ANZCOR Guidelines 13.1 to 13.10 and the Newborn Life Support algorithm are provided to assist in the resuscitation of newborn infants. Differences from the adult and paediatric guidelines reflect differences in the anatomy and physiology and the causes of cardiorespiratory arrest for newborns, older infants, children and adults. These guidelines draw from Neonatal Life Support 2020 and 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR), ^{1, 2} the development of which included representation from ANZCOR. The 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Care ³ and local practices have also been taken into account.

To whom do these guidelines apply?

The term ‘newborn’ or ‘newborn infant’ refers to the infant in the first minutes to hours following birth. In contrast, the neonatal period is defined as the first 28 days of life. Infancy includes the neonatal period and extends through the first 12 months of life.

ANZCOR Guidelines 13.1 to 13.10 and the Newborn Life Support algorithm are mainly for the care of newborns. The exact age at which paediatric techniques and in particular, compression-ventilation ratios, should replace the techniques recommended for newborns is unknown, especially in the case of very small preterm infants. For term infants beyond the first minutes to hours following birth, and particularly in those with known or suspected cardiac aetiology of their arrest, paediatric techniques may be used (refer to Paediatric Advanced Life Support ANZCOR Guidelines 12.1 to 12.7).

Who is the audience for these guidelines?

ANZCOR Guidelines 13.1 to 13.10 and the Newborn Life Support algorithm are for health professionals and those who provide healthcare in environments where equipment and drugs are available (such as a hospital). When parents are taught CPR for their infants who are being discharged from birth hospitals, the information in Basic Life Support Guidelines (ANZCOR Guidelines 2 to 8) is appropriate.

Recommendations

The Australian and New Zealand Committee on Resuscitation (ANZCOR) makes the following recommendations:

