Search

Abstract Epinephrine is the only recommended vasopressor during neonatal cardiopulmonary resuscitation. However, there are concerns about the potential adverse effects of epinephrine, which might hamper efficacy during cardiopulmonary resuscitation. An alternative might be vasopressin, which has a preferable adverse effect profile, however, its optimal dose and route of administration is unknown. We aimed to compare the pharmacodynamics and pharmacokinetics of various vasopressin doses administered via intravenous (IV), intraosseous (IO), endotracheal (ETT), and intranasal (IN) routes in healthy neonatal piglets. Forty-four post-transitional piglets (1–3 days of age) were anesthetized, intubated via a tracheostomy, and randomized to receive vasopressin via intravenous (control), IO, ETT, or IN route. Heart rate (HR), arterial blood pressure, carotid blood flow, and cardiac function (e.g., stroke volume, ejection fraction) were continuously recorded throughout the experiment. Blood was collected prior to drug administration and throughout the observation period for pharmacodynamics and pharmacokinetic analysis. Significant changes in hemodynamic parameters were observed following IO administration of vasopressin while pharmacokinetic parameters were not different between IV and IO vasopressin. Administration of vasopressin via ETT or IN did not change hemodynamic parameters and had significantly lower maximum plasma concentrations and systemic absorption compared to piglets administered IV vasopressin (p

Aim: To examine speed and accuracy of newborn heart rate measurement by various assessment methods employed at birth. Methods: A search of Medline, SCOPUS, CINAHL and Cochrane was conducted between January 1, 1946, to until August 16, 2023. (CRD 42021283364) Study selection was based on predetermined criteria. Reviewers independently extracted data, appraised risk of bias and assessed certainty of evidence. Results: Pulse oximetry is slower and less precise than ECG for heart rate assessment. Both auscultation and palpation are imprecise for heart rate assessment. Other devices such as digital stethoscope, Doppler ultrasound, an ECG device using dry electrodes incorporated in a belt, photoplethysmography and electromyography are studied in small numbers of newborns and data are not available for extremely preterm or bradycardic newborns receiving resuscitation. Digital stethoscope is fast and accurate. Doppler ultrasound and dry electrode ECG in a belt are fast, accurate and precise when compared to conventional ECG with gel adhesive electrodes. Limitations: Certainty of evidence was low or very low for most comparisons. Conclusion: If resources permit, ECG should be used for fast and accurate heart rate assessment at birth. Pulse oximetry and auscultation may be reasonable alternatives but have limitations. Digital stethoscope, doppler ultrasound and dry electrode ECG show promise but need further study.

Background: A new cardiopulmonary resuscitation technique, chest compressions with sustained inflation (CC + SI) might be an alternative to both the neonatal [3:1compressions to ventilations (3:1C:V)] and paediatric [chest compression with asynchronous ventilation (CCaV)] approaches. The human factors associated with this technique are unknown. We aimed to compare the physical, cognitive, and team-based human factors for CC + SI to standard CPR (3:1C:V or CCaV). Methods: Randomized crossover simulation study including 40 participants on 20 two-person teams. Workload [National Aeronautics and Space Administration Task Load Index (NASA-TLX)], crisis resource management skills (CRM) [Ottawa Global Rating Scale (OGRS)], and debrief analysis were compared. Results: There was no difference in paired NASA-TLX scores for any dimension between the CC + SI and standard, adjusting for CPR order. There was no difference in CRM scores for CC + SI compared to standard. Participants were less familiar with CC + SI although many found it simpler to perform, better for transitions/switching roles, and better for communication. Conclusions: The human factors are no more physically or cognitively demanding with CC + SI compared to standard CPR (NASA-TLX and participant debrief) and team performance was no different with CC + SI compared to standard CPR (OGRS score).

Aim: Compare heart rate assessment methods in the delivery room on newborn clinical outcomes. Methods: A search of Medline, SCOPUS, CINAHL and Cochrane was conducted between January 1, 1946, to until August 16, 2023. (CRD 42021283438) Study Selection was based on predetermined criteria. Reviewers independently extracted data, appraised risk of bias and assessed certainty of evidence. Results: Two randomized controlled trials involving 91 newborns and 1 nonrandomized study involving 632 newborns comparing electrocardiogram (ECG) to auscultation plus pulse oximetry were included. No studies were found that compared any other heart rate measurement methods and reported clinical outcomes. There was no difference between the ECG and control group for duration of positive pressure ventilation, time to heart rate ≥ 100 beats per minute, epinephrine use or death before discharge. In the randomized studies, there was no difference in rate of tracheal intubation [RR 1.34, 95% CI (0.69–2.59)]. No participants received chest compressions. In the nonrandomized study, fewer infants were intubated in the ECG group [RR 0.75, 95% CI (0.62–0.90)]; however, for chest compressions, benefit or harm could not be excluded. [RR 2.14, 95% (CI 0.98–4.70)]. Conclusion: There is insufficient evidence to ascertain clinical benefits or harms associated with the use of ECG versus pulse oximetry plus auscultation for heart rate assessment in newborns in the delivery room.

Abstract Background Immediately after birth, the oxygen saturation is between 30 and 50%, which then increases to 85–95% within the first 10 min. Over the last 10 years, recommendations regarding the ideal level of the initial fraction of inspired oxygen (FiO2) for resuscitation in preterm infants have changed from 1.0, to room air to low levels of oxygen (

Background: Recently, the American Heart Association released a statement calling for research examining the appropriate age to transition from the neonatal to pediatric cardiopulmonary resuscitation approach to resuscitation. Aim: To compare neonatal and pediatric resuscitation approach by using either continuous chest compression with asynchronized ventilation (CCaV) or continuous chest compression superimposed with sustained inflation (CC + SI) during infant cardiopulmonary resuscitation. We hypothesized that CC + SI compared to CCaV would reduce time to return of spontaneous circulation (ROSC) in infantile piglets with asphyxia-induced bradycardic cardiac arrest. Methods: Twenty infantile piglets (5–10 days old) were anesthetized and asphyxiated by clamping the endotracheal tube. Piglets were randomized to CC + SI or CCaV for resuscitation (n = 10/group). Heart rate, arterial blood pressure, carotid blood flow, cerebral oxygenation, intrathoracic pressure and respiratory parameters were continuously recorded throughout the experiment. Main results: The median (IQR) time to ROSC with CC + SI compared to CCaV was 179 (104–447) vs 660 (189–660), p = 0.05. The number of piglets achieving ROSC with CC + SI and CCaV were 8/10 and 6/10, p = 0.628. Piglets resuscitated with CC + SI required less epinephrine compared to CCaV (p = 0.039). CC + SI increased the intrathoracic pressure throughout resuscitation (p = 0.025) and increased minute ventilation (p

Background: Healthcare providers (HCPs) working in labour and delivery rooms need to undergo regular refresher courses to maintain their neonatal resuscitation skills, which are shown to decline over time. However, due to their irregular schedules and limited time, HCPs encounter difficulties in readily accessing refresher programs. RETAIN is a digital game that simulates a delivery room to facilitate neonatal resuscitation training for HCPs. Objective: This study aims to ascertain whether participants enjoyed the RETAIN digital game simulator and whether it was at least as good as a video lecture at refreshing and maintaining participants’ neonatal resuscitation knowledge. Methods: In this randomized controlled simulation trial, n = 42 labour and delivery room HCPs were administered a pre-test of neonatal resuscitation knowledge using a manikin. Then, they were randomly assigned to a control or a treatment group. For 20–30 min, participants in the control group watched a neonatal resuscitation lecture video, while those in the treatment group played the RETAIN digital game simulator of neonatal resuscitation scenarios. Then, all participants were administered a post-test identical to the pre-test. Additionally, participants in the treatment group completed a survey of attitudes toward the RETAIN simulator that provided a measure of enjoyment of the RETAIN game simulator. After two months, participants were administered another post-test identical to the pre-test. Results: For the primary outcome (neonatal resuscitation performance), an analysis of variance revealed that participants significantly improved their neonatal resuscitation performance over the first two time points, with a significant decline to the third time point, the same pattern of results across conditions, and no differences between conditions. For the secondary outcome (attitudes toward RETAIN), participants in the treatment condition also reported favourable attitudes toward RETAIN. Conclusions: Labour and delivery room healthcare providers in both groups (RETAIN simulator or video lecture) significantly improved their neonatal resuscitation performance immediately following the intervention, with no group differences. The findings suggest that participants enjoyed interacting with the RETAIN digital game simulator, which provided a similar boost in performance right after use to the more traditional intervention.

