Not Crying After Birth as a Predictor of Not Ashish KC, PhD,a,b,* Joy E. Lawn, PhD,c,* Hong Zhou, PhD,d Uwe Ewald, PhD,a Rejina Gurung, MSc,e Abhishek Gurung, MPH,e Avinash K. Sunny, MD,e Louise Tina Day, MRCPCH,c Nalini Singhal, MDf

BACKGROUND: Worldwide, every year, 6 to 10 million infants require resuscitation at birth abstract according to estimates based on limited data regarding “nonbreathing” infants. In this article, we aim to describe the incidence of “noncrying” and nonbreathing infants after birth, the need for basic resuscitation with bag-and-mask ventilation, and before discharge. METHODS: We conducted an observational study of 19 977 infants in 4 hospitals in Nepal. We analyzed the incidence of noncrying or nonbreathing infants after birth. The sensitivity of noncrying infants with nonbreathing after birth was analyzed, and the risk of predischarge mortality between the 2 groups was calculated. RESULTS: The incidence of noncrying infants immediately after birth was 11.1%, and the incidence of noncrying and nonbreathing infants was 5.2%. Noncrying after birth had 100% sensitivity for nonbreathing infants after birth. Among the “noncrying but breathing” infants, 9.5% of infants did not breathe at 1 minute and 2% did not to breathe at 5 minutes. Noncrying but breathing infants after birth had almost 12-fold odds of predischarge mortality (adjusted odds ratio 12.3; 95% confidence interval, 5.8–26.1). CONCLUSIONS: All nonbreathing infants after birth do not cry at birth. A proportion of noncrying but breathing infants at birth are not breathing by 1 and 5 minutes and have a risk for predischarge mortality. With this study, we provide evidence of an association between noncrying and nonbreathing. This study revealed that noncrying but breathing infants require additional care. We suggest noncrying as a clinical sign for initiating resuscitation and a possible denominator for measuring coverage of resuscitation.

aUppsala University, Uppsala, Sweden; bSociety of Public Health Physicians Nepal, Kathmandu, Nepal; cLondon WHAT’S KNOWN ON THIS SUBJECT: Global protocols School of Hygiene and Tropical Medicine, London, United Kingdom; dPeking University Health Science Center, for neonatal resuscitation are based on “noncrying” Peking University, Beijing, China; eGolden Community, Lalitpur, Nepal; and fUniversity of Calgary, Calgary, Canada being a marker of “nonbreathing,” but the relationship *Contributed equally as co-first authors between noncrying and nonbreathing, or the Drs KC, Singhal, and Lawn conceptualized and designed the analyses, drafted the initial manuscript, predictive risk for each of these for mortality, has not and reviewed and revised the manuscript; Ms Gurung, Mr Gurung, and Dr Sunny designed the data been examined in a large study. collection instruments, collected data, conducted the initial analyses, and reviewed and revised the manuscript; Dr Ewald conceptualized and designed the study, coordinated and supervised data WHAT THIS STUDY ADDS: In this study, we analyzed the collection, and critically reviewed the manuscript for important intellectual content; Drs Zhou and incidence of noncrying and nonbreathing infants after Day supported the analyses and reviewed and revised the manuscript; and all authors approved the birth. All nonbreathing infants were noncrying. Half of final manuscript as submitted and agree to be accountable for all aspects of the work. noncrying infants were nonbreathing, and 9.3% of This trial has been registered with the ISRCTN Register (http://isrctn.org) (identifier noncrying but breathing infants received bag-and- ISRCTN30829654). mask ventilation. Noncrying but breathing infants after birth had 12-fold odds of predischarge mortality. DOI: https://doi.org/10.1542/peds.2019-2719

Accepted for publication Mar 9, 2020 To cite: KC A, Lawn JE, Zhou H, et al. Not Crying After Birth as a Predictor of Not Breathing. Pediatrics. 2020;145(6): e20192719

