Two rescuers provide CPR to an infant child

Neonatal CPR: how to perform resuscitation on an infant

By Cristiano Antonino On Apr 15, 2023

Let’s talk about neonatal CPR: according to the American Heart Association, infancy includes the neonatal period and extends for 12 months

During the first 28 days of life, a baby is called a ‘neonate’.

The neonatal period is the most vulnerable time for a child’s survival.

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Here is all you need to know about neonatal CPR

When an infant does not start breathing spontaneously after birth, CPR is performed.

The neonatal resuscitation procedure provides oxygen, stimulates breathing and causes the heart to start pumping normally.

Although neonatal resuscitation guidelines focus on newborns, most of the principles apply throughout the neonatal period and early childhood.

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Physiology of a newborn baby

At birth, infants’ lungs are filled with fluid. They are not inflated.

The baby takes its first breath about 10 seconds after birth.

This breath sounds like a gasp as the infant’s central nervous system reacts to the sudden change in temperature and environment.

After birth, the newborn starts to lose heat. Receptors on the baby’s skin send messages to the brain that the baby’s body is cold.

The baby’s body creates heat by burning reserves of brown fat, a type of fat found only in foetuses and newborns. As a result, infants rarely shiver.

What is neonatal resuscitation (CPR)?

Neonatal CPR or neonatal resuscitation is performed if an infant is not breathing spontaneously immediately after birth.

Neonatal resuscitation will provide oxygen, stimulate the infant’s breathing and allow the heart to start pumping normally.

Most newborns start breathing on their own and require only routine neonatal care.

Approximately 10% of newborns require fetal-to-newborn transition assistance and about 1% require extensive resuscitation measures.

Premature infants and infants with certain congenital conditions require extensive resuscitation.

For premature infants, an intensive care unit is required to avoid rapidly administering volume expanders.

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How to perform neonatal CPR

CPR is initiated if the human infant’s heart rate remains below 60 BPM after 30 seconds of PPV (positive pressure ventilation).

Neonatal CPR involves intubation, continuous chest compressions and administration of drugs that increase the heart rate.

Preparation

The two most essential components of successful neonatal resuscitation are preparedness and the ability to manage a potential emergency during delivery.

In a prospective interventional clinical trial, a video-based debriefing was associated with better preparedness and adherence to the initial steps of the neonatal resuscitation algorithm.

Furthermore, improved PPV quality, team function and communication were associated with better team communication and short-term clinical outcomes, such as decreased intubation and increased frequency of normothermia upon admission to the neonatal intensive care unit.

It is also crucial to identify perinatal risk factors, assign roles to team members and prepare and monitor equipment such as the following:

At least one person experienced in the initial stages of neonatal resuscitation, including the administration of PPV, should attend each delivery.
Additional medical personnel capable of performing full resuscitation should be readily available even in the absence of specific risk factors.
A complex resuscitation may require a team of 4 or more health workers. Depending on the risk factors, it may be appropriate for the entire resuscitation team to be present before delivery.
For premature infants < 32 weeks’ gestation, a hat, thermal mattress and plastic bag or band should be used.

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Intubation

Intubation in an infant involves inserting a thin, flexible tube directly into the trachea.

The endotracheal tube helps keep the airway clear and open and delivers oxygen directly to the lungs.

An infant will need intubation in the following situations:

Ineffective balloon-mask ventilation
Before performing chest compressions
Prolonged need for effective ventilation
To administer drugs
Suspected congenital hernia in the diaphragm
Positioning

Infants should be positioned supine or lying on their side, with their head in a neutral or slightly extended position.

If respiratory efforts are present but effective and adequate ventilation is not produced, the airway is often obstructed.

Therefore, immediate measures must be taken to remove secretions.

A blanket or towel under the shoulders can help maintain a correct head position.

Ventilation

The key to successful neonatal resuscitation is the establishment of adequate ventilation.

Adequate ventilation results in a rapid increase in heart rate.

Most neonates requiring positive pressure ventilation can be adequately ventilated with a mask ventilation bag.

Based on a clinical study, indications for positive pressure ventilation include apnoea or laboured breathing, heart rate <100 bpm and persistent central cyanosis despite 100% oxygen.

The reversal of hypoxia, acidosis and bradycardia depends on a good inflation of the fluid-filled lungs with air or oxygen.

Although 100% oxygen has traditionally been used for rapid reversal of hypoxia.

Biochemical and preliminary evidence from clinical studies support resuscitation with lower oxygen concentrations.

Neonatal CPR, chest compressions

After PPV or positive pressure ventilation with intubation for 30 seconds, if the infant’s heart rate remains below 60 BPM, continuous chest compressions should be performed.

