Heart Rate Assessment Immediately after Birth

Newborn heart rate monitoring methods at birth and clinical outcomes: A systematic review

Aim

Compare heart rate assessment methods in the delivery room on newborn clinical outcomes.

Methods

A search of Medline, SCOPUS, CINAHL and Cochrane was conducted between January 1, 1946, to until August 16, 2023. (CRD 42021283438) Study Selection was based on predetermined criteria. Reviewers independently extracted data, appraised risk of bias and assessed certainty of evidence.

Results

Two randomized controlled trials involving 91 newborns and 1 nonrandomized study involving 632 newborns comparing electrocardiogram (ECG) to auscultation plus pulse oximetry were included. No studies were found that compared any other heart rate measurement methods and reported clinical outcomes. There was no difference between the ECG and control group for duration of positive pressure ventilation, time to heart rate ≥ 100 beats per minute, epinephrine use or death before discharge. In the randomized studies, there was no difference in rate of tracheal intubation [RR 1.34, 95% CI (0.69-2.59)]. No participants received chest compressions. In the nonrandomized study, fewer infants were intubated in the ECG group [RR 0.75, 95% CI (0.62-0.90)]; however, for chest compressions, benefit or harm could not be excluded. [RR 2.14, 95% (CI 0.98-4.70)].

Conclusion

There is insufficient evidence to ascertain clinical benefits or harms associated with the use of ECG versus pulse oximetry plus auscultation for heart rate assessment in newborns in the delivery room.

Fast and accurate newborn heart rate monitoring at birth: A systematic review

Aim

To examine speed and accuracy of newborn heart rate measurement by various assessment methods employed at birth.

Methods

A search of Medline, SCOPUS, CINAHL and Cochrane was conducted between January 1, 1946, to until August 16, 2023. (CRD 42021283364) Study selection was based on predetermined criteria. Reviewers independently extracted data, appraised risk of bias and assessed certainty of evidence.

Results

Pulse oximetry is slower and less precise than ECG for heart rate assessment. Both auscultation and palpation are imprecise for heart rate assessment. Other devices such as digital stethoscope, Doppler ultrasound, an ECG device using dry electrodes incorporated in a belt, photoplethysmography and electromyography are studied in small numbers of newborns and data are not available for extremely preterm or bradycardic newborns receiving resuscitation. Digital stethoscope is fast and accurate. Doppler ultrasound and dry electrode ECG in a belt are fast, accurate and precise when compared to conventional ECG with gel adhesive electrodes.

Limitations

Certainty of evidence was low or very low for most comparisons.

Conclusion

If resources permit, ECG should be used for fast and accurate heart rate assessment at birth. Pulse oximetry and auscultation may be reasonable alternatives but have limitations. Digital stethoscope, doppler ultrasound and dry electrode ECG show promise but need further study.

Does ECG monitoring affect resuscitation for neonates with pulseless electrical activity in the delivery room? A simulated, pilot, crossover randomised trial

OBJECTIVE

To evaluate whether ECG monitoring impacts resuscitative steps during simulated neonatal resuscitation in the setting of pulseless electrical activity (PEA) in the delivery room.

DESIGN

This pilot, crossover randomised controlled trial recruited providers in teams of three who participated in two simulation scenarios (PEA with and without ECG monitoring). Teams were randomised to one scenario and then crossed over. All sessions were video-recorded. The primary outcome was time to pulse check once the manikin was programmed to become pulseless. The secondary outcomes were total pulse checks, time to positive pressure ventilation, intubation, chest compressions and administration of epinephrine, and teams' quotes and behaviours during resuscitation. The primary outcome was analysed using Kaplan-Meier survival curve. The secondary outcomes were compared with Wilcoxon signed-rank test. The quotes were analysed using content analysis with pattern coding.

RESULTS

Eighty-two healthcare providers were approached and 30 consented (10 teams). The mean time to check the pulse once the manikin was pulseless was 38.5 s (SD 30.1) without ECG vs 88.1 s (SD 46.1) with ECG (p<0.01). There was a significantly decreased number of pulse checks with the ECG compared with without (p<0.01). Time to intubation, chest compressions, start of positive pressure ventilation and epinephrine administration was not different between the groups. Quotes/behaviours revealed false reassurance and over-reliance on ECG monitoring, repeated pulse check errors and troubleshooting behaviours.

CONCLUSIONS

ECG monitoring in simulated neonatal resuscitation results in delayed recognition of a pulseless state, decreased number of pulse checks and a possible false sense of security. Simulated resuscitation clinical endpoints are unaffected.

Electronic Heart (ECG) Monitoring at Birth and Newborn Resuscitation

BACKGROUND

Approximately 10% of newborns require assistance at delivery, and heart rate (HR) is the primary vital sign providers use to guide resuscitation methods. In 2016, the American Heart Association (AHA) suggested electrocardiogram in the delivery room (DR-ECG) to measure heart rate during resuscitation. This study aimed to compare the frequency of resuscitation methods used before and after implementation of the AHA recommendations.

METHODS

This longitudinal retrospective cohort study compared a pre-implementation (2015) cohort with two post-implementation cohorts (2017, 2021) at our Level IV neonatal intensive care unit.

RESULTS

An initial increase in chest compressions at birth associated with the introduction of DR-ECG monitoring was mitigated by focused educational interventions on effective ventilation. Implementation was accompanied by no changes in neonatal mortality.

CONCLUSIONS

Investigation of neonatal outcomes during the ongoing incorporation of DR-ECG may help our understanding of human and system factors, identify ways to optimize resuscitation team performance, and assess the impact of targeted training initiatives on clinical outcomes.

Reference Ranges for Arterial Oxygen Saturation, Heart Rate, and Cerebral Oxygen Saturation during Immediate Postnatal Transition in Neonates Born Extremely or Very Preterm

OBJECTIVE

To define percentile charts for arterial oxygen saturation (SpO2), heart rate (HR), and cerebral oxygen saturation (crSO2) during the first 15 minutes after birth in neonates born very or extremely preterm and with favorable outcome.

STUDY DESIGN

We conducted a secondary-outcome analysis of neonates born preterm included in the Cerebral regional tissue Oxygen Saturation to Guide Oxygen Delivery in preterm neonates during immediate transition after birth III (COSGOD III) trial with visible cerebral oximetry measurements and with favorable outcome, defined as survival without cerebral injuries until term age. We excluded infants with inflammatory morbidities within the first week after birth. SpO2 was obtained by pulse oximetry, and electrocardiogram or pulse oximetry were used for measurement of HR. crSO2 was assessed with near-infrared spectroscopy. Measurements were performed during the first 15 minutes after birth. Percentile charts (10th to 90th centile) were defined for each minute.

RESULTS

A total of 207 neonates born preterm with a gestational age of 29.7 (23.9-31.9) weeks and a birth weight of 1200 (378-2320) g were eligible for analyses. The 10th percentile of SpO2 at minute 2, 5, 10, and 15 was 32%, 52%, 83%, and 85%, respectively. The 10th percentile of HR at minute 2, 5, 10, and 15 was 70, 109, 126, and 134 beats/min, respectively. The 10th percentile of crSO2 at minute 2, 5, 20, and 15 was 15%, 27%, 59%, and 63%, respectively.

CONCLUSIONS

This study provides new centile charts for SpO2, HR, and crSO2 for neonates born extremely or very preterm with favorable outcome. Implementing these centiles in guiding interventions during the stabilization process after birth might help to more accurately target oxygenation during postnatal transition period.

Contactless assessment of heart rate in neonates within a clinical environment using imaging photoplethysmography

Introduction

In neonatology, the accurate determination of vital parameters plays a pivotal role in monitoring critically ill newborns and premature infants, as well as aiding in disease diagnosis. In response to the limitations associated with contact-based measurement methods, substantial efforts have been directed toward developing contactless measurement techniques, particularly over the past decade.

