Neonatal resuscitation in the delivery room Author Caraciolo J Fernandes, MD Section Editor Leonard E Weisman, MD Deputy Editor Melanie

S Kim, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Nov 2013. | This topic last updated: ago 26, 2013. INTRODUCTION The successful transition from intrauterine to extrauterine life is dependent upon significant physiologic changes that occur at birth. In almost all infants (90 percent), these changes are successfully completed at delivery without requiring any special assistance. However, about 10 percent of infants will need some intervention, and 1 percent will require extensive resuscitative measures at birth [1]. The indications and principles of neonatal resuscitation will be reviewed here. The physiological changes that occur in the transition from intrauterine to extrauterine life are discussed separately. (See "Physiologic transition from intrauterine to extrauterine life".) ANTICIPATION OF RESUSCITATION NEED Being prepared is the first and most important step in delivering effective neonatal resuscitation [1]. Neonates requiring resuscitation are inevitably born in locations where resuscitation is uncommon because most newborns are healthy and do not require additional special assistance. In these settings, the need for resuscitation is not anticipated in most infants who require resuscitation [2]. As a result, at every birthing location, personnel who are adequately trained in neonatal resuscitation should be readily available to perform neonatal resuscitation whether or not problems are anticipated. In all instances, at least one healthcare provider is assigned primary responsibility for the newborn infant. This person should have the necessary skills to evaluate the infant, and, if required, to initiate resuscitation procedures such as positive pressure ventilation and chest compressions. In addition, either this person or another who is immediately available should have the requisite knowledge and skills to carry out a complete neonatal resuscitation including endotracheal intubation and administration of medications. Equipment needed for resuscitation should be available at every delivery area (table 1), and routinely checked to ensure the equipment is functioning properly [3]. Training The neonatal resuscitation program (NRP) was developed by the American Academy of Pediatrics (AAP) and American Heart Association (AHA) as a training program aimed at teaching the principles and skills of neonatal resuscitation [3]. Studies have demonstrated that NRP training improves the correct sequencing and timing of the resuscitative steps and procedures by healthcare providers [2], provider knowledge and comfort in performing neonatal resuscitation [4], and fiveminute Apgar scores [5]. By 2005, the NRP had trained two million health care providers in the United States and was a model for similar neonatal resuscitation programs in over 100 countries [6]. The NRP has been updated five times since its inception. The most recent version is based upon the 2010 AHA, AAP, and International Liaison Committee on Resuscitation (ILCOR) neonatal resuscitative guidelines [1].

In our institution, all healthcare providers who care for newborn infants (clinicians, nurses, neonatal nurse practitioners, and respiratory therapists) are required to be NRP trained. It is recommended that all delivery room personnel complete the NRP in an effort to improve their individual and group performance in neonatal resuscitation. High-risk delivery Infants who are more likely to require resuscitation can be identified by the presence of one or more of the following risk factors (table 2) [3,7]: Maternal conditions Advanced or very young maternal age, maternal diabetes mellitus or hypertension, maternal substance abuse, or previous history of stillbirth, fetal loss, or early neonatal death. Fetal conditions Prematurity, postmaturity, congenital anomalies, or multiple gestations. Antepartum complications Placental anomalies (eg, placenta previa), or presence of either oligohydramnios or polyhydramnios. Delivery complications Transverse lie or breech presentation, chorioamnionitis, foulsmelling or meconium-stained amniotic fluid, antenatal asphyxia with abnormal fetal heart rate pattern, maternal administration of a narcotic within four hours of birth, or delivery that requires instrumentation (eg, forceps, vacuum, or cesarean delivery).

Individuals fully skilled in neonatal resuscitation should be present to care for the high-risk infant. If time permits, the team should meet with the parents and discuss the anticipated problems and plans for care of the infant, and address parental concerns to the best of their ability. Necessary equipment should be assembled prior to the birth of at-risk newborns as follows [3]: The radiant warmer is turned on and is heating. The oxygen source is open with adequate flow through the tubing. The suctioning apparatus is tested and is functioning properly. The laryngoscope is functional with a bright light. Testing of resuscitation bag and mask demonstrates an adequate seal and generation of pressure.

In high-risk deliveries of multiple gestations, each infant will require a full complement of personnel and equipment. Preterm infants Preterm infants pose a greater challenge than term infants because they are more likely to require resuscitation and develop complications from the resuscitative process. If a preterm birth can be anticipated and time permits, it is preferable to transfer the mother prior to delivery to a perinatal center that has fully trained staff with expertise and experience in the care of these infants [8,9]. The following factors make the preterm infant more likely to require resuscitation and to be more susceptible to sequelae [3]: Hypothermia The risk of heat loss leading to hypothermia is increased in infants with a large body surface area to mass, thin skin, and decreased subcutaneous fat. The smaller the infant, the more difficult it is to prevent hypothermia. (See 'Provide warmth' below.) Inadequate ventilation Immature lungs may be deficient in surfactant, and therefore difficult to inflate and ventilate. Immature respiratory drive and weak respiratory muscles increase the likelihood of apnea and inadequate respiratory effort. The greater the degree

of prematurity, the more likely the infant will require intubation and positive pressure support. (See'Next steps' below.) Infection Maternal infection is associated with premature delivery, and offspring of infected mothers are at risk for antenatal infection. Premature infants also have immature immune systems, which increases the risk of acquiring postnatal infection. (See "Pathogenesis of spontaneous preterm birth", section on 'Bacteria'.) Organ damage Immature tissues and capillaries (eg, retina or germinal matrix) are more vulnerable to injury resulting in complications (eg, retinopathy of prematurity and intracranial hemorrhage, respectively). (See "Clinical manifestations and diagnosis of intraventricular hemorrhage in the newborn" and "Retinopathy of prematurity", section on 'Risk factors'.) Reduced antioxidant function Immature antioxidant defense systems may be unable to counteract the effects of free radicals. Free radicals and reactive oxygen species are speculated to contribute to many of the morbidities of prematurity (eg, bronchopulmonary dysplasia and necrotizing enterocolitis) [10]. The very preterm infant may be particularly susceptible to oxidant injury from the use of excess supplemental oxygen in the delivery room [11]. (See "Pathogenesis and clinical features of bronchopulmonary dysplasia", section on 'Oxygen toxicity' and "Pathology and pathogenesis of necrotizing enterocolitis in newborns".)

