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Benjamin A Kamala,1,2 Hussen L Kidanto,3,4 Peter J Wangwe,2,5 Ingvild Dalen,3 Estomih R Mduma,3,6 Jeffrey M Perlman,7 Hege L Ersdal1,8 1Faculty of Health Sciences, University of Stavanger, Stavanger, Norway; 2Department of Obstetrics and Gynecology, Muhimbili National Hospital, Dar es Salaam, Tanzania; 3Department of Research, Stavanger University Hospital, Stavanger, Norway; 4School of Medicine, Aga Khan University, Dar es Salaam, Tanzania; 5Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania; 6Department of Research, Haydon Lutheran Hospital, Manyara, Tanzania; 7Department of Pediatrics, Weill Medical College, New York, NY, USA; 8Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway Background: Fetal stethoscopes are mainly used for intermittent monitoring of fetal heart rate (FHR) during labor in low-income countries, where perinatal mortality is still high. Handheld Dopplers are rarely available and are dependent on batteries or electricity. The objective was to compare the Pinard stethoscope versus a new wind-up handheld Doppler in the detection of abnormal FHR. Materials and methods: We conducted a randomized controlled study at Muhimbili National Hospital, Tanzania, from April 2013 to September 2015. Women with gestational age ≥37 weeks, cephalic presentation, normal FHR on admission, and cervical dilatation 160 beats/min). Secondary endpoints were time to delivery, mode of delivery, and perinatal outcomes. χ2, Fisher’s exact test, Mann–Whitney test, and logistic regression were conducted. Unadjusted and adjusted odds ratios were calculated with respective 95% confidence interval. Results: In total, 2,844 eligible women were assigned to FHR monitoring with Pinard (n=1,423) or Doppler (n=1,421). Abnormal FHRs were more often detected in the Doppler (6.0%) versus the Pinard (3.9%) arm (adjusted odds ratio =1.59, 95% confidence interval: 1.13–2.26, p=0.008). Median (interquartile range) time from abnormal FHR detection to delivery was comparable between Doppler and Pinard, ie, 80 (60,161) and 89 (52,165) minutes, respectively, as was the incidence of cesarean delivery (12.0% versus 12.2%). The incidence of adverse perinatal outcomes (fresh stillbirths, 24-hour neonatal admissions, and deaths) was similar overall; however, among newborns with abnormal FHR delivered vaginally, adverse outcomes were less incident in Doppler (7 of 43 births, 16.3%) than in the Pinard arm (10 of 23 births, 43.5%), p=0.021. Conclusion: Intermittent FHR monitoring using Doppler was associated with an increased detection of abnormal FHR compared to Pinard in a low-risk population. Time intervals from abnormal FHR detection to delivery were longer than recommended in both arms. Perinatal outcomes were better among vaginally delivered newborns with detected abnormal FHR in the Doppler arm. Keywords: fetal heart rate, perinatal outcomes, Pinard stethoscope, Doppler

Periventricular-intraventricular hemorrhage (PV-IVH) remains the major cause of injury to the developing brain. Predisposing factors include a germinal matrix with an immature vasculature, a pressure passive cerebral circulation, and hemodynamic perturbations in sick premature infants. Intact cerebral autoregulation has been documented in stable premature infants; however, it functions within a limited blood pressure range and is likely to be absent in the sick hypotensive infant, which increases the risk for PV-IVH with perturbations in blood pressure. The risk for PV-IVH is markedly increased in the absence of antenatal glucocorticoid exposure in the intubated low birthweight infant <1000 g with respiratory distress syndrome; +/- other complications. Although surfactant administration reduces the severity of respiratory distress syndrome, it has not led to a reduction in PV-IVH. Early postnatal administration of indomethacin has been associated with a reduction in PV-IVH, although this has not translated into long-term neurocognitive benefits.Copyright © 2009 by Elsevier Inc. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To characterize use of volume infusion (VI) for infants who are > or =34 weeks' gestational age and receive intensive cardiopulmonary resuscitation (CPR; defined as >1 minute of positive-pressure ventilation and chest compressions, with or without the administration of medications) in the delivery room and are admitted to the NICU. METHODS: A retrospective review of a resuscitation registry between January 1999 and June 2001 was conducted. RESULTS: Of 37,972 infants, 23 received CPR, including 13 with VI. Ten of 13 received VI for persistent bradycardia despite CPR, and only 3 of 13 received VI for suspicion of hypovolemia with poor perfusion. More VI versus no VI infants had Apgar scores < or =2 at 5 and 10 minutes. VI versus no VI infants had lower cord arterial pH, had higher arterial partial pressure of carbon dioxide, had larger base deficit, required longer CPR, and required more epinephrine. On admission to the NICU, VI versus no VI infants had lower blood pressure and larger base deficit over the first 2 hours but did not differ in arterial pH, arterial partial pressure of carbon dioxide, heart rate, mortality, or use of additional VI or buffer. CONCLUSIONS: VI is rarely given for overt hypovolemia and more often for asphyxiated infants who are slow to respond to intensive CPR. Persistent postnatal hypotension in VI infants suggests that other factors, eg, myocardial dysfunction, may be important contributors to lack of response to CPR. [ABSTRACT FROM AUTHOR]

