Colin J. Morley

Part 11: Neonatal Resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

2010;126;e1319-e1344; originally published online Oct 18, 2010; Pediatrics COLLABORATORS CHAPTER Sithembiso Velaphi and on behalf of the NEONATAL RESUSCITATION Sam Richmond, Wendy M. Simon, Nalini Singhal, Edgardo Szyld, Masanori Tamura, Chameides, Jay P. Goldsmith, Ruth Guinsburg, Mary Fran Hazinski, Colin Morley, Jeffrey M. Perlman, Jonathan Wyllie, John Kattwinkel, Dianne L. Atkins, Leon Recommendations Resuscitation and Emergency Cardiovascular Care Science With Treatment Neonatal Resuscitation: 2010 International Consensus on Cardiopulmonary http://www.pediatrics.org/cgi/content/full/126/5/e1319 located on the World Wide Web at: The online version of this article, along with updated information and services, is rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Grove Village, Illinois, 60007. Copyright

Defining the reference range for oxygen saturation for infants after birth.

OBJECTIVE: The goal was to define reference ranges for pulse oxygen saturation (Spo2) values in the first 10 minutes after birth for infants who received no medical intervention in the delivery room. METHODS: Infants were eligible if a member of the research team was available to record Spo2 immediately after birth. Infants were excluded if they received supplemental oxygen or any type of assisted ventilation. Spo2 was measured with a sensor applied to the right hand or wrist as soon as possible after birth; data were collected every 2 seconds. RESULTS: We studied 468 infants and recorded 61650 Spo2 data points. The infants had a mean ± SD gestational age of 38 ± 4 weeks and birth weight of 2970 ± 918 g. For all 468 infants, the 3rd, 10th, 50th, 90th, and 97th percentile values at 1 minute were 29%, 39%, 66%, 87%, and 92%, respectively, those at 2 minutes were 34%, 46%, 73%, 91%, and 95%, and those at 5 minutes were 59%, 73%, 89%, 97%, and 98%. It took a median of 7.9 minutes (interquartile range: 5.0–10 minutes) to reach a Spo2 value of >90%. Spo2 values for preterm infants increased more slowly than those for term infants. We present percentile charts for all infants, term infants of ≥37 weeks, preterm infants of 32 to 36 weeks, and extremely preterm infants of <32 weeks. CONCLUSION: These data represent reference ranges for Spo2 in the first 10 minutes after birth for preterm and term infants.

Special Report—Neonatal Resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

Note From the Writing Group: Throughout this article, the reader will notice combinations of superscripted letters and numbers (eg, “Peripartum SuctioningNRP-011A, NRP-012A”). These callouts are hyperlinked to evidence-basedworksheets, whichwere used in the development of this article. An appendix of worksheets, applicable to this article, is located at the end of the text. The worksheets are available in PDF format and are open access.

The International Liaison Committee on Resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: Neonatal resuscitation

APPROXIMATELY 10% OF newborns require some assistance to begin breathing at birth, and about 1% require extensive resuscitation. Although the vast majority of newborn infants do not require intervention to make the transition from intrauterine to extrauterine life, the large number of births worldwide means that many infants require some resuscitation. Newborn infants who are born at term, had clear amniotic fluid, and are breathing or crying and have good tone must be dried and kept warm but do not require resuscitation. All others need to be assessed for the need to receive 1 or more of the following actions in sequence:

Delaying cord clamping until ventilation onset improves cardiovascular function at birth in preterm lambs

•  Delayed cord clamping improves circulatory stability in preterm infants at birth, but the underlying reason is not known. •  In a new preterm lamb study we investigated whether delayed cord clamping until ventilation had been initiated improved pulmonary, cardiovascular and cerebral haemodynamic stability. •  We demonstrated that ventilation prior to cord clamping markedly improves cardiovascular function by increasing pulmonary blood flow before the cord is clamped, thus further stabilising the cerebral haemodynamic transition. •  These results show that delaying cord clamping until after ventilation onset leads to a smoother transition to newborn life, and probably underlies previously demonstrated benefits of delayed cord clamping.

Part 11: Neonatal Resuscitation

Note From the Writing Group: Throughout this article, the reader will notice combinations of superscripted letters and numbers (eg, “Peripartum Suctioning ”). These callouts are hyperlinked to evidence-based worksheets, which were used in the development of this article. An appendix of worksheets, applicable to this article, is located at the end of the text. The worksheets are available in PDF format and are open access.

