Susan Niermeyer, MD, MPH, FAAPUniversity of Colorado School of Medicine

Colorado School of Public HealthAurora, Colorado USA

NEONATAL RESUSCITATION:

1987 vs. 2015

1999

• ILCOR invites neonatal group into evidence-based review process

AustralianResuscitation

Council

Organizing the workflow within ILCOR

Evidence evaluation

Recent DRAFT CoSTRon initial oxygen concentration for preterm and term neonatal resuscitation

www.ilcor.org – public review

Change to GRADE System

Guyatt, et al, BMJ, 2008

GRADE = Grading of Recommendations Assessment, Development and Evaluation

2019 NLS guidelines focused update

IN PRESS - Circulation

2019 American Heart Association Focused Update on Neonatal Resuscitation

An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Initial Oxygen Concentration for Term Neonatal Resuscitation

Initial Oxygen Concentration for Preterm Neonatal Resuscitation

2019 NLS guidelines focused updateTerm and late preterm (> 35 wks)

• 7 randomized and quasi-randomized trials (N=1469)

• Meta-analysis confirming reduced short-term mortality with 21 vs. 100% oxygen

Preterm (< 35 wks)

• 10 RCTs (N=968)

• Meta-analysis showed no difference short-term mortality with low (<50%) vs. high oxygen

Initial use of 21% oxygen is reasonable (Class IIa, Level B-R). One hundred per cent (100%) oxygen should not be used to initiate resuscitation as it is associated with excess mortality (Class III-Harm, Level B-R).

It is reasonable to begin with 21% to 30% oxygen with subsequent oxygen titration based on pulse oximetry (Class IIb, Level C-LD)

Escobedo MB et al. Circulation, in press

Meconium—What to do about it?Changes in recommendations regarding suctioning over

the last 2 decades

Meconium—new evidence in 2015Nangia S et al. Resuscitation 2015 and Chettri S et al. J Pediatr 2015:166:1208

• RCTs of oropharyngeal suction in infants born through MSAF

Nangia: OP suction (N=253) vs. no OP suction (N=256)Chettri: OP suction (N=61) vs. no OP suction (N=61)

• No differences in…• Baseline characteristics• Incidence of MAS or death similar between groups• Neonatal outcomes (Nangia)

• need for any respiratory support• severity and duration of respiratory distress • duration of oxygen therapy, duration of ventilation, length of stay• incidence and grade of HIE

• Developmental outcomes (Chettri)

More to consider…with change to expectant managementChiruvolu A et al. Pediatrics 2018; 142(6):e20181485

• Comparison a prospective cohort (N=101) to a retrospective cohort (N=130) pre/post the change in NRP recommendations

• In the prospective group, there were

• Higher rates of NICU admission (40% vs. 22%--OR 2.2 [1.2-3.9])

• Mechanical ventilation (19% vs. 9%--OR 2.6 [1.1-5.8])

• Surfactant (10% vs 2%--OR 5.8 [1.5-21.8])

• Oxygen therapy (37% vs. 19%--OR 2.5 [1.1-5.8])

• No differences in mortality or MAS

Management of meconium-stained amniotic fluid

PICOST Description (with recommended text)Population For non-vigorous infants born at ≥34 weeks’

gestation delivered through meconium-stained amniotic fluid of any consistency (non-vigorous defined as heart rate <100 bpm, decreased muscle tone and/or depressed breathing at delivery)

Intervention does immediately performing direct laryngoscopy with or without intubation and suctioning at the start of resuscitation

Comparison compared to immediate resuscitation without direct laryngoscopy

Outcomes change the following outcomes (see Outcomes list below)

Study Design Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded.

Timeframe All years and all languages are included as long as there is an English abstract

OutcomesCritical

9: Survival to discharge

9: Meconium aspiration syndrome

8: Resuscitation interventions (CPR/meds in DR; Apgar scores)

7: Neurodevelopmental outcomes

Very important

6: Respiratory complications (Need for mechanical ventilation, ECMO, pulmonary hypertension, pneumothorax/air leak, duration of mechanical ventilation, duration of oxygen supplementation)

Delayed umbilical cord clamping2015 recommendations

• DCC > 30 sec for term and preterm infants not requiring resuscitation

• Insufficient evidence to recommend an approach for infants requiring resuscitation

• Recommendation against routine use of cord milking for infants < 29 weeks outside of a research setting

Delayed cord clamping in relation to ventilation

• Initiation of breathing (ventilation) before umbilical cord clamping increases physiologic stability

• Change from absolute time interval to more physiologic concept of transition that includes relative timing of a baby’s first breaths and cord clamping

Bhatt S et al. J Physiol 2013

Delayed cord clamping - new evidence and analysis

• Australian Placental Transfusion Study (Tarnow-Mordi W et al. NEJM 2017)• 782 ICC vs 784 DCC for 60 seconds