Methods

Building upon the insights gained from our pilot study, we realized a new investigation to assess the precision of our imaging photoplethysmography-based system within a clinical environment of the neonatal intermediate care unit. We conducted measurements in 20 preterm infants or newborns requiring therapeutic interventions. As a point of reference, we employed a conventional pulse oximeter. To analytically predict measurement artifacts, we analyzed the potential influence of confounding factors, such as motion artifacts, illumination fluctuations (under- and overexposure), and loss of region of interest prior to heart rate evaluation. This reduced the amount of data we evaluated for heart rate to 56.1% of its original volume.

Results

In artifact-free time segments, the mean difference between the pulse oximetry and the imaging photoplethysmography-based system for 1 s sampling intervals resulted in -0.2 bpm (95% CI -0.8 to 0.4, LOA ± 12.2). For the clinical standard of 8 s averaging time, the mean difference resulted in -0.09 bpm (95% CI -0.7 to 0.6, LOA ± 10.1). These results match the medical standards.

Discussion

While further research is needed to increase the range of measurable vital parameters and more diverse patient collectives need to be considered in the future, we could demonstrate very high accuracy for non-contact heart rate measurement in newborn infants in the clinical setting, provided artifacts are excluded. In particular, performing a priori signal assessment helps make clinical measurements safer by identifying unreliable readings.

The critical role of technologies in neonatal care

Neonatal care has made significant advances in the last few decades. As a result, mortality and morbidity in high-risk infants, such as extremely preterm infants or those infants with birth-related brain injury, has reduced significantly. Many of these advances have been facilitated or delivered through development of medical technologies allowing clinical teams to be better supported with the care they deliver or provide new therapies and diagnostics to improve management. The delivery of neonatal intensive care requires the provision of medical technologies that are easy to use, reliable, accurate and ideally developed for the unique needs of the newborn population. Many technologies have been developed and commercialised following adult trials without ever being studied in neonatal patients despite the unique characteristics of this population. Increasingly, funders and industry are recognising this major challenge which has resulted in initiatives to develop new ideas from concept through to clinical care. This review explores some of the key medical technologies used in neonatal care and the evidence to support their adoption to improve outcomes. A number of devices have yet to realise their full potential and will require further development to optimise and find their ideal target population and clinical benefit. Examples of emerging technologies, which may soon become more widely used, are also discussed. As neonatal care relies more on medical technologies, we need to be aware of the impact on care pathways, especially from a human factors approach, the associated costs and subsequent benefits to patients alongside the supporting evidence.

Evaluating a Novel Infant Heart Rate Detector for Neonatal Resuscitation Efforts: Protocol for a Proof-of-Concept Study

BACKGROUND

Over 10 million newborns worldwide undergo resuscitation at birth each year. Pediatricians may use electrocardiogram (ECG), pulse oximetry (PO), and stethoscope in determining heart rate (HR), as HR guides the need for and steps of resuscitation. HR must be obtained quickly and accurately. Unfortunately, the current diagnostic modalities are either too slow, obtaining HR in more than a minute, or inaccurate. With time constraints, a reliable robust heart rate detector (HRD) modality is required. This paper discusses a protocol for conducting a methods-based comparison study to determine the HR accuracy of a novel real-time HRD based on 3D-printed dry-electrode single-lead ECG signals for cost-effective and quick HR determination. The HRD's HR results are compared to either clinical-grade ECG or PO monitors to ensure robustness and accuracy.

OBJECTIVE

The purpose of this study is to design and examine the feasibility of a proof-of-concept HRD that quickly obtains HR using biocompatible 3D-printed dry electrodes for single-lead neonatal ECG acquisition. This study uses a novel HRD and compares it to the gold-standard 3-lead clinical ECG or PO in a hospital setting.

METHODS

A cross-sectional study is planned to be conducted in the neonatal intensive care unit or postpartum unit of a large community teaching hospital in Toronto, Canada, from June 2023 to June 2024. In total, 50 newborns will be recruited for this study. The HRD and an ECG or PO monitor will be video recorded using a digital camera concurrently for 3 minutes for each newborn. Hardware-based signal processing and patent-pending embedded algorithm-based HR estimation techniques are applied directly to the raw collected single-lead ECG and displayed on the HRD in real time during video recordings. These data will be annotated and compared to the ECG or PO readings at the same points in time. Accuracy, F1-score, and other statistical metrics will be produced to determine the HRD's feasibility in providing reliable HR.

RESULTS

The study is ongoing. The projected end date for data collection is around July 2024.

CONCLUSIONS

The study will compare the novel patent-pending 3D-printed dry electrode-based HRD's real-time HR estimation techniques with the state-of-the-art clinical-grade ECG or PO monitors for HR accuracy and examines how fast the HRD provides reliable HR. The study will further provide recommendations and important improvements that can be made to implement the HRD for clinical applications, especially in neonatal resuscitation efforts. This work can be seen as a stepping stone in the development of robust dry-electrode single-lead ECG devices for HR estimations in the pediatric population.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45512.

Fetal to Neonatal Heart Rate Transition during Normal Vaginal Deliveries: A Prospective Observational Study

Documentation of fetal to neonatal heart rate (HR) transition is limited. The aim of the current study was to describe HR changes from one hour before to one hour after normal vaginal deliveries. We conducted a prospective observational cohort study in Tanzania from 1 October 2020 to 30 August 2021, including normal vaginal deliveries with normal neonatal outcomes. HR was continuously recorded from one hour before to one hour after delivery, using the Moyo fetal HR meter, NeoBeat newborn HR meter, and the Liveborn Application for data storage. The median, 25th, and 75th HR percentiles were constructed. Overall, 305 deliveries were included. Median (interquartile range; IQR) gestational age was 39 (38-40) weeks and birthweight was 3200 (3000-3500) grams. HR decreased slightly during the last 60 min before delivery from 136 (123,145) to 132 (112,143) beats/minute. After delivery, HR increased within one minute to 168 (143,183) beats/min, before decreasing to around 136 (127,149) beats/min at 60 min after delivery. The drop in HR in the last hour of delivery reflects strong contractions and pushing. The rapid increase in initial neonatal HR reflects an effort to establish spontaneous breathing.

Non-invasive sensor methods used in monitoring newborn babies after birth, a clinical perspective

Background

Reducing the global new-born mortality is a paramount challenge for humanity. There are approximately 786,323 live births in the UK each year according to the office for National Statistics; around 10% of these newborn infants require assistance during this transition after birth. Each year around, globally around 2.5 million newborns die within their first month. The main causes are complications due to prematurity and during delivery. To act in a timely manner and prevent further damage, health professionals should rely on accurate monitoring of the main vital signs heart rate and respiratory rate.

Aims

To present a clinical perspective on innovative, non-invasive methods to monitor heart rate and respiratory rate in babies highlighting their advantages and limitations in comparison with well-established methods.

Methods

Using the data collected in our recently published systematic review we highlight the barriers and facilitators for the novel sensor devices in obtaining reliable heart rate measurements. Details about difficulties related to the application of sensors and interfaces, time to display, and user feedback are explored. We also provide a unique overview of using a non-invasive respiratory rate monitoring method by extracting RR from the pulse oximetry trace of newborn babies.

Results

Novel sensors to monitor heart rate offer the advantages of minimally obtrusive technologies but have limitations due to movement artefact, bad sensor coupling, intermittent measurement, and poor-quality recordings compared to gold standard well established methods. Respiratory rate can be derived accurately from pleth recordings in infants.

Conclusion

Some limitations have been identified in current methods to monitor heart rate and respiratory rate in newborn babies. Novel minimally invasive sensors have advantages that may help clinical practice. Further research studies are needed to assess whether they are sufficiently accurate, practical, and reliable to be suitable for clinical use.

