Highlights of the New Neonatal ResuscitationProgram Guidelines

Jeffrey M. Perlman, MB, ChB*

*Division of Newborn Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY, and

New York Presbyterian Hospital, Komansky Centre for Children’s Health, New York, NY.

Practice Gap

Scientific recommendations and treatment guidelines for neonatal

resuscitation need to be applied to clinical practice.

Abstract

In 2015, the neonatal guidelines for resuscitation were published with several

new treatment guidelines. Many of these are highlighted in this review. They

included changes in the algorithm, timing of cord clamping in the preterm

infant, optimizing detection of heart rate after birth, maintaining the

premature infant temperature in the delivery room, initiating oxygen use

during resuscitation, and using sustained inflation to establish functional

residual capacity. In the term infant, changes included management of the

nonbreathing infant delivered in the presence of meconium-stained amniotic

fluid and consideration for when to continue/discontinue resuscitation in infants

with an Apgar score of 0 after 10 minutes of resuscitation.

Objectives After completing this article, readers should be able to:

1. Understand the GRADE process for evaluating the science and significance

of the recommendations.

2. Understand the rationale behind delayed cord clamping in the premature

infant.

3. Understand the starting concentration of supplemental oxygen in the

premature infant needing resuscitation.

4. Understand the importance of avoiding moderate hypothermia after birth

and the methods of achieving this goal.

5. Understand the suggestive approach to managing the term

depressed infant delivered in the presence of meconium-stained

amniotic fluidAUTHOR DISCLOSURE Dr Perlman hasdisclosed no financial relationships relevant tothis article. This commentary does contain adiscussion of an unapproved/investigativeuse of a commercial product/device.

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INTRODUCTION

The neonatal guidelines for resuscitation were recently

published and reflected a summary of the evidence pre-

sented in the 2015 International Consensus on Cardiopul-

monary Resuscitation and Emergency Cardiovascular Care

Science with Treatment Recommendations. (1)(2) This

review of the guidelines will highlight some of the newer

and potentially controversial issues brought about by new

evidence. Importantly, some of the new recommendations

are based on “Grading of Recommendations, Assessment,

Development and Evaluation” (GRADE), a new system

for evaluating the quality of evidence and strength of the

recommendations (Table 1). (3)(4) In this review, the GRADE

process will be briefly described, and the following new/

controversial issues will be highlighted: the algorithm,

timing of cord clamping in the preterm infant, optimizing

detection of heart rate after birth, maintaining the tem-

perature of the premature infant in the delivery room,

initiating oxygen use during resuscitation, and using sus-

tained inflation to establish functional residual capacity

(FRC). This article also will include a discussion of the man-

agement approach to the nonbreathing term infant deliv-

ered in the presence of meconium-stained amniotic fluid

(MSAF) and consideration for when to continue/discontinue

TABLE 1. Topics Reviewed for the 2015 ILCOR Process

Optimal assessment of heart rate

Delayed cord clamping in preterm infants requiring resuscitation

Umbilical cord milking

Temperature maintenance in the delivery room

Maintaining infant temperature during delivery room resuscitation

Warming of hypothermic newborns

Infants born to mothers who are hypothermic or hyperthermic in labor

Continuous positive airway pressure and intermittent positive pressure ventilation

Sustained inflations

Outcomes for PEEP versus no PEEP in the delivery room

T-piece resuscitator and self-inflating bag

Intubation and tracheal suctioning in nonvigorous infants born through MSAF vs no intubation for tracheal suctioning

Oxygen concentration for resuscitating premature newborns

Two thumb vs two finger for chest compression

Chest compression ratio

Oxygen delivery during CPR (neonatal)

Laryngeal mask airway

Newborn infants who receive positive pressure ventilation for resuscitation, and use of a device to assess respiratory function

Use of feedback CPR devices for neonatal cardiac arrest

Limited resource-induced hypothermia

Delivery room assessment <25 weeks and prognostic score

Apgar score of 0 for ‡10 minutes

Predicting death or disability of newborns >34 weeks based on Apgar and/or absence of breathing

Resuscitation training frequency

Neonatal resuscitation instructors

CPR¼cardiopulmonary resuscitation; ILCOR¼International Liaison Committee on Resuscitation; MSAF=meconium-stained amniotic fluid; PEEP¼positiveend-expiratory pressure.