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 145, number 6, June 2020:e20192719 ARTICLE An infant’s smooth transition from an neonatal care reduces the risks for In the community-based study, lay intra- to extrauterine life depends on mothers and infants. Basic neonatal workers were trained to recognize healthy cardiorespiratory function,1 resuscitation has been shown to “nonbreathing” or gasping infants at with onset of spontaneous breathing reduce intrapartum-related stillbirth birth to require resuscitation.15 with effective cardiac output.2 and first-day neonatal death by 26% In 2015, International Liaison Prematurity or acute intrapartum and 42%, respectively.10,11 Committee on Resuscitation (ILCOR) events may disrupt this transition, guidance estimated that 15% of leading to death or survival with Globally, every year, an estimated 10 infants require some assistance at impairment and disability.3 According million infants need some degree of 12 birth, 10% respond to stimulation to the 2016 global burden of disease resuscitation. Between 6 and 10 and/or suctioning, 3% require BMV, estimates, 2.1 million are million infants have been estimated and 0.1% will requiring advanced attributable to intrapartum-related to require stimulation and/or resuscitation support.18 This events, of which 1.2 million deaths suctioning, 2 to 4 million infants will estimation is based on Grading of are intrapartum stillbirths.4 Most of require bag-and-mask ventilation Recommendations Assessment, these deaths take place in low- and (BMV), and 1 million infants will 12 Development, and Evaluation criteria middle-income countries, where require advanced resuscitation. 5,6 (level of evidence: 4, low) from 3 access to and quality of care is poor. This estimate, based on 3 studies, – observational studies.19 21 Because the pathway to survival is revealed that the quality of evidence unpredictable during the high-risk for infants requiring resuscitation ILCOR 2015 guidance for neonatal 13–15 period of birth in these settings, was low. Of these 3 studies, 2 resuscitation is based on 4 factors: providing optimal quality of were hospital based, and Apgar gestation (term or preterm), intrapartum and immediate postnatal scores at 1 and 5 minutes were used breathing, crying, and tone.22 The care is critical.7,8 as a measure to guide guidance stipulates that infants who 13,14 resuscitation. However, Apgar are “noncrying” or nonbreathing Through periodic systematic reviews, scoring is a subjective clinical require additional stimulation and neonatal survival interventions have assessment and is known to have that those who still do not initiate been updated to provide guidance to high interobserver variability and spontaneous breathing and have 9 reduce mortality and morbidity. a low predictive value to determine rate ,100 beats per minute will 16,17 High-quality emergency obstetric and need for neonatal resuscitation. require BMV.22 In 2010, the Helping Babies Breathe (HBB) program, a pictorial flowchart neonatal resuscitation algorithm for low- and

FIGURE 1 FIGURE 2 Strengthening the Reporting of Observational Studies in Epidemiology flow diagram from the Nepal Incidence of noncrying and nonbreathing neo- Perinatal Quality Improvement Project study for inclusion in this analysis. nates at birth (all gestations).

Downloaded from www.aappublications.org/news by guest on September 24, 2021 2 KC et al middle-income countries, was is to describe the incidence of infants and neonatal care and sick neonatal adapted from ILCOR guidance to who did not cry (noncrying) and/or and pediatric referral services. These better equip first responders to did not breathe (nonbreathing) at hospitals were Koshi Zonal Hospital, manage high-risk newborns at the 3 time points: immediately after birth Bharatpur Hospital, Western Regional time of birth.18 The entry point for and at 1 and 5 minutes after birth. In Hospital, and Lumbini Zonal Hospital. the HBB algorithm is noncrying this article, we will also provide Births in these hospitals occurred in 2 infants at birth to initiate neonatal a description of the outcome at units: the labor and delivery unit for resuscitation steps. The HBB 1.0 and discharge on the basis of a large-scale vaginal deliveries performed by 2.0 versions have been rolled out in multicenter observational study in nurse-midwives and obstetricians $80 countries with 500 000 health Nepal. and the operation theater for workers trained on the neonatal cesarean deliveries performed by the resuscitation protocol.23 Evaluations METHODS obstetricians and anesthetists. As per have revealed that the effect of the Study Design the standard protocol, fetal heart rate HBB algorithm can reduce is first assessed at the time of intrapartum-related mortality by This was an observational nested admission. Fetal heart rate 50% as well as improve health study to evaluate the scale up of the monitoring is done by using the workers’ performance by more than HBB quality improvement (QI) intermittent auscultation method twofold.24–26 package in hospitals of Nepal (Nepal during the first and second stages of Perinatal Quality Improvement labor. Women who had obstetric Both the neonatal resuscitation Project).27,28 and/or neonatal complications were program and the HBB advisory group considered for cesarean delivery. have identified the need for better Study Sites quality data to inform guidance on This study was conducted in 4 In both the units, nurse-midwives provision of resuscitation care at the publicly funded hospitals providing were the primary responders for time of birth. Our aim for this article comprehensive emergency obstetric neonatal resuscitation. The annual number of hospital births ranges from 9007 to 11 318 a year, with an intrapartum-related mortality (intrapartum stillbirth and first-day mortality) rate of 8.6 to 14.2 per 1000 total births. After the introduction of the HBB QI package in the hospitals, health workers were trained to provide stimulation to “noncrying but breathing” infants.

