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Special Report—Neonatal Resuscitation

:
2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care
The following guidelines are an interpretation of the evidence present- John Kattwinkel, Co-Chair*, Jeffrey M. Perlman, Co-Chair*,
ed in the 2010 International Consensus on Cardiopulmonary Resusci- Khalid Aziz, Christopher Colby, Karen Fairchild, John
Gallagher, Mary Fran Hazinski, Louis P. Halamek, Praveen
tation and Emergency Cardiovascular Care Science With Treatment Kumar, George Little, Jane E. McGowan, Barbara
Recommendations1). They apply primarily to newly born infants under- Nightengale, Mildred M. Ramirez, Steven Ringer, Wendy
going transition from intrauterine to extrauterine life, but the recom- M. Simon, Gary M. Weiner, Myra Wyckoff,
mendations are also applicable to neonates who have completed peri- Jeanette Zaichkin
natal transition and require resuscitation during the first few weeks to KEY WORDS
cardiopulmonary resuscitation
months following birth. Practitioners who resuscitate infants at birth
The American Heart Association requests that this document be
or at any time during the initial hospital admission should consider cited as follows: Kattwinkel J, Perlman JM, Aziz K, Colby C,
following these guidelines. For the purposes of these guidelines, the Fairchild K, Gallagher J, Hazinski MF, Halamek LP, Kumar P, Little
terms newborn and neonate are intended to apply to any infant during G, McGowan JE, Nightengale B, Ramirez MM, Ringer S, Simon
WM, Weiner GM, Wyckoff M, Zaichkin J. Part 15: neonatal
the initial hospitalization. The term newly born is intended to apply resuscitation: 2010 American Heart Association Guidelines for
specifically to an infant at the time of birth. Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care. Circulation. 2010;122:S909 –S919.
Approximately 10% of newborns require some assistance to begin
*Co-chairs and equal first co-authors.
breathing at birth. Less than 1% require extensive resuscitative mea-
(Circulation. 2010;122:S909 –S919.)
sures.2,3 Although the vast majority of newly born infants do not require
© 2010 American Heart Association, Inc.
intervention to make the transition from intrauterine to extrauterine
Circulation is available at http://circ.ahajournals.org.
life, because of the large total number of births, a sizable number will
doi:10.1542/peds.2010-2972E
require some degree of resuscitation.
Those newly born infants who do not require resuscitation can gener-
ally be identified by a rapid assessment of the following 3
characteristics:
● Term gestation?
● Crying or breathing?
● Good muscle tone?
If the answer to all 3 of these questions is “yes,” the baby does not need
resuscitation and should not be separated from the mother. The baby
should be dried, placed skin-to-skin with the mother, 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,” the infant
should receive one or more of the following 4 categories of action in
sequence:
A. Initial steps in stabilization (provide warmth, clear airway if neces-
sary, dry, stimulate)
B. Ventilation

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When minutes to apply. Newborn Resuscitation Algorithm.5 or volume expansion or unlabored breathing) and heart rate A pulse oximeter can provide a contin- Approximately 60 seconds (“the Golden (whether greater than or less than 100 uous assessment of the pulse without Minute”) are allotted for completing the beats per minute). palpation of the tion during states of very poor cardiac steps is determined by simultaneous umbilical pulse can also provide a rapid output or perfusion. 2017 . Chest compressions assessment of 2 vital characteristics: estimate of the pulse and is more accu- D. Assessment of heart interruption of other resuscitation initial steps. but the device takes 1 to 2 ventilation if required (see Figure). The auscultating the precordial pulse. FROM THE AMERICAN ACADEMY OF PEDIATRICS FIGURE. and beginning rate should be done by intermittently measures. and it may not func- decision to progress beyond the initial a pulse is detectable. reevaluating. Administration of epinephrine and/ respirations (apnea. November 2010 e1401 Downloaded from by guest on June 28. Once positive PEDIATRICS Volume 126. Number 5.4. C. gasping. or labored rate than palpation at other sites.

