During the transition from intrauterine to extrauterine life, the NB may require routine care or initial stabilisation measures (“support of transition”) that are different from “resuscitation measures”.

Delayed cord clamping (DCC) 30–60s after birth is recommended in term NBs and preterm NBs that do not require resuscitation. As yet there is insufficient evidence to support cord milking as an alternative, and milking is contraindicated in NBs of less than 28 weeks’ gestational age (GA) because there is no evidence on its safety. We emphasise the importance of the “golden minute” mark for completing the initial steps, evaluating the state of the NB and avoiding unnecessary delays in the initiation of ventilation when it is required by the NB.

The temperature of nonasphyxiated NBs should be maintained between 36.5°C and 37.5°C after birth and through admission.

Electrocardiographic data should be used to estimate heart rate (HR) faster and more accurately to facilitate decision-making.

Routine endotracheal intubation and suctioning is not recommended in nonvigorous NBs, and should only be performed for suspected tracheal obstruction. The emphasis should be on initiating ventilation within the first minute of life.

The initial use of room air is still recommended in term NBs. Low oxygen concentrations (21–30%) are recommended in patients born before 32 weeks’ gestation if they exhibit laboured breathing. Higher concentrations should be considered if oxygen saturation continues to be inadequate despite adequate ventilation.6

There is growing evidence supporting the recommendation of its use in preterm NBs delivered before 30 weeks’ gestation with spontaneous but laboured breathing to avoid intubation and mechanical ventilation.

The use of positive-end respiratory pressure (PEEP) is recommended in ventilated preterm NBs.

There are many points of contention in relation to the use of initial supportive measures in the NB: resuscitation at the limit of viability, Apgar score of 0 at 10min from the start of resuscitation as a predictor of morbidity and mortality, respiratory monitoring, capnography, or the clinical use of sustained inflation (SI), among others, and different randomised studies have been proposed.

The temperature of nonasphyxiated NBs should be maintained between 36.5°C and 37.5°C, and this is increasingly important with decreasing gestational age (GA). Skin-to-skin contact with ongoing monitoring of the NB is preferable to any other source of warmth, as it decreases heat losses by 50% to 90% and promotes bonding.

Delayed cord clamping (by 30–60s) is recommended in NBs that do not require resuscitation.2 There is insufficient data to recommend it in NBs that require resuscitation or to recommend cord milking (of 20cm of umbilical cord, 3 times, with NB held at the level of the introitus) as an alternative. The only clinical study published recently on the subject analysed preterm NBs delivered before 32 weeks’ gestation by caesarean section, and found an improvement in systemic blood flow after cord milking compared to DCC that was not observed in NBs delivered vaginally.8 One drawback of DCC studies is that they have not been designed to aerate the lungs prior to clamping the cord. Katheria et al. reviewed the existing evidence and recommendations regarding initiation of ventilation prior to DDC.9 Ongoing clinical trials with initiation of ventilation prior to DCC that will study neurodevelopmental outcomes will guide future recommendations.

Three-lead ECG is the fastest and most accurate method for measuring HR.10 However, early data should be interpreted with caution to avoid unnecessary resuscitation measures, especially in extremely preterm NBs in whom immediate cord clamping prior to initiation of ventilation leads to transient bradycardia (<100bpm) that improves with lung aeration.11 The use of ECG supplements but does not replace pulse oximetry and auscultation for the assessment of oxygen saturation and ventilation, respectively. The ILCOR guidelines1 did not specify an order for the use of different monitoring methods; one possible arrangement would be to assign the following sequence of tasks to the second resuscitator: auscultation, placement of pulse oximeter, and placement of ECG leads to increase monitoring accuracy.

The ventilatory values associated with the establishment of an adequate functional residual capacity (FRC) have yet to be determined in clinical practice. Respiratory function monitors and capnographs offer valuable information on tidal volume: they can be used to optimise ventilation, prevent volutrauma or barotrauma and detect adverse events.12 Further research is required to determine adequate tidal volumes for GA so that they can be used as objective paramenters13 to adjust inspiratory pressure and thus minimise lung damage during neonatal stabilisation.

