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DOI: 10.1161/CIRCULATIONAHA.105.166574
2005;112;188-195; originally published online Nov 28, 2005; Circulation
Part 13: Neonatal Resuscitation Guidelines
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Part 13: Neonatal Resuscitation Guidelines
T
he following guidelines are intended for practitioners
responsible for resuscitating neonates. They apply pri-
marily to neonates undergoing transition from intrauterine to
extrauterine life. The recommendations are also applicable to
neonates who have completed perinatal transition and require
resuscitation during the first few weeks to months following
birth. Practitioners who resuscitate infants at birth or at any
time during the initial hospital admission should consider
following these guidelines. The terms newborn and neonate
are intended to apply to any infant during the initial hospi-
talization. The term newly born is intended to apply specifi-
cally to an infant at the time of birth.
Approximately 10% of newborns require some assistance
to begin breathing at birth. About 1% require extensive
resuscitative measures. Although the vast majority of newly
born infants do not require intervention to make the transition
from intrauterine to extrauterine life, because of the large
number of births, a sizable number will require some degree
of resuscitation.
Those newly born infants who do not require resuscitation
can generally be identified by a rapid assessment of the
following 4 characteristics:
●
Was the baby born after a full-term gestation?
●
Is the amniotic fluid clear of meconium and evidence of
infection?
●
Is the baby breathing or crying?
●
Does the baby have good muscle tone?
If the answer to all 4 of these questions is “yes,” the baby
does not need resuscitation and should not be separated from
the mother. The baby can be dried, placed directly on the
mother’s chest, and covered with dry linen to maintain
temperature. Observation of breathing, activity, and color
should be ongoing.
If the answer to any of these assessment questions is “no,”
there is general agreement that the infant should receive one
or more of the following 4 categories of action in sequence:
A. Initial steps in stabilization (provide warmth, position,
clear airway, dry, stimulate, reposition)
B. Ventilation
C. Chest compressions
D. Administration of epinephrine and/or volume expansion
The decision to progress from one category to the next is
determined by the simultaneous assessment of 3 vital signs:
respirations, heart rate, and color. Approximately 30 seconds
is allotted to complete each step, reevaluate, and decide
whether to progress to the next step (see the Figure).
Anticipation of Resuscitation Need
Anticipation, adequate preparation, accurate evaluation, and
prompt initiation of support are critical for successful neona-
tal resuscitation. At every delivery there should be at least one
person whose primary responsibility is the newly born. This
person must be capable of initiating resuscitation, including
administration of positive-pressure ventilation and chest com-
pressions. Either that person or someone else who is imme-
diately available should have the skills required to perform a
complete resuscitation, including endotracheal intubation and
administration of medications.
1
With careful consideration of risk factors, the majority of
newborns who will need resuscitation can be identified before
birth. If the possible need for resuscitation is anticipated,
additional skilled personnel should be recruited and the
necessary equipment prepared. Identifiable risk factors and
the necessary equipment for resuscitation are listed on the
Neonatal Resuscitation Program website: www.aap.org/NRP.
If a preterm delivery (H1102137 weeks of gestation) is expected,
special preparations will be required. Preterm babies have
immature lungs that may be more difficult to ventilate and are
also more vulnerable to injury by positive-pressure ventila-
tion. Preterm babies also have immature blood vessels in the
brain that are prone to hemorrhage; thin skin and a large
surface area, which contribute to rapid heat loss; increased
susceptibility to infection; and increased risk of hypovolemic
shock caused by small blood volume.
Initial Steps
The initial steps of resuscitation are to provide warmth by
placing the baby under a radiant heat source, position the head in
a “sniffing” position to open the airway, clear the airway with a
bulb syringe or suction catheter, and dry the baby and stimulate
breathing. Recent studies have examined several aspects of these
initial steps. These studies are summarized below.
Temperature Control
Very low birth weight (H110211500 g) preterm babies are likely to
become hypothermic despite the use of traditional techniques
for decreasing heat loss (LOE 5).
