Elsevier

Resuscitation

Volume 40, Issue 2, March 1999, Pages 71-88
Resuscitation

Special Report
Resuscitation of the newly born infant: an advisory statement from the Pediatric Working Group of the International Liaison Committee on Resuscitation,☆☆

https://doi.org/10.1016/S0300-9572(99)00012-XGet rights and content

Abstract

The International Liaison Committee on Resuscitation (ILCOR), with representation from North America, Europe, Australia, New Zealand, Africa, and South America, was formed in 1992 to provide a forum for liaison between resuscitation organizations in the developed world. This consensus document on resuscitation extends previously published ILCOR advisory statements on resuscitation to address the unique and changing physiology of the newly born infant within the first few hours following birth and the techniques for providing advanced life support. After careful review of the international resuscitation literature and after discussion of key and controversial issues, consensus was reached on almost all aspects of neonatal resuscitation, and areas of controversy and high priority for additional research were delineated. Consensus on resuscitation for the newly born infant included the following principles. (i) Personnel trained in the basic skills of resuscitation should be in attendance at every delivery. A minority (fewer than 10%) of newly born infants require active resuscitative interventions to establish a vigorous cry and regular respirations, maintain a heart rate greater than 100 beats per minute (bpm), and maintain good color and tone. (ii) When meconium is present in the amniotic fluid, it should be suctioned from the hypopharynx on delivery of the head. If the meconium-stained newly born infant has absent or depressed respirations, heart rate, or muscle tone, residual meconium should be suctioned from the trachea. (ii) Attention to ventilation should be of primary concern. Assisted ventilation with attention to oxygen delivery, inspiratory time, and effectiveness judged by chest rise should be provided if stimulation does not achieve prompt onset of spontaneous respirations and/or the heart rate is less than 100 bpm. (iv) Chest compressions should be provided if the heart rate is absent or remains less than 60 bpm despite adequate assisted ventilation for 30 s. Chest compressions should be coordinated with ventilations at a ratio of 3:1 and a rate of 120 ‘events’ per minute to achieve approximately 90 compressions and 30 rescue breaths per minute. (v) Epinephrine should be administered intravenously or intratracheally if the heart rate remains less than 60 bpm despite 30 s of effective assisted ventilation and chest compression circulation. Common or controversial medications (epinephrine, volume expansion, naloxone, bicarbonate), special resuscitation circumstances affecting care of the newly born, continuing care of the newly born after resuscitation, and ethical considerations for initiation and discontinuation of resuscitation are discussed. There was agreement that insufficient data exist to recommend changes to current guidelines regarding the use of 21% versus 100% oxygen, neuroprotective interventions such as cerebral hypothermia, use of a laryngeal mask versus endotracheal tube, and use of high-dose epinephrine. Areas of controversy are identified, as is the need for additional research to improve the scientific justification of each component of current and future resuscitation guidelines.

Section snippets

Purpose

The International Liaison Committee on Resuscitation (ILCOR) was formed in 1992 to provide a forum for liaison between the following principal resuscitation organizations in the developed world: the American Heart Association (AHA), European Resuscitation Council (ERC), Heart and Stroke Foundation of Canada (HSFC), Australian Resuscitation Council (ARC), Resuscitation Council of Southern Africa (RCSA), and Council of Latin America for Resuscitation (CLAR). Since 1992, international consensus

Need for BLS and ALS guidelines for the newly born

Resuscitation of the newly born infant presents a different set of challenges than resuscitation of the adult or even the older infant or child. The transition from dependence on placental gas exchange in a liquid-filled intrauterine environment to spontaneous breathing of air presents dramatic physiological challenges to the infant within the first minutes to hours after birth. Approximately 5–10% of the newly born population require some degree of active resuscitation at birth (e.g.

Personnel

Personnel trained in the basic skills of resuscitation at birth should be in attendance at every delivery. Ideally, at least one person should be responsible solely for the care of the infant. A person trained in ALS techniques for the newly born should be available for normal low-risk deliveries and in attendance for all deliveries considered at high risk for neonatal resuscitation. Appendix A lists the maternal, fetal, and intrapartum circumstances that place the newly born infant at risk.

Techniques of resuscitation

The techniques of ALS resuscitation are discussed below and are outlined in the Fig. 1, which shows the universal template for ALS of the newly born.

Special resuscitation circumstances

Several circumstances have unique implications for resuscitation of the newly born infant. Birth attendants are sometimes aware of these special circumstances through prenatal diagnostic information. While the implications of these circumstances for resuscitation are described below, full consideration and discussion of these entities are beyond the scope of this advisory statement.

Continuing care of the newly born infant after resuscitation

After resuscitation with ALS, ongoing supportive care, monitoring, and appropriate diagnostic evaluation must be provided. Once adequate ventilation and circulation have been established, the infant who has required resuscitation is still at risk and should be maintained in or transferred to an environment in which close monitoring and anticipatory care can be provided. This should include oxygen saturation and heart rate monitoring with blood gas measurement as indicated. Blood pressure should

Initiation of resuscitation

The delivery of extremely immature infants and those with severe congenital anomalies raises questions about initiation of resuscitation [77], [78], [79], [80], [81]. In such cases, initiation of resuscitation at delivery does not mandate continued support. Non-initiation of support and later withdrawal of support are generally considered to be ethically equivalent; however, the latter approach allows time to gather more complete clinical information and to provide counseling to the family.

Documentation of resuscitation

It is essential for good clinical care, for communication, and for medicolegal concerns that the findings at each assessment and the actions taken in resuscitation are fully documented. The Apgar scores quantify and summarize the response of the newly born infant to the extrauterine environment and to resuscitation [84], [85]. An Apgar score is used to assess and record breathing, heart rate, muscle tone, reflex irritability, and color at 1 and 5 min after birth and then sequentially every 5

Areas of controversy and need for additional research

The ILCOR Pediatric Working Group recognizes the difficulty in creating advisory statements for universal application. After careful review of the rationale for current guideline recommendations from among the constituent resuscitation councils (Table 2), the working group identified the following areas of controversy regarding resuscitation of the newly born infant. The group believes that additional research is required in these areas before more specific, evidence-based universal ALS

Summary

Scientific justification of each component of current resuscitation council guidelines is difficult because of the paucity of outcome data specifically addressing interventions in the newly born. Rapid transitions from intrauterine to extrauterine physiology further complicate the interpretation of findings and make education of trained birth attendants more complex. Assessment, stimulation, and provision of the first breaths of life are simultaneous critical steps in initial resuscitation of

Pediatric and neonatal ILCOR participants and expert reviewers

Walter Kloeck, MD; Efraim Kramer, MD; Jelka Zupan, MD; Amelia Reis, MD; David Burchfield, MD; David Boyle, MD; Waldemar Carlo, MD; Linda McCollum, RN; Susan E. Denson, MD; Martha Mullett, MD; Alfonso Solimano, MD; Michael Speer, MD; Jeffrey Perlman, MD; Robert Berg, MD; Robert Hickey, MD; Amy Davis, RN; Jay Deshpande, MD; Thomas Terndrup, MD; Lisa Carlson, RN; Mary E. Fallat, MD; Dianne Atkins, MD; Sally Reynolds, MD; Charles Schleien, MD; Tres Scherer, MD; Pip Mason; Petter Steen, MD; Richard

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    ‘Resuscitation of the Newly Born Infant’ is being copublished in Circulation, Pediatrics, Resuscitation and European Journal of Pediatrics.

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