Guidelines have reviewed the various improvements applied in the establishment of adequate FRCs or lung volumes, and there is an open debate on the monitoring of the volumes delivered during preterm NB resuscitation.1,14

On the other hand, the efficacy of SI with prolonged inspiration times in establishing better FRC levels in the transition of NBs with no spontaneous breathing has also been evaluated.15 Our algorithm does not include SI because there is no evidence that it improves long-term morbidity, it is associated with an increased incidence of pneumothorax,16 and there is no standardised procedure for its administration,17 although experiments have demonstrated its efficacy15 (its use is accepted in the context of research) and a clinical trial showed that it decreases the need for intubation and for mechanical ventilation in the first 72h of life.16

We recommend the use of continuous positive airway pressure in term NBs with spontaneous breathing and respiratory distress, although there are not sufficient data on its efficacy and some authors have even warned of the dangers of its excessive use in this age group.

According to the ILCOR,1 the existing evidence does not support recommending a specific ventilation interface (T-tube vs different masks). When intubation is not feasible and after IPPV fails, the use of a supreme laryngeal mask is recommended in the resuscitation of NBs delivered at 34 or more weeks’ gestation. Future studies should assess the effectiveness of its use as the initial interface in reducing the need for intubation.18

Monitoring by pulse oximetry should be established in all NBs in whom the need of resuscitation is anticipated based on their clinical condition or persisting central cyanosis.

The ERC3 has set up target oxygen saturation values at the 25th percentile of the normal SpO2 distribution in the first 10min of life,6 similar to the target set by AHA.4 A recent clinical trial found a higher mortality in the subset of newborns delivered before 29 weeks’ gestation resuscitated in room air (16.2%) compared to the group resuscitated with 100% oxygen (6%; P=.013).19 A retrospective cohort study found an increased risk of severe neurologic impairment or death in NBs delivered at 27 or fewer weeks’ gestation following the change in 2006 of the practice of initiating resuscitation with high oxygen concentrations (100%) versus intermediate concentrations (21–40%).20 Following the publication of these recommendations, there have been studies by other groups analysing initial FiO2 values21,22 in the management of moderate to late preterm NBs, and their adjustment after initiation of oxygen supplementation. Due to a lack of clinical trials with representative samples, caution must be exercised in the management of preterm NBs when resuscitation is initiated with room air and in the application of target preductal SpO2 values used to determine adjustments in FiO2. The GRN-SENeo has set the minimum value of SpO2 as above the 15th percentile of the nomograph6 in the first 5min of life.

The current evidence does not suffice to recommend a specific range of glycaemia based on its association to decreased neurologic damage following reanimation of asphyxiated NBs. Sussman et al. have proposed a lower limit of normal of 60mg/dL.24

Studies in neonates25 and experiments in asphyxiated newborn models26 have found an association between hypoglycaemia and adverse neurologic outcomes and decreased survival. Different studies have demonstrated that hyperglycaemia in hypoxic NBs is not associated with adverse outcomes and can even have a protective effect.25,27 However, a recent study that included 528 NBs delivered at 35 or more weeks’ gestation found neurodevelopmental impairment in NBs with higher blood glucose levels, even when they were within the normal range (47–150mg/dL).28 In asphyxiated NBs, IV glucose infusion should be initiated during stabilisation to maintain a blood glucose level between 47 and 150mg/dL.

