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Initial Oxygen Concentration for Term Neonatal Resuscitation (NLS 1554): Systematic Review

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Initial Oxygen Concentration for Term Neonatal Resuscitation

Citation

Isayama T, Dawson JA, Roehr CC, Rabi Y, Weiner GM, Aziz K, Kapadia VS, de Almeida MF, Trevisanuto D, Mildenhall L, Liley HG, Hosono S, Kim HS, Szyld E, Perlman JM, Velaphi S, Guinsburg R, Welsford M, Nishiyama C, Wyllie JP and Wyckoff MH. Initial oxygen concentration for term neonatal resuscitation [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Neonatal Life Support Task Force, November 12, 2018

Available from: http://ilcor.org

Methodological Preamble and Link to Published Systematic Review

The continuous evidence process for the production of Consensus of Science and Treatment Recommendations (CoSTR) started with a systematic review regarding oxygen use in the delivery room for term infants (Welsford M, 2018, PROSPERO CRD42018084902 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=84902) conducted by Dr. Michelle Welsford, McMaster University, Canada with involvement of clinical content experts. Evidence for neonatal literature was sought and considered by the Neonatal Life Support Task Force. These data were taken into account when formulating the Treatment Recommendations.

Systematic Review

Welsford M, Nishiyama C, Shortt C, Isayama T, Dawson JA, Weiner G, Roehr CC, Wyckoff MH, Rabi Y on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Initial Oxygen Use for Preterm Newborn Resuscitation: A Systematic Review With Meta-analysis. Pediatrics on-line Dec 21, 2018. DOI: 10.1542/peds.2018-1825

Initial Oxygen Concentration for Term Neonatal Resuscitation PICOST

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

Population: Newborn infants who receive respiratory support at birth (Term or Late preterm, ≥ 35 weeks gestation)

Intervention: Lower initial oxygen concentration

Comparison: Higher initial oxygen concentration

Outcomes:

Primary:

  • All cause short-term mortality (in-hospital or 30 days)

Secondary:

  • All cause long-term mortality (1-3 years)
  • Long-term neurodevelopmental impairment(1-3 years)
  • Hypoxic-ischemic encephalopathy (Sarnat Stage 2-3)

Study Designs: Randomized controlled trials (RCT), quasi-randomized controlled trials (qRCT), and non-randomised cohort studies were included . Excluded animal studies, unpublished studies (e.g., conference abstracts).

Timeframe: 1980 to August 10, 2018

A priori subgroups to be examined: gestational age (≥ 35 weeks, ≥37 weeks); grouped lower and higher oxygen concentrations; explicit oxygen saturation targeting vs no oxygen saturation targeting

PROSPERO Registration: CRD42018084902

Consensus on Science

For the critical outcome of all cause short-term mortality (in-hospital or 30 days), the evidence of low certainty (downgraded for risk of bias and imprecision) from 7 RCTs (and quasi RCTs) involving 1469 term and late preterm newborns (≥ 35 weeks gestation) receiving respiratory support at birth showed benefit of starting with 21% compared to 100% oxygen (RR=0.73 95% CI 0.57-0.94, I2=0%); 46/1000 fewer babies died when respiratory support at birth was started with 21% compared to 100% oxygen [95% CI: 73/1000 fewer to 10/1000 fewer] (Ramji 1993 809; Saugstad 1998 e1; Vento 2003 240; Ramji 2003 510; Bajaj 2005 206; Vento 2005 1393; Toma 2006 33).

For the critical outcome of all cause long-term mortality (1-3 years), no evidence was identified.

For the critical outcome of long-term neurodevelopmental impairment (NDI, 1-3 years) among survivors who were assessed, evidence of very low certainty (downgraded for risk of bias and imprecision) from 2 RCTs (and quasi RCTs) involving 360 term and late preterm newborns (≥ 35 weeks gestation) receiving respiratory support at birth showed no benefit or harm of starting with 21% compared to 100% oxygen (RR=1.41 95% CI 0.77-2.60, I2=0%); 36/1000 more babies with NDI when respiratory support at birth was started with 21% compared to 100% oxgyen [95% CI: 20/1000 fewer to 142/1000 more] (Saugstad 2003 e1; Bajaj 2005 206).

