NRP 2020…

INTERNATIONAL CONSENSUS ON
CARDIOPULMONARY RESUSCITATION AND
EMERGENCY CARDIOVASCULAR CARE SCIENCE
WITH TREATMENT RECOMMENDATIONS (COSTR)
FOR NEONATAL LIFE SUPPORT

Dr. Sushree Smita Behura

 NRP 2020 TOPICS REVIEWED
 Anticipation and Preparation
1. Prediction of need of respiratory support in the delivery room (NLS 611: EvUp)
2. Effect of briefing/debriefing following neonatal resuscitation (NLS 1562: ScopRev)

 Initial Assessment and Intervention

1. Warming adjuncts (NLS 599: EvUp)
2. Suctioning of clear fluid (NLS 596: ScopRev)
3. Tracheal intubation and suction of nonvigorous meconium-stained newborns (NLS
865: SysRev)

 Physiological Monitoring and Feedback Devices

1. Heart rate monitoring during neonatal resuscitation (NLS 898: EvUp)

 Ventilation and Oxygenation

1. Sustained inflation (NLS 809: SysRev)
2. Positive end-expiratory pressure (PEEP) versus no PEEP (NLS 897: EvUp)
3. Continuous positive airway pressure (CPAP) versus intermittent PPV (NLS 590: EvUp)
4. T-piece resuscitator versus self-inflating bag for ventilation (NLS 870: ScopRev)
5. Oxygen for preterm resuscitation (NLS 864: 2019 CoSTR publication)
6. Oxygen for term resuscitation (NLS 1554: 2019 CoSTR publication)
 Circulatory Support
1. CPR ratios for neonatal resuscitation (NLS 895: EvUp)
2. 2-thumb versus 2-finger compressions for neonatal resuscitation (NLS 605: EvUp)

 Drug and Fluid Administration

1. Epinephrine (adrenaline) for neonatal resuscitation (NLS 593: SysRev)
2. Intraosseous versus umbilical vein for emergency access (NLS 616: SysRev)
3. Volume infusion during neonatal resuscitation (NLS 598: EvUp)
4. Sodium bicarbonate during neonatal resuscitation (NLS 606: EvUp)

 Prognostication During CPR

1. Impact of duration of intensive resuscitation (NLS 896: SysRev)

o Postresuscitation Care
1. Rewarming of hypothermic newborns (NLS 858: EvUp)
2. Induced hypothermia in settings with limited resources (NLS 734: EvUp)
3. Postresuscitation glucose management (NLS 607: EvUp)
TOPICS NOT REVIEWED IN 2020
 Term umbilical cord management (NLS 1551-SysRev in process)

 Preterm umbilical cord management (NLS 787-Sys Rev in process)

 Babies born to mothers who are hypothermic or hyperthermic (NLS 804)

 Stimulation for apneic newborns (NLS 1558)

 Respiratory function monitoring in the delivery room (NLS 806)

 Laryngeal mask for neonatal resuscitation (NLS 618)

 Less-invasive surfactant administration (New)

 CPAP versus increased oxygen for term infants in the delivery room (NLS
1579)
 Optimal peak inspiratory pressure (New)
 Oxygen saturation target percentiles (NLS 1580)

 Use of feedback CPR devices for neonatal cardiac arrest (NLS 862)

 Oxygen use post-ROSC for newborns (NLS 1569)

 Oxygen delivery during CPR (Neonatal) (NLS 738)

 Hypovolemia (risk factors for newborns) (NLS 1555)

 Effect of monitoring technology on team function (NLS 1559)

ANTICIPATION

AND

PREPARATION
1.PREDICTION OF NEED OF RESPIRATORY SUPPORT IN DELIVERY
ROOM
 When an infant without antenatally identified risk factors is
delivered at term by cesarean delivery under regional
anesthesia, a provider capable of performing assisted
ventilation should be present at the delivery. It is not
necessary for a provider skilled in neonatal intubation to be
present at that delivery.
2.EFFECT OF BRIEFING/DEBRIEFING
FOLLOWING RESUSCITATION
 Population: Among healthcare professionals involved in the
resuscitation or simulated resuscitation of a neonate
 Intervention: Does briefing/debriefing

 Comparator: In comparison with no briefing/debriefing

 Outcome: Improve outcomes for infants, families, or clinicians

 Study design: RCTs and nonrandomized studies (non-RCTs,

interrupted time series, controlled before-and-after studies, cohort
studies) were eligible for inclusion. Manikin studies were eligible for
inclusion; animal studies were excluded. Conference abstracts were
included; unpublished studies (eg, trial protocols) were excluded.
 Time frame: All years and all languages were included if there was
an English abstract.
THE SCOPREV IDENTIFIED 1 RCT AND 3 OBSERVATIONAL
STUDIES OF PREINTERVENTION AND
POSTINTERVENTION DESIGN