Study Dates The study was conducted between July 2017 and September 2018.

Participants Eligible participants were consenting women in labor at $22 weeks’ gestation in admission to the labor and delivery room. We excluded women whose fetus had died before admission to labor and delivery (no fetal heart sound), those referred to the operation theater for FIGURE 3 cesarean delivery, and women who Flow diagram of noncrying and nonbreathing infants after birth (all gestations). NCB, noncrying but were referred to other facilities breathing; NCNB, noncrying and nonbreathing. before delivery.

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 145, number 6, June 2020 3 membranes, prostaglandins, and/or oxytocin; • appropriate for gestational age: birth weight in the $10th percentile for gestational age based on the INTERGROWTH-21st study reference point for South Asia29; • small for gestational age (SGA): birth weight in the ,10th percentile for gestational age based on the INTERGROWTH-21st study reference point for South Asia29; • predischarge neonatal death: infants who died before discharge from the hospital; and • intrapartum stillbirth: infants born at or after 22 weeks’ gestation who had a fetal heart sound during the antepartum period and no fetal heart sound during labor, with no signs of life (breathing or heart rate) after neonatal resuscitation at birth.

Data Collection The data collection team consisted of FIGURE 4 clinical nurse-midwives who have at Flow diagram of noncrying and nonbreathing infants after birth (term infants). NCB, noncrying but least one year of experience in breathing; NCNB, noncrying and nonbreathing. midwifery and research. The data collection team received a week of rigorous training before the start of Sample Size • nonbreathing at 1 minute: infants training on the HBB program as well This was a secondary data analysis of who were not breathing 1 minute as the labor and delivery clinical an estimated sample of 20 000 birth after birth; observation tool. The data collection observations as part of the HBB scale- • nonbreathing at 5 minutes: infants team was placed in admission, labor up evaluation to detect any change in who were not breathing at and delivery, postnatal, and sick the health workers’ practice after QI 5 minutes after birth; newborn care units in each hospital. 27 interventions. • extremely preterm: infants The team had 8 data collectors with ’ Variables between 22 and 28 weeks a data coordinator to ensure data gestational age; collection and management quality. We included the following variables: • very preterm: infants between 29 Periodic data quality assessments • noncrying infants after birth: and 32 weeks’ gestational age; were done by an independent team of infants who did not cry clinicians. On a quarterly basis, an • late preterm infants between- 33 to immediately after birth; independent clinical team assessed 36 weeks’ gestational age; • noncrying but breathing infants the accuracy of the clinical • term: infants $37 weeks’ gestation; after birth: infants who did not cry observation recorded by the data but spontaneously breathed • mode of delivery: infants who were collectors. Discrepancies on the immediately after birth; delivered either by spontaneous or accuracy of the clinical observation assisted vaginal delivery (the made by data collectors were • noncrying and nonbreathing reviewed, and feedback was provided infants after birth: infants who did assisted vaginal delivery included by the independent clinical team. not cry and did not breathe vacuum and forceps deliveries); spontaneously immediately after • induction of labor: labor that was Data collectors observed clinical birth; started by artificial rupture of events and clinical service provided