Additional resources and personnel should be present when a preterm birth is anticipated. These include: Equipment to keep the infant warm. In infants less than 28 weeks gestation, the use of polyethylene bags and wraps have been used to maintain body temperature. (See "Shortterm complications of the premature infant", section on 'Hypothermia'.) Personnel skilled in intubation are especially important for the extremely low birth weight infant (birth weight <1000 g). In infants less than 30 weeks gestation who are more likely to be surfactant deficient, equipment and personnel should be available to deliver positive pressure to infants who fail to exhibit adequate spontaneous respiratory effort and to consider administering surfactant. (See "Prevention and treatment of respiratory distress syndrome in preterm infants".) Compressed air sources, oxygen blenders, and pulse oximeters should be available to allow delivery of less than 100 percent oxygen and allow monitoring of both the oxygen content of the air delivered and the oxygen saturation of the infant. This could reduce the potential oxidant injury that results from unnecessary exposure of supplemental oxygen. (See'Supplemental oxygen' below.) Prewarmed transport incubator (with the capability to transport a ventilated infant), particularly if the delivery room is not in close proximity to the neonatal intensive care nursery.

ANTENATAL COUNSELING Each birth institution should have a consistent approach based upon the best available evidence regarding clinical care and parental counseling in cases where the fetal outcome is a concern. In particular, antenatal counseling should be provided to parents in the setting of an anticipated delivery of an extremely low birth weight infant (birth weight <1000 g) as recommended by the American Academy of Pediatrics (AAP) [12]. Counseling should include information regarding prognosis. (See "Limit of viability".) We agree with the following AAP guidelines:

If there is no chance of survival, resuscitation should not be initiated. (See 'Withholding resuscitation' below.) When a good outcome is considered very unlikely, the parents should be given the choice of whether resuscitation should be initiated, and clinicians should respect their preference. If a good outcome is considered reasonably likely, clinicians should initiate resuscitation and, together with the parents, continually reevaluate whether intensive care should be continued. (See 'Postresuscitation' below.)

OVERVIEW OF RESUSCITATIVE STEPS Although there is increasing emphasis to incorporate the highest quality of evidence (ie, randomized clinical trials) into the American Heart Association (AHA)/American Academy of Pediatrics (AAP) and International Liaison Committee on Resuscitation (ILCOR) neonatal resuscitative guidelines [1], this is not always possible. Randomized trials are difficult to perform in the delivery room because of difficulties in obtaining consent before resuscitation, difficulty in blinding care providers regarding intervention, and the relatively uncommon occurrence of a poor neonatal outcome to measure the effectiveness of an intervention. As a result, many of the guideline recommendations are based upon extensive clinical experience [1]. The following discussion and our own practice are in compliance with the 2010 AHA/AAP/ILCOR guidelines for neonatal resuscitative care [1,13,14]. The 2010 AHA/AAP/ILCOR guidelines include a rapid assessment of the neonate's clinical status based on the following questions: Is the infant full-term? Is the infant breathing or crying? Does the infant have good muscle tone?

If the answer to all three questions is yes, the newborn does not need resuscitation, should not be separated from the mother, and is managed by routine neonatal care. (See "Overview of the routine management of the healthy newborn infant".) The basic steps ("ABCDs") in resuscitation in any age group still apply in the newborn period. However, there are aspects of neonatal resuscitation that are unique and lead to differences in the initial resuscitative steps. (See 'Initial steps' below.) The 2010 AHA/AAP/ILCOR guidelines recommend the following approach (algorithm 1) [1,3]: Initial steps (provide warmth, clear Airway if necessary, dry, and stimulate) Breathing (ventilation) Chest compressions Administration of Drugs, such as epinephrine and/or volume expansion

The decision to progress from one step to the next is determined by the time-dependent response of the infant to the applied resuscitative effort based upon his/her respirations and heart rate (algorithm 1). A time allocation of 30 seconds is given to apply the resuscitative procedure, evaluate, and decide whether to proceed to the next intervention. Monitoring of oxygen saturation by using pulse oximetry should be performed in infants who are gasping, apneic, have labored breathing, have persistent cyanosis, or have a heart rate less than 100 beats per minute (bpm). No

further resuscitative actions are required if the infant responds with adequate spontaneous respirations and a heart rate above 100 beats per minute. (See 'Pulse oximetry'below.) It is vital that each step be performed optimally because subsequent resuscitative efforts are dependent on the success of previous steps. Thus, more time should be spent if 30 seconds is not sufficient to effectively complete the components of an intervention. Inadequate attention to ensuring completeness and effectiveness of earlier steps will jeopardize the utility of subsequent actions and unnecessarily expose infants to more aggressive intervention when they only required the earlier steps of resuscitation. Apgar scores are not used to guide resuscitation but are useful as a measure of the newborn's overall status and response to resuscitation. When the five-minute Apgar score is less than seven, additional scores should be assigned every five minutes for up to 20 minutes. Apgar scores are not good predictors of outcome. Scores may be determined using the Apgar score calculator (calculator 1). The following discussion will describe each resuscitative action in depth. INITIAL STEPS Initial care steps in the delivery room are started within a few seconds of birth and should be applied throughout resuscitation. Provide warmth Hypothermia in the delivery room or immediate newborn period is independently associated with an increase in mortality [15,16]. Thus, maintaining body heat is the initial step in neonatal resuscitation. Hypothermia in the newborn increases oxygen consumption and metabolic demands, which can impair subsequent resuscitative efforts, especially in the asphyxiated or extremely low birth weight (ELBW) infant. Low birth weight and preterm infants are particularly prone to rapid loss of body heat because of their large body surface area relative to their mass, thin skin, and decreased subcutaneous fat. To minimize heat loss, the delivered infant is first placed in a warmed towel or blanket and then under a prewarmed radiant heat source, where he/she is dried with another warmed towel or blanket. The infant should remain uncovered to allow full visualization and permit the radiant heat to reach the patient. The radiant warmer also allows easy access to the infant for multiple members of the resuscitative team. As soon as possible after the infant is placed on the warmer, the temperature control of the warmer should be regulated by servo-control to avoid hyperthermia; the servocontrolled temperature of the warmer is set to maintain the infant's temperature at 36.5C, which is monitored by a temperature skin probe placed upon the infant's abdomen. Healthcare providers should understand how the warmer and temperature probe work, since a malfunctioning warmer and/or temperature probe may lead to inadvertent underheating or overheating of the infant. Although studies have not examined the effects of postnatal hyperthermia in the delivery room on neonatal outcome, there are data demonstrating that maternal fever is associated with neonatal respiratory depression, neonatal encephalopathy, cerebral palsy, and increased mortality [17]. It is unclear whether hyperthermia directly contributes to morbidity or whether it is a marker for an underlying pathological process (eg, chorioamnionitis). Nevertheless, until further data are available, it is prudent to avoid neonatal hyperthermia, as well as hypothermia, in the delivery room. The following methods of warming infants are also used depending upon the condition of the neonate and the need for further resuscitative efforts:

