Neonatal Resuscitation

R Kishore Kumar, P.C. Nayana Prabha
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 of 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.

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 countries (9). 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 settings (10).

Many of the low-middle income countries have newborn resuscitation programmes 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 death (11). In Indonesia, a village- based midwife program was established in 1989 which also demonstrated similar results (12, 13).

The NRP instructor programmes have been conducted by the National Neonatology Forum since 1990 with the aim of ultimately increasing the pool of trained NRP providers (14). 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 academic grant from Johnson & Johnson, India. With the launch of IAP-NRP-FGM, it was envisaged at that time, that along with Federation of Obstetrics and Gynecological Society of India (FOGSI) and NNF members, it may be possible to have a NRP trained skilled birth attendant for every delivery (15).

Two simulation based programmes which has 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 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 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 mask (16). 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% 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, HBB initiative has been integrated into the Navjyata Shishu Sureksha Karyakaram (NSSK) (17).

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 resuscitation (18).

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.

Neonatal resuscitation training programs have undoubtedly reduced neonatal mortality and morbidity. A multi-centric study demonstrated a reduction in still birth which was attributed to effective resuscitation of newborns who would have not been resuscitated before the initiation of training programs (19). Other studies have shown similar results (20, 21, and 22). A study from India showed that HBB training reduced stillbirth rate without increasing neonatal mortality, indicating that resuscitated babies survived the neonatal period (23). The success of neonatal resuscitation training programmes 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 a NMR of 9 per 1000 live births worldwide (24).

Neonatal Resuscitation Neonatal Resuscitation 03/18/2016
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