Highlights of the New Neonatal Resuscitation

Program Guidelines
Jeffrey M. Perlman, MB, ChB*
*Division of Newborn Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY, and
New York Presbyterian Hospital, Komansky Centre for Childrens Health, New York, NY.

Practice Gap
Scientic recommendations and treatment guidelines for neonatal
resuscitation need to be applied to clinical practice.

Abstract
In 2015, the neonatal guidelines for resuscitation were published with several
new treatment guidelines. Many of these are highlighted in this review. They
included changes in the algorithm, timing of cord clamping in the preterm
infant, optimizing detection of heart rate after birth, maintaining the
premature infant temperature in the delivery room, initiating oxygen use
during resuscitation, and using sustained ination to establish functional
residual capacity. In the term infant, changes included management of the
nonbreathing infant delivered in the presence of meconium-stained amniotic
uid and consideration for when to continue/discontinue resuscitation in infants
with an Apgar score of 0 after 10 minutes of resuscitation.

Objectives

After completing this article, readers should be able to:

1. Understand the GRADE process for evaluating the science and signicance
of the recommendations.
2. Understand the rationale behind delayed cord clamping in the premature
infant.
3. Understand the starting concentration of supplemental oxygen in the
premature infant needing resuscitation.
4. Understand the importance of avoiding moderate hypothermia after birth
and the methods of achieving this goal.

AUTHOR DISCLOSURE Dr Perlman has

disclosed no nancial relationships relevant to
this article. This commentary does contain a
discussion of an unapproved/investigative
use of a commercial product/device.

5. Understand the suggestive approach to managing the term

depressed infant delivered in the presence of meconium-stained
amniotic uid

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INTRODUCTION

recommendations (Table 1). (3)(4) In this review, the GRADE

The neonatal guidelines for resuscitation were recently

published and reected a summary of the evidence presented in the 2015 International Consensus on Cardiopul-

process will be briey described, and the following new/

controversial issues will be highlighted: the algorithm,
timing of cord clamping in the preterm infant, optimizing

monary Resuscitation and Emergency Cardiovascular Care

detection of heart rate after birth, maintaining the tem-

Science with Treatment Recommendations. (1)(2) This

perature of the premature infant in the delivery room,

review of the guidelines will highlight some of the newer

initiating oxygen use during resuscitation, and using sus-

and potentially controversial issues brought about by new

tained ination to establish functional residual capacity

evidence. Importantly, some of the new recommendations

(FRC). This article also will include a discussion of the man-

are based on Grading of Recommendations, Assessment,

agement approach to the nonbreathing term infant deliv-

Development and Evaluation (GRADE), a new system

ered in the presence of meconium-stained amniotic uid

for evaluating the quality of evidence and strength of the

(MSAF) and consideration for when to continue/discontinue

TABLE 1.

Topics Reviewed for the 2015 ILCOR Process

Optimal assessment of heart rate

Delayed cord clamping in preterm infants requiring resuscitation
Umbilical cord milking
Temperature maintenance in the delivery room
Maintaining infant temperature during delivery room resuscitation
Warming of hypothermic newborns
Infants born to mothers who are hypothermic or hyperthermic in labor
Continuous positive airway pressure and intermittent positive pressure ventilation
Sustained inations
Outcomes for PEEP versus no PEEP in the delivery room
T-piece resuscitator and self-inating bag
Intubation and tracheal suctioning in nonvigorous infants born through MSAF vs no intubation for tracheal suctioning
Oxygen concentration for resuscitating premature newborns
Two thumb vs two nger for chest compression
Chest compression ratio
Oxygen delivery during CPR (neonatal)
Laryngeal mask airway
Newborn infants who receive positive pressure ventilation for resuscitation, and use of a device to assess respiratory function
Use of feedback CPR devices for neonatal cardiac arrest
Limited resource-induced hypothermia
Delivery room assessment <25 weeks and prognostic score
Apgar score of 0 for 10 minutes
Predicting death or disability of newborns >34 weeks based on Apgar and/or absence of breathing
Resuscitation training frequency
Neonatal resuscitation instructors
CPRcardiopulmonary resuscitation; ILCORInternational Liaison Committee on Resuscitation; MSAF=meconium-stained amniotic uid; PEEPpositive
end-expiratory pressure.

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resuscitation in infants with an Apgar score of 0 after 10

minutes of resuscitation.

USING GRADE TO DEVELOP RECOMMENDATIONS

GRADE is an emerging consensus process that rates quality
of evidence and strength of recommendations along with
values and preferences. (3)(4) In brief, GRADE classies
quality of evidence as: high quality (where one has high
condence in the estimate of effect as reported in a synthesis
of the literature); moderate quality (moderate condence,
but there may be differences from a further elucidated

truth); low quality (where one has low condence in the

estimate of the effect, which may be substantially different
from the true effect); and very low quality (it is possible that
the estimate of effect is substantially different from the true
effect). The quality of a body of evidence involves consideration of 5 unique domains, including risk of bias for each
outcome as reported across relevant studies (methodological quality), as well as the directness of evidence (such
as, was the population studied the same as that for which
the guideline will be used), heterogeneity of the results of
individual studies, precision of effect estimates, and risk of
publication bias. Randomized studies start off as high quality

Figure. Neonatal resuscitation algorithm.

CPAP=continuous positive airway pressure,
ECG=electrocardiography, ET=endotracheal
intubation, HR=heart rate, IV=intravenous,
PPV=positive pressure ventilation,
SpO2=peripheral capillary oxygen saturation.