Swaddling the infant after drying "Skin to skin" contact with mother and covering the infant with a blanket Use of polyurethane bags or wraps in infants with birth weights less than 1500 g Raise the environmental (room) temperature to 26C (78.8F) Warming pads

In infants who require respiratory support, the use of humidified and heated air versus nonheated air decreases the rate of both mild (36 to 36.4C) and moderate hypothermia (<36C) [18]. (See "Short-term complications of the premature infant", section on 'Hypothermia'.) Airway The infant is positioned to open the airway by placing the infant on his/her back on a flat radiant warmer bed with the neck in a neutral to slightly extended position; the neck should not be hyperextended or flexed (figure 1). The proper position aligns the posterior pharynx, larynx, and trachea, and facilitates air entry. If needed, a rolled blanket or towel may be placed under the infant's shoulder to slightly extend the neck to maintain an open airway. Suctioning immediately after birth is reserved for babies with obvious obstruction due to secretions or who require positive pressure ventilation. Once the infant has been correctly positioned, the mouth and nose should be suctioned either with a bulb syringe or mechanical suction device. The mouth is suctioned first and then the nares to decrease the risk for aspiration. Suctioning of either the esophagus or stomach should be avoided if not indicated, as it can produce a vagal response, resulting in apnea and/or bradycardia. Wiping the mouth and nose may be an alternative to suctioning for removal of secretions in infants who are greater than 35 weeks gestation. In a randomized, but not masked, equivalency trial conducted in a single center in the United States, wiping the face, mouth, and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery, based on the primary outcome of mean respiratory rate in the first 24 hours after birth [19]. Of note, nonvigorous neonates with meconium-stained amniotic fluid and those with major malformations were excluded from the study. Although there were no statistically significant differences in the secondary outcomes of need for more advanced interventions (eg, intubation, positive pressure ventilation, chest compression, and mediations), one and five-minute Apgar scores, and admission to the neonatal intensive care unit (NICU), there was a trend for increased NICU admissions in the wipe group. In addition, there were protocol deviations in 117 of the 488 cases (24 percent), and almost all occurred in patients assigned to wiping who received suctioning. Further investigations are needed to confirm the equivalency of wiping compared to suctioning, as wiping could potentially reduce healthcare costs. Meconium stained amniotic fluid In the presence of meconium-stained amniotic fluid (MSAF), it had been common practice for obstetrical care providers to aspirate the upper airway of the infant on the perineum of the mother. This was thought to reduce the risk of meconium aspiration syndrome. However, subsequent data has demonstrated no benefit from this procedure. As a result, the 2010 American Heart Association/American Academy of Pediatrics/International Liaison Committee on Resuscitation (AHA/AAP/ILCOR) neonatal resuscitation guidelines nolonger recommend routine intrapartum suctioning for meconium-stained infants [1]. Although data are insufficient, the guidelines do not recommend changing the current practice of endotracheal suctioning of nonvigorous babies with MSAF. A more detailed discussion of the management of an infant with MSAF is presented separately. (See "Prevention and management of meconium aspiration syndrome".)

Stimulation Tactile stimulation of the newborn should be initiated promptly after birth, except in the case of the "nonvigorous" infant born with meconium-stained amniotic fluid who first requires endotracheal intubation. Drying and suctioning the infant, which is performed as part of the initial steps, may provide adequate stimulation. Safe, appropriate ways of providing additional stimulation include briefly slapping or flicking the soles of the feet, and rubbing the infant's back. More vigorous stimulation is not helpful and may cause injury. If, after one or two attempts of additional stimulation, the infant still remains apneic, positive pressure ventilation (PPV) should be initiated. (See 'Positive pressure ventilation' below.) Given that most infants will be stimulated from the moment of birth, efforts at stimulating the infant should not be prolonged. The time elapsed from the baby's birth to placing the baby under the warmer, positioning, suctioning, and providing additional stimulation should be no more than 30 seconds (algorithm 1) [3]. Pulse oximetry The 2010 AHA/AAP/ILCOR guidelines recommend the use of pulse oximetry to determine oxygen saturation (SpO2) in the following settings because oxyhemoglobin saturation may normally remain in the 70 to 80 percent range for several minutes following birth, which may result in the appearance of cyanosis, and the assessment of skin color is a poor indicator of oxyhemoglobin saturation during the immediate neonatal period [1]: When resuscitation is anticipated Positive pressure ventilation is used for more than a few breaths Persistent cyanosis Use of supplementary oxygen

For these infants, the oximeter probe should be attached to a preductal location on the right upper extremity, usually the wrist or medial surface of the palm, as soon as possible. The targeted SpO2 levels for term infants born at sea level are as follows based on the time after delivery [1,20]: 1 minute 60 to 65 percent 2 minutes 65 to 70 percent 3 minutes 70 to 75 percent 4 minutes 75 to 80 percent 5 minutes 80 to 85 percent 10 minutes 85 to 95 percent

