Prepublication Release Neonatal Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Myra H. Wyckoff, MD, Chair; Gary M. Weiner, MD; On behalf of the Neonatal Life Support Collaborators DOI: 10.1542/peds.2020-038505C Journal: Pediatrics Article Type: Supplement Article Citation: Wyckoff MH, Weiner GM, et al. Neonatal Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Pediatrics. 2020; doi: 10.1542/peds.2020-038505C This article has been copublished in Circulation. This is a prepublication version of an article that has undergone peer review and been accepted for publication but is not the final version of record. This paper may be cited using the DOI and date of access. This paper may contain information that has errors in facts, figures, and statements, and will be corrected in the final published version. The journal is providing an early version of this article to expedite access to this information. The American Academy of Pediatrics, the editors, and authors are not responsible for inaccurate information and data described in this version. ©2020 AmericanDownloaded Academy from www.aappublications.org/news of Pediatrics and American by guest on September Heart Association, 26, 2021 Inc. Neonatal Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Myra H. Wyckoff, MD, Chair; Gary M. Weiner, MD; On behalf of the Neonatal Life Support Collaborators ABSTRACT: This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for neonatal life support includes The full author list is available on page S214. evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid. Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed. All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published. Over 140 million babies are born annually worldwide (https:// Key Words: AHA Scientific Statements ourworldindata.org/grapher/births-and-deaths-projected-to-2100). If up cardiopulmonary resuscitation to 5% receive positive-pressure ventilation, this evidence evaluation is neonatal resuscitation neonate ■ relevant to more than 7 million newborn infants every year. However, in ■© 2020 American Heart ◼Association, terms of early care of the newborn infant, some of the topics addressed Inc., European Resuscitation Council, International Liaison Committee on are relevant to every single baby born. Resuscitation, and American Academy of Pediatrics This article has been copublished in Circulation. Downloaded from www.aappublications.org/news by guest on September 26, 2021 S185 CONTENTS Topics Not Reviewed in 2020… ............................ S214 Acknowledgments… ............................................ S214 Abstract. ................................................................. S185 Disclosures ................................................................. S215 Evidence Evaluation Process. .................................. S187 References. ................................................................. S216 Generation of Topics. ................................................. S188 2020 Topics Reviewed… ...................................... S189 Anticipation and Preparation… ............................... S189 Transition from intrauterine to extrauterine life at Prediction of Need of Respiratory Support birth requires several critical interdependent in the Delivery Room (NLS 611: EvU… .......... S189 physiological events to occur rapidly to allow suc- Effect of Briefing/Debriefing Following cessful conversion from placental to pulmonary gas ex- Neonatal Resuscitation (NLS 1562: ScopRev) …S190 change.1 Air breathing leads to significant reductions Initial Assessment and Intervention. ....................... S190 in pulmonary vascular resistance, which increases pul- Warming Adjuncts (NLS 599: EvUp). ............. S190 monary blood flow and thereby maintains left ventric- Suctioning of Clear Fluid (NLS 596: ular filling and output (vital for coronary and cerebral ScopRev) ...................................................... S191 perfusion) when the umbilical cord is clamped.2 When Tracheal Intubation and Suction of the low-resistance placental circulation is removed, sys- Nonvigorous Meconium-Stained Newborns temic vascular resistance and blood pressure increase (NLS 865: SysRev) .......................................... S192 and right-to-left shunting across the ductus arteriosus Physiological Monitoring and Feedback Devices… S194 decreases. Heart Rate Monitoring During Neonatal The majority (approximately 85%) of babies born Resuscitation (NLS 898: EvUp) ...................... S194 at term will initiate breathing within 10 to 30 seconds Ventilation and Oxygenation… ............................... S195 of birth.3 An additional 10% will do so in response to Sustained Inflation (NRP 809: SysRev) ............... S195 stimulation and drying.4 Nevertheless, approximately PEEP Versus No PEEP (NLS 897: EvUp) .............. S199 5% of term infants receive positive-pressure ventilation CPAP Versus Intermittent Positive Pressure (PPV) to successfully transition, 2% are intubated, 0.1% Ventilation (NLS 590: EvUp) ............................ S199 receive cardiac compressions, and 0.05% receive com- T-Piece Resuscitator Versus Self-Inflating Bag pressions with epinephrine.5–8 Although most infants for Ventilation (NLS 870: ScopRev) ..................... S200 successfully transition without assistance, the large Oxygen for Preterm Resuscitation (NLS 864: number of births worldwide means that availability of 2019 CoSTR). ............................................. S201 appropriate, timely intervention can prevent morbidity Oxygen for Term Resuscitation (NLS 1554: and save millions of newborn lives each year. 2019 CoSTR) ................................................ S201 Newborn infants who are breathing or crying and Circulatory Support. .............................................. S202 have good tone and an adequate heart rate may un- CPR Ratios for Neonatal Resuscitation (NLS dergo delayed cord clamping and should be dried and 895: EvUp) .................................................... S202 placed skin to skin with their mothers to prevent hy- 2-Thumb Versus 2-Finger Compressions for pothermia. This does not preclude the need for clinical Neonatal Resuscitation (NLS 605: EvUp) ....... S202 assessment of the newborn as secondary apnea, per- Drug and Fluid Administration. ............................... S203 sistent cyanosis, or breathing difficulties can still occur. Epinephrine (Adrenaline) for Neonatal For the approximately 5% of newborn infants who do Resuscitation (NLS 593: SysRev) .................... S203 not initiate adequate respiratory effort after stimulation Intraosseous Versus Umbilical Vein for by drying and warming, providers must deliver effective Emergency Access (NLS 616: SysRev) ............ S205 ventilation with a face mask. This is effective in most Volume Infusion During Neonatal cases. If it is not effective, providers should take mea- Resuscitation (NLS 598: EvUp) ....................... S207 sures to eliminate mask leaks, check for airway patency, Sodium Bicarbonate During Neonatal and ensure that adequate inflation pressures are used; Resuscitation (NLS: 606 EvUp) ....................... S207 if ventilation is still not effective, an alternative airway Prognostication During CPR. ................................... S208 (endotracheal tube or supraglottic airway) must be con- Impact of Duration of Intensive Resuscitation sidered. Providers must optimize ventilation because it (NLS 896: SysRev) .......................................... S208 is the most important step for successful transition. If, Postresuscitation Care. ........................................... S212 despite efforts to optimize ventilation, the newborn Rewarming of Hypothermic Newborns (NLS has a persistent heart rate less than 60/min or asystole, 858: EvUp) .................................................... S212 then chest compressions are needed. Epinephrine and Induced Hypothermia in Settings With administration