2
For this reason it is
recommended that additional warming techniques be used,
such as covering the baby in plastic wrapping (food-grade,
heat-resistant plastic) and placing him or her under radiant
heat (Class IIa; LOE 2
3,4
; LOE 4
5,6
; LOE 5
7
). Temperature
must be monitored closely because of the slight but described
(LOE 2)
4
risk of hyperthermia with this technique. Other
techniques to maintain temperature during stabilization of the
baby in the delivery room (eg, drying and swaddling, warm-
ing pads, increased environmental temperature, placing the
baby skin-to-skin with the mother and covering both with a
blanket) have been used (LOE 8),
8,9
but they have not been
(Circulation. 2005;112:IV-188-IV-195.)
? 2005 American Heart Association.
This special supplement to Circulation is freely available at
http://www.circulationaha.org
DOI: 10.1161/CIRCULATIONAHA.105.166574
IV-188
evaluated in controlled trials nor compared with the plastic
wrap technique for premature babies. All resuscitation pro-
cedures, including endotracheal intubation, chest compres-
sion, and insertion of lines, can be performed with these
temperature-controlling interventions in place.
Infants born to febrile mothers have been reported (LOE
4)
10–12
to have a higher incidence of perinatal respiratory
depression, neonatal seizures, and cerebral palsy and in-
creased risk of mortality. Animal studies (LOE 6)
13,14
indicate
that hyperthermia during or after ischemia is associated with
Figure. Neonatal Flow Algorithm.
Part 13: Neonatal Resuscitation Guidelines IV-189
progression of cerebral injury. Hyperthermia should be
avoided (Class IIb). The goal is to achieve normothermia and
avoid iatrogenic hyperthermia.
Clearing the Airway of Meconium
Aspiration of meconium before delivery, during birth, or
during resuscitation can cause severe aspiration pneumonia.
One obstetrical technique to try to decrease aspiration has
been to suction meconium from the infant’s airway after
delivery of the head but before delivery of the shoulders
(intrapartum suctioning). Although some studies (LOE 3
15
;
4
16,17
) suggested that intrapartum suctioning might be effec-
tive for decreasing the risk of aspiration syndrome, subse-
quent evidence from a large multicenter randomized trial
(LOE 1)
18
did not show such an effect. Therefore, current
recommendations no longer advise routine intrapartum oro-
pharyngeal and nasopharyngeal suctioning for infants born to
mothers with meconium staining of amniotic fluid (Class I).
Traditional teaching (LOE 5)
19–21
recommended that
meconium-stained infants have endotracheal intubation im-
mediately following birth and that suction be applied to the
endotracheal tube as it is withdrawn. Randomized controlled
trials (LOE 1)
15,22
have shown that this practice offers no
benefit if the infant is vigorous (Class I). A vigorous infant is
defined as one who has strong respiratory efforts, good
muscle tone, and a heart rate H11022100 beats per minute (bpm).
Endotracheal suctioning for infants who are not vigorous
should be performed immediately after birth (Class
Indeterminate).
Periodic Evaluation at 30-Second Intervals
After the immediate postbirth assessment and administration
of initial steps, further resuscitative efforts should be guided
by simultaneous assessment of respirations, heart rate, and
color. After initial respiratory efforts the newly born infant
should be able to establish regular respirations that are
sufficient to improve color and maintain a heart rate H11022100
bpm. Gasping and apnea indicate the need for assisted
ventilation.
23
Increasing or decreasing heart rate can also
provide evidence of improvement or deterioration.
A newly born infant who is uncompromised will achieve
and maintain pink mucous membranes without administration
of supplementary oxygen. Evidence obtained with continuous
oximetry, however, has shown that neonatal transition is a
gradual process. Healthy babies born at term may take H1102210
minutes to achieve a preductal oxygen saturation H1102295% and
nearly 1 hour to achieve postductal saturation H1102295% (LOE
5).
