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Official reprint from UpToDate????2017 UpToDate?Neonatal resuscitation in the delivery roomAuthor:Caraciolo J Fernandes, MDSection Editor:Leonard E Weisman, MDDeputy Editor:Melanie S Kim, MDAll topics are updated as new evidence becomes available and our?peer review process?is complete.Literature review current through:?Jul 2017.?|?This topic last updated:?Jun 07, 2017.INTRODUCTION?—?The successful transition from intrauterine to extrauterine life is dependent upon significant physiologic changes that occur at birth. In almost all infants (90 percent), these changes are successfully completed at delivery without requiring any special assistance. However, about 10 percent of infants will need some intervention, and 1 percent will require extensive resuscitative measures at birth [1].The indications and principles of neonatal resuscitation will be reviewed here. The physiological changes that occur in the transition from intrauterine to extrauterine life are discussed separately. (See?"Physiologic transition from intrauterine to extrauterine life".)ANTICIPATION OF RESUSCITATION NEED?—?Being prepared is the first and most important step in delivering effective neonatal resuscitation [1]. However, most newborns are healthy and do not require additional special assistance and the need for resuscitation is often not anticipated even in tertiary birth centers [2,3]. As a result, at every birthing location, personnel who are adequately trained in neonatal resuscitation should be readily available to perform neonatal resuscitation whether or not problems are anticipated [1].In all instances, at least one healthcare provider is assigned primary responsibility for the newborn infant. This person should have the necessary skills to evaluate the infant, and, if required, to initiate resuscitation procedures such as positive pressure ventilation and chest compressions. In addition, either this person or another who is immediately available should have the requisite knowledge and skills to carry out a complete neonatal resuscitation including endotracheal intubation and administration of medications.Equipment needed for resuscitation should be available at every delivery area (table 1), and routinely checked to ensure the equipment is functioning properly [1,4].Training?—?The neonatal resuscitation program (NRP) was developed by the American Academy of Pediatrics (AAP) and American Heart Association (AHA) as a training program aimed at teaching the principles and skills of neonatal resuscitation [4]. Studies have demonstrated that NRP training improves the correct sequencing and timing of the resuscitative steps and procedures by healthcare providers [2], provider knowledge and comfort in performing neonatal resuscitation [5], and five-minute Apgar scores [6].By 2005, the NRP had trained two million health care providers in the United States and was a model for similar neonatal resuscitation programs in over 100 countries [7]. In our institution, all healthcare providers who care for newborn infants (clinicians, nurses, neonatal nurse practitioners, and respiratory therapists) are required to be NRP trained. It is recommended that all delivery room personnel complete the NRP in an effort to improve their individual and group performance in neonatal resuscitation.High-risk delivery?—?Infants who are more likely to require resuscitation can be identified by the presence of one or more of the following risk factors (table 2) [4,8-10]:●Maternal conditions – Advanced or very young maternal age, maternal diabetes mellitus or hypertension, maternal substance abuse, or previous history of stillbirth, fetal loss, or early neonatal death.●Fetal conditions – Prematurity, postmaturity, congenital anomalies, intrauterine growth restriction, or multiple gestations.●Antepartum complications – Placental anomalies (eg, placenta previa or placental abruption), or presence of either oligohydramnios or polyhydramnios.●Delivery complications – Transverse lie or breech presentation, chorioamnionitis, foul-smelling or meconium-stained amniotic fluid, antenatal asphyxia with abnormal fetal heart rate pattern, maternal administration of a narcotic within four hours of birth, deliveries that require instrumentation (eg, forceps or vacuum deliveries) or cesarean delivery for maternal or fetal compromise.Individuals fully skilled in neonatal resuscitation should be present to care for the high-risk infant. If time permits, the team should meet with the parents and discuss the anticipated problems and plans for care of the infant, and address parental concerns to the best of their ability.Necessary equipment should be assembled prior to the birth of at-risk newborns as follows [4]:●The radiant warmer is turned on and is heating.●The oxygen source is open with adequate flow through the tubing.●The suctioning apparatus is tested and is functioning properly.●The laryngoscope is functional with a bright light.●Testing of resuscitation bag and mask demonstrates an adequate seal and generation of pressure.In high-risk deliveries of multiple gestations, each infant will require a full complement of personnel and equipment.Preterm infants?—?Preterm infants pose a greater challenge than term infants because they are more likely to require resuscitation and develop complications from the resuscitative process, particularly those with a birth weight below 1000 g [11]. If a preterm birth can be anticipated and time permits, it is preferable to transfer the mother prior to delivery to a perinatal center that has fully trained staff with expertise and experience in the care of these infants [12,13].The following factors make the preterm infant more likely to require resuscitation and to be more susceptible to sequelae [4]:●Hypothermia – The risk of heat loss leading to hypothermia is increased in infants with a large body surface area to mass, thin skin, and decreased subcutaneous fat. The smaller the infant, the more difficult it is to prevent hypothermia. (See?'Maintain temperature'?below.)●Inadequate ventilation – Immature lungs may be deficient in surfactant, and therefore difficult to inflate and ventilate. Immature respiratory drive and weak respiratory muscles increase the likelihood of apnea and inadequate respiratory effort. The greater the degree of prematurity, the more likely the infant will require intubation and positive pressure support. (See?'Next steps'?below.)●Infection – Maternal infection is associated with premature delivery, and offspring of infected mothers are at risk for antenatal infection. Premature infants also have immature immune systems, which increases the risk of acquiring postnatal infection. (See?"Pathogenesis of spontaneous preterm birth", section on 'Bacteria'.)●Organ damage – Immature tissues and capillaries (eg, retina or germinal matrix) are more vulnerable to injury resulting in complications (eg, retinopathy of prematurity and intracranial hemorrhage, respectively). (See?"Clinical manifestations and diagnosis of intraventricular hemorrhage in the newborn"?and?"Retinopathy of prematurity: Pathogenesis, epidemiology, classification, and screening", section on 'Risk factors'.)●Reduced antioxidant function – Immature antioxidant defense systems may be unable to counteract the effects of free radicals. Free radicals and reactive oxygen species are speculated to contribute to many of the morbidities of prematurity (eg, bronchopulmonary dysplasia and necrotizing enterocolitis) [14]. The very preterm infant may be particularly susceptible to oxidant injury from the use of excess supplemental oxygen in the delivery room [15]. (See?"Pathogenesis and clinical features of bronchopulmonary dysplasia", section on 'Oxygen toxicity'?and?"Pathology and pathogenesis of necrotizing enterocolitis in newborns".)Additional resources and personnel should be present when a preterm birth is anticipated. These include:●Equipment to keep the infant warm. In infants less than 28 weeks gestation, the use of polyethylene bags and wraps have been used to maintain body temperature. (See?"Short-term complications of the preterm infant", section on 'Hypothermia'.)●Personnel skilled in intubation are especially important for the extremely low birth weight infant (birth weight <1000 g).●In infants less than 30 weeks gestation who are more likely to be surfactant deficient, equipment and personnel should be available to deliver positive pressure to infants who fail to exhibit adequate spontaneous respiratory effort and to consider administering surfactant. (See?"Prevention and treatment of respiratory distress syndrome in preterm infants".)●Compressed air sources, oxygen blenders, and pulse oximeters should be available to allow delivery of less than 100 percent oxygen and allow monitoring of both the oxygen content of the air delivered and the oxygen saturation of the infant. This could reduce the potential oxidant injury that results from unnecessary exposure of supplemental oxygen. (See?'Supplemental oxygen'?below.)