For the critical outcome of hypoxic-ischemic encephalopathy (Sarnat Stage 2-3) evidence of low certainty (downgraded for risk of bias and imprecision) from 5 RCTs (and quasi RCTs) involving 1359 term and late preterm newborns (≥ 35 weeks gestation) receiving respiratory support at delivery showed no benefit or harm of 21% compared to 100% oxygen (RR=0.90 95% CI 0.71-1.14, I2=8%); 20/1000 fewer babies with hypoxic-ischemic encephalopathy when respiratory support at birth was started with 21% compared to 100% oxygen [95% CI: 57/1000 fewer to 27/1000 more] (Ramji 1993 809; Saugstad 1998 e1; Ramji 2003 510; Bajaj 2005 206; Toma 2006 33).

No studies were identified that compared any intermediate oxygen concentrations.

Treatment Recommendations

For term and late preterm newborns (≥ 35 weeks gestation) receiving respiratory support at birth, we suggest starting with 21% oxygen (weak recommendation, low certainty evidence). We recommend against starting with 100% oxygen (strong recommendation, low certainty evidence).

Justification and Evidence to Decision Highlights

In making this recommendation, the Neonatal Life Support Task Force considered the following:

Parents and clinicians rate mortality as a critical outcome. Despite low certainty of the evidence, the large reduction in the primary outcome of short term mortality (NNT=22) with no demonstrated adverse effects favors use of 21% oxygen as the initial gas for resuscitation in term and late preterm newborns. Although there are no published cost data, it is likely that initiating resuscitation with 21% oxygen does not add cost and might result in cost savings compared to initial 100% oxygen in some settings. Babies born in low resource settings are disadvantaged by increased mortality and morbidity. Therefore, it is plausible that using 21% oxygen compared to 100% oxygen has greater impact in low resource settings. Use of 21% oxygen for initial resuscitation is universally feasible and is now accepted by the neonatal community world-wide.

Knowledge Gaps

  • There were relatively few late preterm (35-36 week gestation) infants in the studies. The confidence in our recommendations for this gestational age group is low. More studies are needed regarding this population
  • Does titration of oxygen to SpO2 targets impact conclusions?
  • Need data comparing intermediate oxygen concentrations
  • Does delayed cord clamping have any effect on the impact of oxygen exposure?

Attachments

EtD table: Should Low FiO2 vs. High FiO2 be used for Term Neonatal Resuscitation?

References

  • Bajaj N, Udani RH, Nanavati RN. Room air vs. 100 per cent oxygen for neonatal resuscitation: a controlled clinical trial. J Trop Pediatr. 2005;51(4):206–11.
  • Ramji S, Ahuja S, Thirupuram S, Rootwelt T, Rooth G, Saugstad OD. Resuscitation of asphyxic newborn infants with room air or 100% oxygen. Pediatr Res. 1993;34(6):809–12.
  • Ramji S, Rasaily R, Mishra PK, Narang A, Jayam S, Kapoor AN, et al. Resuscitation of asphyxiated newborns with room air or 100% oxygen at birth: a multicentric clinical trial.Indian Pediatr. 2003;40(6):510–7.
  • Saugstad OD, Rootwelt T, Aalen O. Resuscitation of asphyxiated newborn infants with room air or oxygen: an international controlled trial: the Resair 2 study. Pediatrics. 1998;102(1):e1.
  • Saugstad OD, Ramji S, Irani SF, El-Meneza S, Hernandez EA, Vento M, et al. Resuscitation of newborn infants with 21% or 100% oxygen: follow-up at 18 to 24 months. Pediatrics. 2003;112(2):296–300.
  • Toma AI, Nanea M, Scheiner M, Mitu R, Petrescu I, Matu E. Effects of the gas used in the resuscitation of the newborn in the post-resuscitation haemodynamics. Asfixia Perinatala Primul Congres National de Neonatologie. 2006: 34–44.
  • Vento M, Asensi M, Sastre J, Lloret A, Garcia-Sala F, Vina J. Oxidative stress in asphyxiated term infants resuscitated with 100% oxygen. J Pediatr. 2003;142(3):240–6.
  • Vento M, Sastre J, Asensi MA, Vina J. Room-air resuscitation causes less damage to heart and kidney than 100% oxygen. Am J Respir Crit Care Med. 2005;172(11):1393–8.


