2005 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) of Pediatric and Neonatal Patients: Neonatal Resuscitation Guidelines

Abstract

The following guidelines are intended for practitioners responsible for resuscitating neonates. They apply primarily 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 hospitalization. The term newly born is intended to apply specifically to an infant at the time of birth.Approximately 10% of newborns require some assistance to begin breathing at birth. Approximately 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: If the answer to all 4 of these questions is “yes,” the infant does not need resuscitation and should not be separated from the mother. The infant 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 1 or more of the following 4 categories of action in sequence: 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 Fig 1).Anticipation, adequate preparation, accurate evaluation, and prompt initiation of support are critical for successful neonatal resuscitation. At every delivery there should be at least 1 person whose primary responsibility is the newly born. This person must be capable of initiating resuscitation, including administration of positive-pressure ventilation and chest compressions. Either that person or someone else who is immediately available should have the skills required to perform a complete resuscitation, including endotracheal intubation and administration of medications.1With 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. If a preterm delivery (<37 weeks of gestation) is expected, special preparations will be required. Preterm infants have immature lungs that may be more difficult to ventilate and are also more vulnerable to injury by positive-pressure ventilation. Preterm infants 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.The initial steps of resuscitation are to provide warmth by placing the infant 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 infant and stimulate breathing. Recent studies have examined several aspects of these initial steps. These studies are summarized below.Very low birth weight (<1500 g) preterm infants are likely to become hypothermic despite the use of traditional techniques for decreasing heat loss (level of evidence [LOE] 5).2For this reason it is recommended that additional warming techniques be used, such as covering the infant in plastic wrapping (food-grade, heat-resistant plastic) and placing him or her under radiant heat (Class IIa; LOE 23,4; LOE 45,6; LOE 57). Temperature must be monitored closely because of the slight but described (LOE 2)4risk of hyperthermia with this technique. Other techniques to maintain temperature during stabilization of the infant in the delivery room (eg, drying and swaddling, warming pads, increased environmental temperature, placing the infant skin-to-skin with the mother and covering both with a blanket) have been used (LOE 8),8,9but they have not been evaluated in controlled trials nor compared with the plastic-wrap technique for premature infants. All resuscitation procedures, including endotracheal intubation, chest compression, and insertion of lines, can be performed with these temperature-controlling interventions in place.Infants born to febrile mothers have been reported (LOE 4)10–12to have a higher incidence of perinatal respi