ARTICLE
Post-Resuscitation Care for Neonates Receiving
Positive Pressure Ventilation at Birth
AUTHORS: Olusegun Akinloye, MD,a Colleen O’Connell,
PhD,b Alexander C. Allen, MD,a,b and Walid El-Naggar, MDa
aDivision of Neonatal Perinatal Medicine, Department of
Pediatrics, and bPerinatal Epidemiology Research Unit,
Departments of Obstetrics & Gynecology and Pediatrics,
Dalhousie University, Halifax, Canada
KEY WORDS
resuscitation, positive-pressure ventilation, infant, birth
ABBREVIATIONS
NRP—Neonatal Resuscitation Program
PPV—positive pressure ventilation
PRC—postresuscitation care
REB—Research Ethics Board
SNCU—special (intermediate/intensive) neonatal care unit
Dr Akinloye was involved in study design, REB approval, data
review, and manuscript first drafting; Dr O’Connell was involved
in data collection and interpretation, study design, and
statistical analysis; Dr Allen was involved in study design, data
review, and manuscript review; Dr El-Naggar was involved in
study design, supervision for REB approval, data review, and
manuscript preparation; and all authors approved the final
manuscript as submitted.
www.pediatrics.org/cgi/doi/10.1542/peds.2014-0554
doi:10.1542/peds.2014-0554
Accepted for publication Jul 28, 2014
Address correspondence to Walid El-Naggar, MD, IWK Health
Centre, Dalhousie University, 5850/5980 University Ave, PO Box
9700, Halifax, NS, Canada B3K 6R8. E-mail: walid.el-naggar@iwk.
nshealth.ca
WHAT’S KNOWN ON THIS SUBJECT: Infants who require positive
pressure ventilation at birth are considered to be at risk for
subsequent compromise and are recommended to receive
postresuscitation care. The supportive evidence and details of
this care have not been fully investigated.
WHAT THIS STUDY ADDS: We investigate the need for
postresuscitation care in infants who require positive pressure
ventilation at birth, review the aspects of care needed, and
explore the important risk factors most predictive of it.
abstract
OBJECTIVES: To investigate if postresuscitation care (PRC) is indicated
for all infants $35 weeks’ gestation who receive positive pressure
ventilation (PPV) at birth, explore the aspects of this care and the
factors most predictive of it.
METHODS: Our hospital admits any infant who requires PPV at birth
to special (intermediate/intensive) neonatal care unit (SNCU) for observation for at least 6 hours. All infants $35 weeks’ gestation born between 1994 and 2013, who received PPV at birth, were reviewed. We
examined perinatal factors that could predict the need for PRC after
short (,1 minute) and prolonged ($1 minute) PPV, admission course,
neonatal morbidities, and the aspects of care given.
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2014 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated
they have no potential conflicts of interest to disclose.
RESULTS: Among 87 464 infants born, 3658 (4.2%) had PPV at birth
with 3305 (90%) admitted for PRC. Of those, 1558 (42.6%) were in the
short PPV group and 2100 (57.4%) in the prolonged PPV group. Approximately 59% of infants who received short PPV stayed in the SNCU
for $1 day. Infants who received prolonged PPV were more likely to
have morbidities and require special neonatal care. Multiple logistic
regression analysis revealed the risk factors of placental abruption,
assisted delivery, small-for-dates, gestational age ,37 weeks, low
5-minute Apgar score, and need for intubation at birth to be independent predictors for SNCU stay $1 day and need for assisted ventilation, central lines, and parenteral nutrition.
CONCLUSIONS: Our data support the need for PRC even for infants
receiving short PPV at birth. Pediatrics 2014;134:e1057–e1062
PEDIATRICS Volume 134, Number 4, October 2014
e1057
Approximately 10% of newborn infants
require some assistance to begin breathing at birth; ,1% require extensive
resuscitative measures.1–3 Infants who
require resuscitation at birth (have
depressed breathing, activity, and/or
require supplemental oxygen) are recommended to be transferred to an environment where close monitoring and
anticipatory care can be provided once
adequate ventilation and circulation
have been established.4,5 There is no
clear distinction in the Neonatal Resuscitation Program (NRP) guidelines
between those who receive short period
of positive pressure ventilation (PPV) at
birth and those who require prolonged
and more extensive resuscitation in
terms of the postresuscitation care
(PRC) needed. The nature and duration
of this PRC may vary significantly after
different degrees of perinatal depression. Although some of these infants can
be at high risk for further deterioration,
others may be able to receive routine
neonatal care.4,6 Indiscriminate inclusion of initially depressed low risk
infants in the general NRP recommendation for the need of PRC may cause
unnecessary separation of the infants from their mothers, compromise bonding and breastfeeding, and
increase parents’ anxiety. In addition,
the high number of resulting admissions of term and late preterm infants for PRC can add a significant
burden to hospital resources and health
care system.
