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Background: Positive pressure ventilation (PPV) is an essential component of neonatal resuscitation. Meta-analytic evidence suggests that, among late preterm and term newborn infants who require resuscitation after birth, a supraglottic airway (SA) device is more effective than a face mask at reducing the probability of PPV failure and reducing the need for endotracheal intubation. However, SA devices are rarely used in routine practice in hospital delivery room settings within the United States., Methods: In preparation for a pragmatic hybrid effectiveness-implementation trial, we used implementation mapping to identify barriers and facilitators to SA use; develop a logic model; identify and operationalize implementation strategies targeting key barriers and facilitators; and refine strategies based on iterative feedback from clinicians and administrators (e.g., physicians, nurse practitioners, nurse managers, and respiratory therapists). We used the Consolidated Framework for Implementation Research (CFIR) to organize barriers and implementation strategies., Results: Across open-ended survey responses and focus groups, identified barriers included: (1) mixed perceptions of the advantages or disadvantages of SA compared to alternatives; (2) insufficient education and training in SA use; and (3) lack of perceived need for an alternative to intubation as a standard practice. The research team's understanding of these barriers and selection of implementation strategies to address them were refined throughout the iterative implementation mapping process, which resulted in the selection of two sets of implementation strategies to be tested in a hybrid trial., Conclusions: The implementation mapping process described in this paper provides an exemplar of a systematic and partner-engaged process to identify and select implementation strategies for the purpose of hybrid trial design., Competing Interests: Declarations. Ethics approval and consent to participate: This research was reviewed and granted exemption by the Institutional Review Board (IRB) of the Children’s Hospital of Philadelphia (IRB number: IRB# 23-021369). All participants provided informed consent prior to participation. Consent for publication: Not Applicable. Competing interests: All other authors declare that they have no competing interests., (© 2024. The Author(s).)

Background: Approximately 10% of newborns require assistance at delivery, and heart rate (HR) is the primary vital sign providers use to guide resuscitation methods. In 2016, the American Heart Association (AHA) suggested electrocardiogram in the delivery room (DR-ECG) to measure heart rate during resuscitation. This study aimed to compare the frequency of resuscitation methods used before and after implementation of the AHA recommendations., Methods: This longitudinal retrospective cohort study compared a pre-implementation (2015) cohort with two post-implementation cohorts (2017, 2021) at our Level IV neonatal intensive care unit., Results: An initial increase in chest compressions at birth associated with the introduction of DR-ECG monitoring was mitigated by focused educational interventions on effective ventilation. Implementation was accompanied by no changes in neonatal mortality., Conclusions: Investigation of neonatal outcomes during the ongoing incorporation of DR-ECG may help our understanding of human and system factors, identify ways to optimize resuscitation team performance, and assess the impact of targeted training initiatives on clinical outcomes.