There is growing evidence that a large number of very low birth weight infants are exhibiting neurobehavioral problems in the absence of cerebral palsy at follow-up that has extended into school age and adolescence. Many clinical factors (ie, chronic lung disease, recurrent apnea and bradycardia, transient hypothyroxemia of prematurity, hyperbilirubinemia, nutritional deficiencies, glucocorticoid exposure), as well as stressful environmental conditions, including infant-provider interaction, constant noise, and bright light, may act in combination to impact on the developing brain, even in the absence of overt hemorrhage and/or ischemia. Any potential intervention strategy designed to prevent cognitive and behavioral problems has to account for the numerous biological and clinical conditions and/or interventions, as well as postdischarge social and environmental influences. [ABSTRACT FROM AUTHOR]

OBJECTIVE. To determine whether the incidence of neurosonographic and neurologic abnormalities is higher in cocaine-exposed infants at birth. METHODS. In utero exposure to cocaine was investigated in 39 term and near-term infants with positive urine screens for cocaine only and 39 matched control infants without drug exposure admitted to the regular term newborn nursery. Serial evaluations were performed on each infant on postnatal days 1 and 2 and included a cranial sonogram, a neurologic and behavioral assessment for drug withdrawal, and Doppler interrogation of the anterior and middle cerebral arteries. RESULTS. There were no differences between groups in neurosonographic abnormalities. Grade I or II intraventricular hemorrhage occurred in 11% of cocaine-exposed and 11% of control infants. There were no cases of grade III intraventricular hemorrhage, cystic periventricular leukomalacia, or neonatal stroke. Head size was smaller in cocaine-exposed infants, ie, 32.7 +/- 0.1 cm versus 33.8 +/- 0.1 cm. The neurologic examination was similar between groups with regard to tone, reflexes, and cranial nerves. Behavioral scores were higher on both days, in cocaine-exposed versus control infants, ie, 4.4 +/- 0.5 versus 2.7 +/- 0.03 on day 1 and 5.0 +/- 0.5 versus 1.71 +/- 0.31 on day 2. Cerebral blood flow velocity measurements in the anterior cerebral artery were similar between groups on both days of examination. However, cocaine-exposed infants demonstrated a significant increase in flow velocity from day 1 to day 2, ie, 0.48 +/- 0.03 to 0.57 +/- 0.04. There was a concomitant decrease in the pulsatility index from day 1 to day 2 in the cocaine-exposed, ie, 0.74 +/- 0.02 to 0.69 +/- 0.02, but not in the control infants. No differences were noted in the flow velocities in the middle cerebral arteries between groups. CONCLUSIONS. Term and near-term infants admitted to a regular nursery who are exposed to cocaine in utero: (1) do not exhibit an increased incidence of neurosonographic abnormalities; (2) do exhibit altered behavior consistent with drug withdrawal; and (3) do demonstrate changes in flow velocity in the anterior cerebral artery consistent with the vasoconstrictive effects of the drug. However, these changes were not accompanied by changes in the neurologic examination or altered care. The long-term neurodevelopmental implications of these subtle abnormalities in the neonatal period remain to be determined. [ABSTRACT FROM AUTHOR]