●Prewarmed transport incubator (with the capability to transport a ventilated infant), particularly if the delivery room is not in close proximity to the neonatal intensive care nursery.ANTENATAL COUNSELING?—?Each birth institution should have a consistent approach based upon the best available evidence regarding clinical care and parental counseling in cases where the fetal outcome is a concern. In particular, antenatal counseling should be provided to parents in the setting of an anticipated delivery of an extremely low birth weight infant (birth weight <1000 g) as recommended by the American Academy of Pediatrics (AAP) [16]. Counseling should include information regarding prognosis. (See?"Periviable birth (Limit of viability)".)We agree with the following AAP guidelines:●If there is no chance of survival, resuscitation should not be initiated. (See?'Withholding resuscitation'?below.)●When a good outcome is considered very unlikely, the parents should be given the choice of whether resuscitation should be initiated, and clinicians should respect their preference.●If a good outcome is considered reasonably likely, clinicians should initiate resuscitation and, together with the parents, continually reevaluate whether intensive care should be continued. (See?'Postresuscitation'?below.)OVERVIEW OF RESUSCITATIVE STEPS?—?Although there is increasing emphasis to incorporate the highest quality of evidence (ie, randomized clinical trials) into the American Heart?Association/American?Academy of?Pediatrics/International?Liaison Committee on Resuscitation?(AHA/AAP/ILCOR)?neonatal resuscitative guidelines [1,17], this is not always possible. Randomized trials are difficult to perform in the delivery room because of difficulties in obtaining consent before resuscitation, difficulty in blinding care providers regarding intervention, and the relatively uncommon occurrence of a poor neonatal outcome to measure the effectiveness of an intervention. As a result, many of the guideline recommendations are based upon extensive clinical experience and limited evidence [17].The following discussion and our own practice are in compliance with the 2015?AHA/AAP/ILCOR?guidelines for neonatal resuscitative care [1,17].The 2015?AHA/AAP/ILCOR?guidelines include a rapid assessment of the neonate's clinical status based on the following questions:●Is the infant full-term?●Does the infant have good muscle tone?●Is the infant breathing or crying?If the answer to all three questions is yes, the newborn does not need resuscitation, should not be separated from the mother, and is managed by routine neonatal care. (See?"Overview of the routine management of the healthy newborn infant".)The basic steps ("ABCDs") in resuscitation in any age group still apply in the newborn period. However, there are aspects of neonatal resuscitation that are unique and lead to differences in the initial resuscitative steps. (See?'Initial steps'?below.)The 2015?AHA/AAP/ILCOR?guidelines recommend the following approach [1,17]:●Initial stabilization (provide warmth, clear?Airway if necessary, dry, and stimulate)●Breathing (ventilation and oxygenate)●Chest compressions●Administration of?epinephrine?and/or?volume expansionThe decision to progress from one step to the next is determined by the response of the infant to the applied resuscitative effort based upon?his/her?respirations and heart rate. A time allocation of 60 seconds is given to evaluate, complete the initial steps, and reevaluate by assessing respiratory status (apnea, gasping, effort of breathing [labor or unlabored]) and heart rate (above or below 100 beats per minute [bpm]). No further resuscitative actions are required if the infant responds to initial intervention with adequate spontaneous respirations and a heart rate above 100 bpm. However, for those who fail to respond to initial interventions and have persistent findings of gasping, apnea, labored breathing, persistent cyanosis, or have a heart rate less than 100 bpm, monitoring of oxygen saturation by using pulse oximetry should be performed and further interventions may be required (eg, positive pressure ventilation and supplemental oxygen). (See?'Initial steps'?below and?'Next steps'?below.)It is vital that each step be performed optimally because subsequent resuscitative efforts are dependent on the success of previous steps. Inadequate attention to ensuring completeness and effectiveness of earlier steps will jeopardize the utility of subsequent actions and unnecessarily expose infants to more aggressive intervention when they only required the earlier steps of resuscitation.The following discussion will describe each resuscitative action in depth.Apgar scores?—?Apgar scores, first introduced in 1953, are an assessment of newborn infants during the first minutes after delivery. They are?not?used to guide resuscitation, but are useful as a measure of the newborn's overall status and response to resuscitation [18]. When the five-minute Apgar score is less than 7, additional scores should be assigned every 5 minutes for up to 20 minutes. The following signs are given values of 0, 1, or 2, and added to compute the Apgar score. Scores may be determined using the Apgar score calculator (calculator 1).●Heart rate●Respiratory effort●Muscle tone●Reflex irritability●ColorAlthough results from large population-based studies have shown that five-minute Apgar scores ≤3 were predictive for neonatal and infantile death and poor neurologic outcome (ie, cerebral palsy) [19,20], they are not precise enough to predict mortality of neurologic outcome for individual infants as stated in an updated American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG) policy statement [18]. The policy statement also recommended that the Apgar score should?not?be used alone to make a diagnosis of asphyxia. For infants with an Apgar score ≤5, it is recommended that an umbilical arterial cord sample be obtained to establish the presence of asphyxia. Assigning Apgar scores during resuscitation is useful to determine the response to resuscitative interventions, it is important, however, to note that the Apgar score assigned during resuscitation is not equivalent to that assigned to an infant who is not being actively resuscitated. The updated policy statement included an expanded reporting form that could be used during active resuscitation.INITIAL STEPS?—?Initial care steps in the delivery room are started within a few seconds of birth and should be applied throughout resuscitation. Our approach that is outlined in the following sections is generally in agreement with the updated 2015 American Heart?Association/AmericanAcademy of?Pediatrics/and?International Liaison Committee on Resuscitation?(AHA/AAP/ILCOR)?neonatal resuscitative guidelines [1,17].Maintain temperature?—?Hypothermia in the delivery room or immediate newborn period is independently associated with an increase in mortality [17,21,22]. Thus, maintaining body heat is the initial step in neonatal resuscitation. Hypothermia in the newborn increases oxygen consumption and metabolic demands, which can impair subsequent resuscitative efforts, especially in the asphyxiated or extremely low birth weight (ELBW) infant. Low birth weight and preterm infants are particularly prone to rapid loss of body heat because of their large body surface area relative to their mass, thin skin, and decreased subcutaneous fat.To minimize heat loss, the delivered infant is first placed in a warmed towel or blanket and then under a prewarmed radiant heat source, where?he/she?is dried with another warmed towel or blanket. The infant should remain uncovered to allow full visualization and permit the radiant heat to reach the patient. The radiant warmer also allows easy access to the infant for multiple members of the resuscitative team.As soon as possible after the infant is placed on the warmer, the temperature control of the warmer should be regulated by servo-control to avoid hyperthermia; the servo–controlled temperature of the warmer is set to maintain the infant's temperature at 36.5?C, which is monitored by a temperature skin probe placed upon the infant's abdomen. Healthcare providers should understand how the warmer and temperature probe work, since a malfunctioning warmer?and/or?temperature probe may lead to inadvertent underheating or overheating of the infant.Although studies have not examined the effects of postnatal hyperthermia in the delivery room on neonatal outcome, there are data demonstrating that maternal fever is associated with neonatal respiratory depression, neonatal encephalopathy, cerebral palsy, and increased mortality [1,17,23]. It is unclear whether hyperthermia directly contributes to morbidity or whether it is a marker for an underlying pathological process (eg, chorioamnionitis). Nevertheless, until further data are available, it is prudent to avoid neonatal hyperthermia, as well as hypothermia, in the delivery room.The following methods of warming infants are also used depending upon the condition of the neonate and the need for further resuscitative efforts:●Swaddling the infant after drying●"Skin to skin" contact with mother and covering the infant with a blanket●Use of polyurethane bags or wraps in infants with birth weights less than 1500 g●Raise the environmental (room) temperature to 26°C (78.8°F)●Warming padsIn infants who require respiratory support, the use of humidified and heated air versus nonheated air decreases the rate of both mild (36 to 36.4?C) and moderate hypothermia (<36?C) [24]. (See?"Short-term complications of the preterm infant", section on 'Hypothermia'.)Airway?