Objective: In 2013, the Section of Neonatal and Perinatal Medicine at the University of Oklahoma's Children's Hospital began providing advanced care to a regional level II neonatal intensive care unit (NICU), using a hybrid telemedicine program. This project compares health care providers' and parents' assessments of health care quality using this program., Study Design: This is a prospective, anonymous, nonrandomized survey of health care providers and parents of neonates using our hybrid telemedicine services. Physicians, neonatal nurse practitioners (NNPs), nurses, and parents completed pencil-and-paper surveys based on their participatory roles. Institutional Review Board approval was obtained at OU Medical Center and Comanche County Memorial Hospital. Surveys consisted of 5-point Likert's scale questions. Descriptive statistics compared the level of agreement with each question across participant groups. A service quality (SQ) composite score was created by summing responses from six SQ questions. Between-group analysis was done on the SQ score using the Mann-Whitney U -test., Results: Nine physicians, 10 NNPs, 12 nurses, and 40 parents completed the survey. Providers agreed (90%) that telemedicine can effectively deliver advanced neonatal care; the care patients receive is comparable to direct patient care (87%); telemedicine enhanced overall patient care quality (90%); providers can effectively interact with each other and families using telemedicine (90.3%), and overall telemedicine experience was good (90%). In total, 61% of providers reported telemedicine improves physician-patient interaction. Parents of newborns agreed that they were well informed about telemedicine use for their child's care (88%), were able to communicate routinely with neonatologists (85%), and were comfortable with their child's physical examinations (93%). Provider's versus family's (SQ) score was not significantly different., Conclusion: All survey participants, including neonatologists, NNPs, nurses, and patient families, reported high levels of satisfaction with the hybrid telemedicine model developed and implemented at this institution which may be comparable to in-person direct patient care., Key Points: · Implementation of a hybrid telemedicine system provides an alternative to the transfer of newborns needing advanced care to tertiary care facilities.. · In this study, both health care providers and patient family members were satisfied with the quality of care using hybrid telemedicine.. · In this study, families of newborns could fully participate in their child's care using the hybrid telemedicine system.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: The U.S. opioid epidemic has been characterized by increases in opioid misuse, overdose deaths, and neonatal opioid withdrawal syndrome. Research suggests that marijuana legalization has contributed to decreased use of opiates, although many studies had methodological weaknesses and failed to address the pregnant population. Implementation of medical cannabis laws has the potential to reduce maternal opioid use and, therefore, neonatal exposure to the drugs. This study aimed to examine the association between Oklahoma's implementation of state medical marijuana laws and the neonatal exposure to opioids., Study Design: Electronic medical records at two sites (Oklahoma City and Lawton) were searched for results of cord, urine, and meconium screens to detect amphetamines, barbiturates, benzodiazepines, cocaine, ethanol, opiates, phencyclidine, and tetrahydrocannabinol (THC). Two study periods were compared: 19 months before Oklahoma's medical marijuana law took effect and 19 months after legalization began., Results: A total of 16,804 babies were born alive at the two sites during the study period. The rate of positive THC tests per 1,000 liveborn infants significantly increased from 16.2 per 1,000 during the prelaw period to 22.2 per 1,000 during the postlaw period ( p  = 0.004). Neonatal opioid exposure incidence showed a nonsignificant decrease from 7.6 positive tests per 1,000 liveborn infants to 6.8 per 1,000 from prelaw to postlaw period ( p  = 0.542). The number of positive tests for THC and concomitant use of opioids doubled from the prelaw period ( n  = 4) to postlaw ( n  = 9), but there were too few cases for statistical significance. Infants at the more rural site had significantly higher rates for amphetamines, benzodiazepines, and THC, with a trend toward higher rates for opiates., Conclusion: Marijuana legalization was related to significant increases in positive test rates for THC, but no significant change/association was noted for neonatal exposure to opioids., Key Points: · Prior studies have not examined neonatal exposure to opioids following marijuana legalization.. · Oklahoma's new law led to higher neonatal marijuana exposure.. · Legalization of medical marijuana did not change Oklahoma's neonatal opioid positivity rate.., Competing Interests: None declared., (Thieme. All rights reserved.)

This 2023 focused update to the neonatal resuscitation guidelines is based on 4 systematic reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Systematic reviewers and content experts from this task force performed comprehensive reviews of the scientific literature on umbilical cord management in preterm, late preterm, and term newborn infants, and the optimal devices and interfaces used for administering positive-pressure ventilation during resuscitation of newborn infants. These recommendations provide new guidance on the use of intact umbilical cord milking, device selection for administering positive-pressure ventilation, and an additional primary interface for administering positive-pressure ventilation.