 Concluded that briefing or debriefing may improve short-term clinical

and performance outcomes for infants and staff. The effects of
briefing or debriefing on long-term clinical and performance
outcomes are uncertain.
INITIAL ASSESSMENT
AND
INTERVENTION
1.WARMING ADJUNCTS
 Population: Preterm neonates less than 32 weeks’ gestational age
who are under radiant warmers in the hospital delivery room
 Intervention: Increased room temperature, thermal mattress, or
another warming adjunct
 Comparator: Compared with plastic wraps alone
 Outcome:
 – Primary: Hypothermia (less than 36.0°C) on admission to
neonatal intensive care unit (NICU)
 – Secondary:
 Survival (critical)
 Morbidities associated with hypothermia

 Hyperthermia and associated morbidities

 13 STUDIES (5 SYSREVS AND 8 RCTS)

 Twenty-five studies across 15 comparison groups met the inclusion criteria, categorised as: barriers to heat loss (18 studies);
external heat sources (3 studies); and combinations of interventions (4 studies).
 Evidence of moderate quality shows that use of plastic wraps or bags compared with routine care led to higher temperatures on
admission to NICUs with less hypothermia, particularly for extremely preterm infants. Thermal mattresses and SSC also reduced
hypothermia risk when compared with routine care, but findings are based on two or fewer small studies. Caution must be taken
to avoid iatrogenic hyperthermia, particularly when multiple interventions are used simultaneously. Limited evidence suggests
benefit and no evidence of harm for most short-term morbidity outcomes known to be associated with hypothermia, including
major brain injury, bronchopulmonary dysplasia, retinopathy of prematurity, necrotising enterocolitis, and nosocomial infection
Preterm infants of less than 32 weeks’ gestation under radiant warmers in the hospital
delivery room, using a combination of interventions that may include environmental
temperature 23°C to 25°C, warm blankets, plastic wrapping without drying, cap, and
thermal mattress to reduce hypothermia (temperature less than 36.0°C) on admission
to NICU.

 Hyperthermia (greater than 38.0°C) be avoided because it introduces potential

associated risks
2. SUCTIONING OF CLEAR FLUID
 Population: Newborns delivered through clear amniotic fluid
 Intervention: Immediate routine suctioning (oropharyngeal or nasopharyngeal)
 Comparator: No suctioning or wiping
 Outcome:
– Survival (critical)
 – Need for delivery room resuscitation and stabilization interventions
 – Oxygen supplementation, use of PPV, intubation, CPR/medications, Apgar scores, time to
reach heart rate greater than 100/min
 – Complications following procedure (desaturation, delay in initiation of PPV, tissue injury,
infection)
 – Respiratory complications (respiratory distress, tachypnea)
 – Other inpatient morbidities

 Study design: RCTs and nonrandomized studies (non-RCTs, interrupted times series,
controlled before-and-after studies, cohort studies) were eligible for inclusion
 Time frame: All years and languages were included if there was an English abstract;
unpublished studies (eg, conference abstracts, trial protocols) were excluded.
 3 RCTs and 1 observational study identified which compared use of “suction clear
amniotic fluid” with “no suction or wipe” in “premature, near term and term infant
population” in 1545 patients .
 Serious consequences such as
 irritation to mucous membranes & increased risk for iatrogenic infection {Gungor 2006},
 bradycardia & apnea {Cordero 1971},
 hypoxemia and arterial oxygen desaturation {Carrasco 1997; Gungor 2005,; Kohlhauser 2000}
 hypercapnea {Skov 1992}
 impaired cerebral blood flow regulation {Van Bel 1988; Perlman 1983}
 increased intracranial pressure {Fisher 1982}, and development of subsequent neonatal brain injury
{Kaiser 2008}.