Background Current neonatal guidelines endorse both the two-thumb and the two-finger techniques for performing chest compressions. It remains unclear whether one method is superior to the other in achieving consistent depth. Objective To compare the compression depth, variability, rate and finger placement of the two-thumb and two-finger techniques using a compression to ventilation (CV) ratio of 3:1. Methods 25 subjects (physicians and neonatal nurses) participated with compressions performed on a manikin. Subjects were video recorded. Evaluations included continuous compression administered for 60 s, followed by 2 min of compressions using a 3:1 CV ratio for each of the two techniques. Results Depth during 60 s of uninterrupted compressions was greater for the two-thumb than the two-finger technique (27.2±5.7 vs 22.1±4.6 mm; p=0.0008), variability was less (6.7%±3.2% vs 9.0%±2.8%; p=0.002) and rate was comparable (118±22 vs 116±24 compressions/min). With a 3:1 CV ratio, depth was greater for the two-thumb compared to the two-finger method (29±5.4 vs 23.7±5.8 mm; p=0.0009), variability was less (6.1%±2.9% vs 9.8%±3.1%; p=0.00002) and rate was comparable (192±26 vs 197±31 compressions/2 min). Correct positioning was accomplished more often with the two-thumb than the two-finger technique (21/25 vs 3/25; p=0.0005). Conclusions The two-thumb technique is superior to the two-finger technique, achieving greater depth and less variability with each compression. The two-finger technique was incorrectly applied in most cases and deviations in technique may have contributed to the significant differences in depth. [ABSTRACT FROM AUTHOR]

Hypoxic-ischemic cerebral injury that occurs during the perinatal period is one of the most commonly recognized causes of severe, long-term neurologic deficits in children; it is often referred to as cerebral palsy. Despite improvements in perinatal practice during the past several decades, the incidence of cerebral palsy attributed to intrapartum asphyxia has remained essentially unchanged, primarily because management strategies were supportive and not targeted toward the processes of ongoing injury. Two processes of neuronal injury can be demonstrated after hypoxia-ischemia: neuronal necrosis and apoptosis. Because the mechanisms of these processes likely differ, strategies to minimize brain damage in an affected infant after hypoxia-ischemia likely will have to include interventions that target both processes. The goals of management of a newborn infant who has sustained a hypoxic-ischemic insult and is at risk for evolving injury should include (1) early identification of the infant at highest risk for evolving to the syndrome of hypoxic-ischemic encephalopathy, (2) supportive care to facilitate adequate perfusion and nutrients to the brain, and (3) consideration of interventions to ameliorate the processes of ongoing brain injury. Although the neurology group was unable to develop a definitive framework for the study of neuroprotective strategies for neonatal encephalopathy, it (1) listed key questions to be addressed before exploring possible study designs for managing hypoxic-ischemic encephalopathy in neonates, (2) identified important study-design issues, (3) determined general principles and key elements for neuroprotective-treatment strategies, (4) identified potential treatment strategies, (5) proposed a clinical-trial framework, and (6) identified key elements for a potential clinical-trial framework comparing hypothermia with hypothermia 'plus' for moderate-to-severe encephalopathy. [ABSTRACT FROM AUTHOR]