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resuscitation in infants with an Apgar score of 0 after 10

minutes of resuscitation.

USING GRADE TO DEVELOP RECOMMENDATIONS

GRADE is an emerging consensus process that rates quality

of evidence and strength of recommendations along with

values and preferences. (3)(4) In brief, GRADE classifies

quality of evidence as: high quality (where one has high

confidence in the estimate of effect as reported in a synthesis

of the literature); moderate quality (moderate confidence,

but there may be differences from a further elucidated

truth); low quality (where one has low confidence in the

estimate of the effect, which may be substantially different

from the true effect); and very low quality (it is possible that

the estimate of effect is substantially different from the true

effect). The quality of a body of evidence involves consid-

eration of 5 unique domains, including risk of bias for each

outcome as reported across relevant studies (methodolog-

ical quality), as well as the directness of evidence (such

as, was the population studied the same as that for which

the guideline will be used), heterogeneity of the results of

individual studies, precision of effect estimates, and risk of

publication bias. Randomized studies start off as high quality

Figure. Neonatal resuscitation algorithm.CPAP=continuous positive airway pressure,ECG=electrocardiography, ET=endotrachealintubation, HR=heart rate, IV=intravenous,PPV=positive pressure ventilation,SpO2=peripheral capillary oxygen saturation.

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but may be downgraded for methodological quality, whereas

observational or cohort studies start off as low quality and can

be further downgraded or upgraded depending on method-

ological quality or positive outcome effect.

Guideline users have to determine how much they can

trust that a recommendation will produce more favorable

rather than unfavorable consequences. The strength of a

recommendation reflects a gradient in guidance, with a

clearer expectation for adherence with strong recommen-

dations and lesser insistence on weak recommendations.

In addition, the effect may be in favor of or against the

recommendation. According to GRADE, several factorsmay

influence the strength of a recommendation, including the

risk-benefit balance, quality of evidence, patient values and

preferences, and finally, costs and resource utilization. If

confidence in these values and preferences is high and

variability is low, it is more likely that the recommendation

will be strong (and vice versa). Recommendations, whether

strong or weak, have different implications for patients,

health care professionals, or health care management.

BACKGROUND

Approximately 85% of infants born at term will initiate

spontaneous respirations within 10 to 30 seconds of birth,

an additional 10% will respond during drying and stim-

ulation, approximately 3% will initiate respirations after

positive pressure ventilation (PPV), 2% will undergo intu-

bation to support respiratory function, and 0.1%will require

chest compressions and/or epinephrine to achieve this

transition. (5)(6)(7) Although the vast majority of newborn

infants do not require intervention to make these transi-

tional changes, the large number of births worldwidemeans

that many infants require some assistance to achieve car-

diorespiratory stability each year.

NEONATAL ALGORITHM

There was considerable debate with regard to modifying the

International Liaison Committee on Resuscitation (ILCOR)

algorithm. First, the 30-second time rule was considered

unreasonable, and not evidence-based; however, there was

strong consensus that a reminder to assess and intervene if

necessary, within 60 seconds after birth, should be retained

to avoid critical delays in initiating resuscitation. This is

based on the fact that more than 95% of newly born in-

fants will start breathing spontaneously or in response to

stimulation within approximately 30 seconds. (5) If apnea

persists, PPV should be initiated within 60 seconds.

Second, given the importance of moderate hypothermia

(temperature <36°C) as a predictor of mortality, and evi-

dence from multiple studies that it can be avoided (as

described later in this article) with simple intervention

strategies, the ILCOR algorithm contains a running line

reminding providers to maintain thermoregulation through-

out the immediate newborn period (Figure). The algorithm

contained in the neonatal guidelines does not include this

important reminder.

DELAYED CORD CLAMPING IN PRETERM INFANTSREQUIRING RESUSCITATION

For many years, the umbilical cord of the preterm neonate

was generally cut soon after birth, so that the newborn can

be transferred immediately to the neonatal team. However,

there is evidence that a delay of clamping by 30 to 60

seconds after birth results in a smoother transition, partic-

ularly if the newborn begins breathing before the cord is

cut. (2) The ILCOR scientific review indicates that delay is

associated with increased placental transfusion, increased

cardiac output, more stable and higher neonatal blood

pressure, less intraventricular hemorrhage (IVH) of any

grade, less need for transfusion after birth, and less necro-

tizing enterocolitis. (2) However, there was no evidence of

decreased mortality or decreased incidence of severe IVH.