area. (NICU) can be associated with deterio- For this reason additional warming tech- tors. cluding administration of positive. tors. LOE B16). The goal is to achieve normothermia and pressure ventilation and chest com. Other be reserved for babies who have obvi- the necessary equipment for resusci. drying and swad- oxygen administration is begun. and increased risk of hypovole- dence of perinatal respiratory depres- RESUSCITATION NEED mic shock related to small blood sion. in prewarming the linen. increased susceptibility to infec- been reported to have a higher inci- ANTICIPATION OF tion.6 Sev. may be more difficult to ventilate and IIb. versus a similar vaginal delivery ration of pulmonary compliance and niques are recommended (eg. palsy and an increased risk of mortal- accurate evaluation.13 covering the risk of the baby requiring endotra. in. 2017 .20 Hyperther- capable of initiating resuscitation.15). have examined several aspects of Clearing the Airway able should have the skills required to these initial steps.22 and that suc- eral studies have demonstrated that a Very low-birth-weight (⬍1500 g) pre- tioning of the trachea in intubated ba- cesarean section performed under re. techniques for maintaining tempera. Either that person or stimulating breathing. Lowering the temperature is the newly born.18. chest as discussed under “Assessment of Ox. LOE A14. Preterm compression. and insertion of intrave- ygen Need and Administration of Oxy. clearing the airway if mia should be avoided (Class IIb. does not increase oxygenation and reduction in cerebral ing the delivery room to 26°C. ventilation (PPV) (Class IIb. thin skin and a large surface place (Class IIb.25 There- for resuscitation is anticipated. nous lines. If the possible need (Class IIb. of the slight. pressions.11 If a preterm delivery (⬍37 dling.pressure ventilation or supplementary (American Academy of Pediatrics. necessary with a bulb syringe or suc.7–10 medical grade. the latter opti. There is evidence that suctioning of the cluding endotracheal intubation and nasopharynx can create bradycardia administration of medications. babies also have immature blood ves. (Class I. LOE C). respirations. LOE B16). crease respiratory resistance. tion catheter. and the term babies have immature lungs that have not been studied specifically (Class state of oxygenation. Recent studies someone else who is promptly avail. The infant’s tempera. and cerebral Anticipation. prewarm- performed at term. addi. All resuscitation procedures. LOE C). Pre.24 However. 6th Edition the delivery room have been used (eg. mally determined by a pulse oximeter are also more vulnerable to injury by including endotracheal intubation. the majority of newborns who exothermic mattress (Class IIb. placing the baby skin-to-skin with sessment should consist of simulta. in. This person must be ing the head in a “sniffing” position to reduces neuronal damage. placing the baby on an nasal or oral secretions). the mother and covering both with a neous evaluation of 3 vital characteris. positive-pressure ventilation. neonatal seizures. volume. The initial steps of resuscitation are to perthermia during or after ischemia is ery delivery there should be at least 1 provide warmth by placing the baby associated with progression of cere- person whose primary responsibility under a radiant heat source. Temperature Control during resuscitation21. which contribute to rapid heat Infants born to febrile mothers have loss. there is also evidence that suctioning will need resuscitation can be identi. INITIAL STEPS ity.12 without antenatally identified risk fac. can be performed with these gen” below. temperature-controlling interventions in tor of a successful response to each orrhage. These studies are When Amniotic Fluid Is Clear perform a complete resuscitation. position. term babies are likely to become hypo- bies receiving mechanical ventilation thermic despite the use of traditional gional anesthesia at 37 to 39 weeks. immediately following birth (including cruited and the necessary equipment thermia when these techniques are used suctioning with a bulb syringe) should prepared. LOE C). in the neonatal intensive care unit techniques for decreasing heat loss. open the airway. The most sensitive indica. blood flow velocity when performed the baby in plastic wrapping (food or cheal intubation. bral injury.19 Animal studies indicate that hy- cessful neonatal resuscitation. but described risk of hyper. At ev. adequate preparation. spe.23. LOE C17). blanket) and are recommended. LOE C). e1402 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from by guest on June 28. cial preparations will be required. summarized below. and placing the baby under radiant heat in the presence of secretions can de- fied before birth. in the absence of obvious With careful consideration of risk fac. and prompt initi- ation of support are critical for suc. press). heat-resistant plastic) routinely (ie. step is an increase in heart rate. ture must be monitored closely because fore it is recommended that suctioning tional skilled personnel should be re. Identifiable risk factors and in combination (Class IIb. as. weeks of gestation) is expected. but they tics: heart rate. ous obstruction to spontaneous breath- tation are listed in the Textbook of ture during stabilization of the baby in ing or who require positive-pressure Neonatal Resuscitation. sels in the brain that are prone to hem. and avoid iatrogenic hyperthermia. drying the baby.

and skin blood flow for the oximeter to ure) measured in healthy term babies uterine values until approximately 10 detect a pulse. LOE B). there is insufficient evi. oximetry be used when resuscitation (Class IIb. thus resulting in than a few breaths. the appearance of cyanosis during persistent. than when resus- trolled trials.41– 43 These oximeters that the goal in babies being resusci- Assessment of Oxygen Need are reliable in the large majority of tated at birth. Hypoxia and ischemia cedure in babies who were vigorous Two meta-analyses of several random- are known to result in injury to multi- at birth. particularly nates. However. LOE C). operative and vaginal deliveries. bin saturation during the immediate probe should be attached to a preduc- fore delivery of the shoulders was con. it is recommended following birth.30. blend of oxygen and air resulted in less included in those studies. if In the absence of studies comparing attempted intubation is prolonged Newer pulse oximeters. table in Figure).42 newborns until a randomized con- dence that either insufficient or exces- trolled trial demonstrated that there Administration of sive oxygenation can be harmful to the was no value in performing this pro. quisition of signal (Class IIb. initiated with other oxygen concentra- tion should be considered. that clinical assessment of skin color To appropriately compare oxygen sat- ommended to reduce the incidence of is a very poor indicator of oxyhemoglo. tal location (ie. compromised baby following birth. Historically a that time.32–34 promised babies born at term (see hypoxemia or hyperoxemia.46 babies with meconium-stained amni. Oxyhemoglo. LOE C). comes when resuscitations are initi- that direct tracheal suctioning of meco- ated with different concentrations of nium may be of value was based on com- Pulse Oximetry oxygen other than 100% or room air. as defined In the absence of randomized. whether born at term or and Administration of Oxygen newborns. strument facilitates the most rapid ac- recommended for all meconium-stained ticularly important because of the evi. creased survival when resuscitation ing has not been associated with reduc- comes may result from even brief ex. parison of suctioned babies with historic Numerous studies have defined the One study in preterm infants showed controls. pressure is administered for more ery.2 when positive Aspiration of meconium before deliv. Supplementary Oxygen newborn infant. 