Recent advances in wearable medical diagnostic sensors and new therapeutic dosage forms for fever in children

Fever in children is one of the most common symptoms of pediatric diseases and the most common complaint in pediatric clinics, especially in the emergency department. Diseases such as pneumonia, sepsis, and meningitis are leading causes of death in children, and the early manifestations of these diseases are accompanied by fever symptoms. Accurate diagnosis and real-time monitoring of the status of febrile children, rapid and effective identification of the cause, and treatment can have a positive impact on relieving their symptoms and improving their quality of life. In recent years, wearable diagnostic sensors have attracted special attention for their high flexibility, real-time monitoring, and sensitivity. Temperature sensors and heart rate sensors have provided new advances in detecting children's body temperature and heart rate. Furthermore, some novel formulations have also received wide attention for addressing bottlenecks in medication administration for febrile children, such as difficulty in swallowing and inaccurate dosing. In this context, the present review provides recent advances of novel wearable medical sensor devices for diagnosing fever. Moreover, the application progress of innovative dosage forms of classical antipyretic drugs for children is presented. Finally, challenges and prospects of wearable sensor-based diagnostics and novel agent-based treatment of fever in children are discussed in brief.

Comparing pulse rate measurement in newborns using conventional and dry-electrode ECG monitors

Aim

Heart rate (HR) is the most important parameter to evaluate newborns’ clinical condition and to guide intervention during resuscitation at birth. The present study aims to compare the accuracy of NeoBeat dry‐electrode ECG for HR measurement with conventional ECG and pulse oximetry (PO).

Methods

Newborns with a gestational age ≥32 weeks and/or birth weight ≥1.5 kg were included when HR evaluation was needed. HR was simultaneously measured for 10 min with NeoBeat, PO and conventional ECG.

Results

A total of 18 infants were included (median (IQR) gestational age 39 (36–39) weeks and birth weight 3 150 (2 288–3 859) grams). Mean (SD) duration until NeoBeat obtained a reliable signal was 2.5 (9.0) s versus 58.5 (171.0) s for PO. Mean difference between NeoBeat and ECG was 1.74 bpm (LoA −4.987–8.459 and correlation coefficient 0.98). Paired HR measurements over 30‐s intervals revealed no significant difference between NeoBeat and ECG. The positive predictive value of a detected HR <100 bpm by NeoBeat compared with ECG was 54.84%, negative predictive value 99.99%, sensitivity 94.44%, specificity 99.99% and accuracy 99.85%.

Conclusions

HR measurement with NeoBeat dry‐electrode ECG at birth is reliable and accurate.

Updates for the Neonatal Resuscitation Program and Resuscitation Guidelines

Although most newborns require no assistance to successfully transition to extrauterine life, the large number of births each year and limited ability to predict which newborns will need assistance means that skilled clinicians must be prepared to respond quickly and efficiently for every birth. A successful outcome is dependent on a rapid response from skilled staff who have mastered the cognitive, technical, and behavioral skills of neonatal resuscitation. Since its release in 1987, over 4.5 million clinicians have been trained by the American Heart Association and American Academy of Pediatrics Neonatal Resuscitation Program®. The guidelines used to develop this program were updated in 2020 and the Textbook of Neonatal Resuscitation, 8th edition, was released in June 2021. The updated guidelines have not changed the basic approach to neonatal resuscitation, which emphasizes the importance of anticipation, preparation, teamwork, and effective ventilation. Several practices have changed, including the prebirth questions, initial steps, use of electronic cardiac monitors, the initial dose of epinephrine, the flush volume after intravascular epinephrine, and the duration of resuscitation with an absent heart rate. In addition, the program has enhanced components of the textbook to improve learning, added new course delivery options, and offers 2 course levels to allow learners to study the material that is most relevant to their role during neonatal resuscitation. This review summarizes the recent changes to the resuscitation guidelines, the textbook, and the Neonatal Resuscitation Program course.

The newborn delivery room of tomorrow: emerging and future technologies

Advances in neonatal care have resulted in improved outcomes for high-risk newborns with technologies playing a significant part although many were developed for the neonatal intensive care unit. The care provided in the delivery room (DR) during the first few minutes of life can impact short- and long-term neonatal outcomes. Increasingly, technologies have a critical role to play in the DR particularly with monitoring and information provision. However, the DR is a unique environment and has major challenges around the period of foetal to neonatal transition that need to be overcome when developing new technologies. This review focuses on current DR technologies as well as those just emerging and further over the horizon. We identify what key opinion leaders in DR care think of current technologies, what the important DR measures are to them, and which technologies might be useful in the future. We link these with key technologies including respiratory function monitors, electoral impedance tomography, videolaryngoscopy, augmented reality, video recording, eye tracking, artificial intelligence, and contactless monitoring. Encouraging funders and industry to address the unique technological challenges of newborn care in the DR will allow the continued improvement of outcomes of high-risk infants from the moment of birth. IMPACT: Technological advances for newborn delivery room care require consideration of the unique environment, the variable patient characteristics, and disease states, as well as human factor challenges. Neonatology as a speciality has embraced technology, allowing its rapid progression and improved outcomes for infants, although innovation in the delivery room often lags behind that in the intensive care unit. Investing in new and emerging technologies can support healthcare providers when optimising care and could improve training, safety, and neonatal outcomes.

A critical appraisal of tools for delivery room assessment of the newborn infant

Assessment of an infant's condition in the delivery room represents a prerequisite to adequately initiate medical support. In her seminal paper, Virginia Apgar described five parameters to be used for such an assessment. However, since that time maternal and neonatal care has changed; interventions were improved and infants are even more premature. Nevertheless, the Apgar score is assigned to infants worldwide but there are concerns about low interobserver reliability, especially in preterm infants. Also, resuscitative interventions may preclude the interpretation of the score, which is of concern when used as an outcome parameter in delivery room intervention studies. Within the context of these changes, we performed a critical appraisal on how to assess postnatal condition of the newborn including the clinical parameters of the Apgar score, as well as selected additional parameters and a proposed new scoring system. The development of a new scoring system that guide clinicians in assessing infants and help to decide how to support postnatal adaptation is discussed. IMPACT: This critical paper discusses the reliability of the Apgar score, as well as additional parameters, in order to improve assessment of a newborn's postnatal condition. A revised neonatal scoring system should account for infant maturity and the interventions administered. Delivery room assessment should be directed toward determining how much medical support is needed and how the infant responds to these interventions.

Heart-rate agreement between ECG and a new, wireless device during early skin-to-skin contact

AIM

To assess the agreement of heart rate (HR) between the new device - a fabric jacket for neonates, with integrated sensors detecting ECG signals and a Bluetooth connection to a computer (ComfTech, HOWDY) - and the clinical reference, ECG, during the skin-to-skin contact (SSC) in the first 2 h after birth, for the potential use of early detection of Sudden and Unexpected Postnatal Collapse (SUPC).

METHODS

We enrolled newborns ≥35⁺⁰  weeks of gestation, with Apgar score >8 at 5 min in a prospective, observational study in the delivery room, excluding infants with need for resuscitation, clinical instability or major malformations. We assessed HR within 20 min after birth by both devices simultaneously: the index test ComfTech HOWDY and the standard ECG (Vita Guard VG 3100, Getemed). We compared HR between the two methods at 0, 15, 30, 45, 60, 90 and 120 min by the Bland-Altman plot.

RESULTS

We included 60 infants. The mean difference between the methods was -1.3 bpm, 95%LoA -12.4 to 9.7 bpm. Spearman rank correlation coefficient ρ = -0.06.

CONCLUSION

ComfTech HOWDY presents reliable agreement with the ECG and might assist in identifying infants at risk for SUPC.

Changes in heart rate from 5 s to 5 min after birth in vaginally delivered term newborns with delayed cord clamping

OBJECTIVE

To determine heart rate centiles during the first 5 min after birth in healthy term newborns delivered vaginally with delayed cord clamping.

DESIGN

Single-centre prospective observational study.

SETTING

Stavanger University Hospital, Norway, March-August 2019.

PATIENTS

Term newborns delivered vaginally were eligible for inclusion. Newborns delivered by vacuum or forceps or who received any medical intervention were excluded.

