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Aim: To determine the relationship between clinical practice and publication of an Australian consensus statement for management of extremely preterm infants in 2006., Methods: A population-based study using linked data from New South Wales, Australia for births between 22 + 0 and 26 + 6 weeks of gestation between 2000 and 2011., Results: There were 4746 births of whom 2870 were liveborn and 1876 were stillborn. Of the live births, 2041 (71%) were resuscitated, 1914 (67%) were admitted into a neonatal intensive care unit (NICU) and 1310 (46%) survived to hospital discharge. Thirty-nine (2%) stillbirths were resuscitated but none survived. No 22-week infant survived to hospital discharge. Fewer 23-week gestation infants were resuscitated between 2004 (52%) and 2005 (20%) but resuscitation rates increased by 2008 (44%). There was no difference at other gestations. Adjusted odds ratio (OR) for resuscitation was increased by birthweight (OR: 1.01), tertiary hospital birth (OR: 3.4) and Caesarean delivery (OR: 11.3) and decreased by rural residence (OR: 0.4) and male gender (OR: 0.7)., Conclusion: Expert recommendations may be shaped by clinical practice rather than the converse, especially for 23-week gestation infants. Recommendations should be revised regularly to include clinical practice changes., (©2019 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Aim: The aim of this study was to survey paediatricians, who taught neonatal resuscitation in Brazil, about when they would apply advanced resuscitation in the delivery room for newborn infants born at 23-26 weeks of gestational age., Methods: This cross-sectional study focused on an electronic questionnaire that was sent to paediatricians who acted as instructors for the Brazilian Neonatal Resuscitation Program from December 2011 to September 2013. The primary outcome was the gestational age at which the respondent would apply advanced resuscitation in the delivery room. Latent class analysis identified the profiles of the instructors, and logistic regression identified the variables associated with belonging to one of the derived classes., Results: The 560 (82%) instructors who agreed to participate fell into three latent classes: pro-resuscitation, intermediate and pro-limitation, with high, intermediate and low probabilities of performing advanced resuscitation in neonates born at 23-26 weeks. In the multivariate model, group membership was associated with the paediatrician's age, years of practice and personal importance of religion and the patient's birthweight, future quality of life and probability of death., Conclusion: The opinions of paediatricians performing advanced resuscitation on extremely preterm infants in the delivery room were diverse and influenced by personal beliefs., (©2016 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Aim: This population-based study determined the delivery room management and outcomes of extremely preterm infants born with Apgar scores of 0., Methods: We linked birth, neonatal intensive care unit (NICU) and death records for babies who were born between 22 + 0 and 27 + 6 weeks of gestation with a one-minute Apgar score of 0, in New South Wales, Australia, between 1998 and 2011., Results: We classified 2173/2262 (96%) of infants with a one-minute Apgar score of 0 as stillborn. Resuscitation was provided for 48/89 (54%) live births and 40/2173 (2%) stillbirths. Cardiac massage was given to 44 infants, including three 22-week stillborn babies. Of the 13 live births admitted to an NICU, 11 survived to hospital discharge. Most (98%) of the 2212 deaths occurred on the first day of life. One baby who was classified as stillborn lived for 51 days. Resuscitation increased the mean (95% confidence interval) duration of survival from 1 (0-2) to 45 (0-104) hours (p < 0.001). No infant with a five-minute Apgar score of 0 survived., Conclusion: Clinicians resuscitated extremely preterm infants without a detectable heartbeat, even at 22 weeks of gestation. No infant survived without resuscitation or if their heartbeat was not regained by five minutes., (©2016 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Aim: Standard resuscitation guidelines are based on data from a range of gestational ages. We sought to evaluate the effectiveness of our delivery room resuscitation protocol across a range of gestational ages in preterm infants born at <29 weeks., Methods: We performed an observational study of prospectively collected video recordings of 73 preterm infants. The percentage of bradycardic patients, time to reach target oxygen saturation and the extent of all interventions were compared between three gestational age groups: 22-24 weeks (n = 22), 25-26 weeks (n = 27) and 27-28 weeks (n = 24)., Results: Although the same resuscitation protocol was followed for all infants, bradycardic infants born <25 weeks responded poorly and required significantly longer to reach oxygen saturation targets of >70%, >80% and >90% (p < 0.03). They required significantly more interventions and had higher rate of death (p < 0.05) and severe intraventricular haemorrhage (p < 0.03). Significantly lower heart rate and oxygen saturation values were found in infants with intraventricular haemorrhage., Conclusion: Current recommendations for resuscitation may fail to achieve timely lung aeration in infants born at the borderline of viability, leading to higher mortality and morbidity. Sustained inflation and delayed cord clamping may be effective alternatives., (©2015 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Aim: Interventions that improve neonatal resuscitation are critical if we are to reduce perinatal mortality. We evaluated the consistency of resuscitation practices, and adherence to the international guidelines for neonatal resuscitation, in a large representative sample of hospitals in Vietnam., Methods: A questionnaire was sent to 187 public central, provincial and district hospitals, representing the three levels of public hospital-based maternity services in Vietnam., Results: The overall response rate was 85.7% (160/187 hospitals), and the response rate was 100%, 90.3% and 81.7% for central, provincial and district hospitals, respectively. There