24–26
Central cyanosis is determined by examining the face,
trunk, and mucous membranes. Acrocyanosis (blue color of
hands and feet alone) is usually a normal finding at birth and
is not a reliable indicator of hypoxemia but may indicate
other conditions, such as cold stress. Pallor or mottling may
be a sign of decreased cardiac output, severe anemia, hypo-
volemia, hypothermia, or acidosis.
Administration of Oxygen
There are concerns about the potential adverse effects of
100% oxygen on respiratory physiology and cerebral circu-
lation and the potential tissue damage from oxygen free
radicals. Conversely there are also concerns about tissue
damage from oxygen deprivation during and after asphyxia.
Studies (LOE 6)
27–31
examining blood pressure, cerebral
perfusion, and various biochemical measures of cell damage
in asphyxiated animals resuscitated with 100% oxygen versus
21% oxygen (room air) have shown conflicting results. One
(LOE 2)
32
study of preterm infants (H1102133 weeks of gestation)
exposed to 80% oxygen found lower cerebral blood flow
when compared with those stabilized using 21% oxygen.
Some animal data (LOE 6)
27
indicated the opposite effect, ie,
reduced blood pressure and cerebral perfusion with 21%
oxygen (room air) versus 100% oxygen. Meta-analysis of 4
human studies (LOE 1)
33,34
showed a reduction in mortality
rate and no evidence of harm in infants resuscitated with
room air versus those resuscitated with 100% oxygen, al-
though these results should be viewed with caution because
of significant methodological concerns.
Supplementary oxygen is recommended whenever
positive-pressure ventilation is indicated for resuscitation;
free-flow oxygen should be administered to babies who are
breathing but have central cyanosis (Class Indeterminate).
The standard approach to resuscitation is to use 100%
oxygen. Some clinicians may begin resuscitation with an
oxygen concentration of less than 100%, and some may start
with no supplementary oxygen (ie, room air). There is
evidence that employing either of these practices during
resuscitation of neonates is reasonable. If the clinician begins
resuscitation with room air, it is recommended that supple-
mentary oxygen be available to use if there is no appreciable
improvement within 90 seconds after birth. In situations
where supplementary oxygen is not readily available,
positive-pressure ventilation should be administered with
room air (Class Indeterminate).
Administration of a variable concentration of oxygen
guided by pulse oximetry may improve the ability to achieve
normoxia more quickly. Concerns about potential oxidant
injury should caution the clinician about the use of excessive
oxygen, especially in the premature infant.
Positive-Pressure Ventilation
If the infant remains apneic or gasping, if the heart rate
remains H11021100 bpm 30 seconds after administering the initial
steps, or if the infant continues to have persistent central
cyanosis despite administration of supplementary oxygen,
start positive-pressure ventilation.
Initial Breaths and Assisted Ventilation
In term infants, initial inflations—either spontaneous or
assisted—create a functional residual capacity (LOE 5).
35–41
The optimum pressure, inflation time, and flow rate required
to establish an effective functional residual capacity have not
been determined. Average initial peak inflating pressures of
30 to 40 cm H
2
O (inflation time undefined) usually success-
fully ventilate unresponsive term infants (LOE 5).
36,38,40–43
Assisted ventilation rates of 40 to 60 breaths per minute are
commonly used, but the relative efficacy of various rates has
not been investigated.
The primary measure of adequate initial ventilation is
prompt improvement in heart rate. Chest wall movement
IV-190 Circulation December 13, 2005
should be assessed if heart rate does not improve. The initial
peak inflating pressures needed are variable and unpredict-
able and should be individualized to achieve an increase in
heart rate and/or movement of the chest with each breath. If
inflation pressure is being monitored, an initial inflation
pressure of 20 cm H
2
O may be effective, but H1135030 to 40
cm H
2
O may be required in some term babies without
spontaneous ventilation (Class IIb). If pressure is not moni-
tored, the minimum inflation required to achieve an increase
in heart rate should be used. There is insufficient evidence to
recommend an optimum inflation time. In summary, assisted
ventilation should be delivered at a rate of 40 to 60 breaths
per minute (Class Indeterminate; LOE 8) to promptly achieve
or maintain a heart rate H11022100 bpm.
