Downloaded from http://fn.bmj.com/ on April 29, 2016 - Published by group.bmj.
com
ADC-FNN Online First, published on April 28, 2016 as 10.1136/archdischild-2015-309472
1
Department of Neonatology,
The James Cook University
Hospital, Middlesbrough, UK
2
Paediatric and Neonatal
Division Planned Care
Directorate, Victoria Hospital,
Kirkcaldy, UK
Correspondence to
Dr Jonathan Wyllie,
Department of Neonatology,
The James Cook University
Hospital, Marton Road,
Middlesbrough TS4 3BW, UK;
jonathan.wyllie@stees.nhs.uk
Received 17 January 2016
Revised 30 March 2016
Accepted 6 April 2016
To cite: Wyllie J,
Ainsworth S. Arch Dis Child
Fetal Neonatal Ed Published
Online First: [ please include
Day Month Year]
doi:10.1136/archdischild-
2015-309472
Wyllie J, Ainsworth S. Arch Dis Child Fetal Neonatal Ed 2016;0:F1F5. doi:10.1136/archdischild-2015-309472
Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd (& RCPCH) under licence.
Review
What is new in the European and UK neonatal
resuscitation guidance?
Jonathan Wyllie,1 Sean Ainsworth2
New European Resuscitation Council (ERC) and
UK guidelines for Resuscitation and support of
transition of babies at birth were published simultan-
eously in October 2015.1 Both are based on the evi-
dence derived from a critical evaluation of relevant
scientic publications over the preceding 5 years
organised and coordinated by the International
Liaison Committee on Resuscitation (ILCOR).2 3
Where there was no new evidence the guidelines
may reect those evidence evaluations carried out in
20054 or 20105 and incorporate published papers
not evaluated by the ILCOR.
This article summarises both the process and the
main areas of change (box 1), which, for the most
part, are renements of previous guidelines. It will
also briey discuss ongoing areas of controversy
where evidence was insufcient to lead to inclusion.
CHANGING GUIDELINES VIA THE ILCOR
PROCESS
The process from 1995 to 2010 has been described
previously.6 For 2015, suitable patient/population,
intervention, comparison, outcome (PICO) ques-
tions were developed by the neonatal ILCOR task
force in 2011. These were rened into 27 topics
each allocated to two reviewers.2 3 The ILCOR also
decided to perform systematic reviews based on the
recommendations of the Institute of Medicine of
the National Academies7 adopting the methodo-
logical approach proposed by the Grading of
Recommendations, Assessment, Development and
Evaluation (GRADE) working group,8 and an
online guidance development tool (http://gdt.
guidelinedevelopment.org/central_prod/_design/client/
index.html#) for all questions.9 Another online plat-
form known as the Scientic Evaluation and
Evidence Review System (SEERS: http://www.ilcor.
org/seers) was developed to support both task forces
and individual reviewers. SEERS functions as the
repository of all the information and reviews pro-
cessed since 2012, as well as discussions from the
C2015 Conference. It also hosts GRADE tutorials,
seminars and training videos. SEERS has the ability
to open all aspects of the process to the public for
comments and suggestions, and it is intended that it
will form the basis for future continuous assessment
of the evidence on which resuscitation practice is
based, although this is at present under review by
ILCOR. The neonatal task force discussed all ques-
tions in detail and there was a detailed iterative
review process culminating in the nal consensus on
science and treatment recommendations (CoSTR),
which then underwent peer review.
The ERC and UK guidelines are based on
ILCOR consensus document and incorporate previ-
ous guidelines and supplementary evidence where
appropriate. The role of guidelines is to direct the
evidence evaluation into practice and effect change.
That changes are relatively few reects the paucity
of human evidence relating to resuscitative practices
at birth. This lack of evidence requires engagement
by the public, practitioners, funding organisations
and ethics committees to ensure that in future
babies requiring help at birth receive timely, appro-
priate intervention based on evidence rather than
historical practice.
