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Heart rate assessment methods in delivery room- diagnostic characteristics: NLS 5200 TF SR

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Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: None applicable

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: Vishal Kapadia has authored one of the studies included in the systematic review but did not participate in the decision to include the study or RoB assessment of the study.

Task Force members Peter Davis and Jonathan Wyllie were coauthors on studies included in the systematic review but did not participate in discussion about inclusion or risk of bias assessment for these studies.

CoSTR Citation

Kawakami MD, Kapadia VS, Strand M, Gately C, Costa-Nobre DT, Davis PG, de Almeida MF, El-Naggar W,Fabres JG, Fawke J, Finan E, Foglia EE, Guinsburg R, Hosono S, Isayama T, Kim HS, Madar RJ, McKinlay CJD,Nakwa FL, Perlman JM, Rabi Y, Roehr CC, Rüdiger M, Schmölzer GM, Sugiura T, Trevisanuto D, Weiner GM, Wyllie JP, Liley HG, Wyckoff MH. Methods of heart rate monitoring in the delivery room (NLS #5200)[Internet] Brussels, Belgium. International Liaison Committee on Resuscitation (ILCOR) Neonatal Life Support Task Force

Methodological Preamble and Link to Published Systematic Review

The Delivery room (DR) heart rate (HR) monitoring question was last reviewed in 2015 {Perlman 2015 S204, Wyckoff 2020 S185} The review’s focus was on assessing which method results in faster and more accurate HR assessment in the DR. Electrocardiogram (ECG) was compared with pulse oximeter or auscultation. While discussing this review, the ILCOR NLS Task force had noted that ECG provides a more accurate heart rate in the first 3 minutes. Fast and accurate HR assessment is critical for appropriate interventions in a timely manner, but concerns were raised about the implications of a recommendation of HR monitoring device on resource-limited settings without a clear idea of cost-benefit ratio. The 2020 evidence update identified additional studies with newer methodologies such as digital stethoscope, photoplethysmography, video plethysmography, audible doppler, display doppler and dry electrode technologies available for use at the delivery room. This question was never put through GRADE analysis. In addition, accuracy of HR assessment was not examined. Recognizing the need to systematically review the methods for heart rate assessment in the delivery room, this PICOST was created and it was prioritized by the Neonatal Life Support Task Force.

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of HR assessment methods in the delivery room (PROSPERO 2021 CRD 42021283364) conducted by Vishal Kapadia, Mandira Daripa Kawakami, Marya Strand and Callum Gately. Evidence from neonatal literature was sought and considered by the Neonatal Life Support Task Force and clinical content experts. These data were taken into account when formulating the Treatment Recommendations.

Systematic Review

Kapadia VS, Kawakami MD, Strand M, Gately C, Perlman JM, Weiner GM, Liley HG, Wyckoff MH; for the International Liaison Committee On Resuscitation Neonatal Life Support Task Force. Heart rate assessment methods in delivery room (diagnostic characteristics): a systematic review. To be submitted.

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Newly born infants in the DR

Intervention: Use of auscultation, palpation, pulse oximetry, Doppler device, digital stethoscope, photoplethysmography, video plethysmography, dry electrode technology or any other newer modalities

Comparators: 1. ECG

2. In between intervention comparison

Outcomes: Time for first HR assessment from the device placement, time for first HR assessment from birth and accuracy of HR assessment were ranked as important outcomes

For the purposes of this systematic review, ECG HR was considered the gold standard. Accuracy of HR assessment was examined using:

1. Pooled Bland-Altman analysis: The Bland-Altman plot is a method to quantify agreement between two quantitative measurements. {Bland 1995 1085, Bland 1999 135, Bland 1986 307, Giavarina 2015 141, Montenij 2016 750} This analysis was used to quantify agreement between ECG (reference technique) and other HR monitoring methods (experimental techniques). Bland–Altman (B-A) analysis determines the bias, or mean difference between the experimental and reference technique, as a measure of accuracy. B-A plot also includes limits of agreement (LoA), as a measure of precision. These statistical limits are calculated by using the mean difference (Bias) and the standard deviation(s) of the differences between two measurements. The LoA indicates the interval within which 95% of the differences between the two methods fall. If more than 1 study reported B-A plot analysis, we pooled that data together to create a summary estimate of accuracy and precision. The B-A plot method only defines the intervals of agreements, it does not say whether those limits are clinically acceptable or not. For this systematic review, agreement within +/- 10 bpm was considered acceptable. The B-A plot can also uncover whether the bias and differences are same or differ across various levels of HR.

