Neonatal and Pediatric Resuscitation – How Similar and How Different

Initial assessment

Initial assessment is similar for both pediatric and neonatal groups:

1. Scene safety before initiation of resuscitation

2. Check response – in neonates by tapping the sole of the foot and in children by tapping on the shoulder.

   1. In case of witnessed and sudden arrest – first call for help and then initiate resuscitation

   2. In case of unwitnessed arrest – first give one cycle of CPR and then call for help.

3. Pulse check – Brachial pulse is the preferred pulse for checking in neonates and infants while in children carotid pulse is preferred. In neonates, cardiac monitoring is recommended for assessing heart rate (HR).^[9]

4. Airway and breathing is a priority in the pediatric population including neonates. Hence, neonatal resuscitation should begin with PPV at the earliest rather than with CC s.^[2]

There are a few differences in PPV recommendations by AAP and ERC, as mentioned in Table 1.

While giving PPV, adequacy of ventilation is confirmed by^[6]

1. Improvement in HR or a stable HR

2. Visible chest rise, failure of which indicates insufficient inflation pressure or delivered volume or obstruction of the airway.

The recommended ventilation corrective steps (MRSOPA)^[9] in neonates are Mask adjustment, Re-position of head and neck, Suction of the mouth and nose, Open the mouth, Pressure increase, and Alternative airway.

While using oropharyngeal airway, it should be used with caution in babies <34 weeks gestation, as it may increase airway obstruction.^[6]

Appropriate mask size selection

The correct size face mask should make an airtight seal between the face mask and face so as to achieve adequate pressure to cause lung inflation. The mask should rest on the chin and cover the mouth and nose, but not the eyes. The different sizes of neonatal masks are size 0, 00 with external diameters of 35, 42, or 50 mm. For infants, size 01 and for older children size 01/02 is commonly used.

Definitive airway indications

Definitive airway (i.e., endotracheal intubation) is considered when there is no HR response or HR response is accompanied by persistent apnea.

A differing range of endotracheal tube sizes should be available [Table 2] to permit placement of most appropriate size of tube to ensure adequate ventilation and minimal leak.^[6]

For estimation of endotracheal tube size in older children various formulae are available, of which Coles formula is often used.^[11] For length of insertion, various recommendations are given as per the gestational age and birth weight.^[6,9]

Most commonly nasal tragus length (NTL) is measured, and the estimated insertion depth is NTL +1 centimeter at lips.^[9]

The correct placement is confirmed by detecting exhaled CO₂ (EtCO₂) and rapidly improving HR.

Role of supraglottic devices in neonatal resuscitation

The laryngeal mask airway (LMA) is an effective alternative airway when attempts at face-mask ventilation or intubation are unsuccessful. It can be considered as a primary interface to administer PPV.^[12] The LMA can effectively transfer positive pressure even during CCs. However, its use in neonatal resuscitation is restricted due to limited experience, lack of awareness, non-availability of appropriate LMA size for the baby, and preference for definitive airway, that is, endotracheal intubation.

The variations of LMA available are as follows: (i) devices with an inflatable mask, (ii) a soft-gel mask that does not require inflation, (iii) device with pre-curved airway tube, and (iv) device with a port for gastric drainage.^[9]

The PPV equipment that should be kept ready for resuscitation is listed in Table 2.

If the baby is put on a mechanical ventilator, and there is deterioration, consider in terms of displaced/obstructed/pneumothorax/equipment failure^[9] and manage accordingly.

Chest compressions

• The CC is indicated when HR is <60/min or not improving in spite of effective ventilation

• Thumb encircling technique in neonates,^[2] and two finger technique for more than 6 months age

• The CC rate is same in all ages 100–120/min

• Depth of CC 1/2–1/3 of anteroposterior chest diameter

• Location for CC – lower one-third of sternum (similar for all groups).

Compression ventilation ratio (CV ratio)

Circulation

If HR is <60/min after 60 s of CC and coordinated ventilation, epinephrine and volume expansion are suggested. Cardiac monitor (electrocardiogram [ECG]) is the preferred method for assessing HR during resuscitation in neonates.

Drugs

The drug dosage is calculated as per the body weight of the child (same in neonates and pediatric). Epinephrine is indicated if there is no increase in HR even after PPV and CCs, in a dose of 0.02 (0.01–0.03) mg/kg IV, every 3–5 min. Three mL normal saline (NS) is used as flush following drug administration.

For volume resuscitation, 0.9% NS is used at 10 mL/kg, given slowly over 30–45 min, to prevent periventricular hemorrhage. In older children, either NS or Lactated Ringers or a balanced salt solution can be used as a bolus.

An IV dose of 250 mg/kg (2.5 mL/kg of 10% glucose) dextrose should be used in case of prolonged resuscitation to reduce the likelihood of hypoglycemia in neonates.^[9] Flush volume and volume of other injectables should always be considered when calculating the total volume used for fluid resuscitation.

Defibrillation

For pediatric defibrillation or cardioversion, biphasic attenuated defibrillators are preferred over adult defibrillators, which are non-attenuated. Since smallest paddle size available is 4.5 cm, it is used for all age pediatric groups. The dose of defibrillation is 2J/kg, which can be increased to 4J/kg (same for all age groups). The pad placement can be anteroposterior (anterior over mid chest left to the sternum and posterior in between the two scapulae) or anterolateral (one below right clavicle and the other one below left axilla).^[13] While placing pads make sure to avoid contact between pads, as this can create charge arcing.^[13]

Temperature

For effective resuscitation, maintaining normothermia is essential. Temperature should be maintained in the range of 36.5–37.5°C. Resuscitation should take place in a warm, well-illuminated, draught-free area with a flat resuscitation surface and a radiant heater (if available).^[6]

Monitoring

To assess the effectiveness of resuscitation, baby should be attached to a monitor as soon as it is made available. Basic monitoring includes ECG, oxygen saturation (SpO₂), EtCO₂, and temperature. Preductal SpO₂ monitoring should be done in neonates to know the saturation of blood flowing to the brain. Re-assessment is done every 60 s using the brachial artery for pulse check or ECG monitor.

Post-resuscitation care

Abnormalities in multiple systems may occur following neonatal or pediatric resuscitation.^[9] The management should be according to the individual circumstances. The underlying principle of post-resuscitation care is the same for the neonatal and pediatric age groups.

1. Maintain adequate oxygenation and ventilation and monitor for signs of pulmonary hypertension.^[9] Avoid hypo/hypercarbia and target SpO₂ 94–98%

2. Monitor blood pressure and HR, volume replacement or inotrope as required (maintain mean arterial pressure >5^th percentile for age)^[10]

3. Avoid wide swings in glucose level (avoid hypo/hyperglycemia).^[9] Consider the use of glucose infusions and replacement of electrolytes as indicated

4. Monitor urine output and other biochemical and hematological parameters

5. For thermal care aim to keep the temperature between 36.5°C and 37.5°C.^[6] If there is clinical/biochemical evidence of moderate or severe hypoxemic ischemic encephalopathy, therapeutic hypothermia 33–34°C can be considered. The reason should be clearly documented (cord blood gases, neurological examination)

6. Evaluate the precipitating cause and manage accordingly.