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but may be downgraded for methodological quality, whereas

observational or cohort studies start off as low quality and can
be further downgraded or upgraded depending on methodological quality or positive outcome effect.
Guideline users have to determine how much they can
trust that a recommendation will produce more favorable
rather than unfavorable consequences. The strength of a
recommendation reects a gradient in guidance, with a
clearer expectation for adherence with strong recommendations and lesser insistence on weak recommendations.
In addition, the effect may be in favor of or against the
recommendation. According to GRADE, several factors may
inuence the strength of a recommendation, including the
risk-benet balance, quality of evidence, patient values and
preferences, and nally, costs and resource utilization. If
condence in these values and preferences is high and
variability is low, it is more likely that the recommendation
will be strong (and vice versa). Recommendations, whether
strong or weak, have different implications for patients,
health care professionals, or health care management.

BACKGROUND
Approximately 85% of infants born at term will initiate
spontaneous respirations within 10 to 30 seconds of birth,
an additional 10% will respond during drying and stimulation, approximately 3% will initiate respirations after
positive pressure ventilation (PPV), 2% will undergo intubation to support respiratory function, and 0.1% will require
chest compressions and/or epinephrine to achieve this
transition. (5)(6)(7) Although the vast majority of newborn
infants do not require intervention to make these transitional changes, the large number of births worldwide means
that many infants require some assistance to achieve cardiorespiratory stability each year.

NEONATAL ALGORITHM
There was considerable debate with regard to modifying the
International Liaison Committee on Resuscitation (ILCOR)
algorithm. First, the 30-second time rule was considered
unreasonable, and not evidence-based; however, there was
strong consensus that a reminder to assess and intervene if
necessary, within 60 seconds after birth, should be retained
to avoid critical delays in initiating resuscitation. This is
based on the fact that more than 95% of newly born infants will start breathing spontaneously or in response to
stimulation within approximately 30 seconds. (5) If apnea
persists, PPV should be initiated within 60 seconds.
Second, given the importance of moderate hypothermia

e438

(temperature <36C) as a predictor of mortality, and evidence from multiple studies that it can be avoided (as
described later in this article) with simple intervention
strategies, the ILCOR algorithm contains a running line
reminding providers to maintain thermoregulation throughout the immediate newborn period (Figure). The algorithm
contained in the neonatal guidelines does not include this
important reminder.

DELAYED CORD CLAMPING IN PRETERM INFANTS

REQUIRING RESUSCITATION
For many years, the umbilical cord of the preterm neonate
was generally cut soon after birth, so that the newborn can
be transferred immediately to the neonatal team. However,
there is evidence that a delay of clamping by 30 to 60
seconds after birth results in a smoother transition, particularly if the newborn begins breathing before the cord is
cut. (2) The ILCOR scientic review indicates that delay is
associated with increased placental transfusion, increased
cardiac output, more stable and higher neonatal blood
pressure, less intraventricular hemorrhage (IVH) of any
grade, less need for transfusion after birth, and less necrotizing enterocolitis. (2) However, there was no evidence of
decreased mortality or decreased incidence of severe IVH.
The only negative consequence appears to be an increased
level of bilirubin associated with more need for phototherapy. Despite drawing evidence from randomized controlled
trials, the small sample size in most trials and the associated
imprecision limit the quality of evidence for all outcomes
of interest. Based on the latter, ILCOR suggests delaying
umbilical cord clamping for preterm infants not requiring
immediate resuscitation after birth (weak recommendation).
The neonatal guidelines translated this scientic statement as follows: DCC [delayed cord clamping] for longer
than 30 seconds is reasonable for both term and preterm
infants who do not require resuscitation at birth. However,
there is insufcient evidence to recommend an approach
to cord clamping for preterm infants who do receive resuscitation immediately after birth. Notably, both ILCOR and
the neonatal guidelines do not specify a maximum time to
delay in cord clamping. (1)(2)

DETERMINATION OF HEART RATE

Neonatal resuscitation success has typically been determined by detecting an increase in heart rate through auscultation. Heart rate also determines the need for changing
interventions and escalating care. However, recent evidence

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demonstrates that auscultation of heart rate is inaccurate,

and pulse oximetry takes several minutes to achieve a signal
and also may be inaccurate during the early minutes after
birth. The ILCOR scientic review identied several nonrandomized studies (deemed very-low-quality evidence)
showing a benet of electrocardiography (ECG) compared
with oximetry for a fast and accurate measurement of heart
rate in infants requiring resuscitation. (8)(9)(10) In addition, clinical assessment was found to be both unreliable and
inaccurate. Among healthy newborns, providers frequently
could not palpate the umbilical pulse and underestimated
the newborns heart rate by auscultation or palpation. (11)
Although the mean differences between the series of heart
rates measured by ECG and pulse oximetry were small,
pulse oximetry tended to underestimate the newborns heart
rate and would have led to potentially unnecessary interventions. (8)(9)(10)(11) In particular, during the rst 2
minutes after birth, pulse oximetry frequently displayed
the newborns heart rate below either 60 or 100 beats per
minute, whereas a simultaneous ECG showed the heart rate
higher than 100 beats per minute. (10)
ILCOR suggests that an ECG can be used to provide a
rapid and accurate estimation of heart rate (weak recommendation, very-low-quality evidence). Importantly, ECG
should not replace the role of auscultation for the assessment of heart rate, as well as pulse oximetry to evaluate
oxygenation. Moreover, each hospital will need to dene
the patient populations that may require ECG placement
and develop methods for rapid application of the leads.