Data on targeted levels for premature infants and term infants born at other altitudes are lacking, and the above levels are thought to be reasonable for these patients. NEXT STEPS The initial steps delineated above are applied in every newborn delivery. Subsequent resuscitative care depends on the evaluation of the infant while performing these initial steps (algorithm 1). No further resuscitative actions are required if the infant responds with adequate spontaneous respirations (eg, sustained regular respirations) and a heart rate above 100 beats per minute, and achieves targeted SpO2 levels. Supplemental oxygen Over the last few decades, the standard practice of initial use of 100 percent oxygen, whenever supplemental oxygen is needed, has been challenged, as increasing evidence has shown that hyperoxia due to oxygen supplementation may result in tissue and organ

injury [21-23]. Hyperoxia is thought to raise cellular oxygen contents, which leads to an increased generation of free oxygen radicals causing cellular and tissue injury [21-24]. In addition, several studies including meta-analyses have shown improved survival and outcome in primarily term infants resuscitated with room air compared with those who received 100 percent oxygen. Two meta-analyses demonstrated a reduction in mortality in primarily term infants with the use of room air compared with 100 percent oxygen, and no difference in the risk of hypoxic ischemic encephalopathy or changes in neurodevelopmental outcome at 18 to 24 months of age [25,26]. Two trials of asphyxiated term infants demonstrated that infants resuscitated in room air compared with those resuscitated with 100 percent oxygen more quickly achieved sustained respirations and had lower concentrations of markers or oxidative stress (ie, glutathione, superoxide dismutase, catalase, and glutathione peroxidase) [22,27]. A retrospective population-based Swedish study compared the outcome of severely depressed infants (defined as a one-minute Apgar score less than four) who were resuscitated at one of four tertiary centers that used either 40 percent oxygen or 100 percent oxygen during neonatal resuscitation. There were no differences in rates of neonatal death, hypoxic ischemic encephalopathy, or seizures between infants resuscitated with 40 percent oxygen and those who received 100 percent oxygen [28].

Data are more limited in premature infants, but suggest that room air may be insufficient to achieve targeted oxygen levels and 100 percent oxygen results in excessive oxygen exposure [29]. As a result, in our practice, blended oxygen with concentration starting at 30 percent is used in the resuscitation of preterm infants below 30 weeks gestation, and oxygen concentration adjusted based on a predetermined SpO2 target range. (See 'Our approach' below.) In one observational study of preterm infants less than 30 weeks gestation, infants resuscitated with room air had median oxygen saturations of 31 and 54 percent at two and five minutes, and almost all of the infants required supplemental oxygen (91 of 106 patients) [30]. In contrast, the median oxygen saturations of the 20 infants resuscitated with 100 percent oxygen at two and five minutes were 84 and 95 percent. A small trial randomly assigned 42 premature infants (gestational age 28 weeks) who required resuscitation to initially receive either 30 percent oxygen, which was increased in a stepwise manner every 60 to 90 seconds by 10 percent if bradycardia (<100 beats per minute [bpm]) occurred, or 90 percent oxygen, which was decreased in a stepwise manner every 60 to 90 seconds by 10 percent if the pulse oxygen saturation was >85 percent [31]. There were no differences in mortality rate and the oxygen saturation values obtained by pulse oximeter from 1 to 20 minutes of life between the two groups. By five to seven minutes of life, the mean oxygen was 45 percent in both groups. In one small trial, preterm infants (24 to 28 weeks gestation) resuscitated with 30 percent oxygen, when compared with those resuscitated with 90 percent oxygen, needed fewer days of oxygen supplementation and mechanical ventilation, and had a lower incidence of bronchopulmonary dysplasia (15 versus 32 percent) [32].

The following 2010 American Heart Association/American Academy of Pediatrics/International Liaison Committee on Resuscitation (AHA/AAP/ILCOR) guidelines reflect

the lack of data needed to establish evidence-based guidelines for a specific initial oxygen concentration for resuscitation [1]: Resuscitation should be initiated with blended oxygen. If blended oxygen is not available, room air should be used. The oxygen concentration should be adjusted to achieve targeted SpO 2 levels, which are monitored by pulse oximetry. (See 'Pulse oximetry' above.) If the heart rate is below 60 bpm after 90 seconds of resuscitation, the oxygen concentration should be increased to 100 percent until recovery of a normal heart rate.

Our approach At our institution, we currently utilize 21 percent oxygen for resuscitation of neonates >30 weeks gestation. For infants 30 weeks gestation, because of the increased risk of hyperoxia-related complications associated with prematurity [10], we initiate resuscitation with 30 percent oxygen by use of a blender. In all infants, pulse oximetry guides further adjustments of the delivered supplemental oxygen in an effort to achieve and maintain the oxygen saturation based on target SpO2. (See 'Pulse oximetry' above.) However, the optimal target SpO2 levels in the delivery room are unknown in preterm infants [33]. Target SpO2 for premature infants is discussed in detail separately. (See "Oxygen monitoring and therapy in the newborn", section on 'Oxygen target levels'.) Positive pressure ventilation Positive pressure ventilation (PPV) is required in the following clinical settings after administering the initial steps of resuscitation: If the infant is gasping or apneic. If the heart rate is <100 bpm. The heart rate can be checked either by auscultation or palpation of the pulse in the umbilical cord.

Although PPV is an important therapeutic intervention in neonatal resuscitation, it is a technique that requires considerable skill and practice to apply it correctly. The different methods and techniques of delivering PPV to the newborn infant are reviewed here. Equipment PPV can be administered to the newborn infant by bag-mask ventilation (BMV) by several different devices: Self-inflating bag Self-inflating bag reinflates when it is released. Unlike the other BMV methods, it does not require a compressed gas source. Thus, it is the only method used when compressed gas sources are not available in resource limited areas. The self-inflating bag has a pressure-release valve, commonly called a pop-off valve that is set by the manufacturer to release at about 30 to 40 cm H2O pressure. However, for the newborn who has not taken its first breath, it may be necessary to occlude this pop-off valve in order to generate sufficient pressure to effectively inflate a newborn's nonaerated lungs. In such instances, care should be taken not to overinflate the lungs because this may increase the risk of causing pulmonary air leak. (See "Pulmonary air leak in the newborn".) Although it has been generally assumed that the delivered oxygen concentration is 40 percent when using a source of 100 percent oxygen without a reservoir, one study demonstrated that delivered oxygen concentration exceeded 60 percent at a minimum flow rate of 1 L/min and rose as the flow rate increased [34]. When the pop-off valve was

