New guidance on umbilical cord management and device selection for administering positive-pressure ventilation (PPV) is among new neonatal resuscitation guidelines endorsed by the American Heart Association (AHA) and AAP.
The 2023 focused update is based on four systematic reviews completed by the International Liaison Committee on Resuscitation (ILCOR) Neonatal Life Support Task Force. The group reviewed the science on umbilical cord management in preterm, late preterm and term newborn infants, and on devices and interfaces for administering PPV for newborn infants.
"The AHA/AAP Neonatal Life Support Writing Group translates evidence from the medical literature to provide guidelines for neonatal resuscitation," said Nicole K. Yamada, M.D., M.S., FAAP, lead author and AAP representative on the group. "There were several relevant evidence reviews from the ILCOR Neonatal Life Support Task Force and recent clinical trials on umbilical cord management that prompted this focused update."
The 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 also is available in Pediatrics at https://doi.org/10.1542/peds.2023-065030.
“This policy is critical to protecting the lives of children and we appreciate the hard work and time that you have invested to develop such an important clinical document,” AAP President Sandy L. Chung, M.D., FAAP, wrote in a July letter to the AHA. The AAP endorsement will apply for five years.
Updated guidelines for neonatal resuscitation involving umbilical cord clamping and milking include the following:
- For term and late preterm newborn infants ≥34 weeks’ gestation who do not require resuscitation, delayed cord clamping (≥30 seconds) can be beneficial compared with early cord clamping (<30 seconds).
- For term and late preterm newborn infants ≥34 weeks’ gestation who do not require resuscitation, intact cord milking is not known to be beneficial compared with delayed cord clamping.
- For nonvigorous term and late preterm newborn infants 35-42 weeks’ gestation, intact cord milking may be reasonable compared with early cord clamping.
- For preterm newborn infants <34 weeks’ gestation who do not require resuscitation, delaying cord clamping can be beneficial compared with early cord clamping.
- For preterm newborn infants between 28 and 34 weeks’ gestation who do not require resuscitation and in whom delayed cord clamping cannot be performed, intact cord milking may be reasonable.
- For preterm newborn infants <28 weeks’ gestation, intact cord milking is not recommended.
Updated guidelines involving PPV include the following:
- Effective PPV is the priority in newborn infants who need support after birth.
- Using a T-piece resuscitator to deliver PPV is preferred to the use of a self-inflating bag.
- Because both T-piece resuscitators and flow-inflating bags require a compressed gas source, a self-inflating bag should be available in the event of compressed gas failure when using either of these devices.
- Use of supraglottic airway may be considered as the primary interface to administer PPV instead of a face mask for newborn infants delivered at ≥34 weeks’ gestation.
Each guideline went through an extensive evidence evaluation by the Neonatal Life Support writing group, which is comprised of numerous experts, including AAP members.
The writing group analyzed and discussed the systematic reviews, considered treatment recommendations drafted by the ILCOR Neonatal Life Support Task Force and incorporated data published since the systematic reviews were completed.
The guidelines are designed for North American health care practitioners who are looking for an up-to-date summary for clinical care and for those seeking more in-depth information on these topics in resuscitation science and gaps in current knowledge.
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