
Take appropriate action to keep the baby warm during these initial Assessment: Satisfactory transition Breathing does not require
steps. support. Heart rate is acceptable (Fig. 4[125_TD$IF]a ).
This rapid assessment serves to establish a baseline, identify the
need for support and/or resuscitation and the appropriateness and Actions:
duration of delaying umbilical cord clamping. Delay cord clamping.
Frequent re-assessment of heart rate and breathing indicates Dry, wrap in warm towel.
whether the infant is adequately transitioning or whether further Keep with mother or carer and ensure maintenance of temperature.
interventions are needed. Consider early skin-to-skin care if stable.
Tactile stimulation 2.
Initial handling is an opportunity to stimulate the infant during
assessment by
Drying the infant.
Gently [1280_TD$IF]stimulating as you dry them, for example by rubbing the
soles of the feet or the back of the chest. Avoid more aggressive
methods of stimulation.
Tone and colour

Fig. 4b – Incomplete transition.
A very floppy infant is likely to need ventilatory support.
Colour is a poor means of judging oxygenation. Cyanosis can be Reduced tone
difficult to recognise. Pallor might indicate shock or rarely hypovolaemia Breathing inadequately (or apnoeic)
consider blood loss and plan appropriate intervention. Heart rate slow (<100 min 1)
Breathing Assessment: Incomplete transition Breathing requires support,

Is the infant breathing? Note the rate, depth and symmetry, slow heart rate may indicate hypoxia (Fig. [128_TD$IF]4b).
work/effort of breathing as

Adequate Actions:
Inadequate/abnormal pattern such as gasping or grunting Delay cord clamping only if you are able to appropriately support
Absent the infant.
Dry, stimulate, wrap in a warm towel. Continue newborn life support according to response.
Maintain the airway, lung inflation and ventilation. Help is likely to be required.
Continuously assess changes in heart rate and breathing
If no improvement in heart rate, continue with ventilation. Preterm infants
Help may be required. Same principles apply.
Consider alternative/additional methods for thermal care e.g.
3. polyethylene wrap.
Gently support, initially with CPAP if breathing.
Consider continuous rather than intermittent monitoring (pulse
oximetry ECG)
Newborn life support
Fig. 4c – Poor/failed transition. Following initial assessment and intervention, continue respiratory
support if:
Floppy Pale The infant has not established adequate, regular breathing, or
Breathing inadequately or apnoeic The heart rate is <100 min 1.
Heart rate very slow (<60 min 1) or undetectable
[1283_TD$IF]Ensuring an open airway, aerating and ventilating the lungs[1284_TD$IF] is
Assessment: Poor/Failed transition Breathing requires support, usually all that is necessary. Without these, other interventions will be
heart rate suggestive of significant hypoxia (Fig. [128_TD$IF]4c). unsuccessful.
Actions: Airway
Clamp cord immediately and transfer to the resuscitation platform.
Delay cord clamping only if you are able to appropriately support/ Commence life support if initial assessment shows that the infant has
resuscitate the infant. not established adequate regular normal breathing, or has a heart rate
Dry, stimulate, wrap in warm towel. <100 min 1 [1285_TD$IF](Fig. 5).
Maintain the airway lung inflation and ventilation. Establishing and maintaining an open airway is essential to
Continuously assess heart rate, breathing, and effect of achieve postnatal transition and spontaneous breathing, or for further
ventilation. resuscitative actions to be effective.[1286_TD$IF]
Fig. 5 – NLS algorithm.
Techniques to help open the airway must be on initiating ventilation as soon as possible in apnoeic or
Place the infant on their back with the head supported in a neutral ineffectively breathing infants born through meconium-stained
position (Fig. [1287_TD$IF]6a). amniotic fluid.
Should initial attempts at aeration and ventilation be unsuccessful
then physical obstruction may be the cause. In this case inspection
and suction under direct vision be considered. Rarely, an infant
may require tracheal intubation and tracheal suctioning to relieve
airway obstruction.
Initial inflations and assisted ventilation
Fig. 6a – Head in a neutral position. Face is horizontal Lung [1289_TD$IF]inflation (Fig. 7)

(middle picture), neither flexed (left) or extended (right). If apnoeic, gasping or not breathing effectively, aim to start positive
pressure ventilation as soon as possible ideally within 60 s of
In floppy infants, pulling the jaw forwards (jaw lift) may be birth.
essential in opening and/or maintaining the airway and reducing Apply an appropriately fitting facemask connected to a means of
mask leak (Fig. [128_TD$IF]6b). When using a facemask, two person providing positive pressure ventilation, ensuring a good seal
methods of airway support are superior and permit true jaw between mask and face.
thrust to be applied. Give five “inflations” maintaining the inflation pressure for up
to 2 3 s.
Provide initial inflation pressures of 30 cm H2O for term
infants commencing with air. Start with 25 cm H2O for preterm
infants 32 weeks using 21 30% inspired oxygen (see ‘air/
oxygen’).
Fig. 6b – Jaw lift jaw lift enlarges the pharyngeal space.
An oropharyngeal airway may be useful in term infants when

having difficulty providing both jaw lift and ventilation, or where the
upper airway is obstructed, for instance in those with micrognathia. Fig. 7 – Five 2 3 s inflations are given via facemask.
However, oropharyngeal airways should be used with caution in Assess heart rate response and chest movement.
infants 34 weeks gestation as they may increase airway
obstruction.
A nasopharyngeal airway may also be considered where there is Assessment
difficulty maintaining an airway and mask support fails to achieve Check the heart rate
adequate aeration. An increase (within 30 s) in heart rate, or a stable heart rate if
initially high, confirms adequate ventilation/oxygenation.

Airway obstruction A slow or very slow heart rate usually suggests continued
Airway obstruction can be due to inappropriate positioning, hypoxia and almost always indicates inadequate ventilation.
decreased airway tone and/or laryngeal adduction, especially in Check for chest movement
preterm infants at birth. Visible chest movement with inflations indicates a patent airway
Suction is only required if airway obstruction due to mucus, vernix, and delivered volume.
meconium, blood clots, etc. is confirmed through inspection of the Failure of the chest to move may indicate obstruction of the
pharynx after failure to achieve aeration. airway, or insufficient inflation pressure and delivered volume to
Any suctioning should be undertaken under direct vision, ideally aerate the lungs.
using a laryngoscope and a wide bore catheter.
Ventilation (Fig. [1290_TD$IF]8 )
Meconium If there is a heart rate response
Non-vigorous newborn infants delivered through meconium- Continue uninterrupted ventilation until the infant begins to
stained amniotic fluid are at significant risk for requiring advanced breathe adequately and the heart rate is above 100 min 1.
resuscitation and a neonatal team competent in advanced Aim for about 30 breaths min 1 with an inflation time of under 1 s.
resuscitation may be required. Reduce the inflation pressure if the chest is moving well.
Routine suctioning of the airway of non-vigorous infants is likely Reassess heart rate and breathing at least every 30 s.
to delay initiating ventilation and is not recommended. In the Consider a more secure airway (laryngeal mask/tracheal tube) if
absence of evidence of benefit for suctioning, the emphasis apnoea continues or if mask ventilation is not effective.
Where possible use a T-piece resuscitator (TPR) capable of

providing either CPAP or PPV with PEEP when providing
ventilatory support, especially in the preterm infant.
Nasal prongs of appropriate size may be a viable CPAP alternative
to facemasks.
If a self-inflating bag is used it should be of sufficient volume to deliver an
adequate inflation. Care should be taken not to deliver an excessive
volume. The self-inflating bag cannot deliver CPAP effectively.
Laryngeal mask
Fig. 8 – Once inflation breaths have been successfully Consider using a laryngeal mask
delivered, ventilate at 30 breaths min 1. Assess heart In infants of 34 weeks gestation (about 2000 g) although some
rate continuously. devices have been used successfully in infants down to 1500 g.
If there are problems with establishing effective ventilation with
Failure to respond a facemask.

If there is no heart rate response and the chest is not moving with Where intubation is not possible or deemed unsafe because
inflations of congenital abnormality, a lack of equipment, or a lack of

Check if the equipment is working properly. skill.
Recheck the head-position and jaw lift/thrust Or as an alternative to tracheal intubation as a secondary
Recheck mask size, position and seal. airway.

Consider other airway manoeuvres:
2-person mask support if single handed initially. Tracheal tube
Inspection of the pharynx and suction under direct vision to Tracheal intubation may be considered at several points during
remove obstructing foreign matter if present. neonatal resuscitation:
Securing the airway via tracheal intubation or insertion of a
When ventilation is ineffective after correction of mask
laryngeal mask. technique and/or the infant's head position, and/or increasing
Insertion of an oropharyngeal/nasopharyngeal airway if unable inspiratory pressure with TPR or bag-mask.
to secure the airway with other means. Where ventilation is prolonged, to enable a more secure airway
Consider a gradual increase in inflation pressure. to be established.

If being used, check on a respiratory function monitor that expired When suctioning the lower airways to remove a presumed
tidal volume is not too low or too high (target about 5 8 mL kg 1). tracheal blockage.
When chest compressions are performed.
Then: In special circumstances (e.g., congenital diaphragmatic hernia
Repeat inflations. or to give surfactant).

Continuously assess heart rate and chest movement. Exhaled CO2 detection should be used when undertaking
intubation to confirm tube placement in the airway.
If the insertion of a laryngeal mask or tracheal intubation is A range of differing sized tracheal tubes should be available to
considered, it must be undertaken by personnel competent in the permit placement of the most appropriate size to ensure adequate
procedure with appropriate equipment. Otherwise continue with ventilation with minimal leak and trauma to the airway [129_TD$IF]Table 1.
mask ventilation and call for help. Respiratory function monitoring may also help confirm tracheal
Without adequate lung aeration, chest compressions will be tube position and adequate ventilation through demonstrating
ineffective; therefore, where the heart rate remains very slow, confirm adequate expired tidal volume (about 5 8 mL kg 1) and minimal
effective ventilation through observed chest movement or other leak.
measures of respiratory function before progressing to chest The use of a video laryngoscope may aid tube placement.
compressions. If retained, the position of the tracheal tube should be confirmed by
radiography.
[129_TD$IF]CPAP and PEEP/airway adjuncts and assisted ventilation
Table 1 – Approximate oral tracheal tube size by
Continuous positive airway pressure (CPAP) and positive gestation (for approximate nasotracheal tube length
end expiratory pressure (PEEP) add 1 cm).
In spontaneously breathing preterm infants consider CPAP as the Gestational Length at External
initial method of breathing support after delivery using either age (weeks) lips (cm) diameter (mm)
mask or nasal prongs.
23 24 5.5 2.5
If equipment permits, apply PEEP at minimum of 5 6 cm H2O 25 26 6.0 2.5
when providing positive pressure ventilation (PPV) to these 27 29 6.5 2.5
infants. 30 32 7.0 3.0
33 34 7.5 3.0
Assisted ventilation devices 35 37 8.0 3.5
38 40 8.5 3.5
Ensure a facemask of appropriate size is used to provide a good
41 43 9.0 4.0
seal between mask and face.
Air/[21_TD$IF]oxygen Delivery of chest compressions

[1295_TD$IF]Use a synchronous technique, providing three compressions to
Pulse-oximetry and oxygen blenders should be used during one ventilation at about 15 cycles every 30 s.
resuscitation in the delivery room. [1296_TD$IF]Use a two-handed technique for compressions if possible.
Aim to achieve target oxygen saturation above the 25th percentile Re-evaluate the response every 30 s.
for healthy term infants in the first 5 min after birth (Table 2). If the heart rate remains very slow or absent, continue ventilation
and chest compressions but ensure that the airway is secured
Table 2 – Approximate target SpO2 in the first 10 min (e.g. intubate the trachea if competent and not done already).
for healthy term infants (derived from Dawson Titrate the delivered inspired oxygen against oxygen saturation if a
et al.281). reliable value is achieved on the pulse oximeter.
Time after birth (min) Lower SpO2 target (%)

Consider
2 65 Vascular access and drugs.
5 85
10 90
Vascular access
During the resuscitation of a compromised infant at birth peripheral

If, despite effective ventilation, there is no increase in heart rate, or venous access is likely to be difficult and suboptimal for vasopressor
saturations remain low, increase the oxygen concentration to administration.
achieve adequate preductal oxygen saturations.
Check the delivered inspired oxygen concentration and satu- Umbilical venous access
rations frequently (e.g. every 30 s) and titrate to avoid both hypoxia The umbilical vein offers rapid vascular access in newborn
and hyperoxia. infants and should be considered the primary method during
wean the inspired oxygen if saturations >95% in preterms. resuscitation.
Ensure a closed system to prevent air embolism during insertion
Term and late preterm infants 35 weeks should the infant gasp and generate sufficient negative pressure.
In infants receiving respiratory support at birth, begin with air Confirm position in a blood vessel through aspiration of blood prior
(21%). to administering drugs/fluids.
Clean, rather than sterile, access technique may be sufficient in an
Preterm infants <35 weeks emergency.
Resuscitation should be initiated in air or a low inspired oxygen The umbilical route may still be achievable some days after birth
concentration based on gestational age: and should be considered in cases of postnatal collapse.