opened at 35 to 40 cm H2O, oxygen concentrations fell to levels of 30 and 45 percent at flow rates 2 L/min. With a 100 percent oxygen source and a reservoir, oxygen delivery is generally 90 to 100 percent oxygen. These findings are significant given the concern for potential oxygen toxicity and episodes of hyperoxia with high concentrations of delivered oxygen. They also demonstrate that pulse oximetry is required when supplemental oxygen and positive pressure ventilation are used. (See 'Supplemental oxygen' above.) Flow-inflating bag The flow-inflating bag (also referred to as an anesthesia bag) fills only when gas from a compressed source flows into it. It is technically more difficult to master than the self-inflating bag because a tight face-mask seal is needed for the bag to inflate; however, this feature may be considered an advantage because it assures an optimal facemask seal is obtained, which is necessary for effective positive pressure ventilation. Because the flow-inflating bag does not have a pressure release valve, a pressure manometer should always be used to minimize the risk of overinflation resulting in pulmonary air leak. (See "Pulmonary air leak in the newborn".) T-piece resuscitator The T-piece resuscitator is similar to the flow-inflating bag, but with the addition of an adjustable flow-control valve, which more precisely controls the peak inflating pressure applied to the infant's lungs, decreasing the risk of pulmonary air leak complications. Like the flow-inflating bag, it requires a compressed gas source. In term infants and preterm infants with birth weights greater than 1500 g, laryngeal mask airway (LMA), which fits over the laryngeal inlet, has been found to be effective when BMV or endotracheal intubation is unsuccessful, or endotracheal intubation is not possible [35]. The LMA is a soft mask with an inflatable cuff attached to a silicone rubber airway, which is inserted through the mouth by the clinician using his/her index finger to guide insertion along the hard palate "blindly" without the use of visualizing instruments. Following insertion and inflation of the cuff, the LMA covers the laryngeal opening and its rim conforms to the contours of the hypopharynx occluding the esophagus with a low-pressure seal. LMA should be considered only if BMV is unsuccessful in providing adequate ventilation, and endotracheal intubation is unsuccessful or not feasible. [1,35-37].

Procedure The following steps are required to effectively provide assisted positive pressure bagmask ventilation (BMV): Position The infant should be positioned with the neck in a neutral to slightly extended position to ensure an open airway (figure 1). The clinician should stand at the head or side of the warmer to view the chest movement of the infant to assess whether ventilation is effectively delivered. (See 'Airway' above.) Suction The nose and mouth should be suctioned as needed to clear any mucous to prevent aspiration prior to delivery of assisted breaths. Seal An airtight seal between the rim of the mask and the face is essential to achieve the positive pressure required to inflate the lungs. An appropriately sized mask is selected and positioned to cover the chin, mouth, and nose, but not the eyes of the infant. The mask is held on the face by positioning the hand of the clinician so that the little, ring, and middle fingers are spread over the mandible in the configuration of the letter "E" and the thumb and index are placed over the mask in the shape of the letter "C". The ring and fifth fingers lift the chin forward to maintain a patent airway. An airtight seal is formed by using light downward pressure on the rim of the mask and gently squeezing the mandible up towards the mask (picture 1).

Initial breaths The initial administered breaths often require pressures of 30 to 40 cm H 2O to inflate the lungs of the newly born term infant. In most preterm infants, an initial inflation pressure of 20 to 25 cm H2O is usually adequate. Adequacy of ventilation is demonstrated by improvement in heart rate. Chest wall movement should be assessed if heart rate does not improve. The infant should be ventilated at a rate of 40 to 60 times per minute to achieve a heart rate >100 bpm. When initiating ventilation, the care provider should try to avoid excess volume or pressure, which can result in volutrauma resulting in lung injury or pulmonary air leak, especially in the premature infant [38]. To minimize volutrauma, the positive pressure should be adjusted to deliver a tidal volume of 4 to 5 mL/kg. In addition, positive end-expiratory pressure (PEEP) of 4 to 5 cm H2O should be used to prevent atelectasis [38]. The self-inflating bag does not provide PEEP. (See "Prevention of bronchopulmonary dysplasia", section on 'Noninvasive mechanical ventilation' and "Pulmonary air leak in the newborn".) Next steps Further resuscitative efforts are based upon the heart rate response of the infant after the initial 30 seconds of BMV.

If the heart rate is greater than 100 beats per minute (bpm) and spontaneous effective respiration has begun, BMV can be discontinued and free-flowing oxygen administered as needed, based on the target oxygen saturations for minutes after birth. The infant is observed closely (heart rate and SpO2) to determine whether his/her spontaneous respiratory effort is adequate without need for further intervention. If the heart rate is between 60 to 100 bpm, continue BMV ventilation and reevaluate after 30 seconds. Reevaluation includes the following sequence of M-Mask readjustment, R-Reposition the airway, S- Suction the mouth and nose, and O- Open the mouth slightly. If these maneuvers fail, consider increasing inflation pressure because failure of establishing effective positive pressure ventilation is an extremely common and potentially preventable cause of failed resuscitation. If the heart rate is below 60 bpm, immediately begin chest compression and reassess that adequate positive pressure ventilation is being delivered. (See 'Chest compressions'below.) CPAP or PEEP Studies in animals suggest the addition of continuous positive airway (CPAP) or end-expiratory pressure (PEEP) may be beneficial for adequate lung recruitment and reduce subsequent lung injury, especially in very premature animals [39,40]. Data from observational studies and a single clinical trial appear to support the use of CPAP versus BMV in the initial resuscitation of preterm infants [41-44]. In a randomized controlled Dutch trial of 207 preterm infants born at a gestational age less than 33 weeks, patients who required ventilatory support were randomized to a single pressure-controlled inflation of 10 seconds followed by CPAP delivered through a nasopharyngeal tube and T-piece resuscitator versus positive BMV [44]. Infants treated with single inflation/CPAP, when compared with those who received conventional BMV, were less likely to be intubated, receive more than one dose of surfactant, or develop bronchopulmonary dysplasia (BPD). However, further studies to confirm these findings are needed before CPAP verus BMV can be recommended for neonatal resuscitation. After BMV ventilation as the initial resuscitative intervention, CPAP rather than intubation and mechanical ventilation may be beneficial in the spontaneously vigorous preterm infants who require continued respiratory support or at risk for respiratory distress syndrome. (See "Prevention and

treatment of respiratory distress syndrome in preterm infants", section on 'Assisted ventilation techniques'.) In infants who require PPV, PEEP is likely to be beneficial, and should be used if suitable equipment is available [1]. Endotracheal intubation Endotracheal (ET) intubation allows direct access to the upper trachea for suctioning (ie, meconium) or delivery of positive pressure ventilation (PPV). Intubation is a skill that must be learned and takes practice for one to become accomplished. While bag-mask ventilation (BMV) may suffice in most instances of neonatal resuscitation, there are instances when ET intubation may be preferred. Thus, when a high-risk delivery is anticipated, at least two individuals should be present for the birth to assist with resuscitation of the infant, and one should be skilled in ET intubation. ET intubation may be indicated if [1]: Tracheal suctioning for meconium is required BMV is ineffective or prolonged Chest compressions are being performed