Introduction: Facemask ventilation is a crucial, but challenging, element of neonatal resuscitation.In a previously reported study, instructor-led training using a novel neonatal simulator resulted in high-level ventilation competence for health care providers (HCPs) involved in newborn resuscitation. The aim of this study was to identify the optimal frequency and dose of simulation training to maintain this competence level., Methods: Prospective observational study of HCPs training through 9 months. All training was logged. Overall ventilation competence scores were calculated for each simulation case, incorporating 7 skill elements considered important for effective ventilation.Overall scores and skill elements were analyzed by generalized linear mixed effects models using frequency (number of months of 9 where training occurred and total number of training sessions in 9 months) and dose (total number of cases performed) as predictors. Training loads (frequency + dose) predictive of high scores were projected based on estimated marginal probabilities of successful outcomes., Results: A total of 156 HCPs performed 4348 training cases. Performing 5 or more sessions in 9 months predicted high global competence scores (>28/30). Frequency was the best predictor for 4 skill elements; success in maintaining airway patency and ventilation fraction was predicted by performing training in, respectively, 2 and 3 months of 9, whereas for avoiding dangerously high inflating pressures and providing adequate mask seal, 5 and 6 sessions, respectively, over the 9 months, predicted success. Skills reflecting global performance (successful resuscitation and valid ventilations) and ventilation rate were more dose-dependent., Conclusions: Training frequency is important in maintaining neonatal ventilation competence. Training dose is important for some skill elements. This offers the potential for individualized training schedules., Competing Interests: J.H. and S.R. have received an unconditional grant from Laerdal Foundation, Stavanger, Norway, to fund PhD and postdoctoral research. The funding grant number is Laerdal Foundation: Safer Healthcare 2017–2021; No. 5007. This study received no specific external funding but was performed using simulation equipment provided by Laerdal Medical and Laerdal Global Health. Laerdal Medical also provided technical assistance as necessary in regard to the mannequins. Laerdal Medical played no role in the design, conduct, or analysis of results in this study, nor in the writing of the manuscript. The other authors have no conflict of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society for Simulation in Healthcare.)

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

Most recommendations on cardiopulmonary resuscitation were developed from the perspective of high-resource settings with the aim of applying them in these settings. These so-called international guidelines are often not applicable in low-resource settings. Organisations including the International Liaison Committee on Resuscitation (ILCOR) have not sufficiently addressed this problem. We formed a collaborative group of experts from various settings including low-income, middle-income, and high-income countries, and conducted a prospective, multiphase consensus process to formulate this ILCOR Task Force statement. We highlight the discrepancy between current cardiopulmonary resuscitation guidelines and their applicability in low-resource settings. Successful existing initiatives such as the Helping Babies Breathe programme and the WHO Emergency Care Systems Framework are acknowledged. The concept of the chainmail of survival as an adaptive approach towards a framework of resuscitation, the potential enablers of and barriers to this framework, and gaps in the knowledge are discussed, focusing on low-resource settings. Action points are proposed, which might be expanded into future recommendations and suggestions, addressing a large diversity of addressees from caregivers to stakeholders. This statement serves as a stepping-stone to developing a truly global approach to guide resuscitation care and science, including in health-care systems worldwide., Competing Interests: Declaration of interests KGM is chair of the European Resuscitation Council (ERC) and has received an unrestricted research grant from the Laerdal Foundation. RGr is ERC director of guidelines and chair of the International Liaison Committee on Resuscitation (ILCOR) and the ILCOR Education, Implementation, and Teams (EIT) Task Force. SS is vice-chair of the Austrian Resuscitation Council, a member of the ERC Adult Advanced Life Support SEC, and an ILCOR EIT task force member, and has received an unrestricted research grant from the Laerdal Foundation. All other authors declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: The most common chronic complication of preterm birth is bronchopulmonary dysplasia (BPD), widely referred to as chronic lung disease of prematurity. All current definitions rely on characterizing the disease based on respiratory support level and do not provide full understanding of the underlying cardiopulmonary pathophysiology., Objective: To evaluate a rapid functional lung imaging technique in premature infants and to quantitate pulmonary ventilation using 1.5 Tesla magnetic resonance imaging (MRI)., Materials and Methods: We conducted a prospective MRI study of 12 premature infants in the neonatal intensive care unit (NICU) using the phase resolved functional lung MRI technique to calculate pulmonary ventilation parameters in preterm infants with and without BPD grade 0/1 (n = 6) and grade 2/3 (n = 6)., Results: The total ventilation defect percentage showed a significant difference between groups (16.0% IQR (11.0%,18%) BPD grade 2/3 vs. 8.0% IQR (4.5%,9.0%) BPD grade 0/1, p = 0.01)., Conclusion: Phase-resolved functional lung MRI is feasible for assessment of ventilation defect percentages in preterm infants and shows regional variation in localized lung function in this population., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: In utero transmission of SARS coronavirus 2 (SARS-CoV-2) has not been fully investigated. We investigated whether newborns of mothers with COVID-19 during pregnancy might harbor SARS-CoV-2 in the gastrointestinal tract., Methods: This cohort study investigated stool from 14 newborns born at 25-41 weeks admitted at delivery to our urban academic hospital whose mothers had COVID-19 during pregnancy. Eleven mothers had COVID-19 resolved more than 10 weeks before delivery. Newborn stool was evaluated for SARS-CoV-2 RNA, Spike protein, and induction of inflammatory cytokines interleukin-6 (IL-6) and interferon-γ (IFN-γ) in macrophages., Results: Despite negative SARS CoV-2 nasal PCRs from all newborns, viral RNAs and Spike protein were detected in the stool of 11 out of 14 newborns as early as the first day of life and increased over time in 6. Stool homogenates from all 14 newborns elicited elevated inflammatory IL-6 and IFN-γ from macrophages. Most newborns were clinically well except for one death from gestational autoimmune liver disease and another who developed necrotizing enterocolitis., Conclusions: These findings suggest in utero transmission of SARS-CoV-2 and possible persistent intestinal viral reservoirs in the newborns. Further investigation is required to understand the mechanisms and their clinical implications., Impact: SARS-CoV-2 RNAs or Spike protein was detected in the stool of 11 out of 14 preterm newborns born to mothers with resolved COVID-19 weeks prior to delivery despite negative newborn nasal PCR swabs. These novel findings suggest risk of in utero SARS-CoV-2 transmission to the fetal intestine during gestation. The presence of SARS-CoV-2 RNAs and Spike protein in the intestines of newborns may potentially impact the development of the gut microbiome and the immune system; the long-term health impact on the preterm infants should be further investigated., (© 2022. The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.)