[1293_TD$IF]32 weeks 21%
28 31 weeks 21 30% Intraosseous access
<28 weeks 30% Intraosseous (IO) access can be an alternative method of
In infants <32 weeks gestation the target should be to avoid an emergency access for drugs/fluids.
oxygen saturation below 80% and/or bradycardia at 5 min of age.
Both are associated with poor outcome. Support of transition/post-resuscitation care
If venous access is required following resuscitation, peripheral
Chest compressions access may be adequate unless multiple infusions are required in
which case central access may be preferred.
Assessment of the need for chest compressions (Fig. [1294_TD$IF]9 ) IO access may be sufficient in the short term if no other site is
If the heart rate remains very slow (<60 min 1) or absent after 30 s available.
of good quality ventilation, start chest compressions.
When starting compressions: Drugs
Increase the delivered inspired oxygen to 100%.
Call for experienced help if not already summoned. During active resuscitation
Drugs are rarely required during newborn resuscitation and the
evidence for the efficacy of any drug is limited. The following may
be considered during resuscitation where, despite adequate
control of the airway, effective ventilation and chest compressions
for 30 s, there is an inadequate response and the HR remains
below 60 min 1.
Adrenaline

When effective ventilation and chest compressions have failed
to increase the heart rate above 60 min 1
Intravenous or intraosseous is the preferred route:
Fig. 9 – Deliver 30 s of good quality ventilation before & At a dose of 10 30 micrograms kg 1 (0.1 0.3 mL kg 1 of
reassessment of the heart rate. 1:10,000 adrenaline [1000 micrograms in 10 mL]).
Intra-tracheally if intubated and no other access available. Therapeutic hypothermia

& At a dose of 50 100 micrograms kg 1. Once resuscitated, consider inducing hypothermia to 33 34 C in

Subsequent doses every 3 5 min if heart rate remains < 60 min 1. situations where there is clinical and/or biochemical evidence of
Glucose significant risk of moderate or severe HIE (hypoxic-ischaemic

In a prolonged resuscitation to reduce likelihood of encephalopathy).
hypoglycaemia. Ensure the evidence to justify treatment is clearly documented;
Intravenous or intraosseous: include cord blood gases, and neurological examination.
1
& 250 mg kg bolus (2.5 mL kg 1 of 10% glucose solution). Arrange safe transfer to a facility where monitoring and treatment
Volume replacement can be continued.

With suspected blood loss or shock unresponsive to other Inappropriate application of therapeutic hypothermia, without
resuscitative measures. concern about a diagnosis of HIE, is likely to be harmful (see
Intravenous or intraosseous: temperature maintenance).
1
& 10 mL kg of group O Rh-negative blood or isotonic
crystalloid. Prognosis (documentation).
Sodium bicarbonate Ensure clinical records allow accurate retrospective time-based

May be considered in a prolonged unresponsive resuscitation evaluation of the clinical state of the infant at birth, any
with adequate ventilation to reverse intracardiac acidosis. interventions and the response during the resuscitation to
[1297_TD$IF]Intravenous or intraosseous: facilitate any review and the subsequent application of any
& 1 2 mmol kg 1 sodium bicarbonate (2 4 mL kg 1 of 4.2% prognostic tool.
solution) by slow intravenous injection.
Communication with the parents
In situations of persistent apnoea
Where intervention is anticipated
Naloxone Whenever possible, the decision to attempt resuscitation of an

Intramuscular extremely preterm or clinically complex infant should be taken in
& An initial 200 microgram dose may help in the close consultation with the parents and senior paediatric,
few infants who, despite resuscitation, remain apnoeic midwifery and obstetric staff.
with good cardiac output when the mother is known Discuss the options including the potential need and magnitude of
to have received opiods in labour. Effects may be resuscitation and the prognosis before delivery in order to develop
transient so continued monitoring of respiration is an agreed plan for the birth.
important. Record carefully all discussions and decisions in the mother's
notes prior to delivery and in the infant's records after birth.
In the absence of an adequate response
For every birth
Consider other factors which may be impacting on the response to Where intervention is required it is reasonable for mothers/fathers/
resuscitation and which require addressing such as the presence of partners to be present during the resuscitation where circum-
pneumothorax, hypovolaemia, congenital abnormalities, equipment stances, facilities and parental inclination allow.
failure etc. The views of both the team leading the resuscitation and the
parents must be taken into account in decisions on parental
Post-resuscitation care attendance.
Irrespective of whether the parents are present at the resuscita-
Infants who have required resuscitation may later deteriorate. Once tion, ensure wherever possible, that they are informed of the
adequate ventilation and circulation are established, the infant should progress of the care provided to their infant.
be cared for in, or transferred to, an environment in which close Witnessing the resuscitation of their infant may be distressing for
monitoring and anticipatory care can be provided. parents. If possible, identify a member of healthcare staff to
support them to keep them informed as much as possible during
Glucose the resuscitation.
Monitor glucose levels carefully after resuscitation. Allow parents to hold or even better to have skin-to-skin contact
Have protocols/guidance on the management of unstable glucose with their infant as soon as possible after delivery or resuscitation,
levels. even if unsuccessful.
Avoid hyper- and hypoglycaemia. Provide an explanation of any procedures and why they were
Avoid large swings in glucose concentration. required as soon as possible after the delivery.
Consider the use of a glucose infusion to avoid hypoglycaemia. Ensure a record is kept of events and any subsequent
conversations with parents.
Thermal care Allow for further discussions later to enable parents to reflect and
Aim to keep the temperature between 36.5 C and 37.5 C. to aid parental understanding of events.
Rewarm if the temperature falls below this level and there are no Consider what additional support is required for parents following
indications to consider therapeutic hypothermia (see below). delivery and any resuscitation.
Withholding and discontinuing resuscitation to occur after which pulmonary gas exchange can be established.6 This
critical event initiates a sequence of inter-dependent cardiopulmonary
Any recommendations must be interpreted in the light of current adaptations which enable transition to independent life.7 Spontaneous
national/regional outcomes. breathing effort (negative pressure) or less effective, artificial ventilation
When discontinuing, withdrawing or withholding resuscitation, (positive pressure) are essential to generate the transpulmonary
care should be focused on the comfort and dignity of the infant and pressures required to aerate the liquid-filled lung to form and then
family. maintain a functional residual capacity.8,9 Most, but not all, infants
Such decisions should ideally involve senior paediatric staff. transition smoothly. Some infants have problems with transition, and
without timely and adequate support, might subsequently need
Discontinuing resuscitation resuscitation. Recent, large-scale observational studies confirm that
National committees may provide locally appropriate recommen- approximately 85% of infants born at term initiate respiration
dations for stopping resuscitation. spontaneously; 10% will respond to drying, stimulation, opening the
When the heart rate has been undetectable for longer than 10 min airway and/or applying CPAP or PEEP, approximately 5% will breathe
after delivery review clinical factors (for example gestation of the following positive pressure ventilation. Estimates of intubation rates
infant, or presence/absence of dysmorphic features), effective- vary between 0.4% and 2%; <0.3% receive chest compressions and
ness of resuscitation, and the views of other members of the approximately 0.05% adrenaline.10 16
clinical team about continuing resuscitation.
If the heart rate of a newborn term infant remains undetectable for Risk factors
more than 20 min after birth despite the provision of all Several maternal and fetal pre- and intrapartum factors increase the risk
recommended steps of resuscitation and exclusion of reversible for compromised birth or transition and the need for resuscitation. In a
causes, consider stopping resuscitation. recent ILCOR evidence update most recent studies confirm previously
Where there is partial or incomplete heart rate improvement identified risk factors for needing assistance after birth.1,17 26 There is
despite apparently adequate resuscitative efforts, the choice is no universally applicable model to predict risk for resuscitation or need
much less clear. It may be appropriate to take the infant to the of support during transition, and the list of risk factors in the guidelines is
intensive care unit and consider withdrawing life-sustaining not exhaustive.
treatment if they do not improve. Elective caesarean delivery at term, in the absence of other risk
Where life-sustaining treatment is withheld or withdrawn, infants factors, does not increase the risk of needing newborn resuscita-
should be provided with appropriate palliative (comfort focused) care. tion.18,27,28 Following the review of evidence, ILCOR recommendations
are unchanged: When an infant is delivered at term by caesarean delivery
Withholding resuscitation under regional anaesthesia a provider capable of performing assisted
Decisions about withholding life-sustaining treatment should ventilation should be present at the delivery. It is not necessary for a
usually be made only after discussion with parents in the light provider skilled in neonatal intubation to be present at that delivery.1
of regional or national evidence on outcome if resuscitation and
active (survival focused) treatment is attempted. Staff attending delivery
In situations where there is extremely high (>90%) predicted It is not always possible to predict the need for stabilisation or
neonatal mortality and unacceptably high morbidity in surviving resuscitation before an infant is born. Interventions may not be
infants, attempted resuscitation and active (survival focused) necessary but those in attendance at a delivery need to be able to
management is usually not appropriate. undertake initial resuscitation steps effectively. It is essential that
Resuscitation is nearly always indicated in conditions associated teams can respond rapidly if not present and needed to provide
with a high (>50%) survival rate and what is deemed to be additional support. The experience of the team and their ability to
acceptable morbidity. This will include most infants with gestational respond in a timely manner can influence outcome.29 Units have
age of 24 weeks or above (unless there is evidence of fetal different guidelines for when teams attend in advance, potentially
compromise such as intrauterine infection or hypoxia-ischaemia) leading to widely different outcomes.30 A prospective audit of 56
and most infants with congenital malformations. Resuscitation Canadian neonatal units found that, with the guidelines in force at that
should also usually be commenced in situations where there is time, the need for resuscitation was unanticipated in 76% of cases.31
uncertainty about outcome and there has been no chance to have In a series of video recorded resuscitations in 2 Norwegian tertiary
prior discussions with parents. level units, the need for resuscitation was not anticipated in 32%.32
In conditions where there is low survival (<50%) and a high rate of Approximately 65% of all deliveries in a single Canadian unit were
morbidity, and where the anticipated burden of medical treatment attended by the resuscitation team only 22% of these infants
for the child is high, parental wishes regarding resuscitation should required IPPV, as did another 4.6% where resuscitation was not
be sought and usually supported. anticipated.17
Equipment and environment

