Introduction

Cessation of fetomaternal circulation at birth and the subsequent rapid physiologic changes involve both the cardiovascular and respiratory systems. Failure of this adaptation results in cardiopulmonary compromise and the need for resuscitation. Approximately, 85% of term infants will initiate breathing spontaneously within 30 s of birth and an additional 10% will respond to drying and tactile stimulation [1]. Around 5% to 10% of all newborns need some assistance to establish normal breathing at birth including positive pressure ventilation (PPV), 0.1% receive cardiac compressions, and 0.05% receive cardiac compressions with epinephrine [1,2,3,4,5]. However, among preterm infants, 10%–15% of extremely low-birth-weight (< 1000 g) and 6% of very-low-birth-weight (< 1500 g) infants receive extensive cardiopulmonary resuscitation including chest compression with or without epinephrine [6,7,8]. Delay in starting PPV in a nonbreathing newborn can increase risk of neonatal morbidity and mortality [1].

In 1987, American Academy of Pediatrics started the Neonatal Resuscitation Program (NRP) with the publication of its first textbook [9]. Every 5 y, the International Liaison Committee on Resuscitation (ILCOR) publishes consensus on cardiopulmonary resuscitation and emergency cardiovascular science and treatment recommendations since 2000 [10,11,12,13,14]. The 2020 recommendations for neonatal resuscitation include evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates [14]. These recommendations form the basis of the American Heart Association (AHA) and American Academy of Pediatrics NRP, 8th edition, which will be available by mid-2021. The objectives of this review are to update the readers with the changes in the latest edition of NRP, and discuss the ILCOR and AHA guidelines along with knowledge gaps in the current literature.

Recent Recommendations in Neonatal Resuscitation

The neonatal resuscitation algorithm remains unchanged from 2015. Table 1 summarizes the recent AHA recommendations.

Table 1 Summary of American Heart Association/neonatal resuscitation recommendations
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Anticipation of Resuscitation Need

Anticipation and Preparation

The key to successful neonatal resuscitation includes an assessment of perinatal risk factors and rapid assembly of a team with members skilled in resuscitation. The recent update reaffirms that at least one personnel responsible for initiating resuscitation, who is trained to begin PPV, is present at each delivery and emphasizes the use of standardized equipment checklists and checking for function.

Umbilical Cord Management

Delayed umbilical cord clamping (DCC) is recommended for both term and preterm neonates in 2015. The 2020 AHA update affirms the previous recommendations (Table 1) [15]. A recent systematic review and meta-analysis showed that DCC reduced mortality before discharge. DCC is associated with a reduction in any grade intraventricular hemorrhage (IVH) but no difference in severe IVH or chronic lung disease [16,17,18].

However, there is insufficient evidence to recommend immediate/early cord clamping versus delayed cord clamping for infants, who require resuscitation at birth. Immediate cord clamping is considered for cases when placental transfusion is unlikely to occur, such as maternal hemorrhage or hemodynamic instability, placental abruption, or placenta previa [19]. Umbilical cord milking significantly increases the risk of severe IVH in preterm infants and recommended to avoid in babies <28 wk. gestational age [20, 21]. There is insufficient data to show what duration of delay is best, one or several minutes, and therefore, the optimal timing of umbilical cord clamping still remains unclear.

Initial Actions

Overall, the components of initial steps of resuscitation remain the same, but the order has been changed to facilitate common practice in the recent edition of NRP textbook (Table 2).

Table 2 Overview of Neonatal Resuscitation Program 8th Edition Practice Changes (adapted from NRP 8th Edition Busy People Update - AAP)
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Airway Management in the Event of Meconium-Stained Amniotic Fluid

The 2015 ILCOR recommendation suggests against routine tracheal intubation for suctioning of meconium in nonvigorous infants born through meconium-stained amniotic fluid (MSAF) [13]. A recent systematic review and meta-analysis of four randomized trials involving nonvigorous newborns delivered through MSAF showed that immediate laryngoscopy with tracheal suctioning did not improve survival at discharge when compared with immediate resuscitation without laryngoscopy [22]. The rates of meconium aspiration syndrome and hypoxic-ischemic encephalopathy did not differ, thus emphasizing that routine laryngoscopy with or without tracheal suctioning is not recommended [14].