Aim: Neonatal resuscitation guidelines promote the laryngeal mask (LM) interface for positive pressure ventilation (PPV), but little is known about how the LM is used among Neonatal Resuscitation Program (NRP) Providers and Instructors. The study aim was to characterize the training, experience, confidence, and perspectives of NRP Providers and Instructors regarding LM use during neonatal resuscitation at birth., Methods: A voluntary anonymous survey was emailed to all NRP Providers and Instructors. Survey items addressed training, experience, confidence, and barriers for LM use during resuscitation. Associations between respondent characteristics and outcomes of both LM experience and confidence were assessed using logistic regression., Results: Between 11/7/22-12/12/22, there were 5,809 survey respondents: 68% were NRP Providers, 55% were nurses, and 87% worked in a hospital setting. Of these, 12% had ever placed a LM during newborn resuscitation, and 25% felt very or completely confident using a LM. In logistic regression, clinical or simulated hands-on training, NRP Instructor role, professional role, and practice setting were all associated with both LM experience and confidence.The three most frequently identified barriers to LM use were insufficient experience (46%), preference for other interfaces (25%), and failure to consider the LM during resuscitation (21%). One-third (33%) reported that LMs are not available where they resuscitate newborns., Conclusion: Few NRP providers and instructors use the LM during neonatal resuscitation. Strategies to increase LM use include hands-on clinical training, outreach promoting the advantages of the LM compared to other interfaces, and improving availability of the LM in delivery settings., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Objective: The aim of this study was to evaluate the level of training, awareness, experience, and confidence of neonatal practice providers in the use of laryngeal mask (LM), and to identify the barriers in its implementation in the neonatal population., Study Design: Descriptive observational study utilizing an anonymous online questionnaire among healthcare providers at the Oklahoma Children's Hospital who routinely respond to newborn deliveries and have been trained in the Neonatal Resuscitation Program (NRP). Participants included physicians, trainees, nurse practitioners, nurses, and respiratory therapists., Results: Ninety-five participants completed the survey (27.5% response rate). The sample consisted of 77 NRP providers (81%), 11 instructors (12%), and 7 instructor mentors (7%). Among 72 respondents who had undergone LM training, 51 (54%) had hands-on manikin practice, 4 (4%) watched the American Academy of Pediatrics (AAP) NRP educational video, and 17 (18%) did both. Nurses (39 out of 46) were more likely to have completed LM training than were physicians (31 out of 47). With only 11 (12%) participants having ever placed a LM in a newly born infant, the median confidence for LM placement during neonatal resuscitation was 37 on a 0 to 100 scale. Frequently reported barriers for LM use in neonates were limited experience (81%), insufficient training (59%), preference for endotracheal tube (57%), and lack of awareness (56%)., Conclusion: While the majority of the neonatal practice providers were trained in LM placement, only a few had ever placed one in a live newborn, with a low degree of confidence overall. Future practice improvement should incorporate ongoing interdisciplinary LM education, availability of LM in the labor and delivery units, and promotion of awareness of LM as an alternative airway., Key Points: · LM is underutilized as an alternative airway.. · Insufficient experience and training limit LM use.. · Providers confidence with LM placement is low.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: To review the current state of the art of positive pressure ventilation (PPV) during resuscitation FINDINGS: The frequency of PPV during delivery room resuscitation varies across settings and gestational age subgroups. Goal targets and parameters for delivery room PPV remain undefined. The T-piece resuscitator provides the most consistent pressures during PPV and may improve clinical outcomes. The laryngeal mask may be an important alternative interface for PPV, but more data are needed to identify the optimal role of the supraglottic airway during PPV. No objective monitors of PPV have conclusively demonstrated improved outcomes to date., Conclusion: More information, including real-world data from population-based studies, is needed to provide data-driven guidelines for positive pressure ventilation during neonatal transition after birth., (Copyright © 2022. Published by Elsevier Inc.)

