HomeCirculationVol. 142, No. 16_suppl_2Part 5: Neonatal Resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessReview ArticlePDF/EPUBPart 5: Neonatal Resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Khalid Aziz, MBBS, MA, MEd(IT), Chair, Henry C. Lee, MD, Vice Chair, Marilyn B. Escobedo, MD, Amber V. Hoover, RN, MSN, Beena D. Kamath-Rayne, MD, MPH, Vishal S. Kapadia, MD, MSCS, David J. Magid, MD, MPH, Susan Niermeyer, MD, MPH, Georg M. Schmölzer, MD, PhD, Edgardo Szyld, MD, MSc, Gary M. Weiner, MD, Myra H. Wyckoff, MD, Nicole K. Yamada, MD, MS and Jeanette Zaichkin, RN, MN, NNP-BC Khalid AzizKhalid Aziz Search for more papers by this author , Henry C. LeeHenry C. Lee Search for more papers by this author , Marilyn B. EscobedoMarilyn B. Escobedo Search for more papers by this author , Amber V. HooverAmber V. Hoover Search for more papers by this author , Beena D. Kamath-RayneBeena D. Kamath-Rayne Search for more papers by this author , Vishal S. KapadiaVishal S. Kapadia Search for more papers by this author , David J. MagidDavid J. Magid Search for more papers by this author , Susan NiermeyerSusan Niermeyer Search for more papers by this author , Georg M. SchmölzerGeorg M. Schmölzer Search for more papers by this author , Edgardo SzyldEdgardo Szyld Search for more papers by this author , Gary M. WeinerGary M. Weiner Search for more papers by this author , Myra H. WyckoffMyra H. Wyckoff Search for more papers by this author , Nicole K. YamadaNicole K. Yamada Search for more papers by this author and Jeanette ZaichkinJeanette Zaichkin Search for more papers by this author Originally published21 Oct 2020https://doi.org/10.1161/CIR.0000000000000902Circulation. 2020;142:S524–S550Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: October 21, 2020: Previous Version of Record Top 10 Take-Home Messages for Neonatal Life SupportNewborn resuscitation requires anticipation and preparation by providers who train individually and as teams.Most newly born infants do not require immediate cord clamping or resuscitation and can be evaluated and monitored during skin-to-skin contact with their mothers after birth.Inflation and ventilation of the lungs are the priority in newly born infants who need support after birth.A rise in heart rate is the most important indicator of effective ventilation and response to resuscitative interventions.Pulse oximetry is used to guide oxygen therapy and meet oxygen saturation goals.Chest compressions are provided if there is a poor heart rate response to ventilation after appropriate ventilation corrective steps, which preferably include endotracheal intubation.The heart rate response to chest compressions and medications should be monitored electrocardiographically.If the response to chest compressions is poor, it may be reasonable to provide epinephrine, preferably via the intravenous route.Failure to respond to epinephrine in a newborn with history or examination consistent with blood loss may require volume expansion.If all these steps of resuscitation are effectively completed and there is no heart rate response by 20 minutes, redirection of care should be discussed with the team and family.PreambleIt is estimated that approximately 10% of newly born infants need help to begin breathing at birth,1–3 and approximately 1% need intensive resuscitative measures to restore cardiorespiratory function.4,5 The neonatal mortality rate in the United States and Canada has fallen from almost 20 per 1000 live births6,7 in the 1960s to the current rate of approximately 4 per 1000 live births. The inability of newly born infants to establish and sustain adequate or spontaneous respiration contributes significantly to these early deaths and to the burden of adverse neurodevelopmental outcome among survivors. Effective and timely resuscitation at birth could therefore improve neonatal outcomes further.Successful neonatal resuscitation efforts depend on critical actions that must occur in rapid succession to maximize the chances of survival. The International Liaison Committee on Resuscitation (ILCOR) Formula for Survival emphasizes 3 essential components for good resuscitation outcomes: guidelines based on sound resuscitation science, effective education of resuscitation providers, and implementation of effective and timely resuscitation.8 The 2020 neonatal guidelines contain recommendations, based on the best available resuscitation science, for the most impactful steps to perform in the birthing room and in the neonatal period. In addition, specific recommendations about the training of resuscitation providers and systems of care are provided in their respective guideline Parts.9,10IntroductionScope of GuidelineThis guideline is designed for North American healthcare providers who are looking for an up-to-date summary for clinical care, as well as for those who are seeking more in-depth information on resuscitation science and gaps in current knowledge. The science of neonatal