Evidence informing the guidelines The detailed specification of the equipment required to support
stabilisation and resuscitation of the newborn may vary and those
Factors before delivery using the equipment need to be aware of any limitations. Suggestions
have been made on standardising an optimal layout of a resuscitation
Transition area,33 but no published evidence has demonstrated improvement in
Survival at birth involves major physiological changes during transition outcome as a result of specific arrangements. The guidelines are
from fetal to newborn life. First, lung liquid-clearance and aeration need based on international expert opinion.1,34
Planned home deliveries A recent ILCOR systematic review included several studies on
A systematic review of 8 studies involving 14 637 low risk planned team training in neonatal resuscitation.51 55 Team performance and
home deliveries compared to 30 177 low risk planned hospital births patient safety appeared to be enhanced by regular practice and drills
concluded that the risks of neonatal morbidity and mortality were that enabled those likely to be involved to rehearse and improve their
similar.35 Those attending deliveries at home need to recognise that abilities at an individual level and in teams. This suggested that
despite risk stratification and measures to avoid the event, infants born specific team and leadership training be included as part of Advanced
at home may still require resuscitation and they must be prepared for Life Support training for healthcare providers (weak recommendation,
this possibility.34 very low certainty of evidence).37
Multi-modal approaches to teaching neonatal resuscitation are
Briefing and checklists thought to be the most beneficial for learning, especially when
Briefing with role allocation to improve team functioning and dynamics simulation-based training with emphasis on feedback on practice is
is recommended36 although there is a lack of evidence of improved incorporated as a teaching method.42,50,56 60 Feedback may come
clinical outcomes.37 Likewise, use of checklists during briefings (and from different sources such as the facilitator, the manikin itself or digital
debriefings) may help improve team communication and process, but recordings (video, audio, respiratory function monitor etc.).37,60 62
again, there is little evidence of effect on clinical outcome.38,39 A recent The role of modalities such as virtual reality, tele-education and board
ILCOR scoping review on the effect of briefing/debriefing on the game simulation in resuscitation training remain to be established. A
outcome of neonatal resuscitation concluded that briefing or debrief- review of 12 such neonatal resuscitation-based games concluded that
ing may improve short-term clinical and performance outcomes for they had a potential to improve knowledge, skills and adherence to the
infants and staff but the effects on long-term clinical and performance resuscitation algorithm.63
outcomes were uncertain.1 Feedback devices providing information on the quality of interven-
The opportunity to brief the family before delivery can significantly tion may also be used in real-life settings to improve performance and
influence their expectation and understanding of events, decision- compliance with guidelines.37,64,65 Debriefing on individual and team
making and interactions with health providers. Therefore, anticipatory performance at resuscitations supported by objective data are
liaison often forms part of national recommendations on practice (see recommended after cardiac arrest for both adult and children (weak
section parents and family).33 recommendation, very low certainty of evidence).37,66 69 This
approach to debrief also applies to neonatal resuscitation.53,70,71
Training/education
Thermal control
Meta-analysis of adult resuscitations showed that attendance by one
or more personnel on an advanced life support course improves Exposed, wet, newborn infants cannot maintain their body tempera-
outcome.40 Research on educational methods in neonatal resuscita- ture in a room that feels comfortably warm for adults. The mechanisms
tion is evolving, but due to study heterogeneity with non-standardised and effects of cold stress and how to avoid these have been
outcome measures, there is still little evidence on the effect of different reviewed.72,73 Heat loss can occur though convection, conduction,
training modalities on clinical outcome.41 43 radiation and evaporation meaning unprotected infants will drop their
For those taking resuscitation courses training or retraining body temperature quickly. Cold stress lowers the arterial oxygen
distributed over time (spaced learning) may be an alternative to tension and increases the risk of metabolic acidosis. Compromised
training provided at one single time point (massed learning) (weak infants are particularly vulnerable to cold stress. The admission
recommendation, very low certainty of evidence).44 Intermittent, temperature of newborn non-asphyxiated infants is a strong predictor
infrequent training without interval refreshment leads to skills decay in of mortality and morbidity at all gestations and in all settings.74,75
neonatal resuscitation.45 whereas frequent and brief, on-site simula- ILCOR recommendations are that it should be recorded as a predictor
tion-based training has been shown to improve patient 24 h survival in of outcomes as well as a quality indicator (strong recommendation,
a low-resource setting.46 Two observational studies analysing video moderate-quality evidence).49 Immediate drying and wrapping infants
recordings of real-time resuscitations against checklists of expected in a warm towel to avoid exposure to a cold environment will help them
actions indicated frequent errors in the application of structured maintain their temperature.
guidelines in newborn resuscitation.15,47 This suggests that training Preterm infants are especially vulnerable and hypothermia is also
should be repeated more frequently than once per year, however, the associated with serious morbidities such as intraventricular haemor-
optimal interval remains to be established.48,49 rhage, need for respiratory support, hypoglycaemia, and in some
A structured educational programme in neonatal resuscitation was studies late onset sepsis.49 In a European cohort study of 5697 infants
recommended in the 2015 ERC guidelines and supported by two <32 weeks gestation admitted for neonatal care, an admission
systematic reviews and meta-analyses.34 A Cochrane review of 14 temperature <35.5 C was associated with increased mortality in the
studies (187 080 deliveries) concluded that there was moderate first 28 days.76 For each 1 C decrease in admission temperature
quality evidence that such training decreased early neonatal mortality below the recommended range, an increase in the baseline mortality
(typical RR 0.88 95% CI 0.78 1.00).50 Findings of a meta-analysis of by 28% has been reported.77
20 trials comparing periods before and after neonatal resuscitation A Cochrane review involving 46 trials and 3850 dyads of infants
training and including 1 653 805 births showed an 18% reduction in >32 weeks gestation where resuscitation was not required
perinatal mortality (RR 0.82 95% CI 0.74 0.91) but these findings had concluded that skin-to-skin care may be effective in maintaining
to be downgraded for risk of bias and indirectness.43 The optimal thermal stability (low quality evidence) and also improves maternal
content or organisation of such training programmes will vary bonding and breast feeding rates (low to moderate quality
according to the needs of the providers and the organisation of the evidence).78 However, most trials were small and unblinded with
institutions. heterogeneity between groups. Skin-to-skin care is feasible in less
mature infants however caution is required in the more preterm or physiological parameters (such as when cord pulsation has ceased or
growth restricted infant in order to avoid hypothermia. In one single breathing has been initiated), without cord milking.90,91
centre observational study of 55 infants between 28+0 and 32+6
weeks gestation randomised to either skin-to-skin or conventional Physiology of cord clamping
thermal care the mean body temperature of the skin-to-skin group Observational data, physiological studies, animal models and some
was 0.3 C lower 1 h after birth (36.3 C 0.52, p = 0.03);79 further clinical studies suggest that ICC, currently widely practiced and
studies are ongoing.80 introduced primarily to prevent maternal postpartum haemorrhage, is
Following a recent ILCOR evidence update including a not as innocuous as was once thought.92,93 ICC significantly reduces
Cochrane systematic review of 25 studies including 2433 preterm ventricular preload whilst simultaneously adding to left ventricular
and low birth weight infants, treatment recommendations are afterload.7,94 Effects of this are seen in observational studies, with a
unchanged from 2015.75 It is recommended that newborn temper- decrease in cardiac size for 3 4 cardiac cycles95 and bradycardia,96
atures be kept between 36.5 C and 37.5 C in order to reduce the and in experimental animal models.97
metabolic stress on the infant (strong recommendation, very low
quality of evidence).1,49 For newborn preterm infants of 32 weeks Differences with gestation
gestation under radiant warmers in the hospital delivery room, a In term infants, DCC results in the transfer of approximately 30 mL kg 1
combination of interventions is suggested which may include raising of blood from the placenta.98 This improves iron status and
the environmental temperature to 23 C 25 C, use of warmed haematological indices over the next 3 6 months in all infants and
blankets, plastic wrapping without drying, cap and thermal mattress reduces need for transfusion in preterm infants.99,100 Concerns about
to reduce hypothermia on admission to the neonatal intensive care polycythaemia and jaundice requiring intervention do not seem to be
unit (NICU) (weak recommendation, very-low quality of evidence).1 borne out in randomised trials. Concerns about the position of the infant
For infants <28 weeks gestation the room temperature should in relation to the introitus also seem unfounded as the effects of uterine
ideally be above 25 C.72,73,81 In the absence of exothermic devices, contraction and lung expansion seem to exert a greater impact on
food grade plastic wrap and swaddling can be effective in preterm umbilical blood flow than gravity.101,102
infants.72,73,82 In an ILCOR meta-analysis of 23 studies of 3514 eligible infants
It is suggested that hyperthermia (greater than 38.0 C) should comparing ICC versus a delay of at least 30 s in preterm infants <34
be avoided because it introduces potential associated risks (weak weeks gestation the conclusion was that compared to ICC DCC may
recommendation, very-low quality of evidence).1,49 Infants born to marginally improve survival (RR 1.02, 95% CI 0.993 1.04)
febrile mothers have a higher incidence of perinatal respiratory (certainty of evidence moderate).90 Early cardiovascular stability
compromise, neonatal seizures, early mortality and cerebral was improved with less inotropic support (RR 0.36, 95% CI 0.17
palsy.83 85 Animal studies indicate that hyperthermia during or 0.75) and higher lowest mean blood pressure (MD 1.79 mmHg,
following ischaemia is associated with a progression of cerebral 95% CI 0.53 3.05) in the first 12 24 h. Infants had better
injury.85 haematological indices: The peak haematocrit appeared higher at
Temperature monitoring is key to avoiding cold stress. However, 24 hrs (MD 2.63, 95% CI 1.85 3.42) and at 7 days (MD 2.70, 95%
there is very little evidence to guide the optimal placement of CI 1.88 3.52). Infants required fewer blood transfusions (MD
temperature monitoring probes on the infant in the delivery room. In an 0.63, 95% CI 1.08 to 0.17). No effects were seen on any of the
observational study of 122 preterm infants between 28 and 36 weeks complications of prematurity such as severe IVH, NEC or chronic
gestation randomised to different sites for temperature monitoring, lung disease, nor was there any obvious adverse impact on other
dorsal, thoracic and axillary sited probes measured comparable neonatal or maternal outcomes (moderate to high quality evidence).
temperatures.29 There are, to date, no published studies comparing In sub-group analyses of DCC vs. ICC, there seemed to be an
the use of rectal temperature probes. almost linear relationship between survival to discharge and
Heated humidified gases reduced the incidence of moderate duration of DCC; DCC for 1 min, RR 1.00 (95% CI 0.97 1.04);
hypothermia in preterm infants.86 A meta-analysis of two RCTs involving DCC for 1 2 min, RR 1.03 (95% CI 1.00 1.05); DCC for >2 min, RR
476 infants <32 weeks gestation indicated that heated, humidified 1.07 (95% CI 0.99 1.15). None of these results were statistically
inspired gases immediately following delivery reduced the likelihood of significant due to the relatively small numbers involved.
admission hypothermia in preterm infants by 36% (95% CI 17 50%) In term and late preterm infants an ILCOR meta-analysis of 33
(high level of evidence).87,88 There was no significant increase in the risk trials (5236 infants) of DCC vs ICC updated the findings of a
of hyperthermia or a difference in mortality between humidified and non- previous 2013 Cochrane study.91,103 Analysis demonstrated no
humidified groups. It is unclear if other outcomes are improved. significant effect on mortality (RR 2.54, 95% CI 0.50 12.74; 4 trials,
Quality improvement programs including the use of checklists and 537 infants) or need for resuscitation (RR 5.08, 95% CI 0.25
continuous feed-back to the team have been shown to significantly 103.58; 3 trials, 329 infants) There were improved early
reduce hypothermia at admission in very preterm infants.81,89 haematological and circulatory parameters (haemoglobin 24 h
after birth (MD 1.17 g dL 1 95% CI 0.48 1.86, 9 trials, 1352 infants)
Clamping the umbilical cord and 7 days after birth (MD 1.11 g dL 1 95% CI 0.40 1.82, 3 trials,
695 infants) but no impact on longer term anaemia. This updated
There is no universally accepted definition of ‘delayed’ or ‘deferred’ review does not suggest clear differences in receipt of phototherapy
cord clamping’ (DCC), only that it does not occur immediately after the (RR 1.28, 95% CI 0.90 1.82) (all findings low or very low certainty
infant is born. In recent systematic reviews and meta-analyses early or evidence). The analysis did not provide clear evidence on longer
immediate cord clamping (ICC) has been defined as application of the term neurodevelopmental outcomes.
clamp within 30 s of birth, later or delayed cord clamping as application Further study is warranted; most studies used a temporal definition
of a clamp to the cord greater than 30 s after birth or based on for the timing of cord clamping, there are insufficient data to
recommend ‘physiological’ cord clamping (i.e. after the onset of introduction of a basic resuscitation training program) was associated
respirations),104 although this may confer benefit.105 Physiological with an increased 24-h survival in a multi-centre observational study in
studies suggest that the hypoxic and bradycardic response observed Tanzania, including 86,624 mainly term/near-term infants.120
after immediate clamping is not seen when clamping occurs after the
first breaths.96,97,106 Tone and colour
The question of resuscitating infants with the intact cord warrants Healthy infants are cyanosed at birth but start to become pink within
further study; in most studies of delayed cord clamping infants who approximately 30 s of the onset of effective breathing.121 Peripheral
required resuscitation at birth were excluded, as resuscitation could cyanosis is common and does not, by itself, indicate hypoxia.
only be undertaken away from the mother. Equipment now exists that Persistent pallor despite ventilation may indicate significant acidosis,
allows mother-side resuscitation and initial studies show that delayed or, more rarely, hypovolaemia with intense cutaneous vascular
cord clamping is feasible in such infants.107 109 However, it remains vasoconstriction. A pink upper-part of the body and a blue lower part
unclear which is the optimum strategy in these infants. can be a sign of right-left shunting over an open duct.
Colour is an unreliable marker of oxygenation which is better
Cord milking assessed using pulse oximetry. There are few studies in the newborn.
Delayed umbilical cord clamping is contra-indicated when placental In an observational study involving 27 clinicians making a subjective
blood flow is compromised by placental abruption, cord prolapse, vasa assessment of oxygenation status using videos of preterm infants
praevia, cord avulsion or maternal haemorrhage. Umbilical cord where saturations were known there was a lack of concordance with
milking with intact or cut cords has been considered an alternative in both under and over estimation of values.122
these situations. In ‘intact cord milking’ the cord is milked 3 5 times,
resulting in a faster blood flow towards the baby than occurs with Breathing
passive return due to uterine contraction. A term infant can receive up Not crying may be due to apnoea but can also function as a marker
to 50 mL of ‘placental’ blood through this action. After milking the cord of inadequate breathing needing support. In an observational study
is clamped and cut, and the infant can be taken to the resuscitation of 19 977 infants just after birth in a rural hospital setting 11% were
area.110 not crying, around half of whom were assessed as apnoeic. About
‘Cut cord milking’ involves milking from a length of cord (25 cm) 10% of those assessed as breathing at birth became apnoeic. Not
after clamping and cutting. The volume of blood is less than from an crying but breathing was associated with a 12-fold increase in
intact cord, but still gives the term infant about 25 mL. The infant is morbidity.123