In nonasphyxiated NBs, body temperature is a strong predictor of morbidity and mortality and a quality indicator in all GAs, and especially in preterm NBs. There is evidence of a dose-dependent effect on mortality, with risk increasing by at least 28% with each degree of temperature at admission below 36.5°C.29 The new algorithm calls for maintaining an axillary temperature of 36.5–37.5°C, avoiding hypothermia and hyperthermia.1

International neonatal resuscitation guidelines, with the exception of those by the AHA,4 do not specify the GA from which the use of hypothermia is indicated. All guidelines agree that clearly defined and consistent protocols developed in randomised clinical trials must be applied in the management of moderate to severe hypoxic-ischaemic encephalopathy. In Spain, this approach has been indicated in NBs delivered at 35 or more weeks’ gestation since 2011 (national guidelines for neuroprotection,30 multicentre national programmes31), and different review studies and clinical trials32 have indicated its use and included NBs delivered at 35 or more weeks’ gestation. Its neuroprotective effects are time-dependent, so passive cooling to core temperatures of 33–34°C should be initiated in patients at risk.33 Active hypothermia should be initiated before 6h of life, but if it is started before 3h it is associated with improved outcomes, especially in the most severe cases.34 This is an advance in that this technique can be applied in countries and settings with few resources.1,3

Fig. 4 shows the algorithm for the resuscitation of preterm newborns less than 32 weeks’ GA developed by the GRN-SENeo.

Figure 4.

Algorithm for the resuscitation of preterm newborns less than 32 weeks’ gestational age.

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Prognostic score: the 2015 ILCOR guidelines reviewed the evidence for the use of a convenient prognostic score to predict survival at ages 1 month and 18–22 months compared to only GA in preterm NBs of less than 25 weeks’ GA. There is not enough evidence in support of its prognostic value.35 It would be reasonable to consider other variables, such as the estimated foetal weight, sex, prenatal corticosteroid exposure, oligohydramnios, single vs multiple pregnancy, history of chorioamnionitis, level of care of the medical facility, and clinical practice guidelines.

Temperature: maintaining NB temperature is essential during delivery (ambient temperature of 23–25°C in the delivery room, thermal mattresses, plastic wrap, caps), admission and stabilisation.

Oxygen administration: initial FiO2 with room air is limited to NBs delivered at 30 or more weeks’ gestation and NBs delivered before 30 weeks’ gestation with no respiratory distress, increasing it to 0.3 in the latter if they have respiratory distress. Target preductal SpO2 values increase above the 10th percentile over the first 3min of life, and 60% (15th percentile) is considered a normal value.

Sustained inflation (>5 s): its use is not recommended in preterm NBs without spontaneous breathing, but SI could be considered in specific clinical situations on a case-to-case basis.

PEEP: the use of PEEP is beneficial for preterm NBs with apnoea that require IPPV; more randomised studies are required to assess its benefits.

Cord milking: it is contraindicated in patients born before 28 weeks’ gestation, as there are no data on its safety or long-term beneficial effects.

The prophylactic endotracheal intubation and suctioning of nonvigorous NBs with MSAF was a controversial issue in the 2010 guidelines. A recent clinical study conducted in India by Chettri et al.36 addressed this issue. In this study, 122 patients were randomly assigned to one of two groups: intubation with IPPV versus endotracheal suctioning followed by IPPV. A similar study conducted in India was presented at the annual conference of the Indian Academy of Paediatrics of 2014.37 Neither study found a difference between the groups. The ILCOR recommendations remain open to three treatment options: “consider in individual cases but do not perform routinely, consider it only if obstruction is suspected or against the recommendation.”1,3,4,38 Our group considers that endotracheal intubation should not be performed routinely in nonvigorous NBs with MSAF, and that the general algorithm should be applied to these NBs. Orotracheal examination and suctioning may be considered if there are signs of airway obstruction by meconium even if ventilation has been initiated and if the resuscitator is experienced in intubation. Repeated intubation is not recommended, and the most important goal is to prevent delays in resuscitation measures, with particular emphasis on initiating ventilation in the first minute of life (Fig. 5).

Figure 5.

Algorithm for the resuscitation of nonvigorous newborns with meconium-stained amniotic fluid.

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