Interaction of spontaneous respiration with artificial ventilation in preterm babies

During a four-month period, all babies who received mechanical ventilation in the Neonatal Intensive Care Unit were studied to determine the effects of artificial ventilation on spontaneous respiratory activity. The babies were either totally apneic or ventilator inflation stimulated one of four distinct spontaneous respiratory patterns: synchronous breathing, Hering-Breuer reflex, augmented inspiration, or active expiration against ventilator inflation. The particular interaction evoked was dependent on the frequency of ventilation and the clinical condition of the baby. Only one pattern, active expiration against ventilator inflation, was consistently recorded before the development of pneumothorax. Preliminary evidence indicates that immediate paralysis of the baby as soon as that pattern is demonstrated may prevent the occurrence of pneumothoraces.

Probiotic Effects on Late-onset Sepsis in Very Preterm Infants: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVE: Late-onset sepsis frequently complicates prematurity, contributing to morbidity and mortality. Probiotics may reduce mortality and necrotizing enterocolitis (NEC) in preterm infants, with unclear effect on late-onset sepsis. This study aimed to determine the effect of administering a specific combination of probiotics to very preterm infants on culture-proven late-onset sepsis. METHODS: A prospective multicenter, double-blinded, placebo-controlled, randomized trial compared daily administration of a probiotic combination (Bifidobacterium infantis, Streptococcus thermophilus, and Bifidobacterium lactis, containing 1 × 109 total organisms) with placebo (maltodextrin) in infants born before 32 completed weeks’ gestation weighing <1500 g. The primary outcome was at least 1 episode of definite late-onset sepsis. RESULTS: Between October 2007 and November 2011, 1099 very preterm infants from Australia and New Zealand were randomized. Rates of definite late-onset sepsis (16.2%), NEC of Bell stage 2 or more (4.4%), and mortality (5.1%) were low in controls, with high breast milk feeding rates (96.9%). No significant difference in definite late-onset sepsis or all-cause mortality was found, but this probiotic combination reduced NEC of Bell stage 2 or more (2.0% versus 4.4%; relative risk 0.46, 95% confidence interval 0.23 to 0.93, P = .03; number needed to treat 43, 95% confidence interval 23 to 333). CONCLUSIONS: The probiotics B infantis, S thermophilus, and B lactis significantly reduced NEC of Bell stage 2 or more in very preterm infants, but not definite late-onset sepsis or mortality. Treatment with this combination of probiotics appears to be safe.

Effect of Sustained Inflation Length on Establishing Functional Residual Capacity at Birth in Ventilated Premature Rabbits

The effect of inflation length on lung aeration pattern, tidal volumes, and functional residual capacity (FRC) immediately after birth was investigated. Preterm rabbits (28 d), randomized into four groups, received a 1-, 5-, 10-, or 20-s inflation (SI) followed by ventilation with 5 cm H2O end-expiratory pressure. Gas volumes were measured by plethysmography and uniformity of lung aeration by phase contrast x-ray imaging for 7 min. The first inspiratory volume significantly (p < 0.001) increased with inflation duration from a median (IQR) of 0.2 (0.1–3.1) mL/kg for 1-s inflation to 23.4 (19.3–30.4) mL/kg for 20-s SI. The lung was uniformly aerated, and the FRC and tidal volume fully recruited after 20-s SI. A 10-s SI caused a higher FRC (p < 0.05) at 7 min, and a 20-s SI caused a higher FRC (p < 0.05) at 20 s and 7 min than a 1- or 5-s SI. The mean (SD) time for 90% of the lung to aerate was 14.0 (4.1) s using 35 cm H2O peak inflation pressure. In these rabbits, 10- and 20-s SI increased the inspiratory volume and produced a greater FRC, and a 20-s SI uniformly aerated the lung before ventilation started.

From liquid to air: breathing after birth.

The first breaths after birth are characterized by a rapid transition from liquid- to air-filled lungs. Air is drawn into the lung during inspiration, and some remains at end expiration to establish an end-expiratory gas volume or functional residual capacity (FRC). This is usually marked by a cry, often misinterpreted as a protest from the baby. Some infants, especially those born preterm, require respiratory support during this transitional phase. To do this effectively, we need to understand the normal physiological processes occurring at this time. Sometimes it can be difficult to aerate the lungs of preterm infants with intermittent positive pressure ventilation with pressures recommended in international guidelines, particularly when the infant does not breathe and aeration is completely dependent on the inflation pressures. Studies have shown that intermittent positive pressure ventilation should be performed without high tidal volumes to avoid damaging the lung while establishing the FRC. 1,2 However, since the use of antenatal steroids, more very preterm infants breathe spontaneously at birth, only requiring support from nasal continuous positive airway pressure. Understanding the normal spontaneous breathing pattern after birth is essential for developing safe, efficient ventilatory strategies when breathing is inadequate. Numerous physiological studies immediately after birth of spontaneously breathing infants were published between 1960 and 1986. 3-10 However, little new data are currently available on this topic, reflecting the difficulties of performing these studies. This review will discuss what happens during the first breaths of air with the emphasis on where the liquid goes and the current knowledge about the spontaneous breathing pattern adopted by infants immediately after birth.