Because the policy of our institution has
been to admit all infants who require
PPV at birth for observation in a special
care unit for at least 6 hours, we were in
a position to audit this practice and
explore the details of the care required.
OBJECTIVES
The main objectives of this study were to
investigate if PRC is indicated for all
infants $35 weeks’ gestation who receive PPV at birth, explore the aspects
e1058
AKINLOYE et al
of the care needed, and characterize
the perinatal risk factors most predictive of the need for this care.
We hypothesized that not all of these
infants need to be admitted to the
neonatal special care unit after restoration of their cardiorespiratory status
in the delivery suites.
METHODS
Study Design and Population
This retrospective study was conducted
by reviewing the database of all infants
born at the IWK Health Centre between
April 1994 and December 2013 at a gestational age $35 weeks. All infants who
received PPV at birth were identified.
Those with recognized major congenital
anomalies were excluded. We defined
PPV as any resuscitation intervention at
birth that provided intermittent PPV. In
this study, PPV was described as “short”
if it was less than 1 minute in duration
and “prolonged” if it was provided for
$1 minute. We examined maternal and
infant characteristics, delivery, and resuscitation data, as well as the admission course, neonatal morbidities, and
the level of care given.
The IWK Health Centre is a tertiary referral center in Nova Scotia, Canada,
with ∼5000 annual birth rate and 1000
NICU admissions. In our hospital, all
healthy infants who are born at $35
weeks’ gestation receive routine neonatal care while staying with their
mothers in the Family and Newborn
Unit. The medical care in this unit is
given by the family physicians rather
than pediatricians. The nurses there,
being busy with the care of postpartum
mothers and their healthy infants,
cannot provide close observation for
those infants who require PRC. After
conducting an audit and considering
the nature of newborn care given in
our institution, a policy of admitting all
newborn infants who require PPV
at birth to special (intermediate/
intensive) neonatal care unit (SNCU)
for observation for at least 6 hours was
established. This practice aimed at
optimizing the PRC of the at-risk infants
and was reinforced by the recent NRP
guidelines.
Delivery room resuscitation practice in
our hospital is as follows: For low risk
deliveries, a designated NRP-certified
obstetrical nurse provides the infant’s
care. High risk deliveries are attended
by an “Alpha Team” which is composed
of an experienced NICU nurse and respiratory therapist and/or by “Beta
Team” if there is a need for backup or
in situations requiring more senior
and experienced individuals as neonatal nurse practitioners, NICU fellows,
or neonatologists.
The decision to provide PPV at birth is
made by the team leader and is based
on NRP guidelines (if the infant has
apnea, gasping breathing, or heart rate
,100 beats per minute after 30 seconds of positioning, stimulation, and
clearing the airway). A resuscitation
record is usually completed by the
team leader and becomes part of the
patient’s permanent chart. All perinatal data are collected by trained dedicated database abstractors.
This study was approved by the Research Ethics Board Committee of the
IWK Health Centre.
Source of Data Collection
Study data were obtained from Nova
Scotia Atlee Perinatal Database, which
is a comprehensive and validated
population-based provincial electronic
storage system that collects maternal
and newborn information at the time of
discharge. Variables recorded in the
Nova Scotia Atlee Perinatal Database
include demographic maternal and
newborn data, medical conditions, labor and delivery events, procedures
and interventions, and maternal and
newborn morbidity and mortality for
all pregnancies and births occurring
among Nova Scotia residents. A data
ARTICLE
quality assurance program, data abstraction studies, and a validation study
have shown the data to be of high
quality.7
Statistical Analysis
Descriptive statistics was used for clinical characteristics of the population
with representation as mean (+/2SD)
or median (range). Significance was
defined as P , .05. x2 and Fisher’s
exact tests were used to compare
categorical variables in the groups.
Multiple logistic regression analysis
was performed to determine the factors predictive for the need of long
($1 day) SNCU stay, as well as different neonatal morbidities. Statistical
analysis was performed by using SPSS
version 14.0 (IBM SPSS Statistics, IBM
Corporation).
