Maureen D.

McCollough, MD, MPH, FACEP

Associate Professor of Pediatrics and Emergency
Medicine, Keck USC School of Medicine; Director,
Pediatric Emergency Medicine, Department of
Emergency Medicine, Los Angeles County USC
Medical Center, Los Angeles, California
Advanced Pediatric Emergency
Medicine Assembly

March 11 14, 2013

Lake Buena Vista, FL

Newborn Resuscitation 2013

A 14-year-old female presents with abdominal pain to
the ED and promptly delivers a premature infant. How
do you prepare to resuscitate this newborn? This expert
will discuss determining viability and the latest
guidelines in newborn resuscitation. Controversies such
as use of oxygen in resuscitation and use of IO for IV
access will be discussed.

Describe methods of determining viability in a

newly born infant.
Outline steps in newborn resuscitation and describe
use of blended oxygen.
Identify controversies in newborn resuscitation
including use of oxygen and vascular access
techniques.

3/12/2013
1:15pm 2:00pm

(+)No significant financial relationships to disclose

 Maureen McCollough MD, FACEP
Associate Professor of Pediatrics and Emergency Medicine
Keck USC School of Medicine
Director, Division of Pediatric Emergency Medicine
Department of Emergency Medicine
Los Angeles County USC School of Medicine

Neonatal Resuscitation

Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care (AHA/ILCOR: American Heart Association and International Liaison Committee on Resuscitation)
*** points here geared for the emergent delivery of a newborn in the ED
applies to newly born and neonates during first few weeks of life
10% newly born require some assistance to begin breathing at birth; 1% require more intensive resuscitation
measures
perinatal asphyxia can only be predicted antenatally 60% of the time; rest not identified until birth
80% of low birth weight babies require resuscitation and stabilization at delivery

High Risk Deliveries:
Maternal very young, advanced age, DM, HTN, substance abuse, hx of stillbirth, fetal loss, early neonatal death
Infant premature, postmature, congenital anomalies, twins/triplets
Antepartum placenta issues e.g. placenta previa, oligohydramnios, polyhydramnios
Delivery breech, transverse lie, chorioamnionitis, foulsmell or meconiumstained amniotic fluid, antenatal
asphyxia with abnormal fetal heart rate, maternal narcotics within 4 hours of birth, delivery needing
instrumentation like forceps, vacuum, cesarean delivery
Preterm Infant issues:
Risk of heat loss increases the more premature the infant is; large body surface area, thin skin, lack of subcut fat
Immature lungs which lack surfactant; immature respiratory drive; weak muscles
Maternal infection predispose to prematurity and immature immune systems pose risks
Immature organ tissue and blood vessels leads to retinopathy of prematurity and intracranial hemorrhages
Immature antioxidant defense systems cannot counteract free radicals leading to possible necrotizing
enterocolitis or bronchopulmonary dysplasia.

For ED deliveries, appropriate equipment must be readily available and organized
Organized neonatal resuscitation cart leads to faster supply/equipment acquisition and higher satisfaction scores
among staff. (Chitkara R et al BMJ Qual Saf Feb 2013)
small hospitals must be prepared for deliveries of all gestational ages
Preterm infant additional resources
Warming equipment and polyethylene wraps for infants less than 28 weeks
Pulse oximeter, compressed oxygen source, oxygen blenders

 Neonatal Resuscitation Clinical Trials vs Expert Opinions Randomized clinical trials difficult to perform in delivery
room because of difficulty in getting consents before resuscitation, difficulty blinding to treatment arms, and low rates
of poor neonate outcomes make finding differences in outcomes difficult

Before ED delivery, limited time to ask Mom questions: Due date to assess for prematurity? Twins or worse? If
ruptured membranes, meconium?

Ultrasound findings on gestational age: crownrumplength (best in first trimester); biparietal diameter; femur
length; head circumference; abdominal circumference
Biparietal diameter is measured from the inner to outer tables of the skull at the level of the thalami (easiest for
ED providers)
femur length may be confused with the humerus
Clinical findings of previability: lanugo, translucent skin, fused eyelids, thick vernix, absence of fingernails

After delivery: Term? Crying or breathing? Good muscle tone? If yes to all 3 dry, place skintoskin with mom,
cover with dry linen
If no to any of three questions, then infant requires at least one of the following. Each intervention should be
performed well for 30 seconds before determining the need to move to the next step; more time can be spent if more
time needed to complete the components of an intervention DO EACH STEP WELL!