2. Pooled sensitivity and specificity analysis to identify ECG HR < 100 bpm and ECG HR < 60 bpm.

The choices of outcomes were debated by the Task Force. Outcomes ratings using the GRADE classifications of critical, important or less important were based on a consensus for international neonatal resuscitation guidelines (range 1-3 low importance for decision-making, 4-6 important but not critical for decision-making, 7-9 critical for decision-making). {Strand 2020 328}
Potential subgroups were defined a priori: receipt of resuscitation (yes or no), gestational age (<28+0 weeks, 28+0-33+6 weeks, ≥34+ 0 weeks), time epoch for the HR assessment (≤60 s, 61 s – 120 s, > 120 s)

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion.

Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. The literature search was first done on October 29, 2021 and updated to August 5, 2022.

PROSPERO registration:

The review was registered with PROSPERO CRD 42021283364.

Consensus on Science

Comparison 1: Pulse oximeter (PO) with electrocardiogram (ECG)

The systematic review identified 3 RCTs {Abbey 2022 1445, Murphy 2019 F547, Murphy 2021 438} including 187 infants and 11 cohort studies {Bjorland 2020 175, Bobillo-Perez 2021 783, Bush 2021 550, Dawson 2013 955, Henry 2021 72, Iglesias 2018 F233, Iglesias 2016 271, Kamlin 2008 756, Katheria 2012 e1177, Mizumoto 2012 205, van Vonderen 2015 49} including 490 infants.

  1. Time for first HR assessment from the device placement:

A1: For the important outcome of time for first HR assessment from the device placement, PO was slower in presenting a HR signal than ECG (pooled difference HR from PO was 57 seconds (s) slower, 95% CI 13 s slower to 101 s slower, p<0.05), low certainty evidence downgraded for risk of bias and imprecision from 6 observational studies including 323 infants. {Bjorland 2020 175, Bush 2021 550, Iglesias 2018 F233, Iglesias 2016 271, Katheria 2012 e1177, van Vonderen 2015 49}

A2: For the important outcome of time for first HR assessment from the device placement, there was no significant difference between PO and ECG (pooled difference HR from PO 12 s slower, 95% CI 13 s faster to 38 s slower, p>0.05), very low certainty evidence downgraded for risk of bias, inconsistency and imprecision from 2 RCTs including 136 infants. {Murphy 2019 F547, Murphy 2021 438}

  1. Time for first heart rate assessment from birth

B1: For the important outcome of time for first HR assessment from birth, PO was slower than ECG (pooled difference HR from PO 52 s slower, 95% CI 9 s slower to 94 s slower, p<0.05), low certainty evidence downgraded for risk of bias and imprecision from 6 observational studies including 334 infants. {Bjorland 2020 175, Bobillo-Perez 2021 783, Dawson 2013 955, Kamlin 2006 319, Mizumoto 2012 205, van Vonderen 2015 49}

B2: For the important outcome of time for first HR assessment from birth, there was no significant difference between PO and ECG (pooled difference HR from PO 6 s slower, 95% CI 10 s faster to 23 s slower, p>0.05), low certainty evidence downgraded for risk of bias and imprecision from 2 RCTs including 87 infants. {Abbey 2022 1445, Murphy 2021 438}

  1. Accuracy of heart rate assessment: For this comparison, the index test was PO and the reference standard was ECG.

C1: One RCT {Abbey 2022 1445} and 4 cohort studies {Dawson 2013 955, Henry 2021 72, Kamlin 2008 756, van Vonderen 2015 49} assessed whether HR measured by PO (HRPO) agreed with HR measured by ECG (HRECG) by reporting average difference (mean bias) and LoA. This was graphically depicted by B-A plots in these studies. We meta-analyzed these data and calculated pooled mean difference (summary bias), LoA and the 95% confidence limit around LoA. This analysis showed that PO may be accurate but imprecise for HR estimation at birth (summary mean bias (HRPO – HRECG) -1.2 bpm; LoA: -17.9 to 15.5, 95% CI -32.8, 30.4), very low certainty evidence downgraded for risk of bias, inconsistency and imprecision from 28,211 observations in 218 infants. Thus, the average difference in the HR measured by PO and ECG in this population was small but 95% CI of LoA were very wide, indicating that at times, PO may underestimate or overestimate the HR substantially.