2017 . usually the wrist or medial surface controlled trial demonstrated it to be of the state of oxygenation of an un. that attaching the probe to the baby dotracheal intubation and direct suc.29 tracheal suction- ing resuscitation. Number 5. LOE B). of the palm). as well as amniotic fluid (MSAF) are at increased evidence from studies of babies receiv.44. and there was apparent selec- percentiles of oxygen saturation as a that initiation of resuscitation with a tion bias in the group of intubated babies function of time from birth in uncom. Conversely there is grow- born to mothers with meconium-stained natal resuscitation initiated with room ing experimental evidence. Other studies have shown ygen is administered (Class I. It is recommended that following vaginal birth at sea level minutes following birth. tions or targeted at various oxyhemo- if there is persistent bradycardia. air versus 100% oxygen showed in- risk to develop MAS. when cyanosis is tion can cause severe meconium aspi. FROM THE AMERICAN ACADEMY OF PEDIATRICS When Meconium is Present bin saturation may normally remain in can be anticipated. November 2010 e1403 Downloaded from by guest on June 28. the 70% to 80% range for several min.45 There are no tion in the incidence of MAS or mortality posure to excessive oxygen during and studies in term infants comparing out- in these infants. following both or 100% oxygen followed by titration current practice of performing endo.43 There is some evidence of no value. or when supplementary ox- ration syndrome (MAS). These targets may be PEDIATRICS Volume 126. con. have been shown to provide re. should be an oxygen satura- There is a large body of evidence that requiring resuscitation or not. Suctioning of the oropharynx be. which employ outcomes of neonatal resuscitation and unsuccessful.31 The only evidence following resuscitation. that adverse out. altitude. and with an adjustable blend of air and tracheal suctioning of nonvigorous those occurring at sea level and at oxygen.26 Elective and routine en. utes following birth. urations to similar published data.27 Although depressed infants ized controlled trials comparing neo- ple organs. liable readings within 1 to 2 minutes globin saturations.35– 40 otic fluid (Class IIb. during birth. was initiated with air. variety of techniques have been rec. Optimal management of oxygen during before connecting the probe to the in- tioning of the trachea were initially neonatal resuscitation becomes par.28. tions measured from both preductal citation was initiated with either air dence to recommend a change in the and postductal sites. This includes satura. bag-mask ventila. by the investigators. both term and preterm. or during resuscita. the MAS. probes designed specifically for neo. as long tion value in the interquartile range of blood oxygen levels in uncompromised as there is sufficient cardiac output preductal saturations (see table in Fig- babies generally do not reach extra. the right upper extrem- sidered routine until a randomized sis appears to be a very poor indicator ity. neonatal period and that lack of cyano. and preterm.

eficial and its use is routine during me- the baby is bradycardic (HR ⬍60 per assisted ventilation should be deliv. There is no evi- ing the oxygen concentration to circumstances preclude the use of dence to support or refute the use of achieve an SpO2 in the target range as pressure monitoring. or if the heart rate remains ⬍100 been reported. and duration of ventilation. (Class IIb. Starting infants on tion pressures will need to change as not improve. choice may be guided by local exper- with air or a blended oxygen and titrat. There is Although positive end– expiratory pres- not available. Evidence from animal studies ficulty.50. resuscitation should be insufficient evidence to recommend an sure (PEEP) has been shown to be ben- initiated with air (Class IIb. livered volume and the optimal volume ized to achieve an increase in heart creased the rate of pneumothorax. LOE C). CPAP in the delivery room in the term described above using pulse oximetry flation required to achieve an increase baby with respiratory distress. Nevertheless. The use of colorimetric CO2 detectors birth. pressures needed are variable and un. ASSISTED-VENTILATION DEVICES tional residual capacity (FRC). menstrual age between infants started bags. ized clinical trial of newborns at 25 to specified by the manufacturer. it is unclear whether the use inflating bag unless an optional PEEP of CO2 detectors during mask ventila. care unit and in the delivery room has LOE C). with either a flow-inflating or self- flow rate required to establish an effec. ered at a rate of 40 to 60 breaths per intensive care units.60. Resuscitators are insensitive to be monitored. surfactant but the relationship of pressures to de- predictable and should be individual.52 Assisted ventila.47–50 The End-Expiratory Pressure Effective ventilation can be achieved optimal pressure. sures generated may exceed the value diately after birth. PEEP is likely to be during mask ventilation of small num. either LOE C). oxygen requirement at 36 weeks post.59 Initial inflations following birth. The initial peak inflating CPAP reduced the rates of intubation compliance improves following birth.64 e1404 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from by guest on June 28.54 If tise and preferences. create a func. In summary. born preterm.60 – 63 The pop-off valves of self- mined. use. LOE C). LOE B). It is likely that infla- should be assessed if heart rate does delivery room. regard- sure of 20 cm H2O may be effective. 2017 .achieved by initiating resuscitation some term babies without spontane. There is. chanical ventilation of neonates in minute) after 90 seconds of resuscita. valve is used.48. Target tion rates of 40 to 60 breaths per minute 28 weeks gestation with signs of respi. the minimal in. ous ventilation (Class IIb. beneficial and should be used if suit- Positive-Pressure Ventilation (PPV) bers of preterm infants in the intensive able equipment is available (Class IIb. oxygen concentration should be tain a heart rate ⬎100 per minute versus no PEEP when PPV is used dur- increased to 100% until recovery of a (Class IIb.51. PEEP can easily be given with a ing. breathing spontaneously. an initial inflation pres. T-piece devices are used rather than The primary measure of adequate ini. following birth. sure. spontaneous or assisted. may be supported with CPAP or with changes in lung compliance. LOE C). inflation time. although its inflating bags are dependent on the indicates that preterm lungs are easily use has been studied only in infants flow rate of incoming gas. However. and such detectors may flow-inflating bag or T-piece resuscita- per minute after administering the ini.58. tion of continuous positive airway inflating bag or with a T-piece mechan- tive FRC when PPV is administered dur.56 tor. A multicenter random.57 to deliver with each breath as FRC is rate or movement of the chest with Spontaneously breathing preterm in. If blended oxygen is in heart rate should be used. Inflation pressure should fants who have respiratory distress ied.53 Chest wall movement placed on mechanical ventilation in the (Class IIb.61 although the clinical implica- tial ventilation is prompt improvement on CPAP versus those intubated and tions of these findings are not clear in heart rate. inflation pressures and long inspira- are commonly used. minute to promptly achieve or main. but it cannot be given with a self- tial steps. LOE B). and mechanical ventilation. inconsistent end-expiratory pressures. but intubation and mechanical ventilation less of the device being used (Class IIb. If optimum inflation time. and Many experts recommend administra. ⱖ30 to 40 cm H2O may be required in (Class IIb. ratory distress showed no significant tory times are more consistently cacy of various rates has not been difference in the outcomes of death or achieved in mechanical models when investigated. LOE C). some Initial Breaths and tion confers additional benefit above evidence that such valves often deliver Assisted Ventilation clinical assessment alone (Class IIb. ing establishment of an FRC following normal heart rate (Class IIb. however. but with dif. LOE B). but in. The most appropriate LOE C).55. If the infant remains apneic or gasp. pressure (CPAP) to infants who are ical device designed to regulate pres- ing resuscitation have not been deter. start PPV. and pres- injured by large-volume inflations imme. but the relative effi. help to identify airway obstruction. being established have not been stud- each breath. there have been tion with a lower concentration of oxy. no studies specifically examining PEEP gen.