1. The newborn who needs resuscitation should be placed on their back with the head in a neutral or slightly extended position (the sniffing position). Particularly if moulding during birth has caused a very prominent occiput, a 2 cm thickness of blanket or towel placed under the shoulders may be helpful in maintaining good positioning. If respiratory efforts are present but not producing effective ventilation (the heart rate does not rise above 100 beats per min) the airway may be obstructed and consideration should be given to other methods to improve airway patency, including support of the lower jaw, opening the mouth, or in some cases upper airway suction. [Good Practice Statements]
2. In general, mouth and pharyngeal suction should not be used except when newborns show obvious signs of obstruction either to spontaneous breathing or to positive pressure ventilation and it should be done briefly and with care. Pharyngeal suction may be required to visualise the vocal cords during intubation. [Good Practice Statements]
3. Aspiration of meconium before or during birth, or during resuscitation can cause meconium aspiration syndrome (MAS) and all newborns born through meconium-stained fluid must be regarded as at risk. [Good Practice Statement]
4. Suctioning the newborns mouth and pharynx before the delivery of the shoulders makes no difference to the outcome of newborns with meconium-stained liquor and is not recommended. [Good practice statement NHMRC LOE II 2015]
5. For newborns who are vigorous after exposure to meconium-stained liquor, (breathing or crying, good muscle tone), routine endotracheal suctioning is discouraged because it does not alter their outcome and may cause harm. [Good practice statement NHMRC LOE II 2015]
6. For all newborns exposed to meconium-stained amniotic fluid, ANZCOR suggests against routine direct laryngoscopy immediately after birth, with or without tracheal suctioning. [CoSTR 2020 Weak recommendation, low-certainty evidence]
7. For the newborn needing assisted ventilation, the primary measure of effectiveness is a prompt improvement in heart rate, which is then sustained. Oxygen saturation levels should also improve. Chest wall movement and other indicators (for example auscultation, colorimetric CO² detector, respiratory function monitoring if available) of adequacy of lung inflation should be assessed if the heart rate does not improve. [Good Practice Statement]
8. If there is little or no visible chest wall movement the technique of ventilation should be improved. This includes assuring the facemask fits well on the face with minimal leak, and that the head and jaw position are correct. Two people may be able to provide mask ventilation more effectively than one, with one person supporting the jaw and holding the mask in place with two hands, and the other providing positive pressure inflations. If these manoeuvres are ineffective in moving the chest wall and increasing the heart rate, the inflating pressure must be increased until chest wall movement is seen and the heart rate increases. Suctioning of the airway is sometimes required. Occasionally an oropharyngeal airway may be helpful, such as when the newborn has an abnormally small jaw or large tongue. A nasopharyngeal airway may be a suitable alternative for those experienced in using them. [Good Practice Statements]
9. For spontaneously breathing term newborns with respiratory distress, a trial of CPAP may be considered, although there are no studies to support this recommendation. [Good Practice Statement]
10. A T-piece resuscitator device, a self-inflating bag (approximately 240 mL), and a flow-inflating bag are all acceptable devices to ventilate newborns either via a facemask, supraglottic airway or endotracheal tube. [Good Practice Statement]
11. ANZCOR suggests the use of a T-piece device for delivery of Intermittent Positive Pressure Ventilation (IPPV) or Continuous Positive Airway Pressure (CPAP) during newborn resuscitation. [Weak recommendation, very low certainty of evidence] A self-inflating bag must always be available for back-up in case of failure of pressurised gas delivery. [Good Practice Statement]
12. An appropriate size of facemask should be selected to seal around the mouth and nose but not cover the eyes or overlap the chin. Therefore, a range of sizes must be available for different sized babies. Masks with a cushioned rim are preferable to masks without one. The face mask should be applied using a rolling motion from chin to nose bridge and held in place using a suitable grip that minimises leaks. The optimal technique for mask grip varies with type of mask. Suction masks are not recommended. [Good Practice Statements]
13. For commencing intermittent positive pressure ventilation in newborns, the suggested initial pressures are 30 cm H₂O for term newborns and 20 to 25 cm H₂O for premature newborns. On devices that can deliver PEEP, 5 cm H₂O is the suggested initial setting. Pressures should be adjusted up or down according to response. For preterm newborns, it is particularly important to avoid creation of excessive lung expansion during ventilation immediately after birth. Although measured peak inspiratory pressure (PIP) does not correlate well with volume delivered in the context of changing respiratory mechanics, monitoring of inflation pressure may help provide consistent inflations and avoid unnecessarily high pressures and excessive volumes. [Good Practice Statements]
14. Higher inflation pressures may be required to aerate the lungs during the first few inflations than for subsequent inflations, particularly in newborns who have not made any respiratory effort. The minimal inflation required to achieve visible chest wall movement and an increase in heart rate should be used. When it becomes evident that the newborn is responding to ventilation, in many cases inflation pressures and rate can (and should) be decreased. [Good Practice Statements]
15. Subsequent ventilation should be provided at 40 to 60 inflations per minute with an inspiratory time of 0.3 to 0.5 seconds. For most newborns, ventilation can be accomplished with progressively lower pressures and rates as resuscitation proceeds. [Good Practice Statements]
16. ANZCOR suggests the use of PEEP (commencing at 5 to 8 cm H₂O pressure) during resuscitation of newborns wherever appropriate equipment is available. [Weak recommendation, very low certainty of evidence.]
17. High levels of PEEP (>8 cm H2O) have the potential to reduce pulmonary blood flow and cause pneumothorax and should be used with caution [Good Practice Statement].
18. If the chest and abdomen do not rise with each inflation, or the heart rate does not increase above 100 beats per minute, the technique of ventilation needs to be improved. Tracheal intubation (or use of a supraglottic airway) should be considered if ventilation via a facemask is still ineffective despite the above measures. [Good Practice Statements].
19. Oximetry is recommended when the need for resuscitation is anticipated, when CPAP or positive pressure ventilation is used, when persistent cyanosis is suspected, or when supplemental oxygen is used. [Good Practice Statement]
20. Use the following target range for oxygen saturations during newborn resuscitation. [Good Practice Statement] 

    Time from birth	Target saturations for newborns during resuscitation in %
    1 min	60-70
    2 min	65-85
    3 min	70-90
    4 min	75-90
    5 min	80-90
    10 min	85-90