Devices
Effective ventilation can be achieved with a flow-inflating
bag, a self-inflating bag, or with a T-piece (LoE 4
44,45
; LOE
5
46
). A T-piece is a valved mechanical device designed to
control flow and limit pressure. The pop-off valves of
self-inflating bags are flow-dependent, and pressures gener-
ated may exceed the value specified by the manufacturer
(LOE 6).
47
Target inflation pressures and long inspiratory
times are more consistently achieved in mechanical models
when T-piece devices are used rather than bags (LOE 6),
48
although the clinical implications are not clear. To provide
the desired pressure, healthcare providers need more training
in the use of flow-inflating bags than with self-inflating bags
(LOE 6).
49
A self-inflating bag, a flow-inflating bag, or a
T-piece can be used to ventilate a newborn (Class IIb).
Laryngeal mask airways (LMAs) that fit over the laryngeal
inlet have been shown to be effective for ventilating newly
born near-term and full-term infants (LOE 2
50
and LOE 5
51
).
There is limited (LOE 5)
52,53
data on the use of these devices
in small preterm infants. Data from 3 case series (LOE
5)
51,54,55
shows that the use of the LMA can provide effective
ventilation in a time frame consistent with current resuscita-
tion guidelines, although the babies being studied were not
being resuscitated. A randomized controlled trial (LOE 2)
50
found no clinically significant difference between the use of
the LMA and endotracheal intubation when bag-mask venti-
lation was unsuccessful. It is unclear whether this study can
be generalized because the LMA was inserted by experienced
providers. Case reports (LOE 5)
56–58
suggest that when
bag-mask ventilation has been unsuccessful and endotracheal
intubation is not feasible or is unsuccessful, the LMA may
provide effective ventilation. There is insufficient evidence to
support the routine use of the LMA as the primary airway
device during neonatal resuscitation, in the setting of
meconium-stained amniotic fluid, when chest compressions
are required, in very low birth weight babies, or for delivery
of emergency intratracheal medications (Class Indeterminate).
Assisted Ventilation of Preterm Infants
Evidence from animal studies (LOE 6)
59
indicates that pre-
term lungs are easily injured by large-volume inflations
immediately after birth. Additional animal studies (LOE
6)
60,61
indicate that when positive-pressure ventilation is
applied immediately after birth, the inclusion of positive
end-expiratory pressure (PEEP) protects against lung injury
and improves lung compliance and gas exchange (LOE
6).
60,61
Evidence from case series in human infants indicates
that most apneic preterm infants can be ventilated with an
initial inflation pressure of 20 to 25 cm H
2
O, although some
infants who do not respond require a higher pressure (LOE
5).
62,63
When ventilating preterm infants after birth, excessive
chest wall movement may indicate large-volume lung infla-
tions, which should be avoided. Monitoring of pressure may
help to provide consistent inflations and avoid unnecessary
high pressures (Class IIb). If positive-pressure ventilation is
required, an initial inflation pressure of 20 to 25 cm H
2
Ois
adequate for most preterm infants (Class Indeterminate). If
prompt improvement in heart rate or chest movement is not
obtained, higher pressures may be needed. If it is necessary to
continue positive-pressure ventilation, application of PEEP
may be beneficial (Class Indeterminate). Continuous positive
airway pressure in spontaneously breathing preterm infants
after resuscitation may also be beneficial
63
(Class
Indeterminate).
Endotracheal Tube Placement
Endotracheal intubation may be indicated at several points
during neonatal resuscitation:
●
When tracheal suctioning for meconium is required
●
If bag-mask ventilation is ineffective or prolonged
●
When chest compressions are performed
●
When endotracheal administration of medications is
desired
●
For special resuscitation circumstances, such as congenital
diaphragmatic hernia or extremely low birth weight
(H110211000 g)
The timing of endotracheal intubation may also depend on
the skill and experience of the available providers.
After endotracheal intubation and administration of inter-
mittent positive pressure, a prompt increase in heart rate is the
best indicator that the tube is in the tracheobronchial tree and
providing effective ventilation (LOE 5).