LOE B68 –71). Compressions and ventilations should of meconium-stained fluid. hands technique in intubated infants tion is unsuccessful and tracheal chea). newly born infants (Class IIb. Endotracheal intubation may be indi. tion where compromise of ventilation haled CO2 detection is effective for con. mask has not been evaluated in cases poor cardiac output. the lower third of the sternum to a ing is preferable to chest compres- ministration of intermittent positive depth of approximately one third of the sions alone when the arrest is of non- pressure. Because the 2 thumb– encir. during be coordinated to avoid simultaneous Other clinical indicators of correct en- chest compressions. compression after each ventilation performed cause ventilation is the most effective (Class IIb. LOE C65– 67). A positive test result (detection of ex. or for adminis. such as congenital dia. action in neonatal resuscitation and There is evidence from animals and stances. sion with 2 thumbs with fingers encir. back (the 2 thumb– encircling hands rescuers should consider using higher ment in infants. although it is possible geal mask should be considered dur. atically evaluated in neonates (Class pressions to ventilations with 90 com- tal resuscitation: 11b. Compressions should be delivered on suggests that CPR with rescue breath- After endotracheal intubation and ad. The laryngeal intubation of critically ill infants with to the umbilicus (Class IIb. no CO2 detected to administer the 2 thumb– encircling ing resuscitation if facemask ventila. The 2-finger technique may be prefer- the use of these devices in small pre. ⬍ 2000 g or ⬍34 should be noted that poor or absent required during insertion of an umbil- weeks (Class IIb. before starting chest compressions. but firmation of endotracheal tube place. There are limited data on mation of endotracheal tube place.82 It is recommended rate is the best indicator that the tube chest (Class IIb. a prompt increase in heart anterior-posterior diameter of the cardiac etiology. Two tech. Respirations. thus permitting adequate access ble (Class IIa. A false-negative result may thus with the rescuer standing at the baby’s intubation is unsuccessful or not feasi. pressions and 30 breaths to achieve approximately 120 events per minute ● Initial endotracheal suctioning of non- Chest Compressions to maximize ventilation at an achiev- vigorous meconium-stained newborns Chest compressions are indicated for able rate. LOE C). despite tube placement in the tra. Number 5. ie. LOE C). but not leave the chest (Class IIb. compressions or a compression ratio birth weight rescuers should ensure that assisted of 15:2 or even 30:2 may be more effec- The timing of endotracheal intubation ventilation is being delivered optimally tive when the arrest is of primary car- may also depend on the skill and expe. cling hands technique may generate tion should be reassessed periodically. diac etiology. Thus each event will be allot- ● If bag-mask ventilation is ineffective a heart rate that is ⬍60 per minute ted approximately 1/2 second. A laryn. pulmonary blood flow may give false. perfusion pressure than the 2-finger the laryngeal inlet have been shown to whereas a negative test result (ie. heart rate. November 2010 e1405 Downloaded from by guest on June 28. LOE B65– 67). LOE C). ation. LOE C). it able when access to the umbilicus is term infants. lead to unnecessary extubation and re. LOE B). One study in children rience of the available providers. and presence of Endotracheal Tube Placement equal breath sounds bilaterally. Be. LOE C73–75). ratios (eg. LOE C). these indicators have not been system. because chest compressions are likely non-neonatal studies that sustained phragmatic hernia or extremely low to compete with effective ventilation. There should be a 3:1 ratio of com- cated at several points during neona. 2017 . ment (Class IIa. LOE B).81 The chest should be per- dotracheal tube placement are con- tration of emergency intratracheal mitted to reexpand fully during relax- densation in the endotracheal tube. but the rescuer’s thumbs should chest movement. including very low. and oxygena- haled CO2) in patients with adequate car. cling the chest and supporting the is nearly always the primary cause. ● For special resuscitation circum. intubation. the recommended method of confir. head. with or prolonged exhalation occurring during the first despite adequate ventilation with sup- ● When chest compressions are plementary oxygen for 30 seconds.53 Ex. gers with a second hand supporting to be of cardiac origin (Class IIb. medications. LOE C). the back. FROM THE AMERICAN ACADEMY OF PEDIATRICS Laryngeal Mask Airways diac output confirms placement of the higher peak systolic and coronary Laryngeal mask airways that fit over endotracheal tube within the trachea. no CO2 technique. negative results (ie.76 – 80 the 2 thumb– encircling be effective for ventilating newborns detected) strongly suggests esophageal hands technique is recommended for weighing more than 2000 g or deliv.68 –72 Exhaled CO2 detection is performing chest compressions in ered ⱖ34 weeks gestation (Class IIb. technique) or compression with 2 fin. However. ical catheter. PEDIATRICS Volume 126. 15:2) if the arrest is believed birth-weight infants (Class IIa. ratio be used for neonatal resuscita- providing effective ventilation. that a 3:1 compression to ventilation is in the tracheobronchial tree and niques have been described: compres. delivery.