CHANGES IN RESUSCITATION MANAGEMENT
Transition versus resuscitation
The title of the new guidelines now incorporates
the term transition to reect that few babies need
resuscitation (with chest compression and drugs)
after birth, instead most requiring any intervention
at all merely need help with transition to air breath-
ing through respiratory support (assisted lung
aeration and, sometimes, continuous positive
airway pressure (CPAP) or ventilation).10 This is
especially true of preterm babies who have not
been exposed to profound hypoxia, but, even
among term babies, the need for chest compres-
sions or drugs is very rare (<0.01%).11 12
Resuscitation is more likely if there is evidence
of intrapartum compromise, preterm delivery
(<35 weeks), breech presentation, multiple preg-
nancy or maternal sepsis. However, any baby may
potentially develop problems during birth, thus
personnel trained in newborn life support should
be readily available for all deliveries. They, in turn,
should be able to rapidly access personnel with
advanced resuscitation skills (including intubation).
Delayed cord clamping
Delayed cord clamping for healthy term and
preterm babies was introduced as part of the 2010
guidelines.13 The 2015 guidelines make little
change here, except to reiterate that a delay of at
least 1 min from the time of complete delivery of
the baby is recommended. There is evidence from
animal models that delaying the clamping of the
cord until after the onset of breathing avoids the
effects of a sudden redistribution of blood volume
into the lungs.14 However, such evidence is lacking
in human studies.
There is still insufcient evidence to recommend
an appropriate time for clamping the cord in babies
who require resuscitation. These babies may
require the umbilical cord to be clamped so that
resuscitation measures can commence.
Maintaining a normal temperature
The present guidelines reemphasise the association
of hypothermia with mortality and morbidity. This
F1
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Review
Box 1 Main areas of change in the 2015 European
Resuscitation Council and UK newborn resuscitation
guidelines
The title of the guidelines has been changed from Resuscitation
at Birth to Resuscitation and support of transition at birth to
reect an emphasis on supporting transition to air breathing
rather than resuscitation.
A delay in the clamping of the cord of at least 1 min from
the time of complete delivery of the baby is recommended for
all babies when possible.
The newborn babys temperature should be maintained in the
normal range (36.5C to 37.5C) unless it is being considered
for therapeutic hypothermia. Active steps should be taken to
achieve this.
An accurate assessment of heart rate can be made using ECG
or pulse oximetry.
Tracheal intubation and suction is no longer routine for any
baby born through meconium-stained liquor. Instead the
emphasis should be on providing appropriate resuscitative
manoeuvres as soon as possible and only intubate the trachea
for suction in those infants whose airway is blocked.
Begin the resuscitation of term babies in air and that of
preterm babies (<35 weeks gestation) in low concentrations of
oxygen (21%30%). Use pulse oximetry to guide subsequent
use of oxygen.
Nasal CPAP may be used during the transition and
subsequent respiratory support of spontaneously breathing
preterm infants (<30 weeks gestation).
Chest compressions are started when the heart rate remains
less than 60/min after ve effective ination breaths and 30 s of
effective ventilation. Coordinate compressions and ventilations
at a ratio of 3:1.
Where possible brief the team before resuscitation and
debrief afterwards. Counsel and communicate with the parents
in a timely manner.
came directly from an extensive ILCOR review. While previous
guidelines have advised maintaining the temperature of
newborn babies, hypothermia after birth remains a worldwide
problem.15 Unless a baby is being considered for therapeutic
hypothermia, its temperature should be maintained in the
normal range (36.5C to 37.5C). Low birthweight babies are
particularly at risk and each 1C decrease in their neonatal unit
admission temperature below this is associated with an add-
itional increase in mortality of 28%.16 Take active steps to main-
tain normal temperature; dry term babies immediately and then
either cover the head and body with a warm dry towel or place
them covered skin to skin with the mother. Preterm babies may
require a combination of interventions including polyethylene
wrapping (without drying), a radiant heater, a hat, thermal mat-
tress, warmed humidied respiratory gases and warmed delivery
rooms. Avoiding hyperthermia (>38.0C) is also important.
Babies born unexpectedly outside a normal delivery environ-
ment should be covered and protected from draughts. They may
benet from placement in a food grade plastic bag after drying
and then swaddling.17 Alternatively, well newborns >30 weeks
gestation may be dried and nursed with skin-to-skin contact or
kangaroo mother care to maintain their temperature during
transfer.
F2 Wyllie J, Ainsworth S. Arch Dis Child Fetal Neonatal Ed 2016;0:F1F5. doi:10.1136/archdischild-2015-309472
Assessment of heart rate
Listening to the heart beat at the apex remains the best way of
assessing heart rate in the initial stages but this, and other
methods of clinical assessment (eg, palpation of the cord), may
underestimate the heart rate. Pulse oximetry may give an accur-
ate heart rate but it can take time to obtain a reliable reading.