taken to the resuscitation area immediately and milking occurs during The presence or adequacy of breathing effort in preterm infants
resuscitation or stabilisation.111 can be difficult to assess as breathing can be very subtle and is often
In preterm infants born before 34 weeks gestation, intact cord missed.121,124 Breathing perceived as inadequate will prompt an
milking shows only transient benefits over ICC including less use of intervention. In a retrospective video based observational study of 62
inotropic support, fewer infants needing blood transfusion, and higher preterm infants delivered at <28 weeks or with birth weight <1000 g
haemoglobin and haematocrit on day 1 but not at 7 days, There were 80% were assessed as showing signs of breathing but all received
no differences in major neonatal morbidities (low to moderate quality respiratory support with CPAP or intubation.125
evidence). There was no demonstrable benefit over DCC.90 In the
meta-analyses, there was no effect on mortality (RR 0.99; 95% CI 0.95 Heart rate
1.02), but of particular concern is that one large study of intact cord Immediately after birth, the heart rate is assessed to evaluate the
milking versus delayed cord clamping was terminated early when condition of the infant and subsequently, heart rate is the most
analysis demonstrated an excess of severe intraventricular haemor- sensitive indicator of a successful response to interventions.126 128
rhage (RD 16% 95% CI 6% to 26%; p = 0.002) in those infants born There is no published evidence unambiguously defining the thresh-
before 28 weeks allocated to the intact cord milking arm.112 olds for intervention during newborn resuscitation. The rates of
In term and late preterm infants there are insufficient data to allow 100 min 1 and 60 min 1 around which interventions are prompted are
meta-analysis of umbilical cord milking.91 essentially pragmatic in nature.129
In uncompromised breathing term infants, where umbilical cord
Initial assessment clamping was delayed, the heart rate is usually above 100 min 1.128 In
an observational study of 1237 term/near-term infants
Initial assessment resuscitated in a rural setting the initial heart rates at birth were
The Apgar score was not designed to identify infants in need of distributed in a bimodal peak around 60 and 165 min 1. Ventilation
resuscitation.113 However, individual components of the score, increased heart rate in most bradycardic newborns to a final median of
namely respiratory rate, heart rate (HR) and tone, if assessed rapidly, 161 min 1. Lower initial and subsequent heart rates were associated
may help identify infants likely to need resuscitation. with poorer outcomes.130 In preterm infants <30 weeks gestation the
heart rate does not stabilise until it reaches approximately 120 min 1
Tactile [1298_TD$IF]stimulation and, in some, stability was only achieved once the heart rate was
Methods of tactile stimulation vary widely but the optimal method >150 min 1.131
remains unknown.114,115 In preterm infants, tactile stimulation is often Auscultation by stethoscope is inexpensive, simple, and permits a
omitted,115 118 but in a single centre RCT of repetitive stimulation reasonably accurate rapid assessment of heart rate. In delivery room
against standard stimulation only if deemed necessary in 51 infants studies of low risk infants heart rate determination was possible within
between 28 and 32 weeks gestation, repetitive stimulation was shown 14(10 18) seconds (median(IQR)) and was found to underestimate
to improve breathing effort and oxygen saturation (SpO2 87.6 3.3% ECG or pulse oximetry (PO) values by between 9(7) and 14
vs 81.7 8.7%, p = 0.007).119 Stimulation of more infants at birth (after (21) min 1 (mean difference (95% CI)).132,133
Palpation for a pulse at the base of the umbilical cord or (less inlet.148 Two-person manual ventilation techniques are superior to
reliably) the brachial or femoral arteries is also simple and rapid. single handed airway support.146
Values may be considered valid if the heart rate is determined to be
fast (>100 min 1), however they are often inaccurate, intermittent and Oropharyngeal/nasopharyngeal airway
affected by movements with a tendency to significantly underestimate, Although the oropharyngeal airway (OPA) has been shown to be
potentially prompting inappropriate interventions.133,134 effective in children,149 there is no published evidence demonstrating
Continuous monitoring provides a more dynamic indication of effectiveness in helping maintain the patency of the airway at birth. In a
heart rate change during resuscitation and is preferable to intermittent randomised study of 137 preterm infants where gas flow through a mask
counting. A pulse oximeter (ideally connected to the right hand) can was measured, obstructed inflations were more common in the OPA
give an accurate heart rate as well as information on oxygenation. group (complete 81% vs. 64%; p = 0.03, partial 70% vs. 54%;
Initial values may underestimate the ECG a little: In a study of 53 p = 0.04).150 However, by helping lift the tongue and preventing it
infants pulse oximeter values were significantly lower than ECG over occluding the laryngeal opening, an OPA may facilitate airway support
the first 2 min (81 (60 109) vs 148 (83 170) min 1 at 90 seconds where difficulty is experienced and manoeuvres, like jaw lift, fail to
(p < 0.001)).135 Later differences of 2(26) min 1 (mean(SD)) were improve ventilation. A nasopharyngeal airway (NPA) may help
observed when compared with ECG,136 but the time to obtain reliable establish an airway where there is congenital upper airway abnormali-
values may take longer than auscultation.137 Findings differ as to ty151 and has been used successfully in preterm infants at birth.152
whether advantage is gained from connecting the sensor to infant138
or oximeter139 first, however, signal acquisition can be achieved within Airway obstruction
about 15 s once connected. Peripheral hypoperfusion, signal dropout, The cause of airway obstruction is usually unknown. It may be due to
movement, arrhythmias, and ambient lighting can interfere with PO inappropriate positioning of the head, laryngeal adduction, or pushing
measurements. Pulse oximetry may significantly underestimate a facemask onto the mouth and nose too hard, especially in preterm
values when signal quality is poor.140 141,142 infants at birth. In an animal model of premature birth Crawshaw used
ECG has been demonstrated to be a practical and rapid means of phase contrast X-ray to demonstrate that the larynx and epiglottis
accurately determining the heart rate which may be a few seconds were predominantly closed (adducted) in those with unaerated lungs
faster than pulse oximetry and more reliable, especially in the first and unstable breathing patterns, making intermittent positive
2 min after birth.141,142 Two RCTs reported faster times to HR pressure ventilation (IPPV) ineffective unless there was an inspiratory
assessment using ECG compared to PO with a mean(SD) 66(20) vs breath, and only opening once the lungs were aerated.153 In an
114(39) seconds and a median(IQR) 24(19 39) vs 48(36 69) observational study of 56 preterm infants <32 weeks gestation
seconds both p = 0.001.132,143 significant mask leak (>75%) and/or obstruction to inspiratory flow
A recent ILCOR evidence update concluded that the 7 new studies (75%) were identified using respiratory function monitoring in 73% of
identified since 2015 (2 systematic reviews, 2 RCTs and 3 interventions during the first 2 min of PPV.154 There is no evidence that
observational studies) supported the previous recommendations that normal lung fluid and secretions cause obstruction, and thus no need
in infants requiring resuscitation.1 ECG can be used to provide a rapid to aspirate fluid from the oropharynx routinely.
and accurate estimation of heart rate (weak recommendation, low
quality of evidence).49,144 Oropharyngeal and nasopharyngeal suction
It is important to be aware of the limitations of the methods. ECG Oropharyngeal and nasopharyngeal suction has in newborn infants
does not replace oximetry as whilst ECG may indicate a heart rate in not been shown to improve respiratory function and may delay other
the absence of output (PEA),145 pulse oximetry has advantages over necessary manoeuvres and the onset of spontaneous breathing,
ECG in providing a measure of perfusion and oxygenation. Newer Consequences may include irritation to mucous membranes,
technologies such as dry electrodes may improve signal; and methods laryngospasm, apnoea, vagal bradycardia, hypoxaemia, desaturation
such as plethysmography and Doppler may permit rapid reliable and impaired cerebral blood flow regulation.155 159 A recent ILCOR
output-based determination of heart rate, but clinical validation is still scoping review of 10 studies (8 RCTs,1 observational study and 1
needed before they can be recommended.141,142 case study) into the suctioning of clear fluid involving >1500 mainly
term/near-term infants found no evidence to challenge the current
Airway recommendations: Routine intrapartum oropharyngeal and naso-
pharygeal suction for newborn infants with clear or meconium-stained
Airway amniotic fluid is not recommended (very low certainty evidence
With flexion and extension, the airway can become occluded.146 The downgraded for risk of bias, indirectness and imprecision).1 If
evidence on the mechanisms of airway occlusion in the newborn is suctioning is attempted it should be undertaken under direct vision,
limited. A retrospective analysis of images of the airway of 53 sedated ideally using a laryngoscope and a wide bore catheter.
infants between 0 and 4 months undergoing cranial MRI indicates There have been few studies investigating the effectiveness of
how, in extension, obstruction might occur through anterior displace- suction devices for clearing the newborn airway. An in vitro study using
ment of the posterior airway at the level of the tongue.147 Therefore, a simulated meconium demonstrated the superiority of the Yankauer
neutral position is favoured to ensure optimal airway patency. sucker in clearing particulate matter when compared to large bore (12
14F) flexible catheters and bulb devices. Most devices could clear
Jaw [129_TD$IF]lift non-particulate matter but the only devices that cleared simulated
There are no studies of jaw thrust/lift in the newborn. Studies in particulate meconium were a Yankauer sucker or a bulb syringe device.
children demonstrate that anterior displacement of the mandible Bulb suction devices are less effective but do not require a separate
enlarges the pharyngeal space through lifting the epiglottis away from vacuum source. Smaller diameter suction catheters were much less
the posterior pharyngeal wall, reversing the narrowing of the laryngeal effective.160 The paediatric Yankauer sucker has the advantage of
single-handed use and effectiveness at lower vacuum pressures which longer duration although there is a lack of evidence demonstrating
may be less likely to damage mucosa. A meconium aspirator, attached advantage or disadvantage over other recommended approaches.
to a tracheal tube functions in a similar manner and can be used to Once an airway is established, five initial breaths with inflation
remove tenacious material from the trachea. These devices should be pressures maintained for up to 2 3 s are suggested and may help lung
connected to a suction source not exceeding 150 mmHg (20 kPa).161 expansion.49,173 175
The evidence for the optimal initial pressure for lung aeration is
Meconium limited The consensus is that inflation pressures of 30 cm H2O are
Lightly meconium-stained liquor is common and does not, in general, usually sufficient to inflate the liquid filled lungs of apnoeic term infants.
give rise to much difficulty with transition. The less common finding of This value was originally derived from historical studies of limited
very thick meconium-stained liquor is an indicator of perinatal distress numbers of infants.173,176,177 A more recent prospective study of 1237
and should alert to the potential need for resuscitation. term and near-term infants resuscitated in a rural setting using a bag-
There is no evidence to support intrapartum suctioning nor routine mask without PEEP suggests that higher initial pressures may
intubation and suctioning of vigorous infants born through meconium- sometimes be required, with median peak pressures of 37 cm H2O
stained liquor.162,163 Retrospective registry based studies do not required for successful stabilisation.178 In preterm infants, critical
demonstrate an increase in morbidity following a reduction in delivery review of the available evidence suggests that previously advocated
room intubation for meconium.164,165 An ILCOR systematic review of initial inflations pressures of 20 cm H2O are probably to be too low to
three RCTs involving 449 infants and one observational study of 231 recruit the lungs effectively.175,179 181 Therefore, it is suggested that a
infants demonstrated no benefit from the use of immediate starting pressure of 25 cm H2O would be reasonable. Acknowledging
laryngoscopy with or without tracheal suctioning compared with that smaller airways have greater resistance than larger airways,
immediate resuscitation without laryngoscopy (RR 0.99; 95% CI 0.93 some preterm infants may need higher pressures than 25 cm H2O for
1.06; p = 0.87).1 Parallel meta-analyses including a further RCT with lung inflation.
132 infants derived similar conclusions.166 168 A post policy change The time to initiation of spontaneous breathing is reported to be
impact analysis of the resuscitation of 1138 non-vigorous neonates inversely correlated with the peak inflation pressure and the inflation
born through meconium-stained amniotic fluid, found reduced NICU time.174 If the infant has any respiratory effort, ventilation is most
admissions and no increase in the incidence of Meconium Aspiration effective when inflation coincides with the inspiratory efforts.181
Syndrome (MAS) where suctioning was omitted in favour of However, the tidal volume of positive pressure ventilations may then
immediate ventilation.169 exceed that of spontaneous breaths.124,182 It is acknowledged that
Routine suctioning of non-vigorous infants may result in delays such synchronisation is difficult to achieve.183
in initiating ventilation although some newborn infants may still A recent observational study in preterm infants under 32 weeks
require laryngoscopy with or without tracheal intubation in order to suggested that the application of a mask to support breathing
clear a blocked airway or for subsequent ventilation. Therefore, in might induce apnoea in spontaneously breathing infants.184
apnoeic or ineffectively breathing infants born through meconium- However, the significance of this effect on outcome is currently
stained amniotic fluid ILCOR treatment recommendations sug- unclear.185
gest against routine immediate direct laryngoscopy and/or
suctioning after delivery with the emphasis on initiating ventilation Ventilation
in the first minute of life (weak recommendation, low certainty There is limited evidence on the optimal rate of ventilation for newborn
evidence).1 resuscitation. In an observational study of 434 mask ventilated late
In infants with respiratory compromise due to meconium preterm and term infants, ventilation at a rate of about 30 min 1
aspiration, the routine administration of surfactant or bronchial lavage achieved adequate tidal volumes without hypocarbia and the
with either saline or surfactant is not recommended.170,171 frequency of 30 min 1 with VTE of 10 14 mL kg 1 was associated
with the highest CO2 clearance.186 In an observational study of 215
Initial inflations and assisted ventilation near-term/term infants there was a non-linear relationship between
delivered tidal volume and heart rate. The minimum volume necessary
After initial assessment at birth, if breathing efforts are absent or to produce an increase in heart rate was 6.0 (3.6 8.0) mL kg 1. A tidal
inadequate, lung aeration is the priority and must not be delayed. An volume of 9.3 mL kg 1 produced the most rapid and largest increase in
observational study in low resource settings suggested those heart rate.127
resuscitating took around 80 55 s to commence ventilation with a The delivered tidal volume required to form the FRC may exceed
16% (p = 0.045) increase in morbidity/mortality in apnoeic infants for that of the exhaled TV: Foglia et al. describe this as being over
every 30 s delay in starting ventilation after birth.10 In term infants, 12 mL kg 1 for a term infant.183 Exhaled tidal volumes increase during
respiratory support should start with air.172 the first positive pressure ventilations as aeration takes place,
compliance increases and the FRC is established.178 In most
Inflation pressure and duration instances, it should be possible to reduce peak pressures once the
In newborn infants, spontaneous breathing or assisted initial inflations lungs are aerated to prevent excessive tidal volumes.183
create the functional residual capacity (FRC).9,173 When assisting There are no published studies clearly determining the optimal
ventilation, the optimum inflation pressure, inflation time and flow inflation time when providing positive pressure ventilation. Longer
required to establish an effective FRC are subject to technical and inspiratory times may permit lower pressures.183 Observational
biological variation and have not yet been conclusively determined. studies on spontaneously breathing newborn infants suggest that
Debate continues about the validity of longer inflation breaths with once lung inflation has been achieved they breathe at a rate between
recent discussion on the merits of sustained inflation (see below).1 30 and 40 breaths min 1, and regardless of which breathing pattern,
Current ERC NLS recommendations on inflation breaths are for a an inspiratory time of 0.3 0.4 s is used.187
Assessment Subgroup analysis of different lengths of SI (6 15 s 9 RCTs