In addition to the above, ET intubation may be electively chosen in certain special circumstances, such as congenital diaphragmatic hernia, airway stabilization of the extremely low birth weight infant, and for administration of surfactant. All necessary supplies should be readied for intubation, including appropriate size ET tubes (ETT). The neonatal resuscitation program (NRP) guidelines use birth weight and gestational age to determine the appropriate ETT size (table 3). An alternate method for selection of ETT size is based upon the length of the infant [45]. However, its use has only been validated in one study. This approach cannot be recommended until further studies verify that it can accurately predict appropriate ETT size for neonates. Suction device should be available to remove secretions in the posterior oropharynx and laryngopharynx that may obstruct the view of the trachea and vocal cords. Procedure Two care providers are required for ET intubation, one to perform the procedure and the other to assist and monitor the status of the infant during the intubation. To minimize hypoxemia, time needed for intubation should be limited to 20 seconds, and free flowing oxygen is administered during the procedure. The following steps are required for successful intubation of the neonate: Initial stabilization Unless contraindicated, the patient should be stabilized by BMV. Positioning The infant is placed on his/her back with the head in the midline and the neck slightly extended. Insertion The laryngoscope is held in the left hand of the clinician between the thumb and the first two or three fingers, with the blade pointing away from the clinician. The right hand stabilizes the head of the infant. The laryngoscope blade is inserted over the right side of the tongue pushing the tongue to the left and is advanced until the blade lies in the vallecula, just beyond the base of the tongue. The entire blade is lifted in the direction of the laryngoscope handle to allow visualization of the vocal cords. It is important not to twist the laryngoscope like a lever, the so-called "can opener" maneuver, as this can elevate the

vocal cords out of view and can damage the alveolar ridge. Once the vocal cords are visualized, an appropriate-sized ETT is inserted through them with the right hand until the vocal cord guide line (heavy black line near the tip of the tube) is at the level of the vocal cords. Some individuals prefer to use a stylet to provide rigidity and curvature to the tube; if a stylet is used, care should be taken that it does not protrude out of the tip of the tube, and when it is removed the tube is not inadvertently dislodged. Assessment of successful intubation Successful intubation following institution of PPV is associated with a prompt increase in heart rate. Other indicators of successful intubation include auscultation of audible breath sounds over both lung fields, vapor condensation inside the ETT during exhalation, and symmetrical chest movement; however, these findings have not been systematically studied in neonates. Chest radiography is needed to confirm that the ETT is correctly placed above the carina of the trachea. Exhaled carbon dioxide (CO2) detectors can be used to confirm ETT placement, especially in very low birth weight infants [46-49]. At our institution, we use CO2 detectors to confirm ETT placement as endorsed by the 2010 guidelines [1]. Securing ETT If the ETT is to be used for ventilation, it needs to be secured and taped. A simple calculation can be used to determine the depth of insertion (referred to as the 7-8-9 or Tochen's rule). The distance measured in cm from the tip of the ETT to the lip of the infant is calculated as the infant's weight in kg plus "6". So for a 1 kg infant, the depth of insertion is 7 cm. This rule accurately places the tip of the ETT just above the midtracheal position in infants with birth weight (BW) 750 g. However, the Tochen's rule is not adequate for ETT placement in infants with BW <750 g. In one study, this calculation overestimated the depth of insertion in very premature infants (BW <750 g), which can result in intubation of the right main stem bronchus [50], whereas another study reported that ETT placement was inadequate (too high) in a group of infants of similar birth weights [51]. Although NRP guidelines caution that the ETT may need to be inserted only 6 cm in infants with BW <750 g, these results emphasize the importance of obtaining radiographic verification of ETT placement as soon as possible.

CHEST COMPRESSIONS Chest compressions are initiated if the infant's heart rate remains <60 beats per minute despite adequate ventilation for 30 seconds [1]. Chest compression applies pressure to the lower one-third of the sternum visualized as an imaginary line between the nipples and the xiphoid process. Two methods are used to deliver neonatal chest compressions. Thumb technique In this method, both hands encircle the infant's chest with the thumbs on the sternum and the fingers under the infant (figure 2). This is the preferred method. Two-finger technique In this method, the tips of the first two fingers, or the middle and ring finger, are placed in a perpendicular position over the sternum (figure 3).

In both methods, pressure is applied downward perpendicular to the chest wall sufficient to depress the sternum about one-third of the anteroposterior diameter of the chest, and then pressure is released to allow the heart to refill. Care should be taken to avoid applying pressure directly over the xiphoid, as this may cause hepatic injury. The thumb technique is recommended by the 2010 American Heart Association/American Academy of Pediatrics/International Liaison Committee on