 The procedure may take a significant time to complete {Konstantelos 2015 } •

 It may delay initiation of ventilation in non-breathing infants {Ersdal 2012 }.
 Newborns who received suctioning compared with a control group had significantly
lower oxygen saturation through the first 6 minutes of life and took longer to reach a
normal saturation range.
Routine intrapartum oropharyngeal and nasopharyngeal
suctioning for newborn infants with clear or meconium-stained
amniotic fluid is no longer recommended
 3. TRACHEAL INTUBATION AND SUCTION OF
NONVIGOROUS MECONIUM-STAINED NEWBORNS 

Trevisanuto, Daniele et al. “Tracheal suctioning of meconium at birth for non-vigorous infants: a systematic review
and meta-analysis.” Resuscitation vol. 149 (2020
 For nonvigorous newborn infants delivered through meconium-
stained amniotic fluid, routine immediate direct laryngoscopy
with or without tracheal suctioning not recommended.
 Meconium-stained amniotic fluid remains a significant risk
factor for receiving advanced resuscitation in the delivery room.
Rarely, an infant may require intubation and tracheal suctioning
to relieve airway obstruction.
PHYSIOLOGICAL MONITORING
AND
FEEDBACK DEVICES
1.HEART RATE MONITORING DURING
NEONATAL RESUSCITATION
 Population: Newborns requiring resuscitation
 Intervention: ECG monitoring

 Comparator: Oximetry or auscultation

 Outcome: Measurement of heart rate (speed and reliability)

  2 SysRevs,2 RCTs, 8 NRCTs  and 3 observational studies.

ANTON O, FERNANDEZ R, RENDON-MORALES E, AVILES-ESPINOSA  R, JORDAN H, RABE H: HEART RATE MONITORINGIN

NEWBORN BABIES: A SYSTEMATIC REVIEW . NEONATOLOGY 2019

 In babies requiring resuscitation, ECG can be used to provide
a rapid and accurate estimation of heart rate
VENTILATION
AND
OXYGENATION
1. SUSTAINED INFLATION
 Population: For newborn infants who receive positive pressure ventilation for bradycardia or ineffective
respirations at birth
 Intervention: Initiating positive pressure ventilation (PPV) with sustained inflation(s) >1 second (s) (SI)

 Comparator: Initiating PPV with intermittent inflations, lasting ≤1 s per breath

 Outcomes:

 Primary Outcome: Death before hospital discharge (critical)

 Secondary Outcomes:

 Death in the delivery room (critical); death within first 48 hours (critical); death at the latest follow-up
(critical)
 Long term neurodevelopmental (ND) or behavioral or education outcomes at >18 months corrected age,
using validated assessment tool(s) (critical)
 Use of mechanical ventilation during hospitalization (important)

 Air leaks reported individually or as a composite outcome, at any time during initial hospitalization

(important)
 BPD, defined as use of supplemental oxygen at 28 days of age; need for supplemental oxygen at 36
weeks of gestational age for infants born at or before 32 weeks of gestation (latest reported outcome)
(critical)
 Intraventricular hemorrhage, grade 3 or 4 (critical)

 Retinopathy of prematurity, stage 3 or above (critical)

 Study Designs: RCTs and NRCTs

SYST.REV & META A - 9 RCTS  (SI 6–15 SECS), 2 RCTS (SI
≥15 SECS), 6 RCTS  (IP ≥20 MM HG), 4 RCTS  (IP≤ 20 MM 
HG).

 For preterm newborns receiving PPV for bradycardia or ineffective respirations at

birth, routine use of initial sustained inflation(s) greater than 5 seconds not
recommended.

 For term or late preterms receiving PPV for bradycardia or ineffective respirations at
birth, it is not possible to recommend any specific duration for initial inflations due to
the very low confidence in effect estimates.
2. PEEP VERSUS NO PEEP
 PEEP for the initial ventilation of premature newborn infants
during delivery room resuscitation is recommended.

 No recommendation for term infants because of insufficient

data.
 3.CPAP VERSUS INTERMITTENT POSITIVE PRESSURE
VENTILATION
Schmölzer, Georg M et al. “Non-invasive versus invasive respiratory support in preterm infants at birth: systematic
review and meta-analysis.” BMJ (Clinical research ed.) vol. 347 f5980. 17 Oct. 2013
 For spontaneously breathing preterm newborn infants with
respiratory distress requiring respiratory support in the DR
,initial use of CPAP recommended rather than intubation and
intermittent PPV
4. T-PIECE RESUSCITATOR VERSUS SELF-
INFLATING BAG FOR VENTILATION

 3 RCTs and 1 observational study

 There is insufficient evidence regarding the use of T-piece
resuscitator or self-inflating bag for initial PPV at birth, so the
recommendation of one device over another would be purely
speculative because the confidence in effect estimates is so
low.
5.OXYGEN FOR PRETERM RESUSCITATION