The primary response to adequate initial lung inflation is a prompt 1300 infants, >15 s 2 RCTs 222 infants) and of different
improvement in heart rate.126,127 Most newborn infants needing inspiratory pressures (>20 mmHg 6 RCTs 803 infants, 20
respiratory support will respond with a rapid increase in heart rate mmHg 699 infants) demonstrated no significant benefit or harm
within 30 s of lung inflation.188 Chest wall movement usually indicates from SI compared to IPPV of 1 s (downgraded for risk of bias
aeration/inflation. This may not be so obvious in preterm infants.189 and variously for imprecision and inconsistency).
Large chest excursions during positive pressure ventilation may be a In subgroup analyses comparing SI >1 s to inflations of 1 s in
marker of excessive tidal volumes, which should be avoided. infants at <28+0 weeks there was low certainty evidence (downgraded
Continued ventilation is required if the heart rate increases but the for risk of bias and imprecision) from 5 RCTs enrolling 862 infants of
infant is not breathing adequately. potential harm (RR 1.38 95% CI 1.00 1.91). In infants 28+1 31+6
Failure of the heart rate to respond is most likely secondary to weeks there was very low certainty evidence (downgraded for risk of
inadequate airway control or inadequate ventilation. Mask position or bias and very serious imprecision) from 4 RCTs enrolling 175 preterm
seal may be suboptimal.182,190,191 Head/Airway position may be in infants demonstrating no significant benefit or harm (RR 1.33 95% CI
need of adjustment.146 Inflation pressures may need to be higher to 0.22 8.20). No SIs were <5 s. There was no published data available
achieve adequate inflation/tidal volumes.178 In preterm infants for more mature infants.
excessive mask pressure and glottal closure have been demonstrated Further sub-analyses excluding studies with a high risk of bias (9
to be factors.8,153,154,192 RCTs 1390 infants RR 1.24 95%CI 0.92 1.68), studies with only a
Using a two-person approach to mask ventilation reduces mask single breath (9 RCTs 1402 infants RR 1.17 95%CI 0.88 1.55) and
leak in term and preterm infants and is superior to the single handed those with sustained inflation with mask only (9 RCTs 1441 infants (RR
approach.191,193 Published evidence on the incidence of physical 1.06 95%CI 0.61 1.39) demonstrated no difference in outcome
matter as a cause of obstruction is lacking but it is recognised that between SI and normal inflations (low certainty evidence, downgraded
meconium or other matter (e.g. blood, mucus, vernix) may cause for risk of bias and imprecision).
airway obstruction.194 The use of adjuncts to support the airway is ILCOR treatment recommendations suggest that the routine
discussed elsewhere (see airway and adjuncts). use of initial SI 5 s cannot be recommended for preterm newborn
infants who receive positive pressure ventilation prompted by
Sustained inflations (SI) > 5 s bradycardia or ineffective respirations at birth (weak recommen-
Animal studies have suggested that a longer SI may be beneficial for dation, low-certainty evidence) but that a sustained inflation might
establishing functional residual capacity at birth during transition be considered in research settings. There was insufficient
from a liquid filled to air-filled lung.195,196 A Cochrane systematic evidence to make any specific recommendation on the duration
review of initial inflation >1 s vs. standard inflations 1 s was of inflations in late preterm or term infants. It was recognised
updated in 2020. Eight RCTs enrolling 941 infants met inclusion that the total number of infants studied were insufficient to
criteria for the primary comparison of the use of SI without chest have confidence in the estimate of effect; larger trials being
compressions. SIs were of 15 20 s at 20 30 cm H2O. No trial used needed to determine if there are benefits or harms from sustained
SIs of 5 s. SI was not better than intermittent ventilation for inflation.1
reducing mortality in the delivery room (low quality evidence There are no randomised trials comparing the use of initial breaths
limitations in study design and imprecision) and during hospital- of 1 s with breaths of 2 3 s. A recent RCT in 60 preterm infants <34
isation (moderate quality evidence limitations in study design). weeks gestation of 2 3 s inflation breaths vs. a single 15 SI
There was no benefit for SI vs. intermittent ventilation for the demonstrated no difference in minute volume or end tidal CO2.199
secondary outcomes of intubation, need for respiratory support or Infants receiving the SI made a respiratory effort sooner (median 3.5
BPD (moderate quality evidence).197 (range 0.2 59) versus median 12.8 (range 0.4 119) seconds,
A large multicentre RCT which was not included in this analysis p = 0.001). SI was associated with a shorter duration of ventilation in
investigating effects of SI vs. IPPV among extremely preterm the first 48 h (median 17 (range 0 48) versus median 32.5 (range 0
infants (23 26 weeks gestational age) concluded that a ventilation 48) h, p = 0.025)
strategy involving 2 SIs of 15 s did not reduce the risk of BPD or
death at 36 weeks postmenstrual age. The study enrolled 460 PEEP [130_TD$IF]and CPAP/airway adjuncts and assisted ventilation
infants out of a planned 600 but was stopped early due to excess devices
early mortality in the SI group possibly attributable to resuscitation.
Death at less than 48 h of age occurred in 16 infants (7.4%) in the SI PEEP
group vs 3 infants (1.4%) in the standard resuscitation group Animal studies have shown that immature lungs are easily damaged
(adjusted risk difference (aRD), 5.6% [95% CI, 2.1% to 9.1%]; by large tidal volume inflations immediately after birth200,201 and
p = 0.002). but this finding could not be attributed to the SI suggest that maintaining a PEEP immediately after birth may help
directly.198 reduce lung damage202,203 although one study suggests no bene-
A recent ILCOR systematic review identified 10 eligible RCTs fit.204 PEEP applied immediately after birth improves lung aeration,
including those above with 1509 newborn infants.1 For the functional residual capacity, compliance and gas exchange, particu-
primary outcome of death before discharge no significant benefit larly oxygenation.205,206
or harm was noted from the use of SI >1 s (actually >5 s) PEEP is more reliably be delivered by pressure limiting devices
compared to PPV with inflations of 1 s (low certainty evidence which use continuous gas flow, like TPR devices. A recent review of
downgraded for risk of bias and inconsistency). No studies were the evidence undertaken by ILCOR identified two randomized trials
identified reporting on the secondary critical outcomes of long- and one quasi-randomized trial (very low quality evidence)
term neurodevelopmental outcome or death at follow up. comparing ventilation with TPR vs. SIB and reported similar rates
of death and chronic lung disease.1 There was no difference in SpO2 Assisted ventilation devices
at 5 min after birth in 80 infants <29 weeks gestation (61% [13 Effective ventilation in the newborn can be achieved with a flow-
72%] versus 55% [42 67%]; p = 0.27).207 No difference was inflating bag (FIB), a self-inflating bag (SIB) or with a pressure limited
identified in achieving HR >100 min 1 in 1027 infants 26 weeks (1 TPR.207,208,218 220 An attribute of a TPR device is its ability to deliver a
(0.5 1.6) vs 1 (0.5 1.8) p = 0.068 (min(IQR)).208 There were consistent measure of PEEP or CPAP when compared to standard
reductions in the magnitude of some interventions with TPR. 86 SIB's and this may be a factor contributing to any observed difference
(17%) vs. 134(26%) were intubated in the delivery room (OR 0.58 in outcomes between the devices (see section on PEEP).
(0.4 0.8) 95% CI p = 0.002). The maximum positive inspiratory Whilst the TPR appears to confer benefit it cannot be used in all
pressure was 26(2) cm H2O TPR vs 28(5) cm H2O SIB (p < 0.001) circumstances. Unlike the TPR, the self-inflating bag can be used in
mean (SD). the absence of a positive pressure gas supply. However, the blow-off
In a quasi-randomised study of 90 infants of 34 (3.7) (mean (SD)) valves of SIB are flow-dependent and pressures generated may
weeks gestation the duration of PPV in delivery room was significantly exceed the value specified by the manufacturer, usually 30 40 cm
less with TPR (median (IQR) 30 s (30 60) vs. 60 s (30 90) H2O, if the bag is compressed vigorously.221,222 More training is
(p < 0.001)).209 A higher proportion were intubated in the SIB group required to provide an appropriate peak and end pressure using FIBs
(34 vs 15% p = 0.04). In one large multicentre observational study of compared with self-inflating bags. In an observational manikin-based
1962 infants between 23 and 33 weeks gestation improved survival study of 50 clinicians, technical difficulties with the FIB impaired
and less BPD was seen when PEEP was used at birth (OR = 1.38; performance when compared to an SIB.223
95% CI 1.06 1.80).210 A qualitative review identified 30 studies comparing TPR against
All term and preterm infants who remain apnoeic despite other neonatal manual ventilation devices and noted that the majority
adequate initial steps must receive positive pressure ventilation. of studies were manikin based with 2 infant based studies.154,207
ILCOR treatment recommendations are unchanged from 2015, Users of the TPR could provide PIPs closest to the target PIP, with
suggesting PEEP should be used for the initial ventilation for least variation when compared to SIB and FIB.224 228 Similarly TPR
premature newborn infants during delivery room resuscitation (weak users provided a PEEP closer to the predetermined PEEP value with
recommendations, low-quality evidence).1 It is suggested that potentially less volutrauma with the TPR as tidal volumes are smaller
positive end expiratory pressure (PEEP) of approximately 5 6 cm and less variable in comparison to the SIB.225 228 TPR provided a
H2O to begin with should be administered to preterm newborn more consistent inspiratory time than SIB independent of experience.
infants receiving PPV. No clear recommendations on the level of Prolonged inflation could be more reliably provided by the TPR.229
PEEP can be made for term infants because of a lack of Limitations of the TPR device were identified. Resuscitation is a
evidence.49,144 dynamic process where the resuscitator needs to adapt to the
response or non-response of the newborn. TPR users were not as
CPAP good at detecting changes in compliance as users of the SIB and
A Cochrane systematic review of CPAP applied within the first 15 min FIB.230 PEEP valves could be inadvertently screwed down leading to
of life in preterm infants <32 weeks identified 7 RCTs involving 3123 excess PEEP.231 TPR users needed more time to change the inflating
infants and concluded that CPAP reduced the need for additional pressures during resuscitation compared to users of the SIB or FIB.
breathing assistance but with insufficient evidence to evaluate Mask leak can be greater with the TPR than with SIB227,228 and
prophylactic CPAP compared to oxygen therapy and other supportive changes to TPR gas flow rate had significant effects on PIP, PEEP232
care.211 Evidence was downgraded to low quality because of 235
and mask leak.232 The TPR can require more training to set up
considerable heterogeneity, imprecision and lack of blinding. In 3 of properly but once in use provided more consistent ventilation than the
the studies involving 2354 infants comparing CPAP with assisted SIB even with inexperienced operators.236 The SIB cannot deliver
ventilation, prophylactic nasal CPAP in very preterm infants reduced CPAP and may not be able to achieve a consistent end expiratory
the need for mechanical ventilation and surfactant and also reduced pressure even with a PEEP valve.224 226,237 240 The performance of
the incidence of BPD and death or BPD (evidence downgraded due to various TPRs and self-inflating bags may differ considerably.241 A
imprecision). newer upright design of SIB and revised mask confers advantages in
Another systematic review included 4 RCTs 3 of which were use including improved delivery of PEEP.188,242 244
included in the Cochrane analysis and one additional study.212 Pooled In addition to the 1107 infants in the two RCTs included in the 2015
analysis showed a significant benefit for the combined outcome of analysis,207,208 a recent ILCOR scoping review of TPR vs. SIB for
death or bronchopulmonary dysplasia, or both, at 36 weeks corrected ventilation1,245 reported a substantial number of additional patients in
gestation for infants treated with nasal CPAP (RR 0.91, 95% CI one further RCT (n = 90)209 and one large observational study
0.84 0.99, RD 0.04, 95% CI 0.07 to 0.00) NNT 25. Following a (n = 1962).210 Studies differed regarding the investigated populations
review of the evidence ILCOR recommendations are unchanged from (two studies included term and preterm infants,208,209 two studies
2015, that for spontaneously breathing preterm newborn infants with were in preterm infants only).207,210 The findings of these studies are
respiratory distress requiring respiratory support in the delivery room, outlined in the section on PEEP and suggest improved survival and
it is suggested that CPAP should be used initially rather than intubation less need for intubation and BPD with TPR use compared to SIB,
and IPPV (weak recommendation, moderate certainly of evi- particularly in preterm infants.
dence).1,49,144 There are few data to guide the appropriate use of The ILCOR task force concluded that whilst the direction of
CPAP in term infants at birth.213,214 Caution is prompted by evidence is shifting towards support for the use of TPR devices, until a
retrospective cohort studies which suggest that delivery room CPAP further systematic review is conducted recommendations would
may be associated with an increased incidence of pneumothorax in remain unchanged.1 The 2015 consensus on science stated that the
term/near term infants.215 217 use of the TPR showed marginally but not statistically significant
benefits for the clinical outcome of achieving spontaneous manufacturer.255 A range of differing sized tubes should be available
breathing.49 to permit placement of that most appropriate to ensure adequate
ventilation with only a small leak of gas around the tracheal tube and
Facemask versus nasal prong without trauma to the airway. A narrow diameter tube in a large airway
A problem when using a facemask for newborn ventilation is a may be confirmed in the correct position but fail to provide adequate
potentially large and variable leak and loss of inflating gas volume ventilation because of low lung compliance and excessive leak. The
arising from suboptimal selection of mask size and poor technique. In tube diameter may be estimated as 1/10 of the gestational age.256
manikin studies using a T-piece and different masks, 50 volunteer Tracheal tube placement should be confirmed by exhaled CO2
operators had variable mask leak up to 80% with improvement after detection (see below), the length inserted assessed visually during
written instruction and demonstration of alternative mask hold intubation and the tip position confirmed clinically and ideally
techniques.190,191 Using flow monitoring recordings of the airway radiographically. Markings on the tips of tracheal tubes to aid tube
management of 56 newborn preterm infants Schmölzer demonstrated placement distal to the vocal cords vary considerably between
variable degrees of either obstruction (75%) and/or leak (>75%) manufacturers.257 Within institutions users will likely gain familiarity
during first 2 min of support in 73% of cases.154 with specific types. Tube position may alter during the securing
Nasopharyngeal tubes have been suggested as an alternative. process.252 A systematic review of published literature on methods of
An observational study investigating respiratory function found confirming correct tube placement concluded that objective assess-
that when using a single nasopharyngeal tube it took longer before ments of tube position were better validated than subjective ones such
PPV was given, leak was increased and obstruction occurred as visual assessment of chest movement.258 Following tracheal
more frequently, inadequate tidal volumes were delivered more intubation and IPPV, a prompt increase in heart rate and observation
often and SpO2 was lower in the first minutes during PPV.246 of expired CO2 are good indications that the tube is in the trachea.258
However, two randomised trials in preterm infants of <31 weeks
gestation involving 507 infants did not find any difference in End tidal CO2 and respiratory function monitoring
intubation rates in the delivery room between facemask and single Detection of exhaled CO2 in addition to clinical assessment is
nasal prong.152,247 recommended to confirm correct placement of a tracheal tube in
neonates with spontaneous circulation.49 Even in VLBW in-
Laryngeal mask fants,259,260 detecting evidence of exhaled CO2 confirms tracheal
The laryngeal mask (LM) may be used in ventilation of the newborn, intubation in neonates with a cardiac output more rapidly and more
particularly if facemask ventilation or tracheal intubation is accurately than clinical assessment alone.260,261 However, studies
unsuccessful or not feasible.49 A recent systematic review of seven have excluded infants in need of extensive resuscitation. Failure to
trials (794 infants) showed that the laryngeal mask was more detect exhaled CO2 strongly suggests tube misplacement, most likely
effective than bag-mask in terms of shorter resuscitation and oesophageal intubation or tube dislodgement.259,261 False negative
ventilation times, and less need for tracheal intubation (low- to end tidal carbon dioxide (ETCO2) readings have been reported during
moderate-quality evidence).248 Of note, bag-mask was effective in cardiac arrest.259 and in VLBW infants despite models suggesting
more than 80% of enrolled infants. Efficacy of the laryngeal mask effectiveness with low tidal volumes.262 Poor or absent pulmonary
was comparable to that offered by tracheal intubation (very low to blood flow or tracheal obstruction may prevent detection of exhaled
low quality evidence), suggesting that it is a valid alternative airway CO2 despite correct tracheal tube placement. There is a lack of
device when attempts at tracheal intubation are unsuccessful during evidence in the neonate as to the effect of drugs on exhaled CO2
resuscitation or where those involved lack the skills or equipment to monitoring, however studies in adults suggest drugs such as
intubate safely. adrenaline and bicarbonate may affect end-tidal CO2 determina-
As available studies included infants with birth weight >1500 g or tion.263 Insufficient inflating pressure to recruit an adequate FRC and
34 or more weeks gestation, evidence supporting laryngeal mask use generate sufficient expiratory flow might also be a factor. The inability
in more premature infants is lacking.248,249 The laryngeal mask has to detect exhaled CO2 despite correct placement may lead to a
not been evaluated in the setting of meconium-stained fluid, during decision to extubate. Where CO2 detection is unreliable tube position
chest compressions, or for the administration of emergency intra- should be confirmed by direct laryngoscopy.
tracheal medications. Both qualitative (colorimetric) and quantitative (waveform) meth-
ods have been successfully used after delivery.264 Studies in adults
Tracheal tube placement suggest that waveform capnography may be more sensitive than
The use and timing of tracheal intubation will depend on the skill and colorimetry in detecting exhaled CO2, however, due to lack of data on
experience of the available resuscitators. Formulae may be unreliable the validity of waveform capnography in neonates, caution must be
in determining tracheal tube lengths.250,251 Appropriate tube lengths exercised when considering its use.263,265,266
for oral intubation derived from observational data based on gestation Flow monitoring is useful for confirming tracheal tube position. In a
are shown in Table 1.[252130_TD$IF] Nasotracheal tube length was found to be randomised controlled trial a flow sensor confirmed appropriate tube
approximately 1 cm more than the oral length.253 Uncuffed tubes are placement faster and more reliably than capnography.267
typically used. There is no published evidence to support the routine Respiratory flow/volume monitoring268 and end tidal CO2 269,270
use of cuffed tubes during neonatal resuscitation. Efficacy has been may be used in non-intubated patients. The effectiveness of
demonstrated in infants <3 kg during perioperative respiratory quantitative capnography in confirming mask ventilation has been
support.254 demonstrated but may not provide reliable ETCO2 values.270 The use
The diameter of the narrowest part of the airway and varies with of exhaled CO2 detectors to assess ventilation with other interfaces
gestational age and size of the infant whereas the external diameter of (e.g., nasal airways, laryngeal masks) during positive pressure
the tube (of the same internal diameter) may vary depending on ventilation in the delivery room has not been reported.
Video-laryngoscopy
A systematic review of studies of video-laryngoscopy in newborn
infants concluded by suggesting that video-laryngoscopy increases
the success of intubation in the first attempt but does not decrease
the time to intubation or the number of attempts for intubation
(moderate to very low-certainty evidence). However, included
studies were conducted with trainees performing the intubations
and highlight the potential usefulness of video-laryngoscopy as a
teaching tool. Well-designed, adequately powered RCTs are
necessary to confirm efficacy and address safety and cost-
effectiveness of video-laryngoscopy for neonatal endotracheal
intubation by trainees and those proficient in direct laryngoscopy.271 Fig. 10 – Oxygen saturations in healthy infants at birth
The effectiveness in the context of resuscitation at birth has not without medical intervention (3rd, 10th, 25th, 50th, 75th,
been fully evaluated. 90th, 97th centiles). Reproduced with permission from
Dawson 2010.
Air/oxygen
Term infants and late preterm infants 35 weeks