INTERVENTIONS

A novel dry electrode electrocardiography monitor (NeoBeat) was applied to the newborn's chest immediately after birth. The newborns were placed on their mother's chest or abdomen, dried and stimulated, and cord clamping was delayed for at least 1 min.

MAIN OUTCOME MEASURES

Heart rate was recorded at 1 s intervals, and the 3rd, 10th, 25th, 50th, 75th, 90th and 97th centiles were calculated from 5 s to 5 min after birth.

RESULTS

898 newborns with a mean (SD) birth weight 3594 (478) g and gestational age 40 (1) weeks were included. The heart rate increased rapidly from median (IQR) 122 (98-146) to 168 (146-185) beats per minute (bpm) during the first 30 s after birth, peaking at 175 (157-189) bpm at 61 s after birth, and thereafter slowly decreasing. The third centile reached 100 bpm at 34 s, suggesting that heart rates <100 bpm during the first minutes after birth are uncommon in healthy newborns after delayed cord clamping.

CONCLUSION

This report presents normal heart rate centiles from 5 s to 5 min after birth in healthy term newborns delivered vaginally with delayed cord clamping.

Delivery room ultrasound study to assess heart rate in newborns: DELIROUS study

During neonatal resuscitation in the delivery room, heart rate guides clinical intervention, and although different methods have been evaluated as auscultation, pulse oximetry, and electrocardiography, they have various limitations. This was a prospective observational study which aim was to evaluate the accuracy and speed of ultrasound for measuring neonatal heart rate compared with stethoscope, pulse oximetry, and electrocardiography. Simultaneous determinations of heart rate using stethoscope, ultrasound, pulse oximetry, and electrocardiography were performed. Fifty term newborns were included. There were no differences according to the turn on time of the ultrasound, pulse oximetry, and electrocardiography (p = 0.666), but the placement time and the detection time from birth were shorter for ultrasound (p < 0.001). A stronger positive correlation was detected between ultrasound and electrocardiography at 90 (Rho = 0.926), and 120 s (Rho = 0.920) with p < 0.001. The Bland-Altman analysis showed a bias of - 2.23 (p = 0.129) between ultrasound and electrocardiography at 90 s, and a bias of 0.44 (p = 0.092) at 120 s. Instead, the bias between auscultation and electrocardiography at 90 s was - 6.71 (p = 0.131), and at 120 s was of - 4.67 (p = 0.793).Conclusions: Ultrasound is a fast method to detect heart rate in the delivery room and has a good correlation with stethoscope and electrocardiography. What is Known: • During neonatal resuscitation in the delivery room, heart rate guides clinical intervention, and although different methods have been evaluated, they have various limitations. What is New: • Heart rate ultrasound is a good and fast method to detect HR in the delivery room with a good correlation with electrocardiography and stethoscope.

Innovations in Cardiorespiratory Monitoring to Improve Resuscitation With Helping Babies Breathe

Ninety percent of intrapartum-related neonatal deaths are attributable to respiratory depression, with the vast majority of these deaths occurring in low- and lower-middle-income countries. Neonatal resuscitation training with Helping Babies Breathe (HBB) decreases mortality from respiratory depression. Cardiorespiratory monitoring in conjunction with HBB can provide valuable resuscitation feedback for both training and bedside purposes. In this article, we discuss 3 innovations that couple cardiorespiratory monitoring with HBB: NeoNatalie Live, the Augmented Infant Resuscitator, and NeoBeat. NeoNatalie Live is a high-fidelity manikin that facilitates bag mask ventilation training through case scenarios of varying difficulty. The Augmented Infant Resuscitator is added in-line between a face mask and ventilation bag during bag mask ventilation training to provide users with real-time feedback on ventilation quality. NeoBeat is a battery-operated heart rate meter that digitally displays the newborn heart rate during bedside resuscitations. For each innovation, we review details of the device, implementation in the field, and areas for further research. Using early experience implementing these devices, we suggest building blocks for effective translation of training into improved care. We also highlight general challenges in implementation of devices in facilities in low- and lower-middle-income countries including considerations for training, adaptations to existing workflow, and integration into the ecosystem. Although the devices highlighted in this article hold promise, more data are needed to understand their impact on newborn outcomes.

Heart Rate Variability in the Perinatal Period: A Critical and Conceptual Review

Neonatal intensive care units (NICUs) greatly expand the use of technology. There is a need to accurately diagnose discomfort, pain, and complications, such as sepsis, mainly before they occur. While specific treatments are possible, they are often time-consuming, invasive, or painful, with detrimental effects for the development of the infant. In the last 40 years, heart rate variability (HRV) has emerged as a non-invasive measurement to monitor newborns and infants, but it still is underused. Hence, the present paper aims to review the utility of HRV in neonatology and the instruments available to assess it, showing how HRV could be an innovative tool in the years to come. When continuously monitored, HRV could help assess the baby’s overall wellbeing and neurological development to detect stress-/pain-related behaviors or pathological conditions, such as respiratory distress syndrome and hyperbilirubinemia, to address when to perform procedures to reduce the baby’s stress/pain and interventions, such as therapeutic hypothermia, and to avoid severe complications, such as sepsis and necrotizing enterocolitis, thus reducing mortality. Based on literature and previous experiences, the first step to efficiently introduce HRV in the NICUs could consist in a monitoring system that uses photoplethysmography, which is low-cost and non-invasive, and displays one or a few metrics with good clinical utility. However, to fully harness HRV clinical potential and to greatly improve neonatal care, the monitoring systems will have to rely on modern bioinformatics (machine learning and artificial intelligence algorithms), which could easily integrate infant’s HRV metrics, vital signs, and especially past history, thus elaborating models capable to efficiently monitor and predict the infant’s clinical conditions. For this reason, hospitals and institutions will have to establish tight collaborations between the obstetric, neonatal, and pediatric departments: this way, healthcare would truly improve in every stage of the perinatal period (from conception to the first years of life), since information about patients’ health would flow freely among different professionals, and high-quality research could be performed integrating the data recorded in those departments.

Heart Rate Assessment during Neonatal Resuscitation

Approximately 10% of newborn infants require some form of respiratory support to successfully complete the fetal-to-neonatal transition. Heart rate (HR) determination is essential at birth to assess a newborn’s wellbeing. Not only is it the most sensitive indicator to guide interventions during neonatal resuscitation, it is also valuable for assessing the infant’s clinical status. As such, HR assessment is a key step at birth and throughout resuscitation, according to recommendations by the Neonatal Resuscitation Program algorithm. It is essential that HR is accurate, reliable, and fast to ensure interventions are delivered without delay and not prolonged. Ineffective HR assessment significantly increases the risk of hypoxic injury and infant mortality. The aims of this review are to summarize current practice, recommended techniques, novel technologies, and considerations for HR assessment during neonatal resuscitation at birth.

Smartphone app for neonatal heart rate assessment: an observational study

BACKGROUND

Heart rate (HR) assessment is crucial in neonatal resuscitation, but pulse oximetry (PO) and electrocardiography (ECG) are rarely accessible in low-resource to middle-resource settings. This study evaluated a free-of-charge smartphone application, NeoTap, which records HR with a screen-tapping method bypassing mental arithmetic calculations.

METHODS

This observational study was carried out during three time periods between May 2015 and January 2019 in Uganda in three phases. In phase 1, a metronome rate (n=180) was recorded by low-end users (midwives) using NeoTap. In phase 2, HR (n=69) in breathing neonates was recorded by high-end users (paediatricians) using NeoTap versus PO. In phase 3, HR (n=235) in non-breathing neonates was recorded by low-end users using NeoTap versus ECG.

