Neonatal Resuscitation

History Of Neonatal Resuscitation

Neonatal resuscitation was first attempted in the 18th century, though there are multiple references to adult cardiopulmonary resuscitation in the Bible prior to that. Much of the early resuscitation techniques involved shaking, hitting, swinging, electrocuting, hanging upside-down to applying gentle pressures, or squeezing of the chest.¹ The late 18th century saw the construction of the first ventilator which was a major landmark in the evolution of neonatal resuscitation². Further research in physiology and biomedical technology paved the way for newer strategies in improving neonatal resuscitation, but much of the advances occurred much later, in the 1950s.² Neonatal resuscitation will be needed in less than 10% of all deliveries and approximately 1% may require intensive resuscitative efforts³.

Background Of Neonatal Resuscitation

It was the seminal work by Virginia Apgar which reoriented the delivery room focus to include neonates. She devised the Apgar score which was published in 1953⁴. In the mid- 1970s the National Institute of Health-funded a few projects to improve neonatal education in the community hospitals of the USA. This resulted in a series of educational modules, slide tapes, and videotapes which was called the Neonatal Education Program (NEP)⁵. In the 1980s, the American Academy of Pediatrics (AAP) established the Resuscitation of the Newborn Task Force with the goal of having a trained professional at every delivery. Building on the basic tenets of NEP, the first Neonatal Resuscitation Program (NRP) textbook was published by the taskforce in 1987 in consultation with the American Heart Association (AHA)^5,6.

Current Scenario

The International Liaison Committee on Resuscitation (ILCOR) was formed in 1992 to achieve an evidence-based consensus in neonatal resuscitation practices in the developed world. ILCOR comprised of various delegations (neonatal, pediatric, adult) representing the American Heart Association, the Heart and Stroke Foundation of Canada the Inter American Heart Foundation, the European Resuscitation Council, the Australian and New Zealand Committee on Resuscitation, and the Resuscitation Councils of Southern Africa⁷. Every 5 years the neonatal experts from various countries collect, analyze, and classify the most recent scientific evidence into various levels of recommendation which is incorporated in the NRP. Over the last 3 decades, this classification system for the levels of recommendation has also evolved, the most recent modification was in 2015⁸.

Resuscitation Councils and Their Guidelines

Though NRP is the most widely used curriculum, many other organizations around the world have developed neonatal resuscitation standards. Some organizations are the United Kingdom Resuscitation Council, European Resuscitation Council, Heart and Stroke Foundation of Canada, Australian Resuscitation Council, Resuscitation Council of Southern Africa, Council of Latin America for Resuscitation. Based on the ILCOR guidelines, these regional councils have developed neonatal resuscitation courses appropriate to the resources available in the respective regions.

Neonatal Resuscitation In Resource Restricted Regions

In technology and resource-restricted settings, NRP may not be practical. Hence in 2009, the AAP in collaboration with the World Health Organization (WHO), US Agency for International Development (USAID), Saving Newborn Lives, the National Institute of Child Health and Development, Save the Children, Laerdal Global Health, Johnson & Johnson, Latter-day Saint Charities, Catholic Medical Missions, Earth Institute/Columbia University, International Pediatric Association, Project C.U.R.E., and USAID initiated a new educational program entitled “Helping Babies Breathe,” (HBB) aimed at local nurses, midwives, and traditional birth attendants in developing countries⁹. In 2012, the World Health Organization (WHO) published guidelines on basic newborn resuscitation for use in first referral and higher level in low resource-limited settings¹⁰.

Many of the low-middle income countries have newborn resuscitation programs adapted to their circumstances. In 2004, China launched the Chinese Neonatal Resuscitation Program (CNRP), “Freedom of Breath, Fountain of Life”, which utilized Mandarin as the medium. Over a period of 3 years, this program covered 100% of the rural and semirural areas resulting in a significant reduction in perinatal asphyxia and death¹¹. In Indonesia, a village-based midwife program was established in 1989 which also demonstrated similar results^12,13.