The only negative consequence appears to be an increased

level of bilirubin associated with more need for photother-

apy. Despite drawing evidence from randomized controlled

trials, the small sample size inmost trials and the associated

imprecision limit the quality of evidence for all outcomes

of interest. Based on the latter, ILCOR suggests delaying

umbilical cord clamping for preterm infants not requiring

immediate resuscitation after birth (weak recommendation).

The neonatal guidelines translated this scientific state-

ment as follows: “DCC [delayed cord clamping] for longer

than 30 seconds is reasonable for both term and preterm

infants who do not require resuscitation at birth. However,

there is insufficient evidence to recommend an approach

to cord clamping for preterm infants who do receive resus-

citation immediately after birth.” Notably, both ILCOR and

the neonatal guidelines do not specify a maximum time to

delay in cord clamping. (1)(2)

DETERMINATION OF HEART RATE

Neonatal resuscitation success has typically been deter-

mined by detecting an increase in heart rate through aus-

cultation. Heart rate also determines the need for changing

interventions and escalating care. However, recent evidence

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demonstrates that auscultation of heart rate is inaccurate,

and pulse oximetry takes several minutes to achieve a signal

and also may be inaccurate during the early minutes after

birth. The ILCOR scientific review identified several non-

randomized studies (deemed very-low-quality evidence)

showing a benefit of electrocardiography (ECG) compared

with oximetry for a fast and accurate measurement of heart

rate in infants requiring resuscitation. (8)(9)(10) In addi-

tion, clinical assessment was found to be both unreliable and

inaccurate. Among healthy newborns, providers frequently

could not palpate the umbilical pulse and underestimated

the newborn’s heart rate by auscultation or palpation. (11)

Although the mean differences between the series of heart

rates measured by ECG and pulse oximetry were small,

pulse oximetry tended to underestimate the newborn’s heart

rate and would have led to potentially unnecessary inter-

ventions. (8)(9)(10)(11) In particular, during the first 2

minutes after birth, pulse oximetry frequently displayed

the newborn’s heart rate below either 60 or 100 beats per

minute, whereas a simultaneous ECG showed the heart rate

higher than 100 beats per minute. (10)

ILCOR suggests that an ECG can be used to provide a

rapid and accurate estimation of heart rate (weak recom-

mendation, very-low-quality evidence). Importantly, ECG

should not replace the role of auscultation for the assess-

ment of heart rate, as well as pulse oximetry to evaluate

oxygenation. Moreover, each hospital will need to define

the patient populations that may require ECG placement

and develop methods for rapid application of the leads.

TEMPERATURE MAINTENANCE IN THE PREMATUREINFANT

It has been known for more than a century that preterm

newborns who become hypothermic after birth have a

higher mortality than those who remain normothermic.

(12)(13)(14) The premature neonate is especially vulnerable

and there appears to be a dose-related effect. Thus, in a large

study involving more than 5,000 premature infants less

than 1,500 g, there was an associated 28% increase in

mortality for every 1 degree decrease in temperature below

36.5°C. (14) Hypothermia is also associated with serious

morbidities, such as increased risk of IVH, respiratory

issues, hypoglycemia, and late-onset sepsis. (2)

The ILCOR treatment recommendation states: “Admis-

sion temperature of newly born nonasphyxiated infants is a

strong predictor of mortality and morbidity at all gestations.

It should be recorded as a predictor of outcomes as well

as a quality indicator” (this was a strong recommendation

based on moderate-quality evidence). Hence, the running

timelinewas added to the algorithm to emphasize this point.

It is recommended that the temperature of newly born

nonasphyxiated infants be maintained between 36.5°C and

37.5°C after birth through admission and stabilization. In

making this strong statement, ILCOR places a higher val-

ue on the strong association of inadvertent hypothermia with

mortality, the apparent dose effect, and the single direction

of the evidence. Most studies reviewed measured axillary

temperature but some older studies used rectal temperature.

The relative benefits of one over the other were not as-

sessed. However, ILCOR suggests that axillary temperature

should be used in the delivery room, but that on admission,

the measurement site should be left to individual local

practice.

