What are the key components of a neonatal resuscitation programme?

Neonatal Resuscitation Programme: Key Components

A comprehensive neonatal resuscitation programme must include structured initial assessment protocols, sequential resuscitation interventions prioritizing effective ventilation, standardized equipment and personnel training, and frequent skills maintenance through simulation-based education at intervals shorter than 2 years. 1

Initial Assessment and Stabilization Protocol

The foundation of any neonatal resuscitation programme begins with rapid assessment using three critical questions 1, 2:

• Term gestation?
• Good muscle tone?
• Breathing or crying?

If all three answers are "yes," the infant stays with the mother for routine care including skin-to-skin contact, drying, and temperature maintenance 1, 2. If any answer is "no," immediate transfer to a radiant warmer is required 1.

The "Golden Minute" Protocol

Approximately 60 seconds are allotted for completing initial steps, reassessment, and initiating ventilation if needed 1, 2. This critical timeframe includes 2, 3:

• Providing warmth by placing under radiant heat source
• Positioning the head in "sniffing" position to open airway
• Clearing secretions only if copious and/or obstructing airway
• Drying thoroughly and removing wet linens
• Stimulating breathing through drying and gentle tactile stimulation

The decision to progress beyond initial steps is determined by simultaneous assessment of two vital characteristics: respirations (apnea, gasping, or labored/unlabored breathing) and heart rate (less than 100/min) 1.

Sequential Resuscitation Algorithm

The programme must follow a structured sequence 1, 2:

1. Positive-Pressure Ventilation (PPV)

Effective PPV is the single most important step and priority in neonatal resuscitation 1. The programme must specify 1, 3:

• T-piece resuscitator is preferred over self-inflating bag for delivering PPV 1
• Self-inflating bag must be available as backup in case of compressed gas failure 1
• Initiate with room air (21% oxygen) for term infants 3
• For preterm infants <35 weeks, initiate with low oxygen (21-30%) and titrate to target saturations 1, 3
• Rate of 40-60 breaths per minute 3
• Initial pressure of 20 cm H₂O 3

The most sensitive indicator of successful response is an increase in heart rate, not chest rise 1, 3.

2. Oxygen Titration and Monitoring

The programme must mandate 1:

• Pulse oximetry use when resuscitation is anticipated, when PPV is administered, or when supplementary oxygen is given 1
• Target preductal oxygen saturations matching healthy term newborns (60% at 1 minute, gradually reaching 90% by 10 minutes) 3
• For preterm infants <35 weeks: start with 21-30% oxygen and titrate (Class I recommendation) 1

3. Chest Compressions

When heart rate remains <60/min despite adequate ventilation 1:

• Increase oxygen concentration to 100% during chest compressions 1
• Coordinate with ventilation
• Reassess after 60 seconds

4. Medications and Volume

The programme must include protocols for 1:

• Epinephrine administration (intravenous preferred route)
• Volume expansion when indicated
• Specific dosing and timing guidelines

Umbilical Cord Management Protocols

The 2024 guidelines provide the most current evidence-based recommendations 1:

For Term and Late Preterm Infants ≥34 Weeks

• Delayed cord clamping (≥30 seconds) is beneficial for infants not requiring resuscitation 1
• Intact cord milking is NOT recommended as it is not known to be beneficial compared to delayed clamping 1
• For nonvigorous infants (35-42 weeks), intact cord milking may be reasonable compared to early clamping 1

For Preterm Infants <34 Weeks

• Delayed cord clamping (≥30 seconds) is beneficial for infants not requiring resuscitation 1
• For 28-34 weeks when delayed clamping cannot be performed, intact cord milking may be reasonable 1
• For infants <28 weeks, intact cord milking is NOT recommended 1

Airway Management Options

The 2024 guidelines introduce supraglottic airway as a primary interface option 1:

• Supraglottic airway may be considered as primary interface instead of face mask for infants ≥34 weeks gestation 1
• Endotracheal intubation remains indicated when PPV is ineffective, prolonged ventilation required, chest compressions needed, or suspected diaphragmatic hernia 3
• Exhaled CO₂ detection must be used as primary confirmation method for tube placement 3

Temperature Management Protocols

The programme must include specific thermoregulation strategies 1, 2:

• Maintain temperature between 36.5°C and 37.5°C 2, 3
• Avoid hyperthermia >38.0°C due to associated risks 3
• For preterm infants: prewarm delivery room, cover in plastic wrapping (up to neck), use exothermic mattress, place under radiant heat 2, 3
• All resuscitation procedures (intubation, chest compressions, IV lines) can be performed with temperature-controlling interventions in place 1

Educational Structure and Training Requirements

Training frequency is a critical programme component that directly impacts performance 1:

Provider Training

• Neonatal resuscitation task training should occur more frequently than the current 2-year interval (Class IIb recommendation) 1
• Studies show advantages in psychomotor performance, knowledge, and confidence when focused training occurs every 6 months or more frequently 1
• No differences in patient outcomes were demonstrated, but the improved skills justify more frequent training 1

Instructor Training

• Instructors should be trained using timely, objective, structured, and individually targeted verbal and/or written feedback 1

Training Methodology

• Simulation-based learning methodologies must be incorporated as they enhance performance in real-life clinical situations 1
• Briefing and debriefing techniques should be integrated into the education program 1
• The programme should adopt these techniques for both acquisition and maintenance of resuscitation skills 1

Equipment and Resource Requirements

The programme must ensure availability of 1, 3:

• T-piece resuscitator (preferred device) 1
• Self-inflating bag (mandatory backup) 1
• Flow-inflating bag option 3
• Pulse oximetry equipment 1
• Radiant warmers 2
• Plastic wrapping for preterm infants 3
• Exhaled CO₂ detectors 3
• Supraglottic airways for infants ≥34 weeks 1
• Compressed gas source with backup systems 1

Guidelines for Withholding and Discontinuing Resuscitation

The programme must address ethical decision-making 1:

• If heart rate remains undetectable after 10 minutes of resuscitation, it may be reasonable to stop assisted ventilations 1
• The decision must be individualized considering: whether resuscitation was optimal, availability of therapeutic hypothermia, specific circumstances before delivery, and family wishes 1
• For infants <25 weeks gestation, decisions should consider gestational age accuracy, presence of chorioamnionitis, level of care available, and region-specific guidelines 1

Quality Assurance Components

The programme should include 1:

• Multidisciplinary care capabilities
• Longitudinal follow-up systems
• Performance monitoring and debriefing
• Regular skills assessment
• Team coordination protocols

This comprehensive structure ensures that approximately 10% of newborns requiring assistance and the less than 1% requiring extensive resuscitation receive standardized, evidence-based care 1.