C2: For the identification of neonatal bradycardia (HRECG < 100 bpm) at birth, the pooled sensitivity of PO was 0.83 (95 % CI 0.76,0.88) and a pooled specificity was 0.97 (95 % CI 0.93,0.94), very low certainty evidence downgraded for risk of bias, inconsistency and imprecision from one RCT {Abbey 2022 1445} and 2 cohort studies {Iglesias 2018 F233, Kamlin 2008 756} enrolling 145 infants.

C3: For the identification of severe neonatal bradycardia (HRECG < 60 bpm) at birth, we could not calculate sensitivity and specificity as no studies reported these data.

Subgroup Analyses:

Receipt of Resuscitation: No studies reported data sufficient to perform this subgroup analysis. One study noted that there were slightly larger differences between HR measurements obtained from the PO and those from ECG when HRECG <100 bpm. {Dawson 2013 955}

Time epoch for heart rate assessment (≤60 s, 61 s – 120 s, > 120 s): No studies reported data sufficient to perform this subgroup analysis.

  • One study noted that for the first 2 minutes after birth, measured HRPO values were significantly lower than HRECG. {van Vonderen 2015 49}
  • Another study noted that PO displayed lower HR values compared to ECG during the first 6 minutes after birth. {Iglesias 2016 271}

Gestational age subgroups: No study provided sufficient data to perform this subgroup analysis. One study compared subgroups of infants of 29-32 and 32-35 weeks’ gestational age and found no difference between them in the time to HR display from the start of monitoring for either ECG or PO. {Murphy 2021 438}

Summary of evidence: PO is slower and imprecise for newborn HR assessment in the delivery room compared to ECG. PO may display lower heart rate values compared to ECG for the first 2 to 6 minutes after birth. There is limited evidence for HR assessment using PO vs ECG in extremely preterm newborns, newborns requiring resuscitation and newborns who have ECG HR< 100 bpm and < 60 bpm.

Comparison 2: Auscultation compared to ECG

The systematic review identified 5 observational studies including 171 infants. {Bobillo-Perez 2021 783, Cavallin 2020 88, Kamlin 2006 319, Murphy 2018 F490, Treston 2019 F227}

For the important outcome of time for first HR assessment from the device placement, there was no significant difference between auscultation and ECG (pooled difference HR by auscultation 4 s faster, 95% CI 10 s faster to 2 s slower, p > 0.05), moderate certainty evidence downgraded for risk of bias from 3 observational studies enrolling 105 infants. {Bobillo-Perez 2021 783, Murphy 2018 F490, Treston 2019 F227}

For the important outcome of time for first HR assessment from birth, auscultation detected HR faster than ECG at birth (pooled difference HR by auscultation 24 s faster, 95% CI 45 s faster to 2 s faster), low certainty evidence downgraded for risk of bias and imprecision from 3 observational studies enrolling 105 infants. {Bobillo-Perez 2021 783, Murphy 2018 F490, Treston 2019 F227} This was considered likely to be due to the time required for the placement of ECG leads and turning on the ECG monitor.

For the important outcome of accuracy of HR assessment, auscultation was accurate but imprecise (summary mean bias (HRAUSC – HRECG) was -9.9 bpm; LoA -32 to 12, 95% CI-217, 198), very low certainty evidence downgraded for risk of bias and imprecision from 3 observational studies including 91 infants. {Kamlin 2006 319, Murphy 2018 F490, Treston 2019 F227}

Subgroup Analyses:

For the pre-defined subgroup analyses by receipt of resuscitation and gestation, no data were available.

