Neonatal Resuscitation Science, Education, And Practice
DOI: 10.1097/JPN.0b013e318253e1aaContinuing EducationC 2012 Wolters Kluwer Health Lippincott Williams & WilkinsJ Perinat Neonat Nurs r Volume 26 Number 2, 158–163 r Copyright Neonatal Resuscitation Science,Education, and PracticeThe Role of the Neonatal Resuscitation ProgramJane E. McGowan, MDABSTRACTFor almost 25 years, the Neonatal Resuscitation Program ofthe American Academy of Pediatrics has provided educational tools that are used in the United States and throughout the world to teach neonatal resuscitation. Over thattime period, the guidelines for resuscitation have been increasingly evidence-based and a formal system has beenestablished to determine which steps should be updatedon the basis of available information. The most recent update occurred in 2010. This article describes the evidencereview process and the specific evidence that lead to anumber of significant changes in practice that were included in the 2010 guidelines.Key Words: evidence-based medicine, oxygen, neonatalresuscitation, newbornffective resuscitation of the newborn with depression has been the subject of many publications, ranging from Victorian novels to entire textbooks. Yet until relatively recently, practicewas guided primarily by empiric data and suppositionrather than rigorous evaluation. Under the leadership ofthe American Academy of Pediatrics and the AmericanHeart Association, practice guidelines for neonatal resuscitation were developed and have evolved over thepast 25 years, becoming increasingly evidence-basedover that period.EAuthor Affiliation: Department of Pediatrics, Drexel UniversityCollege of Medicine, and St. Christopher’s Hospital for Children,Philadelphia, Pennsylvania.Disclosure: Dr McGowan receives a stipend from the AmericanAcademy of Pediatrics as associate editor of the NeonatalResuscitation Textbook.Correspoding Author: Jane E. McGowan, MD, Neonatology, StChristopher’s Hospital for Children, 2nd Floor, 3601 A St, Philadelphia,PA 19134 (jane.mcgowan@drexelmed.edu).Submitted for publication: November 30, 2011; accepted for publication:March 2, 2012.158www.jpnnjournal.comThe Neonatal Resuscitation Program (NRP) had itsorigins in the Neonatal Education Program developedat the Drew Postgraduate Medical School in Los Angelesin the mid-1970s. Shortly thereafter, in light of the increasing number of intensive care nurseries throughoutthe United States, the American Academy of Pediatricsasked Dr George Peckham to develop a standardizedapproach to the teaching and practice of neonatal resuscitation that could be disseminated to practitioners.With the support of the American Academy of Pediatrics Section on Perinatal Pediatrics and a grant fromMead Johnson, a modified version of the Neonatal Education Program was developed by a group of providersled by Dr Peckham as well as Dr Ronald Bloom andCathy Cropley, MSN, RN, and was dubbed the “Neonatal Resuscitation Program.” The first regional instructorcourses were conducted in 1987 by some of the founding members, and the individuals who participated inthese courses started the cascade that has continued tothe present. As of 2008, there were more than 2 millionproviders who had been trained by more than 27 000instructors.Although material contained in the initial NRPcourses was, in large part, based on what was then considered standard practice, one of the key principles ofthe NRP from the beginning was to base practice guidelines on evidence whenever possible. By the 1990s, theAmerican Heart Association, along with other international resuscitation councils and the American Academyof Pediatrics (collectively known as the International Liaison Committee on Resuscitation, or ILCOR), had begun to develop a process for reviewing the literature onresuscitation and emergency cardiac care with the goalof evaluating current practice in the context of availableevidence and modifying clinical care guidelines whenindicated. The first set of comprehensive internationalguidelines was published in 2000.April/June 2012Copyright 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
THE ILCOR REVIEW PROCESSThe current process for evaluating available evidence todetermine whether practice changes are warranted occurs on a 5-year cycle and requires rigorous evaluationof the literature and, often, heated discussion amongthose charged with completing the review process. Forthose in the ILCOR Neonatal Task Force, the processbegins with a meeting of its members shortly after thepublication of the previous guidelines to identify unanswered question and new topics to be investigated. Thetopics are assigned to task force members for review.The review process consists of a literature search, followed by a rigorous assessment of the relevant literature. The information from the review is synthesizedto develop a Consensus on Science statement, and aTreatment Recommendation is made on the basis of theavailable evidence. The steps from the initial meetingof the task force to the final results take almost 5 years.This process is outlined in the following text (Figure 1).The most recent ILCOR review was completed inearly 2010, and the Guidelines for Neonatal Resuscitation, developed by the members of the NRP SteeringCommittee using the Consensus on Science and Treat-Figure 1. International Liaison CommitteeResuscitation (ILCOR) evidence review process.The Journal of Perinatal & Neonatal Nursingonment Recommendations (CoSTR) document written bythe ILCOR Neonatal Task Force, were published in October 2010.1 On the basis of the evidence presented,a number of significant practice changes were