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Neonatal CPR: How to Perform CPR on a Newborn Child

neonatal cpr

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July 22, 2022

Table of Contents

Newborn babies refer specifically to human infants in the first minutes to hours after birth. According to the American Heart Association, infancy includes the neonatal period and extends through 12 months. During the first 28 days of life, an infant is called a “neonate.” The Neonatal period is the most vulnerable time for a child’s survival. Here’s everything you need to know about neonatal CPR.

When a newborn infant does not start breathing spontaneously after birth, Cardiopulmonary Resuscitation is performed . The Newborn Resuscitation procedure provides oxygen, stimulates breathing, and gets the heart to start pumping normally. Although the Neonatal Resuscitation guidelines focus on newly born infants, most principles apply throughout the neonatal period and early infancy. 

Physiology of a Newborn 

At birth, the newborn infants’ lungs are filled with fluid. They are not inflated. The baby takes the first breath about 10 seconds after delivery. This breath sounds like a gasp as the newborn’s central nervous system reacts to the sudden change in temperature and environment. After delivery, the newborn begins to lose heat. Receptors on the baby’s skin send messages to the brain that the baby’s body is cold. The baby’s body creates heat by burning stores of brown fat, a type of fat found only in fetuses and newborns. As a result, newborns are rarely seen to shiver.

neonatal cpr

What is Neonatal Resuscitation?

Neonatal CPR or Newborn Resuscitation is performed if an infant does not breathe spontaneously immediately after birth. Neonatal Resuscitation will provide oxygen, stimulate the newborn’s breathing, and get the heart to start pumping normally.

Most newborns start breathing on their own and need only routine neonatal care. Approximately 10% of newborns require assistance transitioning from fetus to newborn, and about 1% require extensive resuscitative measures. Premature infants and infants with certain congenital conditions require extensive Resuscitation. For premature infants, an intensive care unit is needed to avoid rapidly giving volume expanders. 

How to Perform CPR on a Newborn Child

CPR is initiated if the human infant’s heart rate remains below 60 BPM after 30 seconds of PPV (Positive Pressure Ventilation ). Neonatal PR involves intubation, continuous chest compressions, and administering medications that increase in heart rate.

Preparation

The two most essential components of successful neonatal Resuscitation are readiness and the capability to handle a potential emergency during delivery. In a prospective interventional clinical study, a video-based debriefing was associated with improved preparation and adherence to the Neonatal Resuscitation Algorithm’s initial steps. In addition, improved PPV quality, team function, and communication were associated with improved team communication and short-term clinical outcomes, such as decreased intubation and increased frequency of normothermia on admission to the neonatal intensive care unit.

It’s also vital to identify perinatal risk factors, assign roles to team members, and prepare and check equipment such as the following:

  • At least one person skilled in the initial steps of neonatal Resuscitation, including giving PPV, should attend at every birth. 
  • Additional medical personnel with the ability to do a complete resuscitation should be rapidly available even without specific risk factors. 
  • A team of 4 or more healthcare providers may be required for a complex resuscitation. Depending on the risk factors, it may be appropriate for the entire resuscitation team to be present before the birth.
  • A hat, thermal mattress, and plastic bag or wrap should be used for premature infants < 32 weeks gestation.

neonatal cpr intubation

Intubation

Intubation in a newborn involves inserting a thin, flexible tube into the trachea directly. The endotracheal tube will help keep the airway clear and open and directly delivers oxygen to the lungs. A newborn will need intubation in the following situations:

  • Ineffective bag-mask ventilation
  • Before performing chest compressions
  • Prolonged need for effective ventilation
  • To administer medications
  • Suspected congenital hernia in the diaphragm

Positioning

Newborn infants must be placed supine or lying on their side, with the head in a neutral position or slightly extended. If respiratory efforts are present but it doesn’t produce effective and adequate ventilation, the airway is often obstructed. Therefore, immediate measures must be made to remove secretions. A blanket or towel under the shoulders may help maintain proper head position.

Ventilation

The key to successful Neonatal Resuscitation is the establishment of adequate ventilation. Adequate ventilation results in a rapid increase in heart rate.

Most newborn infants who need positive-pressure ventilation can be adequately ventilated with a bag mask ventilation. Based on clinical study, indications for positive-pressure ventilation include apnea or gasping respirations, heart rate <100 bpm, and persistent central cyanosis despite 100% oxygen.