Background: Epinephrine is currently the only recommended cardio-resuscitative medication for use in neonatal cardiopulmonary resuscitation (CPR), as per the consensus of science and treatment recommendations. An alternative medication, vasopressin, might be beneficial in neonatal CPR due to its combined pulmonary vasodilation and systemic vasoconstriction properties. Aim: We aimed to compare the time to return of spontaneous circulation (ROSC) with administration of vasopressin or epinephrine during CPR of asphyxiated post-transitional piglets. Methods: Newborn piglets (n = 8/group) were anesthetized, tracheotomized and intubated, instrumented, and exposed to 50 min normocapnic hypoxia followed by asphyxia and cardiac arrest. Piglets were randomly allocated to receive vasopressin (Vaso, 0.4 U/kg) or epinephrine (Epi, 0.02 mg/kg) during CPR. Piglets were resuscitated with chest compressions superimposed with sustained inflations, and were administered either Vaso or Epi intravenously every 3 min until ROSC (max. 3 doses). Hemodynamic and cardiac function parameters were collected. Main Results: The median (IQR) time to ROSC was 106 (93–140) s with Vaso and 128 (100–198) s with Epi (p = 0.28). The number of piglets that achieved ROSC was 8 (100%) with Vaso and 7 (88%) with Epi (p = 1.00). Vaso-treated piglets had a significantly longer post-resuscitation survival time (240 (240–240) min) than Epi-treated piglets (65 (30–240) min, p = 0.02). Vaso-treated piglets had significantly improved carotid blood flow immediately after ROSC (p

BackgroundTo compare chest compression (CC) rates of 60/min with 90/min and their effect on the time to return of spontaneous circulation (ROSC), survival, hemodynamic, and respiratory parameters. We hypothesized that asphyxiated newborn piglets that received CC at 60/min vs. 90/min during cardiopulmonary resuscitation would have a shorter time to ROSC.MethodsNewborn piglets (n = 7/group) were anesthetized, tracheotomized and intubated, instrumented and exposed to 45 min normocapnic hypoxia followed by asphyxia and cardiac arrest. Piglets were randomly allocated to a CC rate of 60/min or 90/min. CC was performed using an automated CC machine using CC superimposed with sustained inflation. Hemodynamic parameters, respiratory parameters, and applied compression force were continuously measured.ResultsThe mean (IQR) time to ROSC was 97 (65–149) s and 136 (88–395) s for CC rates of 60/min and 90/min, respectively (p = 0.31). The number of piglets that achieved ROSC was 5 (71%) and 5 (71%) with 60/min and 90/min CC rates, respectively (p = 1.00). Hemodynamic parameters (i.e., diastolic and mean blood pressure, carotid blood flow, stroke volume, end-diastolic volume, left ventricular contractile function) and respiratory parameters (i.e., minute ventilation, peak inflation and peak expiration flow) were all similar with a CC rate of 60/min compared to 90/min.ConclusionTime to ROSC, hemodynamic, and respiratory parameters were not significantly different between CC rates of 60/min vs. 90/min. Different CC rates during neonatal resuscitation warrant further investigation.

Neonatal resuscitation is a skill set that comprises procedures, assessment, decision-making, communication, and teamwork. It is used in an emergency situation in the delivery room with the aim of supporting newborn infants who are not able to begin breathing on their own. Thus, healthcare providers need to refresh their neonatal resuscitation skills periodically, according to the Neonatal Resuscitation Program, to ensure that they can react quickly and effectively in emergency situations. The RETAIN digital game simulator was designed to enable healthcare providers to practice their neonatal resuscitation skills. To evaluate the effectiveness of this game in a laboratory setting, a randomized control trial sampled 42 paramedics who completed a pre-test, were randomly assigned to watch a traditional lecture video on the neonatal resuscitation procedure or to play a novel digital game simulation on the same topic, and then completed a following test. A two-way mixed ANOVA revealed a statistically significant improvement in paramedics’ neonatal resuscitation performance over time, which did not differ between conditions. Thus, digital games can provide an enjoyable alternative to traditional practices in refreshing neonatal resuscitation knowledge.

Background: Respiratory distress is common during transition after birth, but the effect of continuous positive airway pressure applied in the delivery room has not been systematically evaluated in spontaneously breathing term and ≥34+0 weeks’ gestation infants.We aimed to compare delivery room continuous positive airway pressure with no delivery room continuous positive airway pressure for term and ≥34+0 weeks’ gestation newborn infants at birth. Methods: Information sources: Medline, Embase, Cochrane Databases, Database of Abstracts of Reviews of Effects, and Cumulative Index to Nursing and Allied Health Literature. The Databases were last searched in October 2021.Eligibility criteria: Randomized, quasi-randomized, interrupted time series, controlled before-after, and cohort studies with English abstracts.Synthesis of results: Two authors independently extracted data, assessed risk of bias, and certainty of evidence. The main outcome was admission to the neonatal intensive care unit (NICU) or higher level of care receiving any positive pressure support. Data were pooled using fixed effects models.Risk of bias: Was assessed using the Cochrane Risk of Bias Tool for randomized trials and the Non-Randomized Studies of Interventions Tool (ROBINS-I) for observational studies. Results: In this meta-analysis, two randomized control trials (323 newborns delivered by cesarean section) showed that delivery room continuous positive airway pressure decreased the likelihood of NICU admission (risk ratio (RR) 95% confidence interval (CI) 0.27 (0.11–0.66), p

We present a novel approach of ventilation, using high-frequency oscillation ventilation (HFOV), during neonatal cardiopulmonary resuscitation (CPR) of a very preterm neonate. This case report highlights the importance of adequate lung inflation, which is a current topic, with neonatal resuscitation guidelines recommending a coordinated 3:1 compression:ventilation ratio during CPR. Our patient, a female infant born at 30 weeks gestational age, weighing 970 g, appeared floppy and apneic following birth in the amniotic sac. Lungs were unfolded and white-out in an x-ray done during resuscitation. The aim was to open lungs effectively using HFOV, instead of positive pressure ventilation, which was used unsuccessfully until the 7th minute of life. Heart rate continuously dropped below 60/min 15 min after birth and chest compressions with asynchronous HFOV were started, adrenalin was administered three times and surfactant was instilled endotracheally twice. It was possible to stabilize the patient after 15 min of CPR, following return of spontaneous circulation. HFOV may have enabled an alternative and rescue option of ventilation during neonatal CPR in this case.

Background: The Neonatal Life Support Consensus on Science With Treatment Recommendations states that chest compressions (CC) be performed preferably with the 2-thumb encircling technique. The aim of this study was to compare the hemodynamic effects of four different finger positions during CC in a piglet model of neonatal asphyxia. Methods: Seven asphyxiated post-transitional piglets were randomized to CC with 2-thumb-, 2-finger-, knocking-fingers-, and over-the-head 2-thumb-techniques for one minute at each technique. CC superimposed with sustained inflations were performed manually. Results: Seven newborn piglets (age 0–4 days, weight 2.0–2.1 kg) were included in the study. The mean (SD) slope rise of carotid blood flow was significantly higher with the 2-thumb-technique and over-the-head 2-thumb-technique (118 (45) mL/min/s and 121 (46) mL/min/s, respectively) compared to the 2-finger-technique and knocking-finger-technique (75 (48) mL/min/s and 71 (67) mL/min/s, respectively) (p < 0.001). The mean (SD) dp/dtmin (as an expression of left ventricular function) was significantly lower with the 2-thumb-technique, with −1052 (369) mmHg/s, compared to −568 (229) mmHg/s and −578(180) mmHg/s (both p = 0.012) with the 2-finger-technique and knocking-finger-technique, respectively. Conclusion: The 2-thumb-technique and the over-the-head 2-thumb-technique resulted in improved slope rises of carotid blood flow and dp/dtmin during chest compression.

Background: To compare chest compression (CC) rates of 90/min with 180/min and their effect on the time to return of spontaneous circulation (ROSC), survival, hemodynamic, and respiratory parameters. We hypothesized that asphyxiated newborn piglets that received CC at 180/min vs. 90/min during cardiopulmonary resuscitation would have a shorter time to ROSC. Methods: Newborn piglets (n = 7/group) were anesthetized, intubated, instrumented and exposed to 45 min normocapnic hypoxia followed by asphyxia and cardiac arrest. Piglets were randomly allocated to a CC rate of 180/min or 90/min. CC was performed using an automated chest compression machine using CC superimposed with sustained inflation. Hemodynamic and respiratory parameters and applied compression force were continuously measured. Results: The mean (SD) time to ROSC was 91 (34) and 256 (97) s for CC rates of 180/min and 90/min, respectively (p = 0.08). The number of piglets that achieved ROSC was 7 (100%) and 5 (71%) with 180/min and 90/min CC rates, respectively (p = 0.46). Hemodynamic parameters (i.e., diastolic and mean blood pressure, carotid blood flow, stroke volume, end-diastolic volume, left ventricular contractile function) and respiratory parameters (i.e., minute ventilation, peak inflation and peak expiration flow) were all improved with a CC rate of 180/min. Conclusion: Time to ROSC and hemodynamic and respiratory parameters were not statistical significant different between CC rates of 90/min and 180/min. Higher CC rates during neonatal resuscitation warrant further investigation.