In order to predict which newborns will require advanced resuscitation (ANR), we developed an ANR risk calculator (calculator) using a bootstrap sample size of 52 973 from a case-control study of newborns ≥34 weeks gestation. Multivariable logistic regression coefficients were obtained for the 10 original risk factors and two interaction terms. The area under the receiving-operating characteristic curve predicting ANR was 0.9243. ANR prediction is improved by accounting for perinatal variables, beyond factors known prenatally. Prospective validation of this model is warranted in a clinical setting., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: We investigated the impact of policy change in delivery room resuscitation from routine endotracheal (ET) suctioning of non-vigorous neonates born through meconium-stained amniotic fluid (MSAF) to immediate non-invasive respiratory support., Design: Single-centre cohort study. Prospective group (October 2016-September 2017)-non-vigorous neonates born through MSAF managed according to the current (2015) guidance of commencing respiratory support without prior suctioning. Retrospective group (August 2015-July 2016)-non-vigorous neonates born through MSAF who underwent routine ET suctioning., Results: 1138 neonates born through MSAF were analysed. No differences in the incidence of meconium aspiration syndrome (MAS), requirement of mechanical ventilation, inhaled nitric oxide or surfactant therapy were found between groups. Less neonatal intensive care unit (NICU) admissions were necessary in the prospective cohort compared with the retrospective group (19.1% vs 55.6%, respectively; p<0.05)., Conclusion: The policy change towards not routinely suctioning non-vigorous neonates born through MSAF at birth was not associated with an increase in the local incidence of MAS and was associated with fewer NICU admissions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Inhaled nitric oxide (iNO) use in premature newborns remains controversial among clinicians. In 2014, the American Academy of Pediatrics, Committee on Fetus and Newborn released a statement that the available data do not support routine iNO use in pre-term newborns. Despite the absence of significant benefits, 2016 California data showed that clinicians continue to utilize iNO in pre-term infants. With studies as recent as January 2017, the Cochrane review confirmed no major advantages of iNO in pre-term newborns. Still, it recognized that a subset of pre-term infants with pulmonary hypertension (PHTN) had not been separately investigated. Furthermore, recent non-randomized controlled trials have suggested that iNO may benefit specific subgroups of pre-term newborns, especially those with PHTN, prolonged rupture of membranes, and antenatal steroid exposure. Those pre-term infants who showed a clinical response to iNO had increased survival without disability. These findings underscore the need for future studies in pre-term newborns with hypoxemic respiratory failure and PHTN. This review will discuss the rationale for using iNO, controversies regarding the diagnosis of PHTN, and additional novel approaches of iNO treatment in perinatal asphyxia and neonatal resuscitation in the pre-term population < 34 weeks gestation., Competing Interests: KS has received research grants from Mallinckrodt and Pfizer Pharmaceuticals. The remaining 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 © 2021 Vieira, Makoni, Szyld and Sekar.)

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.)

There is a widespread shortage of physicians worldwide, especially in rural areas. This shortage is more prevalent when it comes to subspecialty care, even in developed countries. One way to provide access to specialty care is using technology via telemedicine. Telemedicine has evolved over the last two decades, and its use is becoming widespread in developed countries. However, its use in the neonatal population is still limited and practiced only in some centers. It is now apparent that telemedicine can be successfully used in the neonatal population for screening premature infants for retinopathy of prematurity, congenital heart disease, bedside clinical rounds, neonatal resuscitation with the support of a tertiary care hospital, and family support. This avoids unnecessary transfer and appears to provide the same quality of care that the baby would have received at the tertiary care facility. This approach also improves family satisfaction, as the baby and the mother are kept together, and reduces the cost of care. This review focuses on the use of telemedicine in neonatal care, concentrating on the main areas where telemedicine has been shown to be successful and effective, including the status of telemedicine in China.

