Warm, dry, and mad - a guide to newborn resuscitation

LAKE BUENA VISTA, FLA. – The best way to take advantage of a struggling newborn’s "Golden Minute" won’t be found in any schmaltzy pregnancy book.

"Dry ’em off and piss ’em off," Dr. Maureen McCollough said at a meeting sponsored by the American College of Emergency Physicians and the American Academy of Pediatrics.

Delivery rooms have the ability to quickly mobilize the high-tech equipment that can mean the difference between life and death for these neonates. But not every baby is considerate enough to arrive under ideal circumstances, said Dr. McCullough, director of pediatric emergency medicine at the University of Southern California Medical Center, Los Angeles.

"Dad might have already delivered this baby in the car, or Mom comes in complaining of stomach pains and there’s a baby crowning right there in the emergency department. You need to be ready."

Dr. McCullough outlined the stepwise resuscitation algorithm endorsed by the American Academy of Pediatrics in its 2010 guidelines.

The algorithm starts with the basics. If the infant looks full term, is crying or breathing, and has good muscle tone, she probably won’t need much in the way of interventions. Dry and swaddle her and get her warm; Mom’s abdomen is the perfect place for this. If the baby is really small – less than 1,500 grams – turn to plastic wrap instead of a blanket. The impermeable barrier decreases heat loss through evaporation and holds more of the baby’s body heat in. If possible, raise the room temperature to around 79 , she advised.

"Hypothermia is associated with increased mortality," Dr McCullough said. In trying to warm herself, the hypothermic newborn increases her metabolic rate, leading to increased oxygen consumption.

Stimulation comes next. "Slapping or flicking the soles of the feet, rubbing the back, and drying and suctioning the baby is often enough to get things going."

If the baby looks preterm, things can get dicey. Lanugo, translucent skin, fused eyelids, a thick vernix coating, and the absence of fingernails are hallmarks of a previable infant. If the baby is clearly premature, very small, or has a less than optimal Apgar score, resuscitation proceeds in a stepwise manner with about 30 seconds devoted to each intervention before moving on to the next.

"Do each step well," Dr. McCullough said. "If you need more time to complete the components of an intervention, take it."

Not all newborns require suctioning. If the amniotic fluid is clear, limit suctioning to those who have obvious respiratory difficulty. If the fluid is meconium stained, the baby is at risk for meconium aspiration syndrome and suctioning is a must.

After addressing respiration, evaluate the infant for apnea, gasping, and labored breathing. There isn’t time to wait for a pulse oximeter to sense the heart rate, she said. Get the device on quickly, but take out a stethoscope and check at the precordial site. Oxygen levels may look low for up to 10 minutes after birth, as the lungs continue to inflate. This means that cyanosis cannot be used as a guide for resuscitation. "A lack of cyanosis does not mean the child isn’t hypoxic. If the baby requires resuscitation, if cyanosis persists, or the baby needs oxygen or positive pressure for more than a few breaths, you have to use a pulse oximeter."

Although 100% oxygen might seem logical, studies continue to show that newborns do better when resuscitated with room air. "Hyperoxia from supplemental oxygen can injure tissues and organs because it promotes the formation of free radicals."

A 2004 Cochrane review determined that newborns resuscitated on room air were about 30% more likely to survive than those who had 100% oxygen. There were no significant between-group differences in hypoxic ischemia or 10-minute Apgar, and no significant differences later in adverse neurodeveopmental outcomes (Cochrane Database Syst Rev. 2004;3:CD002273).

"Initiate resuscitation with blended oxygen. One suggestion is 21% oxygen for newborns older than 30 weeks’ gestation and 30% for those younger than 30 weeks. If the heart rate stays below 60 after about 90 seconds, increase the oxygen to 100% until the heart rate recovers. If, after this, the infant is still apneic or gasping, or the heart rate is still low, start with positive pressure ventilation."

If, after another 30 seconds of positive pressure ventilation, the heart rate is still low, try readjusting the mask and repositioning the baby. If there’s still no good response, consider increasing the inflation pressure, but don’t go above the recommended limit of more than 40 cm H₂0 of pressure.

The next steps would be to move on to an alternative ventilation method, like intubation, and to initiate chest compressions. Give 100% oxygen during compressions and reassess after 20 seconds.

Epinephrine, volume expanders, naloxone, and sodium bicarbonate have never really been studied in newborns but may be considered as a last resort. The umbilical vein provides ready access. Intraosseous administration can also be considered.

If the baby simply doesn’t respond, with no heartbeat for 10 minutes after 10 minutes of resuscitation efforts, consider stopping the interventions. Some parents prefer to withhold resuscitation altogether if the infant is unlikely to survive long, especially in cases of extreme prematurity, chromosomal abnormalities, or anencephaly.

"If you’re not sure whether resuscitation is indicated or not, it’s much better to err on the side of trying," Dr. McCullough said. "You can always discontinue support after speaking with parents."