—?The infant is positioned to open the airway by placing the infant on?his/her?back on a flat radiant warmer bed with the neck in a neutral to slightly extended position; the neck should not be hyperextended or flexed (figure 1). The proper position aligns the posterior pharynx, larynx, and trachea, and facilitates air entry. If needed, a rolled blanket or towel may be placed under the infant's shoulder to slightly extend the neck to maintain an open airway.Suctioning immediately after birth is reserved for babies with obvious obstruction due to secretions or who require positive pressure ventilation [1]. Once the infant has been correctly positioned, the mouth and nose should be suctioned either with a bulb syringe or mechanical suction device. The mouth is suctioned first and then the nares to decrease the risk for aspiration. Suctioning of either the esophagus or stomach should be avoided if not indicated, as it can produce a vagal response, resulting in apnea?and/or?bradycardia.Wiping the mouth and nose may be an alternative to suctioning for removal of secretions in infants who are greater than 35 weeks gestation. In a randomized, but not masked, equivalency trial conducted in a single center in the United States, wiping the face, mouth, and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery, based on the primary outcome of mean respiratory rate in the first 24 hours after birth [25]. Of note, nonvigorous neonates with meconium-stained amniotic fluid and those with major malformations were excluded from the study. Although there were no statistically significant differences in the secondary outcomes of need for more advanced interventions (eg, intubation, positive pressure ventilation, chest compression, and medications), one and five-minute Apgar scores, and admission to the neonatal intensive care unit (NICU), there was a trend for increased NICU admissions in the wipe group. In addition, there were protocol deviations in 117 of the 488 cases (24 percent), and almost all occurred in patients assigned to wiping who received suctioning. Further investigations are needed to confirm the equivalency of wiping compared to suctioning, as wiping could potentially reduce healthcare costs.Meconium stained amniotic fluid?—?In the presence of meconium-stained amniotic fluid (MSAF), intrapartum suctioning for meconium-stained infants who are vigorous is?not?recommended [1,17]. In addition, limited data suggest that endotracheal suctioning of?nonvigorous?neonates with MSAF is not beneficial and routine intubation and suctioning is also?not?recommended for nonvigorous infants with MSAF. The care of these infants should be guided by the same general principles for further intervention that are based on inadequate respiratory effort (gasping, labored breathing, or poor oxygenation) or heart rate (<100 beats per minute [bpm]).A more detailed discussion of the management of an infant with MSAF is presented separately. (See?"Prevention and management of meconium aspiration syndrome".)Heart rate?—?Assessment of heart rate is used to evaluate the effectiveness of the neonate's respiratory efforts and determine whether additional intervention is required. Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room. However, there is evidence that auscultation is imprecise and it usually takes several minutes for a reliable signal to be established with pulse oximetry [1,17]. As a result, the 2015?AHA/APA/ILCOR?guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room [1,17]. However, data comparing outcome using the three different methods of heart assessment are not available. It remains uncertain whether the extra time needed to place ECG leads may be detrimental or if the information provided by ECG will be more beneficial. In addition, the use of ECG does not replace the need for pulse oximetry, which is still important to assess oxygenationAt our center, we are in the process of determining the best way and device to assess heart rate. One challenge is to find leads that will not injure the fragile skin of very premature infants.Stimulation?—?Tactile stimulation of the newborn should be initiated promptly after birth. Drying and suctioning the infant, which is performed as part of the initial steps, may provide adequate stimulation. Safe, appropriate ways of providing additional stimulation include briefly slapping or flicking the soles of the feet, and rubbing the infant's back. More vigorous stimulation is not helpful and may cause injury. If, after one or two attempts of additional stimulation, the infant still remains apneic, positive pressure ventilation (PPV) should be initiated. (See?'Positive pressure ventilation'?below.)Given that most infants will be stimulated from the moment of birth, efforts at stimulating the infant should not be prolonged. The time elapsed from the baby's birth to placing the baby under the warmer, positioning, suctioning, and providing additional stimulation should be no more than 30 seconds [4].Pulse oximetry?—?The 2015?AHA/AAP/ILCOR?guidelines continue to recommend the use of pulse oximetry to determine oxygen saturation (SpO2) in the following settings because oxyhemoglobin saturation may normally remain in the 70 to 80 percent range for several minutes following birth, which may result in the appearance of cyanosis, and the assessment of skin color is a poor indicator of oxyhemoglobin saturation during the immediate neonatal period [1]:●When resuscitation is anticipated●Positive pressure ventilation is used for more than a few breaths●Persistent cyanosis●Use of supplementary oxygenFor these infants, the oximeter probe should be attached to a preductal location on the right upper extremity, usually the wrist or medial surface of the palm, as soon as possible.The targeted SpO2?levels for term infants born at sea level are as follows based on the time after delivery [1,26]:●1 minute – 60 to 65 percent●2 minutes – 65 to 70 percent●3 minutes – 70 to 75 percent●4 minutes – 75 to 80 percent●5 minutes – 80 to 85 percent●10 minutes – 85 to 95 percentData on targeted levels for premature infants and term infants born at other altitudes are lacking, and the above levels are thought to be reasonable for these patients.NEXT STEPS?—?The initial steps delineated above are applied in every newborn delivery. Subsequent resuscitative care depends on the evaluation of the infant while performing these initial steps. No further resuscitative actions are required if the infant responds with adequate spontaneous respirations (eg, sustained regular respirations) and a heart rate above 100 beats per minute, and achieves targeted SpO2?levels.Supplemental oxygen?—?Over the last few decades, the standard practice of initial use of 100 percent oxygen, whenever supplemental oxygen is needed, has been challenged, as increasing evidence has shown that hyperoxia due to oxygen supplementation may result in tissue and organ injury [27-29]. Hyperoxia is thought to raise cellular oxygen contents, which leads to an increased generation of free oxygen radicals causing cellular and tissue injury [27-30].Data for term infants?—?Several studies including meta-analyses have shown improved survival and outcome in primarily term infants resuscitated with room air compared with those who received 100 percent oxygen.●Two meta-analyses demonstrated a reduction in mortality in primarily term infants with the use of room air compared with 100 percent oxygen, and no difference in the risk of hypoxic ischemic encephalopathy or changes in neurodevelopmental outcome at 18 to 24 months of age [31,32].●Two trials of asphyxiated term infants demonstrated that infants resuscitated in room air compared with those resuscitated with 100 percent oxygen more quickly achieved sustained respirations and had lower concentrations of markers or oxidative stress (ie, glutathione, superoxide dismutase, catalase, and glutathione peroxidase) [28,33].●A retrospective population-based Swedish study compared the outcome of severely depressed infants (defined as a one-minute Apgar score less than four) who were resuscitated at one of four tertiary centers that used either 40 percent oxygen or 100 percent oxygen during neonatal resuscitation. There were no differences in rates of neonatal death, hypoxic ischemic encephalopathy, or seizures between infants resuscitated with 40 percent oxygen and those who received 100 percent oxygen [34].Data for preterm infants?