resuscitation applies to newly born infants transitioning from the fluid-filled environment of the womb to the air-filled environment of the birthing room and to newborns in the days after birth. In circumstances of altered or impaired transition, effective neonatal resuscitation reduces the risk of mortality and morbidity. Even healthy babies who breathe well after birth benefit from facilitation of normal transition, including appropriate cord management and thermal protection with skin-to-skin care.The 2015 Neonatal Resuscitation Algorithm and the major concepts based on sections of the algorithm continue to be relevant in 2020 (Figure). The following sections are worth special attention.Download figureDownload PowerPointFigure. Neonatal Resuscitation Algorithm. CPAP indicates continuous positive airway pressure; ECG, electrocardiographic; ETT, endotracheal tube; HR, heart rate; IV, intravenous; O2, oxygen; Spo2, oxygen saturation; and UVC, umbilical venous catheter.Positive-pressure ventilation (PPV) remains the main intervention in neonatal resuscitation. While the science and practices surrounding monitoring and other aspects of neonatal resuscitation continue to evolve, the development of skills and practice surrounding PPV should be emphasized.Supplemental oxygen should be used judiciously, guided by pulse oximetry.Prevention of hypothermia continues to be an important focus for neonatal resuscitation. The importance of skin-to-skin care in healthy babies is reinforced as a means of promoting parental bonding, breast feeding, and normothermia.Team training remains an important aspect of neonatal resuscitation, including anticipation, preparation, briefing, and debriefing. Rapid and effective response and performance are critical to good newborn outcomes.Delayed umbilical cord clamping was recommended for both term and preterm neonates in 2015. This guideline affirms the previous recommendations.The 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) recommended against routine endotracheal suctioning for both vigorous and nonvigorous infants born with meconium-stained amniotic fluid (MSAF). This guideline reinforces initial steps and PPV as priorities.It is important to recognize that there are several significant gaps in knowledge relating to neonatal resuscitation. Many current recommendations are based on weak evidence with a lack of well-designed human studies. This is partly due to the challenges of performing large randomized controlled trials (RCTs) in the delivery room. The current guideline, therefore, concludes with a summary of current gaps in neonatal research and some potential strategies to address these gaps.COVID-19 GuidanceTogether with other professional societies, the AHA has provided interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed coronavirus disease 2019 (COVID-19) infection. Because evidence and guidance are evolving with the COVID-19 situation, this interim guidance is maintained separately from the ECC guidelines. Readers are directed to the AHA website for the most recent guidance.12Evidence Evaluation and Guidelines DevelopmentThe following sections briefly describe the process of evidence review and guideline development. See “Part 2: Evidence Evaluation and Guidelines Development” for more details on this process.11Organization of the Writing CommitteeThe Neonatal Life Support Writing Group includes neonatal physicians and nurses with backgrounds in clinical medicine, education, research, and public health. Volunteers with recognized expertise in resuscitation are nominated by the writing group chair and selected by the AHA ECC Committee. The AHA has rigorous conflict of interest policies and procedures to minimize the risk of bias or improper influence during development of the guidelines.13 Before appointment, writing group members and peer reviewers disclosed all commercial relationships and other potential (including intellectual) conflicts. Disclosure information for writing group members is listed in Appendix 1.Methodology and Evidence ReviewThese 2020 AHA neonatal resuscitation guidelines are based on the extensive evidence evaluation performed in conjunction with the ILCOR and affiliated ILCOR member councils. Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process. Each of these resulted in a description of the literature that facilitated guideline development.14–17Class of Recommendation and Level of EvidenceEach AHA writing group reviewed all relevant and current AHA guidelines for CPR and ECC18–20 and all relevant 2020 ILCOR International Consensus on CPR and ECC Science With Treatment Recommendations evidence and recommendations21 to determine if current guidelines should be reaffirmed, revised, or retired, or if new recommendations were needed. The writing groups then drafted, reviewed, and approved recommendations, assigning to each a Level of Evidence (LOE; ie, quality) and Class of Recommendation (COR; ie, strength) (Table).11Table. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*This table defines the Classes of Recommendation (COR) and Levels of Evidence (LOE). COR indicates the strength the writing group assigns the recommendation, and the LOE is assigned based on the quality of the scientific evidence. The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information).Classes of RecommendationCOR designations include Class 1, a strong recommendation for which the potential benefit greatly outweighs the risk; Class 2a, a moderate recommendation for which benefit most likely outweighs the risk; Class 2b, a weak recommendation for which it’s unknown whether benefit will outweigh the risk; Class 3: No Benefit, a moderate recommendation signifying that there is equal likelihood of benefit and risk; and Class 3: Harm, a strong recommendation for which the risk outweighs the potential benefit.Suggested phrases for writing Class 1 recommendations includeIs recommendedIs indicated/useful/effective/beneficialShould be performed/administered/otherComparative-effectiveness phrases include treatment/strategy A is recommended/indicated in preference to treatment B, and treatment A should be chosen over treatment B.Suggested phrases for writing Class 2a recommendations includeIs reasonableCan be useful/effective/beneficialComparative-effectiveness phrases include treatment/strategy A is probably recommended/indicated in preference to treatment B, and it is reasonable to choose treatment A over treatment B.For comparative-effectiveness recommendations (COR 1 and 2a; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.Suggested phrases for writing Class 2b recommendations includeMay/might be reasonableMay/might be consideredUsefulness/effectiveness is unknown/unclear/uncertain or not well-establishedSuggested phrases for writing Class 3: No Benefit recommendations (generally, LOE A or B use only) includeIs not recommendedIs not indicated/useful/effective/beneficialShould not be performed/administered/otherSuggested phrases for writing Class 3: Harm recommendations includePotentially harmfulCauses harmAssociated with excess morbidity/mortalityShould not be performed/administered/otherLevels of EvidenceFor LOEs, the method of assessing quality is evolving, including the application of standardized, widely-used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee. LOE designations include Level A, Level B-R, Level B-NR, Level C-LD, and Level C-EO.Those categorized as Level A are derived fromHigh-quality evidence from more than 1 randomized clinical trial, or RCTMeta-analyses of high-quality RCTsOne or more RCTs corroborated by high-quality registry studiesThose categorized as Level B-R (randomized) are derived fromModerate-quality evidence from 1 or more RCTsMeta-analyses of moderate-quality RCTsThose categorized as Level B-NR (nonrandomized) are derived fromModerate-quality evidence from 1 or more well-designed, well-executed nonrandomized studies, observational studies, or registry studiesMeta-analyses of such studiesThose categorized as Level C-LD (limited data) are derived fromRandomized or nonrandomized observational or registry studies with limitations of design or executionMeta-analyses of such studiesPhysiological or mechanistic studies in human subjectsThose categorized as Level C-EO (expert opinion) are derived fromConsensus of expert opinion based on clinical experienceCOR and LOE are determined independently (any COR may be paired with any LOE).A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.Table. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*Guideline StructureThe 2020 guidelines are organized into “knowledge chunks,” grouped into discrete modules of information on specific topics or management issues.22 Each modular knowledge chunk includes a table of recommendations using standard AHA nomenclature of COR and LOE. A brief introduction or short synopsis is provided to put the recommendations into context with important background information and overarching management or treatment concepts. Recommendation-specific text clarifies the rationale and key study data supporting the recommendations. When appropriate, flow diagrams or additional tables are included. Hyperlinked references are provided to facilitate quick access and review.Document Review and ApprovalEach 2020 AHA Guidelines for CPR and ECC document was submitted for blinded peer review to 5 subject matter experts nominated by the AHA. Before appointment, all peer reviewers were required to disclose relationships with industry and any other potential conflicts of interest, and all disclosures were reviewed by AHA staff. Peer reviewer feedback was provided for guidelines in draft format and again in final format. All guidelines were reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and AHA Executive Committee. Disclosure information for peer reviewers is listed in Appendix 2.
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