Time epoch for HR assessment (≤60 s, 61 s – 120 s, > 120 s): No studies reported data sufficient to fully perform this subgroup analysis. Some data were available to compare accuracy at 90 s vs 120 s after birth. These analyses showed very wide confidence intervals for the comparison of methods at both times, so the only conclusion that can be drawn is that auscultation was accurate but imprecise at both times.

For accuracy of HR assessment at 90 s, auscultation was accurate but imprecise (summary mean bias (HRAUSC – HRECG) -9.6 bpm; LoA -52 to 33 bpm, 95% CI -307, 203), very low certainty evidence downgraded for risk of bias and imprecision from 2 observational studies including 80 infants. {Bobillo-Perez 2021 783, Cavallin 2020 88}

For accuracy of HR assessment at 120 s, auscultation was accurate but imprecise (summary mean bias (HRAUSC – HRECG) – 0.4 bpm; LoA: -34 to 35 bpm, 95% CI -594, 189 bpm), very low certainty evidence downgraded for risk of bias and imprecision from 2 observational studies including 80 infants. {Bobillo-Perez 2021 783, Cavallin 2020 88}

Comparison 3: Palpation compared to ECG

The systematic review identified 2 observational studies including 86 infants. {Cavallin 2020 88, Kamlin 2006 319}

For the important outcome of time for first HR assessment from the device placement neither study reported this outcome.

For the important outcome of time for first HR assessment from birth neither study reported this outcome.

For the important outcome of accuracy of HR assessment, palpation was inaccurate and imprecise (mean bias of -21bpm with SD of 21 bpm), very low certainty evidence downgraded for risk of bias and applicability concerns from one observational study including 26 infants. {Kamlin 2006 319}

Subgroup analysis:

For the pre-defined subgroup analyses by receipt of resuscitation and gestational age, no data were available.

For accuracy of HR assessment by time epochs, palpation was similarly inaccurate and imprecise when assessed at 60 s, 90 s, 120 s and 300 s (mean difference between HR palpation and HR ECG of -20 bpm (LoA -80 to 40 bpm) at 60 s, -25 bpm (LoA -73 to 22 bpm) at 90 s, -23 bpm (LoA -67 to 20 bpm) at 120 s, and -31 bpm (LoA -96 to 34 bpm) at 300 s), very low certainty evidence downgraded for risk of bias and applicability concerns from one observational study including 60 infants. {Cavallin 2020 88}

Comparison 4: Palpation compared to auscultation

The systematic review identified 1 RCT including 60 infants {Owen 2004 213} and 1 observational study including 60 infants. {Cavallin 2020 88}

For the important outcome of time for first heart rate assessment from the device placement neither study reported this outcome.

For the important outcome of time for first heart rate assessment from birth neither study reported this outcome.

For the important outcome of accuracy of heart rate assessment, data were not available in a format that allowed calculation of a pooled summary estimate. {Owen 2004 213} The study authors noted that all palpation methods (femoral pulse, brachial pulse and umbilical cord pulse) showed very poor agreement with auscultated HR. {Owen 2004 213}

Comparison 5: Digital stethoscope compared to ECG

The systematic review identified 2 observational studies including 77 infants, {Gaertner 2017 F370, Treston 2019 F227} only one of which provided data assessing prespecified outcomes of the review. {Gaertner 2017 F370}

For the important outcome of time for first HR assessment from the device placement neither study reported this outcome.

For the important outcome of time for first HR assessment from birth neither study reported this outcome.

For the important outcome of accuracy of HR assessment, the digital stethoscope was accurate but imprecise (mean difference (HRDS –HRECG) of 0.2 bpm 95% CI −17.6 to 18 including crying periods and 1 bpm 95% CI −10.5 to 12.6 if excluding crying periods), very low certainty evidence downgraded for risk of bias and applicability concerns from 1 observational study including 37 infants. {Gaertner 2017 F370} The study authors found the digital stethoscope unreliable in detecting a signal during crying but suggested that since crying may be a sign of a successful transition, measurement of HR may not be necessary during crying.

Comparison 6: Doppler ultrasound (DU) compared to ECG

The systematic review identified 2 observational studies including 164 infants. {Agrawal 2021 2053, Shimabukuro 2017 1069}

For the important outcome of time for first heart rate assessment from the device placement neither study reported this outcome.