RESULTS
Of 87 464 infants born at the IWK Health
Centre during the 20-year study period,
3658 (4.2%) had PPV at birth with 3305
(90%) admitted to the SNCU for PRC
(Fig 1). Of those admitted to the SNCU,
1429 (43%) were in the short PPV
group (gestational age 39.3 6 1.7
weeks and birth weight 3.5 6 0.6 kg)
and 1876 (57%) were in the prolonged
PPV group (gestational age 39.2 6 1.8
weeks and birth weight 3.4 6 0.6 kg).
Infants who required prolonged PPV
were more likely to be born after placental abruption, have cord arterial pH
#7 and 5-minute Apgar score #3 (P ,
.0001) as compared with those who
required short PPV (Table 1). Among
those who received short PPV for ,1
minute at birth, 911 infants (58.5%)
stayed in SNCU for $1 day (Table 2).
Infants who received any PPV at birth
were more likely to have neonatal
morbidities and require special care
measures (assisted ventilation and/or
parenteral nutrition) even if PPV was
for ,1 minute (P , .0001). Similarly,
infants who received prolonged PPV
PEDIATRICS Volume 134, Number 4, October 2014
FIGURE 1
Study flowchart.
were more likely to develop complications and require assisted ventilation,
central venous catheters, and longer
stay in SNCU (P , .0001, Table 3). The
same outcomes remained significant
after comparing the 2 groups during 2
different epochs: 1994–2003 and 2004–
2013 (Table 4).
Multiple regression analysis indicated
that placental abruption, assisted vaginal delivery/cesarean delivery, small for
gestational age, gestational age ,37
weeks, longer duration of PPV, need for
intubation at birth, and 5-minute Apgar
score #3 were independent predictors
of SNCU stay $1 day, need for assisted
ventilation, central lines, and parenteral
nutrition.
DISCUSSION
There is little information in literature
to describe the need and the nature of
PRC that should be provided for term
and late preterm infants after substantial resuscitation. The current NRP
recommendation of providing PRC for
those who have depressed breathing at
birth does not differentiate between
those who need extensive resuscitation
and those who recover quickly after
TABLE 1 Maternal and Infantile Baseline Characteristics (Admitted Infants)
Maternal age, mean (SD)*
Assisted vaginal delivery, n (%)
Cesarean delivery, n (%)
PROM $ 24 h, n (%)
Antenatal steroids, n (%)
Gestational diabetes, n (%)
Preexisting hypertension, n (%)
Severe PIH, n (%)
Placental abruption, n (%)
Gender, % boy
Gestational age, mean (SD)**
Birth weight in grams, mean (SD)***
SGA, ,3rd percentile, n (%)
5-min Apgar score #3, n (%)
Cord arterial pH #7, n (%)
PPV ,1 min, N = 1429
PPV $1 min, N = 1876
OR (95% CI)
29.5 (5.6)
213 (15.2)
440 (31.5)
43 (3.1)
44 (3.2)
44 (3.2)
24 (1.7)
48 (3.4)
22 (1.6)
56.5
39.3 (1.7)
3454 (611)
49 (3.4)
9 (0.6)
24 (2.2)
29.2 (5.6)
250 (13.8)
612 (33.7)
72 (4)
89 (4.9)
83 (4.6)
36 (2)
89 (4.9)
69 (3.8)
60.8
39.2 (1.8)
3392 (634)
81 (4.3)
71 (3.8)
100 (7.6)
—
0.9 (0.7–1.1)
1.1 (0.95–1.3)
1.3 (0.9–1.9)
1.58 (1.1–2.3)
1.47 (1–2.2)
1.2 (0.7–2)
1.5 (1–2.1)
2.5 (1.5–4.1)
1.2 (1–1.4)
—
—
1.3 (0.9–1.9)
6.2 (3–13.3)
3.75 (2.3–6.1)
CI, confidence interval; OR, odds ratio; PIH, pregnancy-induced hypertension; PROM, prolonged rupture of membranes; SGA,
small for gestational age. * P = .15; ** P = .02; *** P = .005.
e1059
TABLE 2 Short-Term Outcomes of Infants Who Had No PPV and Those Who Had Short PPV (,1
Minute)
Outcome
No PPV, N = 83 806, n (%)
PPV ,1 min, N = 1558, n (%)
OR (95% CI)
SNCU stay $1 d
Pneumothorax
Seizures
Assisted ventilation
Parenteral nutrition
Mortality
5879 (7)
228 (0.3)
114 (0.1)
367 (0.4)
233 (0.3)
7 (0.01)
911 (58.5)
21 (1.4)
11 (0.7)
84 (5.4)
26 (1.7)
,5
18.7 (16.8–20.7)
5 (3.1–8)
5.2 (2.7–10)
13 (10.1–16.6)
6.1 (4–9.3)
7.7 (0.3–49.8)
CI, confidence interval; OR, odds ratio.