TEMPERATURE MAINTENANCE IN THE PREMATURE

INFANT
It has been known for more than a century that preterm
newborns who become hypothermic after birth have a
higher mortality than those who remain normothermic.
(12)(13)(14) The premature neonate is especially vulnerable
and there appears to be a dose-related effect. Thus, in a large
study involving more than 5,000 premature infants less
than 1,500 g, there was an associated 28% increase in
mortality for every 1 degree decrease in temperature below
36.5C. (14) Hypothermia is also associated with serious
morbidities, such as increased risk of IVH, respiratory
issues, hypoglycemia, and late-onset sepsis. (2)
The ILCOR treatment recommendation states: Admission temperature of newly born nonasphyxiated infants is a
strong predictor of mortality and morbidity at all gestations.
It should be recorded as a predictor of outcomes as well
as a quality indicator (this was a strong recommendation
based on moderate-quality evidence). Hence, the running

timeline was added to the algorithm to emphasize this point.

It is recommended that the temperature of newly born
nonasphyxiated infants be maintained between 36.5C and
37.5C after birth through admission and stabilization. In
making this strong statement, ILCOR places a higher value on the strong association of inadvertent hypothermia with
mortality, the apparent dose effect, and the single direction
of the evidence. Most studies reviewed measured axillary
temperature but some older studies used rectal temperature.
The relative benets of one over the other were not assessed. However, ILCOR suggests that axillary temperature
should be used in the delivery room, but that on admission,
the measurement site should be left to individual local
practice.

INTERVENTIONS TO MAINTAIN NEWBORN

TEMPERATURE IN THE DELIVERY ROOM THROUGH
ADMISSION TO A NEONATAL INTENSIVE AREA IN
THE PREMATURE INFANT
Various strategies have been suggested to maintain a preterm infants temperature; it is unknown which of these
strategies is most effective. The scientic evidence indicates
that the use of radiant warmers and plastic wrap with a cap
has signicantly improved but not eliminated the risk of
hypothermia in preterm infants in the delivery room. (15)
(16)(17) Other strategies have been introduced, including
thermal mattresses, increased room temperature, and the
use of warmed humidied resuscitation gases. (18)(19)(20)
(21)(22) Various combinations of these strategies may be
reasonable to prevent hypothermia in infants born at less
than 32 weeks of gestation. (23)(24)(25)
The ILCOR treatment recommendation focuses on preterm infants of less than 32 weeks of gestation in the delivery
room and suggests using a combination of interventions,
which may include environmental temperature 23C to
25C, warm blankets, plastic wrapping without drying,
cap, and thermal mattress to reduce hypothermia (temperature <36.0C) on admission to NICU. This is a weak
recommendation, based on very-low-quality evidence. In
addition, it was pointed out that hyperthermia (>38.0C)
should be avoided because of potential associated risks.
However no study showed any harm from hyperthermia.

Practical Considerations
Many of the studies used multiple strategies, so it is not
possible to identify a specic intervention that is effective in
maintaining infant temperature. Each unit should develop
specic strategies to avoid moderate hypothermia.

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OXYGEN CONCENTRATION FOR PREMATURE

NEWBORNS
The fact that high oxygen concentrations can be toxic to the
newly born lungs has long been recognized by ILCOR. The
original studies examined only air versus 100% oxygen and
led to a recommendation that blended oxygen be used to
titrate the concentration to achieve a targeted oxygen saturation. It is uncertain whether the preterm newborn should
be started in a high (50%100%) or low (21%30%) oxygen
concentration while a pulse oximeter is being attached.
Review of the science revealed the following salient ndings:
initiating resuscitation of preterm newborns (<35 weeks of
gestation) with high oxygen (65%) or low oxygen (21%
30%) showed no improvement in survival to hospital discharge with the use of high oxygen. (26)(27)(28)(29)(30)
Similarly, in the subset of studies that evaluated these outcomes, no benet was seen in preventing bronchopulmonary dysplasia, IVH, or retinopathy of prematurity. In all
studies, irrespective of whether air or high oxygen (including 100%) was used to initiate resuscitation, most infants
were receiving approximately 30% oxygen by the time of
stabilization. (27)(29)(30) ILCOR recommends against initiating resuscitation of preterm newborns (<35 weeks of
gestation) with high-supplemental oxygen concentrations
(65%100%). Rather, it recommends initiating with a low
oxygen concentration (21%30%) (strong recommendation,
moderate-quality evidence). In making this recommendation, ILCOR places value on not exposing preterm newborns
to additional oxygen without proven benet for outcomes.
The neonatal guidelines state more clearly that resuscitation of preterm newborns of less than 35 weeks of gestation
should be initiated with low oxygen (21%30%), and the oxygen concentration should be titrated to achieve preductal
oxygen saturation approximating the interquartile range measured in healthy term infants after vaginal birth at sea level.