Initial stabilization dry em off and piss em off, provide warmth; Golden Minute
Provide warmth dry, swaddle, skintoskin, cover mom/baby with blankets; plastic wrap for premature <1500g,
radiant heat; raise room temp to 78.8F; humidified warmed air if respiratory support needed
Hypothermia associated with an increase in mortality; can increase metabolic demand, O2 consumption
Radiant warmers provide best access to the child; temp skin probe placed on abdomen; temp set to 36.5C;
avoid hyperthermia
Stimulation slapping or flicking soles of feet, rubbing back (drying and suctioning often is enough stimulation_
Clearing airway
Suctioning after birth only required for newly born with obvious obstruction due to secretions or those who
require positivepressure ventilation; bulb syringe or mechanical suction device; avoid esophagus and
stomach if possible as this may cause profound vagal and bradycardic response
if amniotic fluid is clear, limit bulb suctioning for babies with obvious obstruction to spontaneous
breathing or who require intubation and positivepressure ventilation
if meconium is present, absence of randomized trials means no change to recommendation of endotracheal
suctioning of nonvigorous babies to prevent meconiumaspiration syndrome;
if intubation is prolonged and unsuccessful, consider bagvalvemask
ventilation especially if baby is bradycardic
evaluate respirations apnea, gasping, labored or unlabored breathing
 evaluate heart rate greater than 100 bpm; check at precordial site
pulse oximeter can take 12 minutes to give HR reading
cardiac monitor gives faster continuous audible (Katheria A et al Pediatrics Nov 2012)
evaluate oxygentation blood oxygen levels in healthy newly born can take
approx 10 minutes to normalize; can be 7080% for several minutes (see table based at sea level); lack of
cyanosis does NOT indicate the child is not hypoxic
use pulse ox if baby requires resuscitation, cyanosis persists, requires O2, requires positive pressure for
more than a few breaths
attach probe to child first then to machine may speed up acquisition of signal
attach probe to preductal area right upper extremity typically wrist or medial palm

Breathing / Ventilation
supplemental O2 randomized trials show newly borns do better if resuscitated with air rather than 100% O2;
hyperoxia due to supplemental O2 may result in tissue and organ injury due to raised cellular O2 contents which results
in free radicals and cellular/tissue injury
reduced mortality in term infants when room air used compared to 100% oxygen; no difference in
encephalopathy or neurodevelopment outcomes at 2 years
initiate resuscitation with blended oxygen, one suggestion 21% O2 for >30 weeks and 30% O2 for <30 weeks ; if
blended oxygen not available, start with room air
achieve targeted SpO2 on Table above via pulse oximeter by adjusting oxygen concentration
if HR is below 60 after 90 seconds, increase to 100% O2 until recovery of normal heart rate

if infant remains apneic or gasping, or if HR remains <100 per minute after initial steps, start positive pressure
ventilation
SelfInflating Bags
initial breaths (assisted or spontaneous) create a functional residual capacity (FRC); optimal pressure, inflation
time, flow rate, ventilation rates required unknown
c grip used to make an airtight seal of mask on face thumb/index finger over mask and other fingers under
mandible but not on softtissue of neck
adequate ventilation = improved heart rate; if heart rate does not improve, assess chest wall movement
even selfinflating bags need pressuremonitoring device (manometer)
if possible, initial inflation pressure 20cm H20 for preterm but > 3040 may be needed for term infants; if no
monitor available, use minimal inflation to increase the heart rate; deliver at 4060 breaths per minute to maintain
HR >100 bpm.
popoff valve set to release at 3040 cm H2O pressure
avoid excess volume or pressure when possible; can result in lung injury or pulmonary air leak
jury is out on benefit of CO2 detection to identify airway obstruction faster than clinical assessment

 if HR does not improve after 30 seconds of good BVM, readjust the airway and the mask, reposition the head, suction
out the mouth and nose, and open the mouth slightly
if HR still not does not improve, consider increasing the inflation pressure to enhance chest rise but >40cm H20 is not
recommended
if HR still not improving, use alternative airway like intubation or LMA
if HR still not improving, start chest compressions

Other options after BVM:
Laryngeal mask airways studied in newly born >2000g or 34 weeks; smaller than this not studied well; use if bag
valvemask not successful and intubation not feasible or successful; not studied in meconiumstained fluid, during
chest compressions, or for administration of emergent intratracheal meds (Schmolzer Resuscitation 2012 Nov)

Novel device RAM Cannula Acta Paediatrica 2005 Capasso L et al; 600+ newly born randomized to intermittent
positive pressure by nasal cannula or mask; less chest compressions and fewer intubations in nasal cannula group;
APGARs, admissions to NICUs, deaths equal in two groups
* mouth is held closed while positive pressure delivered; eliminates the dead space of the oropharynx