Assessment of Heart Rate

Heart rate (HR) is the most important clinical sign to evaluate compromised newborns and to guide resuscitation efforts in the delivery room. Auscultation remains the preferred clinical method for initial assessment of HR in the delivery room [15]. Studies have shown that clinical assessment of HR by auscultation or palpation may be unreliable and inaccurate [23,24,25,26]. Pulse oximetry and electrocardiography (ECG) remain important adjuncts to provide continuous HR assessment. In babies needing resuscitation, ECG provides the most rapid and accurate measurement of the newborn’s HR at birth and during resuscitation. In contrast to ECG, pulse oximetry is slower in detecting the HR and can be inaccurate during the first few minutes after birth [27,28,29].

The 2020 recommendation of “ECG may be used for the rapid and accurate measurement of the newborn’s HR during resuscitation” remains unchanged from the 2015 recommendation. However, if the infant needs chest compression, an ECG should be used for the rapid and accurate assessment of HR [15]. However, since the introduction of ECG for HR assessment in the delivery room, several animal studies and case series have reported pulseless electric activity during neonatal asphyxia [30,31,32,33,34]. Initiation of chest compressions can be delayed, if clinicians rely solely on the ECG display of HR. Therefore, ECG should be used in conjunction with other assessment methods including auscultation, palpation and pulse oximetry.

Ventilatory Support after Birth

Positive-Pressure Ventilation

Ventilation of the newborn’s lung is the single most important and most effective step in neonatal resuscitation. The indications for PPV and rate of ventilation (40–60 breaths/min) remains unchanged. Use of positive end expiratory pressure (PEEP) with the initial breath may help achieve stable lung inflation more quickly, clear lung fluid, and prevent alveolar collapse during exhalation. Therefore, it is reasonable to provide PEEP in newborn infants receiving PPV, but the evidence from human studies is limited [15]. Excessive peak inflation pressure should be avoided, as it has been implicated in various complications such as pneumothorax.

Role of Sustained Inflation (SI) During Resuscitation

Animal studies have demonstrated that a longer SI before initiating PPV can inflate the lungs and increase functional residual capacity [35, 36]. However, a meta-analysis of 10 trials involving 1502 infants showed no benefit of sustained inflation > 5 s during resuscitation [37]. SI was associated with increased death before discharge among preterm infants < 29 wk and currently, SI is not recommended [15]. There is insufficient evidence for or against the use of SI for term and late preterm infants.

T-Piece Resuscitator Versus Self-Inflating Bag for Ventilation

A recent scoping review included 4 clinical studies representing 2889 newborns [927 in three randomized, control trials (RCTs) and 1962 in one observational study] [14]. The large observational study in preterm infants from Brazil reported that the use of a T-piece resuscitator increased survival and decreased bronchopulmonary dysplasia and intubation in the delivery room [38]. Another clinical trial reported decreased intubation rates in the delivery room when T-piece resuscitators were used [39]. Currently, there is insufficient evidence regarding the use of T-piece resuscitator or self-inflating bag for initial PPV at birth, so no one device could be recommended over the other, as the confidence in the effect estimates is so low [14].

Oxygen Therapy

The recommendations for oxygen therapy in term and preterm infants remain largely unchanged [40].

Chest Compression

The indications and ratio of chest compression to ventilation remain unchanged. It is prudent to optimize ventilation before starting chest compression with endotracheal intubation, when possible. The current guidelines recommend using 100% oxygen while providing chest compressions; however, no studies have confirmed a benefit of this approach compared to any other oxygen concentration. It may be reasonable to increase inspired oxygen to 100% if there is no response to PPV with lower oxygen concentrations. Once the return of spontaneous circulation (ROSC) is achieved, the supplemental oxygen concentration needs to be titrated.