Context: The International Liaison Committee on Resuscitation sought to review the initial management of non-vigorous newborns delivered through meconium stained amniotic fluid (MSAF)., Objective: To complete a systematic review and meta-analysis comparing endotracheal intubation and suctioning to immediate resuscitation without intubation for non-vigorous infants born at ≥34 weeks gestation delivered through MSAF., Data Sources: Medline, EMBASE, the Cochrane Database of Systematic Reviews, and other registries were searched from 1966 to November 7, 2019., Study Selection: Studies were selected by pairs of independent reviewers in 2 stages., Data Extraction: Reviewers extracted data, appraised risk of bias, and assessed Grading of Recommendations Assessment, Development and Evaluation certainty of evidence for each outcome., Results: Four randomized controlled trials (RCTs) included 581 patients and one observational study included 231 patients. No significant differences were observed between the group treated with tracheal suctioning compared with immediate resuscitation for survival at discharge (4 RCTs; risk ratio [RR] = 1.01; 95 % CI, 0.96-1.06; p = 0.69; observational study; no deaths), hypoxic ischemic encephalopathy and meconium aspiration syndrome., Limitations: The certainty of evidence was low for survival at discharge and very low for all other outcomes., Conclusions: For non-vigorous newborns delivered through MSAF, there is insufficient evidence to suggest routine immediate direct laryngoscopy with tracheal suctioning., Prospero: CRD42019122778., Clinical Trials Registration: PROSPERO; CRD42019122778., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Nitric oxide (NO) plays an important role in normal postnatal transition. Our aims were to determine whether adding inhaled NO (iNO) decreases supplemental oxygen exposure in preterm infants requiring positive pressure ventilation (PPV) during resuscitation and to study iNO effects on heart rate (HR), oxygen saturation (SpO 2 ), and need for intubation during the first 20 min of life., Methods: This was a pilot, double-blind, randomized, placebo-controlled trial. Infants 25 0/7-31 6/7 weeks' gestational age requiring PPV with supplemental oxygen during resuscitation were enrolled. PPV was initiated with either oxygen (FiO 2 -0.30) + iNO at 20 ppm (iNO group) or oxygen (FiO 2 -0.30) + nitrogen (placebo group). Oxygen was titrated targeting defined SpO 2 per current guidelines. After 10 min, iNO/nitrogen was weaned stepwise per protocol and terminated at 17 min., Results: Twenty-eight infants were studied (14 per group). The mean gestational age in both groups was similar. Cumulative FiO 2 and rate of exposure to high FiO 2 (>0.60) were significantly lower in the iNO group. There were no differences in HR, SpO 2 , and need for intubation., Conclusions: Administration of iNO as an adjunct during neonatal resuscitation is feasible without side effects. It diminishes exposure to high levels of supplemental oxygen.

Objective: To evaluate the safety and efficacy of premature infant treatment managed by hybrid telemedicine versus conventional care. Methods: Prospective, noninferiority study comparing outcomes of premature infants at Comanche County Memorial Hospital's (CCMH) Level II neonatal intensive care unit (NICU) with outcomes at OU Medical Center's (OUMC) Level IV NICU. All 32-35 weeks gestational age (GA) infants admitted between May 2015 and October 2017 were included. Infants requiring mechanical ventilation >24 h or advanced subspecialty care were excluded. Outcome variables were: length of stay (LOS), respiratory support, and time to full per oral (PO) feeds. Parents at both centers were surveyed about their satisfaction with the care provided. Between-group comparisons were performed by using Chi-square or Fisher's exact test. LOS was assessed for normality by using the Shapiro-Wilk test, and robust regression was used to construct a multivariable regression model to test the independent effect of location on LOS. All analyses were performed by using SAS v. 9.3 (SAS Institute, Cary, NC). Results: Data from 85 CCMH and 70 OUMC neonates were analyzed. CCMH neonates had significantly shorter LOS, reached full PO feeds sooner, and had fewer noninvasive ventilation support days. Location had a significant independent effect (p = 0.001) on LOS while controlling for GA, gender, race, surfactant use, inborn/outborn status, and 5-min APGAR scores. CCMH patients had reduced LOS of 3.01 days (95% confidence interval 1.1-4.8) than OUMC patients. Eighty-five surveys at CCMH and 66 at OUMC were analyzed. Compared with CCMH, OUMC parents reported more travel distance difficulties. 92.5% reported telemedicine experience as good or excellent, whereas 1.5% reported it as poor. Conclusion(s): Hybrid telemedicine is a safe and effective way to extend intensive neonatal care to medically underserved areas. Parental satisfaction with use of hybrid telemedicine is high and comparable to conventional care.

