1. NRP 7th Edition Materials: Where NRP is Going
NRP Current Issues Seminar
October 23, Washington, DC
Gary Weiner, MD, FAAP
University of Michigan, Ann Arbor, MI
Jeanette Zaichkin RN MN, NNP-BC
Tacoma WA

2. Faculty Disclosure Information
In the past 12 months, we have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity.
We are compensated editors and consultants for the American Academy of Pediatrics/NRP and, as such, have contractual relationships to produce AAP/Laerdal co-branded educational materials
We receive no financial benefit from the sale of these materials
We do NOT intend to discuss an unapproved/investigative use of a commercial product/device in this presentation.

3. Session Objectives
Discuss changes to the requirements for achieving Provider status
Describe how eSimulation integrates into 7th edition NRP
Describe changes in the path to becoming an instructor
Identify improvements for NRP instructors and providers in the new database
Discuss changes to the structure of the 7th edition textbook
Identify major changes in resuscitation practice

4. How to achieve Provider status
Self-study the textbook as needed
Pass the online examination (all 11 lessons)
Complete at least 3 online eSimulation practice scenarios
Meet the objectives of the in-person Provider course

5. eSimulation What it is Anyone can do it
Learning experience, not testing
After accessing eSimulation for Provider status, you may access scenarios for practice anytime
Ann is covering eSimulation at 10:40

6. Path to becoming an instructor
Beginning January 1, 2017 NRP instructor candidates must
be physicians, registered nurses, respiratory care practitioners, or physician assistants with experience in the hospital care of newborns in the delivery room
have current maternal-child educational or clinical responsibility within a hospital setting
It is recommended that NRP instructors and instructor candidates have ongoing delivery room experience.

7. Path to becoming an instructor
Possess a current NRP provider card for all lessons
Apply online through the AAP
Review Instructor Toolkit content and complete the online instructor course
Pass the NRP online instructor examination
Designate an eligible NRP instructor mentor
Co-teach 2 provider courses with your instructor mentor
Participate in at least one “debrief the debriefer” session with your instructor mentor

8. Online Instructor Toolkit
All instructional resources in one location (keyword searchable)
Replaces the NRP Instructor Manual
No NRP Instructor DVD to purchase
No additional fee to access the instructor course, eSimulation, and the online examination for instructors (includes continuing education credits)
A webinar for NRP instructor mentors available anytime
Downloadable PDFs of most commonly used documents and checklists for use in NRP Provider courses
Podcasts by neonatal resuscitation experts
Continuously updated educational materials and new resources throughout the life of the 7th Edition

9. The new NRP Database and Learning Management System
Launching with NRP 7th edition materials in Spring 2016
Course registration, completion history and educational resources (eg, online examination, eSimulation, instructor resources) in one place.
Can access/ eCard at any time

10. What’s new about the textbook’s structure?

11. Preparing for Resuscitation Post-resuscitation Care
Foundations
Medications
Preparing for Resuscitation
Post-resuscitation Care
Initial Steps of Newborn Care
Resuscitation and Stabilization of Babies Born Preterm
Positive-pressure Ventilation
Special Considerations
Alternative Airways
Ethics and Care at the End of Life
Chest Compressions
Want to tell them that there is no DVD-ROM this time?
Sure.

12. “Frequently Asked Questions”
New sections
“Focus on Teamwork”
Integrates emphasis on teamwork and communication with lesson content
“Frequently Asked Questions”
Controversies and questions commonly sent to the NRPSC
“Ethical considerations”
Highlight questions to consider in context of lesson content
I just made this up.

