Updates on Neonatal Resuscitation from the American Heart Association

November 29, 2023

Written by Samuel Rouleau

Spoon Feed
The American Heart Association updated their neonatal resuscitation recommendations based on new evidence. The update focuses on umbilical cord management and best practices for administering positive pressure ventilation. Check-out these videos on neonatal resuscitation on Journal Feed!

Deliveries in the ED are stressful – here are the newest recommendations from the AHA!

Early versus Delayed Cord Clamping
Delayed cord clamping (DCC) is clamping the umbilical cord greater than 30 seconds after delivery, which typically maximizes the volume of blood transferred to the newborn from the placenta. Early cord clamping (ECC) is clamping the umbilical cord before 30 seconds after delivery and is typically reserved when the neonate is in distress. The updated guidelines clearly state the preference for DCC versus ECC in the neonate that does not require resuscitation.

• For newborns born ≥ 34 weeks of gestation, DCC is beneficial compared to ECC.
• For preterm newborns born < 34 weeks, DCC is beneficial compared to ECC, and DCC should be pursued if the neonate does not require resuscitation.

Umbilical Cord Milking
If you’re not familiar with this technique, umbilical cord milking is the practice of gripping the umbilical cord and squeezing/milking the umbilical cord about 3 – 4 times prior to cutting the cord.^{1, 2} The updated guidelines offer recommendations when providers should consider umbilical cord milking.

• For “nonvigorous” newborns between 35-42 weeks of gestation, intact cord milking with early cord clamping (prior to 30 seconds) “may be reasonable.”
• For preterm newborns who are between 28-34 weeks of gestation, intact cord milking “may be reasonable” if delayed cord clamping cannot be performed.
• For preterm newborns who are < 28 weeks of gestation, do not perform umbilical cord milking.
• For newborns ≥ 34 weeks that do not require resuscitation, umbilical cord milking is not beneficial.

Positive-Pressure Ventilation
Positive-pressure ventilation (PPV) is the mainstay of neonatal resuscitation and is the priority for neonates who require support. The guidelines offer updates on equipment and PPV techniques for neonatal resuscitation.

• A T-piece resuscitator is preferred over a self-inflating bag for resuscitating neonates. When compared to self-inflating bags, a meta-analysis found that T-piece resuscitators reduce the duration of PPV and decrease risk of bronchopulmonary dysplasia.³
• When delivering PPV, a supraglottic airway is a reasonable option in lieu of a face mask for newborns ≥ 34 weeks. A meta-analysis demonstrated that supraglottic airways decreased likelihood of intubation and failure to improve with selected device.⁴

How will this change my practice?
This update was focused on select topics, though it does clarify practice.

• The standard should be DCC, I will only perform ECC if the neonate requires resuscitation.
• Honestly, I have never seen umbilical cord milking done, and I will not start performing it during neonatal resuscitations. The guidelines offer only class 2 recommendations for this technique, and it has the possibility of delaying the next steps of neonatal resuscitation.
• The most important part of neonatal resuscitation is PPV. T-piece resuscitator is the best tool for this. Be familiar with the equipment you have available, and, if your shop does not have a T-piece resuscitator, strongly consider getting this.
• I love the idea of using a supraglottic airway for PPV in neonates born ≥ 34 weeks requiring resuscitation. If there is difficulty with the face mask positioning or seal, it is easy to convert to a supraglottic airway, buying more time to adequately prepare for intubation.
• The most important aspect of neonatal resuscitation is being familiar with your equipment, where it is, and how to use it.

Source
2023 American Heart Association and American Academy of Pediatrics Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2023 Nov 16. doi: 10.1161/CIR.0000000000001181. Online ahead of print.

Works Cited

1. Jain SN, Mehendale AM. A Review on Umbilical Cord Milking and Its Implications in Neonatal Health. Cureus. 2022;14(10):e30610. Published 2022 Oct 23. doi:10.7759/cureus.30610
2. Katheria AC. Umbilical Cord Milking: A Review. Front Pediatr. 2018;6:335. Published 2018 Nov 13. doi:10.3389/fped.2018.00335
3. Trevisanuto D, Roehr CC, Davis PG, et al. Devices for Administering Ventilation at Birth: A Systematic Review. Pediatrics. 2021;148(1):e2021050174. doi:10.1542/peds.2021-050174
4. Yamada NK, McKinlay CJ, Quek BH, et al. Supraglottic Airways Compared With Face Masks for Neonatal Resuscitation: A Systematic Review. Pediatrics. 2022;150(3):e2022056568. doi:10.1542/peds.2022-056568