2. University of Oklahoma, Children’s Hospital

3. I have nothing to disclose

4. NRP: Current Focus The development of the scientific
evidence based foundation for NRP
The fostering of the search for
new knowledge
The integration of the cognitive, technical and behavioral aspects for better performance of neonatal resuscitation
This is one of your programs from the Section on Perinatal Pediatrics, AAP 4 4

5. Guidelines periodically revised based on new scientific evidence.
The International Liaison Committee on Neonatal Resuscitation’s reviews can be seen at
Another Apgar 9 this one’s also dried off
Perlman PEDIATRICS Nov 2015 5 5

6. Algorithm changed Equipment required Teaching Blenders Oximeters EKG
Content on line exam
Course
Skills
Team work
Debriefing

7. Key dates
The guidelines serve as foundation for the Neonatal Resuscitation Program® (NRP®) 7th edition materials that will be released in Spring 2016 and must be in use by January 1, 2017.

8. Changes Oxygen use down in the algorithm Suction only if necessary
Oximetry guides use
Heart rate is the measure of success
Suction only if necessary
Thermal management
CPAP,PEEP
Two thumb cardiac compressions
Meconium stained fluid management

9. The New Algorithm

11. Learning Objectives
How do we best defend the tiny baby’s thermal integrity?
How do we judge the adequacy of oxygenation of the baby?

13. Thermal management

14. Is it just theoretically important?
Keeping babies warm…
Is it just theoretically important?

15. Reduction in Mortality by Reducing Hypothermia
Comparison of Mortality in the Maternite (the usual standard of care) with
The Tarnier (the preventive approach to Hypothermia)
Budin, Pierre in The Nursling

16. Silverman to Costeloe
Early studies showed survival significantly higher
in incubators kept at 32 C. vs 29 C (Silverman1958)
in radiantly heated incubators vs convectively heated due to stability of the environmental temp (Silverman1963)
in computer controlled SKIN temperature environment (1976 Ahlgren)
Hypothermia remains an independent risk factor for mortality in very small preterm babies
Admission temps <35 C in 40% of infants <26 wks
(Costeloe 2000)

17. How is a baby not a frog?
This was an evolutionary LEAP

18. Poikiolotherms vs homeotherms
Homeotherms have 2-3 times metabolic rate
Homeothermy demands that heat production precisely compensates losses to the environment

19. The human baby maintains his body temperature with energy –
Think of neutral thermal environment as the speed at which your car gets its best gas mileage 19

20. The human baby maintains his body temperature with energy –
Think of neutral thermal environment as the speed at which your car gets its best gas mileage 20

21. The human baby maintains his body temperature with energy –
Think of neutral thermal environment as the speed at which your car gets its best gas mileage 21

22. What is the thermoneutral zone in humans?
Unclothed resting adult : °C (73 °F)
Unclothed full term neonate:32-35 °C (90 °F)
Unclothed 1 Kg preterm neonate:35 °C (90 °F) 22

23. How does this apply to the DR?
LOSSES
Radiation : Cold walls, all solid furnishings of the theatre, poor muscle tone increasing surface area exposed, low mass for surface
Conduction: Cold blankets, instruments, mattresses
Convection: Vents from HVAC system, Movement of personnel, Doors, Gases
Evaporation: Amniotic fluid, no clothing

24. How does this apply to the DR?
INTERVENTIONS
Radiation: Increase room temperature in advance, use radiant warmer for care
Conduction: Warm blankets, exothermic mattresses
Convection: Design appropriate HVAC system, be aware of movement of personnel, doors, gases, use transport incubator
Evaporation: Dry or place barriers to evaporation on body and head

25. HOW do we best defend the tiny baby’s thermal integrity?
McCall, Alderdice, Halliday Jenkins Vohra Cochrane Review 25 25

26. Barrier Methods to prevent evaporative heat loss
Polyethylene occlusive wrapping of ELGANs immediately upon delivery (Vohra, et al J Pediatr 2004, HeLP study
extremely low gestational age newborns
Decreases the incidence of hypothermia
Increases the NICU admission temperature Fewer deaths (all hypothermic) but NS