RESULTS

In high-end users the mean difference was 3 beats per minute (bpm) higher with NeoTap versus PO (95% agreement limits -14 to 19 bpm), with acquisition time of 5 seconds. In low-end users, the mean difference was 6 bpm lower with NeoTap versus metronome (95% agreement limits -26 to 14 bpm) and 3 bpm higher with NeoTap versus ECG in non-breathing neonates (95% agreement limits -48 to 53 bpm), with acquisition time of 2.7 seconds. The agreement between NeoTap and ECG was good in the HR categories of 60-99 bpm and ≥100 bpm; HR <60 bpm had few measurements (kappa index 0.71, 95% CI 0.63 to 0.79).

CONCLUSION

HR could be accurately and rapidly assessed using a smartphone application in breathing neonates in a low-resource setting. Clinical assessment by low-end users was less accurate with wider CI but still adds clinically important information in non-breathing neonates. The authors suggest low-end users may benefit from auscultation-focused training. More research is needed to evaluate its feasibility in clinical use.

Compliance with Guidelines and Efficacy of Heart Rate Monitoring during Newborn Resuscitation: A Prospective Video Study

OBJECTIVE

Newborn resuscitation guidelines recommend initial assessment of heart rate (HR) and initiation of positive pressure ventilation (PPV) within 60 s after birth in non-breathing newborns. Pulse oximeter (PO) and electrocardiogram (ECG) are suggested methods for continuous HR monitoring during resuscitation. Our aim was to evaluate compliance with guidelines and the efficacy of PO versus ECG monitoring in real-life newborn resuscitations.

METHODS

In this prospective observational study, we video recorded resuscitations of newborns ≥34 weeks of gestation receiving PPV at birth.

RESULTS

104 resuscitations were analysed. Median (IQR) time from birth to arrival at the resuscitation bay was 48 (22-68) s (n = 62), to initial HR assessment 70 (47-118) s (n = 61), and to initiation of PPV 78 (42-118) s (n = 62). Initial HR assessment (stethoscope or palpation) and initiation of PPV were achieved within 60 s for 35% of the resuscitated newborns. Time to initial HR assessment and initiating PPV was significantly longer following vaginal deliveries than caesarean sections: 84 (70-139) versus 44 (30-66) s (p < 0.001) and 93 (73-139) versus 38 (30-66) s (p < 0.001). Time from birth and sensor application to provision of a reliable HR signal from PO versus ECG was 348 (217-524) (n = 42) versus 174 (105-277) s (n = 30) (p < 0.001) and 199 (77-352) (n = 65) versus 16 (11-22) s (n = 52) (p < 0.001).

CONCLUSION

Initial HR assessment and initiation of PPV were achieved within 60 s after birth in only 1/3 of newborn resuscitations. When applied for continuous HR monitoring, ECG was superior to PO in time to achieve reliable HR signals in real-life resuscitations.

Doppler Ultrasound for Heart Rate Assessment in a Porcine Model of Neonatal Asphyxia

Objectives: Approximately 10% of newborn infants require resuscitation at birth. Accurate heart rate (HR) assessment guides resuscitation interventions, thereby reducing morbidities and mortality. While existing HR assessment methods have several limitations, the Doppler ultrasound (Doppler-US) might be a promising alternative. We aimed to evaluate accuracy and optimal use of Doppler-US for HR assessments during neonatal asphyxia in a pre-clinical model. Design: HR assessments were performed in 16 term newborn piglets that were anesthetized, intubated, and instrumented. Study I evaluated optimal transducer position, Study II compared aortic (AV) and pulmonary (PV) examination modes, and Study III examined accuracy during asphyxia, for HR assessment. Setting: Experimental setting. Subjects: Asphyxia-induced piglets. Interventions: Study I: Doppler-US (USCOM® 1A) HR was assessed on upper (A), middle (B), and lower (C) third of the sternum; study II: Doppler-US HR was assessed using AV and PV examination modes; study III: HR was assessed during asphyxia. Comparisons were made between Doppler-US and the clinical gold standard for HR assessments, electrocardiography (ECG). Measurements and Main Results: Study I: Mean (SD) Doppler-US HR at position A, B, and C showed no difference when compared to ECG HR. Study II: The mean (SD) Doppler-US HR using AV and PV modes also showed no difference when compared to ECG HR. Study III: Bland-Altman analysis revealed a mean difference (95% limits of agreement) between Doppler-US and ECG HR of 1.5 (-16 to 19) bpm. Additionally, motion artifacts produced false peaks and peak size was seen to decrease as bradycardia progressed. Conclusions: HR assessment using Doppler-US during asphyxia is accurate but has limitations and must be further evaluated prior to clinical use. Doppler-US can be positioned along the sternum and use either AV or PV mode for accurate assessments in a piglet model of neonatal asphyxia.

Delivery room handling of the newborn

For newly born babies, especially those in need of intervention at birth, actions taken during the first minute after birth, the so-called "Golden Minute", can have important implications for long-term outcomes. Both delivery room handling, including identification of maternal and infant risk factors and provision of effective resuscitation interventions, and antenatal care decisions regarding antenatal steroid administration and mode of delivery, are important and can affect outcomes. Anticipating risk factors for neonates at high risk of requiring resuscitation can decrease time to resuscitation and improve the prognosis. Following a review of maternal and fetal risk factors affecting newborn resuscitation, we summarize the current recommendations for delivery room handling of the newborn. This includes recommendations and rationale for the use of delayed cord clamping and cord milking, heart rate assessment [including the use of electrocardiogram (ECG) electrodes in the delivery room], role of suctioning in newborn resuscitation, and the impact of various ventilatory modes. Oxygenation should be monitored by pulse oximetry. Effects of oxygen and surfactant on subsequent pulmonary outcomes, and recommendations for provisions of appropriate thermoregulatory support are discussed. Regular teaching of delivery room handling should be mandatory.

Neonatal monitoring during delivery room emergencies

Fetal to neonatal transition after birth is a complex, well-coordinated process involving multiple organ systems. Any significant derangement in this process increases the risk of death and other adverse outcomes, underlying the importance of continuous monitoring to promptly detect and correct these derangements by effective resuscitative support. In recent years, there has been increasing efforts to move from subjective and discontinuous monitoring to more objective and continuous monitoring of different physiological parameters. Some of them like pulse oximetry for arterial oxygen saturation and electrocardiography for heart rate monitoring are now part of resuscitation guidelines whereas others like respiratory function monitoring, near infrared spectroscopy, or amplitude integrated electroencephalography are being evaluated. In this review, we describe some of the physiological parameters that can be monitored during delivery room emergencies and review the evidence for some of the monitoring technologies currently being evaluated.

Circulatory emergencies in the delivery room

The transition from fetal to neonatal life is a dramatic and complex process involving extensive physiologic changes, which are most obvious at the time of birth. Individuals who care for newly born infants must monitor the progress of the transition and be prepared to intervene when necessary. In the majority of births, this transition occurs without a requirement for any significant assistance. If newborns require assistance, the majority of the time respiratory support is all that is required. In some instances, however, there are circulatory emergencies that need to be rapidly identified or there may be dire consequences including death in the delivery room. This chapter will review various pathologies that are circulatory emergencies, and discuss how to assess them. We will also review new technologies which may help providers better understand the circulatory status or hemodynamic changes in the delivery room including heart rate, cardiac output, cerebral oxygenation and echocardiography.

Cardiac arrest with pulseless electrical activity rhythm in newborn infants: a case series

The 2015 neonatal resuscitation guidelines added ECG to assess an infant's heart rate when determining the need for resuscitation at birth. However, a recent case report raised concerns about this technique in the delivery room. We report four cases of pulseless electrical activity during neonatal cardiopulmonary resuscitation in levels II-III neonatal intensive care units in Canada (Edmonton [n=3] and Winnipeg [n=1]).Healthcare providers should be aware that pulseless electrical activity can occur in newborn infants during cardiopulmonary resuscitation. We propose an adapted neonatal resuscitation algorithm to include pulseless electrical activity. Furthermore, in compromised newborns, heart rate should be assessed using a combination of methods/techniques to ensure accurate heart rate assessment. When ECG displays a heart rate but the infant is unresponsive, pulseless electrical activity should be suspected and chest compression should be started.