For the important outcome of time for first heart rate assessment from birth, DU was faster for presenting a HR signal than ECG (time to DU HR 76 s interquartile range (IQR) 51 s to 91 s vs ECG HR 96.5 s, IQR 74.2 s to 118 s, p<0.05), very low certainty evidence downgraded for severe risk of bias and applicability concerns from 1 observational study including 131 infants. {Agrawal 2021 2053}

For the important outcome of accuracy of heart rate assessment, DU (considered as index test) was accurate and precise compared to ECG (reference standard) (summary mean bias (HRDU – HRECG) was – 0.2 bpm; LoA -5 to 6, 95%CI -222, 223), very low certainty evidence downgraded for risk of bias, imprecision and applicability concerns from 2 observational studies including 164 infants. {Agrawal 2021 2053, Shimabukuro 2017 1069}

Comparison 7: Dry electrodes incorporated in a belt (DEB) compared to (conventional 3 lead) ECG

The systematic review identified 3 observational studies including 94 infants. {Bush 2021 550, Rettedal 2021 1092, van Twist 2022 1137}

For the important outcome of time for first HR assessment from the device placement, DEB was faster for presenting a HR signal than ECG (HRDEB at 22 s, IQR CI 13s to 45s, HRECG 171 s, IQR 129s to 239s), very low certainty evidence downgraded for risk of bias and imprecision from 1 observational study including 48 infants. {Rettedal 2021 1092}

For the important outcome of time for first HR assessment from birth, DEB was faster for presenting a HR signal than ECG (HRDEB 13 s IQR 10s to 18s, HRECG 42 s IQR 31 s to 63 s), very low certainty evidence downgraded for severe risk of bias and imprecision from 1 observational study including 28 infants. {Bush 2021 550}

For the important outcome of accuracy of HR assessment, DEB (considered as index test) was accurate and precise for HR estimation when compared to ECG (reference standard) (summary mean bias (HRDEE – HRECG) – 1.4 bpm; LoA -2.5 to 5.2, 95% CI -30, 33), very low certainty evidence downgraded for risk of bias and applicability concerns from 2 observational studies including 66 infants. {Rettedal 2021 1092, van Twist 2022 1137}

Treatment Recommendations

Where accurate heart rate estimation is needed at birth and resources permit, we suggest that the use of ECG for heart rate assessment of a newly born infant in the delivery room is reasonable. (Conditional recommendation, low certainty of evidence)

Pulse oximetry and auscultation may be reasonable alternatives for heart rate assessment, but the limitations of these modalities should be kept in mind. (Conditional recommendation, low certainty of evidence)

There is insufficient evidence to make a treatment recommendation regarding use of digital stethoscope, audible or visible Doppler ultrasound, dry electrode technology or any other newer modalities for heart rate assessment of a newborn in the delivery room.

Auscultation with or without pulse oximetry should be used to confirm the heart rate when ECG is unavailable, not functioning or when pulseless electrical activity is suspected. (Good practice point)

Justification and Evidence to Decision Framework Highlights

In making these recommendations, the Neonatal Life Support Task Force acknowledges the following:

  • The available data suggest that ECG provides a more rapid and accurate assessment of heart rate in the delivery room when compared to any other newer modalities, but the certainty of evidence is very low.
  • Very few infants who had any of the following characteristics were included in these studies: those who were bradycardic, those requiring resuscitation as positive pressure ventilation, or extremely premature infants.
  • Evidence from ILCOR CoSTR 5201 showed that it is unclear if the level of speed and accuracy/precision of HR estimation at birth translates to clinically relevant differences in resuscitation interventions, resuscitation team performance or clinical outcomes for newborn infants.
  • Either auscultation or pulse oximetry or both have been commonly and routinely used for HR assessment in newborns at birth. In a resource limited setting, where ECG is not available, auscultation and/or pulse oximetry may serve as reasonable alternatives to ECG. HR estimation with these methods may be accurate but imprecise than ECG in the first few minutes after birth, especially in newborns who are bradycardic and are receiving resuscitation.
  • Palpation for heart rate assessment at birth is inaccurate but certainty of evidence is very low.
  • Dry electrode belt and Doppler US devices show good accuracy and speed for HR detection at birth. Larger studies which include extremely premature newborns and infants who are bradycardic and require resuscitation are needed.
  • The cost-effectiveness and effects on equity of routine use of various HR assessment methods remain unclear. Some devices are likely to be unaffordable in low resource settings.