has been debated for many decades. In the 1980s, Vyas et al

(31) suggested a technique for administering a sustained
ination of up to 5 seconds in duration. Both standard
PPV with or without positive end-expiratory pressure (PEEP)
and ination breaths up to 3 seconds in duration are the initial
strategies currently advocated to initiate ventilation (Neonatal
Resuscitation Program, European Resuscitation Council). (1)
(32) Several recent animal studies have suggested that a
longer sustained ination (up to 30 seconds) may be benecial for establishing FRC during transition from uid-lled
to air-lled lungs after birth. (33)(34) Three randomized
studies demonstrated a benet of sustained ination (up to
15 seconds) for reducing the need for mechanical ventilation,
but no benet was found for reduction of mortality, bronchopulmonary dysplasia, or air leak (very-low-quality evidence, downgraded for variability of interventions). (35)(36)
(37) Importantly, a recent randomized study showed an
increase in pneumothorax and pulmonary interstitial emphysema (Table 2). (37) The ILCOR treatment recommendation
is against the routine use of initial sustained ination (>5
seconds duration) for preterm infants without spontaneous
respirations immediately after birth. It is suggested that
sustained ination may be considered in individual clinical
circumstances or research settings (weak recommendation,
low-quality evidence). In making this recommendation and
in the absence of long-term benets, ILCOR places a higher
value on the negative aspect involving lack of clarity as to how
to administer sustained ination and the duration of the
breath compared with the positive ndings of a reduced need
for intubation at 72 hours. In addition, the methods used to
deliver sustained ination varied among studies. It was
stressed that different devices varied in their ability to generate pharyngeal pressures. Moreover, recent experimental
data suggest that an unintended glottis closure may be
associated with sustained ination.

Intubation and Tracheal Suctioning in Nonvigorous

Infants Born Through Meconium-Stained Amniotic Fluid

Practical Considerations
There is much debate among physicians as to the appropriate saturation targets to follow in the rst 5 to 10 minutes
after birth. This issue is further complicated by the fact that
the oximeter may underestimate heart rate during the rst 2
minutes after birth, (10) raising serious questions regarding
reliability of saturation values during this critical period.

RESPIRATORY SUPPORT IN THE PREMATURE INFANT

Establishing Functional Residual Capacity
The most effective method for establishing FRC in the uidlled lung of a newborn who does not breathe spontaneously

For many years, it has been recommended that newborns

with MSAF should receive tracheal suctioning using an
endotracheal tube as a suction device. Approximately 15
years ago, as a result of a multicenter randomized clinical
trial, the recommendation was restricted to infants who
appeared to have respiratory compromise at birth (ie, were
nonvigorous). ILCOR revisited this issue with regard to
the risks/benets of routine suctioning, and analyzed the
data for the critical outcomes of mortality and/or meconium
aspiration syndrome (MAS). Since the last ILCOR review
(2010), 1 randomized study involving 122 infants showed
no benet to suctioning versus no suctioning in either

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TABLE 2.

Occurrence of Air Leaks in Infants Exposed to Normal Ination

Pressures and Sustained Ination of 15 seconds

OUTCOME

CONTROL GROUP (N [ 143)

SLI GROUP (N [ 148)

UNADJUSTED ODDS RATIO (95% CI)

Respiratory distress syndrome

134 (94%)

133 (90%)

0.60 (0.251.41)

.23

Pneumothorax

2 (1%)

9 (6%)

4.57 (0.9721.50)

.06

Interstitial emphysema

2 (1%)

7 (5%)

3.50 (0.7217.10)

.09

Relative risk 4.01 (95% condence interval [CI] 1.3811.73); P .01 (when combining pneumothorax and interstitial emphysema).
Adapted from Lista et al. (37)

reducing mortality and/or MAS (low-quality evidence,

downgraded for risk of bias and imprecision). (38) Older
evidence was re-reviewed and the following ndings were
noted: three nonrandomized very-low-quality evidence studies showed a higher incidence of MAS in depressed infants who had tracheal intubation for suctioning (26%)
compared with vigorous infants who did not undergo intubation (0.3%) (downgraded for indirectness). (39)(40)(41)
Six very-low-quality observational studies demonstrated improved survival and lower incidence of MAS when infants
(including depressed and/or vigorous infants) born through
MSAF were intubated for tracheal suctioning (downgraded
for indirectness and inconsistency). (42)(43)(44)(45)(46)
(47) Six very-low-quality observational studies demonstrated
no improvement in survival and/or incidence of MAS
(including depressed and/or vigorous infants) when infants
born through MSAF underwent intubation for tracheal
suctioning (downgraded for indirectness). (48)(49)(50)(51)
(52)(53)
Based on this re-review of the data, the ILCOR treatment
recommendation stated the following: There is insufcient published human evidence to suggest routine tracheal
intubation for suctioning of meconium in nonvigorous
infants born through MSAF as opposed to no tracheal intubation for suctioning. In making this suggestion, ILCOR
places a value on both harm avoidance (delays in providing bag-mask ventilation, potential harm of the procedure)
and the unclear benets of routine tracheal intubation and
suctioning.
The neonatal guidelines state: If an infant born through
MSAF presents with poor tone and inadequate breathing efforts, the initial steps of resuscitation should be completed
under the radiant warmer. PPV should be initiated if the
infant is not breathing or the heart rate is less than 100 beats
per minute. Routine suctioning of nonvigorous infants is
more likely to result in delays in initiating ventilation, especially where the provider is unable to promptly intubate

the infant or suction attempts are repeated. In the absence

of evidence of benet for suctioning, the emphasis should
be on initiating ventilation within the rst minute after birth
in nonbreathing or ineffectively breathing infants.