Downloaded from www.aappublications.org/news by guest on September 24, 2021 4 KC et al TABLE 1 Incidence of Noncrying and Nonbreathing After Birth by Different Obstetric Conditions Crying After Birth Noncrying After Birth Noncrying and Nonbreathing After Birth Noncrying but Breathing After Birth (17 752; (2225; (1037; (1188; 88.9%), n (%) 11.1%), n (%) 5.2%), n (%) 5.9%), n (%) Estimated gestational age, wk 22–28 20 (46.5) 23 (53.5) 21 (48.8) 2 (4.7) 29–32 93 (66.4) 47 (33.6) 26 (18.6) 21 (15.0) 33–36 1470 (86.3) 233 (13.7) 116 (6.8) 117 (6.9) $37 16 169 (89.4) 1922 (10.6) 874 (4.8) 1048 (5.8) Mode of delivery Spontaneous vaginal 16 966 (89.5) 1984 (10.5) 913 (4.8) 1071 (5.7) delivery Assisted vaginal delivery 786 (76.5) 241 (23.5) 124 (12) 117 (11.4) Induction of labor None 12 400 (89.3) 1485 (10.7) 753 (5.4) 732 (5.3) ARM 107 (76.4) 33 (23.6) 3 (2.2) 30 (21.4) Prostaglandin 3788 (90.7) 388 (9.3) 196 (4.7) 192 (4.6) Oxytocin 1457 (82.0) 319 (18.0) 85 (4.8) 234 (13.2) Sex of infant Male 9305 (87.8) 1295 (12.2) 643 (6.1) 652 (6.2) Female 8447 (90.1) 930 (9.9) 394 (4.2) 536 (5.7) SGA ,10th percentile 2009 (84.4) 372 (15.6) 192 (8.1) 1008 (5.7) $10th percentile 15 743 (89.5) 1853 (10.5) 845 (4.8) 180 (7.6) ARM, artificial rupture of membranes. to the women and infants in the labor System database. Data were backed noncrying infants after birth with and delivery room but not in the up on an external hard drive nonbreathing infants were calculated. operation theater . Observers every month. A bivariate analysis was conducted to recorded the induction of labor, time assess the level of association of and mode of delivery, and the status To ensure data entry accuracy, 10% noncrying but breathing and of infant crying and infant breathing of the data were reentered by the noncrying and nonbreathing infants after birth at 3 distinct times: data coordinator each month, with after birth with predischarge neonatal immediately after birth and at 1 and feedback provided to the data entry mortality. A multiple regression 5 minutes. Immediate newborn care officers. analysis of noncrying but breathing practices, including any additional and noncrying and nonbreathing after stimulation, suctioning or clearing Data Analysis birth with predischarge neonatal of airways, BMV, additional mortality, after adjusting for resuscitation care, and mortality We categorized infants into 2 gestational age, birth weight, outcomes of the infant, were assessed overlapping groups by their status at induction of labor, mode of delivery, via observation. Recording of the birth: (1) crying or noncrying and and sex of the infant, was performed. observation was done in real time on (2) breathing or nonbreathing were Missing variables and loss to follow- paper-based data collection proforma. categorized into noncrying but up were excluded during the data The pretesting of the observation breathing and noncrying and analysis. checklist was done in another tertiary nonbreathing after birth. We analyzed hospital of Nepal. the incidence of noncrying after birth and nonbreathing after birth and at 1 Ethics Approval Data Management and 5 minutes. We analyzed the Written consent from each The collected information on the incidence of noncrying, noncrying participant included in the study was observed data were reviewed by the and nonbreathing, and noncrying but taken during admission to the data coordinator to check for breathing after birth by different hospital. Ethical approval was completeness. The completed data determinants: gestational age, birth received from the Ethical Review collection tools were transferred by weight as per gestational age, Board of Nepal Health Research data coordinators to the central induction of labor, and mode of Council (17/2017). Registration in research office in Kathmandu, where delivery. The sensitivity, specificity, the ISRCTN registry was done for the they were indexed and entered into positive predictive value, and large-scale evaluation of the scale up the Census and Survey Processing negative predictive value of of the HBB QI package.