LOE C). doses Glucose Drugs are rarely indicated in resusci. exaggerated hypertension. Brady. LOE C). cose concentration range can be iden- ered when blood loss is known or sus.05 to 0.03 mg/kg per dose is the pre. volume expanders rapidly. mal86. although no or profound hypoxemia.87 and pediatric88. LOE C). and worse neuro- Heart rate and oxygenation should be coronary blood flow (Class IIb. ic).1 mg/kg. as they will com. tained. Rarely. IV administration of levels are at increased risk for brain cardia in the newborn infant is usually 0.94 and they tubation) with 100% oxygen and chest rine for either route should be 1:10. a VOLUME EXPANSION paucity of data. IV doses in the range of 0.03 mg/kg will likely be inef. animal studies that showed a hemorrhage (Class IIb. if the heart rate remains the safety and efficacy of this prac. of 0. the should be maintained in. ity and less neurodevelopmental dis- positive effect of endotracheal epi. results using different methods of used currently recommended doses tal signs have returned to normal.83. Therefore. that examine this question. buffers. If MEDICATIONS the endotracheal route is used. the goal of avoiding hypoglycemia suscitative measures (Class IIb.85 Given the lack of supportive tion have been established.000 may be protective. Once adequate ventilation and circula. the infant born at ⱖ36 weeks gestation with data for endotracheal epinephrine. The concentration of epineph. or ischemia were not associated with ⬍60 per minute despite adequate ven. but pected (pale skin. tice have not been evaluated (Class IIb. Higher IV doses Administration of naloxone is not rec- quent interruptions of compressions are not recommended because ani- ommended as part of initial resuscita- should be avoided. 0.89 studies show tive efforts in the delivery room for promise artificial maintenance of sys. adverse effects in a recent pediatric tilation (usually with endotracheal in. cooling (selective head versus system- via endotracheal tube showed no ef. temic perfusion and maintenance of myocardial function. evolving moderate to severe hypoxic- IV route should be used as soon as ferred to an environment where close ischemic encephalopathy should be e1406 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from by guest on June 28.1 mg/mL).95 However. (0. there compressions. LOE C).01 to 0. or both. Babies who require resuscitation are randomized trials produced similar ed. which may need to be repeated. injury and adverse outcomes after a the result of inadequate lung inflation ferred route. hypoxic-ischemic insult. or trans. Due to the may be indicated. tracheal tube may be considered. administration of a higher dose specific glucose level associated with ing adequate ventilation is the most (0. Past guidelines recommended (33. and establish.5°C to 34.01 or 0. ability at 18-month follow-up than ba- nephrine used considerably higher POSTRESUSCITATION CARE bies who were not cooled. LOE C).96 –100 It is recommended that infants fect. with moderate When resuscitating premature infants. Induced Therapeutic Hypothermia Epinephrine is recommended to be ad- pansion in the delivery room (Class IIb.5°C) of newborns ⱖ36 mL/kg. series93 or in animal studies.84 and the one animal study that at risk for deterioration after their vi.96 –98 The doses than are currently recommend. center trials of induced hypothermia LOE C). given through an endotracheal tube to severe hypoxic-ischemic encepha- care should be taken to avoid giving because the dose can be administered lopathy as defined by strict criteria. LOE C). Several randomized controlled multi- ministered intravenously (Class IIb. logical function after administration of restored by supporting ventilation. Newborns with lower blood glucose tation of the newly born infant. the spontaneous heart rate is ⱖ60 per The recommended IV dose is 0. The recommended dose is 10 LOE C). been associated with intraventricular cooled had significantly lower mortal- However. not responded adequately to other re.1 mg/kg) through the endo. poor perfusion. administration of epi.and coordinated chest compressions venous access is established (Class monitoring and anticipatory care can and ventilations should continue until IIb. fre. rapid infusions of large volumes have showed that those babies who were venous route must be established. However. but Increased glucose levels after hypoxia However. be provided. that initial doses of epinephrine be weeks gestational age. Rate and Dose of An isotonic crystalloid solution or Epinephrine Administration blood is recommended for volume ex.01 to Naloxone minute (Class IIb. because more quickly than when an intra. fective. worse outcome has been identified. Intravenous glucose may be useful after resuscitation.03 mg/kg per dose.91. or vasopressors Volume expansion should be consid.90 (Class IIb. are no randomized controlled trials nephrine or volume expansion. LOE C). 2017 . decreased newborns with respiratory depression. weak infusion should be considered as soon these are not recommended in the de- pulse) and the baby’s heart rate has as practical after resuscitation. with livery room. tified at present. While access is being ob.92 important step toward correcting it. no specific target glu- narcotic antagonist.