13. Drawings replaced with color photos

14. What are the major changes in the NRP practice recommendations?

15. No delay if placental circulation disrupted (abruption, avulsion)
Delay cord clamping for seconds for most term and preterm newborns
Place skin-to-skin with mom
No delay if placental circulation disrupted (abruption, avulsion)
Insufficient evidence re: timing if baby is not vigorous
Original Investigation | July 2015
Effect of Delayed Cord Clamping on Neurodevelopment at 4 Years of AgeA Randomized Clinical Trial
Ola Andersson, MD, PhD1; Barbro Lindquist, PhD2; Magnus Lindgren, PhD3; Karin Stjernqvist, PhD3; Magnus Domellöf, MD, PhD4; Lena Hellström-Westas, MD, PhD1
JAMA Pediatr. 2015;169(7): doi: /jamapediatrics
ABSTRACT
ABSTRACT | INTRODUCTION | METHOD | RESULTS | DISCUSSION | CONCLUSIONS |ARTICLE INFORMATION | REFERENCES
Importance  Prevention of iron deficiency in infancy may promote neurodevelopment. Delayed umbilical cord clamping (CC) prevents iron deficiency at 4 to 6 months of age, but long-term effects after 12 months of age have not been reported.
Objective  To investigate the effects of delayed CC compared with early CC on neurodevelopment at 4 years of age.
Design, Setting, and Participants  Follow-up of a randomized clinical trial conducted from April 16, 2008, through May 21, 2010, at a Swedish county hospital. Children who were included in the original study (n = 382) as full-term infants born after a low-risk pregnancy were invited to return for follow-up at 4 years of age. Wechsler Preschool and Primary Scale of Intelligence (WPPSI-III) and Movement Assessment Battery for Children (Movement ABC) scores (collected between April 18, 2012, and July 5, 2013) were assessed by a blinded psychologist. Between April 11, 2012, and August 13, 2013, parents recorded their child’s development using the Ages and Stages Questionnaire, Third Edition (ASQ) and behavior using the Strengths and Difficulties Questionnaire. All data were analyzed by intention to treat.
Interventions  Randomization to delayed CC (≥180 seconds after delivery) or early CC (≤10 seconds after delivery).
Main Outcomes and Measures  The main outcome was full-scale IQ as assessed by the WPPSI-III. Secondary objectives were development as assessed by the scales from the WPPSI-III and Movement ABC, development as recorded using the ASQ, and behavior using the Strengths and Difficulties Questionnaire.
Results  We assessed 263 children (68.8%). No differences were found in WPPSI-III scores between groups. Delayed CC improved the adjusted mean differences (AMDs) in the ASQ personal-social (AMD, 2.8; 95% CI, ) and fine-motor (AMD, 2.1; 95% CI, ) domains and the Strengths and Difficulties Questionnaire prosocial subscale (AMD, 0.5; 95% CI, > ). Fewer children in the delayed-CC group had results below the cutoff in the ASQ fine-motor domain (11.0% vs 3.7%; P = .02) and the Movement ABC bicycle-trail task (12.9% vs 3.8%; P = .02). Boys who received delayed CC had significantly higher AMDs in the WPPSI-III processing-speed quotient (AMD, 4.2; 95% CI, ; P = .02), Movement ABC bicycle-trail task (AMD, 0.8; 95% CI, ; P = .03), and fine-motor (AMD, 4.7; 95% CI, ; P = .01) and personal-social (AMD, 4.9; 95% CI, ; P = .004) domains of the ASQ.
Conclusions and Relevance  Delayed CC compared with early CC improved scores in the fine-motor and social domains at 4 years of age, especially in boys, indicating that optimizing the time to CC may affect neurodevelopment in a low-risk population of children born in a high-income country.
Trial Registration  clinicaltrials.gov Identifier: NCT

16. Time of birth is still the time when the baby emerges from its mother, not the time of cord clamping…

17. Routine tracheal suction no longer recommended for NON-VIGOROUS babies with meconium stained fluid
MSAF is a risk factor that requires presence of a team member with intubation skill

18. Initial HR assessed by auscultation
Palpation of the umbilical cord is less reliable and less accurate

19. Initial HR assessed by auscultation
PPV begins, consider electronic cardiac monitor
Resuscitation anticipated or chest compressions begin, electronic cardiac monitor is preferred method

20. Initial FiO2 for PPV
 35 weeks’ GA = 21%
< 35 weeks’ GA = 21-30%

21. PPV Steps Clarified

22. Intubation Strongly recommended before starting chest compressions
Estimate tip-to-lip distance with new table or nasal-tragus length (NTL)

23. Nasal-Tragus Length

24. Compressions Use 2-thumb technique Head-of-bed compressions
Cardiac monitor recommended
Continue for 60 seconds prior to checking a heart rate.

25. Medications Only 2 medications to remember Epinephrine Normal saline
IV or IO preferred
ET x 1 while achieving intravascular access
Normal saline

26. Preterm Less than 32 weeks’ gestation If PPV, use a device with PEEP
Without drying, cover in food-grade plastic wrap or bag and use a hat and thermal mattress
Use a 3-lead cardiac monitor (chest or limb leads) for rapid and reliable continuous HR
If PPV, use a device with PEEP
Consider CPAP immediately after birth as an alternative to routine intubation and surfactant administration.

27. Increased Emphasis Teamwork Preparation before resuscitation
Structured check of equipment and supplies
Identifying roles
Accurate documentation

28. What hasn’t changed?

29. Veni, Venti, Vici
“Ventilation of the lungs is the single most important and most effective step in cardiopulmonary resuscitation of the compromised newborn.”
The mantra of ILCOR and the AAP guidelines has been ventilation, ventilation, ventilation since the beginning and it has not changed in the guidelines published last fall or in the 6th edition textbook.
Ventilation of the lungs is the single most important and most effective step in cardiopulmonary resuscitation of the compromised newborn.