A recent ILCOR CoSTR suggests that for term and late preterm A recent European consensus statement recommended the use of
newborns (35 weeks gestation) receiving respiratory support at birth, an initial inspired oxygen concentration of 30% for newborns <28
support should start with 21% oxygen (weak recommendation, low weeks gestation, of 21 30% for 28 31 weeks gestation, and of 21%
certainty evidence).1 It recommends against starting with 100% for >32 weeks gestation.280
inspired oxygen (strong recommendation, low certainty evidence). A
systematic review and meta-analysis of 5 RCTs and 5 quasi RCTs Target oxygen saturation
included 2164 patients demonstrated a 27% relative reduction in short- The target range recommended for both term and preterm infants
term mortality when initial room air was used compared with 100% are similar and based upon time based values for preductal
oxygen for neonates 35 weeks gestation receiving respiratory support saturations in normal term infants in air.281 Consensus recom-
at birth (RR = 0.73; 95% CI 0.57 0.94).172 No differences were noted in mendations suggest aiming for values approximating to the
neurodevelopmental impairment or hypoxic-ischaemic encephalopa- interquartile range,282 or using the 25th centile as the lower
thy (low to very low certainty evidence). Use of low concentrations of threshold value49 (Fig. [1302_TD$IF]6710).
inspired oxygen may result in suboptimal oxygenation where there is A systematic review of 8 RCTs with 768 preterm infants <32 weeks
significant lung disease272 and in term infants a high inspired oxygen involving low (30%) vs higher (60%) initial oxygen concentrations,
may be associated with a delay in onset of spontaneous breathing.273 concluded that failure to reach a minimum SpO2 of 80% at 5 min was
Therefore oxygen should be titrated to achieve adequate preductal associated with a two-fold risk of death (OR 4.57, 95% CI 1.62 13.98,
saturations. If increased oxygen concentrations are used, they should p < 0.05), and had an association with lower heart rate (mean
be weaned as soon as possible.274 276 difference 8.37, 95% CI 15.73 to 1.01, p < 0.05) and a higher
risk of severe intraventricular haemorrhage (OR 2.04, 95% CI 1.01
Preterm infants <35 weeks 4.11, p < 0.05).283 It remained unclear whether this was because of
In an ILCOR systematic review and meta-analysis of 10 RCTs and 4 the severity of illness, or the amount of oxygen administered during
cohort studies including 5697 infants comparing initial low with high stabilisation.
inspired oxygen for preterm infants <35 weeks gestation who Available data suggest nearly all preterm newborns <32 weeks
received respiratory support at birth, there were no statistically gestation will receive oxygen supplementation in the first 5 min after
significant benefits or harms from starting with lower compared to delivery in order to achieve commonly recommended oxygen
higher inspired oxygen in short or long term mortality (n = 968; saturation targets.276,281,283 However, it may be difficult to titrate
RR = 0.83 (95% CI 0.50 1.37)), neurodevelopmental impairment or the oxygen concentration in the first minutes and preterm infants <32
other key preterm morbidities.277 It is suggested that low (21 30%) weeks gestation may spend a significant time outside the intended
rather than a higher initial concentration (60 100%) be used (weak target range.284,285 In an individual patient analysis of the 706 preterm
recommendation, very low certainty evidence). The range selected infants enrolled in the RCTs only 12% reached the threshold SpO2 of
reflects the low oxygen range used in clinical trials. Oxygen 80% at 5 min after birth.283
concentration should be titrated using pulse oximetry (weak
recommendation, low certainty evidence).1 Titration of oxygen
In contrast to term infants, in preterm infants the use of It is important to select the appropriate initial oxygen concentration,
supplemental oxygen to reach adequate oxygenation increases with careful and timely titration of inspired oxygen against time
breathing efforts. In an animal experimental study278 and one RCT in sensitive threshold saturation levels in order to avoid extremes of
52 preterm infants <30 weeks gestation,279 initiating stabilisation with hypoxia and hyperoxia and avoid bradycardia. A recent review
higher oxygen concentrations (100% vs. 30%) led to increased suggested that oxygen delivery should be reviewed and titrated as
breathing effort, improved oxygenation, and a shorter duration of necessary every 30 s to achieve this.286
mask ventilation. Minute volumes were significantly higher at 100% An important technical aspect of the titration of supplemental
(146.34 112.68 mL kg 1 min 1) compared to 30% (74.43 52.19 oxygen when using a TPR device is that it takes a median 19 s (IQR 0
mL kg 1 min 1), p = 0.014. 57) to achieve the desired oxygen concentration at the distal end of
the TPR.287 Although the cause of this delay is unclear, mask leak human studies to support this and animal studies demonstrate no
contributes significantly. A good mask seal can lead to a longer delay advantage to 100% inspired oxygen during CPR.306 312
with a resulting lag between adjustment and response. Unless using continuous monitoring such as pulse oximetry or
ECG, check the heart rate after no longer than 30 s and periodically
Circulatory support thereafter. Whilst chest compressions may be discontinued when the
spontaneous heart rate is faster than 60 min 1, a continued increase
Circulatory support with chest compressions is effective only if the in rate is necessary to truly demonstrate improvement. It is not until the
lungs have been successfully inflated and oxygen can be delivered to heart rate exceeds 120 min 1 that it becomes stable.130,131
the heart. Ventilation may be compromised by compressions so it is Exhaled carbon dioxide monitoring and pulse oximetry have been
vital to ensure that satisfactory ventilation is occurring before reported to be useful in determining the return of spontaneous
commencing chest compressions.288 circulation313 316; however, current evidence does not support the
The most effective traditional technique for providing chest use of any single feedback device in a clinical setting and extrapolation
compressions is with two thumbs over the lower third of the sternum of their use from adult and paediatric settings have, for a variety of
with the fingers encircling the chest and supporting the back.289 292 reasons, been proven error prone in neonates.49,144,265
This technique generates higher blood pressures and coronary artery
perfusion with less fatigue than the alternative two-finger tech- Vascular access
nique.293,294 In a manikin study, overlapping the thumbs on the
sternum was more effective than adjacent positioning but more likely Umbilical vein catheterisation (UVC) and intraosseous (IO)
to cause fatigue.295 The sternum is compressed to a depth of access
approximately one-third of the anterior-posterior diameter of the chest In a systematic review no evidence was identified comparing the
allowing the chest wall to return to its relaxed position between umbilical venous route or use of intravenous (IV) cannulas against
compressions.296 300 Delivering compressions from ‘over the head’ the IO route in the newborn for drug administration in any setting.1
appears as effective as the lateral position.301 No case series or case reports on IO administration in the delivery
A recent ILCOR review of the evidence identified 19 studies room setting were identified. Consensus suggests UVC as the
published since 2015 including one systematic review and 18 RCTs all primary method of vascular access. If umbilical venous access is not
of which were manikin studies.302 No evidence was found to alter feasible, or delivery occurs in another setting, the IO route is
treatment recommendations from 2015 in suggesting that chest suggested as a reasonable alternative (weak recommendation, very
compressions in the newborn should be delivered by the two thumb, low certainty of evidence).
hand encircling the chest method as the preferred option (weak A systematic review on the use of IO in neonates in any situation
recommendation, very low certainty evidence).1 However newer identified one case series and 12 case reports of IO device insertion
techniques, one using two thumbs at an angle of 90 to the chest and into 41 neonates delivering several drugs including adrenaline and
the other a ‘knocking finger’ technique, have been reported in volume.317 However, whilst the IO route has been demonstrated to be
manikins. Further studies are required to determine if they have any a practical alternative to the UVC significant adverse events include
clear advantage over the standard two thumb technique.1,303 tibial fractures, osteomyelitis, and extravasation of fluid and
A recent evidence update was undertaken by ILCOR to identify the medications resulting in compartment syndrome and amputation.1
most effective compression to ventilation ratio for neonatal resuscita- The actual route and method used may depend on local availability
tion.1 13 trials published since 2015 were found to be relevant. Four of equipment, training and experience.1 There is limited evidence on
neonatal manikin studies comparing alternative compression to the effective use of IO devices immediately after birth, or the optimal
ventilation ratios or asynchronous ventilation strategies found no site or type of device318 although simulation studies undertaken in a
advantage over traditional synchronised 3:1 techniques. A number of delivery room setting suggest that the IO route can be faster to insert
animal trials compared the delivery of cardiac compressions during a and use than UVC.319
sustained inflation with traditional 3:1 compression to ventilation. No
consistently clear advantages were identified. Some trials are Peripheral access
ongoing. No studies were identified reviewing the use of peripheral IV
ILCOR found no evidence to change the 2015 recommendations for a cannulation in infants requiring resuscitation at birth. A retrospective
3:1 compression to ventilation ratio (weak recommendation, very low analysis of 61/70 newborn preterm infants requiring i/v access in a
quality evidence), aiming to achieve a total of approximately 90 single centre showed that peripheral i/v cannulation is feasible and
compressions and 30 ventilations per minute.1,49,144 Compressions successful in most cases at first attempt.320
and ventilations should be coordinated to avoid simultaneous delivery.304
There are theoretical advantages to allowing a relaxation phase that is Drugs
slightly longer than the compression phase, however, the quality of the
compressions and breaths are probably more important than the rate.305 Drugs are rarely indicated in resuscitation of the newborn infant.11,12
A 3:1 compression to ventilation ratio is used at all times for Bradycardia is usually caused by profound hypoxia and the key to
resuscitation at birth where compromise of gas exchange is nearly resuscitation is aerating the fluid filled lungs and establishing
always the primary cause of cardiovascular collapse. Rescuers may adequate ventilation. However, if the heart rate remains less than
consider using higher ratios (e.g. 15:2) if the arrest is believed to be of 60 min 1 despite apparently effective ventilation and chest com-
cardiac origin, more likely in a witnessed postnatal collapse than at pressions, it is reasonable to consider the use of drugs.
birth.When chest compressions are indicated by a persistent very Knowledge of the use of drugs in newborn resuscitation is largely
slow/absent heart rate, it would appear reasonable to increase the limited to retrospective studies, as well as extrapolation from animals
supplementary inspired oxygen to 100%. However, there are no and adult humans.321
Adrenaline In the absence of suitable blood (i.e. group O Rh-negative blood),