—?Data in preterm infants report no difference in outcome when initial resuscitation with high or low concentration of oxygen is used.This was illustrated by the following two systematic reviews:●The first review of trials that enrolled preterm infants less than 32 weeks gestation showed no difference in the primary outcome of mortality (relative risk [RR] 0.62, 95% CI 0.37-1.04) between infants initially resuscitated with low oxygen concentration (21 to 30 percent) compared with those who received high oxygen concentration (60 to 100 percent) [35]. There also was no difference between the two groups for the secondary outcomes of bronchopulmonary dysplasia (BPD) (RR 1.11, 95% CI 0.73-1.68) and intraventricular hemorrhage (IVH) (RR 0.90, 95% CI 0.53-1.53).●The second subsequent review that included trials of preterm infants less than 28 weeks gestation showed no difference between infants initially resuscitated with low oxygen concentration (≤30 percent) compared with those who received high oxygen concentration (≥60 percent) in overall mortality (RR 0.99, 95% CI 0.52-1.91), BPD (RR 0.88, 95% CI 0.68-1.14), IVH (RR 0.81, 95% CI 0.52-1.27), retinopathy of prematurity (RR 0.82, 95% CI 0.46-1.46), patent ductus arteriosus (RR 0.95, 95% CI 0.8-1.14), and necrotizing enterocolitis (RR 1.61, 95% CI 0.67-3.36) [36].One trial that was included in the second systematic review that compared 21 percent (room air) with 100 percent oxygen as the initial oxygen concentration reported a higher mortality for infants that were initially resuscitated with room air [37]. Although this trial was terminated early based on its Data and Safety Monitoring Committee's recommendation because of the concern of serious adverse effects of room air, it is the largest trial to compare low and high oxygen concentration.Follow-up of two trials included in the systematic review of preterm infants less than 32 weeks gestation that compared 30 with 65 percent oxygen as the initial oxygen concentration for neonatal resuscitation showed there was no difference in survival or neurodevelopmental outcome at 24 months corrected age [38,39]. Neurodevelopmental assessment used the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) to assess visual acuity, neurosensory deafness, and language skills.As the sample sizes in the above studies in preterm infants are small and it is not clear if initial resuscitation with high concentrations of oxygen are needed, many clinicians prefer to resuscitate preterm infants with lower concentrations of supplemental oxygen [40].The above data supports our practice to use blended oxygen with concentration starting at 30 percent in the resuscitation of preterm infants below 30 weeks gestation, and adjust the oxygen concentration based on a predetermined SpO2?targets. (See?'Our approach'?below and?"Neonatal target oxygen levels for preterm infants", section on 'Oxygen target levels'.)AHA/AAP/ILCOR guidelines?—?Based on the above data, the American Heart?Association/American?Academy of?Pediatrics/International?Liaison Committee on Resuscitation?(AHA/AAP/ILCOR)?revised their guidelines in 2015 regarding the initial concentration of supplemental oxygen for neonatal resuscitation as follows [1,17]:●For neonates born at ≥35 weeks gestation, resuscitation is initiated with room air (21 percent oxygen).●For neonates <35 weeks gestation, resuscitation is initiated with 21 to 30 percent oxygen.●The oxygen concentration should be adjusted to achieve targeted SpO2?levels, which are monitored by pulse oximetry. (See?'Pulse oximetry'?above.)●If the heart rate is below 60 bpm after 90 seconds of resuscitation, the oxygen concentration should be increased to 100 percent until recovery of a normal heart rate.Our approach?—?At our institution, we currently utilize the following approach, which complies with the above guidelines:●For neonates >30 weeks gestation, we initiate resuscitation with 21 percent oxygen.●For infants ≤30 weeks gestation, we initiate resuscitation with 30 percent oxygen by use of a blender.In all infants, pulse oximetry monitoring guides further adjustments of the delivered supplemental oxygen in an effort to achieve and maintain the oxygen saturation based on target SpO2. However, optimal target levels for preterm infants remains unknown and is discussed separately. (See?'Pulse oximetry'?above and?"Neonatal target oxygen levels for preterm infants", section on 'Oxygen target levels'.)Positive pressure ventilation?—?Positive pressure ventilation (PPV) is required in the following clinical settings after administering the initial steps of resuscitation:●If the infant is gasping or apneic.●If the heart rate is <100 bpm. The heart rate can be checked either by auscultation or palpation of the pulse in the umbilical cord.Although PPV is an important therapeutic intervention in neonatal resuscitation, it is a technique that requires considerable skill and practice to apply it correctly. The different methods and techniques of delivering PPV to the newborn infant are reviewed here.Equipment?—?PPV is routinely administered to the newborn infant by bag-mask ventilation (BMV) by the self-inflating bag, flow-inflating bag, or T-piece resuscitator [1]. In our center, we use both the flow-inflating bag and the self-inflating bag because we have a large diverse group of healthcare givers, including many trainees. The more experienced clinicians prefer the flow-inflating bag for its advantages of providing a continuous flow of supplemental oxygen and continuous positive airway pressure (CPAP), if needed, in addition to its ability to deliver PPV.●Self-inflating bag – Self-inflating bag reinflates when it is released. Unlike the other BMV methods, it does not require a compressed gas source. Thus, it is the only method used when compressed gas sources are?not?available in resource limited areas. The self-inflating bag has a pressure-release valve, commonly called a pop-off valve that is set by the manufacturer to release at about 30 to 40 cm H2O pressure. However, for the newborn who has not taken its first breath, it may be necessary to occlude this pop-off valve in order to generate sufficient pressure to effectively inflate a newborn's nonaerated lungs. In such instances, care should be taken not to overinflate the lungs because this may increase the risk of causing pulmonary air leak. (See?"Pulmonary air leak in the newborn".)It has been generally assumed that the delivered oxygen concentration using a bag without a reservoir is 40 percent when using a source of 100 percent oxygen. However, one study demonstrated that delivered oxygen concentration exceeded 60 percent at a minimum flow rate of 1?L/minand rose as the flow rate increased [41]. When the pop-off valve was opened at 35 to 40 cm H2O, oxygen concentrations fell to levels of 30 and 45 percent at flow rates ≤2?L/min.With a self-inflating bag and a reservoir, oxygen delivery is thought to be about 90 to 100 percent oxygen with a 100 percent oxygen source. However, a study in resource-limited settings reported that delivered oxygen concentration could be controlled from <40 to >60 percent by varying the oxygen flow rate from 0.25?L/min?to 1?L/min?regardless of positive inspiratory pressure (PIP) with PIP levels from 20 to 25 cm H2O [42].Another study reported that oxygen concentration can be controlled without a blender using self-inflating bags with a reservoir [42]. These findings are significant given the concern for potential oxygen toxicity and episodes of hyperoxia with high concentrations of delivered oxygen. They also demonstrate that pulse oximetry is required when supplemental oxygen and positive pressure ventilation are used. (See?'Supplemental oxygen'?above.)●Flow-inflating bag – The flow-inflating bag (also referred to as an anesthesia bag) fills only when gas from a compressed source flows into it. It is technically more difficult to master than the self-inflating bag because a tight face-mask seal is needed for the bag to inflate; however, this feature may be considered an advantage because it assures an optimal face-mask seal is obtained, which is necessary for effective positive pressure ventilation. Because the flow-inflating bag does not have a pressure release valve, a pressure manometer should always be used to minimize the risk of overinflation resulting in pulmonary air leak. (See?"Pulmonary air leak in the newborn".)●T-piece resuscitator – The T-piece resuscitator is similar to the flow-inflating bag, but with the addition of an adjustable flow-control valve, which more precisely controls the peak inflating pressure applied to the infant's lungs, decreasing the risk of pulmonary air leak complications. Like the flow-inflating bag, it requires a compressed gas source. Limited data suggest using a T-piece resuscitator reduces the rate of intubation compared with use of a self-inflating bag [43,44]. This was best illustrated in a trial of 1027 neonates with a gestational age ≥26 weeks who required PPV that showed patients assigned to resuscitation using the T-piece resuscitator compared with those assigned to the self-inflating bag had a lower intubation rate (17 versus 26 percent) and mean maximum PIP (26 versus 28 cm H20) [43]. There was no difference in the rate of achieving a heart rate ≥100 bpm (94 versus 90 percent).