Background: During pediatric cardiopulmonary resuscitation (CPR), resuscitation guidelines recommend 100% oxygen (O2); however, the most effective O2 concentration for infants unknown. Aim: We aimed to determine if 21% O2 during CPR with either chest compression (CC) during sustained inflation (SI) (CC + SI) or continuous chest compression with asynchronized ventilation (CCaV) will reduce time to return of spontaneous circulation (ROSC) compared to 100% O2 in infant piglets with asphyxia-induced cardiac arrest. Methods: Piglets (20–23 days of age, weighing 6.2–10.2 kg) were anesthetized, intubated, instrumented, and exposed to asphyxia. Cardiac arrest was defined as mean arterial blood pressure < 25 mmHg with bradycardia. After cardiac arrest, piglets were randomized to CC + SI or CCaV with either 21% or 100% O2 or the sham. Heart rate, arterial blood pressure, carotid blood flow, and respiratory parameters were continuously recorded. Main results: Baseline parameters, duration, and degree of asphyxiation were not different. Median (interquartile range) time to ROSC was 107 (90–440) and 140 (105–200) s with CC + SI 21% and 100% O2, and 600 (50–600) and 600 (95–600) s with CCaV 21% and 100% O2 (p = 0.27). Overall, six (86%) and six (86%) piglets with CC + SI 21% and 100% O2, and three (43%) and three (43%) piglets achieved ROSC with CCaV 21% and 100% O2 (p = 0.13). Conclusions: In infant piglets resuscitated with CC + SI, time to ROSC reduced and survival improved compared to CCaV. The use of 21% O2 had similar time to ROSC, short-term survival, and hemodynamic recovery compared to 100% oxygen. Clinical studies comparing 21% with 100% O2 during infant CPR are warranted.

Background Chest compression (CC) during sustained inflations (CC+SI) compared with CC with asynchronized ventilation (CCaV) during cardiopulmonary resuscitation in asphyxiated pediatric piglets will reduce time to return of spontaneous circulation (ROSC). Methods and Results Piglets (20–23 days of age, weighing 6.2–10.2 kg) were anesthetized, intubated, instrumented, and exposed to asphyxia. Cardiac arrest was defined as mean arterial blood pressure

Aim: We aimed to describe the cognitive processes of healthcare providers participating as airway leads in delivery room neonatal resuscitations using eye-tracking assisted debriefing to facilitate recall and provide situational context. Methods: Delivery room neonatal resuscitations were recorded using eye-tracking glasses worn by participants who acted as airway leads. These glasses analyze eye-movements to produce an audio-visual recording approximating what was “seen” by the participant and marking their visual attention. Participants then reviewed and debriefed their recordings. Debriefing involved a retrospective think-aloud prompted by eye-tracked recordings and an integrated semi-structured interview. Debriefing sessions were transcribed and subjected to thematic analysis. Results: Eight healthcare providers participated in 10 interviews; two providers participated twice in two separate resuscitations. Most visual attention was directed at the infant (62%), with 16% directed to monitors/gauges, 3% to team members. Five major themes emerged including situation awareness, performance, working in teams, addressing threats to performance, and perception of eye-tracking. Information processing was complex and involved top-down and bottom-up processing of environmental stimuli, integration of knowledge/experience, and anticipation of patient response. Despite the focus on individual cognition, interpersonal interactions and teamwork emerged as key aspects of resuscitation performance. Potential threats to performance include equipment issues, mental stress, distractions, and parental presence. Eye-tracking recordings were well-received by the participants. Conclusion: Retrospective think-aloud prompted by point-of-view eye-tracked recordings is a useful means of examining cognition of healthcare providers during neonatal resuscitation. Themes identified in this project aligned with existing models of clinical reasoning.

Abstract Background Transition immediately after birth is a complex physiological process. The neonate has to establish sufficient ventilation to ensure significant changes from intra-uterine to extra-uterine circulation. If hypoxia or bradycardia or both occur, as commonly happens during immediate transition in preterm neonates, cerebral hypoxia–ischemia may cause perinatal brain injury. The primary objective of the COSGOD phase III trial is to investigate whether it is possible to increase survival without cerebral injury in preterm neonates of less than 32 weeks of gestation by targeting cerebral tissue oxygen saturation (crSO2) using specified clinical treatment guidelines during the immediate transition period after birth (the first 15 min) in addition to the routine monitoring of arterial oxygen saturation (SpO2) and heart rate (HR). Methods/Design COSGOD III is an investigator-initiated, randomized, multi-center, multi-national, phase III clinical trial. Inclusion criteria are neonates of less than 32 weeks of gestation, decision to provide full life support, and parental informed consent. Exclusion criteria are severe congenital malformations of brain, heart, lung, or prenatal cerebral injury or a combination of these. The premature infants will be randomly assigned to study or control groups. Both groups will have a near-infrared spectroscopy (NIRS) device (left frontal), pulse oximeter (right palm/wrist), and electrocardiogram placed immediately after birth. In the study group, the crSO2, SpO2, and HR readings are visible, and the infant will receive treatment in accordance with defined treatment guidelines. In the control group, only SpO2 and HR will be visible, and the infant will receive routine treatment. The intervention period will last for the first 15 min after birth during the immediate transition period and resuscitation. Thereafter, each neonate will be followed up for primary outcome to term date or discharge. The primary outcome is mortality or cerebral injury (or both) defined as any intra-ventricular bleeding or cystic periventricular leukomalacia (or both). Secondary outcomes are neonatal morbidities. Discussion crSO2 monitoring during immediate transition has been proven to be feasible and improve cerebral oxygenation during immediate transition. The additional monitoring of crSO2 with dedicated interventions may improve outcome of preterm neonates as evidenced by increased survival without cerebral injury. Trial registration ClinicalTrials.gov Identifier: NCT03166722. Registered March 5, 2017.

Abstract Background The need for cardiopulmonary resuscitation (CPR) is often unexpected, and the infrequent use of CPR in the delivery room (DR) limits the opportunity to perform rigorous clinical studies to determine the best method for delivering chest compression (CC) to newborn infants. The current neonatal resuscitation guidelines recommend using a coordinated 3:1 compression-to-ventilation (C:V) ratio (CC at a rate of 90/min and ventilations at a rate of 30/min). In comparison, providing CC during a sustained inflation (SI) (CC + SI) significantly improved hemodynamics, minute ventilation, and time to return of spontaneous circulation (ROSC) compared to 3:1 C:V ratio in asphyxiated piglets. Similarly, a small pilot trial in newborn infants showed similar results. Until now no study has examined different CC techniques during neonatal resuscitation in asphyxiated newborn infants in the DR. To date, no trial has been performed to directly compare CC + SI and 3:1 C:V ratio in the DR during CPR of asphyxiated newborn infants. Methods This is a large, international, multi-center, prospective, unblinded, cluster randomized controlled trial in asphyxiated newborn infants at birth. All term and preterm infants > 28+ 0 by best obstetrical estimate who require CPR at birth due to bradycardia ( 28+ 0 weeks’ gestational age with bradycardia (

Summary: Newborn infants receiving chest compressions in the delivery room have a high incidence of mortality (41%) and short-term neurological morbidity (e.g., 57% hypoxic-ischemic encephalopathy and seizures). Furthermore, infants who have no signs of life at 10 min despite chest compressions have 83% mortality, with 93% of survivors experiencing moderate-to-severe disability. The poor prognosis associated with receiving chest compressions in the delivery room raises questions as to whether improved cardiopulmonary resuscitation methods specifically tailored to the newborn could improve outcomes. Combining chest compressions during sustained inflation (CC+SI) has recently been shown to improve morbidity and mortality outcomes during cardiopulmonary resuscitation. Overall, CC+SI accomplishes the following: 1) significantly reduces time to return of spontaneous circulation, mortality, and epinephrine administration, and improves systemic and regional hemodynamic recovery; 2) significantly increases tidal volume and minute ventilation, and therefore alveolar oxygen delivery; 3) allows for passive ventilation during chest compression; and 4) does not increase lung or brain injury markers compared with the current standard of using 3:1 compression:ventilation ratio. A randomized trial comparing CC+SI versus a 3:1 compression:ventilation ratio during cardiopulmonary resuscitation in the delivery room is therefore warranted. Key Words: asphyxia, cardiopulmonary resuscitation, delivery room, newborn/infant