Practical Considerations
This change in the ILCOR treatment recommendation is
based on 1 low-quality randomized study that showed no
difference in outcomes (death and/or MAS), regardless of
whether the infant underwent suctioning. In keeping with
the low-quality evidence, it is important to restate that this
is a suggestion and not a recommendation. It is also important to recognize that many cases of MAS described in the
literature occur in the context of associated clinical events,
chorioamnionitis, and/or fetal heart rate abnormalities.
Clearly, under clinical circumstances that increase the
potential for aspiration, the provider should anticipate and
be prepared for the possibility that immediate intubation
may be indicated, rather than waiting for signs of obstruction. The spirit of the ILCOR treatment recommendation
recognized that a provider at delivery may not be skilled in
intubation. Under such circumstances, delay in providing
bag-mask ventilation versus potential harm of attempting
intubation would favor the former approach while additional assistance is sought.

APGAR SCORE OF 0 FOR 10 MINUTES OR LONGER

Controversy exists as to how long after attempting resuscitation after birth, when a heart rate cannot be detected,
should the provider continue or discontinue resuscitation
efforts. The Apgar score of 0 has typically been the criterion
used as the marker, because it indicates no detectable signs
of life. The current recommendation for duration of resuscitative efforts is 10 minutes after birth. This guideline was
revisited because the therapeutic hypothermia (TH) trials
showed an increasing number of intact survivors with an

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Apgar score of 0 after birth. The ILCOR science review

indicates that 106 (82%) of 129 infants of gestational age of
greater than or equal to 36 weeks, and an Apgar score of 0 at
10 minutes after birth, either died or exhibited moderate
to severe neurodevelopmental impairment at 22 months
of age or later (very-low-quality evidence, downgraded for
risk of bias, inconsistency, indirectness, and imprecision).
(54)(55)(56)(57)(58)(59) Results from 3 of these studies,
which included nested observational series in randomized
clinical trials of TH and series of infants who received TH,
showed that this adverse outcome occurred in 68 (76%) of
90 infants with an Apgar score of 0 at 10 minutes. Among
the 56 cooled infants in these studies, 15 (27%) survived
without major/moderate disabilities. (56)(57)(59) The cur-

American Board of Pediatrics

NeonatalPerinatal Content
Specications
Know the rationale, risks, and benets of delayed cord
clamping.
Understand the signicance, limitations, and causes of low Apgar
scores, including the relationship between Apgar scores and later
outcomes in preterm and full-term infants.
Know the current recommendations regarding suctioning
meconium from the airway during and following delivery.
Know indications for and proper administration of supplemental
oxygen immediately after birth.
Know the causes, metabolic consequences, and treatment of
infants with hypothermia.

rent ILCOR treatment recommendation states that an

Apgar score of 0 at 10 minutes is a strong predictor of
mortality and morbidity in late-preterm and term infants. It
is suggested that in infants with an Apgar score of 0 after 10
minutes of resuscitation, if the heart rate remains undetectable, it may be reasonable to stop resuscitation; however,
the decision to continue or discontinue resuscitative efforts
should be individualized. Variables to be considered may
include whether the resuscitation was considered to be
optimal, availability of advanced neonatal care such as TH,
specic circumstances before delivery, and the familys
wishes (weak recommendation, very-low-quality evidence.)
Importantly, the number of infants with no heart rate at 10
minutes who died in the delivery room is unknown.

Practical Considerations
There is a subtle but important distinction in the current
recommendation. This refers to the Apgar score of 0 after 10
minutes of resuscitation, which is distinct from 0 at 10
minutes. In addition, it states that consideration should be
given as to whether the resuscitation was optimal. Examples
of optimization would include intubation before initiating
chest compressions and administering intravenous rather
than endotracheal epinephrine if indicated. (60)

CONCLUSIONS
This brief review highlights several of the new neonatal
guideline recommendations that should enhance management options for the compromised infant immediately
after delivery. There are many gaps in current management, which demands ongoing research to further optimize care.

References
1. Wyckoff MH, Aziz K, Escobedo MB, et al. Part 13: Neonatal
Resuscitation: 2015 American Heart Association Guidelines Update
for Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care (Reprint). Pediatrics. 2015;136(suppl 2):S196S218
2. Perlman JM, Wyllie J, Kattwinkel J, et al; Neonatal Resuscitation
Chapter Collaborators. Neonatal Resuscitation: 2015 International
Consensus on Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care Science With Treatment Recommendations.
Pediatrics. 2015;136(suppl 2):S120S166
3. Schnemann H, Broek J, Guyatt G, Oxman A. 5. Quality of
evidence. In: GRADE Handbook. 2013. http://www.
guidelinedevelopment.org/handbook/#h.9rdbelsnu4iy. Accessed
February 2016, 2015.
4. Schnemann H, Broek J, Guyatt G, Oxman A. 5.1 Factors
determining the quality of evidence. In: GRADE Handbook. 2013.
http://www.guidelinedevelopment.org/handbook/
#h.9rdbelsnu4iy. Accessed February, 2016.
5. Ersdal HL, Mduma E, Svensen E, Perlman JM. Early initiation of
basic resuscitation interventions including face mask ventilation
may reduce birth asphyxia related mortality in low-income
countries: a prospective descriptive observational study.
Resuscitation. 2012;83(7):869873
6. Perlman JM, Risser R. Cardiopulmonary resuscitation in the
delivery room. Associated clinical events. Arch Pediatr Adolesc Med.
1995;149(1):2025
7. Barber CA, Wyckoff MH. Use and efcacy of endotracheal versus
intravenous epinephrine during neonatal cardiopulmonary
resuscitation in the delivery room. Pediatrics. 2006;118(3):
10281034
8. Katheria A, Rich W, Finer N. Electrocardiogram provides a
continuous heart rate faster than oximetry during neonatal
resuscitation. Pediatrics. 2012;130(5):e1177e1181
9. Mizumoto H, Tomotaki S, Shibata H, et al. Electrocardiogram
shows reliable heart rates much earlier than pulse oximetry during
neonatal resuscitation. Pediatr Int. 2012;54(2):205207

e442 NeoReviews
Downloaded from http://neoreviews.aappublications.org/ by guest on August 9, 2016