●In term infants and preterm infants with birth weights greater than 1500 g (≥34 weeks gestation), laryngeal mask airway (LMA), which fits over the laryngeal inlet, has been found to be effective when BMV or endotracheal intubation is unsuccessful, or endotracheal intubation is not possible [45]. The LMA is a soft mask with an inflatable cuff attached to a silicone rubber airway, which is inserted through the mouth by the clinician using?his/her?index finger to guide insertion along the hard palate "blindly" without the use of visualizing instruments. Following insertion and inflation of the cuff, the LMA covers the laryngeal opening and its rim conforms to the contours of the hypopharynx occluding the esophagus with a low-pressure seal. LMA should be considered only if BMV is unsuccessful in providing adequate ventilation, and endotracheal intubation is unsuccessful or not feasible. [45-48].Procedure?—?The following steps are required to effectively provide assisted positive pressure bag-mask ventilation (BMV):●Position – The infant should be positioned with the neck in a neutral to slightly extended position to ensure an open airway (figure 1). The clinician should stand at the head or side of the warmer to view the chest movement of the infant to assess whether ventilation is effectively delivered. (See?'Airway'?above.)●Suction – The nose and mouth should be suctioned as needed to clear any mucous to prevent aspiration prior to delivery of assisted breaths.●Seal – An airtight seal between the rim of the mask and the face is essential to achieve the positive pressure required to inflate the lungs. An appropriately sized mask is selected and positioned to cover the chin, mouth, and nose, but not the eyes of the infant [49]. The mask is held on the face by positioning the hand of the clinician so that the little, ring, and middle fingers are spread over the mandible in the configuration of the letter "E" and the thumb and index are placed over the mask in the shape of the letter "C". The ring and fifth fingers lift the chin forward to maintain a patent airway. An airtight seal is formed by using light downward pressure on the rim of the mask and gently squeezing the mandible up towards the mask (picture 1).●Initial breaths – The initial administered breaths often require pressures of 30 to 40 cm H2O to inflate the lungs of the newly born term infant. In most preterm infants, an initial inflation pressure of 20 to 25 cm H2O is usually adequate. Adequacy of ventilation is demonstrated by improvement in heart rate. Chest wall movement should be assessed if heart rate does not improve. The infant should be ventilated at a rate of 40 to 60 times per minute to achieve a heart rate >100 bpm.When initiating ventilation, the care provider should try to avoid excess volume or pressure, which can result in volutrauma resulting in lung injury or pulmonary air leak, especially in the premature infant [50]. To minimize volutrauma, the positive pressure should be adjusted to deliver a tidal volume of 4 to 5?mL/kg. In addition, positive end-expiratory pressure (PEEP) of 4 to 5 cm H2O should be used to prevent atelectasis [50]. The self-inflating bag does not provide PEEP. (See?"Prevention of bronchopulmonary dysplasia", section on 'Noninvasive mechanical ventilation'?and?"Pulmonary air leak in the newborn".)●Next steps – Further resuscitative efforts are based upon the heart rate response of the infant after the initial 30 seconds of BMV.?If the heart rate is greater than 100 beats per minute (bpm) and spontaneous effective respiration has begun, BMV can be discontinued and free-flowing oxygen administered as needed, based on the target oxygen saturations for minutes after birth. The infant is observed closely (heart rate and SpO2) to determine whether?his/her?spontaneous respiratory effort is adequate without need for further intervention.?If the heart rate is between 60 to 100 bpm, continue BMV ventilation and reevaluate after 30 seconds. Reevaluation includes the following sequence of M-Mask readjustment, R-Reposition the airway, S- Suction the mouth and nose, and O- Open the mouth slightly. If these maneuvers fail, consider increasing inflation pressure because failure of establishing effective positive pressure ventilation is an extremely common and potentially preventable cause of failed resuscitation.?If the heart rate is below 60 bpm, immediately begin chest compression and reassess that adequate positive pressure ventilation is being delivered. (See?'Chest compressions'?below.)CPAP?—?Continuous positive airway (CPAP) in very preterm infants at risk for respiratory distress syndrome (RDS) with spontaneous ventilation is the preferred intervention versus the combined regimen of endotracheal intubation, surfactant therapy, and mechanical ventilation [1,17]. CPAP and neonatal RDS are discussed separately. (See?"Prevention and treatment of respiratory distress syndrome in preterm infants", section on 'Nasal continuous positive airway pressure'.)Endotracheal intubation?—?Endotracheal (ET) intubation allows direct access to the upper trachea for delivery of positive pressure ventilation (PPV). Intubation is a skill that must be learned and takes practice for one to become accomplished. While bag-mask ventilation (BMV) may suffice in most instances of neonatal resuscitation, there are instances when ET intubation may be preferred. Thus, when a high-risk delivery is anticipated, at least two individuals should be present for the birth to assist with resuscitation of the infant, and one should be skilled in ET intubation.ET intubation may be indicated if [1]:●BMV is ineffective or prolonged●Chest compressions are being performedIn addition to the above, ET intubation may be electively chosen in certain special circumstances, such as congenital diaphragmatic hernia, airway stabilization of the extremely low birth weight infant, and for administration of surfactant.All necessary supplies should be readied for intubation, including appropriate size ET tubes (ETT). The neonatal resuscitation program (NRP) guidelines use birth weight and gestational age to determine the appropriate ETT size (table 3). An alternate method for selection of ETT size is based upon the length of the infant [51]. However, its use has only been validated in one study. This approach cannot be recommended until further studies verify that it can accurately predict appropriate ETT size for neonates.Suction device should be available to remove secretions in the posterior oropharynx and laryngopharynx that may obstruct the view of the trachea and vocal cords.Procedure?—?Two care providers are required for ET intubation, one to perform the procedure and the other to assist and monitor the status of the infant during the intubation. To minimize hypoxemia, time needed for intubation should be limited to 20 seconds, and free flowing oxygen is administered during the procedure.The following steps are required for successful intubation of the neonate:●Initial stabilization – Unless contraindicated, the patient should be stabilized by BMV.●Positioning – The infant is placed on?his/her?back with the head in the midline and the neck slightly extended.●Insertion – The laryngoscope is held in the left hand of the clinician between the thumb and the first two or three fingers, with the blade pointing away from the clinician. The right hand stabilizes the head of the infant. The laryngoscope blade is inserted over the right side of the tongue pushing the tongue to the left and is advanced until the blade lies in the vallecula, just beyond the base of the tongue. The entire blade is lifted in the direction of the laryngoscope handle to allow visualization of the vocal cords. It is important not to twist the laryngoscope like a lever, the so-called "can opener" maneuver, as this can elevate the vocal cords out of view and can damage the alveolar ridge. Once the vocal cords are visualized, an appropriate-sized ETT is inserted through them with the right hand until the vocal cord guide line (heavy black line near the tip of the tube) is at the level of the vocal cords.Some individuals prefer to use a stylet to provide rigidity and curvature to the tube; if a stylet is used, care should be taken that it does not protrude out of the tip of the tube, and when it is removed the tube is not inadvertently dislodged.●Assessment of successful intubation – Successful intubation following institution of PPV is associated with a prompt increase in heart rate. Other indicators of successful intubation include auscultation of audible breath sounds over both lung fields, vapor condensation inside the ETT during exhalation, and symmetrical chest movement; however, these findings have not been systematically studied in neonates. Chest radiography is needed to confirm that the ETT is correctly placed above the carina of the trachea.Exhaled carbon dioxide (CO2) detectors can be used to confirm ETT placement, especially in very low birth weight infants [52-55]. At our institution, we use CO2?detectors to confirm ETT placement as endorsed by the 2015 guidelines [1].