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed., (Copyright © 2023 by the American Academy of Pediatrics.)

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Delivery room management of infants delivered through meconium stained amniotic fluid has evolved over the past four decades. The burden of disease weighs more heavily in low- and middle-resource areas. Current information does not allow for precise prediction of infants that will require resuscitation at delivery versus those that need simple stabilization. Optimal care of newborns requires assessment of risk factors and obstetrical and pediatric team preparation to respond to the needs of the newborn., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The objective of this chapter is to trace the evolution of intraventricular hemorrhage in the premature infant highlighting the importance of the germinal matrix, a critical role for cerebral blood flow changes in the genesis of hemorrhage, clinical factors that increase the bleeding risk, and potential preventative strategies. In 1976, neuropathological studies demonstrated capillary rupture within the germinal matrix as the precursor of hemorrhage. In 1980, introduction of cranial ultrasound facilitated diagnosis of intraventricular hemorrhage. In 1979, loss of cerebral autoregulation in sick newborn infants was demonstrated. In the 1980's, studies demonstrated the importance of intravascular factors in provoking hemorrhage. In 1983, the association of cerebral blood flow velocity fluctuations and subsequent hemorrhage was demonstrated. In 1994, antenatal steroids use to accelerate lung development was recommended. This was associated with an unanticipated reduction in hemorrhage. In the mid 1990's early indomethacin administration was associated with a reduction of severe hemorrhage., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Training in the Helping Babies Breathe (HBB) Program has been associated with a reduction in early neonatal mortality rate (ENMR), the neonatal mortality rate (NMR), and fresh stillbirth rate (FSBR) in low- and middle-income countries (LMICs). This program was implemented in five different healthcare facilities in the Oliver Reginald Tambo (ORT) District, South Africa from September 2015 to December 2020., Objective: To determine and compare the FSBR, ENMR, and NMR between 2015 before initiation of the program (baseline) and subsequent years up to 2020 following the implementation of facility-based training of HBB in five hospitals in ORT District., Methods: Records of perinatal statistics from January 2015 to December 2020 were reviewed to calculate FSBR, ENMR, and NMR. Data were collected from the five healthcare facilities which included two district hospitals (Hospital A&B), two regional hospitals (Hospital C&D), and one tertiary hospital (Hospital E). Comparisons were made between pre- (2015) and post- (2016-2020) HBB implementation periods. Differences in changes over time were also assessed using linear regression analysis., Results: There were 19,275 births in 2015, increasing to 22,192 in 2020 with the majority (55.3%) of births occurring in regional hospitals. There were significant reductions in ENMR (OR-0.78, 95% CI 0.70-0.87) and NMR (OR-0.81, 95% CI 0.73-0.90), but not in FSBR, in the five hospitals combined when comparing the two time periods. Significant reduction was also noted in trends over time in ENMR ( r 2 = 0.45, p = 0.001) and NMR ( r 2 = 0.23, p = 0.026), but not in FSBR ( r 2 = 0.0, p = 0.984) with all hospitals combined. In looking at individual hospitals, Hospital A ( r 2 = 0.61, p < 0.001) and Hospital E ( r 2 = 0.19, p = 0.048) showed a significant reduction in ENMR over time, but there were no significant changes in all mortality rates for Hospitals B, C, and D, and for the district or regional hospitals combined., Conclusion: There was an overall reduction of 22% and 19% in ENMR and NMR, respectively, from pre- to post-HBB implementation periods, although there were variations from year to year over the 5-year period and, across hospitals. These differences suggest that there were other factors that affected the perinatal/neonatal outcomes in the hospital sites in addition to the implementation of training in HBB., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Mayer, Xhinti, Mashao, Mlisana, Bobotyana, Lowman, Patterson, Perlman and Velaphi.)

