Neonatal Resuscitation Guidelines versus the Reality of the Delivery Room
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he key to successful neonatal resuscitation is to estabcurrent recommendations is not yet available. To date, it has lish effective ventilation of the newborn lungs in a been the practice of ILCOR to retain previous recommendatimely manner. The neonatal resuscitation algorithm tions until new evidence to support change is available so as was designed to help focus medical providers on initial steps to not create the inevitable chaos of changing from one to promote initiation of spontaneous breathing and then opinion/physiologic plausibility-based recommendation to rapid assessment as to a newborn’s success another. With the latest ILCOR guidelines, See related article, p 1553 in taking effective breaths. If the infant is 30-second intervals were removed after the not breathing, is gasping, or has an inadequate heart rate first minute of life as evidence grew that resuscitation prodespite providing warmth, opening the airway, and stimulaviders often skipped ahead to initiate cardiac compressions tion by rubbing the back, effective positive pressure ventilawithout first taking the time to establish the effective ventilation must be initiated by the provider. Ventilation is tion, the very step that almost always obviates the need for judged to be effective once the heart rate is stabilized above cardiopulmonary resuscitation.7,8 Thus, providers are now “allowed the time” to go through a series of steps to correct 100 beats per minute. ventilation, including intubation, before starting compresIn this issue of The Journal, McCarthy et al examine differsions. ences between the suggested timing of interventions for McCarthy et al raise the question as to the validity and goal neonatal resuscitation proposed by the International Liaison of continuing to include the arbitrary 30-second intervals for Committee on Resuscitation (ILCOR) guidelines1 compared with the actual timing of interventions as measured on video the initial steps of resuscitation and assessments. They recordings of a cohort of deliveries where need for resuscitacounter that because the initial steps are rarely completed tion was anticipated.2 The delivery room resuscitation videos within the given time frame, perhaps providers are jumping came from 2 tertiary academic centers with trained neonatal to initiate positive pressure ventilation that might have been resuscitation teams, and the majority of the deliveries were avoided if the initial steps of resuscitation had been carried either preterm or had known congenital anomalies. In this out in a thorough and effective manner. The authors raise cohort of high risk deliveries, the recommended initial steps this question after noting that for some newborns, ventilator of neonatal resuscitation (providing warmth by putting the support was initiated before the heart rate was known. infant in a polyethylene bag under a radiant warmer, opening Although it is possible that providers felt pressure to jump the airway through effective positioning and, if needed, sucto ventilation, the current algorithm supports initiation of tioning, drying, and stimulation) followed by assessment for positive pressure ventilation if the newborn is apneic or gaspadequate respiratory effort and heart rate were rarely accoming regardless of the heart rate, which may be an alternative plished within the suggested 30-second time frame. The auexplanation for their finding. Certainly, it is critical that the thors note that a significant number of infants had not resuscitation steps are done effectively rather than just even made it from the mother to the radiant warmer and quickly but more data are needed to prove how much time into the polyethylene bag within 30 seconds. A minority of is needed for the initial steps to be done consistently well. such infants had a heart rate determined by 60 seconds; howThe question as to whether timing should start from the ever, the authors note that the resuscitation teams preferred time of birth or rather at the time the infant is placed under to wait for the pulse oximeter to provide the heart rate. Prior the radiant warmer is a valid one, especially in the era of deevidence suggests that auscultation and palpation of heart layed cord clamping.9 It is unknown whether ILCOR will recommend delayed cord clamping for non-vigorous infants rate is less accurate than pulse oximetry or cardiac monitor in need of resuscitation but the question is under review for determinations.3,4 Neonatal resuscitation guidelines as initially proposed in the 2016 guidelines. Clearly, timelines may shift if such recthe late 1980s were based primarily on expert opinion and ommendations are adopted. As McCarthy et al note, the purrational conjecture because of a lack of available evidence pose of the neonatal resuscitation algorithm is to provide but over the past decade have undergone cyclical evidence reguidance while recognizing that it is not an exclusive course view through the ILCOR process. The intensive 5-year eviof treatment. There will always be the need to rationally baldence reviews coupled with a recent explosion of neonatal ance careful initial steps and clinical assessment in the hopes resuscitation research has allowed the algorithm to become of avoiding the need for positive pressure ventilation more evidence-based with each iteration1,5,6; however, there are still parts of the algorithm for which evidence to counter The author declares no conflicts of interest.
ILCOR
International Liaison Committee on Resuscitation
0022-3476/$ - see front matter. Copyright ª 2013 Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2013.09.038
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Vol. 163, No. 6 December 2013 altogether with the risk of additional hypoxic/ischemic injury if ventilation is not assisted in a timely enough manner. n Myra H. Wyckoff, MD Division of Neonatal-Perinatal Medicine Department of Pediatrics The University of Texas Southwestern Medical Center at Dallas Dallas, Texas Reprint requests: Myra H. Wyckoff, MD, Division of Neonatal-Perinatal Medicine, Department of Pediatrics, The University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390-9063. E-mail:
[email protected] References 1. Perlman JM, Wyllie J, Kattwinkel J, Atkins DL, Chameides L, Goldsmith JP, et al. Part 11: Neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation 2010;122(16 Suppl 2):S516-38. 2. McCarthy LK, Morley CJ, Davis PG, Kamlin CO, O’Donnell CP. Timing of interventions in the delivery room: does reality compare with neonatal resuscitation guidelines? J Pediatr 2013;163:1553-7.
3. Kamlin CO, Dawson JA, O’Donnell CP, Morley CJ, Donath SM, Sekhon J, et al. Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room. J Pediatr 2008;152:756-60. 4. Voogdt KG, Morrison AC, Wood FE, van Elburg RM, Wyllie JP. A randomised, simulated study assessing auscultation of heart rate at birth. Resuscitation 2010;81:1000-3. 5. Niermeyer S, Kattwinkel J, Van Reempts P, Nadkarni V, Phillips B, Zideman D, et al. International Guidelines for Neonatal Resuscitation: An excerpt from the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science. Contributors and Reviewers for the Neonatal Resuscitation Guidelines. Pediatrics 2000;106:E29. 6. International Liaison Committee on Resuscitation. The International Liaison Committee on Resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: neonatal resuscitation. Pediatrics 2006;117:e978-88. 7. Perlman JM, Risser R. Cardiopulmonary resuscitation in the delivery room. Associated clinical events. Arch Pediatr Adolescent Med 1995; 149:20-5. 8. Wyckoff MH, Berg RA. Optimizing chest compressions during delivery-room resuscitation. Semin Fetal Neonatal Med 2008;13: 410-5. 9. Rabe H, Diaz-Rossello JL, Duley L, Dowswell T. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database Syst Rev 2012;8:CD003248.
The Nutritional Dilemma for Preterm Infants: How to Promote Neurocognitive Development and Linear Growth, but Reduce the Risk of Obesity
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lmost universally, very preterm infants do not grow at formation, all of which are associated with reduced cognition the in utero growth rates of normal human fetuses. At and abnormal behavior.8 This problem is not confined to animal models. Preterm infants who are underfed and under36 weeks postmenstrual age, 79% of infants born at grown by term equivalent age have been shown to have worse