Objective: Pulseless electrical activity (PEA) occurs in asphyxiated newborn piglets and infants. We aimed to examine whether different cardiac rhythms (asystole, bradycardia, PEA) affects the resuscitation outcomes during continuous chest compressions (CC) during sustained inflations (CC+SI).Design: This study is a secondary analysis of four previous randomized controlled animal trials that compared CC+SI with different CC rate (90 or 120/min), SI duration (20 or 60 s), peak inflation pressure (10, 20, or 30 cmH2O), and oxygen concentration (18, 21, or 100%).Setting and Subjects: Sixty-six newborn mixed breed piglets (1–3 days of age, weight 1.7–2.4 kg) were obtained on the day of experimentation from the University Swine Research Technology Center.Interventions: In all four studies, piglets were randomized into intervention or sham. Piglets randomized to “intervention” underwent both hypoxia and asphyxia, whereas, piglets randomized to “sham” received the same surgical protocol, stabilization, and equivalent experimental periods without hypoxia and asphyxia.Measurements: To compare differences in asphyxiation time, time to return of spontaneous circulation (ROSC), hemodynamics, and survival rate in newborn piglets with asystole, bradycardia or PEA.Main Results: Piglets with PEA (n = 29) and asystole (n = 13) had a significantly longer asphyxiation time and time to ROSC vs. bradycardia (n = 24). Survival rates were similar between all groups. Compared to their baseline, mean arterial pressure and carotid blood flow were significantly lower 4 h after resuscitation in all groups, while being significantly higher in the bradycardia group.Conclusion: This study indicates that cardiac rhythm before resuscitation influences the time to ROSC and hemodynamic recovery after ROSC.

Background: Simulation education can benefit healthcare providers (HCPs) by providing opportunities to practice complex neonatal-resuscitation tasks in low-stake environments. To our knowledge, no study investigated the role of growth mindset on longitudinal performance on neonatal resuscitation before and after simulation-based training.Objectives: This study examines whether 1) the RETAIN digital/table-top simulators facilitate HCPs' neonatal resuscitation knowledge gain, retention, and transfer and 2) growth mindset moderates HCPs' longitudinal performance in neonatal resuscitation.Methods: Participants were n = 50 HCPs in a tertiary perinatal center in Edmonton, Canada. This longitudinal study was conducted in three stages including 1) a pretest and a mindset survey, immediately followed by a posttest using the RETAIN digital simulator from April to August 2019; 2) a 2-month delayed posttest using the same RETAIN neonatal resuscitation digital simulator from June to October 2019; and 3) a 5-month delayed posttest using the low-fidelity table-top neonatal resuscitation digital simulator from September 2019 to January 2020. Three General Linear Mixed Model (GLMM) repeated-measure analyses investigated HCPs' performance on neonatal resuscitation over time and the moderating effect of growth mindset on the association between test time points and task performance.Results: Compared with their pretest performance, HCPs effectively improved their neonatal resuscitation knowledge after the RETAIN digital simulation-based training on the immediate posttest (Est = 1.88, p < 0.05), retained their knowledge on the 2-month delayed posttest (Est = 1.36, p < 0.05), and transferred their knowledge to the table-top simulator after 5 months (Est = 2.01, p < 0.05). Although growth mindset did not moderate the performance gain from the pretest to the immediate posttest, it moderated the relationship between HCPs' pretest and long-term knowledge retention (i.e., the interaction effect of mindset and the 2-month posttest was significant: Est = 0.97, p < 0.05). The more they endorsed a growth mindset, the better the HCPs performed on the posttest, but only when they were tested after 2 months.Conclusions: Digital simulators for neonatal resuscitation training can effectively facilitate HCPs' knowledge gain, maintenance, and transfer. Besides, growth mindset shows a positive moderating effect on the longitudinal performance improvement in simulation-based training. Future research can be conducted to implement growth-mindset interventions promoting more effective delivery of technology-enhanced, simulation-based training and assessment.

Purpose: To safely care for their newborn patients, health-care professionals (HCP) must undergo frequent training to improve and maintain neonatal resuscitation knowledge and skills. However, the current approach to neonatal resuscitation simulation training is time and resource-intensive, and often inaccessible. Digital neonatal resuscitation simulation may present a convenient alternative for more frequent training.Method: Fifty neonatal HCPs participated in the study (44 female; 27 nurses, 3 nurse practitioners, 14 respiratory therapists, 6 doctors). This study was conducted at a tertiary perinatal center in Edmonton, Canada from April–August 2019, with 2-month (June–October 2019) and 5-month (September 2019–January 2020) follow-up. Neonatal HCPs were recruited by volunteer sampling to complete a demographic survey, pre-test (baseline knowledge), two digital simulation scenarios (intervention), and post-test (knowledge acquisition). Two months later, participants repeated the post-test (knowledge retention). Five months after the initial intervention, participants completed a post-test using a table-top simulation (knowledge transfer). Longitudinal analyses were used to compare participants' performance over time.Results: Overall the proportion of correct performance increased: 21/50 (42%) passed the pre-test, 39/50 (78%) the post-test, 30/43 (70%) the 2-month post-test, and 32/40 (80%) the 5-month post-test. GLMM and GEE analyses revealed that performance on all post-tests was significantly better than the performance on the pre-test. Therefore, training with the RETAIN digital simulation effectively improves, maintains, and transfers HCPs' neonatal resuscitation knowledge.Conclusions: Digital simulation improved, maintained, and helped transfer HCPs' neonatal resuscitation knowledge over time. Digital simulation presents a promising approach for frequent neonatal resuscitation training, particularly for distance-learning applications.

Background: Male newborns have a greater risk of poor cardiovascular and respiratory outcomes compared to females. The mechanisms associated with the “male disadvantage” remains unclear. We have previously shown no difference between male and female newborn piglets during hypoxia, asphyxia, resuscitation, and post-resuscitation recovery. However, it is unknown if there are differences in resuscitation outcomes between males and females during different cardiopulmonary resuscitation techniques.Intervention and Measurements: Secondary analysis of 184 term newborn mixed breed duroc piglets (1–3 days of age, weighing 2.0 (0.2) kg) from seven different studies, which were exposed to 30–50 min of normocapnic hypoxia followed by asphyxia until asystole. This was followed by cardiopulmonary resuscitation. For the analysis, piglets were divided into male and female groups, as well as resuscitation technique groups (sustained inflation, 3:1 compression-to-ventilation ratio, or asynchronous ventilations during chest compressions). Cardiac function, carotid blood flow, and cerebral oxygenation were continuously recorded throughout the experiment.Main results: Regardless of resuscitation technique, there was no significant difference between males and females in the number achieving return of spontaneous circulation (ROSC) [95/123 (77%) vs. 48/61 (79%)], the time to achieve ROSC [112 (80–185) s vs. 110 (77–186) s], and the 4-h survival rate [81/95 (85%) vs. 40/48 (83%)]. Levels of the injury markers interleukin (IL)−1ß, IL-6, IL-8, and tumor necrosis factor-α in frontoparietal cortex tissue homogenates were similar between males and females.Conclusions: Regardless of resuscitation technique, there was no significant effect of sex on resuscitation outcome, survival, and hemodynamic recovery in asphyxiated newborn piglets.