Dr. McCullough has no relevant conflicts of interest.

msullivan@frontlinemedcom.com

LAKE BUENA VISTA, FLA. – The best way to take advantage of a struggling newborn’s "Golden Minute" won’t be found in any schmaltzy pregnancy book.

"Dry ’em off and piss ’em off," Dr. Maureen McCollough said at a meeting sponsored by the American College of Emergency Physicians and the American Academy of Pediatrics.

Delivery rooms have the ability to quickly mobilize the high-tech equipment that can mean the difference between life and death for these neonates. But not every baby is considerate enough to arrive under ideal circumstances, said Dr. McCullough, director of pediatric emergency medicine at the University of Southern California Medical Center, Los Angeles.

"Dad might have already delivered this baby in the car, or Mom comes in complaining of stomach pains and there’s a baby crowning right there in the emergency department. You need to be ready."

Dr. McCullough outlined the stepwise resuscitation algorithm endorsed by the American Academy of Pediatrics in its 2010 guidelines.

The algorithm starts with the basics. If the infant looks full term, is crying or breathing, and has good muscle tone, she probably won’t need much in the way of interventions. Dry and swaddle her and get her warm; Mom’s abdomen is the perfect place for this. If the baby is really small – less than 1,500 grams – turn to plastic wrap instead of a blanket. The impermeable barrier decreases heat loss through evaporation and holds more of the baby’s body heat in. If possible, raise the room temperature to around 79 , she advised.

"Hypothermia is associated with increased mortality," Dr McCullough said. In trying to warm herself, the hypothermic newborn increases her metabolic rate, leading to increased oxygen consumption.

Stimulation comes next. "Slapping or flicking the soles of the feet, rubbing the back, and drying and suctioning the baby is often enough to get things going."

If the baby looks preterm, things can get dicey. Lanugo, translucent skin, fused eyelids, a thick vernix coating, and the absence of fingernails are hallmarks of a previable infant. If the baby is clearly premature, very small, or has a less than optimal Apgar score, resuscitation proceeds in a stepwise manner with about 30 seconds devoted to each intervention before moving on to the next.

"Do each step well," Dr. McCullough said. "If you need more time to complete the components of an intervention, take it."

Not all newborns require suctioning. If the amniotic fluid is clear, limit suctioning to those who have obvious respiratory difficulty. If the fluid is meconium stained, the baby is at risk for meconium aspiration syndrome and suctioning is a must.

After addressing respiration, evaluate the infant for apnea, gasping, and labored breathing. There isn’t time to wait for a pulse oximeter to sense the heart rate, she said. Get the device on quickly, but take out a stethoscope and check at the precordial site. Oxygen levels may look low for up to 10 minutes after birth, as the lungs continue to inflate. This means that cyanosis cannot be used as a guide for resuscitation. "A lack of cyanosis does not mean the child isn’t hypoxic. If the baby requires resuscitation, if cyanosis persists, or the baby needs oxygen or positive pressure for more than a few breaths, you have to use a pulse oximeter."

Although 100% oxygen might seem logical, studies continue to show that newborns do better when resuscitated with room air. "Hyperoxia from supplemental oxygen can injure tissues and organs because it promotes the formation of free radicals."

A 2004 Cochrane review determined that newborns resuscitated on room air were about 30% more likely to survive than those who had 100% oxygen. There were no significant between-group differences in hypoxic ischemia or 10-minute Apgar, and no significant differences later in adverse neurodeveopmental outcomes (Cochrane Database Syst Rev. 2004;3:CD002273).

"Initiate resuscitation with blended oxygen. One suggestion is 21% oxygen for newborns older than 30 weeks’ gestation and 30% for those younger than 30 weeks. If the heart rate stays below 60 after about 90 seconds, increase the oxygen to 100% until the heart rate recovers. If, after this, the infant is still apneic or gasping, or the heart rate is still low, start with positive pressure ventilation."

If, after another 30 seconds of positive pressure ventilation, the heart rate is still low, try readjusting the mask and repositioning the baby. If there’s still no good response, consider increasing the inflation pressure, but don’t go above the recommended limit of more than 40 cm H₂0 of pressure.

The next steps would be to move on to an alternative ventilation method, like intubation, and to initiate chest compressions. Give 100% oxygen during compressions and reassess after 20 seconds.

Epinephrine, volume expanders, naloxone, and sodium bicarbonate have never really been studied in newborns but may be considered as a last resort. The umbilical vein provides ready access. Intraosseous administration can also be considered.

If the baby simply doesn’t respond, with no heartbeat for 10 minutes after 10 minutes of resuscitation efforts, consider stopping the interventions. Some parents prefer to withhold resuscitation altogether if the infant is unlikely to survive long, especially in cases of extreme prematurity, chromosomal abnormalities, or anencephaly.

"If you’re not sure whether resuscitation is indicated or not, it’s much better to err on the side of trying," Dr. McCullough said. "You can always discontinue support after speaking with parents."