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 145, number 6, June 2020 5 TABLE 2 Risk of Predischarge Neonatal Mortality With Noncrying and Nonbreathing Infants After Birth Alive at Discharge Predischarge Neonatal Mortality cOR (95% CI) aOR (95% CI) (19 826; 99.5%), n (%) (94; 0.4%), n (%) Noncrying and nonbreathing Noncrying and nonbreathinga 976 (94.1) 61 (5.9) 69.3 (39.8–120.6) 46.0 (25.8–81.9) Crying and breathingb 17 736 (99.9) 16 (0.1) Reference — Noncrying but breathing Noncrying but breathinga 1171 (98.6) 17 (1.4) 16.1 (8.11–31.9) 12.3 (5.8–26.1) Crying and breathingc 17 736 (99.9) 16 (0.1) Reference — Gestational age, wk 22–28 24 (68.6) 11 (31.4) 161.9 (75.3–347.8) 61.8 (21.4–178.1) 29–32 119 (91.5) 11 (8.5) 32.7 (16.6–64.2) 14.1 (6.0–32.8) 33–36 1672 (98.8) 21 (1.2) 4.4 (2.7–7.4) 3.7 (2.2–6.4) $37 18 011 (99.7) 51 (0.3) Reference — Mode of delivery Assisted vaginal 1006 (98.2) 18 (1.8) 4.4 (2.6–7.4) 2.4 (1.4–4.3) Normal vaginal 18 820 (99.6) 76 (0.4) Reference — Induction of labor Induction with amniotomy 140 (100.0) 0 (0.0) —— Induction with prostaglandin 4158 (99.6) 15 (0.4) 0.7 (0.4–1.3) — Induction with oxytocin 1764 (99.3) 12 (0.7) 1.4 (0.8–2.6) — None 13 764 (99.5) 67 (0.5) Reference — Sex of infant Male 10 514 (99.5) 52 (0.5) 0.9 (0.6–1.4) — Female 9312 (99.6) 42 (0.4) Reference — SGA ,10th percentile 2324 (98.6) 32 (1.4) 3.9 (2.5–6.0) 1.5 (0.9–2.6) $10th percentile 17 502 (99.6) 62 (0.4) Reference — cOR, crude odds ratio; —, not applicable. a Sample size = 1037. b Sample size = 17 752. c Sample size = 1188.

RESULTS spontaneously until 1 minute, and were nonbreathing at 1 minute, Of the total 33 430 pregnant women 0.8% (168) did not breathe 22.9% received BMV, and 10.8% admitted into the hospitals during the spontaneously until 5 minutes (Fig 2). were nonbreathing at 5 minutes. Among the term noncrying but 15-month study period, 26 345 were Among noncrying and nonbreathing breathing infants after birth, 96.4% assessed for eligibility, of whom infants after birth, 71.0% received received stimulation, 9.2% were 22 340 (84.8%) women were stimulation, 25.1% were nonbreathing at 1 minute, 8.9% recruited. Among the total women nonbreathing at 1 minute, 23.8% received BMV, and 1.8% were recruited, 183 (0.8%) had stillbirths, received BMV, and 13.9% were nonbreathing at 5 minutes (Fig 4). 169 (0.8%) had neonatal deaths, and nonbreathing at 5 minutes. Among Among the term noncrying but 8% were lost to follow-up (Fig 1). noncrying but breathing infants after breathing infants after birth, 9 of birth, 96.3% received stimulation, Of the 19 977 infants observed, them died before discharge. 9.5% were nonbreathing at 1 minute, 11.1% did not cry after birth. Of the 9.3% received BMV, and 2.0% were infants observed, 5.2% were Among the extremely preterm infants nonbreathing at 5 minutes (Fig 3). noncrying and nonbreathing and (22–28 weeks), 53.5% were 5.9% were noncrying but breathing Among the term noncrying and noncrying after birth, with 48.8% after birth. Of the infants observed, nonbreathing infants after birth, noncrying and nonbreathing after 1.9% (373) did not breathe 73.1% received stimulation, 22.3% birth and 4.7% noncrying but breathing after birth. Among the infants born with assisted vaginal TABLE 3 Noncrying Infants After Birth and Nonbreathing Infants After Birth delivery, a higher proportion (23.5%) Nonbreathing Breathing After Birth Total were noncrying after birth, with After Birth 11.4% noncrying but breathing and Noncrying after birth 1037 1188 2225 12.0% noncrying and nonbreathing Crying after birth 0 17 752 17 752 after birth. Among women with Total 1037 18 940 19 977 induced labor by using artificial