ECG can reliably and accurately provide a heart rate within the
rst 2 min,18 but does not replace the need for a pulse oximeter
to monitor oxygenation. As with many newly introduced techni-
ques it will be a while before ECG monitoring during newborn
resuscitation becomes more widespread. With earlier use of
accurate heart rate recording, it should be remembered that in
the rst minute a normal heart rate for a healthy baby may be
<100/min19 and that heart rate may also be inuenced by the
timing of cord clamping.20
Management of the baby who is born through
meconium-stained liquor
All aspects of the previously advocated combined obstetric
and neonatal approach are now obsolete. The 2005 guide-
lines4 advised against the routine intrapartum oropharyngeal
and nasopharyngeal suctioning of vigorous babies who were
born with meconium-stained amniotic uid. Robust evaluation
of the evidence in 2015 found no evidence that tracheal suc-
tioning of the trachea improved outcome. Two small rando-
mised studies21 22 compared routine tracheal intubation and
suction of the airways with no tracheal suction in obtunded
babies born through meconium-stained liquor. They found no
difference in outcome other than a longer time to achieving a
heart rate of more than 100/min in the intubation group.
Attention is better focused on initiating resuscitative man-
oeuvres as quickly as possible. It is now recommended that
tracheal intubation and suction should not be a routine pro-
cedure for such babies. It should only be performed when,
after appropriate airway opening manoeuvres, the chest does
not move during positive pressure breaths and tracheal
obstruction is suspected.
Air versus oxygen
For term babies, positive pressure ventilation, if required,
should be started using air. The available evidence in preterm
babies <35 weeks supports lower concentrations of oxygen (air
to 30%) as opposed to 65% but could not rene this further.
Pulse oximetry should be used to guide the need for supplemen-
tal oxygen with an acceptable SpO2 being the 25th centile of
the values published by Dawson et al.23 Pulse oximetry should
be used to avoid excessive use of oxygen as well as to direct its
judicious use. If a pulse oximeter is unavailable, then it is rea-
sonable to increase the concentration of oxygen if you reach the
stage of needing chest compressions.
Support the transition of spontaneously breathing preterm
babies (<30 weeks) with or at risk of respiratory distress by
using CPAP
There is now good evidence from three randomised controlled
trials (RCTs) enrolling 2358 infants born <30 weeks gestation
that preterm babies who are breathing spontaneously can be
managed using nasal CPAP as their primary mode of respiratory
support.2426 This may be preferable to intubation, especially
when the personnel involved are inexperienced at tracheal
intubation. However, there are few data to guide the appropri-
ate use of CPAP in newborn term infants and further clinical
studies are required.27
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When to start compressions and what to do
Chest compressions will be performed when the heart rate
remains less than 60/min after ve effective ination breaths and
30 s of effective ventilation. In the majority of babies, a slow
heart rate will usually increase within the time it takes to com-
plete these manoeuvres. This clarication to the guidelines means
that lung expansion and ventilation is established and minimises
the potential compromise of ventilation by compressions.
Compressions and ventilations should be coordinated to
avoid simultaneous delivery. A 3:1 compression to ventilation
ratio is used for resuscitation at birth where compromise of gas
exchange is nearly always the primary cause of cardiovascular
collapse, but rescuers may consider using higher ratios (eg,
15:2) if the arrest is believed to be of cardiac origin. The hand
encircling technique with overlapping thumbs on the lower
third of the sternum is recommended. This is a reinforcement
and development of previous advice.28
Brieng/debrieng
The importance of counselling and communicating with parents
and team brieng and debrieng has been highlighted in these
guidelines. They form the start and end of the mnemonic algo-
rithm and are covered in slightly more detail than previously.
ONGOING AREAS OF UNCERTAINTY
While there have been some areas where newborn resuscitation
has become more evidenced based, there remain many areas
where the evidence is not yet strong enough to categorically
support a robust recommendation. This highlights that we still
do not know everything about the transition of babies. The fol-
lowing are several areas where consensus could not be reached.