Resuscitation (AHA/AAP/ILCOR) guidelines in neonates because it generates higher systolic and coronary perfusion pressure [52-57]. Chest compressions must always be accompanied by positive pressure ventilation (PPV). During neonatal resuscitation, the chest compression rate is 90 per minute accompanied by 30 ventilations per minute with one ventilation interposed after every third compression. Thus, the ventilation rate is reduced from the 40 to 60 breaths per minute used in the absence of chest compression to 30 breaths in the presence of chest compression. After 30 seconds of chest compression and PPV, reassessment of the infant's heart rate, color, and respiratory rate should determine whether further interventions are required (eg, intubation or administration of medications). DRUGS Drugs are rarely required in neonatal resuscitation. Delivering adequate ventilation is the most important resuscitative step because the most common cause of bradycardia is inadequate lung inflation or profound hypoxemia. However, if the heart rate remains <60 beats per minute despite adequate ventilation and chest compressions, administration of epinephrine is indicated (algorithm 1). Rarely, volume expansion or a narcotic antagonist (eg, naloxone) may be useful. The following table lists the medications used in neonatal resuscitation (table 4). Vascular access Medications need to be given intravenously. The quickest means of obtaining intravenous access in the newborn is cannulation of the umbilical vein. This is accomplished by aseptically inserting a catheter into the umbilical vein to a depth of two to four cm until there is free flow of blood. Epinephrine Although epinephrine is widely used in neonatal resuscitation, it has never been prospectively studied and validated in placebo-controlled clinical trials [35,58]. Epinephrine increases the workload and oxygen consumption of the cardiac muscle, and therefore, it is only administered after ventilation has been established to avoid injury to the myocardium. Prior neonatal resuscitation program (NRP) guidelines suggested that the epinephrine could be delivered through the endotracheal tube (ETT); however, epinephrine given intravenously is more efficacious than ETT administration [59]. Current guidelines recommend intravenously administered epinephrine at a dose of 0.01 to 0.03 mg/kg (0.1 to 0.3 mL/kg of a 1:10,000 solution [concentration 0.1 mg/mL]). Higher doses of epinephrine have not been shown to be more effective and there are some data that higher doses may result in brain and cardiac injury [1,3]. Epinephrine may be repeated every three to five minutes if the heart rate remains <60 beats per min. The ETT route may be used while intravenous access is being obtained, but the safety and efficacy of this practice has not been evaluated. The current guidelines recommend if epinephrineis given through an ETT, a dose of 0.05 to 0.1 mg/kg (0.3 to 1 mL/kg of a 1:10,000 solution) should be used [1,3]. After ETT administration, another dose of epinephrine could be administered intravenously when vascular access is obtained [3]. If there is no response to the dose of epinephrine, the clinician should reassess the earlier steps in the resuscitation algorithm to ensure that they have been performed correctly. If resuscitative efforts were completed correctly, then another problem such as hypovolemia might be present (algorithm 1).

Volume expansion In the delivery room, neonatal hypovolemia requiring volume expansion is rarely needed. Hypovolemia may be suspected if there is ante- or intrapartum hemorrhage, which could be due to an umbilical cord accident, placenta previa, or trauma, or if there are clinical signs of hypovolemia seen despite an adequate heart rate, such as pallor, poor perfusion, and weak pulses. Because isotonic crystalloid solution is as effective as 5 percent albumin in restoring effective circulating volume in neonates [60-62], the current guidelines recommend a 10 mL/kg bolus of normal saline given over 5 to 10 minutes to correct hypovolemia. This dose can be repeated if necessary based upon the response to the initial bolus. Other acceptable solutions include Ringer's lactate or O Rh-negative blood. The latter may be preferable if severe blood loss and/or anemia is suspected or documented. Naloxone In the 2010 American Heart Association/International Liaison Committee on Resuscitation (AHA/ILCOR) guidelines, administration of naloxone, a narcotic antagonist, is notrecommended as part of initial resuscitation in the delivery room because data are lacking demonstrating its efficacy, and there remains uncertainty regarding its dosing, routes of administration, and safety [1,63]. Although, maternally administered opioids in the perinatal period may cause neonatal respiratory depression, attention to ventilation and oxygenation as described earlier is generally adequate for neonatal resuscitation. Sodium bicarbonate There is insufficient evidence to determine whether sodium bicarbonate is beneficial or harmful in neonatal resuscitation [3,64,65]. Although theoretically sodium bicarbonate should be beneficial to correct acidosis, there is also evidence that sodium bicarbonate could adversely affect myocardial and cerebral function [66]. Given the uncertainty of benefit and the potential for adverse effects, we do not routinely recommend the use of sodium bicarbonate. This approach is consistent with the 2010 AHA/American Academy of Pediatrics(AAP)/ILCOR guidelines for neonatal resuscitative care, which do not include the use of sodium bicarbonate as a recommended or useful medication [1,13,14]. (See "Approach to the child with metabolic acidosis", section on 'Bicarbonate therapy in neonates'.) If sodium bicarbonate is used, it should be given only after adequate ventilation and circulation has been established to prevent increased CO2 retention. Sodium bicarbonate is a caustic and hypertonic agent, and, if administered, it must be given through a large vein. Given the controversy over its use in neonatal resuscitation, no dose for sodium bicarbonate use has been established. If it is used, the usual dose is 1 or 2 mEq/kg, given at a rate no faster than 1 mEq/kg per minute. (See "Primary drugs in pediatric resuscitation", section on 'Sodium bicarbonate'.) FAILURE OF INITIAL RESUSCITATION Rarely, infants will not respond to the initial resuscitative efforts. The clinical team needs to review that all the resuscitative steps were fully and properly administered. If the infant fails to respond despite properly executed resuscitation, the following clinical approach may help ascertain the cause: Failure to respond to positive pressure ventilation (PPV): Mechanical blockage (eg, meconium, mucus, choanal atresia, pharyngeal airway malformation [Robin sequence], or laryngeal web)

Impaired lung function (pneumothorax, pleural effusions, congenital diaphragmatic hernia, pulmonary hypoplasia, congenital pneumonia, or hyaline membrane disease)

Central cyanosis Congenital heart disease Persistent bradycardia Heart block Apnea Brain injury (hypoxic ischemic encephalopathy), congenital neuromuscular disorder, or respiratory depression from maternally administered opioids

WITHHOLDING RESUSCITATION With antenatal screening, it is now possible to identify conditions associated with high neonatal mortality or poor outcome. In these settings, intensive therapy including neonatal resuscitation may result in prolongation of dying with significant pain and discomfort for the neonate or survival with unacceptable quality of life. Decisions regarding whether intervention should be initiated and to what degree are difficult and are made together by parents and care providers, guided by their understanding of the child's best interests. Our approach in deciding whether resuscitation should be initiated or withheld is consistent with the recommendations of the American Academy of Pediatrics (AAP) and includes the following [1,67]. The decision not to initiate intensive therapy is made together by the parents and the healthcare team. Parents should be active participants in the decision-making process concerning the treatment of their child. Discussion, if possible, should occur prior to the birth of the infant. Noninitiation of resuscitation may be considered if early death is very likely and survival would be accompanied by unacceptably high morbidity. These clinical conditions include infants with gestational age <23 weeks or birth weight <400 g, anencephaly, or chromosomal abnormalities incompatible with life (eg, trisomy 13 or 18) [1]. (See "Limit of viability", section on 'Management approach'.) Intensive care including neonatal resuscitation is always indicated when there is a high likelihood of survival and acceptable morbidity. In settings in which the prognosis of the infant is unclear but likely poor, and survival may be associated with a diminished quality of life, parental wishes should determine management decisions. At delivery, if the appropriate course is uncertain, it is preferable to initiate resuscitation. After delivery, the healthcare team can review with the parents the clinical status and prognosis of their infant, and determine the parents' wishes. If additional data demonstrate that the outcome is almost certain early death or unacceptably high morbidity, support can be discontinued if agreed upon by the parents and healthcare team. Basic care that provides comfort to the infant must be given at all times, even when intensive therapy is not initiated. When there is disagreement between the parents and healthcare team, continued discussion is recommended. Other resources that are useful in resolving disagreement include consultation with the hospital's ethics committee or finding healthcare providers that will provide care for the infant in the manner desired by the parents. At times, unresolved disagreement may result in the involvement of the court system. At all times, the clinician must serve as an advocate of the infant and what he/she judges to be in the infant's best interest. The clinician needs to know the relevant laws in his/her local area of practice.

