Updated Neonatal Resuscitation Guidelines 2015

update

Indian Pediatr 2016;53: 403-408

Updated Neonatal Resuscitation Guidelines 2015 – Major Changes

Satvik C Bansal and ^#Somashekhar M Nimbalkar

From Department of Pediatrics, Pramukhswami Medical College, and #Central Research Services, Charutar Arogya Mandal; Karamsad, Gujarat, India.

Correspondence to: Dr. Somashekhar Nimbalkar, Professor, Department of Pediatrics, Pramukhswami Medical College,
Karamsad, Anand, Gujarat 388 325, India.
Email: [email protected]

The latest guidelines on neonatal resuscitation from American Heart Association (AHA) [1] and European Resuscitation Council (ERC) [2] were released in October 2015. There have been slight variations between these guidelines; although they use nearly identical literature for evidence evaluation. We present here the major changes in the recent guidelines [3,4], and comparison between the ERC and AHA guidelines of 2015. The major changes are detailed in Table I. Some of the major recommendations of previous AHA guidelines are continued without reviews and are elaborated in Table II. The major recommendations are summarized in Box 1.

TABLE  II  Recommendations That Remain Unchanged

Temperature control	Resuscitation should be performed with temperature-controlling interventions.
Clearing the airway when amniotic fluid is clear	Routine suctioning is not recommended.
Assessment of need of oxygen therapy	Oximetry should be used to monitor if any neonate needs PPV, with persistent and monitoring of oxygen therapy central cyanosis persists and with the use of supplementary oxygen.
Administration of oxygen in term infants	Initiate resuscitation with room air. Supplementary oxygen may be administered to achieve appropriate pre-ductal oxygen saturation.
Initial breaths and assisted ventilation	An initial inflation pressure of 20 cm water is adequate; some term babies may require up to ³30 to 40 cm water. Rate of giving PPV- 40 to 60 per minute.
Endotracheal tube placement	Exhaled CO₂ detection is most reliable.
Chest compressions	Coordinated chest compressions and PPV should be done if heart rate<60 per minute after establishing effective ventilation.
Epinephrine	IV dose - 0.01 to 0.03 mg/kg of 1:10 000 epinephrine. For an endotracheal route - 0.05 to 0.1 mg/kg.
Volume expansion	Volume expansion when blood loss is known/suspected.Dose - 10 mL/kg of isotonic crystalloid solution or blood, may be repeated.

Implications for Resource-limited Settings

With the emergence of scientific evidence from developing countries, these studies from resource-limited countries are forming the basis of major changes in clinical practice guidelines. Also, specific and separate recommendations are being made for resource-limited settings, as many of the standard recommendations may not be feasible in these settings.

We discuss some of the points below to put things into perspective:

• Therapeutic hypothermia has been recommended in resource-limited setups. The cost is still forbidding for those in need as well as the availability of centers that can provide it. Newer phase-change material based devices are available and evidence is increasing of its safety for use in Indian conditions [7].

• Skin-to-skin contact has been stressed as a method for maintaining newborn temperature in the peri-partum period based on evidence drawn from India and other resource-limited countries [8].

• The evidence for delayed cord clamping has grown stronger as well as the evidence for cord milking. The guidelines caution against cord milking below 29 weeks. This has great relevance to neonatal management and is a significant change.

• Removal of routine tracheal suction in non-vigorous neonates is a welcome change, leading to uniformity of the guidelines in all the scenarios. This significant change is contributed by evidence drawn from India [9].

• The routine use of ECG and pulse oximeters, might find little practical use in resource— limited settings. There is still no data available of widespread use of pulse oximeters in India and given the resource constraints this change may not be practiced uniformly.

• Similarly, use of exhaled CO2 monitors, oxygen blenders, and laryngeal mask airways will remain out of reach in most resuscitation situations in resource limited settings

• Decreased usage of oxygen in preterm newborns, and preference CPAP over mechanical ventilation might contribute to the decentralization of newborn care and better care at level 1 or level 2 setups.

• While earlier there was a mandate for training all health personnel involved in neonatal care every two years in neonatal resuscitation, the committees have recommended more frequent trainings without stipulating, a duration between trainings. The evidence is rising for ‘Low Dose High Frequency’ trainings for neonatal resuscitation.

Conclusion

There are critical changes in updated resuscitation guidelines of 2015 with subtle differences between the AHA and ERC. The authors believe that the Indian Academy of Pediatrics and the National Neonatology Forum of India will bring out India-specific recommendations to guide the resuscitation methods to be followed in India. This will ensure that the clinicians practicing resuscitation on a daily basis have some basis for their variance from International Guidelines.

Contributors: SB: Searched the literature, wrote the paper, and approved the final manuscript; SN: conceived the study, designed the study, gave critical inputs to the paper, and approved the final manuscript.

Funding: None; Competing interests: SN was part of the guideline development group for India in 2011 which has been used in training of participants of the Indian Academy of Pediatrics National Neonatology Forum Neonatal Resuscitation Program First Golden Minute. The guideline is an Indian Adaptation of the Neonatal Resuscitation Guidelines of the American Heart Association and the American Academy of Pediatrics that were published in October 2010.

References

1. Wyckoff MH, Aziz K, Escobedo MB, Kapadia VS, Kattwinkel J, Perlman JM, et al. Part 13: Neonatal Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132:S543-60.

2. Wyllie J, Bruinenberg J, Roehr CC, Rüdiger M, Trevisanuto D, Urlesberger B. European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation. 2015;95:249-63.

3. Kattwinkel J, Perlman JM, Aziz K, Colby C, Fairchild K, Gallagher J, et al. Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2010;126:e1400-13.

4. Roehr CC, Hansmann G, Hoehn T, Bührer C. The 2010 Guidelines on Neonatal Resuscitation (AHA, ERC, ILCOR): similarities and differences—what progress has been made since 2005? Klin Padiatr. 2011;223:299-307.

5. Kattwinkel J, ed. Textbook of Neonatal Resuscitation. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics, American Heart Association, 2010. p.146

6. Dalili H, Nili F, Sheikh M, Hardani AK, Shariat M, Nayeri F. Comparison of the four proposed Apgar scoring systems in the assessment of birth asphyxia and adverse early neurologic outcomes. PloS One. 2015;10:e0122116.

7. Thomas N, Chakrapani Y, Rebekah G, Kareti K, Devasahayam S. Phase changing material: an alternative method for cooling babies with hypoxic ischaemic encephalopathy. Neonatology. 2015;107:266-70.

8. Nimbalkar SM, Patel VK, Patel DV, Nimbalkar AS, Sethi A, Phatak A. Effect of early skin-to-skin contact following normal delivery on incidence of hypothermia in neonates more than 1800 g: randomized control trial. J Perinatol. 2014;34:364-8.

9. Chettri S, Adhisivam B, Bhat BV. Endotracheal suction for nonvigorous neonates born through meconium stained amniotic fluid: a randomized controlled trial. J Pediatr 2015;166:1208-13.