Umbilical cord milking (stripping)
While there is clear evidence that it is advantageous to allow
placental transfusion by delaying the clamping of the cord for
healthy babies of any gestation provided they can be kept warm,
less is known about what to do with those babies who appear to
need immediate resuscitation. The milking (stripping) of the
cord has been proposed as an alternative when the cord must be
clamped immediately to allow treatment of either the baby or
the mother. It involves transfer of blood from a segment of the
cord by actively milking the blood towards the baby three to
ve times. It can be completed in around 20 s29 and produces
improved short-term haematological outcomes, admission tem-
perature and urine output when compared with delayed cord
clamping (>30 s) in babies born by caesarean section, although
these differences were not observed in infants born vaginally.30
The ILCOR/CoSTR process examined the evidence for this
procedure in preterm babies (<29 weeks gestation) and felt that
there was currently insufcient evidence of any long-term bene-
ts for this to be recommended routinely without further
studies, particularly of the longer term neurological outcomes.
Resuscitation before cord clamping
While there is a signicant amount of animal data favouring
delaying clamping the cord until after the lungs are aerated,
there is as yet insufcient human evidence to determine whether
resuscitation can be safely accomplished while the cord remains
unclamped and placental gas exchange and transfusion can still
occur. In many instances, existing equipment is not designed for
this and in some cases placental abruption or maternal condi-
tions will prevent it. While the potential clearly exists, many
questions remain about the impact especially on mothers and
Wyllie J, Ainsworth S. Arch Dis Child Fetal Neonatal Ed 2016;0:F1F5. doi:10.1136/archdischild-2015-309472
Review
babies and equipment and staff requirements.31 These need to
be answered before this approach can be accepted or implemen-
ted routinely.
Sustained inations
The ERC and UK guidelines advocate the use of initial ination
breaths sustained for 23 s duration based on human data which
is decades old.32 The sustained inations evaluated in the
ILCOR/CoSTR process were even longer (520 s3335), and
several studies had co-interventions that limited any direct com-
parisons. While the evidence of benet from animal studies is
persuasive,36 there are important differences (studied animals
were non-breathing, intubated or tracheotomised), which limit
the immediate applicability to humans. Furthermore, variations
in duration and number of breaths, as well as pressures, used
were considerable. Thus, the recommendation, until further
supportive evidence is available, was that sustained inations of
5 s duration should not be used unless in an individual clinical
situation or as part of a research study.
Positive end expiratory pressure in term babies receiving
positive pressure ventilation
Although positive end expiratory pressure (PEEP) is widely used
in preterm babies both during resuscitation and in neonatal
units, there are scant data to support its use in term babies who
require positive pressure ventilation at birth. Animal models
would suggest that PEEP is benecial in helping to clear the
lung uid; however, there are major limitations to their applic-
ability to human newborns, not least that most babies will
respond to lung ination (with or without PEEP) due to Heads
paradoxical reex where ination of the lung triggers an inspira-
tory effort.37 Whether PEEP is more benecial than no PEEP in
infants who remain apnoeic is unknown. If a clear benet for
using PEEP was found then, because self-inating bags are the
most common devices used for newborn resuscitation world-
wide but cannot reliably deliver PEEP,38 there would be fairly
major resource implications.
T-piece resuscitator versus self-inating bags
Both T-piece resuscitators and self-inating bags are widely used
but the former is becoming more commonplace, in part,
because of its ease of use and its ability to deliver PEEP. Using a
T-piece resuscitator with an air/oxygen blender also allows for
better control of inspired oxygen. A major disadvantage is that
they require a pressurised gas source whereas self-inating bags
do not. For reasons discussed previously both devices are effect-
ive in resuscitating the apnoeic term baby, while PEEP may be
advantageous, present evidence is not sufciently compelling to
recommend one over the other.39 40
Laryngeal mask airways
Laryngeal mask airways (LMAs) are widely used for advanced
airway management in adult and paediatric resuscitation instead
of tracheal intubation. The LMA has been suggested as an alter-
native, either as a primary device (replacing facemask ventila-
tion) or as a secondary device (for failed or not-possible
tracheal intubation).41 They can be reliably used in babies of
>34 weeks gestation as an alternative to intubation; but costs
and the fact that effective facemask ventilation can resuscitate
most term and near-term babies probably limits their applicabil-
ity as a primary device.