Neonatal life support
Airway and ventilation

Discussion

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ILCOR staff

(modified: )

Is there any data on how (amount and frequency) to titrate oxygen, as for example, from 21% to 40% vs 60%, if there is no response within 30 seconds?
Reply
profile avatar
ILCOR staff

(modified: )

No unfortunately there are no data available to guide titration. This is an area which needs more research. Part of the difficulty is that good trials which inform this question were performed at a time when use of saturation monitoring was less prevalent. Similarly there is no data to compare other starting concentrations of oxygen.
profile avatar
ILCOR staff

(modified: )

Completely agree.
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profile avatar
ILCOR staff

(modified: )

Thank you
profile avatar
ILCOR staff

(modified: )

Timely article. Ebp has been proving this.
Reply
profile avatar
ILCOR staff

(modified: )

Agree with findings of study.
Reply
profile avatar
ILCOR staff

(modified: )

If you think about the lung maturation of a term/late preterm, the majority will have some surfactant production in place, So starting at 21% seems logical. You may want to start a higher if your infant has other risk factors such as diabetic mother, meconium-stained fluid, or hypolplastic lungs.
Reply
profile avatar
ILCOR staff

(modified: )

You may want to do this but whilst there may be theoretical advantages to such an approach we need to be aware that they are unproven. Therefore for this international CoSTR we could not recommend such an approach in the absence of evidence to support it. Guideline authors, or institutions may choose to alter approaches for specific groups. If they do it would be helpful to publish results.
profile avatar
ILCOR staff

(modified: )

Please suggest the source of the cost savings with 21%.
Reply
profile avatar
ILCOR staff

(modified: )

Thank you. This was not the focus of the PICOST and there is insufficient data to define this. It will in fact vary according to the current clinical practice and level of resources available. If BVM is used in a low resource setting the cost of 21% is zero. However, if T-piece is used and piped air is required the cost may be significant. It will need institutions or health economies to look at this locally.
profile avatar
ILCOR staff

(modified: )

We are a low resource setting and I we use 21% oxygen and increase as needed depending on the needed of the resuscitation and use of O2 sat.
Reply
profile avatar
ILCOR staff

(modified: )

Agree with recommendation for starting with Room Air oxygen for Term Neonates. As a practicing Neonatologist have following this recommendation for term newborns for the past 10 years and now we have definite science to show that is good practice to start resuscitation in term newborn with room air
Reply
profile avatar
ILCOR staff

(modified: )

Thank you
profile avatar
ILCOR staff

(modified: )

Usually just ensuring adequate ventilation with a lower oxygen concentration is enough to transition the baby unless there is something else going on. Trouble shooting and making sure that you are adequately ventilating works. People seem to want to jump to the next step and next step when the first is not being done properly. And sometimes this can lead to invasive procedures with poor results. The most important thing is using good judgement as you proceed.
Reply
profile avatar
ILCOR staff

(modified: )

We agree absolutely that ensuring adequate ventilation is essential although this PICOST and the studies included did not specifically address and report on the adequacy of ventilation.
profile avatar
ILCOR staff

(modified: )

The ILCOR draft recommendations are consistent with the evidence and form the basis for valuable guidelines across the globe. The knowledge gaps identified are important areas for future study. Effects of Oxygen administration with delayed cord clamping and titration to pre-ductal SpO2 targets.
Reply
profile avatar
ILCOR staff

(modified: )