Context: For many years the International Liaison Committee on Resuscitation has recommended the use of tactile stimulation for initial management of infants born with inadequate respiratory effort at birth without systematically examining its effectiveness., Objective: Systematic review to compare the effectiveness of tactile stimulation with routine handling in newly born term and preterm infants., Data Sources: Medline, Embase, Cochrane CENTRAL, along with clinical trial registries., Study Selection: Randomized and non-randomized studies were included based on predetermined criteria., Data Extraction: Data were extracted independently by authors. Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) was used to assess risk of bias in non-randomized studies. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to assess the certainty of evidence., Results: Among 2455 unique articles identified, 2 observational studies were eligible and qualitatively summarized. Because one of the studies was at critical risk of bias, only the other study including 243 preterm infants on continuous positive airway pressure with clinical indications for tactile stimulation was analyzed. It showed a reduction in tracheal intubation in infants receiving tactile stimulation compared with no tactile stimulation (12 of 164 vs 14 of 79, risk ratio of 0.41 [95% confidence interval 0.20 to 0.85]); however, the certainty of evidence was very low., Limitations: The available data were limited and only from observational studies., Conclusions: A potential benefit of tactile stimulation was identified but was limited by the very low certainty of evidence. More research is suggested to evaluate the effectiveness as well as the optimal type and duration of tactile stimulation., Competing Interests: CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no financial relationships relevant to this article to disclose., (Copyright © 2022 by the American Academy of Pediatrics.)

Maternal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can present with or without symptoms at the time of birth. Symptomatic mothers are more likely be associated with preterm births. Population studies demonstrate a consistent association of SARS-CoV-2 infection and a reduction in preterm birth rate. Newborns with positive SARS-CoV-2 test results appear to have minimal burden of illness that is directly associated with a viral infection. Neonatal mortality directly related to SARS-CoV-2 is extremely rare. Maternal vaccination in pregnant women leads to maternal antibody production, and this can occur as early as 5 days after the first vaccination dose., Competing Interests: Disclosure The authors have no commercial or financial conflicts of interest to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