F3
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Review
Chest compressions: ratio and to synchronise or not
The 3:1 ratio of synchronised ventilations to chest compressions
is unique to newborn resuscitation and is unchanged from previ-
ous guidelines. This ratio allows for more ventilation breaths
per minute than either the paediatric (15:2) or adult (30:2)
ratios and is a reection of need to rst address the hypoxic
state of the newborn baby requiring resuscitation. That said, the
ratio providing the best combination of ventilation and both
cardiac and cerebral perfusion in the newborn baby requiring
resuscitation is unknown.
Non-synchronised ventilations and compressions may be used
in adult resuscitations, especially following tracheal tube place-
ment. Adult tracheal tubes are cuffed whereas neonatal ones are
not, meaning compressions performed at the time of a breath
may limit the volume of that breath. Nonetheless in a manikin
model, because asynchronous ventilations and compressions
allow for more breaths per minute, the minute volume can be
greater.42 It remains unclear whether this is advantageous in
newborn humans and thus asynchronous ventilations and com-
pressions cannot be recommended as there remain concerns that
they may impede ventilation in practice.
Sodium bicarbonate: to use or not to use
Sodium bicarbonate has not featured as part of the American
newborn resuscitation guidelines since 200043 but has continued
to feature in the ERC and UK guidelines. Human evidence for
the effectiveness of any drug during newborn resuscitation is
extremely limited due to the rarity of this situation. There is a
reluctance to totally abandon this drug.44 This is because there
is some evidence that reversal of intracardiac acidosis using
alkali may sometimes restore the heart rate when all else has
failed45 and because many of the concerns about potential harm
from bicarbonate relate to its use to correct acidosis after restor-
ation of the circulation and not during resuscitation. For now,
sodium bicarbonate remains part of the guidelines, nonetheless
the outlook for a baby who has reached the stage of requiring
any drug during resuscitation remains poor.11
Discontinuing resuscitation
Little has changed in the ILCOR consensus statement or the
ERC and UK guidelines due to the paucity of new evidence.
These merely state that If the heart rate of a newly born baby is
not detectable and remains undetectable for 10 min, it may be
appropriate to consider stopping resuscitation. Evidence of
good outcome after this time period exists46 but has important
limitations.47 There have been suggestions based on this limited
evidence that a cut-off of 20 min should be used.48 This is hard
to justify on the evidence available and, in any case, the current
recommendations require that the decision be individualised
and inuenced by aetiology, the gestation of the baby, the poten-
tial reversibility of the situation, the availability of therapeutic
hypothermia and the parents previous expressed feelings about
acceptable risk of morbidity.
SUMMARY
The ILCOR process has been robust in the assessment of avail-
able evidence for the questions addressed and is now in line
with accepted standards for reviews and guidelines. It is
intended to make evidence evaluation a continuous process with
ILCOR position statements when appropriate. However, it is
likely that the formal process of collating UK national and
European guidelines will remain ve yearly. Those guidelines
remain, in part, based on consensus or historical precedent due
F4 Wyllie J, Ainsworth S. Arch Dis Child Fetal Neonatal Ed 2016;0:F1F5. doi:10.1136/archdischild-2015-309472
to the continued lack of human evidence to justify change. It is
appropriate for all aspects of the pragmatic unied approach,
which guidelines represent, be subject to examination by
research studies. It is vital that such studies are not prevented
purely on the basis of historical practice without any true evi-
dential support. The challenge for the future is to provide that
evidence to ensure that babies at birth get the best and most
effective care.
Contributors JW and SA had joint responsibility writing the rst draft, editing the
manuscript and approval of the nal draft.
Competing interests JW is an unpaid co-chair of the ILCOR newborn task force
and a member of the European Resuscitation Council developing guidelines for
newborn resuscitation, both JW and SA are unpaid members of the Newborn Life
Support Subcommittee of the Resuscitation Council (UK) developing the UK
guidelines for newborn resuscitation.
Provenance and peer review Commissioned; externally peer reviewed.
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 Downloaded from http://fn.bmj.com/ on April 29, 2016 - Published by group.bmj.com

What is new in the European and UK neonatal

resuscitation guidance?
Jonathan Wyllie and Sean Ainsworth

Arch Dis Child Fetal Neonatal Ed published online April 28, 2016

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http://fn.bmj.com/content/early/2016/04/28/archdischild-2015-309472

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