• No difference in primary outcome (death or major morbidity)

• Mortality 6.4% in DCC and 9.0% in ICC, p=0.03 in unadjusted analyses and p=0.039 after post hoc adjustment for multiple secondary outcomes

• Meta-analysis (Fogarty M et al. AJOG 2018)• DCC reduced in-hospital mortality (RR 0.68 [0.52—0.90]), NNT 33, GRADE high

• DCC did not reduce intubation, IVH, admission temperature, NEC, ROP

• Possible harms—polycythemia and hyperbilirubinemia

Delayed cord clamping in relation to ventilationprobability of death or admission to special care

Ersdal H et al. Pediatrics 2014

BW < 2500 g

BW > 2500 g

Cord clamping

Deaths/admissions

Normal

Umbilical cord milking in very preterm infants

• International randomized controlled non-inferiority trial of delayed clamping vs. cord milking

• N = 474 infants 23-31 wks

• 19/238 (8%) in DCC vs. 28/238 (12%) in UCM died or developed severe IVH (p=0.16)

• Severe IVH higher in 23-27 week infants with UCM (4% vs 22%, p=0.0007)

• DSMB recommended stopping recruitment

Katheria A et al. Am J Ob Gyn Supplement Jan 2019

Cord management at birth in preterm and term/late preterm babies (>34 weeks or equivalent birth weight)

• P - population

• I - intervention

• C - comparison

• O - outcomes

• S - study design

• T - timeframe

Early cord clamping(<30 seconds)

Intact-cord milking without respiratory

support before clamping

Intact-cord milking with respiratory support before

clamping

Delayed cord clamping without

respiratory support before clamping

Delayed cord clamping with

respiratory support before clamping

Cut-cord milking without respiratory

support before clamping

Cut-cord milking with respiratory support

before clamping

KSU – Network meta-analysis

Cord management at birth in preterm and term/late preterm babies (>34 weeks or equivalent birth weight)

• Preterm • Term/late pretermShort term (delivery setting)

6 (Important) – Resuscitation and stabilization interventions 7 (Critical) - Maternal complication (post-partum hemorrhage, infection)

Medium term (inpatient)7 (Critical) - Inpatient morbidities (e.g. intraventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity, hyperbilirubinemia, etc)6 (Important) - Hematological status (in-hospital)

Longer term9 (Critical) – Survival and/or mortality8 (Critical) – Neurodevelopmental outcomes (with age-appropriate, validated tools)

Short term (delivery setting)6 (Important) - Resuscitation and stabilization interventions 7 (Critical) - Maternal complication (post-partum hemorrhage, infection)

Medium term (inpatient)6 (Important) - Hyperbilirubinemia and treatment

Longer term9 (Critical) – Survival and/or mortality (any stage)8 (Critical) – Neurodevelopmental outcomes (with age-appropriate, validated tools)6 (Important) - Hematological status (at any age)

Alternative surfactant delivery methodsPICOST (a) Description (with recommended text)Population Preterm newborn infants receiving respiratory support in the

delivery room Intervention First administration of surfactant using techniques that

include brief endotracheal intubation with a catheter or an endotracheal tube with immediate or prompt extubation, administration via a supraglottic airway, nebulized surfactant delivered from CPAP or non-invasive ventilation, and administration via intrapharyngeal tube

Comparison (a) First administration of surfactant via an endotracheal tube, followed by ventilation

Comparison (b) No initial intubation and management of baby on CPAPOutcomes Survival, disability-free survival, chronic neonatal lung

disease/bronchopulmonary dysplasia, intubation for ventilation after first intervention, pneumothorax

Study Design Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded. (preset text)

Timeframe All years and all languages are included as long as there is an English abstract(preset text)

• P: preterm

• I : administration by catheter, in-and-out endotracheal tube, supraglotticairway, nebulization with CPAP/NIPPV, intrapharygeal tube

• C: administration with endotracheal tube followed by ventilation OR no initial intubation, but management on CPAP

• O: survival, disability-free survival, CLD/BPD, intubation for ventilation after first intervention, pneumothorax

More of what’s hot and what’s not…….

• Apgar score of 0 or 1 for > 10 min

• Therapeutic hypothermia in limited-resource settings

• Temperature maintenance in delivery room

• Laryngeal mask airway

• Respiratory function monitoring during positive-pressure ventilation

• Oxygen delivery during CPR

• Use of feedback CPR devices

• Resuscitation training frequency

EVERY NEWBORN ACTION PLAN: NEONATAL MORTALITY GOAL

Unless we greatly accelerate newborn survival efforts, goal to end preventable

child deaths by 2035 unreachable

Every Newborn Action Plan