Not Crying After Birth as a Predictor of Not Breathing 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 death 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 29, 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 deaths 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 heart 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 29, 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.