A comparative evaluation of portable Doppler ultrasound versus electrocardiogram in heart-rate accuracy and acquisition time immediately after delivery: a multicenter observational study

BACKGROUND

The assessment of newborns' heart rate (HR) in the delivery room is one of the important steps to ascertain the need for initiation and continuation of resuscitation. At present, ECG is the "gold standard" to monitor neonatal HR in the delivery room. However, various limitations with the use of ECG exist. Furthermore, in developing countries, ECG may not be universally available in delivery rooms.

OBJECTIVE

To compare the accuracy and HR acquisition time of portable Doppler ultrasound (PDU) versus electrocardiogram (ECG) in newborns.

METHODS

This multicenter, prospective, observational study across five centers in India between January and September 2017 included neonates more than 34 weeks of gestation (n = 131) delivered by cesarean section. The accuracy of HR recorded by PDU (HR_PDU) versus that by ECG (HR_ECG) was the primary outcome. Secondary outcomes included time to acquisition of an audible and/or visible signal and device application.

RESULTS

Mean (±SD) gestational age and birthweight were 37.7 (±1.2) weeks and 2954 (±457) g, respectively. The mean (±SD) visible HR_PDU was 158 (±21) bpm versus HR_ECG of 161.3 (±20) bpm (p = .07) which were comparable. The median (1st, third quartile) time to acquisition of audible HR_PDU (76 [51, 91] s), was significantly shorter than that of HR_ECG (96.5 [74.2, 118] s; p < .001).

CONCLUSION

Portable Doppler has similar accuracy to ECG and is faster in acquiring the signal.

Who's counting? Assessing the effects of a simulation-based training intervention on the accuracy of neonatal heart rate auscultation

OBJECTIVE

To determine if simulation-based medical education could improve pediatric residents' ability to accurately assess neonatal heart rate via auscultation.

STUDY DESIGN

Primary outcomes included heart rate accuracy and Neonatal Resuscitation Program (NRP) group accuracy, defined as whether a heart rate estimation fell in the appropriate NRP algorithm group. Pediatric residents completed a pre-assessment and then participated in a simulation training intervention on high-fidelity manikins. Residents completed a post-assessment 1 month later.

RESULTS

Heart rate estimates from 21 pediatric residents showed improved overall heart rate accuracy and NRP group accuracy from 53.6 to 78.7% (p < 0.0001) and 68.3 to 80% (p = 0.0002), respectively. Residents were more likely to overestimate low heart rates and underestimate high heart rates.

CONCLUSION

Heart rate simulation-based training significantly improved residents' ability to assess heart rate on high-fidelity neonatal manikins. Providers participating in NRP may benefit by receiving heart rate skills assessment-focused training during an NRP provider course.

European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2019 Update

As management of respiratory distress syndrome (RDS) advances, clinicians must continually revise their current practice. We report the fourth update of "European Guidelines for the Management of RDS" by a European panel of experienced neonatologists and an expert perinatal obstetrician based on available literature up to the end of 2018. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, need for appropriate maternal transfer to a perinatal centre and timely use of antenatal steroids. Delivery room management has become more evidence-based, and protocols for lung protection including initiation of CPAP and titration of oxygen should be implemented immediately after birth. Surfactant replacement therapy is a crucial part of management of RDS, and newer protocols for its use recommend early administration and avoidance of mechanical ventilation. Methods of maintaining babies on non-invasive respiratory support have been further developed and may cause less distress and reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation using caffeine and, if necessary, postnatal steroids are also important considerations. Protocols for optimising general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome.

Non-perfusing cardiac rhythms in asphyxiated newborn piglets

Aim

We recently demonstrated that asphyxiated piglets commonly had bradycardia displayed on electrocardiography (ECG) while no carotid blood flow (CBF) or audible heart sounds could be detected. Such pulseless electrical activity (PEA) in newborn infants has not previously been thoroughly described. The aim of this study was to further investigate the occurrence of non-perfusing cardiac rhythms in asphyxiated piglets and the potential implications for the success of cardiopulmonary resuscitation (CPR) and short-term survival.

Methods

Neonatal piglets (1–4 days, 1.7–2.4kg) had their right common carotid artery exposed and enclosed with a real-time ultrasonic flow probe. Heart rate (HR) was continuously measured and recorded using ECG. This allowed simultaneous monitoring of HR via ECG and CBF. The piglets were asphyxiated until cardiac arrest, defined as no CBF and no audible beat upon precordial auscultation. CPR was performed until return of spontaneous circulation (ROSC, defined as a HR ≥100 bpm). ECG traces were retrospectively assessed.

Results

Nine out of 21 piglets (43%) had QRS-complexes on their ECG while no CBF and no audible heart sounds could be detected. Five (56%) of the piglets with PEA and 12/12 (100%) piglets with asystole at cardiac arrest obtained ROSC (p = 0.02). Thirty-three per cent of the piglets with PEA versus 58% with asystole survived to 4 hours post-ROSC (p = 0.39).

Conclusion

Cardiac arrest in the presence of a non-perfusing cardiac rhythm on ECG is common in asphyxiated piglets. Clinical arrest in the presence of a non-perfusing cardiac rhythm on ECG may reduce the success of CPR.

Pulseless electrical activity: a misdiagnosed entity during asphyxia in newborn infants?

BACKGROUND

The 2015 neonatal resuscitation guidelines added ECG as a recommended method of assessment of an infant's heart rate (HR) when determining the need for resuscitation at birth. However, a recent case report raised concerns about this technique in the delivery room.

OBJECTIVES

To compare accuracy of ECG with auscultation to assess asystole in asphyxiated piglets.

METHODS

Neonatal piglets had the right common carotid artery exposed and enclosed with a real-time ultrasonic flow probe and HR was continuously measured and recorded using ECG. This set-up allowed simultaneous monitoring of HR via ECG and carotid blood flow (CBF). The piglets were exposed to 30 min normocapnic alveolar hypoxia followed by asphyxia until asystole, achieved by disconnecting the ventilator and clamping the endotracheal tube. Asystole was defined as zero carotid blood flow and was compared with ECG traces and auscultation for heart sounds using a neonatal/infant stethoscope.

RESULTS

Overall, 54 piglets were studied with a median (IQR) duration of asphyxia of 325 (200-491) s. In 14 (26%) piglets, CBF, ECG and auscultation identified asystole. In 23 (43%) piglets, we observed no CBF and no audible heart sounds, while ECG displayed an HR ranging from 15 to 80/min. Sixteen (30%) piglets remained bradycardic (defined as HR of <100/min) after 10 min of asphyxia, identified by CBF, ECG and auscultation.

CONCLUSION

Clinicians should be aware of the potential inaccuracy of ECG assessment during asphyxia in newborn infants and should rather rely on assessment using a combination of auscultation, palpation, pulse oximetry and ECG.

Haemodynamic Instability and Brain Injury in Neonates Exposed to Hypoxia⁻Ischaemia

Brain injury in the asphyxic newborn infant may be exacerbated by delayed restoration of cardiac output and oxygen delivery. With increasing severity of asphyxia, cerebral autoregulatory responses are compromised. Further brain injury may occur in association with high arterial pressures and cerebral blood flows following the restoration of cardiac output. Initial resuscitation aims to rapidly restore cardiac output and oxygenation whilst mitigating the impact of impaired cerebral autoregulation. Recent animal studies have indicated that the current standard practice of immediate umbilical cord clamping prior to resuscitation may exacerbate injury. Resuscitation prior to umbilical cord clamping confers several haemodynamic advantages. In particular, it retains the low-resistance placental circuit that mitigates the rebound hypertension and cerebrovascular injury. Prolonged cerebral hypoxia⁻ischaemia is likely to contribute to further perinatal brain injury, while, at the same time, tissue hyperoxia is associated with oxidative stress. Efforts to monitor and target cerebral flow and oxygen kinetics, for example, using near-infrared spectroscopy, are currently being evaluated and may facilitate development of novel resuscitation approaches.