DISCONTINUING RESUSCITATION Resuscitation efforts may be discontinued if the neonate has demonstrated no signs of life (no heart beat or no respiratory effort for greater than 10 minutes) after 10 minutes of resuscitation [1,3], because outcome is associated with high early mortality and unacceptably high morbidity among the rare survivors [68-70]. As previously discussed, if additional data obtained after resuscitation is started demonstrates that neonatal outcome is almost certain early death or unacceptably high morbidity, support can be discontinued if agreed upon by the parents and healthcare team. POSTRESUSCITATION Infants who required resuscitation are at risk of developing postresuscitative complications [71]. These include: Hypo- or hyperthermia Hypoglycemia (see "Neonatal hypoglycemia") Central nervous system (CNS) complications: apnea, seizures, or hypoxic ischemic encephalopathy (see "Clinical features, diagnosis, and treatment of neonatal encephalopathy") Pulmonary complications: Pulmonary hypertension, pneumonia, pulmonary air leaks, or transient tachypnea of the newborn (see "Overview of neonatal respiratory distress: Disorders of transition") Hypotension Electrolyte abnormalities: Hyponatremia or hypocalcemia Feeding difficulties: Ileus, gastrointestinal bleeding, or dysfunctional sucking or swallowing

The longer and the greater the extent of resuscitation, the more likely that there will be subsequent and serious complications. Thus, infants who required resuscitation should be placed in a setting in which close monitoring and ongoing appropriate care can be provided. SUMMARY AND RECOMMENDATIONS Most infants successfully transfer from intrauterine to extrauterine life without any special assistance. However, about 10 percent of newborns will need some intervention, and 1 percent will require extensive resuscitative measures at birth. Because the need for resuscitation is not anticipated in the majority of neonates, personnel who are adequately trained should be readily available to perform neonatal resuscitation at every birthing location, whether or not problems are anticipated. (See 'Anticipation of resuscitation need' above.) Infants who are more likely to require resuscitation can be identified by maternal and neonatal risk factors, and the presence of antepartum and delivery room complications. Care providers skilled in neonatal resuscitation should be present and equipment should be prepared prior to the birth of the high-risk infant. (See 'High-risk delivery' above.) Preterm infants are more likely to require resuscitation and develop complications from resuscitation than term infants. If a preterm birth can be anticipated and time permits, it is preferable to transfer the mother prior to delivery to a perinatal center. (See 'Preterm infants' above.)

Resuscitation steps We suggest the following practices described in the 2010 American Heart Association, American Academy of Pediatrics, and International Liaison Committee on

Resuscitation (ILCOR) guidelines for neonatal resuscitation be followed when providing resuscitation to newborn infants (algorithm 1) (Grade 2C). Neonatal resuscitation may be required in infants who are premature, do not have good muscle tone, and are not breathing or crying. Initial care includes providing warmth to the infant, clearing his/her airway, and drying and stimulating the infant. (See 'Initial steps' above.) If there is meconium-stained amniotic fluid and the infant is not vigorous, suctioning of residual meconium should be performed. (See 'Meconium stained amniotic fluid' above and"Prevention and management of meconium aspiration syndrome".) After the above initial steps are completed, if further resuscitative efforts are required or if resuscitation was anticipated, pulse oximetry should be initiated to determine oxygen saturation levels and to guide the administration of appropriate amounts of oxygen. Positive pressure ventilation (PPV) is required if the infant has an inadequate respiratory effort or a heart rate <100 beats per minute (bpm). PPV is started with bag-mask ventilation (BMV) at a rate of 40 to 60 times per minute for 30 seconds, after which the heart rate is measured. We suggest that resuscitation begin with blended oxygen or room air and the concentration of oxygen is adjusted based on targeted oxygen saturation levels measured by pulse oximetry (Grade 2B). In our practice, we initiate resuscitation with room air in infants greater than 30 weeks gestation, and use 30 percent oxygen concentration for those 30 weeks gestation. (See 'Supplemental oxygen' above and 'Pulse oximetry' above.) Intubation is needed if tracheal suctioning for meconium is required, BMV is ineffective or prolonged, or chest compressions are being performed. (See 'Endotracheal intubation'above.) Chest compressions are required if the infant's heart rate remains <60 bpm despite adequate ventilation for 30 seconds. Chest compressions must always be accompanied by PPV. Chest compression rate is 90 per minute accompanied by 30 ventilations per minute with one ventilation interposed after every third compression. (See 'Chest compressions' above.) Drugs are rarely required in neonatal resuscitation. However, if the heart rate remains <60 bpm despite adequate ventilation and chest compressions, intravenous administration ofepinephrine is indicated (table 4). Cannulation of the umbilical vein is the quickest means of obtaining intravenous access in the newborn. (See 'Epinephrine' above.) Resuscitation can be withheld if it is legally acceptable and there is complete agreement among parents and care providers that the neonatal outcome is dismal. (See 'Withholding resuscitation' above.) Resuscitation efforts may be discontinued if the neonate has demonstrated no signs of life (no heart beat or no respiratory effort for greater than 10 minutes) after 10 minutes of resuscitation. (See 'Discontinuing resuscitation' above.) Infants who required resuscitation are at risk of developing postresuscitative complications. After successful resuscitation, they require placement in a setting in which close monitoring and ongoing appropriate care can be provided. (See 'Postresuscitation' above.) Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES

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