Neonatal Resuscitation: Specific treatment recommendations (ILCOR 2015)

The International Liaison Committee on Resuscitation (ILCOR) Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR) guidelines were released in October 2015.

You may wish to refer to the previous ILCOR guidelines (2006 and 2010) to see where changes have been made in 2015.

Management of meconium (2006, 2010 versions)

Level 1 evidence has shown that intrapartum pharyngeal suctioning (suctioning the infant’s mouth & pharynx before delivery of the shoulders) does not reduce the incidence of meconium aspiration syndrome (Vain, et al., 2004)

Intubating & suctioning the trachea of a vigorous infant born through meconium stained amniotic fluid has not been shown to alter the infant’s outcome and may cause harm. (Wiswell, et al., 2000)

Recommendations:

Routine intrapartum suctioning of the infant’s oropharynx and nasopharynx in the presence of meconium is no longer recommended.

The benefit of tracheal suctioning in meconium stained depressed infants has not been systematically studied. The current guidelines state that if the amniotic fluid contains thick meconium and the infant is depressed at birth (as indicated by absent or depressed respirations and decreased muscle tone) the infant should receive brief tracheal suctioning (if a person with the professional expertise to perform this procedure is available).

Temperature control (2010 version)

Hypothermia can increase oxygen consumption, so the prevention of hypothermia during resuscitation is important. Well grown term infants who do not require resuscitation can be kept warm by being placed skin to skin with their mother. Preterm infants are at particular risk of hypothermia.

Recommendations:

To prevent hypothermia during resuscitation, infants less than 28 weeks gestation (or less than 1500 grams birth weight) should be placed immediately (wet & warm) into a polyethylene bag or wrap (food grade, heat resistant plastic) with their head outside the bag, a woolen hat placed onto their head and their body completely covered.

While there have not been any randomised controlled trials directly examining the effects of hyperthermia on newborn infants following resuscitation, it has been shown that babies born to febrile mothers (maternal temperature in labour > 38^OC) have an increased risk of death, perinatal respiratory depression, neonatal seizures and cerebral palsy (Petrova, et al., 2001).

Iatrogenic hyperthermia should be avoided in infants who require resuscitation at birth. Achieving normothermia (temperature 36.5 – 37.2^OC) should be the goal.

Supplementary oxygen (2006 version)

There is growing evidence from both animal and human studies that air (21% oxygen) is as effective as 100% oxygen for the resuscitation of most infants at birth. The use of 100% oxygen has potential adverse effects on breathing physiology, cerebral circulation and potential tissue damage from oxygen free radicals. Meta-analysis of human studies have shown that commencing resuscitation with air instead of 100% oxygen results in significantly lower mortality rates, especially in very premature infants (Davis, et al., 2004)
Recent randomised controlled trials have shown that even extremely pre-term infants can achieve a targeted oxygen saturation of > 85% by 7 – 10 minutes of postnatal age when resuscitation is commenced in low concentrations of oxygen (30 – 40%) (Wang, et al., 2008; Escrig, et al., 2008).

Recommendations:

Initially, medical air should be used for resuscitation with supplemental oxygen reserved for infants whose condition does not improve within the first minutes of life. If medical air is unavailable, oxygen should be used.
Oximetry studies of both term and pre-term infants have shown that even brief exposure to supplemental oxygen at birth can produce a SpO₂ > 95%. Very preterm infants who are resuscitated in 100% oxygen can become rapidly hyperoxic (Dawson, et al, 2008).

Hyperoxia should be avoided, especially in premature infants.

Ventilation strategies (2010 version)

While the recommended peak inspiratory pressure for commencing positive pressure ventilation with a T- piece device is 30 cmH₂O, higher inflation pressures may be needed to open the lungs during the first few positive pressure breaths in an infant of any gestation who has never breathed. A 240 mL self inflating bag should be more than adequate to inflate any newborn infant’s lungs.
Bear in mind that pre-term lungs are more easily damaged by large volume inflations immediately after birth, thus an appropriate tidal volume of gas needs to be delivered. The tidal volume required by a newborn infant is approximately 5 – 10 mL/kg. The peak inspiratory pressure on the Neopuff may therefore need to be reduced if chest wall movement is excessive or exhaled tidal volume (V_T) is greater than 6 – 10 mL/kg when measured on a respiratory monitor.