Pulseless Electrical Activity Complicating Neonatal Resuscitation

BACKGROUND

The most recent guidelines by the Neonatal Resuscitation Program recommend use of electrocardiography monitoring during advanced resuscitation.

OBJECTIVE

We describe a case in whom detection of pulseless electrical activity (PEA) on electronic heart rate monitoring complicated delivery room management of an extremely low birth weight infant and offer suggestions for the identification of PEA for neonatal providers.

CONCLUSION

Further prospective studies are needed to determine the true incidence of PEA in the delivery room setting as well as its prognosis in newborns.

Heart Rate Monitoring in Newborn Babies: A Systematic Review

BACKGROUND

Around 10% of newborn infants require assistance during transition after birth. Heart rate (HR) is the most important clinical indicator to evaluate the clinical status of a newborn.

AIM

Our study aimed to review all established and novel methods to detect HR in babies giving special consideration to non-invasive techniques.

METHODS

We performed a systematic literature search on the following databases: MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL. The inclusion criteria were studies on methods to detect HR in both term and preterm infants in comparison to one of the current gold standards: pulse oximetry (PO) or electrocardiography (ECG) published in the last 15 years. Two independent reviewers screened titles and abstracts for eligibility. Data extracted in an Excel table were analysed to produce a narrative review structured around the type of monitoring, identified obstacles in use, as well as methods to overcome these limitations.

RESULTS

The search revealed 649 studies after duplicates were removed. Full article analysis was performed on 26 studies of which 25 met the inclusion criteria. Well established methods such as auscultation and palpation, although rapid and easily available, have been shown to be inaccurate. ECG and PO were both more precise but the delay in obtaining a reliable HR signal from birth often exceeded 1-2 min. Novel sensors offered the advantages of minimally obtrusive technologies but have limitations mainly due to movement artefact, bad sensor coupling, intermittent measurement, and poor-quality recordings.

CONCLUSIONS

The limitations of existing methods have a potential impact on short- and long-term morbidity and mortality outcomes. The development of a technological solution to determine HR accurately and quickly in babies at birth has immense implications for further research and can guide interventions, such as placental transfusion and resuscitation.

Monitoring heart rate in the delivery room

Resuscitation algorithms and guidelines highlight the importance of heart rate (HR) in determining interventions and assessing their effect. However, the actual HR values used are historical based upon normal physiology, and HR at birth may be affected by mode of delivery and timing of cord clamping as well as respiratory status and condition at delivery. Furthermore, the most accurate and effective ways to assess and monitor HR in the newborn infant are only now becoming established. This article examines the importance of HR values and the most widely used methods of estimation as well as some newer modalities which are being developed.

Accurate and fast neonatal heart rate assessment with a smartphone-based application - a manikin study

AIM

This study determined the accuracy and speed of the NeoTapLifeSupport (NeoTapLS), a free smartphone application that aims to assess a neonate's heart rate.

METHODS

We asked 30 participants with a variety of backgrounds to test the NeoTapLS, which was developed by our own nonprofit organisation Tap4Life, to determine a randomly selected heart rate by auscultation or palpation. The study was carried out in 2014 at Sachs' Children and Youth Hospital, Sweden, using a Laerdal SimNewB manikin that simulates true values. The NeoTapLS calculates the heart rate based on the user's last three taps on the smartphone screen.

RESULTS

A total of 1200 measurements were carried out. A high correlation was found between measured and true values by auscultation (correlation coefficient 0.993) as well as by palpation (correlation coefficient 0.986) with 93.5% of the auscultations and 86.3% of the palpations differing from the true value by five beats or fewer. The mean time to the first estimated heart rate was 14.9 seconds for auscultation and 16.3 seconds for palpation.

CONCLUSION

Heart rates could be accurately and rapidly assessed using the NeoTapLS on a manikin. A globally accessible mobile health system could offer a low-cost alternative to expensive medical equipment.

Baby-directed umbilical cord clamping: A feasibility study

INTRODUCTION

Over five percent of infants born worldwide will need help breathing after birth. Delayed cord clamping (DCC) has become the standard of care for vigorous infants. DCC in non-vigorous infants is uncommon because of logistical difficulties in providing effective resuscitation during DCC. In Baby-Directed Umbilical Cord Clamping (Baby-DUCC), the umbilical cord remains patent until the infant's lungs are exchanging gases. We conducted a feasibility study of the Baby-DUCC technique.

METHODS

We obtained antenatal consent from pregnant women to enroll infants born at ≥32 weeks. Vigorous infants received ≥2 min of DCC. If the infant received respiratory support, the umbilical cord was clamped ≥60 s after the colorimetric carbon dioxide detector turned yellow. Maternal uterotonic medication was administered after umbilical cord clamping. A paediatrician and researcher entered the sterile field to provide respiratory support during a cesarean birth. Maternal and infant outcomes in the delivery room and prior to hospital discharge were analysed.

RESULTS

Forty-four infants were enrolled, 23 delivered via cesarean section (8 unplanned) and 15 delivered vaginally (6 via instrumentation). Twelve infants were non-vigorous. ECG was the preferred method for recording HR. Two infants had a HR < 100 BPM. All HR values were >100 BPM by 80 s after birth. Median time to umbilical cord clamping was 150 and 138 s in vigorous and non-vigorous infants, respectively. Median maternal blood loss was 300 ml.

CONCLUSIONS

It is feasible to provide resuscitation to term and near-term infants during DCC, after both vaginal and cesarean births, clamping the umbilical cord only when the infant is physiologically ready.

3-lead electrocardiogram is more reliable than pulse oximetry to detect bradycardia during stabilisation at birth of very preterm infants

OBJECTIVES

Current neonatal resuscitation guidelines suggest the use of ECG in the delivery room (DR) to assess heart rate (HR). However, reliability of ECG compared with pulse oximetry (PO) in a situation of bradycardia has not been specifically investigated. The objective of the present study was to compare HR monitoring using ECG or PO in a situation of bradycardia (HR <100 beats per minute (bpm)) during preterm stabilisation in the DR.

STUDY DESIGN

Video recordings of resuscitations of infants <32 weeks of gestation were reviewed. HR readings in a situation of bradycardia (<100 bpm) at any moment during stabilisation were registered with both devices every 5 s from birth.

RESULTS

A total of 29 episodes of bradycardia registered by the ECG in 39 video recordings were included in the analysis (n=29). PO did not detect the start of these events in 20 cases (69%). PO detected the start and the end of bradycardia later than the ECG (median (IQR): 5 s (0-10) and 5 s (0-7.5), respectively). A decline in PO accuracy was observed as bradycardia progressed so that by the end of the episode PO offered significantly lower HR readings than ECG.

CONCLUSIONS

PO detects the start and recovery of bradycardia events slower and less accurately than ECG during stabilisation at birth of very preterm infants. ECG use in this scenario may contribute to an earlier initiation of resuscitation manoeuvres and to avoid unnecessary prolongation of resuscitation efforts after recovery.

A pilot randomized controlled trial of EKG for neonatal resuscitation

BACKGROUND

The seventh edition of the American Academy of Pediatrics Neonatal Resuscitation Program recommends the use of a cardiac monitor in infants that need resuscitation. Previous trials have shown that EKG heart rate is available before pulse rate from a pulse oximeter. To date no trial has looked at how the availability of electrocardiogram (EKG) affects clinical interventions in the delivery room.

OBJECTIVE

To determine whether the availability of an EKG heart rate value and tracing to the clinical team has an effect on physiologic measures and related interventions during the stabilization of preterm infants.