Reversal of hypoxia, acidosis, and bradycardia depends on good inflation of fluid-filled lungs with air or oxygen. Although 100% oxygen has been used traditionally for rapid reversal of hypoxia. Biochemical and preliminary evidence from clinical studies argues for Resuscitation with lower oxygen concentrations. 

neonatal cpr

Chest compressions

After PPV or Positive Pressure Ventilation with intubation for 30 seconds, if the newborn’s heart rate remains below 60 BPM, continuous chest compressions must be performed. Ideally, the Neonatal CPR cycle consists of three chest compressions to one breath from the ventilator at the rate of 90 compressions per minute to 30 breaths per minute. 3:1 ratio for 120 total events per minute comprising a single set of compressions and adequate ventilation. The respiration, increase in heart rate, and infant color is evaluated every 60 seconds. In doing chest compressions, you should remember 

  • Compressions must be performed on the lower third of the breastbone (sternum). 
  • Continuous chest compressions are given using thumbs with the fingers encircling the chest.
  • The compression depth is one-third of the anterior-posterior diameter of the chest. 

High-quality chest compression is essential during neonatal cardiopulmonary Resuscitation (CPR). The 3:1 is superior to a 15:2 ratio in a newborn manikin model in terms of quality of chest compressions and the number of adequate ventilation. More consistent compression depth over time was achieved with 3:1 as opposed to the other ratios. Thus, the 3:1 ratio is appropriate for newly born human infants requiring Resuscitation.

Newer methods of chest compression using sustained inflation that maintains lung inflation while providing chest compressions at the rate of 90 compressions per minute (3:1 ratio for 120 total events per minute) are under investigation and cannot be recommended outside research and clinical studies. Outcomes vary between neonatal studies, and there has been no comprehensive investigation of differences in the Sustained Inflations approach and study outcome in pre-clinical and clinical studies.

Medications

Medications are administered if the newborn’s heart rate remains below 60 BPM after chest compressions and effective ventilation while continuing with the next cycle of newborn Resuscitation. The recommended medications include epinephrine to increase the heart rate and blood pressure, a saline solution to increase the blood volume, or O-negative packed red blood cells to supplement red blood cells in case of blood loss. These medications may be administered through the endotracheal tube into the lungs or intravenously through an umbilical catheter.

neonatal cpr

What are the immediate steps post-resuscitation?

After successful Resuscitation, the newborn is continuously monitored to ensure normal vital signs. Human infants who sustain spontaneous breathing and heart rates above 100 BPM with initial steps of CPR are placed close to their mother and kept under observation.

Extremely premature infants and babies who undergo PPV and more extensive Resuscitation will need post-resuscitation care which may include the following:

  • Once the lungs and heart have functioned, mechanical ventilation may be continued for a period.
  • Glucose, electrolytes levels, and fluids are monitored and maintained with an appropriate infusion of glucose and fluids to achieve an average balance (homeostasis).
  • Extremely premature infants and newborns who need continued intensive care are moved to a remote neonatal intensive care unit for further care.

What is Neonatal Mortality?

Human infants face the highest risk of dying in their first month of life. The number of resident newborns in a specified area dying at less than 28 days of age is called neonatal mortality. Early neonatal mortality refers to death before seven days, and late neonatal mortality refers to death on days 7-28. Neonatal mortality is often used as an indicator of the quality of neonatal care without consideration of their many limitations

In 2020, there’s an average global neonatal mortality rate of 17 deaths per 1,000 live births. Globally, 6,500 neonatal deaths every day, with about a third of all neonatal mortality death occurring within the first day after birth and close to three-quarters occurring within the first week of the infant’s life. In addition, there is a dramatic difference in survival for premature infants depending on where they are born. For example, more than 90% of extremely premature infants born in low-income countries die within the first few days after birth, yet less than 10% of premature infants die in high-income settings.

Key Takeaways

About 10% of infants require help to begin breathing at birth, and 1% need intensive Resuscitation. Therefore, when providing chest compressions to a newborn, it may be reasonable to deliver three compressions before or after each inflation: providing 30 inflations and 90 compressions per minute (3:1 ratio for 120 total events per minute).

Healthcare providers should follow the Neonatal Resuscitation guidelines and the most recent American Academy of Pediatrics and the American Heart Association recommendations. Here are some key takeaways from this post

  • For newborns who do not need Resuscitation, delaying cord clamping for more than 30 seconds reduces anemia, especially in preterm infants.
  • For premature infants, an intensive care unit is needed to avoid rapidly giving volume expanders. 
  • No routine suctioning is helpful, even for non-vigorous newborns delivered through meconium-stained amniotic fluid.
  • If CPR is required, electrocardiography should monitor heart rate as soon as possible.
  • Adequate and effective ventilation should be started in newborns who are gasping, apneic, or have a heart rate below 100 beats per minute by 60 seconds.
  • The respiration, heart rate increase, and infant color are evaluated every 60 seconds.
  • Avoid using sustained inflation while providing chest compressions at 90 compressions per minute. (3:1 ratio for 120 total events per minute)
  • The 3:1 ratio is recommended for neonatal CPR to provide effective and adequate ventilation.