64
Exhaled CO
2
de-
tection is effective for confirmation of endotracheal tube
placement in infants, including very low birth weight infants
(LOE 5).
65–68
A positive test result (detection of exhaled CO
2
)
in patients with adequate cardiac output confirms placement
of the endotracheal tube within the trachea, whereas a
negative test result (ie, no CO
2
detected) strongly suggests
esophageal intubation (LOE 5).
65,67
Poor or absent pulmonary
blood flow may give false-negative results (ie, no CO
2
detected despite tube placement in the trachea), but endotra-
cheal tube placement is correctly identified in nearly all
patients who are not in cardiac arrest (LOE 7).
69
A false-
negative result may also lead to unnecessary extubation in
critically ill infants with poor cardiac output.
Other clinical indicators of correct endotracheal tube place-
ment are evaluation of condensed humidified gas during
exhalation and the presence or absence of chest movement,
but these have not been systematically evaluated in neonates.
Endotracheal tube placement must be assessed visually dur-
ing intubation and by confirmatory methods after intubation
if the heart rate remains low and is not rising. Except for
Part 13: Neonatal Resuscitation Guidelines IV-191
intubation to remove meconium, exhaled CO
2
detection is the
recommended method of confirmation (Class IIa).
Chest Compressions
Chest compressions are indicated for a heart rate that is H1102160
bpm despite adequate ventilation with supplementary oxygen
for 30 seconds. Because ventilation is the most effective
action in neonatal resuscitation and because chest compres-
sions are likely to compete with effective ventilation, rescuers
should ensure that assisted ventilation is being delivered
optimally before starting chest compressions.
Compressions should be delivered on the lower third of the
sternum
70,71
to a depth of approximately one third of the
anterior-posterior diameter of the chest. Two techniques have
been described: compression with 2 thumbs with fingers
encircling the chest and supporting the back
72–74
(the 2
thumb–encircling hands technique) or compression with 2
fingers with a second hand supporting the back. Because the
2 thumb–encircling hands technique may generate higher
peak systolic and coronary perfusion pressure than the
2-finger technique (LOE 5
75
; LOE 6
76
), the 2 thumb–encir-
cling hands technique is recommended for performing chest
compressions in newly born infants. However, the 2-finger
technique may be preferable when access to the umbilicus is
required during insertion of an umbilical catheter.
A compression-relaxation ratio with a slightly shorter
compression than relaxation phase offers theoretical advan-
tages for blood flow in the very young infant.
77
Also,
compressions and ventilations should be coordinated to avoid
simultaneous delivery (LOE 6).
78
The chest should be per-
mitted to fully reexpand during relaxation, but the rescuer’s
thumbs should not leave the chest. There should be a 3:1 ratio
of compressions to ventilations with 90 compressions and 30
breaths to achieve approximately 120 events per minute to
maximize ventilation at an achievable rate (Class Indetermi-
nate). Thus, each event will be allotted approximately
1
?2
second, with exhalation occurring during the first compres-
sion after each ventilation.
Respirations, heart rate, and color should be reassessed
about every 30 seconds, and coordinated chest compressions
and ventilations should continue until the spontaneous heart
rate is H1135060 bpm (Class IIa; LOE 8).
Medications
Drugs are rarely indicated in resuscitation of the newly born
infant.
79
Bradycardia in the newborn infant is usually the
result of inadequate lung inflation or profound hypoxemia,
and establishing adequate ventilation is the most important
step to correct it. But if the heart rate remains H1102160 bpm
despite adequate ventilation with 100% oxygen and chest
compressions, administration of epinephrine or volume ex-
pansion, or both, may be indicated. Rarely, buffers, a narcotic
antagonist, or vasopressors may be useful after resuscitation.
Route and Dose of Epinephrine Administration
Past guidelines recommended that initial doses of epinephrine
be given through an endotracheal tube because the dose can
be administered more quickly than when an intravenous route
must be established. But animal studies (LOE 6)
80–82
that
showed a positive effect of endotracheal epinephrine used
considerably higher doses than are currently recommended,
and the one animal study (LOE 6)
83
that used currently
recommended doses given endotracheally showed no effect.