Dear Highly Respected Committee members, Present resuscitation practices are OK for full term babies who are mildly sick/ almost well babies. It is not acceptable in moderate to severely ill babies those are limp, moderate to severe respiratory distress, cyanotic and gasping for oxygen. They deserve fast track resuscitation that means use higher oxygen concentration, use Neo Puff/ PPV to make them better quickly and to achieve normal oxygen saturation ( 95-100% ) within 1 minute ( not 10 minutes ) and reduce the oxygen supply as soon as reaches normal oxygen saturation. In first 30 seconds, we can dry, stimulate, minimal suction and give oxygen at the same time. Newborn babies brain needs 3-4 mL of oxygen per 100 g of brain tissues per minute ( Ex: 3 kg baby needs about 9-12 mL of oxygen per minute considering brain weighs 300 g that is 10% of body weight). Besides other organs need oxygen as well. Waiting, watching, and monitoring pulse oxymetry and keeping them blue for 10 minutes are simply harming newborn babies brain, destroying their future and at least putting children behind the class. Pulse oxymetry don't pick up normal saturation for couple of minutes for poor perfusion in sick babies. We must prevent brain damages by all means. Honestly I see billions of dollars future litigation in USA and other countries against our respected organization. Litigation already started by individual lawyers in USA against the institution and got millions of dollars in each cases. We must protect our organization as well as our children. They are the future. I hope that we take this matter very seriously. In USA, EX Fed chairman Dr. Greenspan said : " No institution is too big to fail ". It is my utmost request to all of you to make them better ASAP.
Reply
profile avatar
ILCOR staff

(modified: )

Can you cite any references for your assertion that pox should be that high that early? Well newborns (spontaneously breathing, cord intact, skin to skin with their mother) in normal (physiologic) transition to extrauterine life do not have oxygen saturations of >95% at one minute and sometimes not at 5 minutes.
profile avatar
ILCOR staff

(modified: )

Thank you for your comments. Your assertions about the brain requirements for oxygen are interesting but not born out by pragmatic randomised controlled trials comparing 21% vs 100%. The recommendation does not advocate maintaining hypoxic for 10 minutes in any circumstance. In fact it is a recommendation for concentration at which to commence resuscitation. ILCOR and the neonatal group exist to examine evidence for practice in terms of resuscitation. Certainly more evidence is required to hone recommendations and improve care but we must guard against implementing change based upon mere unproven opinion be it medical or legal. In the past that approach has led to serious harm in neonatology. This PICOST addressed the evidence for the initial oxygen concentration at which to commence resuscitation of the newborn.
profile avatar
ILCOR staff

(modified: )

Continued research in this area is important Agree with current recommendation
Reply
profile avatar
ILCOR staff

(modified: )

I agree with the recommendations.
Reply
profile avatar
ILCOR staff

(modified: )

I agree
profile avatar
ILCOR staff

(modified: )

I agree that starting at 21% is reasonable for most term infants. How ever I am quick to move to much higher FIO2 if the infant does not respond in 30 to 60 sec...I do not wait minutes for HR perfusion color pulse ox to improve....in that I agree with guest..Debasis Kanjilal
Reply
profile avatar
ILCOR staff

(modified: )

This recommendation does not prevent that approach as it was not addressed by the PICOST. However, there is no evidence in terms of the outcomes assessed to either support or refute the approach you suggest. It is interesting that in the RESAIR studies as many babies were switched to air from 100% oxygen as the reverse. However, those studies were not performed in the era of widespread saturation assessment. It may be that more data will become available on HR response with the wider use of ECG.
profile avatar
ILCOR staff

(modified: )

I agree with the recommendations.
Reply
profile avatar
ILCOR staff

(modified: )

I accept the information and the recommendations and will practice accordingly until there is evidence to the contrary.
Reply
profile avatar
ILCOR staff

(modified: )

In my experience in the delivery room, I did not notice any worsening of survival or morbidity in those patients when I started resuscitation with room air.
Reply
profile avatar
ILCOR staff

(modified: )

I believe very much in the recommendations of ILCOR. We have indeed observed that neonates respond very well to cardiorespiratory resuscitation even without the use of supplemental oxygen and, when necessary, low inspired fractions of O2. I observe that positive expiratory pressure is more effective than increases in the inspired fraction of O2.
Reply
profile avatar
ILCOR staff

(modified: )