●Securing ETT – If the ETT is to be used for ventilation, it needs to be secured and taped. A simple calculation can be used to determine the depth of insertion (referred to as the 7-8-9 or Tochen's rule). The distance measured in cm from the tip of the ETT to the lip of the infant is calculated as the infant's weight in kg plus "6". So for a 1 kg infant, the depth of insertion is 7 cm. This rule accurately places the tip of the ETT just above the midtracheal position in infants with birth weight (BW) ≥750 g. However, the Tochen's rule is not adequate for ETT placement in infants with BW <750 g. In one study, this calculation overestimated the depth of insertion in very premature infants (BW <750 g), which can result in intubation of the right main stem bronchus [56], whereas another study reported that ETT placement was inadequate (too high) in a group of infants of similar birth weights [57]. Although NRP guidelines caution that the ETT may need to be inserted only 6 cm in infants with BW <750 g, these results emphasize the importance of obtaining radiographic verification of ETT placement as soon as possible.●PEEP – In infants who require PPV, PEEP is likely to be beneficial, and should be used if suitable equipment is available. In our practice, we routinely use PEEP in accordance with the 2015?AAP/AHA/ILCOR?guidelines that suggest 5 cm H2O PEEP be used whenever PPV is provided to neonates [1].CHEST COMPRESSIONS?—?Chest compressions are initiated if the infant's heart rate remains <60 beats per minute despite adequate ventilation for 30 seconds [1].Chest compression applies pressure to the lower one-third of the sternum visualized as an imaginary line between the nipples and the xiphoid process. Although two methods are available, the two thumb technique is performed as it because it generates higher systolic and coronary perfusion pressure, and it allows better access for umbilical line insertion [1,17,58-63].●Thumb technique – In this method, both hands encircle the infant's chest with the thumbs on the sternum and the fingers under the infant (figure 2). This is the preferred method.●Two-finger technique – In this method, the tips of the first two fingers, or the middle and ring finger, are placed in a perpendicular position over the sternum (figure 3).Pressure is applied downward perpendicular to the chest wall sufficient to depress the sternum about one-third of the anteroposterior diameter of the chest, and then pressure is released to allow the heart to refill. Care should be taken to avoid applying pressure directly over the xiphoid, as this may cause hepatic injury.Chest compressions must always be accompanied by positive pressure ventilation (PPV). During neonatal resuscitation, the chest compression rate is 90 per minute accompanied by 30 ventilations per minute with one ventilation interposed after every third compression. Thus, the ventilation rate is reduced from the 40 to 60 breaths per minute used in the absence of chest compression to 30 breaths in the presence of chest compression. Whenever chest compressions are provided, the oxygen concentration should be increased to 100 percent [1].After 30 seconds of chest compression and PPV, reassessment of the infant's heart rate, color, and respiratory rate should determine whether further interventions are required (eg, intubation or administration of medications).DRUGS?—?Drugs are rarely required in neonatal resuscitation. Delivering adequate ventilation is the most important resuscitative step because the most common cause of bradycardia is inadequate lung inflation or profound hypoxemia.However, if the heart rate remains <60 beats per minute despite adequate ventilation and chest compressions, administration of?epinephrine?is indicated. Rarely, volume expansion or a narcotic antagonist (eg,?naloxone) may be useful. The following table lists the medications used in neonatal resuscitation (table 4).Vascular access?—?Medications need to be given intravenously. The quickest means of obtaining intravenous access in the newborn is cannulation of the umbilical vein. This is accomplished by aseptically inserting a catheter into the umbilical vein to a depth of two to four cm until there is free flow of blood.Epinephrine?—?Although?epinephrine?is widely used in neonatal resuscitation, it has never been prospectively studied and validated in placebo-controlled clinical trials [45,64].Epinephrine?increases the workload and oxygen consumption of the cardiac muscle, and therefore, it is only administered after ventilation has been established to avoid injury to the myocardium.Prior neonatal resuscitation program (NRP) guidelines suggested that the?epinephrine?could be delivered through the endotracheal tube (ETT); however, epinephrine given intravenously is more efficacious than ETT administration [65].Current guidelines recommend intravenously administered?epinephrine?at a dose of 0.01 to 0.03?mg/kg?(0.1 to 0.3?mL/kg?of a 1:10,000 solution [concentration 0.1?mg/mL]). Higher doses of epinephrine have not been shown to be more effective and there are some data that higher doses may result in brain and cardiac injury [4,46]. Epinephrine may be repeated every three to five minutes if the heart rate remains <60 beats per min.The ETT route may be used while intravenous access is being obtained, but the safety and efficacy of this practice has not been evaluated. The current guidelines recommend if?epinephrine?is given through an ETT, a dose of 0.05 to 0.1?mg/kg?(0.3 to 1?mL/kg?of a 1:10,000 solution) should be used [1]. After ETT administration, another dose of epinephrine could be administered intravenously when vascular access is obtained [4].If there is no response to the dose of?epinephrine, the clinician should reassess the earlier resuscitative steps to ensure that they have been performed correctly. If resuscitative efforts were completed correctly, then another problem such as hypovolemia might be present.Volume expansion?—?In the delivery room, neonatal hypovolemia requiring volume expansion is rarely needed. Hypovolemia may be suspected if there is ante- or intrapartum hemorrhage, which could be due to an umbilical cord accident, placenta previa, placental abruption, or trauma, or if there are clinical signs of hypovolemia seen despite an adequate heart rate, such as pallor, poor perfusion, and weak pulses.Because isotonic crystalloid solution is as effective as 5 percent albumin in restoring effective circulating volume in neonates [66-68], the current guidelines recommend a 10?mL/kg?bolus of normal saline given over 5 to 10 minutes to correct hypovolemia [1]. This dose can be repeated if necessary based upon the response to the initial bolus.Other acceptable solutions include Ringer's lactate or O Rh-negative blood. The latter may be preferable if severe blood loss?and/or?anemia is suspected or documented.Naloxone?—?Since the 2010 American Heart?Association/International?Liaison Committee on Resuscitation?(AHA/ILCOR)?guidelines, administration of?naloxone, a narcotic antagonist, is?not?recommended as part of initial resuscitation in the delivery room because data are lacking demonstrating its efficacy, and there remains uncertainty regarding its dosing, routes of administration, and safety [46,69]. Although, maternally administered opioids in the perinatal period may cause neonatal respiratory depression, attention to ventilation and oxygenation as described earlier is generally adequate for neonatal resuscitation.Sodium bicarbonate?—?There is insufficient evidence to determine whether?sodium bicarbonate?is beneficial or harmful in neonatal resuscitation [4,70,71]. Although theoretically sodium bicarbonate should be beneficial to correct acidosis, there is also evidence that sodium bicarbonate could adversely affect myocardial and cerebral function [72]. Given the uncertainty of benefit and the potential for adverse effects, we do?not?recommend the routine use of sodium bicarbonate as part of neonatal resuscitation. (See?"Approach to the child with metabolic acidosis", section on 'Neonates'.)If?sodium bicarbonate?is used, it should be given only after adequate ventilation and circulation has been established to prevent increased CO2?retention. Sodium bicarbonate is a caustic and hypertonic agent, and, if administered, it must be given through a large vein. Given the controversy over its use in neonatal resuscitation, no dose for sodium bicarbonate use has been established. If it is used, the usual dose is 1 or 2?mEq/kg,?given at a rate no faster than 1?mEq/kg?per minute. (See?"Primary drugs in pediatric resuscitation", section on 'Sodium bicarbonate'.)FAILURE OF INITIAL RESUSCITATION?