INTERVENTIONS TO MAINTAIN NEWBORNTEMPERATURE IN THE DELIVERY ROOM THROUGHADMISSION TO A NEONATAL INTENSIVE AREA INTHE PREMATURE INFANT

Various strategies have been suggested to maintain a pre-

term infant’s temperature; it is unknown which of these

strategies is most effective. The scientific evidence indicates

that the use of radiant warmers and plastic wrap with a cap

has significantly improved but not eliminated the risk of

hypothermia in preterm infants in the delivery room. (15)

(16)(17) Other strategies have been introduced, including

thermal mattresses, increased room temperature, and the

use of warmed humidified resuscitation gases. (18)(19)(20)

(21)(22) Various combinations of these strategies may be

reasonable to prevent hypothermia in infants born at less

than 32 weeks of gestation. (23)(24)(25)

The ILCOR treatment recommendation focuses on pre-

term infants of less than 32weeks of gestation in the delivery

room and suggests “using a combination of interventions,

which may include environmental temperature 23°C to

25°C, warm blankets, plastic wrapping without drying,

cap, and thermal mattress to reduce hypothermia (temper-

ature <36.0°C) on admission to NICU.” This is a weak

recommendation, based on very-low-quality evidence. In

addition, it was pointed out that hyperthermia (>38.0°C)

should be avoided because of potential associated risks.

However no study showed any harm from hyperthermia.

Practical ConsiderationsMany of the studies used multiple strategies, so it is not

possible to identify a specific intervention that is effective in

maintaining infant temperature. Each unit should develop

specific strategies to avoid moderate hypothermia.

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OXYGEN CONCENTRATION FOR PREMATURENEWBORNS

The fact that high oxygen concentrations can be toxic to the

newly born lungs has long been recognized by ILCOR. The

original studies examined only air versus 100% oxygen and

led to a recommendation that blended oxygen be used to

titrate the concentration to achieve a targeted oxygen satu-

ration. It is uncertain whether the preterm newborn should

be started in a high (50%–100%) or low (21%–30%) oxygen

concentration while a pulse oximeter is being attached.

Review of the science revealed the following salientfindings:

initiating resuscitation of preterm newborns (<35 weeks of

gestation) with high oxygen (‡65%) or low oxygen (21%–

30%) showed no improvement in survival to hospital dis-

charge with the use of high oxygen. (26)(27)(28)(29)(30)

Similarly, in the subset of studies that evaluated these out-

comes, no benefit was seen in preventing bronchopulmo-

nary dysplasia, IVH, or retinopathy of prematurity. In all

studies, irrespective of whether air or high oxygen (includ-

ing 100%) was used to initiate resuscitation, most infants

were receiving approximately 30% oxygen by the time of

stabilization. (27)(29)(30) ILCOR recommends against ini-

tiating resuscitation of preterm newborns (<35 weeks of

gestation) with high-supplemental oxygen concentrations

(65%–100%). Rather, it recommends initiating with a low

oxygen concentration (21%–30%) (strong recommendation,

moderate-quality evidence). In making this recommenda-

tion, ILCOR places value on not exposing pretermnewborns

to additional oxygen without proven benefit for outcomes.

The neonatal guidelines state more clearly that resuscita-

tion of preterm newborns of less than 35 weeks of gestation

should be initiated with low oxygen (21%–30%), and the oxy-

gen concentration should be titrated to achieve preductal

oxygen saturation approximating the interquartile range mea-

sured in healthy term infants after vaginal birth at sea level.

Practical ConsiderationsThere is much debate among physicians as to the appro-

priate saturation targets to follow in the first 5 to 10 minutes

after birth. This issue is further complicated by the fact that

the oximeter may underestimate heart rate during the first 2

minutes after birth, (10) raising serious questions regarding

reliability of saturation values during this critical period.

RESPIRATORY SUPPORT IN THE PREMATURE INFANT

Establishing Functional Residual CapacityThemost effective method for establishing FRC in the fluid-

filled lung of a newborn who does not breathe spontaneously

has been debated for many decades. In the 1980s, Vyas et al

(31) suggested a technique for administering a sustained

inflation of up to 5 seconds in duration. Both standard

PPV with or without positive end-expiratory pressure (PEEP)

and inflation breaths up to 3 seconds in duration are the initial

strategies currently advocated to initiate ventilation (Neonatal

Resuscitation Program, European Resuscitation Council). (1)