Objective: Human errors or protocol deviations during neonatal resuscitation are common. Excess workload has been proposed as a contributor to human error during medical tasks. We aim to characterize healthcare providers' perceived workload during neonatal resuscitation.Design: Perceived workload was measured using a multi-dimensional retrospective National Aeronautics and Space Administration Task Load Index (NASA TLX) survey. The NASA TLX collects data on mental, physical, and temporal demand, performance, effort, and frustration. Each section is rated independently by participants on a scale of 0–20 (0 being lowest and 20 being highest). The Raw-TLX score is a composite score of all dimensions and presented on a scale of 0–100. Healthcare providers complete a paper and pencil survey after attending delivery room resuscitations within 3 months.Setting: Level three neonatal intensive care unit at the Royal Alexandra Hospital, Edmonton, AB, Canada.Participants: All neonatal healthcare providers who attended deliveries.Exposure: Participation in the delivery room care of newborns.Measurement: Raw TLX scores as a measure of overall workload and scores for each dimension of workload.Main Results: During the study period, ~880 neonatal resuscitation events occurred, and a total of 204 surveys were completed. Healthcare providers completed one survey for 179 deliveries, two surveys for 20 deliveries, and three surveys for 5 deliveries. The mean (standard deviation) gestational age was 35 (5) weeks, and the median (interquartile range) birth weight was 2,690 (1,830–3,440) g. Interventions at delivery were (i) stimulation 149 (73%), suction 130 (64%), continuous positive airway pressure 120 (59%), positive pressure ventilation 105 (52%), intubation 33 (16%), chest compression 10 (5%), and epinephrine 4 (2%). The overall median (interquartile range) Raw-TLX was 34 (18–49). The scores varied by dimension with mental demand 10 (5–14), physical demand 4 (1–6), temporal demand 8 (3–14), performance 4 (2–6), effort 8 (4–13), and frustration 4 (1–10). Raw-TLX scores were higher when healthcare providers performed any intervention compared to no intervention [35 (22–49) vs. 8 (6–18), p = 0.0011]; intubation and no intubation was [55 (46–62) vs. 30 (17–46), p = 0.0001], and between performing chest compression vs. no chest compression [55 (49–64) vs. 33 (18–47), p = 0.001].Conclusion: Perceived workload of neonatal healthcare providers increases during higher acuity deliveries. Healthcare providers' workload during neonatal resuscitation can be measured using NASATLX and was inversely associated with 5-min Apgar score. Future studies assessing healthcare providers' perceived workload during neonatal resuscitation in different settings are warranted.

Background: Eye exam for Retinopathy of prematurity (ROP) is a painful procedure and pharmacological analgesia might be ineffective. We hypothesized that magnetic auricular acupuncture (MAA) compared to placebo will decrease pain during ROP exam in preterm infants.Methods: Multicentre randomized controlled trial conducted in three hospitals (Australia, Canada, and Malaysia). Eligibility: >32 weeks, ROP exam, not sedated, and parental consent. A total of 100 infants were randomized (1:1) to MAA (n = 50) or placebo (n = 50). MAA stickers or placebo were placed on both ears by an unblinded investigator. Pain was assessed using the Premature Infant Pain Profile. Primary analyses were by intention-to-treat. ClinicalTrials.gov:NCT03650621.Findings: The mean (standard deviation, SD) gestation, birthweight, and postnatal age were (MAA 28(3) vs. placebo 28(2) weeks; MAA 1,057(455) vs. placebo 952(273) g; MAA 7(3) vs. placebo 7(3) weeks. Placebo infants had significantly higher PIPP scores during [mean difference 1.6 points (95%CI 0.1–3.1)] and 1 h mean difference 1.5 points (95%CI 0.7–2.2) after the procedure (p < 0.03). Heart rate was lower (173(22) vs. 184(18)/min) and oxygen saturations were higher (93.8(6.2) vs. 91.7(6.1)%, p = 0.05) in MAA infants. No adverse effects.Interpretation: MAA may reduce physiological pain responses during and after ROP exam in preterm infants. Assessment of long-term effects are warranted.Clinical trial registration: www.ClinicalTrials.gov, identifier: NCT03650621.

Background: Frequent and objective summative assessment of neonatal healthcare providers is important to ensure high-quality care to patients during neonatal resuscitation. Currently, neonatal resuscitation providers are only individually assessed using an at-home online multiple-choice questionnaire. While simulation-based assessment is preferred, resource constraints limit its widespread uptake. An alternative approach to simulation-based summative assessment is needed. Simulation-based serious games may provide a solution.Objective: The aim of this study was to examine if individual performance on the RETAIN (REsuscitation TrAINing for healthcare professionals) tabletop simulator can be used as a summative assessment of neonatal resuscitation providers, regardless of their prior board game experience.Method: Neonatal healthcare providers were recruited from a tertiary perinatal center to complete a (1) demographic pre-survey, (2) neonatal resuscitation scenario using an open-answer written pre-test, (3) neonatal resuscitation scenario using the RETAIN tabletop simulator, and (4) post-survey measuring usage and attitudes toward board games. Multiple linear regression analyses using the Johnson–Neyman technique were conducted in R to probe the moderation effect of years of board game on the relationship between pre-test and game performance.Results: Twenty Neonatal Resuscitation Program-trained healthcare providers (nurses, nurse practitioners, respiratory therapists, and fellows) were recruited for this study (n = 19 females). Participants' mean (standard deviation) pre-test score was 8.35 (1.81) out of a total 16 possible points (52%) and a score of 18 (4.41) out of a total of 40 possible points (45%) using RETAIN. Overall board game experience was 22.5 (12.6) years. Finally, years of board game moderated significantly the relation between the pre-test and game performance (B = −0.13, SE = 0.05, beta = −0.48, t = −2.77, p < 0.05; 95% CI [−0.24, −0.03]). Thus, participants' performance on the two tests (written and simulator) was significantly positively associated, but only for those who reported fewer than 21.5 years of board game experience.Conclusion: This study reports the preliminary results of a pilot study, indicating that the RETAIN tabletop simulator could be used as a simulation-based summative assessment, an enjoyable, low-cost alternative to traditional assessment approaches. RETAIN offers a solution to the need for more frequent and continued assessment of neonatal resuscitation providers.

Background: Frequent simulation-based education is recommended to improve health outcomes during neonatal resuscitation but is often inaccessible due to time, resource, and personnel requirements. Digital simulation presents a potential alternative; however, its effectiveness and reception by healthcare professionals (HCPs) remains largely unexplored.Objectives: This study explores HCPs' attitudes toward a digital simulator, technology, and mindset to elucidate their effects on neonatal resuscitation performance in simulation-based assessments.Methods: The study was conducted from April to August 2019 with 2-month (June–October 2019) and 5-month (September 2019–January 2020) follow-up at a tertiary perinatal center in Edmonton, Canada. Of 300 available neonatal HCPs, 50 participated. Participants completed a demographic survey, a pretest, two practice scenarios using the RETAIN neonatal resuscitation digital simulation, a posttest, and an attitudinal survey (100% response rate). Participants repeated the posttest scenario in 2 months (86% response rate) and completed another posttest scenario using a low-fidelity, tabletop simulator (80% response rate) 5 months after the initial study intervention. Participants' survey responses were collected to measure attitudes toward digital simulation and technology. Knowledge was assessed at baseline (pretest), acquisition (posttest), retention (2-month posttest), and transfer (5-month posttest).Results: Fifty neonatal HCPs participated in this study (44 females and 6 males; 27 nurses, 3 nurse practitioners, 14 respiratory therapists, and 6 doctors). Most participants reported technology in medical education as useful and beneficial. Three attitudinal clusters were identified by a hierarchical clustering algorithm based on survey responses. Although participants exhibited diverse attitudinal paths, they all improved neonatal resuscitation performance after using the digital simulator and successfully transferred their knowledge to a new medium.Conclusions: Digital simulation improved HCPs' neonatal resuscitation performance. Medical education may benefit by incorporating technology during simulation training.

Many preterm neonates require mechanical ventilation which increases the risk of cerebral inflammation and white matter injury in the immature brain. In this review, we discuss the links between ventilation and brain injury with a focus on the immediate period after birth, incorporating respiratory support in the delivery room and subsequent mechanical ventilation in the neonatal intensive care unit. This review collates insight from large animal models in which acute injurious ventilation and prolonged periods of ventilation have been used to create clinically relevant brain injury patterns. These models are valuable resources in investigating the pathophysiology of ventilation-induced brain injury and have important translational implications. We discuss the challenges of reconciling lung and brain maturation in commonly used large animal models. A comprehensive understanding of ventilation-induced brain injury is necessary to guide the way we care for preterm neonates, with the goal to improve their neurodevelopmental outcomes.

Adaptations have been proposed for resuscitation of infants born to women with COVID-19, to protect health care providers, maintain infection control, and limit post-natal transmission. Changes especially impact respiratory procedures, personal protective equipment (PPE) use, resuscitation environments, teamwork, and family involvement. Adding viral filters to ventilation devices and modifications to intubation procedures might hinder effective ventilation. PPE could delay resuscitation, hinder task performance, and degrade communication. Changes to resuscitation locations and team composition alter workflow and teamwork. Physical distancing measures and PPE impede family-integrated care. These disruptions need to be considered given the uncertainty of vertical transmission of SARS-CoV-2.