The difference in mortality is compelling. Starting with 21% FiO2 in mildly depressed term neonates with in-utero primary apnea is reasonable. In moderate to severely compromised term infants who suffered from secondary apnea in-utero, starting with slightly higher FiO2, like 30%-40% may be prudent and needed in order to reverse the process of severe hypoxia and persistent R-L shunting. It may be increased thereafter as per the improvement, assessed q 15-30 seconds. A good FRC established with the use of adequate positive pressure breaths may decrease the need of high FiO2. Judgement must be used about escalating FiO2 to 100%, as severely depressed moribund term babies in imminent threat of death may be difficult to reverse and need it. Such cases are also most susceptible to medicolegal liability. Use of 100% oxygen should not be completely ruled out. Establishing optimum perfusion is critical to assure expected response from PPV/FiO2 supplementation.
Reply
profile avatar
ILCOR staff

(modified: )

Thank you as in my comments above: this recommendation does not rule out increasing the concentration of oxygen as it refers to the starting concentration. Your suggestion of starting at 30-40% in secondary apnoea and subsequent increases is interesting but there is no evidence to support or refute such an approach. We are therefore not able to comment upon this in our recommendation.
profile avatar
ILCOR staff

(modified: )

The use of supplemental oxygen in the assistance to term and preterm newborn at birth with FiO2 of 21% is feasible, reduces costs and improves some neonatal outcomes.
Reply
profile avatar
ILCOR staff

(modified: )

Thank you. If you have good evidence for the relative costs in your own working environment that would be helpful if published.
profile avatar
ILCOR staff

(modified: )

Completely agree, in most cases term newborn need just pressure, not oxygen!
Reply
profile avatar
ILCOR staff

(modified: )

I agree that starting at 21%.
Reply
profile avatar
ILCOR staff

(modified: )

I agree with the recommendation and I firmly believe most of my insecurities are being taken away with the fact that they do recover quite well, in the majority, when we do all the steps in the program. Sometimes I do fell a bit of doubt when we have vigorous, but cyanotic babies.
Reply
profile avatar
ILCOR staff

(modified: )

I agree with the recommendation
Reply
profile avatar
ILCOR staff

(modified: )

I agree that beginning with 21% O2 is appropriate for the newborn born at 35+ weeks gestation. The goal is to support initiation of spontaneous respiration and closure of the ductus arteriosus. The current NRP guidelines are very clear that when 21% is not effective, one can transition to a higher percentage of O2. It would be useful to provide information on the normal range of O2 saturation of the well fetus to highlight that this is a period of transition, best supported with an intact cord (https://www.nature.com/articles/jp2016151 and https://www.frontiersin.org/articles/10.3389/fped.2017.00001/full) to assure a gradual increase in oxygenation and blood volume while respirations are being established. This is consistent with providing 21% O2 in the first 30 seconds of respiratory support. The resilient neonate will typically respond in the first 30 seconds, and when continued respiratory support is required, titration O2 levels is appropriate, based on heart rate or SPO2 levels. Including information on underlying physiology is very helpful to support continued learning for those providing neonatal resuscitation, and to illustrate why 21% O2 is appropriate. Use of 21% O2 also would allow for initial PPV at the field during cesarean with a sterile bag-valve-mask device, while maintaining an intact cord during initiation of respirations.
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profile avatar
ILCOR staff

(modified: )

I agree with the recommendations to start in 21% oxygen as most infants will transition with good airway management, may be there could be some suggested guidance as to when you would consider increasing the oxygen concentration.... e.g. at time of starting chest compressions?
Reply
profile avatar
ILCOR staff

(modified: )

Thank you. Unfortunately the PICOST only addressed the initial oxygen concentration at which to commence resuscitation. In 2015 the timing of any increase in concentration was addressed and there was no human and conflicting animal data. It was a consensus agreement that it was reasonable to increase the concentration of oxygen if the heart rate did not respond to adequate ventilation and should be increased if compressions were commenced if it had not occurred before. More evidence is of course required
John Mouw
(5 posts)

(modified: )

I agree with the recommendations of starting at room air, 21%.
Reply
profile avatar
ILCOR staff

(modified: )

