S E M I N A R S I N P E R I N A T O L O G Y 46 (2022) 151619
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Seminars in Perinatology
www.seminperinat.com
Neonatal Resuscitation: Recent Advances and Future
Challanges
Timely and effective neonatal resuscitation saves newborn
lives.1 Although only 10% of newly born infants require
some assistance at birth and only 0.1% of newly born
infants require chest compressions at birth, these num-
bers on a population level tell us that in the United States,
more than 350,000 newly born infants require some form
of assistance at birth every year and > 3,500 newly born
infants require extensive neonatal resuscitation every
year.2,3 On a global scale, the number of newly born
infants needing neonatal resuscitation (13-26 million per
year) is much higher given the incidence of perinatal
asphyxia in developing countries.4 A higher intensity of
delivery room resuscitation appears to be a harbinger of
adverse neonatal outcomes.5,6 Evidence based high quality
neonatal resuscitation improves neonatal outcomes.
Significant progress has been made in the last decade, but
several key knowledge gaps remain. Conducting research to
generate evidence for optimal neonatal resuscitation in the
stressful environment of delivery room is quite challenging.
Nevertheless, the science of neonatal resuscitation continues to
evolve. The International Liaison Committee on Resuscitation
(ILCOR) continues to conduct a transparent evidence evaluation
of resuscitation science, providing a consensus of science and
treatment recommendations on a periodic basis. Based on the
work by ILCOR, American Heart Association and American
Academy of Pediatrics create neonatal resuscitation guidelines
taking into account local context, values and preferences. The
neonatal resuscitation program (NRP) incorporates the changes
in resuscitation science, guidelines and advances in training
methodology to create a training program for anyone who pro-
vides care to a newborn. This issue aims to provide clinicians a
deeper understanding of various key aspects of neonatal resus-
citation and provide an update on recent development in neo-
natal resuscitation science, practice and training.
Our understanding of fetal to neonatal transition physiology
and pathophysiology of neonatal resuscitation has markedly
improved in recent times. Sankaran, Lakshminrusimha and
Saugstad review the physiology of fetal to neonatal transition,
delayed cord clamping and physiologic basis behind different
interventions of neonatal resuscitation. In the last decade, mul-
tiple studies were published investigating optimal umbilical
https://doi.org/10.1016/j.semperi.2022.151619
0146-0005/Ó 2022 Elsevier Inc. All rights reserved.
cord management at birth. ILCOR and NRP recommend delayed
cord clamping for all vigorous newly born infants. Koo, Katheria
and Polglase give us an update by summarizing old, new and
upcoming literature on various strategies for umbilical cord
management at birth. Too much or too little oxygen use during
neonatal resuscitation can have a significant impact on neona-
tal outcomes. Xavier, Vento, Saugstad and Oei review the
conundrum of the optimal oxygenation at birth and discuss
modifiable and non-modifiable factors affecting oxygenation at
birth. Positive pressure ventilation remains the backbone of
neonatal resuscitation. Foglia, Shah and Szyld discuss the opti-
mal ventilation targets and how to achieve them. Cardiopulmo-
nary resuscitation (CPR) in the delivery room remains
associated with a very high burden of morbidity and mortality.
Ramachandran, Buckner, Schmolzer and Kapadia review the
chest compression technique, compression to ventilation ratio
and monitoring during CPR. They also review the mechanism
of action, dose, route and timing of epinephrine during neona-
tal resuscitation. The delivery room management of newborn
with meconium-stained amniotic fluid has undergone signifi-
cant changes recently. Strand and Perlman review physiology
and rationale for change in the guidelines for the delivery room
management of infants with meconium-stained amniotic fluid.
Delivery room resuscitation of newly born infants with congen-
ital anomalies or the resuscitation of a newborn delivered in
locations other than the delivery room does not receive a lot of
attention. These special situations are equally important for
clinicians taking care of neonates. Ali and Sawyer review the
best practice guidelines for such circumstances and discuss
how to prepare for them. Decisions surrounding neonatal
resuscitation in the delivery room sometimes can present a
number of ethical issues. Ennis, Reed and Lantos discuss cur-
rent controversies in neonatal resuscitation including the dura-
tion of resuscitation, shifting limits of viability, fetal care
centers and the evolving practice of shared decision making.
Training healthcare professionals to perform the most optimal
evidence based neonatal resuscitation under a high stress envi-
ronment requires evidence-based training in necessary cogni-
tive, technical and behavioral skills. Halamek and Weiner
discuss the state-of-the-art training in neonatal resuscitation.
Quality improvement efforts continue to grow and continue to
2 S E M I N A R S I N
improve outcomes for newborns requiring assistance in the
delivery room. Whitesel, Goldstein, Lee and Gupta examine
published literature, specific challenges related to quality
improvement in the delivery room and potential strategies on
how to overcome barriers. Although in the last three decades,
there has been some improvement in global neonatal survival,
the burden of perinatal and neonatal mortality remains high in
low resource settings. Shukla, Carlo, Niermeyer and Guinsburg
address the health care disparities and barriers to optimal
resuscitation care at birth in low resource settings and give us
an update on what is being done to overcome them.
I thank the experts who contributed to this state-of-the-art
neonatal resuscitation edition of Seminars in Perinatology. I
hope that this issue focused on various aspects of neonatal
resuscitation will provide up-to-date knowledge to the health-
care professionals taking care of newborn infants, but will also
give impetus to the neonatal community to address knowledge
gaps presented in each chapter.
R E F E R E N C E S
1. Wyckoff MH, Wyllie J, Aziz K, et al. Neonatal life support: 2020
international consensus on cardiopulmonary resuscitation
P E R I N A T O L O G Y 46 (2022) 151619
and emergency cardiovascular care science with treatment
recommendations. Circulation. 2020;142:S185–S221.
2. Aziz K, Lee CHC, Escobedo MB, et al. Part 5: neonatal resuscita-
tion 2020 American Heart Association guidelines for cardiopul-
monary resuscitation and emergency cardiovascular care.
Pediatrics. 2021;147:e2020038505E.
3. Osterman M, Hamilton B, Martin JA, Driscoll AK, Valenzuela
CP. Births: final data for 2020. Natl Vital Stat Rep. 2021;70:1–50.
4. Paulson KR, Kamath AM, Alam T, et al. Global, regional, and
national progress towards Sustainable development goal 3.2
for neonatal and child health: all-cause and cause-specific
mortality findings from the global burden of disease study
2019. Lancet. 2021;398:870–905.
5. Bajaj M, Natarajan G, Shankaran S, et al. Delivery room resuscita-
tion and short-term outcomes in moderately preterm infants. J
Pediatr. 2018;195:33–38: e32.
6. DeMauro SB, Roberts RS, Davis P, Alvaro R, Bairam A, Schmidt
A. Impact of delivery room resuscitation on outcomes up to 18
months in very low birth weight infants. J Pediatr.
2011;159:546–550: e541.
Vishal Kapadia
Department of Pediatrics, Division of Neonatal-Perinatal Medicine,
U.T. Southwestern Medical Center at Dallas, 5323 Harry Hines
Blvd, Dallas, TX 75390-9063, United States
E-mail address: Vishal.kapadia@utsouthwestern.edu