(32) Several recent animal studies have suggested that a

longer sustained inflation (up to 30 seconds) may be bene-

ficial for establishing FRC during transition from fluid-filled

to air-filled lungs after birth. (33)(34) Three randomized

studies demonstrated a benefit of sustained inflation (up to

15 seconds) for reducing the need for mechanical ventilation,

but no benefit was found for reduction of mortality, bron-

chopulmonary dysplasia, or air leak (very-low-quality evi-

dence, downgraded for variability of interventions). (35)(36)

(37) Importantly, a recent randomized study showed an

increase in pneumothorax and pulmonary interstitial emphy-

sema (Table 2). (37) The ILCOR treatment recommendation

is against the routine use of initial sustained inflation (>5

seconds’ duration) for preterm infants without spontaneous

respirations immediately after birth. It is suggested that

sustained inflation may be considered in individual clinical

circumstances or research settings (weak recommendation,

low-quality evidence). In making this recommendation and

in the absence of long-term benefits, ILCOR places a higher

value on the negative aspect involving lack of clarity as to how

to administer sustained inflation and the duration of the

breath compared with the positive findings of a reduced need

for intubation at 72 hours. In addition, the methods used to

deliver sustained inflation varied among studies. It was

stressed that different devices varied in their ability to gen-

erate pharyngeal pressures. Moreover, recent experimental

data suggest that an unintended glottis closure may be

associated with sustained inflation.

Intubation and Tracheal Suctioning in NonvigorousInfants Born Through Meconium-Stained Amniotic FluidFor many years, it has been recommended that newborns

with MSAF should receive tracheal suctioning using an

endotracheal tube as a suction device. Approximately 15

years ago, as a result of a multicenter randomized clinical

trial, the recommendation was restricted to infants who

appeared to have respiratory compromise at birth (ie, were

“nonvigorous”). ILCOR revisited this issue with regard to

the risks/benefits of routine suctioning, and analyzed the

data for the critical outcomes ofmortality and/or meconium

aspiration syndrome (MAS). Since the last ILCOR review

(2010), 1 randomized study involving 122 infants showed

no benefit to suctioning versus no suctioning in either

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reducing mortality and/or MAS (low-quality evidence,

downgraded for risk of bias and imprecision). (38) Older

evidence was re-reviewed and the following findings were

noted: three nonrandomized very-low-quality evidence stud-

ies showed a higher incidence of MAS in depressed in-

fants who had tracheal intubation for suctioning (26%)

compared with vigorous infants who did not undergo in-

tubation (0.3%) (downgraded for indirectness). (39)(40)(41)

Six very-low-quality observational studies demonstrated im-

proved survival and lower incidence of MAS when infants

(including depressed and/or vigorous infants) born through

MSAF were intubated for tracheal suctioning (downgraded

for indirectness and inconsistency). (42)(43)(44)(45)(46)

(47) Six very-low-quality observational studies demonstrated

no improvement in survival and/or incidence of MAS

(including depressed and/or vigorous infants) when infants

born through MSAF underwent intubation for tracheal

suctioning (downgraded for indirectness). (48)(49)(50)(51)

(52)(53)

Based on this re-review of the data, the ILCOR treatment

recommendation stated the following: “There is insuffi-

cient published human evidence to suggest routine tracheal

intubation for suctioning of meconium in nonvigorous

infants born through MSAF as opposed to no tracheal intu-

bation for suctioning.” In making this suggestion, ILCOR

places a value on both harm avoidance (delays in provid-

ing bag-mask ventilation, potential harm of the procedure)

and the unclear benefits of routine tracheal intubation and

suctioning.

The neonatal guidelines state: “If an infant born through

MSAFpresents with poor tone and inadequate breathing ef-

forts, the initial steps of resuscitation should be completed

under the radiant warmer. PPV should be initiated if the

infant is not breathing or the heart rate is less than 100 beats

per minute. Routine suctioning of nonvigorous infants is

more likely to result in delays in initiating ventilation, es-

pecially where the provider is unable to promptly intubate

the infant or suction attempts are repeated.” In the absence

of evidence of benefit for suctioning, the emphasis should

be on initiating ventilation within the first minute after birth

in nonbreathing or ineffectively breathing infants.

Practical ConsiderationsThis change in the ILCOR treatment recommendation is

based on 1 low-quality randomized study that showed no

difference in outcomes (death and/or MAS), regardless of

whether the infant underwent suctioning. In keeping with

the low-quality evidence, it is important to restate that this

is a suggestion and not a recommendation. It is also impor-

tant to recognize that many cases of MAS described in the

literature occur in the context of associated clinical events,

chorioamnionitis, and/or fetal heart rate abnormalities.