Starting with 21% O2 is reasonably the best approach, but I usually increase O2 concentration if the baby does not respond with an increase in heart rate in 15-20 seconds. Most babies react well rapidly and I do not believe that few seconds of O2 at higher-than-normal concentration can be harmful for their future. The problem is different when infants DO NOT respond rapidly and are moderately to severely asphyxiated: should we increase O2 to...what? In this case, reperfusion injury should always be kept in mind, as a consequence of too much O2
Reply
profile avatar
ILCOR staff

(modified: )

I agree the current recommendation.
Reply
profile avatar
ILCOR staff

(modified: )

I agree with findings of study.
Reply
profile avatar
ILCOR staff

(modified: )

In our low clinically resourced setting with 100 deliveries per day - we use room air to start resus - if compressions we use oxygen concentrator. If the power is off we have no oxygen concentrator - Just bag and mask on room air. Most babies respond well initially. Very sick babies - Moderate to severe birth asphyxia we only have low oxygen available. We practice delayed cord clamping and start resus at the mother on her chest Immediately including when starting compressions - we do not wait to clamp & cut cord - the baby requires the vital extra few minutes of blood to help in the ongoing care and neonatal outcomes both in the initial stages of resus and beyond. Assists with thermoregulation as well because if power is off we have no heater.
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ILCOR staff

(modified: )

As per Jan's comments above and in-conjunction with the recommendations for commencing and continuing 21% O2 during resuscitation - I agree.
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ILCOR staff

(modified: )

Agree with starting in Air in term and near term infants Problem is it gets turned up slowly or not at all.... I would suggest if starting CPR t turn I up to 100% and then titrate down if Sats >95%
Reply
profile avatar
ILCOR staff

(modified: )

Thank you. Your point is well made and really needs to be addressed by: 1. Evidence that of slow increase perhaps from video assessments which are more common now. 2. Regional guidelines to address this pragmatic problem. Whilst your approach is understandable there is no evidence to support it at resent and this PICOST was only addressing initial oxygen concentration. As some others have suggested, when more evidence is available, we need to address issues such as increasing and weaning oxygen concentrations.
profile avatar
ILCOR staff

(modified: )

I certainly agree with recommendation for starting with Room Air oxygen for Term Neonates. As a Neonatologist have following this recommendation for term newborns since NRP 5th edition was released, and now we have definite science to show that is good practice to start resuscitation in term newborn with room air. Oxygen free radicals can cause much more harm, than transient hypoxia.
Reply
profile avatar
ILCOR staff

(modified: )

I agree with the recommendations.
Reply
profile avatar
ILCOR staff

(modified: )

Thank you for the review. It would be useful to have specific comments on populations that are expected to have high mortality, such as congenital diaphragmatic hernia. Many guidelines (example - see citation) comment on risks, but do not provide specific guidance. Snoek KG, Reiss IK, Greenough A, Capolupo I, Urlesberger B, Wessel L, Storme L, Deprest J, Schaible T, van Heijst A, Tibboel D; CDH EURO Consortium. Standardized Postnatal Management of Infants with Congenital Diaphragmatic Hernia in Europe: The CDH EURO Consortium Consensus - 2015 Update. Neonatology. 2016;110(1):66-74. doi: 10.1159/000444210. Epub 2016 Apr 15. PubMed PMID: 27077664.
Reply
Chris McKinlay
(1 posts)

(modified: )

Thanks to the authors of this statement. It would be helpful to mention if any studies used pulse oximetry and saturation targeting, and how many babies who were commenced in air required oxygen. I think the recommendation should say something like "consider subsequent supplemental oxygen, titrated using pulse oximetry, if the baby's condition does not improve following initial resuscitation measures."
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profile avatar
ILCOR staff

(modified: )

I agree with the findings of the study. I find very few term babies need more than 21% oxygen.
Reply
profile avatar
ILCOR staff

(modified: )