recommended. Although the most significant changes dealwith the use of supplementary oxygen, the changesin practice described impact all aspects of resuscitation,from the initial steps to educational methodology. Someof the most substantive changes are described here.OxygenThe recommendations for use of supplementary oxygen during resuscitation of the newborn have changedsignificantly compared with previous guidelines. In thefifth edition of the Neonatal Resuscitation Textbook,providers were instructed to provide free-flow oxygen for babies who were breathing but had “persistent cyanosis.” However, a study by O’Donnell et al2demonstrated that there is very little correlation between the perception of skin color by providers andactual oxygen saturation as measured by pulse oximetry. Furthermore, even brief exposure to oxygen hasbeen associated with detrimental effects, including persistent evidence of oxidative stress, delay in taking thefirst spontaneous breath, and even an increase in theincidence of childhood leukemia.3,4 Thus, the currentrecommendation is to use pulse oximetry to assess oxygenation in any infant in whom use of supplementaryoxygen is considered, whether administered via a freeflow device or positive pressure ventilation (PPV). Toprovide sufficient but not excessive oxygen during thefirst few minutes after birth, providers should attemptto match the oxygen saturation (SpO2 ) levels measuredas those in healthy term infants.5,6In cases where PPV is deemed necessary, the NRPhas previously recommended the use of 100% oxygen.However, since the late 1990s, evidence has been growing to suggest that in many cases, 100% oxygen is notnecessary for effective resuscitation and, in some instances, may be detrimental. Although there was considerable discussion during the 2005 consensus conference regarding the oxygen concentration (FIO2 ) to useto initiate resuscitation in term infants, the membersof the NRP Steering Committee came to the conclusion then that the evidence was not strong enough towarrant a change in practice. Additional evidence wasreviewed by the neonatal task force for the 2010 guidelines, including several meta-analyses that showed similar or better outcomes7,8 as well as less evidence ofoxidative stress9 in term infants resuscitated with 21%oxygen compared with those resuscitated with 100%oxygen. In addition, recent studies in animal models ofpulmonary hypertension suggest that initial ventilationwith 100% oxygen does not result in lower pulmonarywww.jpnnjournal.comCopyright 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.159
artery pressures than by use of 21% oxygen and mayblunt the pulmonary vascular response to later treatment with inhaled nitric oxide.10,11 On the basis of thisevidence, the recommendations in the sixth edition textbook are to use 21% oxygen when initiating PPV in terminfants, as well as in bradycardic infants, to increase theFIO2 if there is no improvement in heart rate within 90seconds.Fewer data are available regarding the use of oxygenduring resuscitation of preterm infants, although optimization of oxygen administration is even more criticalin these babies since they are more susceptible to oxidant injury. Several studies have been published thatcompare resuscitation of preterm infants with variousinitial oxygen concentrations ranging from 21% to 100%and subsequent titration of the FIO2 up or down basedon SpO2 and response to resuscitation.12,13 The resultsof these studies suggest that starting resuscitation ofpreterm infants with 100% oxygen may result in periods of hyperoxemia whereas initial resuscitation with21% oxygen may be associated with marked hypoxemia during the first few minutes after birth in somepreterm infants. Clearly, further studies are needed tofurther refine the management of oxygen use duringresuscitation in the preterm population, particularly inthose infants who are less than 28 weeks’ gestation. Inthe absence of additional data, the recommendation inthe sixth edition is to use blended oxygen to resuscitatepreterm infants, titrating the FIO2 up or down as neededto achieve the same target SpO2 levels as those in terminfants. There currently is insufficient evidence to allow identification of the optimal starting oxygen levelbetween 30% and 90%, the minimum and maximumlevels of blended oxygen used in studies to date.It is important to keep in mind that the sixth editionguidelines for the use of oxygen are based on investigations completed as of mid-2010 and reflect only theconditions and populations investigated by the authorsof those studies. For example, there have been no published studies comparing resuscitation with an oxygenconcentration greater than 21% (eg, 40%) with use of21% or 100% oxygen in term infants. In addition, thedegree of compromise in the subjects studied variedwidely. Thus, it is not possible to draw conclusions regarding the potential risks or benefits of using specificoxygen concentrations in infants with severe asphyxia,due to the likelihood that the number of such infantswas not high enough to make this determination, evenin the largest studies.depression in the newborn result from decreased orabsent respiratory drive with subsequent failure to adequately clear fetal lung fluid and establish the functional residual volume.14 This leads to hypoxemia andprevents the normal increase in blood oxygen levelsand resulting decrease in pulmonary artery pressures.If PPV is provided in an effective and timely fashion,the situation can be reversed quickly and the baby’srespiratory status and heart rate will increase.14 However, ensuring adequate ventilation can be difficult