Objective: A positive significant association has been found between behavior problems and lower cognition in very low birthweight (VLBW) preterm children at school age, but there is relatively little information about whether such an association exists in toddlers and on the continuity of this association. The aim of this study was to assess if there is a relationship between behavior problems and cognitive performance in VLBW preterm children at 18 months post conception and 3 years old, independent of socioeconomic status and sex., Method: Parents of 124 preterm children completed a behavior rating questionnaire (Child Behavior Checklist 1.5-5) to measure behavior problems characteristic of preterm children (Withdrawn, Anxious/Depressed, and Attention Problems). Children completed the Cognitive Scale of the Bayley Scales of Infant Development-III at 18 months and the Wechsler Preschool and Primary Scale (III or IV) at 36 months old. Socioeconomic status (SES), sex, and diagnoses of autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) at 3 years were recorded for each child., Results: Withdrawn problems at 18 months were associated with lower cognitive scores at 18 months and both Withdrawn problems at 18 months and 36 months were associated with lower cognitive scores at 36 months. Increases in Attention Problems scores from 18 to 36 months were associated with decreases in cognitive scores over that period. Lower SES was associated with lower cognitive scores at 36 months and decreases in cognitive scores between 18 and 36 months. Sex was not related to behavior problems or cognition. Diagnoses of ASD and ADHD were significantly associated with increased Withdrawn behavior and Attention Problems, respectively., Conclusions: The early association of Withdrawn behaviors with less favorable cognitive performance at 18 months and 36 months and the relationship between increases in Attention Problems with decreases in cognitive scores between the toddler and preschool period indicate the need for early assessment of and intervention for behavior problems, as well as concurrent cognitive delays, in VLBW preterm children., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research., (Copyright © 2021 European Resuscitation Council, American Heart Association, Inc. and International Liaison Committee on Resuscitation. Published by Elsevier B.V. All rights reserved.)

The immediate delivery room (DR) management of non-vigorous (NV) infants with meconium stained amniotic fluid (MSAF) is controversial. A recent ILCOR suggestion is not to perform routine direct laryngoscopy (DL) with or without tracheal suctioning in NV infants. Our practice is to perform DL and endotracheal (ET) suctioning in targeted NV infants. The study objective was to describe the perinatal characteristics and DR Management of infants born through MSAF and admitted to the neonatal intensive care unit (NICU)., Methods: Retrospective study evaluating the DR management of infants >35 weeks delivered through MSAF. Data retrieved included fetal heart rate abnormalities (FTHR), presence of thick/thin MSAF, DR management and postnatal course., Results: 118 infants were resuscitated and directly admitted to the NICU, including 58 intubated for meconium, 29 receiving immediate PPV (n = 25) or CPAP (n = 4) and 31 (17%) initially stable developed delayed respiratory symptoms and administered CPAP. Sixty-four (35.2%) infants initially stable in the DR were subsequently admitted to NICU. ET suctioning was performed in 58/182 infants with meconium obtained in 41/58; meconium aspiration syndrome (MAS) was diagnosed in 21 infants. ET suctioning was positive in 10/21 cases. FHRT abnormalities (n = 50) were noted with thick meconium and associated with a 2.8-fold increased risk for meconium below the cords, and 3.1-fold increased risk of MAS., Conclusion: NV infants delivered through thick versus thin meconium were more likely to be intubated with a high yield of recovery. Serious pulmonary morbidity was uncommon. Most respiratory symptomatology were not related to MAS., (Copyright © 2020 Elsevier B.V. All rights reserved.)

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid. Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed. All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published. Over 140 million babies are born annually worldwide (https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born., (Copyright © 2020. Published by Elsevier B.V.)

Helping Babies Breathe (HBB) was piloted in 2009 as a program targeted to reduce neonatal mortality (NM). The program has morphed into a suite of programs termed Helping Babies Survive that includes Essential Care for Every Baby. Since 2010, the HBB and Helping Babies Survive training programs have been taught to >850 000 providers in 80 countries. Initial HBB training is associated with a significant improvement in knowledge and skills. However, at refresher training, there is a knowledge-skill gap evident, with a falloff in skills. Accumulating evidence supports the role for frequent refresher resuscitation training in facilitating skills retention. Beyond skill acquisition, HBB has been associated with a significant reduction in early NM (<24 hours) and fresh stillbirth rates. To evaluate the large-scale impact of the growth of skilled birth attendants, we analyzed NM rates in sub-Saharan Africa ( n = 11) and Nepal (as areas of growing HBB implementation). All have revealed a consistent reduction in NM at 28 days between 2009 and 2018; a mean reduction of 5.34%. The number of skilled birth attendants, an indirect measure of HBB sustained rollout, reveals significant correlation with NM, fresh stillbirth, and perinatal mortality rates, highlighting HBB's success and the need for continued efforts to train frontline providers. A novel live newborn resuscitation trainer as well as a novel app (HBB Prompt) have been developed, increasing knowledge and skills while providing simulation-based repeated practice. Ongoing challenges in sustaining resources (financial and other) for newborn programming emphasize the need for innovative implementation strategies and training tools., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Drs Perlman, Clarke, and Merali are current and/or past members of the Helping Babies Survive Planning Group; and Drs Velaphi, Massewe, and Ersdal have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