Thank you for the review. Our work with ECEB has a big task of encouraging delayed cord clamping, while starting resuscitations. This is the biggest resistance I find when working globally, including the global north. There could be inclusive diagrams of babies being resuscitated on the maternal abdomen, for fast recovery within the golden minute. I have gotten into the 'teaching habit' of timing how long it takes for providers to 'cut and tie' the cord. This exercise while adding a lot of humor to class, also adds reality for the providers responsible for resuscitation. The lengthy time taken to cut/tie makes an impression and reinforces that starting the stimulation, bag and mask (after suctioning if that is indicated), can be done so effectively with room air, on maternal abdomen, while calling for help, hoping that an additional set of hands shows up to assist when it is time to cut the cord, or change location for better access to surveillance and continued care.
Reply
profile avatar
ILCOR staff

(modified: )

I agree with the recommendations of starting at room air, 21%.
Reply
profile avatar
ILCOR staff

(modified: )

Thank you for the review. I agree with the recommendation.
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ILCOR staff

(modified: )

My humble request to you all: Report from 195 countries suggest children are suffering from hypoxia during birth and suffering from brain damages and exponential rise of Autism PLEASE SAVE THE CHILDREN IN THIS WORLD NOW AND MAKE A BETTER WORLD FOR TOMORROW . NEWBORN BLUE BABIES HAVE BEEN SUFFERING FROM HYPOXIA ( LOW OXYGEN ) INJURIES TO THEIR BRAIN, BEGAN IN 2006 AND MUST END NOW. THE TIME HAS COME TO CHANGE THE NRP/ILCOR/ANZCOR/ EUROPEAN NEWBORN RESUSCITATION COMMITTEES GUIDELINES IMMEDIATELY # REPORT FROM 195 COUNTRIES ( FROM 1990 TO 2015 ) ; GLOBAL BURDEN OF DISEASES ( GBD ) AND DEATHS FROM PRETERM BIRTH COMPLICATIONS, LOWER RESPIRATORY INFECTIONS, BIRTH ASPHYXIA, TRAUMA, CANCERS AND EXPONENTIAL RISE OF AUTISM. 90% newborn babies are pink within 1 minute. Why remaining 10% will suffer ? We are supposed to help them in the delivery room. # Care for Autism and Other Disabilities — A Future in Jeopardy ( USA ) http://jamanetwork.com/journals/jamapediatrics/fullarticle/2613463?utm_medium=alert&utm_source=JAMA%20PediatrPublishAheadofPrint&utm_campaign=03-04-2017 http://jamanetwork.com/journals/jamapediatrics/fullarticle/2613461?utm_medium=alert&utm_source=JAMA%20PediatrPublishAheadofPrint&utm_campaign=03-04-2017 http://www.nejm.org/doi/full/10.1056/NEJMp1700697?query=pediatrics
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profile avatar
ILCOR staff

(modified: )

I am sorry but I am unable to follow your reasoning or indeed the point you are trying to make. Are you suggesting that the guidelines and evidence evaluated and presented is incorrect? You seem to be suggesting that guidelines are harming although the papers you quote actually show reduced neonatal, childhood and adolescent death and morbidity. However, the reduction in neonatal issues was less than in other age groups, but is was still an improvement. I am not clear how our evaluation of the evidence in this PICOST can change that fact but implementation of evidence based guidelines must be the correct way forward?
profile avatar
ILCOR staff

(modified: )

I agree with the recommendations of starting at room air, 21%.
Reply
profile avatar
ILCOR staff

(modified: )

I agree. The majority of late premature and term infants with indication of ventilation with positive pressure, improve with increasing residual capacity without the use of oxygen in high concentrations.
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profile avatar
ILCOR staff

(modified: )

I agree with your treatment recommendations for term and late preterm newborns (≥ 35 weeks gestation).
Reply
profile avatar
ILCOR staff

(modified: )

Thank you for all the interaction and the many comments.
Reply
profile avatar
ILCOR staff

(modified: )

Having attended thousands of deliveriesband being a national NRP instructor, I'm of the opinion that room air is physiological and works absolutely fine. Single most important event is ventilating the lungs and in resource poor settings, where the burden of neonatal resuscitation is really huge, it makes sense to come up with a feasible guideline. Room air should be made the norm without any ambiguity.
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