CPAP (continuous positive airway pressure) can be an alternative to intubation for babies with respiratory distress;
provider preference (te Pas AB et al Pediatrics 2007)

PEEP (positive endexpiratory pressure) beneficial for intubated neonates in NICU; ??beneficial for positive pressure
ventilation immediately after birth; optional PEEP valve for selfinflating bags may give unreliable endexpiratory
pressures

Intubation used for meconiumstained fluid in nonvigorous babies; if BVM ineffective or prolonged; when chest
compressions performed; for special cases like congenital diaphragmatic hernia, very low birth weight, or
administering surfactant
size of ETT based on birth weight and gestational age; using length of infant studied but not validated
limit to 30 seconds (increased from 20 secs in new recommendations)
administration of free flow oxygen during intubation for infants not breathing is no longer recommended
best clinical indicator of tracheal placement is increase in heart rate!!
Chest xray remains gold standard; exhaled CO2 may give misleading false neg result; others like video
laryngoscope, fiber optic, and ultrasound have not been tested (Schmolzer Resuscitation
CO2 detection recommended even on low birth weight babies; false negatives can occur in poor or absent
pulmonary blood flow or in critically ill with poor cardiac output
look for condensation, chest movement, equal breath sounds but not well studied in newly born
depth of insertion: infants wt (kg) + 6 = depth of insertion (cm) should work for infants >750kg; NRP suggests
in infants <750g, ETT may need to be only inserted to 6cm

 Chest compressions ensure optimal assisted ventilation with supplemental O2 for at least 30 seconds prior; if HR
remains <60 bpm despite good oxygenation, start compressions
lower 1/3 of sternum, depth of 1/3 antpost chest diameter; compressions with 2 thumbs and fingers encircling
chest and supporting back optimal (higher systolic pressures and coronary perfusion pressures); technique can be
done from head of bed if umbilical line needed
with positive pressure ventilation
coordinate compressions and ventilation; 90 compressions and 30 breaths to achieve 120 cycles per minute
frequent interruptions in compressions should be avoided as this will compromise perfusion and coronary blood
flow
oxygen should be increased to 100% during compressions
reassess after 30 seconds for need for intubation and/or medications

Epinephrine and/or volume expansion rarely indicated in newly born resuscitation; recommended if heart
remains if <60 per minute despite adequate ventilation with 100% O2, usually intubation, and compressions for at least
4560 seconds
rarely buffers, narcotic antagonist, vasopressors may be useful but not in the delivery room
Epinephrine:
never been studied in placebo controlled, randomized trials
IV/umbilical/IO dose is recommended over endotracheal; IV/umbilical/IO dose 0.010.03 mg/kg , using
1:10,000 solution (0.1mg/ml conc); higher doses may result in brain or cardiac injury;
endotracheal dose 0.050.1 mg/kg (0.5 1ml/kg of 1:10,000 solution) may be considered while access
being obtained but safety/efficacy has not been evaluated;
Volume expansion: consider when blood loss is known or suspected (ante or intrapartum hemorrhage, or
pale skin, poor perfusion, weak pulse) and infants heart rate as not responded to previous measures
isotonic crystalloid solution or blood is recommended; dose is 10cc/kg; in premature infants, avoid giving
volume expanders rapidly (associated with intraventricular hemorrhage)
Ringers lactate is also acceptable; O Rhneg for severe blood loss and/or anemia
Naloxone not part of initial resuscitation; data lacking re: efficacy; uncertain dosing, safety
Sodium bicarbonate data lacking re: benefits or harm; could affect cerebral and myocardial function;
generally not recommended; if used, ventilation and circulation must be established; must use large vein; no
dose established so use 12 mEq/kg, no faster than 1mEq/kg/minute

Line access Umbilical line standard of care for newly born resuscitation BUT IO appears faster and less difficult for
providers
Comparison of umbilical venous and intraosseous access during simulated neonatal resuscitation Rajani AK et al
Pediatrics 2011: 40 health care providers with umbilical line experience; watched instructional videos on both
techniques; then two simulated scenarios requiring IV epi one required UVC placement and one IO placement; on
average, IO 46 seconds faster than UVC; no sig difference in errors or perceived ease of use
 Intraosseous is faster and easier than umbilical venous catheterization in newborn emergency vascular access models
Abe KK et al Amer J Emerg Med March 2000: 42 medical students with no prior experience; all did UVC and then
randomized by coin flip to either IO with turkey leg or plastic infant leg; each MS got a practice try for each
procedure; successful placement faster in IO, 52 vs 134 sec for practice attempts, 45 vs 95 secs for experienced
attempts; difficulty scores lower for IO, practice or experience, 3.5 vs 5.5/10