and the anticipated consider stopping resuscitation if the Opinions among neonatal providers burden to the child is high. AND DISCONTINUING rate of survival and acceptable mor. LOE C). minutes (Class IIb. 2017 . Number 5. only ⫾1 to 2 weeks subsequently. few studies have found no differences PEDIATRICS Volume 126. A consistent and coordinated ap. such as thrombocytopenia and long-term morbidity. PROGRAMS TO TEACH stetric and neonatal teams and the lected by perinatal centers in the US NEONATAL RESUSCITATION parents is an important goal. beyond 10 minutes with no heart rate should take into consideration factors Withholding Resuscitation Assessment of morbidity and mortality such as the presumed etiology of the It is possible to identify conditions as. mates of fetal weight are accurate to in published clinical trials and in facili. (Class IIb. there may be some associated adverse may have implications for survival and and some major chromosomal ab- effects. LOE C). Discontinuing Resuscitative Efforts larger role in decisions to initiate re.103 birth-weight babies born in a network treatment should be implemented ac. or tion. techniques used for obstetric dat- 72 hours. Mortality and morbidity data by gesta. ⱖ25 weeks and those with most portunity to examine the baby after attitudes and practice vary according congenital malformations (Class IIb. and GUIDELINES FOR WITHHOLDING ● In conditions associated with a high outcomes may be less predictable. This will generally mitments about withholding or provid- or those with conditions which predict include babies with gestational age ing resuscitation until you have the op- a high risk of mortality or morbidity. vors. FROM THE AMERICAN ACADEMY OF PEDIATRICS offered therapeutic hypothermia. Also. resuscitation is not indicated. unless con- currently include commencement within outcomes: ception occurred via in vitro fertiliza- 6 hours following birth.aap. able heart rate. These uncertainties underscore the RESUSCITATION bidity. parental heart rate remains undetectable for 10 vary widely regarding the benefits and desires concerning initiation of re. Even small discrep- ties with the capabilities for multidisci. the sociated with high mortality and poor available data. A link to a computerized tool real-life clinical situations and simu- equivalent. gies enhances performance in both ing or after resuscitation are ethically org/nrp). The following guidelines must be inter. data from specific populations. anencephaly. and several other countries may be Studies have demonstrated that use of tiation of resuscitation and discontinu. only ⫾15% to 20%. of regional perinatal centers may be cording to the studied protocols. and slow rewarming over at congenital anomalies are associ. occur over time. risks should take into consideration arrest. LOE A). found on the Neonatal Resuscitation simulation-based learning methodolo- ation of life-sustaining treatment dur.107–110 although a hesitate to withdraw support when from a population of extremely low. can be misleading if there has been (Class IIb. November 2010 e1407 Downloaded from by guest on June 28. The de- disadvantages of aggressive therapies suscitation should be supported cision to continue resuscitation efforts in such newborns. and may be augmented presence or absence of complications. Therapeutic hypothermia ated with almost certain early death applied in the first trimester and to should be administered under clearly and when unacceptably high mor. atively high. Studies suggest that 100. ancies of 1 or 2 weeks between esti- Examples include extreme prematu- plinary care and longitudinal follow-up mated and actual gestational age or a rity (gestational age ⬍23 weeks or (Class IIa. and the parents’ previously sonable. STRUCTURE OF EDUCATIONAL proach to individual cases by the ob. outcome in which withholding resusci. to region and availability of resources. the gestation of the baby. However. fetal weight normalities. Esti- defined protocols similar to those used bidity is likely among the rare survi. and clinicians should not to estimate mortality and morbidity lated resuscitations. intrauterine growth restriction. Nonini. LOE C104 –106). the morbidity rate is rel. tional age compiled from data col. LOE C). such as trisomy 13 increased need for inotropic support. importance of not making firm com- For neonates at the margins of viability ways indicated. LOE C101. which preted according to current regional found at that site. birth. by use of published tools based on the potential role of therapeutic hypo- tative efforts may be considered rea. tain prognosis in which survival is In a newly born baby with no detect- suscitation and continue life support borderline.to 200-g difference in birth weight birth weight ⬍400 g). resuscitation is nearly al. birth weight. Studies indicate that parents desire a ● In conditions associated with uncer. agreement (Class IIb. Deci- thermia. The functional survival is highly unlikely. continuation for ● When gestation.102). particularly when there has sions should also take into account expressed feelings about acceptable been the opportunity for parental changes in medical practice that may risk of morbidity. ing are accurate to only ⫾3 to 4 days if least 4 hours. it is appropriate to of severely compromised newborns. Program (NRP) website (www.