TABLE 3 Short-Term Outcomes of All Infants Who Received Short PPV and Those Who Had
Prolonged PPV
Outcome
PPV ,1 min, N = 1558
PPV $1 min, N = 2100
OR (95% CI)
SCNU stay $1 d, n (%)
SCNU days, mean (SD)*
Pneumothorax, n (%)
Seizures, n (%)
Assisted ventilation, n (%)
Parenteral nutrition, n (%)
Mortality
911 (58.5)
3.4 (6.7)
21 (1.4)
11 (0.7)
84 (5.4)
26 (1.7)
,5
1347 (64.1)
4.9 (9.4)
86 (4.1)
75 (3.6)
329 (15.7)
97 (4.6)
19 (0.9)
1.3 (1.1–1.5)
—
3.1 (1.9–5.2)
5.2 (2.7–10.4)
3.3 (2.5–4.2)
2.9 (1.8–4.5)
24.2 (2.6–298.6)
CI, confidence interval; OR, odds ratio. * P , .0001.
TABLE 4 Short-Term Outcomes of Infants Who Received Short Versus Prolonged PPV During the 2
Study Epochs
During 1994–3003
PPV ,1 min, N = 786
PPV $1 min, N = 927
OR (95% CI)
SCNU stay $1 d, n (%)
SCNU days, mean (SD)*
Pneumothorax, n (%)
Seizures, n (%)
Assisted ventilation, n (%)
Parenteral nutrition, n (%)
Mortality, n (%)
During 2004–2013
521 (66.3)
3.5 (7.5)
17 (2.2)
,5
19 (2.4)
14 (1.8)
,5
PPV ,1 min, N = 772
679 (73.3)
4.7 (9.1)
46 (5)
48 (5.2)
93 (10)
39 (4.2)
10 (1.1)
PPV $1 min, N = 1173
1.4 (1.1–1.7)
—
2.4 (1.3–4.3)
10.7 (3.7–35)
4.5 (2.7–7.7)
2.4 (1.3–4.7)
8.5 (1.4–187.6)
OR (95% CI)
SCNU stay $1 d, n (%)
SCNU days, mean (SD)**
Pneumothorax, n (%)
Seizures, n (%)
Assisted ventilation, n (%)
Parenteral nutrition, n (%)
Mortality, n (%)
390 (50.5)
3.3 (5.4)
,5
7 (0.9)
65 (8.4)
12 (1.6)
0
668 (57)
5.2 (9.7)
40 (3.4)
27 (2.3)
236 (20.1)
58 (4.9)
9 (0.8)
1.3 (1.1–1.6)
—
6.8 (2.3–22.4)
2.6 (1.1–6.5)
2.7 (2–3.7)
3.3 (1.7–6.5)
Undefined
CI, confidence interval; OR, odds ratio. * P = .01; ** P , .0001.
short PPV.4 The nature, duration, and
level of PRC provided are left to clinician’s discretion. This can be difficult in
the delivery room where the prediction
will largely depend on the experience of
the care provider and may lead to
marked variability in practice and different adherence to NRP guidelines. In
this study, we examined the evidence
behind the NRP recommendation to
elaborate more on this less-studied
area of resuscitation practice where
e1060
AKINLOYE et al
the main attention is usually directed to
the acute resuscitation phase and to the
care of very preterm infants.
As our hospital policy has been to admit
these infants routinely for observation to
SNCU for 6 hours, we used SNCU stay $1
day, need for central lines, parenteral
nutrition, and assisted ventilation as surrogates for the significant need for PRC.
Our data revealed that 4.2% of all infants
born at $35 weeks’ gestation required
PPV at birth. In a previous small study,
the PPV percentage in full-term infants
was 2.8%.8 In late preterm infants (34–36
completed weeks’ gestation), the need
for PPV by using bag and mask at birth
was reported to be higher; up to 14%.9
A good proportion of our study infants
who received PPV at birth developed
significant morbidities and required
SNCU admission for more than 1 day.