were 620 300 births in the surveyed hospitals during the year 2011, representing almost half of all inpatient births in Vietnam. Neonatal resuscitation was provided by obstetricians and, or, midwives at all levels. Half of the hospitals did not follow recommendations for delaying cord clamping. The majority of the hospitals did not have a wall thermometer in the delivery room (80.5%) and did not monitor neonatal temperature after birth (64.1%). A large proportion of hospitals (39.9%) used 100% oxygen to initiate resuscitation and only central hospitals avoided this practice., Conclusion: Our survey identified significant variations in resuscitation practices between central, provincial and district hospitals and limited adherence to international recommendations., (©2015 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Aim: Neonatal resuscitation requires minimal equipment, but the immediate availability of expert staff accounts for the largest proportion of the costs. Despite this, staff requirements and timetables are currently planned without comprehensive epidemiologic data. The aim of this study was to evaluate the staffing required for neonatal resuscitations in the delivery room., Methods: We measured attendance for each specific role in a tertiary university-affiliated hospital and for four possible intervention levels: preparation time, basic paediatric care, moderate resuscitation and extended resuscitation., Results: Between 2005 and 2012, resuscitation staff attended 11 561 of the 32 799 births: 27.2% for preparation time, 17.7% for basic paediatric care, 6.4% for moderate resuscitation and 3.5% for extended resuscitation. Moderate and extended resuscitations occurred in roughly 10% of births and evenly during 24-h periods. Basic paediatric care levels were higher during weekday mornings, and extended resuscitations were uniformly distributed. However, there was a drop in all types of interventions around 7 a.m. to 8 a.m., when staff were changing shifts., Conclusion: Moderate and extended resuscitations occurred evenly over 24 h in roughly 10% of births, stressing the importance of having a highly competent neonatal team constantly available. All activities associated with resuscitation were lower during morning shift changes., (©2015 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Aim: To evaluate any geographical variations in practice and adherence to international guidelines for early delivery room management of extremely low birthweight (ELBW) infants in the North, Centre and South of Italy., Methods: A questionnaire was sent to all 107 directors of Italian level III centres between April and August 2012., Results: There was a 92% (n = 98) response rate. A polyethylene bag/wrap was used by 54 centres (55.1%), with the highest rate in Northern Italy (77.5%) and the lowest rate in Southern (37.7%) areas. In Northern regions, one centre (2.5%) said it used oxygen concentrations >40% to initiate positive pressure ventilation in ELBW infants. These proportions were higher in the Central (14.3%) and Southern (16.2%) areas. A T-piece device for positive pressure ventilation was more frequently available in the Northern (95%) units than in those in the Central (66.7%) and Southern (69.4%) regions. A median of 13% (IQR: 5%-30%) of ELBW infants received chest compressions at birth in Italy: 5%, 18% and 22% in Northern, Central and Southern units, respectively., Conclusion: In Italy, delivery room management of ELBW infants showed marked geographical variations. Implementation of national training programmes could increase adherence to the guidelines and reduce such discordance., (©2014 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Objectives: To audit the knowledge and application of internationally recommended newborn resuscitation (NR) guidelines among delivery room (DR) caregivers of Spanish hospitals., Methods: A questionnaire-type survey on NR equipment and practices was performed in hospitals of the Spanish National Health System classified according to level of care provided., Results: 88% of the questionnaires were complimented. Limit of viability was set in 23-24 weeks in 78% of the centres. Availability of board-certified and instructors in NR was significantly higher in level III versus level I-II centres (94 vs. 70% and 78 vs. 51%, respectively). No differences in equipment or knowledge of guidelines of resuscitation were found between centres. Substantial differences were observed in supplementation and monitorization of oxygen, and positive pressure ventilation during resuscitation and transportation., Conclusion: Equipment availability and knowledge of guidelines of NR does not differ between hospitals independent of their level of care. However, performance during resuscitation and transportation in level III hospitals is in significantly greater acquaintance with internationally recommended NR guidelines.

Aim: To determine the safety and efficacy of neonatal nurses attending at-risk deliveries., Methods: An audit of 2 years of delivery attendance by neonatal nurses at an urban hospital. Attendance also by a paediatrician if expected birth weight <2 kg, gestation < 35 weeks, twin pregnancy, foetal distress or any anomaly anticipated to seriously affect the newborn's health., Results: About 3021 deliveries were attended, 2228 (74%) by a neonatal nurse, 776 (25%) by a neonatal nurse and a paediatrician and 17 (1%) by a paediatrician. Twenty-three children required intermittent positive pressure ventilation via endotracheal tube and/or cardiac massage. All but five of these were deliveries where both a neonatal nurse and a paediatrician were present. Three of these five deliveries had foetal tachycardia. There were 33 deliveries managed by the neonatal nurse alone where the 1-min Apgar was three or less. All achieved a 10-min Apgar of seven or greater. Over the study interval, the proportion of deliveries attended only by a neonatal nurse increased and intensity of resuscitation administered decreased., Conclusion: Appropriately trained neonatal nurses can safely resuscitate newborns. Addition of foetal tachycardia to the indications for paediatrician attendance identifies infants likely to require more resuscitation.