Recommendations:

Avoid excessive pressure and chest wall movement during ventilation of premature infants immediately after birth.
The application of positive end expiratory pressure (PEEP) has been shown to protect against lung injury, improve lung compliance and improve gas exchange in animal studies. The application of PEEP has also been shown to contribute to the clearance of fetal lung fluid and the establishment of functional residual capacity in preterm animal studies (Siew, et al., 2009).

A CPAP or PEEP of at least 5 cmH₂O (but no higher than 8 cmH₂O) should be considered when resuscitating very premature infants to assist their lung expansion, help establish a functional residual capacity and improve oxygenation.
If positive pressure ventilation with a bag or T – piece device is ineffective or if intubation is not successful, a laryngeal mask airway (LMA) may be used as a rescue airway. The LMA does not replace all the functions of an endotracheal tube. At present, the smallest LMA (size 1) only fits infants > 1500 grams. There is inadequate evidence to recommend use of an LMA as the primary device in the setting of meconium stained amniotic fluid or when chest compressions are required. No randomised study has compared the LMA with bag mask ventilation during neonatal resuscitation.

The LMA may enable effective ventilation during neonatal resuscitation if bag mask ventilation is unsuccessful and tracheal intubation is unsuccessful or not feasible.

Use of CO₂ detector to confirm endotracheal tube position (2006 version)

Clinical methods of endotracheal tube placement have not been systematically evaluated in neonates.

Recommendations:

An end tidal CO₂ detector attached to the outside end of the endotracheal tube is recommended for verification of correct tube placement.
For more information regarding the Pedi-Cap CO₂ detector, please refer to the Pedi-Cap CO₂ detector (PDF 168KB) presentation in the Learning Resources section of this web site and refer to the research article by Garey, et al., (2008)

Medications (2006 version)

The administration of medications and fluids are rarely indicated during the resuscitation of newborn infants. As bradycardia in newborns is usually caused by hypoxia and inadequate ventilation, the establishment of effective ventilation is more critical than the administration of drugs to improve the infant’s heart rate in the first instance.

Recommendations:

Be careful that administering medications or fluids does not detract from the efficiency of the positive pressure ventilation and chest compressions.
As drugs exert their effect by their action on the heart, it is important to give them as close to the heart as possible, ideally as a rapid bolus through an umbilical venous catheter.

Post-resuscitation care (2010 version)

An infant who has experienced perinatal compromise may have had an ischaemic insult to the heart, brain, gastrointestinal tract or kidneys and thus remains at risk in the newborn period. These infants require ongoing evaluation and close monitoring for the first few days following birth. This may necessitate transfer to a higher level of care in some instances.

Recommendations:

Any infant who has been intubated and ventilated for resuscitation should not be extubated until the infant is in a nursery and has been carefully assessed.

The neonatal retrieval service should be consulted early for stabilsation advice and to arrange for transfer of the infant to a higher level of care. PIPER-Neonatal (NETS, Victoria) can be contacted 24 hours a day on 1300 137 650. Whilst awaiting the neonatal retrieval team, the first priority is to pay close attention to maintaining the infant’s airway, breathing and circulation. If intubated, the endotracheal tube should be left in situ, even if the infant is breathing spontaneously. Assessment of blood sugar is imperative as infants who require resuscitation are more likely to develop dangerous hypoglycaemia.

Adverse neurological outcomes have been demonstrated in asphyxiated animal models when hypoglycaemia is present at the time of a hypoxic ischaemic insult. The optimal range of blood glucose concentration to minimise brain injury following asphyxia and resuscitation is yet to be defined. Blood sugar levels should be monitored in all neonates who require resuscitation and treated to maintain in the normal range (above 2.6 mmol/L) and above 3.0 mmol/L in any infant who has signs of neurological compromise following birth.

The PIPER neonatal consultant will also give the referring hospital advice on whether the infant meets the criteria for therapeutic hypothermia (cooling). Pilot studies in human neonates and animal studies suggest that inducing hypothermia (reducing the body temperature to 34^OC) in newborn infants with moderate to severe cerebral hypoxic ischaemic encephalopathy (HIE) may reduce neurological sequelae without adverse effects. A Cochrane review by Jacobs, et al., (2007) found that therapeutic hypothermia resulted in a statistically significant and clinically important reduction in the combined outcome of mortality or major neurodevelopmental disability to 18 months of age.

Based on current evidence, therapeutic hypothermia is now offered to infants in Australia with moderate or severe HIE based on strict selection criteria.