Dr. McCullough has no relevant conflicts of interest.

msullivan@frontlinemedcom.com

LAKE BUENA VISTA, FLA. – The best way to take advantage of a struggling newborn’s "Golden Minute" won’t be found in any schmaltzy pregnancy book.

"Dry ’em off and piss ’em off," Dr. Maureen McCollough said at a meeting sponsored by the American College of Emergency Physicians and the American Academy of Pediatrics.

Delivery rooms have the ability to quickly mobilize the high-tech equipment that can mean the difference between life and death for these neonates. But not every baby is considerate enough to arrive under ideal circumstances, said Dr. McCullough, director of pediatric emergency medicine at the University of Southern California Medical Center, Los Angeles.

"Dad might have already delivered this baby in the car, or Mom comes in complaining of stomach pains and there’s a baby crowning right there in the emergency department. You need to be ready."

Dr. McCullough outlined the stepwise resuscitation algorithm endorsed by the American Academy of Pediatrics in its 2010 guidelines.

The algorithm starts with the basics. If the infant looks full term, is crying or breathing, and has good muscle tone, she probably won’t need much in the way of interventions. Dry and swaddle her and get her warm; Mom’s abdomen is the perfect place for this. If the baby is really small – less than 1,500 grams – turn to plastic wrap instead of a blanket. The impermeable barrier decreases heat loss through evaporation and holds more of the baby’s body heat in. If possible, raise the room temperature to around 79 , she advised.

"Hypothermia is associated with increased mortality," Dr McCullough said. In trying to warm herself, the hypothermic newborn increases her metabolic rate, leading to increased oxygen consumption.

Stimulation comes next. "Slapping or flicking the soles of the feet, rubbing the back, and drying and suctioning the baby is often enough to get things going."

If the baby looks preterm, things can get dicey. Lanugo, translucent skin, fused eyelids, a thick vernix coating, and the absence of fingernails are hallmarks of a previable infant. If the baby is clearly premature, very small, or has a less than optimal Apgar score, resuscitation proceeds in a stepwise manner with about 30 seconds devoted to each intervention before moving on to the next.

"Do each step well," Dr. McCullough said. "If you need more time to complete the components of an intervention, take it."

Not all newborns require suctioning. If the amniotic fluid is clear, limit suctioning to those who have obvious respiratory difficulty. If the fluid is meconium stained, the baby is at risk for meconium aspiration syndrome and suctioning is a must.

After addressing respiration, evaluate the infant for apnea, gasping, and labored breathing. There isn’t time to wait for a pulse oximeter to sense the heart rate, she said. Get the device on quickly, but take out a stethoscope and check at the precordial site. Oxygen levels may look low for up to 10 minutes after birth, as the lungs continue to inflate. This means that cyanosis cannot be used as a guide for resuscitation. "A lack of cyanosis does not mean the child isn’t hypoxic. If the baby requires resuscitation, if cyanosis persists, or the baby needs oxygen or positive pressure for more than a few breaths, you have to use a pulse oximeter."

Although 100% oxygen might seem logical, studies continue to show that newborns do better when resuscitated with room air. "Hyperoxia from supplemental oxygen can injure tissues and organs because it promotes the formation of free radicals."

A 2004 Cochrane review determined that newborns resuscitated on room air were about 30% more likely to survive than those who had 100% oxygen. There were no significant between-group differences in hypoxic ischemia or 10-minute Apgar, and no significant differences later in adverse neurodeveopmental outcomes (Cochrane Database Syst Rev. 2004;3:CD002273).

"Initiate resuscitation with blended oxygen. One suggestion is 21% oxygen for newborns older than 30 weeks’ gestation and 30% for those younger than 30 weeks. If the heart rate stays below 60 after about 90 seconds, increase the oxygen to 100% until the heart rate recovers. If, after this, the infant is still apneic or gasping, or the heart rate is still low, start with positive pressure ventilation."

If, after another 30 seconds of positive pressure ventilation, the heart rate is still low, try readjusting the mask and repositioning the baby. If there’s still no good response, consider increasing the inflation pressure, but don’t go above the recommended limit of more than 40 cm H₂0 of pressure.

The next steps would be to move on to an alternative ventilation method, like intubation, and to initiate chest compressions. Give 100% oxygen during compressions and reassess after 20 seconds.

Epinephrine, volume expanders, naloxone, and sodium bicarbonate have never really been studied in newborns but may be considered as a last resort. The umbilical vein provides ready access. Intraosseous administration can also be considered.

If the baby simply doesn’t respond, with no heartbeat for 10 minutes after 10 minutes of resuscitation efforts, consider stopping the interventions. Some parents prefer to withhold resuscitation altogether if the infant is unlikely to survive long, especially in cases of extreme prematurity, chromosomal abnormalities, or anencephaly.

"If you’re not sure whether resuscitation is indicated or not, it’s much better to err on the side of trying," Dr. McCullough said. "You can always discontinue support after speaking with parents."

Dr. McCullough has no relevant conflicts of interest.

msullivan@frontlinemedcom.com