A recent systematic review identified 2 observational studies isotonic crystalloid rather than albumin is the solution of choice for
involving 97 newborn infants comparing doses and routes of restoring intravascular volume. Give a bolus of 10 mL kg 1 initially. If
administration of adrenaline.322 There were no differences between successful it may need to be repeated to maintain an improvement.
IV and endotracheal adrenaline for the primary outcome of death at When resuscitating preterm infants, volume is rarely needed and has
hospital discharge (RR = 1.03 [95% CI 0.62 1.71]) or for failure to been associated with intraventricular and pulmonary haemorrhages
achieve return of spontaneous circulation, time to return of when large volumes are infused rapidly.325
spontaneous circulation (1 study; 50 infants), or proportion
receiving additional adrenaline (2 studies; 97 infants). There were Sodium bicarbonate
no differences in outcomes between 2 endotracheal doses (1 If effective spontaneous cardiac output is not restored despite
study). No human infant studies were found addressing IV dose or adequate ventilation and adequate chest compressions, reversing
dosing interval (very low certainty evidence). Despite the lack of intracardiac acidosis may improve myocardial function and achieve
newborn human data it is reasonable to use adrenaline when a spontaneous circulation. There are insufficient data to recommend
effective ventilation and chest compressions have failed to increase routine use of bicarbonate in resuscitation of the newborn. The
the heart rate above 60 min 1. ILCOR treatment recommendations hyperosmolarity and carbon dioxide-generating properties of
suggest that if adrenaline is used, an initial dose of 10 30 micro- sodium bicarbonate may impair myocardial and cerebral
grams kg 1 (0.1 0.3 mL kg 1 of 1:10,000 adrenaline [1 mg in function.326
10 mL)) should be administered intravenously (weak recommen- A recent review of the evidence1 concluded that there were no
dation, very low certainty evidence). If intravascular access is not reasons to change the 2010 recommendations.34,274 Use of sodium
yet available, endotracheal adrenaline at a larger dose of 50 bicarbonate is not recommended during brief cardiopulmonary resusci-
100 micrograms kg 1 (0.5 1.0 mL kg 1 of 1:10,000 adrenaline tation. Use, however, may be considered during prolonged cardiac arrest
[1 mg in 10 mL]) is suggested (weak recommendation, very low unresponsive to other therapy, when it should be given only after
certainty evidence) but should not delay attempts at establishing adequate ventilation is established and chest compressions are being
venous access (weak recommendation, very low certainty evi- delivered. A dose of 1 2 mmol kg 1 sodium bicarbonate (2 4 mL kg 1 of
dence). If the heart rate remains less than 60 min 1 further doses 4.2% solution) may be given by slow intravenous injection.
preferably intravascularly every 3 5 min are suggested (weak
recommendation, very low certainty evidence). If the response to Naloxone
tracheal adrenaline is inadequate it is suggested an intravenous There is no strong evidence that naloxone confers any clinically
dose is given as soon as venous access is established regardless important benefits to newborn infants with respiratory depression due
of the interval between doses (weak recommendation, very low to hypoxia.327,328 Current recommendations do not support use of
certainty evidence).1 naloxone during resuscitation with the preference being to concen-
trate on providing effective respiratory support.
Glucose Use is best reserved for those infants whose cardiac output has
Hypoglycaemia is an important additional risk factor for perinatal been restored but who remain apnoeic despite resuscitation and
brain injury.323 Endogenous glycogen stores are rapidly depleted where the mother has received opioid analgesia in labour. An initial
during prolonged hypoxia. In one study infants with birth asphyxia intramuscular 200 microgram dose, irrespective of weight, provides a
had, prior to administration of glucose in the delivery room, pragmatic delivery room approach suitable for most infants. An IM
significantly lower blood glucose (1.9 0.6 mmol/L vs. 3.2 0.3 dose provides steady plasma concentrations for about 24 h.329 Infants
mmol/L),324 therefore in protracted resuscitation it is reasonable to whose breathing is suppressed by opioids may show a rebound
use glucose by giving a 250 mg kg 1 bolus (2.5 mL kg 1 of 10% tachypnoea after naloxone is given.330
glucose). After successful resuscitation formal steps to prevent both
hypoglycaemia and hyperglycaemia should be instituted (see post- Post-resuscitation care
resuscitation care).
Hypo and hyperglycaemia
Volume replacement Perinatal hypoxia interferes with metabolic adaptation and mainte-
A recent ILCOR evidence update1 identified no further human studies nance of cerebral energy supply in several ways. Significantly lower
and a single animal RCT which supported the 2010 CoSTR blood glucose levels in the delivery room promote ketogenesis.324
recommendations.34,274 Early volume replacement is indicated for Hypoglycaemia is common; a quarter of infants with moderate to
newborn infants with blood loss who are not responding to severe HIE reported to a national cooling registry had a blood glucose
resuscitation. Therefore, if there has been suspected blood loss or less than 2.6 mmol/L.331
the infant appears to be in shock (pale, poor perfusion, weak pulse) Animal studies suggest hypoxic cerebral injury is worsened by both
and has not responded adequately to other resuscitative measures hypoglycaemia and hyperglycaemia.332 334 In human infants with
then consider giving volume replacement with crystalloid or red cells. hypoxic ischaemic encephalopathy an abnormal early postnatal
Blood loss causing acute hypovolaemia in the newborn infant is a rare glycaemic profile (i.e. hypoglycaemia, hyperglycaemia or labile blood
event. There is little to support the use of volume replacement in the glucose) is associated with distinct patterns of brain injury on MRI
absence of blood loss when the infant is unresponsive to ventilation, compared to normoglycaemia.324 Hyperglycaemia and a labile blood
chest compressions and adrenaline. However, because blood loss glucose were also associated with amplitude-integrated electroen-
may be occult and distinguishing normovolaemic infants with shock cephalography evidence of worse global brain function and seizures.335
due to asphyxia from those who are hypovolaemic can be problematic, Both hypoglycaemia and hypoglycaemia were associated with
a trial of volume administration may be considered.1 poorer neurological outcomes in the CoolCap study336 and there is a
clear association between initial hypoglycaemia and poorer neuro- effectiveness.345 Such therapy is at the discretion of the treating team
logical outcome in infants with perinatal hypoxia.337,338 on an individualised basis. Current evidence is insufficient to
A recent ILCOR review of the evidence on the post resuscitation recommend routine therapeutic hypothermia for infants with mild
management of glucose identified no systematic reviews or RCTs encephalopathy.346
specifically addressing the management of blood glucose in the first
few hours after birth.1 13 non randomised trials or observational Prognostic tools
studies were identified published since 2015 investigating whether the This subject was not reviewed through the ILCOR process. No
maintenance of normoglycaemia during or immediately after resusci- systematic or scoping reviews have been identified.
tation improved outcome. The APGAR score was proposed as a “simple, common, clear
The update suggests that infants who require significant classification or grading of newborn infants” to be used “as a basis for
resuscitation should be monitored and treated to maintain glucose discussion and comparison of the results of obstetric practices, types
in the normal range. Protocols for blood glucose management should of maternal pain relief and the effects of resuscitation” (our
be used that avoid both hypo and hyperglycaemia and also avoid large emphasis).113 Although widely used in clinical practice and for
swings in blood glucose level. The evidence update suggests that research purposes, the applicability has been questioned due to large
research to determine the optimal protocols for glycaemic manage- inter- and intra-observer variations. In a retrospective study involving
ment for preterm and term infants in the aftermath of resuscitation, and 42 infants between 23 and 40 weeks gestation O’Donnell found a
the optimal target range should be a high priority. Overall no change significant discrepancy (average 2.4 points) between observers
has been made to the previous recommendation that intravenous retrospectively scoring the APGAR from videos of the deliveries
glucose infusion should be considered soon after resuscitation with compared to the scores applied by those attending the delivery.347
the goal of avoiding hypoglycaemia (low certainty evidence).339 A lack of correlation with outcome is partly explained by a lack of
agreement on how to score infants receiving medical interventions or
Rewarming being born preterm. Variations in the APGAR score have been
If therapeutic hypothermia is not indicated, hypothermia after birth proposed attempting to correct for maturity and the interventions
should be corrected because of evidence of poor outcomes.76,77 undertaken, such as the Specified, Expanded and Combined versions
Infants should be maintained within the normal range of temperature. (which incorporates elements of both). These might have greater
A recent ILCOR evidence review identified no systematic reviews or precision in predicting outcome in preterm and term infants when
RCTs published since the previous guidelines.1 Two retrospective compared to the conventional score, but are not used widely.348,349
observational studies involving 182340 and 98341 patients were
identified which investigated whether in hypothermic infants (36 C Communication with the parents
on admission) rapid or slow rewarming changed outcome. The findings
of both studies were that the rate of rewarming (after adjustment for The principles governing the need for good communication with
confounders) did not affect the critical and important outcomes. parents are derived from clinical consensus and enshrined in
However, one study suggested that rapid rewarming reduces risk for published European and UK guidance.350,351
respiratory distress syndrome.340 The conclusion was that there was no Mortality and morbidity for newborns varies according to region,
new evidence to alter the 2015 ILCOR consensus that a recommenda- ethnicity and to availability of resources.352 354 Social science studies
tion for either rapid (0.5 C/h or greater) or slow rewarming (0.5 C/h or indicate that parents wish to be involved in decisions to resuscitate or to
less) of unintentionally hypothermic newborn infants (temperature less discontinue life support in severely compromised infants.355,356 Local
than 36 C) at hospital admission would be speculative.274,339,342 survival and outcome data are important in appropriate counselling of
parents. The institutional approach to management (for example at the
Induced hypothermia border of viability) affects the subsequent results in surviving infants.357
This topic has not been reviewed as part of the most recent ILCOR European guidelines are supportive of family presence during
process. A Cochrane review including 11 randomised controlled trials cardiopulmonary resuscitation.358 Healthcare professionals are
comprising 1505 term and late preterm infants calculated that increasingly offering family members the opportunity to remain
therapeutic hypothermia resulted in a statistically significant and present during resuscitation and this is more likely if this takes place
clinically important reduction in the combined outcome of mortality or within the delivery room. Parents’ wishes to be present during
major neurodevelopmental disability to 18 months of age (typical RR resuscitation should be supported where possible.1,359,360
0.75 (95% CI 0.68 0.83); typical RD 0.15 (95% CI 0.20 0.10)) and There is insufficient evidence to indicate an interventional effect on
concluded that newborn infants at term or near-term with evolving patient or family outcome. Being present during the resuscitation of
moderate to severe hypoxic-ischaemic encephalopathy should be their baby seems to be a positive experience for some parents but
offered therapeutic hypothermia.343 Cooling should be initiated and concerns about an effect upon performance exist in professionals and
conducted under clearly defined evidence-based protocols with family members (weak recommendation very low certainty of
treatment in neonatal intensive care facilities and with the capabilities evidence).1,360
for multidisciplinary care. Treatment should commence within 6 h of In a single centre review of management of birth at the bedside,
birth, target a temperature between 33.5 C and 34.5 C, continue for parents who were interviewed were supportive but some found
72 h after birth and re-warm over at least 4 h. A four way clinical trial of witnessing resuscitation difficult.361 Clinicians involved felt the close
364 infants randomised to receive longer (120 h) or deeper (32 C) proximity improved communication but interviews suggested support
cooling found no evidence of benefit of longer cooling or lower and training in dealing with such situations might be required for
temperatures.344 Animal data strongly suggests that the effectiveness of staff.362 In a retrospective questionnaire based survey of clinicians’
cooling is related to early intervention. Hypothermia initiated at 6 24 h workload during resuscitation the presence of parents appeared to be
after birth may have benefit but there is uncertainty in its beneficial in reducing perceived workload.363
Qualitative evidence emphases the need for support during and after of morbidity, and where the anticipated burden to the child is high,
any resuscitation, without which the birth may be a negative experience parental wishes regarding resuscitation should be sought and
with post traumatic consequences.364,365 There should be an opportunity supported.351
for the parents to reflect, ask questions about details of the resuscitation
and be informed about the support services available.359 It may be helpful
to offer any parental witness of a resuscitation the opportunity to discuss Conflict of interest
what they have seen at a later date.364,365
Decisions to discontinue or withhold resuscitation should ideally CR declares speaker honorarium from Chiesi and funding from the
involve senior paediatric staff. National Institute for Health Research. JM declares occasional advice
to Laerdal Medical and Brayden on Newborn Resuscitation
Discontinuing or withholding treatment Equipment. HE declares research funding for Safer Births project
from Laerdal foundation, Governmental, World Bank, Global Financ-
Discontinuing resuscitation ing Facility and Laerdal Global Health. CM declares honorarium from
Failure to achieve return of spontaneous circulation in newborn infants Dräger and Chiesi, and his role of consultant for Fisher and Paykel and
after 10 20 min of intensive resuscitation is associated with a high risk Laerdal. TS declares educational funding from GE and Chiesi. CS
of mortality and a high risk of severe neurodevelopmental impairment Research declares funding from Government and ZOLL foundation.
among survivors. There is no evidence that any specific duration of ATP is science advisor for CONCORD neonatal; he is patent holder of
resuscitation universally predicts mortality or severe neurodevelop- the Concord resuscitation table. MR declares his role of consultant for
mental impairment. surfactant study Chiesi. JW declares NIH grant as co-applicant for
When the heart rate has been undetectable for longer than 10 min “Baby-OSCAR” project.
outcomes are not universally poor.366 368 For the composite outcome
of survival without neurodevelopmental impairment a recent ILCOR
systematic review identified low certainty evidence (downgraded for Appendix A. Supplementary data
risk of bias and inconsistency) from 13 studies involving 277 infants
reporting neurodevelopmental outcomes. Among all 277 infants 69% Supplementary data associated with this article can be found, in the
died before last follow up, 18% survived with moderate to severe online version, at https://doi.org/10.1016/j.resuscitation.2021.02.014.
neurodevelopmental impairment and 11% were judged to have
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RESUS 8907 No.