Downloaded from www.aappublications.org/news by guest on September 24, 2021 6 KC et al TABLE 4 Sensitivity, Specificity, Positive Predictive Value, Negative Predictive Value, Area Under the 12-fold odds for predischarge Curve, and Inflation Factor of Noncrying Infants After Birth on Nonbreathing Infants After mortality. Crying assists in clearing Birth fluid, and it may assist in Value 95% CI establishment of functional residual Sensitivity 100.00% 99.60%–100.00% capacity. Noncrying of the infant Specificity 93.70% 93.40%–94.10% coupled with perinatal depression ROC area 0.97 0.97–0.97 might increase the risk of mortality. – PPV 46.60% 44.50% 48.70% Further mechanistic studies are NPV 100.00% 100.00%–100.00% Prevalence 5.20% 4.90%–5.50% required to understand the physiology. NPV, negative predictive value; PPV, positive predictive value; ROC, receiver operating characteristic. So far, the incidence of infants who rupture of membranes, 23.6% of DISCUSSION received resuscitation at birth is mostly derived from intervention- infants were noncrying after This is the largest study to date in birth, with 21.4% noncrying but based studies in which the effects of which we report on observation at neonatal resuscitation interventions breathing and 2.2% noncrying and birth of noncrying and nonbreathing nonbreathing after birth. Among SGA on clinical performance and mortality infants. Among the total 19 977 are reported.19,20,30 For example, in infants, 15.6% were noncrying after observed births, approximately one- birth, with 5.7% noncrying but a study conducted in Tanzania, Ersdal tenth of infants did not cry after birth. et al19 proposed that 16% of the breathing and 8.1% noncrying and Almost half of the noncrying infants nonbreathing after birth (Table 1). infants who did not breathe after birth were breathing. The spontaneously received basic Compared with infants crying proportion of noncrying infants resuscitation. From our study, of the and breathing after birth, increases with lower gestational age, noncrying infants after birth, 16.8% . noncrying and nonbreathing with 50% of infants at 22 to 28 did not breathe at 1 minute and ’ infants had 46 times higher odds weeks gestation not crying at birth. required BMV. of predischarge neonatal In the ILCOR guideline for neonatal mortality (adjusted odds ratio Defining the population of infants resuscitation, the clinical algorithms [aOR] 46.0; 95% confidence who require resuscitation is crucial use noncrying as decision points for interval [CI], 25.8–81.9) after for measuring the coverage of resuscitation steps. In this cohort, all adjustment for , neonatal resuscitation interventions. nonbreathing infants were noncrying assisted vaginal delivery, and SGA. The Every Newborn Action Plan after birth (100%). The positive Preterm birth, assisted vaginal Measurement Improvement Roadmap predictive value of noncrying infants delivery, and SGA revealed an (2016–2020) prioritized research to was 50% for nonbreathing infants. association with predischarge validate the coverage indicators for neonatal mortality. Compared with In the cohort of noncrying and neonatal interventions (including infants crying and breathing after nonbreathing infants at birth, more neonatal resuscitation) to improve birth, noncrying but breathing than two-thirds received simple tracking of national and global infants had 12 times higher odds measures of stimulation, and almost progress to the Sustainable (aOR 12.3; 95% CI, 5.8–26.1) of one-fourth of them received BMV. In Development Goals for newborn 31,32 predischarge mortality after the cohort of noncrying but breathing survival. The Every adjustment for risk of preterm infants at birth, almost all of them Newborn–Birth Indicators Research birth, assisted vaginal delivery, received simple measures of Tracking in Hospitals study in Nepal, and SGA (Table 2). stimulation, and 1 in 10 infants Bangladesh, and Tanzania is designed received BMV. Infants who are to validate these indicators for use in This study revealed that all noncrying but breathing may have maternal-report surveys and in nonbreathing infants after birth 33 primary or secondary apnea. These routine facility data. Because were noncrying (sensitivity = infants would require additional documentation of facility data is often 100%). The positive predictive stimulation to assist in transition to done by the health worker providing value after birth of noncrying spontaneous breathing, whereas the care, ensuring measurement infants with nonbreathing was (both numerator and denominator) – some would require BMV. 46.0% (95% CI, 44.5% 48.7%). that is meaningful to reinforce clinical The negative predictive value after Among the noncrying but breathing practice is crucial.33 birth of noncrying infants with infants after birth, 9.5% were nonbreathing was 100% (95% CI, nonbreathing at 1 minute and 2.0% This study has several strengths, 100%–100%) (Tables 3 and 4). did not breathe at 5 minutes and had including that observation was done