The fetal inflammatory response syndrome (FIRS) is characterized by umbilical cord inflammation and elevated fetal pro-inflammatory cytokines. Surviving neonates, especially very preterm infants, have increased rates of neonatal morbidity including neurodevelopmental impairment. The mechanism of brain injury in FIRS is complex and may involve "multiple hits." Exposure to in utero inflammation initiates a cascade of the fetal immune response, where pro-inflammatory cytokines can cause direct injury to oligodendrocytes and neurons. Activation of microglia results in further injury to vulnerable pre-myelinating oligodendrocytes and influences the integrity of the fetal and newborn's blood-brain barrier, resulting in further exposure of the brain to developmental insults. Newborns exposed to FIRS are frequently exposed to additional perinatal and postnatal insults that can result in further brain injury. Future directions should include evaluations for new therapeutic interventions aimed at reducing brain injury by dampening FIRS, inhibition of microglial activation, and regeneration of immature oligodendrocytes., (© 2020 Published by Elsevier Ltd.)

Birth asphyxia (BA), assumed to be related to intrapartum related hypoxia-ischemia, accounts for one million neonatal deaths annually. In the low resource setting BA is usually defined as a failure to initiate or sustain spontaneous breathing at birth. In the resource replete setting BA is a biochemical definition related to impaired gas exchange, due to interruption of placental blood flow (PBF). An umbilical arterial pH <7.00 referred to as severe fetal acidemia, reflects a degree of acidosis, where potential risk of adverse neurologic sequelae is increased. However, even with this degree of acidemia, the likelihood of mortality or adverse neurologic sequelae remains low. The aim is to focus on the definition of BA in the low resource setting, and compare it to the diagnosis in the resource replete setting, highlighting the importance of interruption of placental blood flow as it relates to morbidity and mortality. With asphyxia, the fetus aims to redistribute cardiac output to protect more vital organs e.g., brain, myocardium, and adrenal gland at the expense of decreased flow to organs such as kidney or intestine. In an experimental newborn model, animals subjected to asphyxia immediately develop primary apnea with bradycardia sustained blood pressure and normal pH. Recovery of respirations follows basic interventions, i.e. stimulation coupled with reversal of asphyxia. However, if asphyxia is sustained, secondary apnea manifests with bradycardia, hypotension, and pH <7.00. More intensive resuscitation including bag mask ventilation ± intubation ± cardio-pulmonary resuscitation may be necessary for correction upon reversal of asphyxia. Identification of a severely acidemic state (cord arterial pH < 7.00) in the newborn, may help to differentiate the truly asphyxiated intrapartum related cases that result in mortality, from those cases where mortality is related to delay in or ineffective basic resuscitation., (Copyright © 2019 Moshiro, Mdoe and Perlman.)

One hundred and nine preterm infants were studied to examine the relative effects of biologic/neurologic factors (length of hospital stay, 18 month cognitive status) and environment (socioeconomic status) on cognition in the toddler (18 months) and preschool periods (3 years). Length of hospital stay was significantly related to toddler cognitive outcome, and less so to preschool outcome. Socioeconomic status predicted only preschool cognitive outcome and not toddler outcome. Cognitive status at 18 months significantly predicted 3 year outcome, and there was relatively little change between those periods. Together, cognitive status at 18 months and socioeconomic status significantly predicted preschool IQ, accounting for 34% of the variance. Results showed that perinatal biologic risks became less salient while socioeconomic status became increasingly important at the preschool period. Relative lack of change in cognitive status indicated the importance of early cognitive evaluation in preterm infants., (© 2019 Wiley Periodicals, Inc.)