Clearly, under clinical circumstances that increase the

potential for aspiration, the provider should anticipate and

be prepared for the possibility that immediate intubation

may be indicated, rather than waiting for signs of obstruc-

tion. The spirit of the ILCOR treatment recommendation

recognized that a provider at delivery may not be skilled in

intubation. Under such circumstances, delay in providing

bag-mask ventilation versus potential harm of attempting

intubation would favor the former approach while addi-

tional assistance is sought.

APGAR SCORE OF 0 FOR 10 MINUTES OR LONGER

Controversy exists as to how long after attempting resus-

citation after birth, when a heart rate cannot be detected,

should the provider continue or discontinue resuscitation

efforts. The Apgar score of 0 has typically been the criterion

used as the marker, because it indicates no detectable signs

of life. The current recommendation for duration of resus-

citative efforts is 10 minutes after birth. This guideline was

revisited because the therapeutic hypothermia (TH) trials

showed an increasing number of intact survivors with an

TABLE 2. Occurrence of Air Leaks in Infants Exposed to Normal InflationPressures and Sustained Inflation of 15 seconds

OUTCOME CONTROL GROUP (N [ 143) SLI GROUP (N [ 148) UNADJUSTED ODDS RATIO (95% CI) P

Respiratory distress syndrome 134 (94%) 133 (90%) 0.60 (0.25–1.41) .23

Pneumothorax 2 (1%) 9 (6%) 4.57 (0.97–21.50) .06

Interstitial emphysema 2 (1%) 7 (5%) 3.50 (0.72–17.10) .09

Relative risk 4.01 (95% confidence interval [CI] 1.38–11.73); P ¼ .01 (when combining pneumothorax and interstitial emphysema).Adapted from Lista et al. (37)

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Apgar score of 0 after birth. The ILCOR science review

indicates that 106 (82%) of 129 infants of gestational age of

greater than or equal to 36 weeks, and an Apgar score of 0 at

10 minutes after birth, either died or exhibited moderate

to severe neurodevelopmental impairment at 22 months

of age or later (very-low-quality evidence, downgraded for

risk of bias, inconsistency, indirectness, and imprecision).

(54)(55)(56)(57)(58)(59) Results from 3 of these studies,

which included nested observational series in randomized

clinical trials of TH and series of infants who received TH,

showed that this adverse outcome occurred in 68 (76%) of

90 infants with an Apgar score of 0 at 10 minutes. Among

the 56 cooled infants in these studies, 15 (27%) survived

without major/moderate disabilities. (56)(57)(59) The cur-

rent ILCOR treatment recommendation states that an

Apgar score of 0 at 10 minutes is a strong predictor of

mortality andmorbidity in late-preterm and term infants. It

is suggested that in infants with an Apgar score of 0 after 10

minutes of resuscitation, if the heart rate remains undetect-

able, it may be reasonable to stop resuscitation; however,

the decision to continue or discontinue resuscitative efforts

should be individualized. Variables to be considered may

include whether the resuscitation was considered to be

optimal, availability of advanced neonatal care such as TH,

specific circumstances before delivery, and the family’s

wishes (weak recommendation, very-low-quality evidence.)

Importantly, the number of infants with no heart rate at 10

minutes who died in the delivery room is unknown.

Practical ConsiderationsThere is a subtle but important distinction in the current

recommendation. This refers to the Apgar score of 0 after 10

minutes of resuscitation, which is distinct from 0 at 10

minutes. In addition, it states that consideration should be

given as to whether the resuscitation was optimal. Examples

of optimization would include intubation before initiating

chest compressions and administering intravenous rather

than endotracheal epinephrine if indicated. (60)

CONCLUSIONS

This brief review highlights several of the new neonatal

guideline recommendations that should enhance manage-

ment options for the compromised infant immediately

after delivery. There are many gaps in current manage-

ment, which demands ongoing research to further opti-

mize care.

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American Board of PediatricsNeonatal–Perinatal ContentSpecifications• Know the rationale, risks, and benefits of delayed cordclamping.

• Understand the significance, limitations, and causes of low Apgarscores, including the relationship between Apgar scores and lateroutcomes in preterm and full-term infants.