This 2019 focused update to the American Heart Association neonatal resuscitation guidelines is based on 2 evidence reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. The International Liaison Committee on Resuscitation Expert Systematic Reviewer and content experts performed comprehensive reviews of the scientific literature on the appropriate initial oxygen concentration for use during neonatal resuscitation in 2 groups: term and late-preterm newborns (≥35 weeks of gestation) and preterm newborns (<35 weeks of gestation). This article summarizes those evidence reviews and presents recommendations. The recommendations for neonatal resuscitation are as follows: In term and late-preterm newborns (≥35 weeks of gestation) receiving respiratory support at birth, the initial use of 21% oxygen is reasonable. One hundred percent oxygen should not be used to initiate resuscitation because it is associated with excess mortality. In preterm newborns (<35 weeks of gestation) receiving respiratory support at birth, it may be reasonable to begin with 21% to 30% oxygen and to base subsequent oxygen titration on oxygen saturation targets. These guidelines require no change in the Neonatal Resuscitation Algorithm-2015 Update., (© 2019 by the American Heart Association, Inc., and the American Academy of Pediatrics. This article has been copublished in Circulation.)

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the 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. The task forces also listed priority knowledge gaps for further research.

This 2019 focused update to the American Heart Association neonatal resuscitation guidelines is based on 2 evidence reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. The International Liaison Committee on Resuscitation Expert Systematic Reviewer and content experts performed comprehensive reviews of the scientific literature on the appropriate initial oxygen concentration for use during neonatal resuscitation in 2 groups: term and late-preterm newborns (≥35 weeks of gestation) and preterm newborns (<35 weeks of gestation). This article summarizes those evidence reviews and presents recommendations. The recommendations for neonatal resuscitation are as follows: In term and late-preterm newborns (≥35 weeks of gestation) receiving respiratory support at birth, the initial use of 21% oxygen is reasonable. One hundred percent oxygen should not be used to initiate resuscitation because it is associated with excess mortality. In preterm newborns (<35 weeks of gestation) receiving respiratory support at birth, it may be reasonable to begin with 21% to 30% oxygen and to base subsequent oxygen titration on oxygen saturation targets. These guidelines require no change in the Neonatal Resuscitation Algorithm-2015 Update.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the 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. The task forces also listed priority knowledge gaps for further research., (Copyright © 2019 European Resuscitation Council and American Heart Association, Inc. Published by Elsevier B.V. All rights reserved.)

Objective: To evaluate dietary protein's effect on fat accretion and weight gain in hospitalized preterm infants., Methods: Prospective, randomized, double-blind, controlled trial of 36 infants born at <32 weeks, hospitalized in a tertiary neonatal intensive care unit. After achieving full enteral volume, infants were randomized to either an enhanced protein diet (EPD) (protein-energy ratio [PER] 4 g/100 calories) or a standard protein diet (SPD) (PER 3 g/100 calories). Macronutrients were calculated using published values for formula, donor milk bank analysis, or weekly analysis of a 24-hour pooled maternal milk sample. Human milk fortifier and/or liquid protein were used to achieve the target PER until discharge or a maximum of 4 weeks. Body composition was measured weekly using air displacement plethysmography. The principal outcomes, rates of weight gain and fat accretion, were compared between groups in linear mixed models., Results: Thirty-three infants received approximately 17 days of the study diet. Relative weight gain was 21.6 g · kg · day (95% confidence interval [CI] 19.5-23.8) for the EPD group (n = 16) versus 19.1 g · kg · day (95% CI 17.0-21.2) for the SPD group (n = 17), P = 0.095. Baseline percent fat mass (FM) in the EPD group was 5.15% (95% CI 3.58%-6.72%) compared with 7.29% (95% CI 5.73%-8.84%) in the SPD group, P = 0.0517. Percent FM increased 0.398%/day (95% CI 0.308-0.488) for the EPD group versus 0.284%/day (95% CI 0.190-0.379) for the SPD group (P = 0.0878)., Conclusions: Preterm infants with a lower baseline FM percentage who received an EPD demonstrated a more pronounced catch-up percentage of fat accretion.