Ideally, the neonatal CPR cycle consists of three chest compressions for one respiratory act from the ventilator at a rate of 90 compressions per minute for 30 acts per minute.

Ratio 3:1 for 120 total events per minute comprising a single set of compressions and adequate ventilation.

Respiration, increased heart rate and colour of the child are assessed every 60 seconds.

When performing chest compressions, you should remember

Compressions should be performed on the lower third of the sternum (breastbone).
Continuous chest compressions are performed using the thumbs with the fingers encircling the chest.
The compression depth is one third of the antero-posterior diameter of the chest.
High quality chest compression is essential during neonatal cardiopulmonary resuscitation (CPR).

The 3:1 ratio is superior to the 15:2 ratio in a newborn manikin model in terms of quality of chest compressions and number of adequate ventilations.

A more constant compression depth over time was obtained with 3:1 than with the other ratios.

Therefore, the 3:1 ratio is appropriate for human neonates requiring resuscitation.

Newer methods of chest compression using sustained inflation that maintains lung inflation while providing chest compressions at a rate of 90 compressions per minute (3:1 ratio for 120 total events per minute) are under investigation and cannot be recommended outside of research and clinical trials.

Results vary between neonatal studies and no comprehensive investigation of differences in the approach to sustained inflammation and study outcome in preclinical and clinical studies has been conducted.

Medications

Medications are administered if the infant’s heart rate remains below 60 BPM after chest compressions and effective ventilation while continuing with the next course of neonatal resuscitation.

Recommended drugs include epinephrine to increase heart rate and blood pressure, a saline solution to increase blood volume or concentrated O-negative red blood cells to supplement red blood cells in case of blood loss.

These drugs can be administered through the endotracheal tube into the lungs or intravenously through an umbilical catheter.

What are the immediate steps after resuscitation?

After successful resuscitation, the infant is continuously monitored to ensure normal vital signs.

Human neonates who sustain spontaneous breathing and a heart rate above 100 BPM with the initial stages of CPR are placed close to the mother and kept under observation.

Extremely premature neonates and infants undergoing VRS and more extensive resuscitation will need post-resuscitation care that may include the following:

Once the lungs and heart have functioned, mechanical ventilation may be continued for a time.
Glucose, electrolyte levels and fluids are monitored and maintained with appropriate glucose and fluid infusion to achieve an average balance (homeostasis).
Extremely premature infants and infants requiring continuous intensive care are transferred to a remote neonatal intensive care unit for further care.

What is neonatal mortality?

Human infants run the highest risk of dying in their first month of life.

The number of infants living in a specific area who die at less than 28 days of age is called neonatal mortality.

Early neonatal mortality refers to death before seven days and late neonatal mortality refers to death in days 7-28.

Neonatal mortality is often used as an indicator of the quality of neonatal care without taking into account their many limitations.

In 2020, there is an average global neonatal mortality rate of 17 deaths per 1,000 live births.

Globally, 6,500 neonatal deaths occur every day, with about one-third of all neonatal mortality deaths occurring within the first day after birth and nearly three-quarters occurring within the first week of a baby’s life.

Moreover, there is a dramatic difference in the survival of premature infants depending on where they are born.

For example, more than 90% of extremely premature infants born in low-income countries die within the first few days after birth, but less than 10% of premature infants die in high-income settings.

Neonatal CPR, the key points

Approximately 10% of newborns require help to start breathing at birth and 1% require intensive resuscitation. Therefore, when giving chest compressions to an infant, it may be reasonable to perform three compressions before or after each insufflation: providing 30 insufflations and 90 compressions per minute (3:1 ratio for 120 total events per minute).

Healthcare providers should follow the guidelines for neonatal resuscitation and the most recent recommendations of the American Academy of Pediatrics and the American Heart Association. Here are some key points from this post

For infants who do not require resuscitation, delaying cord clamping for more than 30 seconds reduces anaemia, especially in premature infants.

For premature infants, an intensive care unit is needed to avoid rapid administration of volume expanders.

No routine suctioning is useful, even for non-vigorous infants delivered through meconium-stained amniotic fluid.

If CPR is required, electrocardiography should monitor the heart rate as soon as possible.

Adequate and effective ventilation must be initiated in neonates who are gasping, apnoeic or have a heart rate below 100 beats per minute within 60 seconds.

The infant’s breathing, heart rate increase and colour are assessed every 60 seconds.

Avoid sustained inflation when performing chest compressions at 90 compressions per minute. (3:1 ratio for 120 total events per minute)

The 3:1 ratio is recommended for neonatal CPR to provide effective and adequate ventilation.

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