—?Rarely, infants will not respond to the initial resuscitative efforts. The clinical team needs to review that all the resuscitative steps were fully and properly administered.If the infant fails to respond despite properly executed resuscitation, the following clinical approach may help ascertain the cause:●Failure to respond to positive pressure ventilation (PPV):?Mechanical blockage (eg, meconium, mucus, choanal atresia, pharyngeal airway malformation [Robin sequence], or laryngeal web)?Impaired lung function (pneumothorax, pleural effusions, congenital diaphragmatic hernia, pulmonary hypoplasia, congenital pneumonia, or hyaline membrane disease)●Central cyanosis – Congenital heart disease●Persistent bradycardia – Heart block●Apnea – Brain injury (hypoxic ischemic encephalopathy), congenital neuromuscular disorder, or respiratory depression from maternally administered opioidsWITHHOLDING RESUSCITATION?—?With antenatal screening, it is now possible to identify conditions associated with high neonatal mortality or poor outcome. In these settings, intensive therapy including neonatal resuscitation may result in prolongation of dying with significant pain and discomfort for the neonate or survival with unacceptable quality of life. Decisions regarding whether intervention should be initiated and to what degree are difficult and are made together by parents and care providers, guided by their understanding of the child's best interests.Our approach in deciding whether resuscitation should be initiated or withheld is consistent with the recommendations of the American Academy of Pediatrics (AAP) and includes the following [1,73].●The decision not to initiate intensive therapy is made together by the parents and the healthcare team. Parents should be active participants in the decision-making process concerning the treatment of their child. Discussion, if possible, should occur prior to the birth of the infant.●Noninitiation of resuscitation may be considered if early death is very likely and survival would be accompanied by unacceptably high morbidity. These clinical conditions include infants with gestational age <23 weeks or birth weight <400 g, anencephaly, or chromosomal abnormalities incompatible with life (eg, trisomy 13 or 18). (See?"Periviable birth (Limit of viability)", section on 'Management approach'.)●Intensive care including neonatal resuscitation is always indicated when there is a high likelihood of survival and acceptable morbidity.●In settings in which the prognosis of the infant is unclear but likely poor, and survival may be associated with a diminished quality of life, parental wishes should determine management decisions.●At delivery, if the appropriate course is uncertain, it is preferable to initiate resuscitation. After delivery, the healthcare team can review with the parents the clinical status and prognosis of their infant, and determine the parents' wishes. If additional data demonstrate that the outcome is almost certain early death or unacceptably high morbidity, support can be discontinued if agreed upon by the parents and healthcare team.●Basic care that provides comfort to the infant must be given at all times, even when intensive therapy is not initiated.●When there is disagreement between the parents and healthcare team, continued discussion is recommended. Other resources that are useful in resolving disagreement include consultation with the hospital's ethics committee or finding healthcare providers that will provide care for the infant in the manner desired by the parents. At times, unresolved disagreement may result in the involvement of the court system.●At all times, the clinician must serve as an advocate of the infant and what?he/she?judges to be in the infant's best interest.●The clinician needs to know the relevant laws in?his/her?local area of practice.DISCONTINUING RESUSCITATION?—?Resuscitation efforts may be discontinued if the neonate has demonstrated no signs of life (no heart beat or no respiratory effort for greater than 10 minutes) after 10 minutes of resuscitation, because outcome is associated with high early mortality and morbidity among the survivors [1,74-77]. While there are reports of rare survivors who are developmentally normal at 18 months of age, which may be reflective of improved resuscitation and postresuscitation care, the outcome of the majority of infants with no signs of life after 10 minutes of resuscitation remains poor due to either death or survival with neurodevelopmental impairment [77].As previously discussed, if additional data obtained after resuscitation is started demonstrates that neonatal outcome is almost certain early death or unacceptably high morbidity, support can be discontinued if agreed upon by the parents and healthcare team.POSTRESUSCITATION?—?Infants who required resuscitation are at risk of developing postresuscitative complications [78]. These include:●Hypo- or hyperthermia (see?"Clinical features, diagnosis, and treatment of neonatal encephalopathy", section on 'Therapeutic hypothermia')●Hypoglycemia (see?"Pathogenesis, screening, and diagnosis of neonatal hypoglycemia")●Central nervous system (CNS) complications: apnea, seizures, or hypoxic ischemic encephalopathy (see?"Clinical features, diagnosis, and treatment of neonatal encephalopathy")●Pulmonary complications: Pulmonary hypertension, pneumonia, pulmonary air leaks, or transient tachypnea of the newborn (see?"Overview of neonatal respiratory distress: Disorders of transition")●Hypotension (see?"Etiology, clinical manifestations, evaluation, and management of neonatal shock")●Electrolyte abnormalities: Hyponatremia or hypocalcemia (see?"Fluid and electrolyte therapy in newborns", section on 'Disorders of sodium, water, and potassium balance')●Feeding difficulties: Ileus, gastrointestinal bleeding, or dysfunctional sucking or swallowing (see?"Neonatal oral feeding difficulties due to sucking and swallowing disorders")The longer and the greater the extent of resuscitation, the more likely that there will be subsequent and serious complications. Thus, infants who required resuscitation should be placed in a setting in which close monitoring and ongoing appropriate care can be provided [79].SUMMARY AND RECOMMENDATIONS●Most infants successfully transfer from intrauterine to extrauterine life without any special assistance. However, about 10 percent of newborns will need some intervention, and 1 percent will require extensive resuscitative measures at birth.●Because the need for resuscitation is not anticipated in the majority of neonates, personnel who are adequately trained should be readily available to perform neonatal resuscitation at every birthing location, whether or not problems are anticipated. (See?'Anticipation of resuscitation need'above.)●Infants who are more likely to require resuscitation can be identified by maternal and neonatal risk factors, and the presence of antepartum and delivery room complications. Care providers skilled in neonatal resuscitation should be present and equipment should be prepared prior to the birth of the high-risk infant. (See?'High-risk delivery'?above.)●Preterm infants are more likely to require resuscitation and develop complications from resuscitation than term infants. If a preterm birth can be anticipated and time permits, it is preferable to transfer the mother prior to delivery to a perinatal center. (See?'Preterm infants'?above.)Resuscitation steps?—?We suggest the following practices described in the 2015American Heart?Association/American?Academy of?Pediatrics/International?Liaison Committee on Resuscitation?(AHA/AAP/ILCOR)?guidelines for neonatal resuscitation be followed when providing resuscitation to newborn infants (Grade 2C).●Neonatal resuscitation may be required in infants who are premature, do not have good muscle tone, and are not breathing or crying. (See?'Overview of resuscitative steps'?above.)●Initial care includes providing warmth to the infant, clearing?his/her?airway, and drying and stimulating the infant. (See?'Initial steps'?above.)●After the above initial steps are completed, if further resuscitative efforts are required or if resuscitation was anticipated, pulse oximetry should be initiated to determine oxygen saturation levels and to guide the administration of appropriate amounts of oxygen.●Positive pressure ventilation (PPV) is required if the infant has an inadequate respiratory effort or a heart rate <100 beats per minute (bpm). PPV is started with bag-mask ventilation (BMV) at a rate of 40 to 60 times per minute for 30 seconds, after which the heart rate is measured.●We recommend that resuscitation begin with blended oxygen or room air and the concentration of oxygen is adjusted based on targeted oxygen saturation levels measured by pulse oximetry (Grade 1B). In our practice, we initiate resuscitation with room air in infants greater than 30 weeks gestation, and use 30 percent oxygen concentration for those ≤30 weeks gestation. (See?'Supplemental oxygen'?above and?'Pulse oximetry'?above.)●Intubation is needed if BMV is ineffective or prolonged, or chest compressions are being performed. (See?'Endotracheal intubation'?above.)