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 145, number 6, June 2020 7 by trained researchers in multiple CONCLUSIONS resuscitation and closer hospitals in Nepal in a consistent way With this study, we provide monitoring and potentially as and with a large sample size. Using incidence of noncrying and a denominator for coverage observational methods limited nonbreathing infants after birth, measurement to maintain integrity recall bias. prediction of infants receiving between clinical and measurement However, there are several resuscitation, and risk of neonatal practice. limitations. First, this observation mortality in Nepal. Eleven was only done for vaginal deliveries percent of the infants did ACKNOWLEDGMENTS and not for cesarean deliveries. not cry after birth. One-fifth of We thank Omkar Basnet and data Second, there might have been infants born by assisted vaginal collectors for the contribution to observer reporting bias, especially delivery and/or with induction of the study. Most of all, we thank when the case load for deliveries was labor (artificial rupture of the women, their newborns, and high; however, periodic quality membranes) were noncrying at their families. assessment was done to reduce the birth. Almost half of these infants bias. Third, we did not assess whether were nonbreathing after birth. the infant cried or breathed after Noncrying but breathing infants stimulation. Fourth, the physiologic after birth had 12-fold odds of ABBREVIATIONS response to is gasping (deep predischarge mortality compared aOR: adjusted odds ratio and irregular breathing), which might with crying infants. All noncrying BMV: bag-and-mask ventilation have been captured by the clinical infants require further assessment CI: confidence interval observers as breathing; however, and initial steps of resuscitation. HBB: Helping Babies Breathe these infants who were gasping With this study, we provide ILCOR: International Liaison would have required BMV. Finally, we evidence of the association Committee on Resuscitation did not have cord base values to between noncrying and nonbreathing. QI: quality improvement determine if infants who did not cry Our findings support noncrying as SGA: small for gestational age had perinatal depression. an indicator for initiating

Address correspondence to Ashish KC, PhD, International Maternal and Child Health, Department of Women’s and Children’s Health, Uppsala University, Dag Hammarskjölds väg 14B, Floor 1, Akademiska sjukhuset SE-751 85, Uppsala, Sweden. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2020 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: Funded by the Swedish Research Council and Laerdal Foundation for Acute Medicine as part of the evaluation of neonatal resuscitation protocols in hospitals of Nepal. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 145, number 6, June 2020 9 Not Crying After Birth as a Predictor of Not Breathing Ashish KC, Joy E. Lawn, Hong Zhou, Uwe Ewald, Rejina Gurung, Abhishek Gurung, Avinash K. Sunny, Louise Tina Day and Nalini Singhal Pediatrics originally published online May 12, 2020;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2020/05/11/peds.2 019-2719 References This article cites 33 articles, 5 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2020/05/11/peds.2 019-2719#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Fetus/Newborn Infant http://www.aappublications.org/cgi/collection/fetus:newborn_infant_ sub Neonatology http://www.aappublications.org/cgi/collection/neonatology_sub Public Health http://www.aappublications.org/cgi/collection/public_health_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 24, 2021 Not Crying After Birth as a Predictor of Not Breathing Ashish KC, Joy E. Lawn, Hong Zhou, Uwe Ewald, Rejina Gurung, Abhishek Gurung, Avinash K. Sunny, Louise Tina Day and Nalini Singhal Pediatrics originally published online May 12, 2020;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2020/05/11/peds.2019-2719

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2020 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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