Elsevier

The Lancet

Volume 389, Issue 10079, 22–28 April 2017, Pages 1639-1648
The Lancet

Series
Towards evidence-based resuscitation of the newborn infant

https://doi.org/10.1016/S0140-6736(17)30547-0Get rights and content

Summary

Effective resuscitation of the newborn infant has the potential to save many lives around the world and reduce disabilities in children who survive peripartum asphyxia. In this Series paper, we highlight some of the important advances in the understanding of how best to resuscitate newborn infants, which includes monitoring techniques to guide resuscitative efforts, increasing awareness of the adverse effects of hyperoxia, delayed umbilical cord clamping, the avoidance of routine endotracheal intubation for extremely preterm infants, and therapeutic hypothermia for hypoxic–ischaemic encephalopathy. Despite the challenges of performing high-quality clinical research in the delivery room, researchers continue to refine and advance our knowledge of effective resuscitation of newborn infants through scientific experiments and clinical trials.

Introduction

Although the transition from fetal to newborn life involves considerable changes to the infant's cardiovascular and respiratory systems, most newborn infants adapt without assistance. About 3% of newborn infants need positive-pressure ventilation at birth, fewer infants will receive endotracheal intubation, and cardiac compressions or epinephrine administration are needed in less than 1% of births.1, 2, 3 Nevertheless, WHO estimates that one million newborn infants die from peripartum asphyxia each year. Children who survive asphyxia have a high risk of long-term neurological disability. Effective resuscitation of newborn infants has the potential to improve survival free of disability.

In this Series paper, we will summarise the evidence supporting existing resuscitation techniques and post-asphyxial care for newborn infants. Much of the included research has been undertaken in high-income countries, and we recommend against extrapolation of these results to clinical settings in low-income and middle-income countries. To provide a broad overview of neonatal resuscitation, we have included many important studies and systematic reviews. We have not undertaken an original systematic review or attempted to perform original pooled analyses of data for each included topic. Related topics, including surfactant administration, mechanical ventilation, and non-invasive respiratory support after resuscitation, are discussed in an accompanying paper in this Series by Owen and colleagues.4

Section snippets

The physiological transition from fetal to newborn life

Caring for infants during the transition from fetal to newborn life is challenging because the airways are initially liquid-filled and pulmonary blood flow is low. However, as the lungs aerate, there are risks of over-distension, lung injury, and hyperoxia. Awareness of the physiological processes that an infant undergoes during transition to newborn life is essential to providing safe and effective care.

Monitoring the transition to newborn life and the response to resuscitation

International clinical guidelines and resuscitation algorithms, such as those issued by the Resuscitation Council (UK) (figure 1), recommend using the newborn infant's breathing, heart rate, and peripheral oxygen saturation (SpO2) to guide the resuscitation process. Neonatal clinicians must therefore be able to quickly and accurately monitor these signs and ensure that normal ranges for these parameters are defined.

Defining the normal range of heart rate and peripheral oxygen saturations

Normal ranges of heart rate and SpO2 within the first 10 min of life in infants born at term or preterm have been defined using pulse oximetry. These values are now incorporated into resuscitation guidelines (figure 1). Centile charts of SpO234 and heart rate35 derived from large cohorts of healthy infants who did not receive resuscitation have been published (figure 2). Median heart rate and SpO2 in healthy infants born at term are slightly higher at each timepoint than in healthy preterm

Antenatal interventions

Interventions to improve outcomes for extremely preterm infants begin before birth and include attempts to delay or prevent preterm birth using tocolytics68, 69 and antibiotics (in the case of preterm birth, prelabour rupture of the membranes).70 The aim of delaying preterm birth is ultimately to increase gestation and therefore improve neonatal and long-term outcomes, but also to allow time for antenatal corticosteroids administered to the mother to improve outcome.71 Transfer of mothers at

Post-resuscitation care: therapeutic hypothermia

Hypoxic–ischaemic encephalopathy is encephalopathy from peripartum asphyxia. Moderate-to-severe hypoxic–ischaemic encephalopathy is a complication in 1–3 infants per 1000 at-term livebirths in high-resourced settings and in up to 20 infants per 1000 at-term livebirths in low-resource settings, with worse outcome related to increasing severity of the disorder. Although most newborn infants with mild hypoxic–ischaemic encephalopathy survive without disability, mortality in infants with

The challenges and ethics of resuscitation research

When prospective consent is required for delivery room interventions, enrolment is limited by the urgency of delivery, the availability of researchers, and the ability of parents to consent immediately before delivery. Mothers who present in active labour and with sepsis, haemorrhage, or other obstetric complications that can increase the risk of adverse neonatal outcome might be less likely to be enrolled, which could limit the generalisability of the results.

These limitations were seen in the

Conclusions

We have highlighted some of the important advances in newborn infant resuscitation (panel 2) and some of the interventions that are promising but require further assessment (panel 3). Clinicians now demand high-quality evidence to guide neonatal practice, with evidence of efficacy and safety in both the short term (until hospital discharge) and long term (childhood and beyond). High-quality clinical research in the delivery room is challenging but possible. Preliminary basic science and animal

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