2023 American Heart Association and American Academy of Pediatrics Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Enhancing neonatal resuscitation outcomes: bridging theory and practice

Neonatal resuscitation practices have undergone tremendous changes over the past two decades, with progress accelerating due to advances in medical technology, scientific research, and improvements in clinical practices. Among other global frameworks, the neonatal resuscitation program has been periodically updated to incorporate evidence-based interventions aimed at improving survival rates, reducing morbidity and enhancing long-term health outcomes for newborns. This review traces the historical development of neonatal resuscitation guidelines from the early days' resuscitation practices of the mid-twentieth century to the present day. It narrates how clinical needs, emerging technologies, and scientific discoveries have shaped the evolution of these guidelines and practices. By reviewing recent guidelines, such as those issued by the American Heart Association and the World Health Organization, this article sheds light on the current core principles of neonatal resuscitation, including effective airway management, appropriate ventilation techniques, and the critical importance of timely intervention. The major determinants of changes in guidelines, as identified through this review, include advancements in scientific research, expert opinion, and international collaboration. Challenges in implementing these guidelines, particularly in low-resource settings, are discussed, along with case studies that demonstrate the impact of updated practices in real-world clinical environments.

CONCLUSION

 The review concludes with a reflection on the continued need for research to close remaining gaps and enhance neonatal resuscitation practices across diverse global contexts.

WHAT IS KNOWN

• Effective neonatal resuscitation significantly improves outcomes by reducing neonatal mortality and morbidity. • Neonatal resuscitation program provides standardized protocols to implement these resuscitation skills.

WHAT IS NEW

• Simulation-based training and real-time feedback can bridge the gap between theoretical guidelines and practical application. • Despite advances in knowledge and application of these guidelines, challenges persist, such as regional differences, lack of resources in lower-income countries, and ideal ventilation devices and oxygenation methods.

Advances in neonatal resuscitation for the obstetric anesthesiologist

PURPOSE OF REVIEW

This review provides an updated overview of neonatal resuscitation practices relevant to obstetric anesthesiologists, with a focus on term and late preterm neonates (>34 weeks' gestation). Key topics include umbilical cord management, temperature regulation, airway strategies, and pharmacological interventions, emphasizing evidence-based approaches.

RECENT FINDINGS

Delayed cord clamping enhances neonatal outcomes, including improved blood volume and oxygenation. Positive pressure ventilation remains the cornerstone of neonatal resuscitation, with early initiation reducing mortality. Supraglottic airways are emerging as effective alternatives to face masks. Advances in epinephrine administration and dosing show promise, though evidence gaps persist. Simulation-based training, telemedicine, and artificial intelligence are advancing skill retention and resuscitation support.

SUMMARY

Recent advancements in neonatal resuscitation focus on precision in ventilation, thermoregulation, and airway management. Obstetric anesthesiologists play a critical role in neonatal emergencies, underscoring the need for continuous training and the integration of emerging technologies like artificial intelligence to optimize neonatal outcomes.

Resuscitation With Placental Circulation Intact Compared With Cord Milking: A Randomized Clinical Trial

Importance

Among preterm newborns undergoing resuscitation, delayed cord clamping for 60 seconds is associated with reduced mortality compared with early clamping. However, the effects of longer durations of cord clamping with respiratory support are unknown.

Objective

To determine whether resuscitating preterm newborns while keeping the placental circulation intact and clamping the cord after a long delay would improve outcomes compared with umbilical cord milking.

Design, Setting, and Participants

This randomized clinical trial (PCI Trial) was conducted at 8 Italian neonatal intensive care units from April 2016 through February 2023 and enrolled preterm newborns born between 23 weeks 0 days and 29 weeks 6 days of gestation from singleton pregnancies.

Interventions

Enrolled newborns were randomly allocated to receive at-birth resuscitation with intact placental circulation for 180 seconds or umbilical cord milking followed by an early cord clamping (within 20 seconds of life).

Main Outcomes and Measures

The primary outcome was the composite end point of death, grade 3 to 4 intraventricular hemorrhage, and bronchopulmonary dysplasia at 36 weeks of postconception age. Prespecified secondary end points were the single components of the composite primary outcome. An intention-to-treat analysis was conducted.

Results

Of 212 mother-newborn dyads who were randomized, 209 (median [IQR] gestational age, 27 [26-28] weeks; median [IQR] birth weight, 900 [700-1070] g) were enrolled in the intention-to-treat population; 105 were randomized to the placental circulation intact group, and 104 were randomized to the cord milking group. The composite outcome of death, grade 3 to 4 intraventricular hemorrhage, or bronchopulmonary dysplasia occurred in 35 of 105 newborns (33%) in the placental circulation intact group vs 39 of 104 newborns (38%) in the cord milking group (odds ratio, 0.83; 95% CI, 0.47-1.47; P = .53).

Conclusions and Relevance

In a randomized clinical trial of preterm newborns at 23 to 29 weeks' gestational age, intact placental resuscitation for 3 minutes did not lower the composite outcome of death, grade 3 to 4 intraventricular hemorrhage, or bronchopulmonary dysplasia compared with umbilical cord milking.

Trial Registration

Clinicaltrials.gov Identifier: NCT02671305.

Hypoxic-ischaemic encephalopathy code: A systematic review for resource-limited settings

It is estimated that 96% of infants with hypoxic-ischaemic encephalopathy (HIE) are born in resource-limited settings with no capacity to provide the standard of care that has been established for nearly 15 years in high-resource countries, which includes therapeutic hypothermia (TH), continuous electroencephalographic monitoring and magnetic resonance imaging (MRI) in addition to close vital signs and haemodynamic monitoring. This situation does not seem to be changing; however, even with these limitations, currently available knowledge can help improve the care of HIE patients in resource-limited settings. The purpose of this systematic review was to provide, under the term "HIE Code", evidence-based recommendations for feasible care practices to optimise the care of infants with HIE and potentially help reduce the risks associated with comorbidity and improve neurodevelopmental outcomes. The content of the HIE code was grouped under 9 headings: (1) prevention of HIE, (2) resuscitation, (3) first 6h post birth, (4) identification and grading of encephalopathy, (5) seizure management, (6) other therapeutic interventions, (7) multiple organ dysfunction, (8) diagnostic tests and (9) family care.