‘Resuscitation’ of Extremely Preterm and/or Low-Birth-Weight Infants – Time to ‘Call It’?

Abstract

Since ancient times, various methods have been used to revive apparently stillborn infants; many were of dubious efficacy and had the potential to cause harm. Based largely on studies of acutely asphyxiated term animal models, clinical assessment and positive pressure ventilation have become the cornerstones of neonatal resuscitation over the last 40 years. Over the last 25 years, care of extremely preterm infants in the delivery room has evolved from a policy of indifference to one of increasingly aggressive support. The survival of these infants has improved considerably in recent years; this has not, however, necessarily been due to more aggressive resuscitation. Urban myths have evolved that all extremely preterm infants died before they were intubated, and that all such infants need to immediately intubated or they will quickly die. This has never been true. Clinical assessment of infants at birth is subjective. Also, many techniques used to support preterm infants at birth have not been well studied and there is evidence that they may be harmful. It may thus be argued that many of our well-intentioned resuscitation interventions are of dubious efficacy and have the potential to cause harm. ‘Resuscitation’ is an emotive term which means ‘restoration of life’. Death, thankfully, is a rare presentation in the delivery room. Therefore, concerning neonatal ‘resuscitation’, it is time to ‘call it’ something else. This will allow us to dispassionately distinguish preterm infants who are dead, or nearly dead, from those who are merely at high risk of parenchymal lung disease. We may then be able to refine our interventions and determine what methods of support benefit these infants most.

European Consensus Guidelines on the Management of Neonatal Respiratory Distress Syndrome in Preterm Infants – 2010 Update

“…These enable a controlled delivery of a set background continuous positive airways pressure (CPAP) with a measured peak inspiratory pressure (PIP) during occlusion of the T-piece. Self-inflating bags do not require a pressurised gas supply to deliver air flow, but cannot deliver CPAP and the PIP cannot be controlled beyond the use of the safety valve which is usually set at about 40 cm H 2 O. Flow-inflating bags cannot deliver accurate CPAP and even in experienced hands produce variable gas volumes during lung inflation [42] . Provision of controlled early CPAP is now the main means of providing safe stabilisation of preterm babies immediately after birth and devices that can provide this, such as the Neopuff infant resuscitation device, are recommended.…”

Outcome of extremely low gestational age newborns after introduction of a revised protocol to assist preterm infants in their transition to extrauterine life

“…Therefore, the authors stressed the need for improved delivery room strategies for these fragile patients. Referring to this, Jobe (4) and other authors (5) emphasized that only few VLBW preterm infants need resuscitation, while the majority only requires assistance to allow transition and adaptation to extrauterine life. In this context, Vento recently (6) referred to the 'first golden minutes of the extremely low gestational age neonate' and placed emphasis on the importance of a gentle delivery room approach.…”

Early skin-to-skin contact or incubator for very preterm infants: study protocol for a randomized controlled trial

“…This view is well described by Jobe and colleagues, who argue that the majority of preterm infants need only supportive treatment in the transition to the extrauterine life, and not resuscitation [48, 49]. The main focus of this approach has, so far, been on early CPAP [50, 51], less invasive ways of surfactant administration [52, 53], avoidance of early mechanical ventilation [54], and maintenance of adequate body temperature [55].…”