10. van Vonderen JJ, Hooper SB, Kroese JK, et al. Pulse oximetry
measures a lower heart rate at birth compared with
electrocardiography. J Pediatr. 2015;166(1):4953

28. Rabi Y, Singhal N, Nettel-Aguirre A. Room-air versus oxygen

administration for resuscitation of preterm infants: the ROAR
study. Pediatrics. 2011;128(2):e374e381

11. Kamlin CO, ODonnell CP, Everest NJ, Davis PG, Morley CJ.
Accuracy of clinical assessment of infant heart rate in the delivery
room. Resuscitation. 2006;71(3):319321

29. Rook D, Schierbeek H, Vento M, et al. Resuscitation of preterm

infants with different inspired oxygen fractions. J Pediatr. 2014;
164(6):13226.e3

12. Budin P. The Nursling. The Feeding and Hygiene of Premature

and Full-term InfantsLecture 1. Maloney WJ, trans. London:
The Caxton Publishing Company; 1907:1

30. Vento M, Moro M, Escrig R, et al. Preterm resuscitation with low

oxygen causes less oxidative stress, inammation, and chronic lung
disease. Pediatrics. 2009;124(3):e439e449

13. Mullany LC, Katz J, Khatry SK, LeClerq SC, Darmstadt GL,
Tielsch JM. Risk of mortality associated with neonatal
hypothermia in southern Nepal. Arch Pediatr Adolesc Med.
2010;164(7):650656

31. Vyas H, Milner AD, Hopkin IE, Boon AW. Physiologic responses to
prolonged and slow-rise ination in the resuscitation of the
asphyxiated newborn infant. J Pediatr. 1981;99(4):635639

14. Laptook AR, Salhab W, Bhaskar B; Neonatal Research Network.

Admission temperature of low birth weight infants: predictors and
associated morbidities. Pediatrics. 2007;119(3):e643e649
15. Reilly MC, Vohra S, Rac VE, et al; Vermont Oxford Network Heat
Loss Prevention (HeLP) Trial Study Group. Randomized trial of
occlusive wrap for heat loss prevention in preterm infants. J Pediatr.
2015;166(2):2628.e2
16. Vohra S, Frent G, Campbell V, Abbott M, Whyte R. Effect of
polyethylene occlusive skin wrapping on heat loss in very low birth
weight infants at delivery: a randomized trial. J Pediatr.
1999;134(5):547551
17. Vohra S, Roberts RS, Zhang B, Janes M, Schmidt B. Heat loss
prevention (HeLP) in the delivery room: a randomized controlled
trial of polyethylene occlusive skin wrapping in very preterm
infants. J Pediatr. 2004;145(6):750753
18. Chawla S, Amaram A, Gopal SP, Natarajan G. Safety and efcacy of
Trans-warmer mattress for preterm neonates: results of a
randomized controlled trial. J Perinatol. 2011;31(12):780784
19. Ibrahim CP, Yoxall CW. Use of self-heating gel mattresses
eliminates admission hypothermia in infants born below 28 weeks
gestation. Eur J Pediatr. 2010;169(7):795799
20. Knobel RB, Wimmer JE Jr, Holbert D. Heat loss prevention for
preterm infants in the delivery room. J Perinatol. 2005;25(5):
304308
21. te Pas AB, Lopriore E, Dito I, Morley CJ, Walther FJ. Humidied and
heated air during stabilization at birth improves temperature in
preterm infants. Pediatrics. 2010;125(6):e1427e1432
22. Doglioni N, Cavallin F, Mardegan V, et al. Total body polyethylene
wraps for preventing hypothermia in preterm infants: a
randomized trial. J Pediatr. 2014;165(2):261266.e1
23. DeMauro SB, Douglas E, Karp K, et al. Improving delivery room
management for very preterm infants. Pediatrics. 2013;132(4):
e1018e1025
24. Lee HC, Powers RJ, Bennett MV, et al. Implementation methods for
delivery room management: a quality improvement comparison
study. Pediatrics. 2014;134(5):e1378e1386
25. Russo A, McCready M, Torres L, et al. Reducing hypothermia in
preterm infants following delivery. Pediatrics. 2014;133(4):e1055e1062
26. Armanian AM, Badiee Z. Resuscitation of preterm newborns with
low concentration oxygen versus high concentration oxygen. J Res
Pharm Pract. 2012;1(1):2529
27. Kapadia VS, Chalak LF, Sparks JE, Allen JR, Savani RC, Wyckoff
MH. Resuscitation of preterm neonates with limited versus high
oxygen strategy. Pediatrics. 2013;132(6):e1488e1496