Background: Current guidelines recommend immediate umbilical cord clamping (UCC) for newborns requiring chest compressions (CCs). Physiological-based cord clamping (PBCC), defined as delaying UCC until after lung aeration, has advantages over immediate UCC in mildly asphyxiated newborns, but its efficacy in asystolic newborns requiring CC is unknown. The aim of this study was to compare the cardiovascular response to CCs given prior to or after UCC in asystolic near-term lambs.Methods: Umbilical, carotid, pulmonary, and femoral arterial flows and pressures as well as systemic and cerebral oxygenation were measured in near-term sheep fetuses [139 ± 2 (SD) days gestation]. Fetal asphyxia was induced until asystole ensued, whereupon lambs received ventilation and CC before (PBCC; n = 16) or after (n = 12) UCC. Epinephrine was administered 1 min after ventilation onset and in 3-min intervals thereafter. The PBCC group was further separated into UCC at either 1 min (PBCC1, n = 8) or 10 min (PBCC10, n = 8) after return of spontaneous circulation (ROSC). Lambs were maintained for a further 30 min after ROSC.Results: The duration of CCs received and number of epinephrine doses required to obtain ROSC were similar between groups. After ROSC, we found no physiological benefits if UCC was delayed for 1 min compared to immediate cord clamping (ICC). However, if UCC was delayed for 10 min after ROSC, we found significant reductions in post-asphyxial rebound hypertension, cerebral blood flow, and cerebral oxygenation. The prevention of the post-asphyxial rebound hypertension in the PBCC10 group occurred due to the contribution of the placental circulation to a low peripheral resistance. As a result, left and right ventricular outputs continued to perfuse the placenta and were evidenced by reduced mean pulmonary blood flow, persistence of right-to-left shunting across the ductus arteriosus, and persistence of umbilical arterial and venous blood flows.Conclusion: It is possible to obtain ROSC after CC while the umbilical cord remains intact. There were no adverse effects of PBCC compared to ICC; however, the physiological changes observed after ROSC in the ICC and early PBCC groups may result in additional cerebral injury. Prolonging UCC after ROSC may provide significant physiological benefits that may reduce the risk of harm to the cerebral circulation.

Background: Cerebral oxygenation monitored non-invasively by near-infrared spectroscopy (NIRS) is of increasing interest in neonatal care. Cerebral oxygenation is determined by cerebral oxygen delivery and cerebral oxygen consumption. Oxygen delivery as well as oxygen consumption might be influenced by metabolic parameters like blood glucose and lactate.Objective: The aim of the present systematic qualitative review is therefore to identify and summarize all studies, which describe cerebral oxygenation measured with NIRS and blood glucose and/or blood lactate levels in neonates.Data sources: A systematic search of Ovid Embase and PubMed was performed. Search terms included near-infrared spectroscopy, fractional tissue oxygen extraction, cerebral tissue oxygen saturation, regional cerebral tissue oxygen saturation, oxygenation, term, and preterm neonates, cesarean delivery, transition, after-birth, newborn, vaginal delivery, cesarean delivery, baby, neonatal transition, metabolism, lactate, glucose, and blood glucose level.Study selection/data synthesis: Studies analyzing cerebral oxygenation and blood glucose and/or blood lactate levels in neonates were included. Animal studies, duplicates, or studies in non-English language were excluded.Results: Twenty-five studies were identified that describe blood glucose and/or blood lactate levels as primary or secondary outcome parameters with additional measured cerebral oxygenation by NIRS in neonates. Twelve studies were included with blood glucose measurements: four described an association between blood glucose levels and cerebral oxygenation, two show no association, and six do not report on possible associations. Eighteen studies were included with lactate measurements: one describe an association between lactate levels and cerebral oxygenation, while three show no association and 14 do not report on possible associations.Discussion: The influence of blood glucose and blood lactate levels on the cerebral oxygenation in neonates is still controversial. However, there seems to be an association between cerebral oxygenation and the metabolic parameter blood glucose and lactate, which need further investigation.

Objectives: Neonatal resuscitation guidelines recommend administering intravenous (IV) adrenaline if bradycardia persists despite adequate ventilation and chest compressions (CC). Rapid IV access is challenging, but little evidence exists for other routes of administration. We compared IV, endotracheal (ET), and intranasal routes for adrenaline administration during resuscitation of asphyxiated newborn lambs.Study design: Near-term lambs (n = 22) were delivered by caesarean section. Severe asphyxia was induced by clamping the umbilical cord while delaying ET ventilation until blood flow in the carotid artery ceased. Following a 30 s sustained inflation and ventilation for 30 s, we commenced uncoordinated CC at 90/min. We randomized four groups receiving repeated treatment doses (Tds) every 3rd min of (i) IV-Adrenaline (50 μg), (ii) ET-Adrenaline (500 μg), (iii) Nasal-Adrenaline via an atomizer (500 μg), and (iv) IV-saline. If return of spontaneous circulation (ROSC) was not achieved after three Tds by the assigned route, up to two rescue doses (Rds) of IV adrenaline were administered. Main outcome measures were achievement of ROSC and time from start of CC to ROSC, defined as heart rate >100/min, and mean carotid arterial pressure >30 mmHg.Results: In the IV-Adrenaline group, 5/6 lambs achieved ROSC after the first Td, whereas 1 lamb required two Tds before achieving ROSC. In the ET-Adrenaline group, 1/5 lambs required one Td, 1 lamb required three Tds, 2 lambs required 2 Rds, and 1 did not achieve ROSC. In the Nasal-Adrenaline group, 1/6 lambs required one Td, 2 required two Tds, whereas 3 lambs required either one (2 lambs) or two (1 lamb) Rds of adrenaline to achieve ROSC. In the IV-saline group, no lambs achieved ROSC until adrenaline Rds; 4/5 lambs required one Rd and 1 lamb required two Rds. Time to ROSC was shorter using IV-Adrenaline (2.4 ± 0.4 min) compared with ET-Adrenaline (10.3 ± 2.4 min), Nasal-Adrenaline (9.2 ± 2.2 min), and IV-saline (11.2 ± 1.2 min).Conclusion: IV adrenaline had superior efficacy compared with nasal or ET administration. Nasal administration had a similar effect as ET administration and is an easier route for early application. Nasal high-dose adrenaline administration for neonatal resuscitation merits further investigation.

Objective: To determine the incidence and risk factors associated with neonatal hypoglycemia in the premature population 90%ile for gestational age). Maternal hypertension was systolic blood pressure >140mmHg.Results: 175 infants

Background Existing systematic reviews of Rh immunoprophylaxis include only data from randomized controlled trials, have dated searches, and some do not report on all domains of risk of bias or evaluate the certainty of the evidence. Our objective was to perform an updated review, by including new trials, any comparative observational studies, and assessing the certainty of the evidence using the GRADE framework. Methods We searched MEDLINE, Embase and the Cochrane Library from 2000 to November 26, 2019. Relevant websites and bibliographies of systematic reviews and guidelines were searched for studies published before 2000. Outcomes of interest were sensitization and adverse events. Risk of bias was evaluated with the Cochrane tool and ROBINS-I. The certainty of the evidence was performed using the GRADE framework. Results Thirteen randomized trials and eight comparative cohort studies were identified, evaluating 12 comparisons. Although there is some evidence of beneficial treatment effects (e.g., at 6-months postpartum, fewer women who received RhIg at delivery compared to no RhIg became sensitized [70 fewer sensitized women per 1,000 (95%CI: 67 to 71 fewer); I2 = 73%]), due to very low certainty of the evidence, the magnitude of the treatment effect may be overestimated. The certainty of the evidence was very low for most outcomes often due to high risk of bias (e.g., randomization method, allocation concealment, selective reporting) and imprecision (i.e., few events and small sample sizes). There is limited evidence on prophylaxis for invasive fetal procedures (e.g. amniocentesis) in the comparative literature, and few studies reported adverse events. Conclusion Serious risk of bias and low to very low certainty of the evidence is found in existing RCTs and comparative observational studies addressing optimal effectiveness of Rh immunoprophylaxis. Guideline development committees should exercise caution when assessing the strength of the recommendations that inform and influence clinical practice in this area.