inthe newborn. There are no current readily availablemethods for measuring the volume delivered with eachpositive pressure breath or to determine whether functional residual capacity has been established in the absence of a clinical response. However, if chest compressions are initiated in response to the presence ofa heart rate of less than 60 breaths per minute whenventilation is not being provided effectively, the heartrate is unlikely to improve.1 This dilemma likely occursmore often than realized during resuscitation, particularly when the providers do not participate in neonatalresuscitations on a regular basis.In previous editions of the NRP, initiation of chestcompressions was recommended if the heart rate remained low after 30 seconds of effective ventilation. Ifthe expected response to PPV does not occur, a series of corrective actions should be taken, includingadjusting the mask on the face to ensure a good seal,repositioning the baby’s head to make sure the airwayis open, suctioning the oropharynx to remove any secretions that might be preventing adequate air entry,opening the baby’s mouth slightly, and increasing theamount of positive pressure being delivered with eachbreath. If there is still no improvement, placement ofa secure airway such as an endotracheal tube or laryngeal mask airway should be considered. Only afterall of the ventilation corrective steps have been takenwithout an improvement in heart rate should a memberof the team begin chest compressions. It is importantto remember that chest compressions are not effectivein improving circulation if oxygen delivery to the myocardium is inadequate, as is the case if the baby isnot being ventilated properly. Thus, even after chestcompressions are started, ongoing assessment of ventilation, including repeating some or all of the steps of theMRSOPA pathway (depending on airway status), maybe necessary to ensure that effective ventilation is stillbeing provided, especially if the baby is not improving.Ensuring effective ventilationThe NRP has always emphasized that the key to resuscitation of the newborn with depression is effectiveventilation. In most cases, bradycardia and respiratoryChest compressionsOne of the major differences between the algorithmfor resuscitation in neonates and those used to guideresuscitation in older children and adults is the ratio of160www.jpnnjournal.comApril/June 2012Copyright 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
chest compressions to ventilations used. In the latter2 groups, the standard compressions to ventilationsratio is 15:2; in contrast, the NRP guidelines call for thecompressions to ventilation ratio of 3:1. Although therehas been considerable discussion regarding whetherneonates would benefit from a higher compression toventilation ratio, there is currently no evidence to support a change in practice. The rationale for suggesting ahigher ratio comes from studies that show that in adultanimal models, giving a greater number of compressions before stopping to ventilate improves coronaryartery perfusion and therefore myocardial function.However, there is a significant difference between theneonate requiring resuscitation and other patient populations, that is, in the vast majority of cases, the etiologyof cardiac arrest or bradycardia in a neonate is respiratory in origin.15 This is in contrast to the situation in theadult with cardiac arrest, where by far the most common cause is ventricular fibrillation or another acutecardiac event. In children greater than 6 months of age,there is a greater incidence of respiratory disease contributing to the need for resuscitation than in the adult,but a significant percentage of arrests are also due to aprimary cardiac problem.16 Another difference betweenresuscitation in the newborn (ie, delivery room resuscitation) and resuscitation in other patient populationsis that the apneic infant in the delivery room may havebeen hypoxemic and bradycardic for some period oftime before birth and therefore is more likely to behypercarbic than the adult who, up until the momentof cardiac arrest, may have had normal respiratoryfunction and normal blood gases.17 These differences,combined with the absence of any data showing benefitto increasing the number of consecutive chest compressions per cycle in the neonate, support the continueduse of the compressions to ventilation ratio of 3:1.There are also some changes in the procedurefor providing chest compressions in the sixth editionNeonatal Resuscitation Textbook. Several studies haveshown that the 2-thumb technique is more effectivethan the 2-finger technique with regard to depth of compressions, pressure delivered, and consistency.18,19 Inaddition, because there is an as yet unresolved questionregarding the potential benefit of fewer interruptions inproviding chest compressions, the time line in the algorithm has been modified. Although evaluation at approximately 30-second intervals is still recommendedduring the initial steps and when PPV is started, oncechest compressions are being performed, the intervalfor assessing heart rate changes to 45 to 60 secondsin order to decrease the frequency of interruptions ofchest compressions which, in adult animal models, hasbeen shown to decrease diastolic blood pressure andcoronary perfusion pressure.20 However, a study of 5The Journal of Perinatal & Neonatal Nursingadults with cardiac arrest found that blood pressure increased during pauses to assess cardiac rhythm21 ; thus,there is no conclusive evidence to support a change to alonger interval of chest compressions at present. Sincemost infants who reach the point of