27. Prevention of Evap Heat Loss
ALL the RCTs of occlusive wrapping of the very preterm baby with food grade plastic wrap
Improved temperatures on admission to NICU of almost 1degree C
Reduced the incidence of hypothermia
Some have studied effects on
Acid base balance
RDS
IVH
NEC
O2 need
LOS
None have shown an effect on Mortality

28. Second barrier to reduction of evap loss of heat:
HATS 28 28 28

29. Second barrier to reduction of evap loss of heat: HATS
Stockinette hat studies >31 wks (Roberts)
Plastic hat study (Trevisunuto)
Plastic hat study in progress (Wyckoff)
Woolen hats studied in terms (Coles 1979; Stothers 1981; Chaput de Saintonge 1979)
NEEDS MORE STUDY

30. Conductive heat transfer
Exothermic warming mattressess

31. THERMAL MATTRESS vs PLASTIC WRAP
RCT < 28 week
Raised NICU adm temp
Allowed more direct access
Improved visualization
Less cumbersome to apply
Reduced hypothermia ( <0.01)
Thermal defense of extremely low gestational age newborns during resuscitation: exothermic mattresses vs polyethylene wrap Simon Dannaway Escobedo et al
J Perinatology 2010 31

32. Various Studies of warming mattresses—all positive
Brennan 1996 RCT Singh 2009 Cohort, historical Almeida 2009 RCT Ibrahim 2010 Retrospective Review

33. Caveat!!

34. Positive transfer of radiant heat
Manual radiant warmer
International Standard requires power cut and alarm if total output has been > 10mW/cm2 for >15 minutes
Most warmers will have shut off before the usual minute resuscitation of VLBW
Servo-controlled radiant warmer
Should probably be used or team member should be assigned to monitor temp to avoid highs and lows
(Rich, Leone, Finer in Clinics in Perinatology Mar 2010)

35. Reducing radiant heat losses beyond the warmer
Delivery room temperature needs to be kept at the WHO standard of 25 °C or higher (mid 70s °F) 35 35

36. Environmental Temps: Birthing and Surgical Suite
Knobel (2005) post hoc analysis
Subjects born in room temps > 26 had higher mean admission temps than those in =<26
Cramer (2005) observational
Positive relationship between DR temp and NICU admission temp
Kent (2008)
Changed environmental temp from 20 to °C along with other interventions and showed a positive effect on T.

37. Humidified and Heated Air during Resuscitation
te Pas AB. Lopriore E. Dito I. Morley CJ. Walther FJ. Pediatrics. 125(6):e , 2010 Jun
Prospective study of <33 wks
"heated" cohort used heated and humidified gas during resuscitation vs “cold” cohort
NICU admission Temp 35.9 vs 36.4 ( P < .0001).
Hypothermia (<36.5 °C ) occurred less often in the heated gas cohort (12% vs 43%; P < .0001)
The use of heated and humidified air during respiratory support in very preterm infants just after birth reduced the postnatal decrease in temperature

38. What about hyperthermia?
As core temperatures increase O2 consumption rises again
This is stressful for any neonate with ELGANs more susceptible
If preterms also have CNS injury, the possibility of hyperthemia exacerbating the injury may exist

39. The evidence shows we should be preventing hypothermia
HOWEVER VON report for 2010 for admission temps shows ½ of VLBWs <36.5 C ¼ < 36 C Why aren’t we doing better?

40. Effect of paying attention40

41. Our protocol
Use of transport isolettes to transfer newborns from the delivery room to the NICU, improved temperature management in the operating room and the introduction of thermoregulation measures, including use of warming mattresses, application of a wool hat and a plastic sac for infants < 30 weeks GA, and ongoing temperature monitoring for delivery room resuscitation lasting >10 min to maintain normothermia. 41

42. Wlodaver et al.
Journal of Perinatology (2016)

43. Thermal Defense for VLBWs
Evidence
Thermal mattresses
Plastic bag with hats
Systematic effort
Emerging concepts
Room and gas temperature
Servo-controlled radiant warmer
The need for multiple modalities 43