21. For term and near-term newborn infants ANZCOR suggests that air should be used initially with supplemental oxygen reserved for those whose saturations do not meet the lower end of the targets despite respiratory support. [CoSTR 2020, weak recommendation, low certainty of evidence] If, despite effective ventilation there is no increase in oxygenation (assessed by oximetry wherever possible) or heart rate, a higher concentration of oxygen should be used. If the saturations reach 90% while supplemental oxygen is being administered, the concentration of oxygen should be decreased. [Good Practice Statement] (For considerations for very preterm infants refer to ANZCOR Guideline 13.8).
22. In all cases, the first priority is to ensure adequate inflation of the lungs, followed by increasing the concentration of inspired oxygen only if needed. [Good Practice Statement]
23. In all newborns, resuscitators should aim to ensure that effective spontaneous or assisted ventilation of the lungs has been established by 1 minute. The response to each set of actions in the algorithm should be assessed. If heart rate, breathing, tone and oxygenation do not improve or the newborn is deteriorating, progress to the next step. [Good Practice Statement]

Abbreviations

EFFECTIVE VENTILATION IS THE KEY TO SUCCESSFUL NEWBORN RESUSCITATION

All personnel involved in the birth and care of newborns must be familiar with the ventilation equipment and be proficient in its use.

The newborn who needs resuscitation should be placed on their back with the head in a neutral or slightly extended position (the sniffing position). Particularly if moulding during birth has caused a very prominent occiput, a 2 cm thickness of blanket or towel placed under the shoulders may be helpful in maintaining good positioning. [Good Practice Statements]

     Hyper-extended.                                  Slightly extended.                                        Flexed

The slightly extended, or sniffing position of the newborn illustrated in the middle panel results in optimal airway patency for resuscitation.

If respiratory efforts are present but not producing effective ventilation (the heart rate does not rise above 100 beats per min) the airway may be obstructed and consideration should be given to other methods to improve airway patency, including support of the lower jaw, opening the mouth, or in some cases upper airway suction. [Good Practice Statement]

Drying and stimulation are both assessment and resuscitative interventions. However, if in response, the term or preterm newborn fails to establish effective respirations and heart rate is below 100 beats per min by 1 minute of age and not increasing, Continuous Positive Airway Pressure (CPAP) or positive pressure ventilation should be commenced. If the newborn is breathing, CPAP may be sufficient to augment endogenous effort. In the non-breathing newborn Intermittent Positive Pressure Ventilation (IPPV) should be started. (Refer to ANZCOR Guideline 13.3).

After stimulation, positive pressure ventilation should be started if the heart rate is less than 100 beats per min and not increasing and either the newborn remains apnoeic or the breathing is inadequate. (Refer to ANZCOR Guideline 13.3).

The primary measure of effectiveness of ventilation is a prompt improvement in heart rate, which is then sustained. Oxygen saturation levels should also improve. Chest wall movement and other indicators (e.g., auscultation, colorimetric CO₂ detector, respiratory function monitoring) of adequacy of lung inflation should be assessed if the heart rate does not improve. [Good Practice Statement]

If there is little or no visible chest wall movement the technique of ventilation should be improved. This includes assuring the facemask fits well on the face with minimal leak, and that the head and jaw position are correct. Two people may be able to provide mask ventilation more effectively than one, with one person supporting the jaw and holding the mask in place with two hands, and the other providing positive pressure inflations. ^{21, 22} If these manoeuvres are ineffective in moving the chest wall and increasing the heart rate, the inflating pressure must be increased until chest wall movement is seen and the heart rate increases. Suctioning of the airway is sometimes required. Occasionally an oropharyngeal airway may be helpful, such as when the newborn has an abnormally small jaw or large tongue. A nasopharyngeal airway may be a suitable alternative for those experienced in using them. [Good Practice Statements]

There are now many studies showing that the blood oxygen levels of normal newborns can take up to 10 minutes to rise above 90%. ^57-63 While insufficient oxygenation can impair organ function or cause permanent injury, there is increasing evidence that even brief exposure to excessive oxygenation can be harmful to the newborn during and after resuscitation. ^64-68

Furthermore, visual assessment of the presence or absence of cyanosis bears a poor relationship to oxyhaemoglobin saturation measured with an oximeter. ⁶⁹

In all newborns, resuscitators should aim to ensure that effective spontaneous or assisted ventilation of the lungs has been established by 1 minute. The response to each set of actions in the algorithm should be assessed. If heart rate, breathing, tone and oxygenation do not improve or the newborn is deteriorating, progress to the next step. [Good Practice Statement]

Footnote; Laryngeal mask is synonymous with supraglottic airway.

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