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Following a recent case involving a neonatal resuscitation performed by general paediatricians, it has become apparent that the instructions for assessing circulation in neonates during resuscitation at birth contained within the Advanced paediatric life support (APLS) course and manual1 are not explicit, and do not highlight the differences between neonatal and paediatric resuscitation practices.
Assessment of circulation in paediatric life support involves checking the pulse, usually at the brachial or femoral artery. The International Liaison Committee on Resuscitation (ILCOR) advisory statement on resuscitation of the newly born infant2 states that heart rate should be determined by listening to the precordium with a stethoscope, feeling for pulsations at the base of the umbilical cord, or feeling the brachial or femoral pulse. It also points out that central and peripheral pulses are often difficult to feel in infants and should not be relied on independently, if they are absent. This has recently been confirmed by findings in healthy term neonates with heart rates of >100 beats/min on auscultation at 5 minutes of age of impalpable pulses in 20–60%, dependent on the artery palpated.3
The APLS chapter on neonatal resuscitation refers to checking the heart rate rather than the pulse,1 but it does not elucidate how this should be done. The European paediatric life support (EPLS) course and manual chapter on resuscitation of the newborn4 does explain how the circulatory status may be assessed, references the ILCOR advisory statement, but errs towards palpation of the umbilical artery rather than an audible heart rate, and does not add the proviso contained within the ILCOR advisory statement regarding absence of a palpable pulse. Only within the Newborn life support (NLS) course and manual5 do the guidelines on assessment of heart rate echo the advisory statement from ILCOR, particularly with reference to weak or absent pulses.
Termination of neonatal resuscitation efforts can be difficult to manage for neonatologists, as even apparently stillborn neonates may respond to prolonged and vigorous resuscitation efforts with relatively good outcomes.6 Among the vast majority of non-neonatologists in the United Kingdom who are very occasionally called upon in this difficult situation, the APLS or EPLS course may constitute the limit of their neonatal resuscitation training, potentially making these decisions even more difficult, because of the lack of specific clarification on how to assess circulatory status and heart rate in neonates. We would urge all those who may at any time undertake neonatal resuscitation to follow the ILCOR advisory statement, and encourage all courses and manuals that include neonatal resuscitation to make their recommendations explicit and concordant with that statement. The Advanced Life Support Group and Resuscitation Council (UK) have both been made aware of our concerns.
Competing interests: none declared