●Chest compressions are required if the infant's heart rate remains <60 bpm despite adequate ventilation for 30 seconds. Chest compressions must always be accompanied by PPV using 100 percent oxygen. Chest compression rate is 90 per minute accompanied by 30 ventilations per minute with one ventilation interposed after every third compression. (See?'Chest compressions'?above.)●Drugs are rarely required in neonatal resuscitation. However, if the heart rate remains <60 bpm despite adequate ventilation and chest compressions, intravenous administration of?epinephrine?is indicated (table 4). Cannulation of the umbilical vein is the quickest means of obtaining intravenous access in the newborn. (See?'Epinephrine'?above.)●Resuscitation can be withheld if it is legally acceptable and there is complete agreement among parents and care providers that the neonatal outcome is dismal. (See?'Withholding resuscitation'?above.)●Resuscitation efforts may be discontinued if the neonate has demonstrated no signs of life (no heart beat or no respiratory effort for greater than 10 minutes) after 10 minutes of resuscitation. (See?'Discontinuing resuscitation'?above.)●Infants who required resuscitation are at risk of developing postresuscitative complications. After successful resuscitation, they require placement in a setting in which close monitoring and ongoing appropriate care can be provided. (See?'Postresuscitation'?above.)Use of UpToDate is subject to the?Subscription and License Agreement.REFERENCESWyckoff MH, Aziz K, Escobedo MB, et al. 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J Pediatr 2014; 165:256.Szyld E, Aguilar A, Musante GA, et al. Comparison of devices for newborn ventilation in the delivery room. J Pediatr 2014; 165:234.Thakur A, Saluja S, Modi M, et al. T-piece or self inflating bag for positive pressure ventilation during delivery room resuscitation: an RCT. Resuscitation 2015; 90:21.International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 7: Neonatal resuscitation. Resuscitation 2005; 67:293.Kattwinkel J, Perlman JM, Aziz K, et al. Part 15: neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S909.Grein AJ, Weiner GM. Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation. Cochrane Database Syst Rev 2005; :CD003314.Gandini D, Brimacombe JR. Neonatal resuscitation with the laryngeal mask airway in normal and low birth weight infants. Anesth Analg 1999; 89:642.O'Shea JE, Thio M, Owen LS, et al. Measurements from preterm infants to guide face mask size. Arch Dis Child Fetal Neonatal Ed 2016; 101:F294.Schm?lzer GM, Te Pas AB, Davis PG, Morley CJ. Reducing lung injury during neonatal resuscitation of preterm infants. J Pediatr 2008; 153:741.Luten R, Kahn N, Wears R, Kissoon N. Predicting endotracheal tube size by length in newborns. J Emerg Med 2007; 32:343.Roberts WA, Maniscalco WM, Cohen AR, et al. The use of capnography for recognition of esophageal intubation in the neonatal intensive care unit. Pediatr Pulmonol 1995; 19:262.Aziz HF, Martin JB, Moore JJ. The pediatric disposable end-tidal carbon dioxide detector role in endotracheal intubation in newborns. J Perinatol 1999; 19:110.Hosono S, Inami I, Fujita H, et al. A role of end-tidal CO(2) monitoring for assessment of tracheal intubations in very low birth weight infants during neonatal resuscitation at birth. J Perinat Med 2009; 37:79.Repetto JE, Donohue PA-C PK, Baker SF, et al. Use of capnography in the delivery room for assessment of endotracheal tube placement. J Perinatol 2001; 21:284.Peterson J, Johnson N, Deakins K, et al. Accuracy of the 7-8-9 Rule for endotracheal tube placement in the neonate. J Perinatol 2006; 26:333.Amarilyo G, Mimouni FB, Oren A, et al. Orotracheal tube insertion in extremely low birth weight infants. J Pediatr 2009; 154:764.Menegazzi JJ, Auble TE, Nicklas KA, et al. Two-thumb versus two-finger chest compression during CRP in a swine infant model of cardiac arrest. Ann Emerg Med 1993; 22:240.THALER MM, STOBIE GH. AN IMPROVED TECHNIC OF EXTERNAL CARDIAC COMPRESSION IN INFANTS AND YOUNG CHILDREN. N Engl J Med 1963; 269:606.Houri PK, Frank LR, Menegazzi JJ, Taylor R. A randomized, controlled trial of two-thumb vs two-finger chest compression in a swine infant model of cardiac arrest [see comment]. Prehosp Emerg Care 1997; 1:65.Christman C, Hemway RJ, Wyckoff MH, Perlman JM. The two-thumb is superior to the two-finger method for administering chest compressions in a manikin model of neonatal resuscitation. Arch Dis Child Fetal Neonatal Ed 2011; 96:F99.Saini SS, Gupta N, Kumar P, et al. A comparison of two-fingers technique and two-thumbs encircling hands technique of chest compression in neonates. J Perinatol 2012; 32:690.Hemway RJ, Christman C, Perlman J. The 3:1 is superior to a 15:2 ratio in a newborn manikin model in terms of quality of chest compressions and number of ventilations. Arch Dis Child Fetal Neonatal Ed 2013; 98:F42.Ziino AJ, Davies MW, Davis PG. Epinephrine for the resuscitation of apparently stillborn or extremely bradycardic newborn infants. Cochrane Database Syst Rev 2003; :CD003849.Barber CA, Wyckoff MH. Use and efficacy of endotracheal versus intravenous epinephrine during neonatal cardiopulmonary resuscitation in the delivery room. Pediatrics 2006; 118:1028.So KW, Fok TF, Ng PC, et al. Randomised controlled trial of colloid or crystalloid in hypotensive preterm infants. Arch Dis Child Fetal Neonatal Ed 1997; 76:F43.Oca MJ, Nelson M, Donn SM. Randomized trial of normal saline versus 5% albumin for the treatment of neonatal hypotension. J Perinatol 2003; 23:473.Niermeyer S. Volume resuscitation: crystalloid versus colloid. Clin Perinatol 2006; 33:133.Guinsburg R, Wyckoff MH. Naloxone during neonatal resuscitation: acknowledging the unknown. Clin Perinatol 2006; 33:121.Wyckoff MH, Perlman JM. Use of high-dose epinephrine and sodium bicarbonate during neonatal resuscitation: is there proven benefit? Clin Perinatol 2006; 33:141.Beveridge CJ, Wilkinson AR. Sodium bicarbonate infusion during resuscitation of infants at birth. Cochrane Database Syst Rev 2006; :CD004864.Aschner JL, Poland RL. Sodium bicarbonate: basically useless therapy. Pediatrics 2008; 122:831.American Academy of Pediatrics Committee on Fetus and Newborn, Bell EF. Noninitiation or withdrawal of intensive care for high-risk newborns. Pediatrics 2007; 119:401.Jain L, Ferre C, Vidyasagar D, et al. Cardiopulmonary resuscitation of apparently stillborn infants: survival and long-term outcome. J Pediatr 1991; 118:778.Haddad B, Mercer BM, Livingston JC, et al. Outcome after successful resuscitation of babies born with apgar scores of 0 at both 1 and 5 minutes. Am J Obstet Gynecol 2000; 182:1210.Harrington DJ, Redman CW, Moulden M, Greenwood CE. The long-term outcome in surviving infants with Apgar zero at 10 minutes: a systematic review of the literature and hospital-based cohort. Am J Obstet Gynecol 2007; 196:463.e1.Kasdorf E, Laptook A, Azzopardi D, et al. Improving infant outcome with a 10?min Apgar of 0. Arch Dis Child Fetal Neonatal Ed 2015; 100:F102.Frazier MD, Werthammer J. Post-resuscitation complications in term neonates. J Perinatol 2007; 27:82.Akinloye O, O'Connell C, Allen AC, El-Naggar W. Post-resuscitation care for neonates receiving positive pressure ventilation at birth. Pediatrics 2014; 134:e1057.Reproduced with permission from: Fernandes CJ. Care of the High-Risk Neonate. In: Conn's Current Therapy 2005, 57th ed, Rakel RE, Bope ET (Eds), WB Saunders, Philadelphia 2005. Copyright ? 2005 Elsevier Science, Inc.Graphic 58639 Version 5.0Head position for neonatal resuscitationThe top panel demonstrates the correct head position with the baby positioned on the back with the neck slightly extended resulting in alignment of the posterior pharynx, larynx, and trachea, which allows unrestricted air entry.Graphic 50607 Version 2.0E-C clamp techniqueThe hand is positioned so that the little, ring, and?middle fingers are spread over the mandible from the angle of the jaw forward towards the chin in the configuration of the letter "E". The jaw is then lifted, pulling the face into the mask. The thumb and forefinger are placed over the mask in the shape of the letter "C". The mask is squeezed onto the face and a seal is formed between the mask and the face.Graphic 55539 Version 6.0Chest compression for infant resuscitation: Two thumb techniqueThe thorax is encircled with the hands and cardiac compressions are performed with both thumbs. The compression site is approximately one finger's breadth below the intermammary line. The area over the xiphoid process should be avoided to prevent injury to the liver, spleen, or stomach.Graphic 77050 Version 2.0Chest compression for infant resuscitation: Two finger techniqueChest compressions for infants (under one year) may be performed with two fingers placed on the sternum just below the nipples. This picture shows the site of compressions. When compressions are performed the two fingers used should be perpendicular to the chest and straight.Graphic 73038 Version 5.0 ................
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