32. Wyllie J, Bruinenberg J, Roehr CC, et al. Urlesberger European

Resuscitation Council Guidelines for Resuscitation 2015 Section 7.
Resuscitation and support of transition of babies at birth.
Resuscitation. 2015;95:e249e263
33. te Pas AB, Walther FJ. A randomized, controlled trial of deliveryroom respiratory management in very preterm infants. Pediatrics.
2007;120(2):322329
34. Klingenberg C, Sobotka KS, Ong T, et al. Effect of sustained ination
duration; resuscitation of near-term asphyxiated lambs. Arch Dis
Child Fetal Neonatal Ed. 2013;98(3):F222F227
35. Harling AE, Beresford MW, Vince GS, Bates M, Yoxall CW. Does
sustained lung ination at resuscitation reduce lung injury in the
preterm infant? Arch Dis Child Fetal Neonatal Ed. 2005;90(5):
F406F410
36. Lindner W, Hgel J, Pohlandt F. Sustained pressure-controlled
ination or intermittent mandatory ventilation in preterm infants in
the delivery room? a randomized, controlled trial on initial
respiratory support via nasopharyngeal tube. Acta Paediatr. 2005;
94(3):303309
37. Lista G, Boni L, Scopesi F, et al; SLI Trial Investigators. Sustained
lung ination at birth for preterm infants: a randomized clinical
trial. Pediatrics. 2015;135(2):e457e464
38. Chettri S, Adhisivam B, Bhat BV. Endotracheal suction for
nonvigorous neonates born through meconium stained amniotic
uid: a randomized controlled trial. J Pediatr. 2015;166(5):
12081213.e1
39. Al Takroni AM, Parvathi CK, Mendis KB, Hassan S, Reddy I, Kudair
HA. Selective tracheal suctioning to prevent meconium aspiration
syndrome. Int J Gynaecol Obstet. 1998;63(3):259263
40. Peng TC, Gutcher GR, Van Dorsten JP. A selective aggressive
approach to the neonate exposed to meconium-stained amniotic
uid. Am J Obstet Gynecol. 1996;175(2):296301, discussion 301303
41. Yoder BA. Meconium-stained amniotic uid and respiratory
complications: impact of selective tracheal suction. Obstet Gynecol.
1994;83(1):7784
42. Chishty AL, Alvi Y, Iftikhar M, Bhutta TI. Meconium aspiration in
neonates: combined obstetric and paediatric intervention improves
outcome. J Pak Med Assoc. 1996;46(5):104108
43. Fox WW, Gutsche BB, DeVore JS. A delivery room approach to the
meconium aspiration syndrome (MAS): immediate intubation,
endotracheal suction, and oxygen administration can reduce
morbidity and mortality. Clin Pediatr (Phila). 1977;16(4):325328
44. Gregory GA, Gooding CA, Phibbs RH, Tooley WH. Meconium
aspiration in infantsa prospective study. J Pediatr. 1974;85(6):
848852
45. Wiswell TE, Tuggle JM, Turner BS. Meconium aspiration syndrome:
have we made a difference? Pediatrics. 1990;85(5):715721

Vol. 17 No. 8
Downloaded from http://neoreviews.aappublications.org/ by guest on August 9, 2016

AUGUST 2016

e443

46. Wiswell TE, Henley MA. Intratracheal suctioning, systemic

infection, and the meconium aspiration syndrome. Pediatrics.
1992;89(2):203206

54. Casalaz DM, Marlow N, Speidel BD. Outcome of resuscitation

following unexpected apparent stillbirth. Arch Dis Child Fetal
Neonatal Ed. 1998;78(2):F112F115

47. Ting P, Brady JP. Tracheal suction in meconium aspiration. Am J

Obstet Gynecol. 1975;122(6):767771

55. Harrington DJ, Redman CW, Moulden M, Greenwood CE. The

long-term outcome in surviving infants with Apgar zero at 10
minutes: a systematic review of the literature and hospital-based
cohort. Am J Obstet Gynecol. 2007;196(5):463.e1463.e5

48. Davis RO, Philips JB III, Harris BA Jr, Wilson ER, Huddleston JF. Fatal
meconium aspiration syndrome occurring despite airway management
considered appropriate. Am J Obstet Gynecol. 1985;151(6):731736
49. Dooley SL, Pesavento DJ, Depp R, Socol ML, Tamura RK, Wiringa
KS. Meconium below the vocal cords at delivery: correlation with
intrapartum events. Am J Obstet Gynecol. 1985;153(7):767770
50. Hageman JR, Conley M, Francis K, et al. Delivery room
management of meconium staining of the amniotic uid and the
development of meconium aspiration syndrome. J Perinatol. 1988;
8(2):127131
51. Manganaro R, Mam C, Palmara A, Paolata A, Gemelli M. Incidence
of meconium aspiration syndrome in term meconium-stained
babies managed at birth with selective tracheal intubation. J Perinat
Med. 2001;29(6):465468

56. Kasdorf E, Laptook A, Azzopardi D, Jacobs S, Perlman JM.

Improving infant outcome with a 10 min Apgar of 0. Arch Dis Child
Fetal Neonatal Ed. 2015;100(2):F102F105
57. Laptook AR, Shankaran S, Ambalavanan N, et al; Hypothermia
Subcommittee of the NICHD Neonatal Research Network.
Outcome of term infants using Apgar scores at 10 minutes following
hypoxic-ischemic encephalopathy. Pediatrics. 2009;124(6):
16191626
58. Patel H, Beeby PJ. Resuscitation beyond 10 minutes of term babies
born without signs of life. J Paediatr Child Health. 2004;40(3):
136138