• Know the current recommendations regarding suctioningmeconium from the airway during and following delivery.

• Know indications for and proper administration of supplementaloxygen immediately after birth.

• Know the causes, metabolic consequences, and treatment ofinfants with hypothermia.

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10. van Vonderen JJ, Hooper SB, Kroese JK, et al. Pulse oximetry

measures a lower heart rate at birth compared with

electrocardiography. J Pediatr. 2015;166(1):49–53

11. Kamlin CO, O’Donnell CP, Everest NJ, Davis PG, Morley CJ.

Accuracy of clinical assessment of infant heart rate in the delivery

room. Resuscitation. 2006;71(3):319–321

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and Full-term Infants—Lecture 1. Maloney WJ, trans. London:

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29. Rook D, Schierbeek H, Vento M, et al. Resuscitation of preterminfants with different inspired oxygen fractions. J Pediatr. 2014;164(6):1322–6.e3

30. Vento M, Moro M, Escrig R, et al. Preterm resuscitation with lowoxygen causes less oxidative stress, inflammation, and chronic lungdisease. Pediatrics. 2009;124(3):e439–e449

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34. Klingenberg C, Sobotka KS, OngT, et al. Effect of sustained inflationduration; resuscitation of near-term asphyxiated lambs. Arch Dis

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35. Harling AE, Beresford MW, Vince GS, Bates M, Yoxall CW. Doessustained lung inflation at resuscitation reduce lung injury in thepreterm infant? Arch Dis Child Fetal Neonatal Ed. 2005;90(5):F406–F410

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37. Lista G, Boni L, Scopesi F, et al; SLI Trial Investigators. Sustainedlung inflation at birth for preterm infants: a randomized clinicaltrial. Pediatrics. 2015;135(2):e457–e464

38. Chettri S, Adhisivam B, Bhat BV. Endotracheal suction fornonvigorous neonates born through meconium stained amnioticfluid: a randomized controlled trial. J Pediatr. 2015;166(5):1208–1213.e1

39. Al Takroni AM, Parvathi CK, Mendis KB, Hassan S, Reddy I, KudairHA. Selective tracheal suctioning to prevent meconium aspirationsyndrome. Int J Gynaecol Obstet. 1998;63(3):259–263

40. Peng TC, Gutcher GR, Van Dorsten JP. A selective aggressiveapproach to the neonate exposed to meconium-stained amnioticfluid. Am J Obstet Gynecol. 1996;175(2):296–301, discussion 301–303

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47. Ting P, Brady JP. Tracheal suction in meconium aspiration. Am JObstet Gynecol. 1975;122(6):767–771

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50. Hageman JR, Conley M, Francis K, et al. Delivery roommanagement of meconium staining of the amniotic fluid and thedevelopment of meconium aspiration syndrome. J Perinatol. 1988;8(2):127–131

51. Manganaro R,Mamì C, Palmara A, Paolata A, Gemelli M. Incidenceof meconium aspiration syndrome in term meconium-stainedbabies managed at birth with selective tracheal intubation. J PerinatMed. 2001;29(6):465–468

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53. Suresh GK, Sarkar S. Delivery room management of infants bornthrough thin meconium stained liquor. Indian Pediatr. 1994;31(10):1177–1181

54. Casalaz DM, Marlow N, Speidel BD. Outcome of resuscitationfollowing unexpected apparent stillbirth. Arch Dis Child FetalNeonatal Ed. 1998;78(2):F112–F115

55. Harrington DJ, Redman CW, Moulden M, Greenwood CE. Thelong-term outcome in surviving infants with Apgar zero at 10minutes: a systematic review of the literature and hospital-basedcohort. Am J Obstet Gynecol. 2007;196(5):463.e1–463.e5

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NeoReviews QuizThere are two ways to access the journal CME quizzes:

1. Individual CME quizzes are available via a handy blue CME link in the Table of Contents of any issue.

2. To access all CME articles, click “Journal CME” from Gateway’s orange main menu or go directly to: http://www.

aappublications.org/content/journal-cme.

NOTE: Learners can takeNeoReviews quizzes andclaim credit online onlyat: http://Neoreviews.org.

To successfully complete2016 NeoReviews articlesfor AMA PRA Category 1CreditTM, learners mustdemonstrate a minimumperformance level of 60%or higher on thisassessment, whichmeasures achievement ofthe educational purposeand/or objectives of thisactivity. If you score lessthan 60% on theassessment, you will begiven additionalopportunities to answerquestions until an overall60% or greater score isachieved.