Given the lack of data on endotracheal epinephrine, the IV
route should be used as soon as venous access is established.
The recommended IV dose is 0.01 to 0.03 mg/kg per dose.
Higher IV doses are not recommended (Class III) because
animal (LOE 6)
84,85
and pediatric (LOE 7)
86
studies show
exaggerated hypertension, decreased myocardial function,
and worse neurologic function after administration of IV
doses in the range of 0.1 mg/kg. If the endotracheal route is
used, doses of 0.01 or 0.03 mg/kg will likely be ineffective.
Therefore, IV administration of 0.01 to 0.03 mg/kg per dose
is the preferred route (Class IIa). While access is being
obtained, administration of a higher dose (up to 0.1 mg/kg)
through the endotracheal tube may be considered (Class
Indeterminate), but the safety and efficacy of this practice
have not been evaluated. The concentration of epinephrine for
either route should be 1:10 000 (0.1 mg/mL).
Volume Expansion
Consider volume expansion when blood loss is suspected or the
infant appears to be in shock (pale skin, poor perfusion, weak
pulse) and has not responded adequately to other resuscitative
measures. An isotonic crystalloid rather than albumin is the
solution of choice for volume expansion in the delivery room
(Class IIb; LOE 7).
87–89
The recommended dose is 10 mL/kg,
which may need to be repeated. When resuscitating premature
infants, care should be taken to avoid giving volume expanders
too rapidly, because rapid infusions of large volumes have been
associated with intraventricular hemorrhage.
Naloxone
Administration of naloxone is not recommended as part of initial
resuscitative efforts in the delivery room for newborns with
respiratory depression. If administration of naloxone is consid-
ered, heart rate and color must first be restored by supporting
ventilation. The preferred route is IV or intramuscular. Given the
lack of clinical data in newborns, endotracheal administration of
naloxone is not recommended (Class Indeterminate). The rec-
ommended dose is 0.1 mg/kg, but no studies have examined the
efficacy of this dose in newborns. In one case report, naloxone
given to a baby born to an opioid-addicted mother was associ-
ated with seizures (LOE 8).
90
Therefore, naloxone should be
avoided in babies whose mothers are suspected of having had
long-term exposure to opioids (Class Indeterminate). Naloxone
may have a shorter half-life than the original maternal opioid;
therefore the neonate should be monitored closely for recurrent
apnea or hypoventilation, and subsequent doses of naloxone may
be required.
Postresuscitation Care
Babies who require resuscitation are at risk for deterioration after
their vital signs have returned to normal. Once adequate venti-
lation and circulation have been established, the infant should be
maintained in or transferred to an environment in which close
monitoring and anticipatory care can be provided.
IV-192 Circulation December 13, 2005
Glucose
Low blood glucose has been associated with adverse neurologic
outcome in a neonatal animal model of asphyxia and resuscita-
tion (LOE 6).
91
Neonatal animals (LOE 6)
92,93
that were hypo-
glycemic at the time of an anoxic or hypoxic-ischemic insult had
larger areas of cerebral infarction or decreased survival, or both,
when compared with controls. One clinical study (LOE 4)
94
showed an association between hypoglycemia and poor neuro-
logic outcome after perinatal asphyxia.
No clinical neonatal studies have investigated the relation
between hyperglycemia and neurologic outcome, although hy-
perglycemia in adults (LOE 7 [extrapolated]
95
) is associated with
worse outcome. The range of blood glucose concentration
associated with the least brain injury after asphyxia and resus-
citation cannot be defined based on available evidence. Infants
who require significant resuscitation should be monitored and
treated to maintain glucose in the normal range (Class
Indeterminate).