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Kaylor CJ. Schwid HA. 64: 112. Wayne DB. Michalowski P. simulated crisis management: oral versus 118.168:1063–1069 106. Schaefer J. Arora V. Sebastian M. FROM THE AMERICAN ACADEMY OF PEDIATRICS 105. The ized trial. Cherry RA. ogy. Arch Dis Child 110. Khaw L.139:229 –235 Govert J. Gaghie WC. Chest. Dicker R. Teach Learn Med. Trauma ing didactic teamwork curriculum? Qual internal medicine residents in advanced training in simulation: translating skills Saf Health Care. team performance when added to an exist.17: 255–263. Adachi M. Fudala MJ. 2007. George J.132:1927–1931 cardiac arrest process and outcomes with pected apparent stillbirth. Que L. Wang H. Edelson DP. discussion 263–254 effectiveness of a human patient simula.105:279 –285 effectiveness of simulation-based team Rosenthal ME. with debriefing improves performance in 115. Crit Care Med. Park J. Dufresne control study. Simulation. McGaghie WC. Screen-based anesthesia simulation 2008. 2009. Res. A method for measuring the 109. Blum RH. Small SD. Jagminas L. Bullard MK. 1998. 107. Wade LD. Williams J. Feinglass J. Ribaudo VA. Fetal Neonatal Ed. Savoldelli GL.13:92–96 team (MET) performance using a novel scores at 10 minutes following hypoxic-is. DeVita MA. November 2010 e1411 Downloaded from by guest on June 28. 2005. Simulation-based training of Howard S. 210 –216 108. Rooke GA. Morey JC.13:417– 421 cardiac life support protocols: a random- from SIM time to real time. Joo HS. Casalaz DM.133:56 – 61 video-assisted oral feedback. Abella BS. Debriefing in the intensive care based education improves quality of care 113. Fudala tor in the ATLS shock skills station. Kim S. training. Out. 114. Feinglass J.14:326 –331 based teamwork training for emergency 116. Qual Saf Health Care. RL. tion training compared with traditional Becker LB.78:F112–F115 BK. Simon R. Shapiro MJ. Didwania A. Lutz J. Barsuk JH. Naik VN. Carlo WA. Chest. Salis. Hamstra SJ. Litzinger B. 2004. J Trauma. 2017 . Suner S. Cooper JB. Wayne DB. Vanden Hoek TL. Raemer DB. patient simulator. 2008. Improving medical emergency Outcome of term infants using apgar Teach Learn Med. Clay AS. 2007. V. Ali J. Gaba D. a mannequin-based anesthesia simulator. Petrusa ER. Ross performance debriefing. 2008. Butter J. Pediatrics.100:1375–1380 PEDIATRICS Volume 126. Initial airway man. Mc- Cohen MJ. Mayo PH. Knudson MM. Anesthesiol. Lauderdale DS. Langford curriculum and a computerized human chemic encephalopathy. Shankaran S. training for improving communication agement skills of senior residents: simula. Das A. Ambalavanan N. Improving in-hospital come of resuscitation following unex.35:738 –754 an academic teaching hospital: a case. Carroll JS. Walsh D. Marlow N. Arch Intern Med. Anesth Analg. Number 5. department staff: does it improve clinical Linquist LA. Siddall VJ. Simulation 2005. 2007. 2006. MJ. skills. Chow unit: a feedback tool to facilitate bedside during cardiac arrest team responses at R. 124:1619 –1626 bury ML. McDonald SA. Sadjadi J. Higgins RD. 2001. 111. 2005. Staudenmayer K. Dongilli T. Speidel BD. Krummel T. Eisen LA. J Surg 117. Laptook AR. Value of debriefing during teaching. Kory PD. Jay GD.

reimburse me directly. Joseph Mercy Hospital-Ann None †Received equipment on-loan None None None None Weiner Arbor Michigan–Attending (3 resuscitation mannequins. None None *Expert for Current expert Ramirez Houston-Physician kine Pharmasciences. Center Neonatologist Jane E. Neonatologist 2 sets of video recording equipment) from Laerdal Medical Corporation to be used to complete a research project evaluating educational methods for teaching neonatal resuscitation. Life Support Programs Gary M. consultation †Several Attorneys.Resp Care Mary Fran Vanderbilt University School of None None None None None None Hazinski Nursing—Professor. *As co-editor for Textbook of Neonatal Resuscitation 6th edition. reimbursed directly.Health Assoc.DISCLOSURES GUIDELINES PART 15: Neonatal Resuscitation Writing Group Disclosures Writing Group Employment Research Grant Other Research Support Speakers’ Bureau/ Honoraria Ownership Consultant/ Advisory Board Other Member Interest John University of Virginia–Professor None None None None None None Kattwinkel of Pediatrics Jeffrey M. being paid a total of $4000 over 3 years by the AAP. St. The value of the on-loan equipment is approximately $35. None None None None None None Professor. serving Hospital–Chief. AHA ECC Product Development-Senior Science Editor †Significant AHA compensation to write. I develop simulation- based training programs and conduct research at CAPE.. This support was provided directly to my institution. Hosp of Cleveland-Crit None None None None None None Gallagher Care Coordinator of Ped. 2017 . Product delivery. St Christopher’s Pediatric None None None None None * reviewed records of cases McGowan Associate/ involving neonatal Tenet Healthcare–Attending resuscitation on one or two neonatologist. Stanford University–Associate †Laerdal Foundation: The Laerdal None *I have received ⬍ 10 honoraria None *Laerdal Medical Advanced *I provide medical Halamek Professor Foundation (not company) in amounts of $500 or less from Medical Simulation Both of consultation to the legal provided a grant to the Center for speaking at various academic these companies profession for which I am Advanced Pediatric and Perinatal meetings in the past 24 months. None None None None None None Kumar ATTENDING NEONATOLOGIST George Little Dartmouth College. (Continued) e1412 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from by guest on June 28. edit and review documents such as the 2010 AHA Guidelines for CPR and ECC.000.Nurse None None None None None None Nightengale Practitioner Mildred M. Weill Cornell-Professor of †NIH-NIH. Barbara Univ. 2008–09. Louis P. Steven Ringer Brigham and Women’s None None *Vermont Oxford Neonatal None *Alere $2000.Improving antimicrobial None None None None None Perlman Pediatrics prescribing practices in the NICU Khalid Aziz University of Alberta– Associate None None None None None None Professor of Pediatrics Christopher Mayo Clinic–physician None None None None None None Colby Karen University of Virginia Health None None None None None None Fairchild System–Associate Professor of Pediatrics John Univ.000 Money to Univ. medical director. occasions over the past 5 NICU years.Ped. Newborn Network. university ’09 $2. $1000. Education at Packard Children’s none of these meetings were Hospital at Stanford during the conducted by for-profit entities. Praveen PEDIATRIC FACULTY FOUNDATION. Dartmouth Hitchcock Medfont. 2007–08. for a case of triplets and preterm lecture in Mexico City. American Academy of None None None None None None Simon Pediatrics–Director. comes to me Dey Pharamaceutical $1000 as expert witness in Medicine Consultation Forrest Medical malpractice cases Pharmaceuticals $1500 Grant Review Committee Wendy M. Money to the Propress for cervical rippening. to be published by the AAP. Univ of Texas Med School None None *Signed as consultant for Cyto. academic years 2006–07. Inc.