DESIGN/METHODS

Forty (40) premature infants enrolled in a neuro-monitoring study (The Neu-Prem Trial: NCT02605733) who had an EKG monitor available were randomized to have the heart rate information from the bedside EKG monitor either displayed or not displayed to the clinical team. Heart rate, oxygen saturation, FiO2 and mean airway pressure from a data acquisition system were recorded every 2 seconds. Results were averaged over 30 seconds and the differences analyzed using two-tailed t-test. Interventions analyzed included time to first change in FiO2, first positive pressure ventilation, first increase in airway pressure, and first intubation.

RESULTS

There were no significant differences in time to clinical interventions between the blinded and unblinded group, despite the unblinded group having access to a visible heart rate at 66 +/- 20 compared to 114 +/- 39 seconds for the blinded group (p < .0001). Pulse rate from oximeter was lower than EKG heart rate during the first 2 minutes of life, but this was not significant.

CONCLUSION(S)

EKG provides an earlier, and more accurate heart rate than pulse rate from an oximeter during stabilization of preterm infants, allowing earlier intervention. All interventions were started earlier in the unblinded EKG group but these numbers were not significant in this small trial. Earlier EKG placement before pulse oximeter placement may affect other interventions, but this needs further study.

Handheld fetal Doppler device for assessing heart rate in neonatal resuscitation

BACKGROUND

The use of neonatal three-lead electrocardiograms (Neo-ECG) is suggested for the assessment of heart rate (HR) in neonatal resuscitation, but primary childbirth facilities (i.e. maternity clinics or maternity homes) are not sufficiently equipped for this. The aim of this study was to therefore to confirm the potential of a handheld fetal Doppler device (FDD), widely used to assess HR in labor room resuscitation, and to compare its equivalency to Neo-ECG.

METHODS

In low-risk full-term infants, HR was measured five times per minute in minutes 1-5 after delivery using the FDD and Neo-ECG, and their equivalence compared. The equivalence margin was set at a HR difference of <±5 beats/min and <±5%. Moreover, the times at which HR was displayed were measured for both methods.

RESULTS

FDD and Neo-ECG HR correlated strongly (r = 0.977) in 155 measurements in 33 cases. The mean HR difference was -0.123 beats/min (95%CI: -0.594 to +0.345), and the logarithmic transformation of the HR ratio was -0.0003 (95%CI: -0.0020 to +0.0015). The mean HR difference and HR ratio were within the equivalence margin. For HR assessment using the FDD, 155 of 165 measurements (93.9%) could be obtained in <10 s.

CONCLUSIONS

In HR assessment, FDD is a valid substitute for Neo-ECG in primary childbirth facilities that are not sufficiently equipped for Neo-ECG.

A systematic review of novel technology for monitoring infant and newborn heart rate

Heart rate (HR) is a vital sign for assessing the need for resuscitation. We performed a systematic review of studies assessing novel methods of measuring HR in newborns and infants in the neonatal unit. Two investigators completed independent literature searches. Identified papers were independently evaluated, and relevant data were extracted and analysed.

CONCLUSION

This systematic review identified seven new technologies, including camera-based photoplethysmography, reflectance pulse oximetry, laser Doppler methods, capacitive sensors, piezoelectric sensors, electromyography and a digital stethoscope. Clinicians should be aware of several of these, which may become available for clinical use in the near future.

Incidence and characteristics of positive pressure ventilation delivered to newborns in a US tertiary academic hospital

INTRODUCTION

The Neonatal Resuscitation Program (NRP) guidelines recommend positive pressure ventilation (PPV) in the first 60s of life to support perinatal transition in non-breathing newborns. Our aim was to describe the incidence and characteristics of newborn PPV using real-time observation in the delivery unit.

METHODS

Prospective, observational, quality improvement study conducted at a tertiary academic hospital. Deliveries during randomized weekday/evening 8-h shifts were attended by a trained observer. Intervention data were recorded for all newborns with gestational age (GA) ≥34wks that received PPV. Descriptive summaries and Kruskal-Wallis test for continuous variables and Fisher's exact test for categorical variables were used to compare characteristics.

RESULTS

Of 1135 live deliveries directly observed over 18mos, 64 (6%) newborns with a mean GA 39±2wks received PPV: Median time from birth to warmer was 20s (IQR 15-22s); PPV was initiated within 60s of life in 29 (45%) and between 60 and 90s of life in 17 (27%). PPV duration was <120s in 38 (60%). Seven/21 (33%) newborns that received PPV after vaginal delivery were not pre-identified and resuscitation team was alerted after delivery. We found no association between PPV start time and duration of PPV (p=0.86).

CONCLUSION

We observed that most (94%) term newborns spontaneously initiate respirations. In over half observed deliveries receiving PPV, time to initiation of PPV was greater than 60s (longer than recommended). Compliance with current NRP guidelines is difficult, and it's not clear whether it is the recommendations or the training to achieve PPV recommendations that should be modified.

Measurement of neonatal heart rate using handheld Doppler ultrasound

OBJECTIVE

This pilot study aimed to determine whether handheld Doppler ultrasound is feasible and reliable for measuring neonatal heart rate (HR) when compared with ECG.

SETTING

Stable newborns were recruited from the neonatal intensive care unit and postnatal ward between July 2014 and January 2015 at Royal North Shore Hospital, Sydney, Australia.

INTERVENTIONS

Each newborn had their HR recorded every 15 s over 145 s using four different modalities: ECG, counted audible Doppler (AD) over 10 s, pulse oximetry (PO) and the Doppler display (DD).

OUTCOME MEASURES

The correlation and variation between each modality and ECG.

RESULTS

51 newborns with a median gestational age of 38 weeks (27-41) and a mean weight of 2.78 kg (0.82 to 4.76) with a median postnatal age of 3 days (0-87) were studied. There was a mean difference of 0.69 bpm (95% CI -2.9 to +1.5) between AD-HR and ECG-HR with good correlation between modalities (r=0.94, p<0.01). The median time to achieve AD-HR was 3 s (1-45). The mean difference between DD-HR and ECG-HR was 5.37 bpm (95% CI -12.8 to +2.1) with moderate correlation (r=0.37, p=0.04). The mean difference between PO-HR and ECG-HR was 0.49 bpm (95% CI -1.5 to +0.51) with good correlation (r=0.99, p<0.01). The variability between AD-HR and ECG-HR decreased with decreasing weight.

CONCLUSIONS

AD-HR correlates well with ECG-HR. Further research in the delivery room is recommended before using AD-HR in this area.

European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2016 Update

Advances in the management of respiratory distress syndrome (RDS) ensure that clinicians must continue to revise current practice. We report the third update of the European Guidelines for the Management of RDS by a European panel of expert neonatologists including input from an expert perinatal obstetrician based on available literature up to the beginning of 2016. Optimizing the outcome for babies with RDS includes consideration of when to use antenatal steroids, and good obstetric practice includes methods of predicting the risk of preterm delivery and also consideration of whether transfer to a perinatal centre is necessary and safe. Methods for optimal delivery room management have become more evidence based, and protocols for lung protection, including initiation of continuous positive airway pressure and titration of oxygen, should be implemented from soon after birth. Surfactant replacement therapy is a crucial part of the management of RDS, and newer protocols for surfactant administration are aimed at avoiding exposure to mechanical ventilation, and there is more evidence of differences among various surfactants in clinical use. Newer methods of maintaining babies on non-invasive respiratory support have been developed and offer potential for greater comfort and less chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease although minimizing the time spent on mechanical ventilation using caffeine and if necessary postnatal steroids are also important considerations. Protocols for optimizing the general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome.

Optimising Intravenous Volume Resuscitation of the Newborn in the Delivery Room: Practical Considerations and Gaps in Knowledge

Volume resuscitation (VR) for the treatment of newborn shock is a rare but potentially lifesaving intervention. Conducting clinical studies to assess the effectiveness of VR in the delivery room during newborn stabilization is challenging. We review the available literature and current management guidelines to determine which infants will benefit from VR, the frequency of VR, and the choice of agents used. In addition, the potential role for placental transfusion in the prevention of newborn shock is explored.