52. Rossi EM, Philipson EH, Williams TG, Kalhan SC. Meconium
aspiration syndrome: intrapartum and neonatal attributes. Am J
Obstet Gynecol. 1989;161(5):11061110

59. Sarkar S, Bhagat I, Dechert RE, Barks JD. Predicting death despite
therapeutic hypothermia in infants with hypoxic-ischaemic
encephalopathy. Arch Dis Child Fetal Neonatal Ed. 2010;95(6):
F423F428

53. Suresh GK, Sarkar S. Delivery room management of infants born

through thin meconium stained liquor. Indian Pediatr. 1994;31(10):
11771181

60. Mckinsey S, Perlman JM. Resuscitative interventions during

simulated asystole deviate from the recommended timeline. Arch
Dis Child Fetal Neonatal Ed. 2016;101(3):F244F247.

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NeoReviews Quiz
There are two ways to access the journal CME quizzes:
1. Individual CME quizzes are available via a handy blue CME link in the Table of Contents of any issue.
2. To access all CME articles, click Journal CME from Gateways orange main menu or go directly to: http://www.
aappublications.org/content/journal-cme.

1. Your hospital team is in the process of implementing the new Neonatal Resuscitation
Program (NRP) guidelines. Which of the following statements correctly describes the
Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process
that informs guideline development?
A. The GRADE process classies articles as either include or exclude based on the
merits of the study.
B. Randomized studies start off as high-quality evidence, but may be downgraded
due to methodological quality.
C. The strength of studies considered for inclusion is determined by the study type
and precision of effect, but does not take into account whether the population
studied is the same as that for which the guideline will be used.
D. Although assessing the strength of the studies is part of the GRADE process of
review, the nal recommendations do not have any language to indicate whether it
is a strong or weak recommendation.
E. Observational studies can only be included in the process if there are no randomized trials that are relevant to the question at hand.
2. You are at the delivery of a 31-week-gestational-age infant. You are discussing the
management of cord clamping with the obstetric and pediatric teams. The plan is to
clamp and cut the cord 60 seconds after delivery. Which of the following statements
correctly describes the relationship of delayed cord clamping (DCC) and potential
effects?
A. Most of the literature on the subject suggests that DCC is most benecial when the
infant does not cry until after cord clamping.
B. DCC is associated with increased placental transfusion, increased cardiac output,
and increase in low-grade intraventricular hemorrhage, with decreased risk of highgrade intraventricular hemorrhage.
C. The current recommendation from ILCOR is a strong recommendation to delay
umbilical cord clamping for all preterm infants.
D. The new guidelines state that DCC for longer than 30 seconds is reasonable for
both term and preterm infants who do not require resuscitation at birth.
E. The ILCOR and NRP recommendation for maximum time until cord clamping is 120
seconds.

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3. You are at the delivery of a term male infant. The infant is apneic and is receiving warming,
drying, and stimulation after being brought to the radiant warmer. Which of the following
is an appropriate method to assess heart rate?
A. In this case, there is no reason to assess heart rate until the apnea is resolved, because the resuscitation steps will be the same regardless of heart
rate.
B. Auscultation of the heart rate at the chest should be the main method of
assessment unless the infant eventually undergoes intubation.
C. Electrocardiography may provide a faster and more accurate measurement of heart
rate than oximetry in infants requiring resuscitation.
D. Pulse oximetry should only be applied to the infant 2 minutes after delivery or later.
E. Palpation of the umbilical cord should be the main method of assessment unless it
has been cut too short for this purpose.

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4. The resuscitation team is brieng before the cesarean delivery for a mother who is at 28
weeks gestation. Which of the following plans for setting the initial oxygen concentration
for starting resuscitation is consistent with the new NRP guidelines?
A.
B.
C.
D.
E.

21%30%.
30%40%.
50%60%.
70%100%.
The new guidelines do not specify a specic range, but recommend somewhere
above 21% and below 100%.

5. The labor and delivery unit calls for a pediatrics team for meconium-stained amniotic uid
in a term infant with no other specied maternal risk factors. Which of the following
regarding planning for this delivery is consistent with the new NRP guidelines regarding
this issue?
A. There is no need for a pediatrics team to attend this delivery.
B. The decision for intubation versus no intubation for tracheal suctioning should be
based on the thickness of the meconium-stained uid.
C. The decision for intubation versus no intubation for tracheal suctioning should be
based on whether the infant is vigorous at birth or not.
D. If the infant presents with poor tone and inadequate breathing efforts, the initial
steps for resuscitation can be completed under the radiant warmer and positive
pressure ventilation provided if the infant is not breathing or heart rate is less than
100 beats per minute.
E. The infant should undergo intubation at least once for tracheal suctioning and
further attempts determined by the consistency of the suctioned uid.

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Highlights of the New Neonatal Resuscitation Program Guidelines

Jeffrey M. Perlman
NeoReviews 2016;17;e435
DOI: 10.1542/neo.17-8-e435

Updated Information &

Services

including high resolution figures, can be found at:

http://neoreviews.aappublications.org/content/17/8/e435

References

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http://neoreviews.aappublications.org/content/17/8/e435#BIBL

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Highlights of the New Neonatal Resuscitation Program Guidelines

Jeffrey M. Perlman
NeoReviews 2016;17;e435
DOI: 10.1542/neo.17-8-e435

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://neoreviews.aappublications.org/content/17/8/e435

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