Welsford, Michelle et al. “Initial Oxygen Use for Preterm Newborn Resuscitation: A Systematic Review With
Meta-analysis.” Pediatrics vol. 143,1 (2019)
 Results for All Preterm Newborns <35 Results for All Preterm Newborns ≤28
Weeks Gestation Weeks Gestation
Welsford, Michelle et al. “Room Air for Initiating Term Newborn Resuscitation: A Systematic Review With Meta-
analysis.” Pediatrics vol. 143,1 (2019)
o For preterm newborn (<35 weeks’ gestation) who receive respiratory support at birth,
starting with a lower oxygen concentration (21% to 30%) rather than higher initial
oxygen concentration (60% to 100%) recommended.
Subsequent titration of oxygen concentration using pulse oximetry is advised

o For newborn infants at ≥35 weeks gestation receiving respiratory support at birth, start
with 21% oxygen (air).
CIRCULATORY SUPPORT
1. CPR RATIOS FOR NEONATAL RESUSCITATION 
o 4 neonatal manikin, various animal studies {Li 2015 14; Boldingh 2016 3202; Boldingh
2016 910; Dellimore 2017 1255}

o cardiac compressions delivered holding a sustained inflation (CC+SI)

compared to synchronized 3:1 compression to ventilation ratio CPR

o found no advantage over 3:1 CPR ratio: though a small pilot trial of 9
preterm newborns reported faster time to ROSC.

o SURV1VE trial is an ongoing large international, prospective

randomized controlled trial in which the primary objective is to
compare the time to ROSC in infants born > 28 weeks gestational
age (GA) with bradycardia (< 60/min) or asystole immediately
after birth who receive either CC + SI or 3:1 C:V ratio as the CPR
strategy :Estimated completion date is August 2021.
Recommendation is to use of a 3:1 compression-to-ventilation ratio for neonatal CPR 
2. 2-THUMB VERSUS 2-FINGER COMPRESSIONS FOR NEONATAL
RESUSCITATION 
 chest compressions in the newborn infant should be
delivered by the 2-thumb, hands-encircling-the-chest
method as the preferred option.
 DRUG AND
FLUID ADMINISTRATION
1. EPINEPHRINE (ADRENALINE) FOR
NEONATAL RESUSCITATION

Isayama, Tetsuya et al. “The Route, Dose, and Interval of Epinephrine for Neonatal Resuscitation: A Systematic
Review.” Pediatrics vol. 146,4 (2020): 
 administration of intravascular epinephrine (adrenaline) (0.01–0.03 mg/kg)
 If intravascular access not yet available, administer endotracheal epinephrine
at a larger dose (0.05–0.1 mg/kg)
 administer further doses of epinephrine every 3 to 5 minutes, preferably
intravascularly
 If response to ET epinephrine inadequate, an intravascular dose be given as
soon as vascular access is obtained, regardless of the interval after any initial ET
dose
2.INTRAOSSEOUS VERSUS UMBILICAL VEIN
FOR EMERGENCY ACCESS
Granfeldt A, Avis SR, Lind PC, Holmberg MJ, Kleinman M, Maconochie I, Hsu CH, Fernanda de Almeida M, Wang
TL, Neumar RW, Andersen LW. Intravenous vs. intraosseous administration of drugs during cardiac arrest: A
systematic review.

 6 observational studies comparing IV to IO administration of drugs

and 2 RCTs assessing the effect of specific drugs in subgroups
related to IV vs. IO administration.
 All studies included adult out-of-hospital cardiac arrest patients.
 No studies were identified in neonatal or paediatric patients.
 Pooled results from four observational studies favoured IV access
with very low certainty of evidence. 
 analyses of two randomized clinical trials, there was no statistically
significant interaction between the route of access and study drug
on outcomes.
 umbilical venous catheterization - primary method of vascular
access during newborn infant resuscitation in the delivery room.

 If umbilical venous access is not feasible, the intraosseous route

is a reasonable alternative for vascular access during newborn
resuscitation.
3.VOLUME INFUSION DURING NEONATAL
RESUSCITATION 
 Early volume replacement with crystalloid or red cells is indicated for
newborn infants with blood loss who are not responding to
resuscitation.
 Normal saline- the crystalloid fluid of choice,@ 10 mL/kg over 5 - 10
mins , repeated if required
 Uncrossmatched type O, Rh-negative blood (or crossmatched, if
immediately available) is preferred when blood loss is substantial
4.SODIUM BICARBONATE DURING
NEONATAL RESUSCITATION
 Sodium bicarbonate is discouraged during brief CPR
but may be useful during prolonged arrests after
adequate ventilation is established and there is no
response to other therapies.
PROGNOSTICATION DURING CPR
1. IMPACT OF DURATION OF INTENSIVE
RESUSCITATION