The Neonatal Resuscitation Program, initially an expertise- and consensus-based approach, has evolved into an evidence-based algorithm. Ventilation remains the key component of successful resuscitation of neonates. Recent changes in recommendations include management of cord clamping, multiple methods to prevent hypothermia, rescinding of mandatory intubation and suction of the nonvigorous meconium-stained infant, electrocardiographic monitoring, and establishing an airway for ventilation before initiation of chest compressions. Emerging science, including issues such as cord milking, oxygen targeting, and laryngeal mask use, may lead to future program modifications. Technology such as video laryngoscopy and telemedicine will affect the way training and care is delivered., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To measure sound and vibration in rotary wing air transport (RWAT) and ground ambulance transport (GAT), comparing them to current recommendations, and correlating them with physiological stability measures in transported neonates., Study Design: This is a prospective cohort observational study including infants ≤ 7 days of age transported over an 8-month period. Infants with neurologic conditions were excluded. Sound and vibration was continuously measured during transport. Transport Risk Index of Physiologic Stability (TRIPS) scores were calculated from vital signs as a proxy for physiological stability., Results: In total, 118 newborns were enrolled, of whom 109 were analyzed: 67 in RWAT and 42 in GAT. Peak sound levels ranged from 80.4 to 86.4 dBA in RWAT and from 70.3 to 71.6 dBA in GAT. Whole-body vibration ranged from 1.68 to 5.09 m/s 2 in RWAT and from 1.82 to 3.96 m/s 2 in GAT. Interval TRIPS scores for each infant were not significantly different despite excessive sound and vibration., Conclusion: Noise levels during neonatal transport exceed published recommendations for both RWAT and GAT and are higher in RWAT. Transported infants are exposed to vibration levels exceeding acceptable adult standards. Despite excessive noise and vibration, levels of physiological stability remained stable after transport in both RWAT and GAT groups., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Introduction: High-quality chest compressions (CCs) are the main component of cardiopulmonary resuscitation (CPR). Objectives. T o assess the depth of CCs during CPR using a pediatric patient manikin. A secondary objective was to explore the association between CC depth and sex, level of training, body mass index, and periodic physical training., Material and Methods: Prospective study with experimental observation. Pediatric residents, pediatricians, nurses, and other health care providers trained in CPR and who attended children were included. A software program was used to record the depth of CCs while performing CPR during 2 minutes. Tiredness was defined as a deterioration in the number of adequately deep CCs (> 50 mm) by more than 3 CCs between the first and the last cycles., Results: A total of 137 subjects participated (85.4 % were women). Only 48 participants (35.8 %) showed an adequate performance in terms of depth. Significant differences were observed for men (p < 0.0001) and trained pediatricians compared to the rest (p = 0.038). A worsening was observed in performance in terms of depth after 2 minutes in 36.5 % of participants. No significant differences were observed in relation to body mass index and physical activity., Conclusions: Depth rate reduced after 2 minutes. No association was observed with the body mass index or regular physical activity of resuscitators but with their sex and level of training., (Sociedad Argentina de Pediatría.)

Objective: To evaluate vitamin D inadequacy among extremely low-birth-weight (ELBW, <1000 g) infants and the association between circulating vitamin D concentrations and perinatal-neonatal outcomes., Study Design: Prospective cohort study of ELBW infants in the neonatal ICU. Blood was collected within the first 3 days after birth after obtaining informed consent. Circulating 25-hydroxyvitamin D concentrations (25(OH)D) were quantified using liquid chromatography-tandem mass spectroscopy and classified as vitamin D deficient, insufficient, or adequate ( < 20, 20-30, or > 30 ng/mL, respectively). Associations between 25(OH)D and perinatal-neonatal outcomes were determined by multivariable regression, adjusted for covariates that differ in the bivariate analysis., Results: Of the 60 ELBW infants enrolled, 13 (22%) were vitamin D deficient, 15 (25%) were insufficient, and 32 (53%) were adequate. 25(OH)D levels were positively associated with fetal growth restriction and prolonged rupture of the membranes., Conclusions: Vitamin D inadequacy was frequent among ELBW infants. Circulating vitamin D concentrations were significantly associated with perinatal outcomes in this contemporary cohort.