requiring chestcompressions will have a pulse oximeter in place, itmay be possible to assess heart rate without stoppingcompressions. However, if the baby is severely bradycardic and/or hypotensive, the pulse oximeter may notbe able to detect adequate signal to provide a heart ratevalue. Thus, there will still be times when compressionsmust be interrupted to auscultate for heart rate.The guidelines for administration of epinephrine ininfants with severe bradycardia or undetectable heartrate remain the same, that is, epinephrine should beadministered via the intravenous route. There is ongoing research to determine the optimal dosing ofepinephrine as well as whether higher doses given viathe endotracheal route might be effective. However, nonew evidence has been published to support a changein the currently recommended dosing.EDUCATIONAlthough the tendency is to focus on the steps of theresuscitation algorithm in any discussion of neonatalresuscitation, one cannot forget that no matter whattechniques are recommended, they are effective onlyif delivered correctly. Thus, the most critical component of the algorithm may well be the NRP instructor.The NRP has relied on thousands of hospital-based andregional trainers to disseminate the educational program to providers throughout the country and aroundthe world. Feedback from instructors and providers hasguided some of the changes in the course materials andthe approach to teaching for more than 20 years. Forexample, the fourth edition reflected a change to aneducational approach that embraced principles of adultlearning. The sixth edition brings even more significantchanges in the way in which NRP education will beprovided.The changes in how NRP courses are taught resultedfrom looking at the process of adult education froma different perspective. In addition to cognitive skills,evaluated by the examination, and hands-on skills, evaluated by the skills stations and Megacode, there hasbeen increasing recognition that the ability to successfully resuscitate a newborn also requires communication and teamwork skills. The last group of skills ismuch more difficult to teach and requires a differentapproach to learning. Whereas there is a right wayand a wrong way to answer a factual questions (eg, “What is the compression to ventilation ratio?”) or how toperform bag-mask ventilation, there are many differentwww.jpnnjournal.comCopyright 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.161
approaches to working as a team during the resuscitation of a newborn. Determining the best way to facilitatethe development of teamwork skills is a challenge facedby the members of the NRP Steering Committee and hasbeen a topic of discussion for a number of years. Onthe basis of these discussions, as well as informationderived from the NRP instructor survey and conversations with long-time instructors a
Neonatal Resuscitation Science, Education, and Practice The Role of the Neonatal Resuscitation Program Jane E. McGowan, MD ABSTRACT For almost 25 years, the Neonatal Resuscitation Program of the American Academy of Pediatrics has provided educa-tional tools that are used in the United States and thr
matters in neonatal resuscitation. Instead of Apgar score, healthcare professionals will focus on three factors at the time of birth: airway, breathing, and circulation. While adult resuscitation guidelines have moved to CAB, neonatal resuscitation still follows the ABCs because most neonatesFile Size: 1MBPage Count: 18
Neonatal The extensively revised and updated 6th edition of the Neonatal Resuscitation Resuscitation Program (NRP) textbook and accompanying DVD-ROM are designed in accord with the program’s curriculum changes and sharpened focus on active, hands-on learning. The text facilitates the
The Neonatal Resuscitation Program (NRP) of the American Academy of Pediatrics and the American Heart Association has been a prominent leader of neonatal resuscitation develop-ment and is now in its third decade. The NRP, along with other neonatal resuscitation programs, has been taught in
1. Foundations of Neonatal Resuscitation 2. Preparing for Resuscitation 3. Initial Steps of Newborn Care 4. Positive-pressure Ventilation 5. Alternative Airways 6. Chest Compressions 7. Medications 8. Post-resuscitation Care 9. Resuscitation and Stabilization of Babies Born Preterm 10. Special Considerations 11. Ethics and Care at the End of Life
related neonatal deaths (RR 0.70, 95%CI 0.59-0.84); this estimate was used for the effect of facility-based basic neonatal resuscitation (additional to stimulation). The evidence for preterm mortality effect was low quality and thus expert opinion was sought. In community-based studies, resuscitation
Part 11: Neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recom-mendations. Resuscitation 2010;81:e260–e287. Corresponding author at: The James
Fact Sheet; Neonatal Biology –An Overview Part 3. Journal of Neonatal Nursing, 17(4), 128-131. Petty, J. (2011b). Fact Sheet; Neonatal Biology –An Overview Part 2. Journal of Neonatal Nursing, 17(3), 89-91. Petty, J. D. (2011c). Fact Sheet; Neonatal Biology –An Overview Part 1. Journal of Neonatal Nursing, 17(1), 8-10. For further detail and more resources, go to the online resource .
Centre for Comparative and Clinical Anatomy, University of Bristol, Southwell Street, Bristol, BS2 8EJ. Receipt of these documents is a condition of our acceptance. If we do not receive these documents within 14 days of registration of the death we will be required to decline the bequest. At the time of donation the next of kin or executor will be asked to complete form ‘Instructions for the .