This observation was relevant even for
those who had short PPV (,1 minute)
as ∼59% of them required significant
PRC. This finding indicates that quick
recovery in the delivery room may not
be a sign of normalization and does not
exclude the risk of subsequent deterioration; hence the decision of providing PRC (or not) should not be based
solely on the PPV duration. In one of the
few studies addressing PRC, Frazier
and Werthammer8 reviewed 33 depressed
term infants who required short PPV
at birth before having quick recovery
(achieving a 5-minute Apgar score
$8). Fifty-two percent of their study
patients required NICU admission and
61% developed short-term complications as compared with 3% in the control group.
In our study, those who received prolonged PPV were significantly more
likely to develop morbidities that required postresuscitation special care
such as assisted ventilation, central
venous lines, parenteral nutrition, in
addition to longer stay in SNCU than
those who received short PPV (P ,
.0001). The significant correlation remained even after excluding infants
who required advanced resuscitation
in the form of chest compression (6
infants in the short PPV group and 70
infants in the long PPV group). The
longer duration of the immediate ventilatory support provided after birth
may reflect a more difficult transition
or ineffective support measures. After
prolonged resuscitation, different organs like brain, lungs, heart, kidneys,
and gut in addition to metabolic and
ARTICLE
cardiovascular systems might be compromised.4 In a population-based study,
Moster et al10 reported that infants
with 5-minute Apgar scores #3 had
a 386-fold increased risk for neonatal
death when compared with those who
had scores 7 to 10. Multivariate logistic
regression analysis revealed the risk
factors of placental abruption, assisted
vaginal delivery or cesarean delivery,
small-for-date, gestational age ,37
weeks, longer duration of PPV, 5-miute
Apgar score #3, and the need for intubation at birth to be independent
predictors for special care unit stay
.1 day and the need for assisted ventilation, central lines, and parenteral
nutrition. This is in keeping with the
previous studies; Aziz et al11 reported
a significantly increased risk for NICU
admissions/death in infants with intrauterine growth retardation but did
not indicate an increased risk after the
use of vacuum or forceps during delivery. Other reports revealed higher
rate of neonatal complications after
operative vaginal delivery with NICU
admission rate up to 38% after forceps
and 11% after vacuum assisted delivery
of term infants. Birth trauma and concomitant fetal distress can provide an
explanation.12–14
Late preterm infants were repeatedly
reported to have more complications
and require more NICU admissions secondary to immaturity of their different
systems.15–18 Endotracheal intubation
may or may not be associated with pro-
longed resuscitation as in many cases it
can be related to the presence of meconium stained amniotic fluid. The impact of
intubation alone may be hard to tease
out especially with the flexibility given in
NRP guidelines regarding the timing of
the decision when to intubate. However,
the assumption that those who required
intubation were sicker and could have
required longer/more efficient PPV
through endotracheal tube cannot be
ignored.
To our knowledge, this is the first study
to examine the evidence behind the
recommendation of providing PRC to
infants who receive PPV at birth and
who otherwise (or at least most of
them) would have stayed with their
mothers receiving routine neonatal
care. A major strength of the study is
that we are able to report reliably
collected data on a large cohort of
neonates who had PPV at birth over a
20-year period. Our study focused on
PRC for late preterm and full-term infants who received PPV at birth in
a tertiary care hospital, so the generalizability to different level of care units
may not be optimal. However, the experience and expertise of our tertiary
care unit-resuscitation team, the high
adherence to a standardized practice of
providing PRC (90% compliance), and
the presence of designated abstractors
for the database enhance the validity of
our results.
carries the potential of changes in
clinical practice and differences in
preferences after patient admission.
The length of stay in the SNCU could have
been affected by physician’s preferences, bed availability, and the different time of admission (late nighttime
versus daytime). In an effort to reduce
this effect, we restricted our study
population to the era when NRP
guidelines were well established in our
institution (NRP was introduced in 1992
to our hospital). In addition, we compared our 2 study groups during older
and recent epochs to examine the
possible effect of changing practice
with time without detecting significant
differences in outcome. Finally, because this is a retrospective study, individual variations in clinical judgment
and time assessment of birth events
may have varied over time. The duration of PPV as documented cannot be
verified with absolute certainty.
CONCLUSIONS
This study supports the need for PRC for
infants receiving PPV at birth regardless to PPV duration. We recommend
considering the outlined perinatal risk
factors to achieve the balance between
improving the care of these infants and
achieving better utilization of hospital
resources.
This study is not without limitations;
a 20-year period is a long time that
ACKNOWLEDGMENT
We thank Dr Douglas McMillan for
reviewing the manuscript.
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