This journal-based CMEactivity is availablethrough Dec. 31, 2018,however, credit will berecorded in the year inwhich the learnercompletes the quiz.

1. Your hospital team is in the process of implementing the new Neonatal ResuscitationProgram (NRP) guidelines. Which of the following statements correctly describes theGrading of Recommendations, Assessment, Development and Evaluation (GRADE) processthat informs guideline development?

A. The GRADE process classifies articles as either “include” or “exclude” based on themerits of the study.

B. Randomized studies start off as high-quality evidence, but may be downgradeddue to methodological quality.

C. The strength of studies considered for inclusion is determined by the study typeand precision of effect, but does not take into account whether the populationstudied is the same as that for which the guideline will be used.

D. Although assessing the strength of the studies is part of the GRADE process ofreview, the final recommendations do not have any language to indicate whether itis a strong or weak recommendation.

E. Observational studies can only be included in the process if there are no ran-domized trials that are relevant to the question at hand.

2. You are at the delivery of a 31-week-gestational-age infant. You are discussing themanagement of cord clamping with the obstetric and pediatric teams. The plan is toclamp and cut the cord 60 seconds after delivery. Which of the following statementscorrectly describes the relationship of delayed cord clamping (DCC) and potentialeffects?

A. Most of the literature on the subject suggests that DCC is most beneficial when theinfant does not cry until after cord clamping.

B. DCC is associated with increased placental transfusion, increased cardiac output,and increase in low-grade intraventricular hemorrhage, with decreased risk of high-grade intraventricular hemorrhage.

C. The current recommendation from ILCOR is a strong recommendation to delayumbilical cord clamping for all preterm infants.

D. The new guidelines state that DCC for longer than 30 seconds is reasonable forboth term and preterm infants who do not require resuscitation at birth.

E. The ILCOR and NRP recommendation for maximum time until cord clamping is 120seconds.

3. You are at the delivery of a termmale infant. The infant is apneic and is receiving warming,drying, and stimulation after being brought to the radiant warmer. Which of the followingis an appropriate method to assess heart rate?

A. In this case, there is no reason to assess heart rate until the apnea is re-solved, because the resuscitation steps will be the same regardless of heartrate.

B. Auscultation of the heart rate at the chest should be the main method ofassessment unless the infant eventually undergoes intubation.

C. Electrocardiographymay provide a faster andmore accuratemeasurement of heartrate than oximetry in infants requiring resuscitation.

D. Pulse oximetry should only be applied to the infant 2minutes after delivery or later.E. Palpation of the umbilical cord should be the main method of assessment unless it

has been cut too short for this purpose.

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4. The resuscitation team is briefing before the cesarean delivery for a mother who is at 28weeks’ gestation. Which of the following plans for setting the initial oxygen concentrationfor starting resuscitation is consistent with the new NRP guidelines?

A. 21%–30%.B. 30%–40%.C. 50%–60%.D. 70%–100%.E. The new guidelines do not specify a specific range, but recommend somewhere

above 21% and below 100%.

5. The labor and delivery unit calls for a pediatrics team for meconium-stained amniotic fluidin a term infant with no other specified maternal risk factors. Which of the followingregarding planning for this delivery is consistent with the new NRP guidelines regardingthis issue?

A. There is no need for a pediatrics team to attend this delivery.B. The decision for intubation versus no intubation for tracheal suctioning should be

based on the thickness of the meconium-stained fluid.C. The decision for intubation versus no intubation for tracheal suctioning should be

based on whether the infant is vigorous at birth or not.D. If the infant presents with poor tone and inadequate breathing efforts, the initial

steps for resuscitation can be completed under the radiant warmer and positivepressure ventilation provided if the infant is not breathing or heart rate is less than100 beats per minute.

E. The infant should undergo intubation at least once for tracheal suctioning andfurther attempts determined by the consistency of the suctioned fluid.

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DOI: 10.1542/neo.17-8-e4352016;17;e435NeoReviews 

Jeffrey M. PerlmanHighlights of the New Neonatal Resuscitation Program Guidelines

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DOI: 10.1542/neo.17-8-e4352016;17;e435NeoReviews 

Jeffrey M. PerlmanHighlights of the New Neonatal Resuscitation Program Guidelines

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