46. How do we assess the need for O2? CYANOSIS
How good are we at judging color
O’Donnell AJDC 2007
Video recording with high fidelity color and simultaneous TcSat O2 monitoring
Asked experienced clinicians to judge pink or blue
Tried to assess at what TcSat O2 are infants first perceived as pink after birth

47. Perceptions of BLUE 47

48. MUST USE PULSE OXIMETRY IF . . .
Cyanosis is present
PPV is administered (> few breaths)
Supplemental O2 is used
<32 week baby
Resuscitation is anticipated

49. What should be the target goals for oxygen saturation at birth?
The mean (or 1 SD below the mean) oxygen saturation observed in healthy terms?
Should the target and the timing be different in preterms of differing gestational ages? (Is there a “normal” preterm?)

50. What are O2 sats in normal terms requiring no intervention?
This is one of many studies now..
Took about 75 secs to get reading 50

51. Preterm Oxygenation during Resuscitation: 21 vs 100%
Wang Peds 51

52. 52

53. What to do with premies?
Use oxygen saturation monitor to guide intervention
Probably start with 21 – 30 % if intervention is needed and adjust up or down depending on saturations achieved.
Saturation goals same for all 53

58. Consequences of the Recommendations
Every location in which a baby may be delivered and resuscitated must be equipped with:
Compressed air
Oxygen
Blenders
Pulse Oximeter
Preferably t –piece or bag/mask 58 58

61. MR. SOPA
MASK, RIGHT SIZE AND fIT

62. Management of meconium stained fluid

63. Management of meconium stained fluid
Suction of mouth, nose, and hypopharynx before the delivery of the shoulders

64. Management of meconium stained fluid
Suction of mouth, nose, and hypopharynx before the delivery of the shoulders

65. Results Suction (n=1263) No Suction (n=1251) RR # MAS (%)
(CI 95%)
# MAS (%)
(% y 95%CI)
52 (4.1%) (2.8%-5.8%)
47 (3.8%)
(2.5%-5.4%)
0.9
( )
Need for mech vent (MV) n (%)
24 (1.9%)
18 (1.4%)
0.8
( )
Mortality n (%)
9 (0.7%)
4 (0.3%)
0.4
( )
Days on O2 n (%)
5.7 ± 8.8
5.1 ± 7.1 ns
Days on MV n (%)
5.1 ± 4.9
4.2 ± 4.6
LANCET 2004;364:

66. An apparently vigorous baby…
…does not need to be intubated and suctioned!
Niermeyer et al. Pediatrics 2000;106:e29

67. Incidence of MAS
*Wiswell TE, et al. PEDIATRICS 2000;105:1-7

68. ?
Does the non-vigorous (“depressed”) meconium-stained infant benefit from immediate intratracheal suctioning?

69. ?
Does the non-vigorous (“depressed”) meconium-stained infant benefit from immediate intratracheal suctioning?
A - YES B - NO

70. ?
Does the non-vigorous (“depressed”) meconium-stained infant benefit from immediate intratracheal suctioning?
B - NO

71. Management of meconium stained fluid
If the baby is depressed- not breathing or crying– proceed with ventilation and the regular algorithm
If the baby has meconium obstructing the airway—intubate and suction
THIS MEANS THAT IN MSAF, A PERSON WHO CAN INTUBATE SHOULD BE PRESENT

72. FUTURE New in 2015 but every five years will be revised
Guidelines WILL change again!
New in 2015 but every five years will be revised
The highest level of evidence available is the basis for the guidelines
More complexity and individualization will characterize future recommendations particularly for the preterm infant 72 72

73. HOME DELIVERY IS FOR PIZZA!!!!!!!
Approximately
10% of babies require some
resuscitation at birth
1% need extensive
resuscitation intervention
HOME DELIVERY IS FOR PIZZA!!!!!!! 73

74. UNDERWATER BIRTH IS FOR WHALES!!!74

75. We need to be prepared….

76. We need to be prepared….

77. WHEN and HOW do we need to intervene?

78. Thank you for your attention