Knowledge Gaps

There were no studies identified that evaluated time to first HR assessment from device placement with newer modalities such as digital stethoscope, audible or visible Doppler ultrasound, reflectance-mode green light photoplethysmography or transcutaneous electromyography of the diaphragm in the delivery room.

There were no studies identified that evaluated time to first HR assessment from birth with newer modalities as digital stethoscope, reflectance-mode green light photoplethysmography or transcutaneous electromyography of the diaphragm in the delivery room.

Cost effectiveness of different modalities for HR assessment in the delivery room was not assessed by any study.

The impact of different HR assessment methods on resuscitation team performance, resuscitation interventions and neonatal clinical outcomes remains uncertain.

Should the HR assessment method in the delivery room be different for a vigorous vs non-vigorous newborn who does not respond to initial steps of resuscitation?

Should the HR assessment method in the delivery room be different for newly born infants in different gestational age (<28+0 weeks, 28+0-33+6 weeks, ≥34+ 0 weeks)?

HR monitoring methods should be evaluated in newborns who received resuscitation as positive pressure ventilation at birth and/or newborns with HRECG < 100 bpm or HRECG< 60 bpm.

Attachment: NLS 5200 HR Monitoring Diagnostic Et D

References

Abbey NV, Mashruwala V, Weydig HM, Steven Brown L, Ramon EL, Ibrahim J, et al. Electrocardiogram for heart rate evaluation during preterm resuscitation at birth: a randomized trial. Pediatr Res. 2022;91(6)1445-1451.

Agrawal G, Kumar A, Wazir S, Kumar NC, Shah P, Nigade A, et al. A comparative evaluation of portable Doppler ultrasound versus electrocardiogram in heart-rate accuracy and acquisition time immediately after delivery: a multicenter observational study. J Matern Fetal Neonatal Med. 2021;34(13)2053-2060.

Bjorland PA, Ersdal HL, Øymar K, Rettedal SI. Compliance with Guidelines and Efficacy of Heart Rate Monitoring during Newborn Resuscitation: A Prospective Video Study. Neonatology. 2020;117(2)175-181.

Bland JM, Altman DG. Comparing methods of measurement: why plotting difference against standard method is misleading. Lancet. 1995;346(8982)1085-7.

Bland JM, Altman DG. Measuring agreement in method comparison studies. Stat Methods Med Res. 1999;8(2)135-60.

Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986;1(8476)307-10.

Bobillo-Perez S, Balaguer M, Jordan I, Batista-Muñoz A, Ramon M, Otero O, et al. Delivery room ultrasound study to assess heart rate in newborns: DELIROUS study. Eur J Pediatr. 2021;180(3)783-790.

Bush JB, Cooley V, Perlman J, Chang C. NeoBeat offers rapid newborn heart rate assessment. Arch Dis Child Fetal Neonatal Ed. 2021;106(5)550-552.

Cavallin F, Cori MS, Negash S, Azzimonti G, Vento G, Putoto G, et al. Heart Rate Determination in Newborns at Risk for Resuscitation in a Low-Resource Setting: A Randomized Controlled Trial. J Pediatr. 2020;22188-92.e1.

Dawson JA, Saraswat A, Simionato L, Thio M, Kamlin CO, Owen LS, et al. Comparison of heart rate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants. Acta Paediatr. 2013;102(10)955-60.

Gaertner VD, Kevat AC, Davis PG, Kamlin COF. Evaluation of a digital stethoscope in transitioning term infants after birth. Arch Dis Child Fetal Neonatal Ed. 2017;102(4)F370-f371.

Giavarina D. Understanding Bland Altman analysis. Biochem Med (Zagreb). 2015;25(2)141-51.

Henry C, Shipley L, Ward C, Mirahmadi S, Liu C, Morgan S, et al. Accurate neonatal heart rate monitoring using a new wireless, cap mounted device. Acta Paediatr. 2021;110(1)72-78.

