| Neonatal resuscitation | |
|---|---|
 | |
| Specialty | Neonatology |
| Frequency | 10% of newborns who do not readily begin breathing |
Neonatal resuscitation, also known asnewborn resuscitation, is anemergency procedure focused on supporting approximately 10% ofnewborn children who do not readily beginbreathing, putting them at risk of irreversible organ injury anddeath.[1] Many of the infants who require this support to start breathing well on their own after assistance. Throughpositive airway pressure, and in severe cases chest compressions, medical personnel certified in neonatal resuscitation can often stimulate neonates to begin breathing on their own, with attendant normalization ofheart rate.[2]
Face masks that cover the infant's mouth and nose are often used in the resuscitation procedures. Nasal prongs/tubes/masks and laryngeal mask airway devices are also sometimes used.[3]
Up to 10% of infants are born requiring assistance to begin breathing. After assistance, many of these infants begin to breath on their own and are healthy. Breathing problems at birth is a high priority emergency and interventions such as breathing support and resuscitation is sometimes required.[3]
All infants who are 'gasping', show signs of beingapnoeic (suspension of breathing), or havebradycardia with a heart rate lower than 100 beats per minute after birth are recommended to be administeredpositive pressure ventilation with a 'manual ventilation device' to provide breathing support.[4] Examples of manual ventilation devices include a self-inflating bag or a T-piece.[3]
About a quarter of all neonatal deaths globally are caused by birth asphyxia.[5] This dangerous condition ofoxygen deprivation may begin before birth. For example, if theumbilical cord, which supplies oxygen throughoutfetal development, is compressed or tears duringdelivery. Depending on how quickly and successfully the infant is resuscitated, hypoxic damage can occur to most of the infant's organs (heart,lungs,liver,gut,kidneys). One serious complication is a brain injury known asneonatal hypoxic-ischemic encephalopathy.[citation needed]
The most widely known training/certification for neonatal resuscitation is theNeonatal Resuscitation Program (NRP).
TheInternational Liaison Committee on Resuscitation (ILCOR) has publishedConsensus on science and treatment recommendations for neonatal resuscitation.[4] Traditionally, newborn children have been resuscitated usingmechanical ventilation with 100% oxygen, but there has since the 1980s increasingly been debated whether newborn infants with asphyxia should be resuscitated with 100% oxygen or normal air, and notablyOla Didrik Saugstad has been a major advocate of using normal air.[7][8]
In 2020, theInternational Liaison Committee on Resuscitation (ILCOR) published its 4th and most recent recommendations for newborn life support. The committee reviewed 8 major topics, including anticipation and preparation, initial assessment and intervention,physiologic monitoring and feedback devices,ventilation andoxygenation,circulatory support, drug and fluid administration,prognostication duringCPR, and post-resuscitation care.[4]
Initial evaluation of a newborn is done by obtaining anApgar score, which gives the clinician an approximation of the infant's cardiovascular and neurologic condition at birth. A score of 7–10 at 5 minutes is normal, a score of 4 to 6 at 5 minutes is intermediate, and a score of 0-3 is considered low. It is important to understand that an Apgar score is not a diagnosis, it is merely a clinical finding.[9] If a newborns score is 0–3, then resuscitation efforts are initiated.
Neonatal resuscitation guidelines closely resemble those of thepediatric basic and advanced life support. The main differences in training include an emphasis onpositive pressure ventilation (PPV), updated timings on ventilation assistance rates, and some differences in thecardiac arrest chain of survival.
Guidelines for neonatal resuscitation are assessed annually and are developed in collaboration with multiple organizations of numerous experts, including theAmerican Academy of Pediatrics (AAP).
In 2020, the ILCOR recommended the following changes to current resuscitation guidelines:[4]
While some guidelines do tend to change, certain elements of neonatal resuscitation have persisted. These include:
Most neonatal deaths (roughly 75%) after resuscitation occur within the first week, but the vast majority occur within 24 hours.[citation needed] This statistic is based on amean Apgar score of 5.9, which is considered intermediate. More data is needed to understand outcomes for more severe patients. Outcomes after resuscitation for neonates vary widely based on many factors. One study inNorway analyzed 15peer-reviewed published articles and found that high-income countries have a mortality rate as high as 10% while low-income countries have a mortality rate as high as 28%.[10] One major factor that improved survival was how quickly medical responders were able to intervene, noting that the first minutes are critical.[11]
It has been demonstrated that high concentrations of oxygen lead to generation of oxygenfree radicals, which have a role inreperfusion injury after asphyxia.[12] Clinical trial evidence suggests that resuscitation using air probably reduces the risk of death[13] and the 2010 ILCOR guidelines recommend the use of normal air rather than 100% oxygen.[14] Another study showed thatpreterm infants have little or no difference in risk of death or neurodevelopment disability when higher concentrations of oxygen are used compared to lower concentrations but the evidence from clinical trials is still relatively uncertain.[15]
Currently, it is thegold standard to place neonates on a cooling blanket for 72 hours to achievetotal body cooling. This is done in order to minimize brain swelling. After cooling is achieved, an MRI is obtained roughly 1 week afterhypoxic brain injury in order to classify the severity of brain damage. However, one study found that there was no significant correlation between MRI findings and developmental delay up to 2 years of life.[16]