Background: Each year, 13–26 million newborn babies require help to breathe at birth. Healthcare professionals (HCPs) who provide neonatal resuscitative care must be frequently evaluated to maintain and improve the quality of healthcare delivered. While simulation-based competence assessment is preferred, resource constraints hinder uptake. We aimed to examine if the RETAIN simulation-based boardgame can be used to assess HCPs' neonatal resuscitation knowledge.Method: Twenty neonatal HCPs (19 females) from the Royal Alexandra Hospital (Edmonton, Canada) were recruited. First, they completed an open-answer written test of one neonatal resuscitation scenario. Then, they completed one neonatal resuscitation scenario of difficulty comparable to that of the open-answer written test, but this time using the RETAIN board game. In the RETAIN board game (https://playretain.com, RETAIN Labs Medical Inc, Edmonton, Canada), players perform simulated neonatal resuscitation scenarios based on real-life cases, using action cards, and equipment pieces. Sessions were video-recorded and scored using Neonatal Resuscitation Program 2015 guidelines. Data are reported as mean (standard deviation) for normally distributed continuous variables, and as median (interquartile range) for non-normal continuous variables.Results: Participants consisted of the following HCPs: 8 nurses, 4 respiratory therapists, 4 nurse practitioners, and 4 neonatal fellows with median (IQR) 10.5(3–17) years of clinical experience. Overall mean (SD) Open-answer test and Game Performance was 8.6(2.1) out of 16 possible points (53%) and 29(3.2) out of 40 possible points (74%), respectively. Out of the 10 actions shared between the open-answer test and game scenario, performance on the open-answer test was mean (SD) 7.2(1.3) (72%) and game performance was mean (SD) 8.8(1.4) (88%) (V = 17, p < 0.01).Conclusion: RETAIN may provide an enjoyable and standardized alternative toward summative assessment of neonatal resuscitation providers. RETAIN may be used to improve more frequent and ubiquitous uptake of simulation-based competence assessment in healthcare settings.

Objectives: Approximately 10% of newborn infants require resuscitation at birth. Accurate heart rate (HR) assessment guides resuscitation interventions, thereby reducing morbidities and mortality. While existing HR assessment methods have several limitations, the Doppler ultrasound (Doppler-US) might be a promising alternative. We aimed to evaluate accuracy and optimal use of Doppler-US for HR assessments during neonatal asphyxia in a pre-clinical model.Design: HR assessments were performed in 16 term newborn piglets that were anesthetized, intubated, and instrumented. Study I evaluated optimal transducer position, Study II compared aortic (AV) and pulmonary (PV) examination modes, and Study III examined accuracy during asphyxia, for HR assessment.Setting: Experimental setting.Subjects: Asphyxia-induced piglets.Interventions: Study I: Doppler-US (USCOM® 1A) HR was assessed on upper (A), middle (B), and lower (C) third of the sternum; study II: Doppler-US HR was assessed using AV and PV examination modes; study III: HR was assessed during asphyxia. Comparisons were made between Doppler-US and the clinical gold standard for HR assessments, electrocardiography (ECG).Measurements and Main Results: Study I: Mean (SD) Doppler-US HR at position A, B, and C showed no difference when compared to ECG HR. Study II: The mean (SD) Doppler-US HR using AV and PV modes also showed no difference when compared to ECG HR. Study III: Bland-Altman analysis revealed a mean difference (95% limits of agreement) between Doppler-US and ECG HR of 1.5 (−16 to 19) bpm. Additionally, motion artifacts produced false peaks and peak size was seen to decrease as bradycardia progressed.Conclusions: HR assessment using Doppler-US during asphyxia is accurate but has limitations and must be further evaluated prior to clinical use. Doppler-US can be positioned along the sternum and use either AV or PV mode for accurate assessments in a piglet model of neonatal asphyxia.

There is a need for feasible and non-invasive diagnostics in perinatal asphyxia. Metabolomics is the study of small molecular weight products of cellular metabolism that may, directly and indirectly, reflect the level of oxidative stress. Saliva analysis is a novel approach that has a yet unexplored potential in metabolomics in perinatal asphyxia. The aim of this review was to give an overview of metabolomics studies of oxidative stress in perinatal asphyxia, particularly searching for studies analyzing non-invasively collected biofluids including saliva. We searched the databases PubMed/Medline and included 11 original human and 4 animal studies. In perinatal asphyxia, whole blood, plasma, and urine are the most frequently used biofluids used for metabolomics analyses. Although changes in oxidative stress-related salivary metabolites have been reported in adults, the utility of this approach in perinatal asphyxia has not yet been explored. Human and animal studies indicate that, in addition to antioxidant enzymes, succinate and hypoxanthine, as well acylcarnitines may have discriminatory diagnostic and prognostic properties in perinatal asphyxia. Researchers may utilize the accumulating evidence of discriminatory metabolic patterns in perinatal asphyxia to develop bedside methods to measure oxidative stress metabolites in perinatal asphyxia. Although only supported by indirect evidence, saliva might be a candidate biofluid for such point-of-care diagnostics.

Premature infants born after less than 25 weeks’ gestation are particularly vulnerable at birth and stabilization in the delivery room (DR) is challenging. After birth, infants born after

Background: Optimal starting oxygen concentration for delivery room resuscitation of extremely preterm infants (50%. Results: Thirty-four infants were born during a 4-month period; consent was obtained in 63%. Thirty (n = 12, 30% group; n = 18, 60% group) were analyzed, including limited data from eight who died or were transferred before parents could be approached. Median cumulative oxygen concentrations were significantly different between the two groups in the first 5 min. Conclusion: Randomized control trial of 30% or 60% oxygen at the initiation of resuscitation of extremely preterm neonates with deferred consent is feasible. Trial registration: Clinicaltrials.gov NCT03706586

Severe desaturation or bradycardia often occur during neonatal endotracheal intubation. Using continuous gas flow through the endotracheal tube might reduce the incidence of these events. We hypothesized that continuous gas flow through the endotracheal tube during nasotracheal intubation compared to standard nasotracheal intubation will reduce the number of intubation attempts in newborn infants. In a randomized controlled pilot study, neonates were either intubated with continuous gas flow through the endotracheal tube during intubation (intervention group) or no gas flow during intubation (control group). Recruitment was stopped early due to financial and organizational issues. A total of 16 infants and 39 intubation attempts were analyzed. The median (interquartile range) number of intubation attempts and number of abandoned intubations due to desaturation and/or bradycardia were 1 (1–2) and 4 (2–5), (p = 0.056) and n = 3 versus n = 20, (p = 0.060) in the intervention group and control group, respectively. Continuous gas flow through the endotracheal tube during intubation seems to be favorable and there are no major unexpected adverse consequences of attempting this methodology.

Objectives: Heart rate (HR) is the most significant parameter to assess a newborn's clinical status at birth. Recently, novel technologies including smartphone applications have been suggested for HR assessment during neonatal resuscitation. The aim of this study was to evaluate the accuracy, speed, and precision of the NeoTapLifeSupport (NeoTapLS) smartphone application using a digital stethoscope (DS) for HR assessment during neonatal resuscitation.Design: Newborn piglets (n = 20, 1–3 days, 1.7–2.4 kg) were anesthetized, intubated, mechanically ventilated, and subjected to 30 min of hypoxia, followed by asphyxia. Asphyxia was induced by clamping the endotracheal tube and disconnecting the ventilator, until asystole was confirmed by zero carotid blood flow (CBF).Setting: Experimental setting.Subjects: Asphyxia-induced newborn piglets.Interventions: During asphyxia, HR assessments were performed with a DS using the NeoTapLS smartphone application, and compared to 6-s method (6 s), and 10-s method (10 s).Measurements and Main Results: Accuracy of obtained HRs was compared to CBF and electrocardiogram and assessment time using NeoTapLS, 6 s, and 10 s were also measured. The mean(SD) HR with the NeoTapLS was 68(26), compared to CBF with 68(27) bpm, 6 s with 68(27), and 10 s with 66(26) bpm during asphyxia. Bland-Altman analysis revealed no difference between HR using the NeoTapLS, 6 s, 10 s, compared to CBF HR, with NeoTapLS showing the smallest difference between 95% limits of agreement. The median (IQR) time required to obtain a HR using the NeoTapLS was 3(2–4) s, compared to 6(6–7), and 10(10–11) s for 6 and 10 s, respectively.Conclusions: Our data suggests that the NeoTapLS is accurate, fast, and precise during neonatal asphyxia to assess heart rate.