Foglia, Elizabeth E et al. “Duration of Resuscitation at Birth, Mortality, and Neurodevelopment: A

Systematic Review.” Pediatrics vol
 Discussion of discontinuing resuscitative efforts with the
clinical team and family in case of failure to achieve ROSC in
newborn infants despite 20 minutes of intensive resuscitation
POSTRESUSCITATION
CARE
1. REWARMING OF HYPOTHERMIC NEWBORNS 
 admission hypothermia was associated with pulmonary
hemorrhage, air-leak, BPD at 36 weeks, pulmonary hypertension,
proven sepsis, seizure, high-grade IVH, and advanced ROP
requiring laser therapy.
 low Apgar score at 5 minutes and intubation in the DR were
independently related to a lower admission temperature.
 reported a significant correlation

between admission hypothermia

and mortality.

Lee NH, Nam SK, Lee J, Jun YH. Clinical impact of admission hypothermia in very low birth weight infants :
results from Korean Neonatal Network. Korean Journal of Pediatrics. 2019 .
 All ELBWIs with hypothermia (temp <36.0°C) on NICU
admission with Rewarming rate (≥0.5°C/h rapid group; <0.5°C/h
slow group)
 no significant differences between rapid or slow rewarming rate
and major neonatal outcomes.
 higher rewarming rate was associated with a reduced incidence
of respiratory distress syndrome.

Rech Morassutti F, Cavallin F, Zaramella P, et al. Association of Rewarming Rate on Neonatal Outcomes in
Extremely Low Birth Weight Infants with Hypothermia. The Journal of Pediatrics. 2015
o admission hypothermia has significant effect on mortality and
hence to be post resucitation warm care is a must.
 recommendation for either rapid (>0.5°C/h) or slow
rewarming (≤0.5°C/h) of unintentionally hypothermic newborn
infants (temperature < 36°C) at hospital admission would be
speculative.
2. INDUCED HYPOTHERMIA IN SETTINGS WITH LIMITED
RESOURCES 

Pauliah, Shreela S et al. “Therapeutic hypothermia for neonatal encephalopathy in low- and middle-income countries:
a systematic review and meta-analysis.” PloS one vol. 8,3 (2013)
 newborn infants at term or near-term with evolving moderate-
to-severe HIE in low-income countries and/or other settings with
limited resources may be treated with therapeutic hypothermia

 Treatment should be consistent with the protocols i.e. cooling to

commence within 6 hours, strict temperature control at 33°C to
34°C for 72 hours and rewarming over at least 4 hours.
3. POSTRESUSCITATION GLUCOSE MANAGEMENT 

Shah R, Harding J, Brown J, McKinlay C: Neonatal Glycaemia and Neurodevelopmental Outcomes:A Systematic
Review and Meta-Analysis. Neonatology 2019
 neonatal hypoglycaemia is associated with 2-3 fold increased
risk of specific cognitive deficits in early childhood (2–5 yrs),
including visual-motor impairment and executive dysfunction,
and general cognitive impairment and literacy and numeracy
problems in later childhood (6–11 yrs)
 Intravenous glucose infusion should be considered as soon as
practical after resuscitation, with the goal of avoiding
hypoglycemia.
TAKE-HOME MESSAGES FOR NEONATAL LIFE SUPPORT
 Newborn resuscitation requires anticipation and preparation by
providers who train individually and as teams.
 Most newly born infants do not require immediate cord clamping
or resuscitation and can be evaluated and monitored during skin-
to-skin contact with their mothers after birth.
 Inflation and ventilation of the lungs are the priority in newly
born infants who need support after birth.
 A rise in heart rate is the most important indicator of effective
ventilation and response to resuscitative interventions.
 Pulse oximetry is used to guide oxygen therapy and meet oxygen
saturation goals.
 Chest compressions are provided if there is a poor heart rate
response to ventilation after appropriate ventilation corrective
steps, which preferably include endotracheal intubation.
 The HR response to chest compressions and medications should
be monitored electrocardiographically.

 If the response to chest compressions is poor, it may be

reasonable to provide epinephrine, preferably via the intravenous
route.

 Failure to respond to epinephrine in a newborn with history or

examination consistent with blood loss may require volume
expansion.

 If all these steps of resuscitation are effectively completed and

there is no HR response by 20 minutes, cessation of resuscitation
should be discussed with the team and family