RESUSCITATION XXX (2021) XXX XXX

Available online at www.sciencedirect.com

European Resuscitation Council Guidelines 2021:

2 RESUSCITATION XXX (2021) XXX XXX

COVID 19 context Concise guideline for clinical practice

RESUSCITATION XXX (2021) XXX XXX 3

feedback on practice from different sources (including feedback

 Additional equipment, that might be required in case of more devices),

 [1278_TD$IF]Ideally, training should be repeated more frequently than once per

4 RESUSCITATION XXX (2021) XXX XXX

Fig. 2 – NLS infographic.

RESUSCITATION XXX (2021) XXX XXX 5

Management of the umbilical cord after birth Heart rate

Fig. 3 – Assessment of tone, breathing and heart rate help

Tone and colour

Breathing Assessment: Incomplete transition Breathing requires support,

6 RESUSCITATION XXX (2021) XXX XXX

Newborn life support

RESUSCITATION XXX (2021) XXX XXX 7

Fig. 5 – NLS algorithm.

8 RESUSCITATION XXX (2021) XXX XXX

Initial inflations and assisted ventilation

Fig. 6a – Head in a neutral position. Face is horizontal Lung [1289_TD$IF]inflation (Fig. 7)

Fig. 6b – Jaw lift jaw lift enlarges the pharyngeal space.

 An oropharyngeal airway may be useful in term infants when

initially high, confirms adequate ventilation/oxygenation.

RESUSCITATION XXX (2021) XXX XXX 9

 Where possible use a T-piece resuscitator (TPR) capable of

Failure to respond a facemask.

inflations of congenital abnormality, a lack of equipment, or a lack of

 Recheck mask size, position and seal. airway.

 Consider a gradual increase in inflation pressure. to be established.

Then: In special circumstances (e.g., congenital diaphragmatic hernia

 Repeat inflations. or to give surfactant).

10 RESUSCITATION XXX (2021) XXX XXX

Air/[21_TD$IF]oxygen Delivery of chest compressions

Time after birth (min) Lower SpO2 target (%)

During the resuscitation of a compromised infant at birth peripheral

RESUSCITATION XXX (2021) XXX XXX 11

Intra-tracheally if intubated and no other access available. Therapeutic hypothermia

12 RESUSCITATION XXX (2021) XXX XXX

Equipment and environment

RESUSCITATION XXX (2021) XXX XXX 13

14 RESUSCITATION XXX (2021) XXX XXX

RESUSCITATION XXX (2021) XXX XXX 15

16 RESUSCITATION XXX (2021) XXX XXX

RESUSCITATION XXX (2021) XXX XXX 17

18 RESUSCITATION XXX (2021) XXX XXX

Assessment Subgroup analysis of different lengths of SI (6 15 s 9 RCTs

RESUSCITATION XXX (2021) XXX XXX 19

20 RESUSCITATION XXX (2021) XXX XXX

RESUSCITATION XXX (2021) XXX XXX 21

Term infants and late preterm infants 35 weeks

22 RESUSCITATION XXX (2021) XXX XXX

RESUSCITATION XXX (2021) XXX XXX 23

Adrenaline In the absence of suitable blood (i.e. group O Rh-negative blood),

24 RESUSCITATION XXX (2021) XXX XXX

RESUSCITATION XXX (2021) XXX XXX 25

Additional equipment, that might be required in case of more devices),

[1278_TD$IF]Ideally, training should be repeated more frequently than once per

An oropharyngeal airway may be useful in term infants when

Where possible use a T-piece resuscitator (TPR) capable of

Recheck mask size, position and seal. airway.

Consider a gradual increase in inflation pressure. to be established.

Repeat inflations. or to give surfactant).

Term infants and late preterm infants 35 weeks