The Indian Scenario

The NRP instructor programs have been conducted by the National Neonatology Forum since 1990 with the aim of ultimately increasing the pool of trained NRP providers¹⁴. However to develop a cost-efficient, sustainable system in NRP training on a large scale in a populous country like ours and to achieve the MDG4 goal, the Indian Academy of Pediatrics (IAP) launched the NRP- First Golden Minute (IAP-NRP-FGM) in 2009. This curriculum is based on the Academy of Pediatrics (AAP) manual of NRP and is sponsored by Later-Day Saint Charities (LDSC) with an academic grant from Johnson & Johnson, India. With the launch of IAP-NRP-FGM, it was envisaged at that time, that along with the Federation of Obstetric and Gynecological Society of India (FOGSI) and NNF members, it may be possible to have an NRP trained skilled birth attendant for every delivery¹⁵.

Bridging The Household to Healthcare Gap

Two simulation-based programs that have succeeded in training the largest number of health care personnel in the world are NRP and HBB, both from the AHA. NRP is in use in more than 150 countries, while HBB has been rolled out in 77. The primary goal is the reduction of asphyxia related mortality and morbidity. The first golden minute (FGM), by which time a newborn has to breathe is the key concept underlying HBB. The skills that are taught are the correct positioning of the head, clearing the airway, providing stimulation for the baby to breathe, evaluating the breathing, initiating ventilation, and continuing ventilation with a bag and a mask¹⁶. HBB does not aim to be a replacement for NRP but aims to provide the continuum of care from the community to the healthcare facility to help the 99% of babies who will respond to minimal resuscitative efforts. NRP is intended to address the problem of the remaining 1% who will need advanced care in the form of chest compressions and adrenaline. In India, the HBB initiative has been integrated into the Navjyata Shishu Suraksha Karyakaram (NSSK)¹⁷.

NRP 2015

Neonatal resuscitation has evolved and metamorphosed from crudity to the most recent evidence-based NRP guidelines 2015 which is the seventh edition since its inception in 1987. Though the basic framework of NRP has remained the same over the years, few conceptual changes have occurred in NRP 2015. They are a) emphasize on euthermia b) adoption of new approaches regarding delayed cord clamping, management of meconium in the amniotic fluid, administration of oxygen to preterm infants, and monitoring of heart rate c)enhanced team communication, skills performance, and outcomes in resuscitation¹⁸.

It has been recommended that the conceptual changes be translated into the following actions:

• In neonates <32 weeks gestation the target body temperature 36.5-37.5°C should be achieved by maintaining room temperature between 23-25°C along with the use of radiant warmer and plastic wrap with a cap, thermal mattress or warm blankets, warmed, humidified resuscitation gases. In stable neonates >30 weeks, skin to skin contact is to be encouraged to maintain euthermia.

• Cord clamping should be delayed for 30-60 seconds in term and preterm babies not requiring resuscitation.

• In non-vigorous babies born through meconium-stained liquor, there is no evidence to support the practice of endotracheal suctioning.

• For babies >35 weeks requiring positive pressure ventilation should be initiated with air and for <35 weeks, 21 to 30% oxygen should be used. In preterm babies, CPAP should be considered immediately instead of intubation and surfactant administration.

• To improve accuracy in heart rate determination, it is recommended that continuous ECG monitoring be used after the initial heart rate assessment by auscultation if the neonate needs positive pressure ventilation.

• There is renewed stress on teamwork and communication skills.

The Future

Neonatal resuscitation training programs have undoubtedly reduced neonatal mortality and morbidity. A multi-centric study demonstrated a reduction in stillbirth which was attributed to effective resuscitation of newborns who would have not been resuscitated before the initiation of training programs¹⁹. Other studies have shown similar results^{20, 21, and 22}. A study from India showed that HBB training reduced the stillbirth rate without increasing neonatal mortality, indicating that resuscitated babies survived the neonatal period²³. The success of neonatal resuscitation training programs depends not only on the curriculum and training but also on political commitment and resources especially the public-private partnership model.

Many of the newborn deaths occur in low and middle-income countries with limited reach of health facilities. Most births occur in the community, whereas most resuscitation programs still are restricted to institutions. Therefore in many countries, the potential for any resuscitation program to achieve impact is restricted. There is thus a need for a more inclusive simple community based neonatal resuscitation program which would include traditional midwives or community health worker whose input would be essential to attain the ambitious the Every Newborn Action Plan (ENAP) goal of an NMR of 9 per 1000 live births worldwide²⁴.