Iglesias B, Rodrí Guez MAJ, Aleo E, Criado E, Martí Nez-Orgado J, Arruza L. 3-lead electrocardiogram is more reliable than pulse oximetry to detect bradycardia during stabilisation at birth of very preterm infants. Arch Dis Child Fetal Neonatal Ed. 2018;103(3)F233-f237.

Iglesias B, Rodríguez MJ, Aleo E, Criado E, Herranz G, Moro M, et al. [Pulse oximetry versus electrocardiogram for heart rate assessment during resuscitation of the preterm infant]. An Pediatr (Barc). 2016;84(5)271-7.

Kamlin CO, Dawson JA, O'Donnell CP, Morley CJ, Donath SM, Sekhon J, et al. Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room. J Pediatr. 2008;152(6)756-60.

Kamlin CO, O'Donnell CP, Everest NJ, Davis PG, Morley CJ. Accuracy of clinical assessment of infant heart rate in the delivery room. Resuscitation. 2006;71(3)319-21.

Katheria A, Rich W, Finer N. Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation. Pediatrics. 2012;130(5)e1177-81.

Mizumoto H, Tomotaki S, Shibata H, Ueda K, Akashi R, Uchio H, et al. Electrocardiogram shows reliable heart rates much earlier than pulse oximetry during neonatal resuscitation. Pediatr Int. 2012;54(2)205-7.

Montenij LJ, Buhre WF, Jansen JR, Kruitwagen CL, de Waal EE. Methodology of method comparison studies evaluating the validity of cardiac output monitors: a stepwise approach and checklist. Br J Anaesth. 2016;116(6)750-8.

Murphy MC, De Angelis L, McCarthy LK, O'Donnell CPF. Comparison of infant heart rate assessment by auscultation, ECG and oximetry in the delivery room. Arch Dis Child Fetal Neonatal Ed. 2018;103(5)F490-f492.

Murphy MC, De Angelis L, McCarthy LK, O'Donnell CPF. Randomised study comparing heart rate measurement in newly born infants using a monitor incorporating electrocardiogram and pulse oximeter versus pulse oximeter alone. Arch Dis Child Fetal Neonatal Ed. 2019;104(5)F547-f550.

Murphy MC, Jenkinson A, Coveney J, McCarthy LK, CPF OD. Randomised study of heart rate measurement in preterm newborns with ECG plus pulse oximetry versus oximetry alone. Arch Dis Child Fetal Neonatal Ed. 2021;106(4)438-441.

Owen CJ, Wyllie JP. Determination of heart rate in the baby at birth. Resuscitation. 2004;60(2)213-7.

Perlman JM, Wyllie J, Kattwinkel J, Wyckoff MH, Aziz K, Guinsburg R, et al. Part 7: Neonatal Resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2015;132(16 Suppl 1)S204-41.

Rettedal S, Eilevstjønn J, Kibsgaard A, Kvaløy JT, Ersdal H. Comparison of Heart Rate Feedback from Dry-Electrode ECG, 3-Lead ECG, and Pulse Oximetry during Newborn Resuscitation. Children (Basel). 2021;8(12).

Shimabukuro R, Takase K, Ohde S, Kusakawa I. Handheld fetal Doppler device for assessing heart rate in neonatal resuscitation. Pediatr Int. 2017;59(10)1069-1073.

Strand ML, Simon WM, Wyllie J, Wyckoff MH, Weiner G. Consensus outcome rating for international neonatal resuscitation guidelines. Arch Dis Child Fetal Neonatal Ed. 2020;105(3)328-330.

Treston BP, Semberova J, Kernan R, Crothers E, Branagan A, O'Cathain N, et al. Assessment of neonatal heart rate immediately after birth using digital stethoscope, handheld ultrasound and electrocardiography: an observational cohort study. Arch Dis Child Fetal Neonatal Ed. 2019;104(2)F227.

van Twist E, Salverda HH, Pas ABT. Comparing pulse rate measurement in newborns using conventional and dry-electrode ECG monitors. Acta Paediatr. 2022;111(6)1137-1143.

van Vonderen JJ, Hooper SB, Kroese JK, Roest AA, Narayen IC, van Zwet EW, et al. Pulse oximetry measures a lower heart rate at birth compared with electrocardiography. J Pediatr. 2015;166(1)49-53.