Umbilical vein line should be inserted to a depth of 24 cm until there is free flow of blood

Post resuscitation care
Naloxone not recommended as part of initial resuscitation efforts
Glucose lower blood glucose levels after hypoxic insult associated with increased risk for brain injury and
adverse outcomes; increased blood glucose levels not associated with adverse outcomes; no randomized trials; no
target glucose range identified; avoid hypoglycemia
Induced therapeutic hypotherma significantly lower mortality and less neurodevelopmental disability in cooled
babies (33.534.5C) with moderate to severe hypoxicischemic encephalopathy; does NOT need to occur in ED but
can be started for babies 36 weeks, with evolving moderate to severe hypoxicischemic encephalopathy, within 6
hours after birth, implement in the NICU, continue for 72 hours and rewarm over 4 hours; head alone versus
systemic cooling found to have equal outcomes (Shankaran S. Curr Treat Options Neurol Dec 2012)

Resuscitation Failure If infant fails to respond, check the following:
Failure to improve with positive pressure ventilation blockage like meconium, mucus, choanal atresia,
malformed airway or laryngeal web; abnormal lung function like congenital diaphragmatic hernia, pulmonary
hypoplasia, hyaline membrane disease, pneumothorax
Persistent central cyanosis congenital heart disease
Persistent bradycardia heartblock
Persistent apnea hypoxicischemic encephalopathy, congenital brain abnormality, respiratory depression from
maternal opioid use

Discontinuing Resuscitation Care
In a newly born baby with no detectable heart rate, it is appropriate to consider stopping resuscitation if the heart
rate remains undetectable for 10 minutes after 10 minutes of care. Other considerations include presumed etiology
of arrest, gestation of baby, presence of complications, potential role of therapeutic hypothermia, and parents
expressed feelings about acceptable risk of morbidity.

Withholding Resuscitation Care
No initiation of care may be considered if early death is very likely and survival would be accompanied by high
mortality, usually <23 weeks or weight <400 grams, anencephaly or chromosome abnormalities incompatible with
life (trisomy 13,18)
Resuscitation IS indicated with survival likelihood is high and there is an acceptable morbidity
 as infant is delivered, if unclear whether resuscitation is indicated, better to err on side of resuscitation;
discussion can continue with parent(s) and support can be discontinued if agreed upon by parents and providers

References:
Kattwinkel J et al Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardipulmonary Resuscitation and
Emergency Cardiovacular Care Pediatrics Nov 2010; 126 (5): e1400-1413

Watkinson M. Temperature control of premature infants in the delivery room. Clin Perinatol 2006;
33:43.

da Mota Silveira SM, Gonalves de Mello MJ, de Arruda Vidal S, et al. Hypothermia on admission: a
risk factor for death in newborns referred to the Pernambuco Institute of Mother and Child Health. J
Trop Pediatr 2003; 49:115.

Tan A, Schulze A, O'Donnell CP, Davis PG. Air versus oxygen for resuscitation of infants at birth.
Cochrane Database Syst Rev 2005; :CD002273.

Rabi Y, Rabi D, Yee W. Room air resuscitation of the depressed newborn: a systematic review and
meta-analysis. Resuscitation 2007; 72:353.

Luten R, Kahn N, Wears R, Kissoon N. Predicting endotracheal tube size by length in newborns. J
Emerg Med 2007; 32:343.

Neonatal Resuscitation Equipment and Supplies
Suction Equipment
Bulb syringe Suction tubing and catheters
Meconium aspirator 8F feeding tube and 20cc syringe
Airway Equipment
Face masks for premie, term infants Laryngoscope with 0, 1 Miller blades
Endotracheal tubes 2.5, 3.0, 3.5 Oxygen with flow meter
Oropharyngeal airways
Vascular Access Equipment
Umbilical Line supplies: Sterile gloves, scalpel, Syringes
antiseptic prep solution, umbilical catheter or
5F feeding tube, tape, threeway stopcock

Medications
10% Dextrose solution 0.9% normal saline solution
Epinephrine 1:1000 (0.1mg/ml) Naloxone (0.4mg/ml)
Monitoring and Heating Equipment
Radiant Warmer with temperature probe Warm towels
Cardiac monitor Pulse oximeter and probe
Plastic wrap for premature babies Transport incubator

Endotracheal Tube Sizing

Tube size, mm Gestational Age, wks Weight, g

2.5 <28 <1000

3 2834 10002000
3.5 2438 20003000
3.54.0 >38 >3000