Induced Hypothermia
In a multicenter trial (LOE 2)
96
involving newborns with
suspected asphyxia (indicated by need for resuscitation at birth,
metabolic acidosis, and early encephalopathy), selective head
cooling (34°C to 35°C) was associated with a nonsignificant
reduction in the overall number of survivors with severe disabil-
ity at 18 months but a significant benefit in the subgroup with
moderate encephalopathy. Infants with severe electrographic
suppression and seizures did not benefit from treatment with
modest hypothermia (LOE 2).
96
A second large multicenter trial
(LOE 2)
97
of asphyxiated newborns (indicated by need for
resuscitation at birth or presence of metabolic encephalopathy)
involved treatment with systemic hypothermia to 33.5°C
(92.3°F) following moderate to severe encephalopathy. Hypo-
thermia was associated with a significant (18%) decrease in
death or moderate disability at 18 months.
97
A third small
controlled pilot study (LOE 2)
98,99
in asphyxiated infants with
early induced systemic hypothermia found fewer deaths and
disability at 12 months.
Modest hypothermia is associated with bradycardia and ele-
vated blood pressure that do not usually require treatment, but a
rapid increase in body temperature may cause hypotension (LOE
5).
100
Cooling to a core temperature H1102133°C may cause arrhyth-
mia, bleeding, thrombosis, and sepsis, but studies so far have not
reported these complications in infants treated with modest (eg,
33°C to 34.5°C [91.4°F to 94.1°F]) hypothermia (LOE 2).
96,101
There is insufficient data to recommend routine use of modest
systemic or selective cerebral hypothermia after resuscitation of
infants with suspected asphyxia (Class Indeterminate). Further
clinical trials are needed to determine which infants benefit most
and which method of cooling is most effective. Avoidance of
hyperthermia (elevated body temperature) is particularly impor-
tant in babies who may have had a hypoxic-ischemic event.
Guidelines for Withholding and
Discontinuing Resuscitation
Morbidity and mortality for newborns varies according to
region and availability of resources (LOE 5).
102
Social sci-
ence studies
103
indicate that parents desire a larger role in
decisions to initiate resuscitation and continue life support of
severely compromised newborns. Opinions among neonatal
providers vary widely regarding the benefits and disadvan-
tages of aggressive therapies in such newborns (LOE 5).
104
Withholding Resuscitation
It is possible to identify conditions associated with high mortal-
ity and poor outcome in which withholding resuscitative efforts
may be considered reasonable, particularly when there has been
the opportunity for parental agreement (LOE 5).
2,105
A consistent and coordinated approach to individual cases by
the obstetric and neonatal teams and the parents is an important
goal. Noninitiation of resuscitation and discontinuation of life-
sustaining treatment during or after resuscitation are ethically
equivalent, and clinicians should not hesitate to withdraw sup-
port when functional survival is highly unlikely. The following
guidelines must be interpreted according to current regional
outcomes:
●
When gestation, birth weight, or congenital anomalies are
associated with almost certain early death and when unac-
ceptably high morbidity is likely among the rare survivors,
resuscitation is not indicated (Class IIa). Examples may
include extreme prematurity (gestational age H1102123 weeks or
birth weight H11021400 g), anencephaly, and chromosomal
abnormalities incompatible with life, such as trisomy 13.
●
In conditions associated with a high rate of survival and
acceptable morbidity, resuscitation is nearly always indicated
(Class IIa). This will generally include babies with gestational
age H1135025 weeks (unless there is evidence of fetal compromise
such as intrauterine infection or hypoxia-ischemia) and those
with most congenital malformations.
●
In conditions associated with uncertain prognosis in which
survival is borderline, the morbidity rate is relatively high, and
the anticipated burden to the child is high, parental desires
concerning initiation of resuscitation should be supported
(Class Indeterminate).
Discontinuing Resuscitative Efforts
Infants without signs of life (no heart beat and no respiratory
effort) after 10 minutes of resuscitation show either a high
mortality or severe neurodevelopmental disability (LOE
5).
106,107
After 10 minutes of continuous and adequate resus-
citative efforts, discontinuation of resuscitation may be jus-
tified if there are no signs of life (Class IIb).
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