Resuscitation and Management of Newborns

Initial Resuscitation

• For newborns with hypoxemia, initiate resuscitation with 21% oxygen (room air) for term/late-preterm infants and 21-30% oxygen for preterm infants, with subsequent titration based on pulse oximetry to meet target saturations, as recommended by the American Heart Association 1, 2
• Do not use 100% oxygen initially as this is potentially harmful, according to the American Heart Association 1

Airway Establishment

• Establish airway by positioning head in "sniffing" position and consider gentle suctioning only if obvious obstruction, as recommended by the American Academy of Pediatrics 3
• Do not routinely suction even if meconium is present, according to the American Academy of Pediatrics 3

Respiratory Support

• Use T-piece resuscitator or self-inflating bag for positive pressure ventilation, with evidence insufficient to recommend one device over another, as stated by the American Heart Association 2
• Monitor heart rate as primary indicator of resuscitation efficacy, as recommended by the American Academy of Pediatrics 3
• Positive pressure ventilation (PPV) should be initiated according to the American Heart Association guidelines if breathing is inadequate or heart rate <100/min 2

Oxygen Titration

• Use pulse oximetry to guide oxygen titration, as recommended by the American Heart Association 1
• Adjust FiO₂ to maintain target saturations, according to the American Heart Association 2
• Avoid FiO₂ >0.3 in preterm infants unless necessary to maintain target saturations, as recommended by the American Heart Association 2

Advanced Support

• Consider discontinuing resuscitation if no detectable heart rate after approximately 20 minutes, as recommended by the American Heart Association 4
• Administering epinephrine 0.01-0.03 mg/kg IV (1:10,000 solution) if heart rate <60/min despite adequate ventilation with 100% oxygen and chest compressions, as recommended by the American Heart Association 5

Sepsis Management

• Neonates showing signs of septic shock, including tachycardia, respiratory distress, poor feeding, poor tone, poor color, tachypnea, diarrhea, or reduced perfusion, particularly with maternal history of chorioamnionitis or prolonged rupture of membranes, should undergo a sepsis workup 6
• Clinical signs of sepsis in neonates include tachycardia, respiratory distress or tachypnea, poor feeding, poor tone, poor color/perfusion, diarrhea, temperature instability, and changes in behavior or pain scores 7
• Establishing airway and providing oxygen, establishing IV/IO access, and beginning high-flow oxygen if respiratory distress is present are crucial steps in managing neonatal sepsis 6
• Administering isotonic fluid boluses (10 mL/kg) up to 60 mL/kg until perfusion improves and beginning empiric antibiotics, including gentamicin for gram-negative coverage, are essential 6

Temperature Management

• Immediate warming and respiratory support should be prioritized for newborns presenting with poor tone and hypothermia, following the neonatal resuscitation algorithm while maintaining temperature between 36.5°C and 37.5°C, as recommended by the American Heart Association 5
• Temperature management is crucial, involving immediate placement under a radiant warmer, drying the infant thoroughly, and recording temperature as a quality indicator, according to the American Heart Association 5
• The classification of hypothermia is as follows:

• Hypothermia in newborns is associated with increased mortality (dose-dependent effect with 28% increased risk for each 1°C below 36.5°C), higher risk of intraventricular hemorrhage, respiratory distress, hypoglycemia, and late-onset sepsis, as stated by the American Heart Association 9, 5

Shock Management

• Resolution of shock is indicated by capillary refill ≤2 seconds, normal pulses, warm extremities, urine output >1 mL/kg/h, normal mental status, normal blood pressure for age, and normal glucose and calcium concentrations 6
• Refractory shock should be managed by considering occult conditions, such as pericardial effusion, pneumothorax, hypoadrenalism, hypothyroidism, or ongoing blood loss 6
• Septic shock should be distinguished from cardiogenic shock caused by ductal-dependent congenital heart disease, and prostaglandin infusion should be started if complex heart disease is suspected 6

Laboratory Tests and Monitoring

• Continuous monitoring of vital signs, including temperature, heart rate, and respiratory rate, is essential in neonates with suspected sepsis 6
• Pre-ductal and post-ductal pulse oximetry, blood pressure monitoring, and capillary refill (target ≤2 seconds) should be performed 6
• Laboratory tests, including complete blood count with differential, blood cultures, serum glucose, serum calcium, arterial blood gas, and serum lactate levels, should be conducted 6
• Cerebrospinal fluid analysis should be performed if meningitis is suspected 7
• Urine culture should be done if urinary tract infection is suspected 7
• Chest radiograph should be obtained if respiratory symptoms are present 7
• Comprehensive wound assessment should be performed if skin infections are present 7