Background: Previous studies have investigated hemodynamic recovery using 21% vs. 100% oxygen during cardiopulmonary resuscitation (CPR) with chest compression (CC) in term infants. Animal studies indicate that systemic circulatory recovery is the same whether 21 or 100% oxygen is used during neonatal CPR. One of the main goals of resuscitation is to maintain cerebral oxygen delivery and prevent cerebral hypo- and hyperoxygenation. Oxygen delivery to the brain depends on cerebral hemodynamics, concentration of inhaled oxygen and blood oxygen content. The aim of this paper was to synthesize available research about cerebral oxygen delivery during CPR using different oxygen concentrations. Our research questions included how do different oxygen concentrations during CPR with CC influence cerebral perfusion and oxygen delivery, and how do cerebral hemodynamics during CC influence outcomes.Methods: A search in Medline Ovid using the search terms hypoxia AND oxygen AND cerebrovascular circulation AND infant, newborn. Inclusion criteria included studies of hypoxia and resuscitation of term infants. Studies were excluded if no measures of cerebral blood flow (CBF), oxygenation, or perfusion were reported.Results: The search retrieved 21 papers. None of the studies directly fulfilled our inclusion criteria. The reference lists of some of the retrieved papers provided relevant animal studies with slightly conflicting results regarding blood flow and oxygen delivery to the brain using 21 or 100% oxygen. No study in term infants was identified, but we included one study in preterm infants. Studies in asphyxiated animals indicate that 100% oxygen increases CBF and oxygenation during and after CC with a potential increase in oxidative stress.Conclusion: In asphyxia, cerebral autoregulation may be impaired. Pure oxygen administration during CC may result in cerebral hyperperfusion and increased cerebral oxygen delivery, which may be associated with oxidative stress-related damage to the brain tissue. As systemic circulatory recovery is the same whether 21 or 100% oxygen is used during neonatal CPR, it is important to investigate whether brain damage could be aggravated when 100% oxygen is used.

Approximately 10% of newborn infants require resuscitative intervention at birth. Ideally, this care is provided by a team of expert healthcare professionals who possess exceptional cognitive, psychomotor, and communication skills. Human errors and deviations from resuscitation protocol are common and may be attributable to excessive cognitive demand experienced by the resuscitation team. Cognitive Task Analysis (CTA) is a group of methods used to assess knowledge, judgments, goals, and decision-making of expert healthcare professionals. These methods may be used during neonatal resuscitation to gain an improved understanding of the approaches used by healthcare professionals. CTA methods have been applied in many medical disciplines including neonatology. CTA has been used to identify information previously confined to the intuition of experts. This information has been used to assess, develop, and improve medical technology, clinical decision support tools (DSTs), communication structure, and training methods. Knowledge attained through CTA might be applied similarly to neonatal resuscitation, which may in turn decrease human errors, and improve patient safety.

Background: Male and female newborns have differences in their fetal development, fetal-to-neonatal transition, and postnatal morbidity. However, the cardiovascular fetal-to-neonatal adaption is similar between sexes. No study has examined sex differences in newborns during hypoxia, asphyxia, cardio-pulmonary resuscitation, or post-resuscitation recovery.Methods: Secondary analysis (two previous publications and two studies currently under peer-review) of 110 term newborn mixed breed piglets (1–3 days of age, weighing 2.0 ± 0.2 kg), which were exposed to 30 min normocapnic hypoxia followed by asphyxia until asystole, which was achieved by disconnecting the ventilator and clamping the endotracheal tube. This was followed by cardio-pulmonary resuscitation. For the analysis piglets were divided into female and male groups. Cardiac function, carotid blood flow, and cerebral and renal oxygenation were continuously recorded throughout the experiment.Results: A total of 35/41 (85%) female and 54/69 (78%) male piglets resuscitated achieved ROSC (p = 0.881). The median (IQR) time to achieve return of spontaneous circulation in females and males was 111 (80–228) s and 106 (80–206) s (p = 0.875), respectively. The 4-h survival rate was similar between females and males with 28/35 (80%) and 49/54 (91%) piglets surviving (p = 0.241), respectively.Conclusions: No difference between female and male newborn piglets was observed during hypoxia, asphyxia, resuscitation, and post-resuscitation recovery.

Background: Asphyxiated neonates often have myocardial dysfunction and renal insufficiency. Previously we demonstrated that doxycycline improved cardio-renal function through matrix metalloproteinase (MMP)-2 inhibition in an acute swine model of neonatal hypoxia-reoxygenation. The prolonged cardio-renal protective effects of doxycycline in neonates still remained unknown. We therefore hypothesized that the protective effects of doxycycline persisted in surviving subjects.Methods: Newborn piglets were instrumented and subjected to 1 h of hypoxia followed by reoxygenation with 21–25% oxygen and observed for 4 days. Intravenous doxycycline (30 mg/kg) or normal saline (1 mL, saline-control group) was given at 5 min of reoxygenation (n = 8/group) in a randomized, blinded fashion. Sham-operated piglets (n = 5) received no hypoxia-reoxygenation. At 96 h after reoxygenation, the left ventricular function was assessed by Millar® catheter. Renal injury was investigated by measuring plasma creatinine, urinary N-acetyl-D-glucosaminidase activity, renal tissue lactate and MMP-2 activity.Results: Both hypoxia-reoxygenation groups had similar hypoxic stress with severe lactate acidosis, and hemodynamic recovery. Doxycycline-treated piglets had higher urine output with lower urine N-acetyl-D-glucosaminidase, plasma creatinine, and renal MMP-2 activity (vs. saline-controls; all p < 0.05). These markers were all negatively correlated with urine output.Conclusions: In newborn piglets surviving hypoxia-reoxygenation, we observed a weak but significant and persistent attenuation of renal injury and improved recovery with the post-resuscitation administration of doxycycline.

Background: The current resuscitation guidelines recommend frequent simulation based medical education (SBME). However, the current SBME approach is expensive, time-intensive, and requires a specialized lab and trained instructors. Hence, it is not offered routinely at all hospitals. We designed the board game “RETAIN” to train healthcare providers (HCPs) in neonatal resuscitation in a cost-friendly and accessible way.Objectives: To examine if a board game-based training simulator improves knowledge retention in HCPs.Methods: “RETAIN” consists of a board using an image of a baby, visual objects, adjustable timer, monitors, and action cards. Neonatal HCPs at the Royal Alexandra Hospital were invited to participate. Participants completed a written pre-test (resuscitation of a 24-week infant), then played the board game (starting with a tutorial followed by free playing of three evidence-based neonatal resuscitation scenarios). Afterwards, a post-test with the same resuscitation scenario and an opinion survey was completed. The answers from the pre- and post-test were compared to assess HCPs' knowledge retention.Results: Thirty HCPs (four doctors, 12 nurses, and 14 respiratory therapist) participated in the study. Overall, we observed a 10% increase in knowledge retention between the pre- and post-test (49–59%, respectively). Temperature management showed the most knowledge gain between the pre- and post-test (14–46%, respectively). Placement of a hat (10–43%), plastic wrap (27–67%), and temperature probe (7–30%) improved between the pre- and post-test.Conclusion: Knowledge retention increased by 12% between pre- and post-test (49–61%, respectively). The improvement in performance and knowledge supports the use of board game simulations for clinical training.

Background: International consensus statements for resuscitation of newborn infants recommend provision of 100% oxygen once chest compressions are required. However, 100% oxygen exacerbates reperfusion injury and reduces cerebral perfusion in newborn babies.Objective: We aimed to establish whether resuscitation with air during chest compression is feasible and safe in newborn infants compared with 100% oxygen.Methods: Systematic search of PubMed, Google Scholar and CINAHL for articles examining variable oxygen concentrations during chest compressions in term newborns.Results: Overall, no human studies but eight animal studies (n = 323 animals) comparing various oxygen concentrations during chest compression were identified. The pooled analysis showed no difference in mortality rates for animals resuscitated with air vs. 100% oxygen (risk ratio 1.04 [0.35, 3.08], I2 = 0%, p = 0.94). ROSC was also similar between groups with a mean difference of −3.8 [−29.7–22] s, I2 = 0%, p = 0.77. No difference in oxygen damage or adverse events were identified between groups.Conclusions: Air had similar time to ROSC and mortality as 100% oxygen during neonatal chest compression. A large randomized controlled clinical trial comparing air vs. 100% oxygen during neonatal chest compression is warranted.

Approximately 0.1% for term and 10–15% of preterm infants receive chest compression (CC) in the delivery room, with high incidence of mortality and neurologic impairment. The poor prognosis associated with receiving CC in the delivery room has raised concerns as to whether specifically-tailored cardiopulmonary resuscitation methods are needed. The current neonatal resuscitation guidelines recommend a 3:1 compression:ventilation ratio; however, the most effective approach to deliver chest compression is unknown. We recently demonstrated that providing continuous chest compression superimposed with a high distending pressure or sustained inflation significantly reduced time to return of spontaneous circulation and mortality while improving respiratory and cardiovascular parameters in asphyxiated piglet and newborn infants. This review summarizes the current available evidence of continuous chest compression superimposed with a sustained inflation.