Background: More than 90% of neonatal intensive care units (NICUs) in the United States are in urban areas, denying rural residents' easy NICU access. Telemedicine use for patient contact and management, although studied in adults and children, is understudied in neonates. A hybrid telemedicine system, with 24/7 neonatal nurse practitioner coverage and with a neonatologist physically present 3 days per week and telemedicine coverage the remaining days, was recently implemented at Comanche County Memorial Hospital's (CCMH) Level II NICU., Objective: To compare outcomes of moderately ill infants between 32-35 weeks gestational age (GA) managed by our hybrid telemedicine program with outcomes of similar neonates receiving standard care in a Level IV NICU at Oklahoma University Medical Center (OUMC)., Design/methods: This was a retrospective, noninferiority study comparing outcomes of neonates receiving hybrid telemedicine versus standard care. All 32-35 weeks GA infants admitted between July 2013 and June 2015 were included. OUMC infants came from areas geographically comparable with CCMH. Infants requiring prolonged mechanical ventilation or advanced subspecialty services were excluded. Outcome variables were length of stay, type and duration of respiratory support, length of antibiotic therapy, and time to full enteral feedings., Results: Eighty-seven neonates at CCMH and 56 neonates at OUMC were included in the analysis. Compared with neonates at OUMC, neonates at CCMH had shorter hospitalizations, fewer days of supplemental oxygen, and fewer noninvasive ventilation support days, and reached full enteral feeds sooner., Conclusions: The hybrid telemedicine system is a safe and effective strategy for extending intensive care to neonates in medically underserved areas.

Objective: The objective of this study was to evaluate chest compression (CC) quality and operator fatigue during CC, with coordinated ventilation, on a neonatal simulator and to explore its association with provider aerobic activity and body mass index., Methods: This was a prospective observational experimental study on pediatricians, neonatologists, and neonatal nurses who frequently deliver newborns and who have signed the informed consent. Subjects performed CC coordinated with ventilations at a ratio of 3:1 for 10 minutes on a neonatal mannequin. Proxy of fatigue was defined as four consecutive CC below target., Results: Forty subjects participated; 62% were women. Twenty one (52%) evidenced weariness, as they performed. No gender-based differences were found in weariness. No subject abandoned the procedure due to fatigue. Subjects who participated in aerobic exercise had a significantly better performance than those who did not participate. Early fatigue was significantly associated with higher BMI. The reduction in effectiveness occurred at a mean time of 7.7 minutes (range 3.5-9 minutes)., Conclusion: CC performance quality decreased and fatigue was frequent before 10 minutes had elapsed on a neonatal simulator. Provider fatigue was associated with both lack of aerobic activity and BMI ≥ 25. Our findings support the need for guidelines requiring frequent rotation of CC providers during prolonged neonatal resuscitation., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: The question of whether or not to allow family to be present during resuscitation is relevant to everyday professional health care assistance, but it remains largely unexplored in the medical literature., Objectives: We conducted an online survey with the aim of increasing our knowledge and understanding of this issue., Methods: This is a cross-sectional, multicenter, descriptive, national, and international study using a web-based, voluntary survey. The survey was designed and distributed through a medical website in Spanish, targeting physicians who frequently deal with critical patients., Results: A total of 1,286 Argentine physicians and 1,848 physicians from other countries responded to this voluntary survey. Of Argentine respondents, 15.8% (203) treat only children, 68.2% (877) treat adults, and 16% (206) treat patients of any age. The survey found that 23% (296) of Argentine and 20% of other respondents favor the presence of family members during cardiopulmonary resuscitation (p = 0.03). This practice was more common among physicians treating pediatric and neonatal patients than among those who treat adults. The most commonly reported reason (21.8%) for avoiding the presence of relatives was concerns that physicians, communications, and medical practices might be misunderstood or misinterpreted., Conclusions: Avoiding relatives' presence while performing cardiopulmonary resuscitation is the most frequent choice made by the surveyed physicians who treat critical Argentine patients. The main causes for discouraging family presence during cardiopulmonary resuscitation or other critical procedures include the following: risk of misinterpretation of the physician's actions and/or words; risk of a relative's decompensation; uncertainty about possible reactions; and interpretation of the relative's presence as negative., (Copyright © 2016 World Heart Federation (Geneva). Published by Elsevier B.V. All rights reserved.)