Wyckoff MH, Wyllie J, Aziz K, de Almeida MF, Fabres J, Fawke J, et al. Neonatal Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142(16_suppl_1)S185-s221.


Discussion

GUEST
Racire Silva
The use of the stethoscope is still the most used, but little by little we are becoming more accustomed to placing the electrodes when necessary.
Reply
GUEST
Rossiclei Pinheiro
We should consider that in low-income countries we do not have available EEG in primary care hospital, so auscultation with conventional stethoscope is still an option. If a pulse oximeter is available, it can be used to confirm the heart rate along side with the stethoscope, including in babies with a pulseless electrical activity where the EEG also does not work. Remembering that in deliveries outside the hospital the stethoscope is the only option for cardiac auscultation.
Reply
GUEST
Norma Suely Oliveira
We use stethoscope and cardiac monitor
Reply
GUEST
Giselda Silva
in the services where I work in the delivery room, and in most services that I know of here in Rio, the initial method of assessing heart rate in the delivery room is still the stethoscope and eventually we have oximetry in parallel, which greatly facilitates taking decisions.
Reply
GUEST
Walusa Gonçalves-Ferri
Conventional stethoscope is still an unique option in most of countries. When ILCOR recommending devices and devices to neonate ressuscitation the LMICs are being isolated of the program. Maybe, you should write a recommendation specific to countries with low resources ( 70% of the newborns in the world born in LMICs), if not the ILCOR guidelines will be attending only 30% of the births in the world.
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GUEST
Silvia Heloisa Moscatel Loffredo
Considering the expressive percentage of neonatal deaths due to asphyxia and that the systematic review showed that heart rate assessment can be obtained more quickly and accurately using the Electrocardiogram (ECG) during newborn resuscitation in the delivery room when compared to other evaluation methods, I believe that these studies will be able to instrumentalize the limited resources institution's managers, showing them that obtaining the ECG equipment to qualify asphyxiated newborn assistance may impact the reduction of expenses with treatment of complications of the asphyxia process.
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GUEST
Mohammad Abdul MANNAN
Cord pulsation (6 sec x 10) for assessing heart rate is better for both LMICs and others to avoid pulseless electrical activity (PEA) and other errors of pulse oximetry.
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GUEST
Jamie Tegart
Regardless of gestation or response to initial steps all our initial HR (heart rates) are achieved by auscultation. We do place ECG & SpO2 devices on infants who remain non vigorous after initial stimulation. ECG is definitely quicker and more accurate than pulse oxymetry for results, especially in those with a lower HR.
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GUEST
Silvia Heloisa Moscatel Loffredo
Considering the expressive percentage of neonatal deaths due to asphyxia and that the systematic review showed that heart rate assessment can be obtained more quickly and accurately using the Electrocardiogram (ECG) during newborn resuscitation in the delivery room when compared to other evaluation methods, I believe that these studies will be able to instrumentalize the limited resources institution's managers, showing them that obtaining the ECG equipment to qualify asphyxiated newborn assistance may impact the reduction of expenses with treatment of complications of the asphyxia process.
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GUEST
Jamie Tegart
Our hospital currently has access to stethoscope, pulse oximeter & ECG. For most codes, initial HR is still obtained by stethoscope as it does not require infant to be moved from Mom unless necessary. ECG monitors are brought to codes or pre-set when time allows. The use of pulse oximetry is more common if the infant is not responding to initial steps, however it is not generally accurate if the HR remains low and shouldn't be solely relied on. While more costly, increasing access to ECG monitors could allow for improved outcomes during resuscitations.
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GUEST
Marynéa Silva do Vale
the conventional stethoscope is available in most places where babies are born, including hospitals and homes. The recommendation should include this information.
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GUEST
Elene Vanderpas
If possible to be made available, an ECG monitor is most reliable for HR, along with auscultation confirmation if concerned about PEA. Pulst oximeter is much less reliable due to more chance of variable signals with decreased perfusion and limb movement. Best to apply ECG leads when commencing PPV, as HR dictates next steps as you are striving to achieve effective ventilation. Think about an adult in ER who is receiving PPV - would you not apply a cardiorespiratory monitor?
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