which all members of the writing group are required to complete and submit. This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire. Continued Writing Employment Research Grant Other Research Support Speakers’ Bureau/ Honoraria Ownership Consultant/ Advisory Board Other Group Interest Member Myra UT Southwestern Medical †American Academy of Pediatrics †Received a SimNewB *Speaker at Symposia on None None None Wyckoff Center–Associate Professor of Neonatal Research Grant. 2017 . November 2010 e1413 Downloaded from by guest on June 28. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period. or owns $10 000 or more of the fair market value of the entity. FROM THE AMERICAN ACADEMY OF PEDIATRICS GUIDELINES PART 15: Neonatal Resuscitation Writing Group Disclosures. or (b) the person owns 5% or more of the voting stock or share of the entity. neonatal simulator for help in Neonatal Care from University of Pediatrics Ergonomics of Neonatal CPR Beta testing prior to final Miami-honoraria paid to me 2008–2009 production Speaker at Symposia on Neonatal Care from Columbia/ Cornell-honoraria paid directly to me Speaker for Grand Rounds from University of Oklahoma- honoraria paid directly to me Jeanette Seattle Children’s None None *I receive honoraria directly to None None None Zaichkin Hospital–Neonatal Outreach me from the AAP as Coordinator compensation for editorial activities for NRP instructor ms. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition. Number 5. *Modest. †Significant. or 5% or more of the person’s gross income. PEDIATRICS Volume 126.

“no.1542/peds.” The corrected figure is below.2011-1260 176 ERRATUM .1542/peds. Pediatrics. “Newborn Resuscitation Algorithm” it reads: “NO” between “Heart rate below 60” and “Consider intubation.126(5):e1400 – e1413 An error occurred in this article by Kattwinkel et al (doi:10. FIGURE doi:10. Special Report: Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.ERRATUM Kattwinkel. et al. On page e1401. 2010.2010- 2972E). Coordinate with PPV.” This should have read: as a double pointed arrow between “Heart rate below 60” and “Take ventilation corrective steps” and dele- tion of the word. in the figure. Chest compres- sions.

2017 .1542/peds. Downloaded from by guest on June 28.2010-2972E The online version of this article. Wendy M. Praveen Kumar. 141 Northwest Point Boulevard. published. Perlman. Barbara Nightengale. 60007. along with updated information and services. Mary Fran Hazinski. Jane E. Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care John Kattwinkel. Gary M. Halamek. Steven Ringer. Print ISSN: 0031-4005. Christopher Colby.html PEDIATRICS is the official journal of the American Academy of Pediatrics. PEDIATRICS is owned. Illinois. All rights reserved. Elk Grove Village. Karen Fairchild. John Gallagher. Jeffrey M. Ramirez. Copyright © 2010 by the American Academy of Pediatrics. it has been published continuously since 1948. Weiner. A monthly publication. Myra Wyckoff and Jeanette Zaichkin Pediatrics 2010. George Little. and trademarked by the American Academy of Pediatrics. DOI: 10. 2010. Online ISSN: 1098-4275. Mildred M. is located on the World Wide Web at: /content/126/5/e1400.e1400. originally published online October 18.full. McGowan. Louis P. Khalid Aziz.126. Simon.

full. A monthly publication.2010-2972E Updated Information & including high resolution figures.full.xhtml PEDIATRICS is the official journal of the American Academy of Pediatrics. tables) or in its entirety can be found online at: /site/misc/Permissions. appears in the following collection(s): Critical Care /cgi/collection/critical_care_sub Errata An erratum has been published regarding this article. All rights reserved. published. Online ISSN: 1098-4275. 2010. Ramirez.xhtml Reprints Information about ordering reprints can be found online: /site/misc/reprints. 2017 . 60007. Christopher Colby. Steven Ringer. Wendy M.html#related-urls Post-Publication 2 P3Rs have been posted to this article Peer Reviews (P3Rs) /cgi/eletters/126/5/e1400 Subspecialty Collections This article. Halamek.126. Print ISSN: 0031-4005.1542/peds. Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care John Kattwinkel. Weiner. Mildred M. Khalid Aziz. 25 of which can be accessed free at: /content/126/5/e1400.html References This article cites 113 articles. Copyright © 2010 by the American Academy of Pediatrics. Simon.e1400.html#ref-list-1 Citations This article has been cited by 46 HighWire-hosted articles: /content/126/5/e1400. Mary Fran Hazinski. George Little. Praveen Kumar. Louis P. Please see: /content/128/1/176. along with others on similar topics. originally published online October 18.full. Downloaded from by guest on June 28. Perlman. John Gallagher. Illinois. Elk Grove Village. Jane E. Barbara Nightengale. Gary M.html Permissions & Licensing Information about reproducing this article in parts (figures. can be found at: Services /content/126/5/e1400. Jeffrey M. 141 Northwest Point Boulevard. PEDIATRICS is owned. Myra Wyckoff and Jeanette Zaichkin Pediatrics 2010. DOI: 10. McGowan. it has been published continuously since 1948.full. Karen Fairchild. and trademarked by the American Academy of Pediatrics.