Vascular Access

Whenever vascular access is desired during resuscitation, the umbilical venous route is still preferred [14]. Outside the delivery room or when the intravenous access is not feasible, the intraosseous route may be an alternative route.

Medications: Epinephrine

The indications and dose of epinephrine remain unchanged. Administration of epinephrine via an umbilical venous catheter provides the most rapid and reliable medication delivery. There is a significant lack of evidence regarding the optimal dosage and efficacy of intravenous (IV) and endotracheal tube (ET) epinephrine in the newborn. In a recent randomized trial in term newborn lamb, epinephrine at 0.03 mg/kg followed by a 3 mL/kg normal saline flush for the first dose of epinephrine resulted in high rates of ROSC (100%) and quicker ROSC compared with use of 0.01 mg/kg of epinephrine with 1 mL or 3 mL/kg of normal saline flush [41].

Volume Expansion

Volume expansion is indicated when blood loss is known or suspected based on history and examination, and there has been no response to epinephrine. This remains unchanged.

Withholding and Discontinuing Resuscitation

Failure to achieve an ROSC in a newborn despite 10 to 20 min of intensive resuscitation is associated with a high risk of mortality and moderate-to-severe neurodevelopmental impairment among survivors. However, there is no evidence that any specific duration of resuscitation consistently predicts these dire outcomes. If there is no heart rate despite performing all the steps of resuscitation, it is reasonable to discuss with the team and family regarding a change in goals of care at around 20 min of age [14]. This process, however, needs to be individualized. Various factors that play a role include whether the resuscitation was optimal, availability of higher level of neonatal care (such as therapeutic hypothermia), circumstances before delivery, and the family’s wishes.

If anticipated birth is at the extreme limit of viability or involves a lethal or severe morbidity, noninitiation or limitation of neonatal resuscitation would be reasonable after expert consultation and parental involvement in this crucial and sensitive shared decision-making process.

Postresuscitation Care

Neonates who receive prolonged PPV or more advanced resuscitation (e.g., intubation, chest compressions with or without epinephrine, etc) should be closely monitored after stabilization in a neonatal intensive care unit or in an area, where they can be closely scrutinized as they are at risk for further deterioration. Refer to the recommendations mentioned in Table 1.

Human and System Performance

Training Frequency

Neonatal resuscitation providers face various challenges with respect to the knowledge, skills, and behaviors needed to perform an effective and quality resuscitation. Historically, the NRP training is repeated every 2 y. Recent evidences suggest that without practice, there is knowledge and skill decay within 3 to 12 mo [42, 43]. Brief and frequent practice (also known as booster training) has been found to have an important role in improving neonatal resuscitation outcomes [44].

Briefing and Debriefing

Scoping reviews on briefing/debriefing following neonatal resuscitation, concluded that such practice might improve short-term clinical and performance outcomes for infants and staff [15]. This positively impacts on a variety of educational and clinical outcomes in neonatal, pediatric, and even adult simulation-based and clinical studies. However, the effects of briefing or debriefing on long-term clinical and performance outcomes are uncertain.

Knowledge Gaps

The most recent guidelines have not delved into the details of the most relevant devices during each step in resuscitation. The potential upcoming reviews will address the choice of devices and key equipment, including those required for ventilation (T-piece, self-inflating bag, flow-inflating bag), ventilation interface (face mask, laryngeal mask), suction (bulb syringe, meconium aspirator), monitoring (respiratory function monitors, heart-rate monitoring, near-infrared spectroscopy), and also focus on relevant contextual topics such as feedback and documentation [15].

Potential areas of future research could include optimal cord management for nonvigorous infants, the impact of routine use of ECG during resuscitation, optimal oxygen management during and after resuscitation, optimal timing and dosing of medication and volume expanders, role of briefing and debriefing on team performance and exploring the factors that could optimize postresuscitation care.