Crocodiles and neonatal resuscitation


Dr Helen Liley, Mater Mothers’ Hospital, South Brisbane, Qld 4101, Australia. Fax: +61 7 3840 1949; email:

I was born and raised with crocodiles; they are a piece of cake. But kids are so . . . unpredictable. (The late Steve Irwin)

See related article by C Morley on pp. 6–8.

The day of life when one is most likely to receive some form of cardiopulmonary resuscitation is probably the day on which one is born. The new Australian Resuscitation Council (ARC) guidelines on neonatal resuscitation1 underscore that up to about 10% of all newborns require some form of assisted ventilation, and about 1% require more advanced measures, including chest compressions, blood volume expansion or adrenaline. Despite so many needing assistance, most compromised newborns respond well to resuscitation, especially support of breathing, for reasons that are well founded in the physiology of perinatal transition.

The more effective health-care interventions are, the more it matters that they are applied skilfully. Among snake oil peddlers, it doesn’t matter much who knows how or when to administer the snake oil, but in the case of an effective intervention, timing and technique of administration matter considerably. Furthermore, effective neonatal resuscitation requires particular precision and skills that cannot be casually extrapolated from paediatric or adult resuscitation.

Advances in maternal and fetal assessment mean that many of the factors predicting the need for resuscitation can be recognised, giving time for maternal transfer and careful preparation to provide life support for the baby. However, the numbers of retrievals and of emergency calls to the birth suite for an unexpectedly ‘flat baby’ are evidence that the crocodile-infested waters are not all well marked.

Thus, there are many convincing arguments for widely applicable and agreed-upon guidelines for neonatal resuscitation, based on best available evidence. The ARC guidelines help meet this need. They are adapted from a consensus achieved by the International Liaison Committee on Resuscitation (ILCOR),2 and so they closely resemble other national guidelines, such as those developed by the American Heart Association and American Academy of Pediatrics (AHA/AAP).3,4 There are a few differences, for example, the ARC guidelines recommend that chest compressions should depress the sternum one finger’s breadth below a line drawn between the nipples, whereas the AAP/AHA recommend positioning the compressing thumbs or fingers immediately below a line between the nipples, with palpation of the lower margin of the ribs and the xiphisternum as an additional guide. The ARC recommends default settings for a T-piece ventilation device as 50, 30 and 5–8 cm H2O for pressure relief, peak inspiratory pressure and end expiratory pressure, respectively, while the AAP/AHA recommends 40 for pressure relief and 0–5 for PEEP, and makes no recommendation for inspiratory pressure. The ARC recommends intubation to suction meconium from the trachea for non-vigorous infants exposed to thick meconium (without defining ‘thick’) whereas AAP/AHA conclude that no studies have differentiated neonatal outcomes based on a distinction between ‘thick’ and ‘thin’ meconium and recommend that the decision to intubate be made only on the basis of vigour. However, most of the differences are in style of presentation rather than substance. The on-line format of the ARC guidelines involves division into discrete topics that must be opened and read one at a time, and commercial constraints preclude printing them from the web. However, booklets can be ordered at very modest cost.

A paper in this issue by Professor Colin Morley, neonatal representative on ARC and representative on the neonatal committee of ILCOR highlights some topics in the ARC guidelines. It has doubtless been difficult to decide which key points to include. The paper includes various ‘hot topics’ among neonatal paediatricians and researchers in neonatal resuscitation such as the use of CPAP during resuscitation and the potential role of hypothermia in mitigating hypoxic ischaemic encephalopathy. However, the guidelines themselves include other many other recommendations that will be new to paediatricians who have not undertaken recent training or retraining in neonatal resuscitation. A few examples include recommending chest compressions (when needed) and assisted breaths in a 3:1 ratio in counterpoint (avoiding simultaneous chest compression and breath), and discouraging routine suctioning of the upper airway and routine use of sodium bicarbonate. There are numerous important differences between the current recommendations and teaching in previous decades, and in recommendations for neonates and for other ages. All paediatricians (and other professionals) involved in care at birth are strongly encouraged to read the full guidelines.

Effective resuscitation of the newborn requires training, planning, teamwork and communication. Outcomes will not improve unless the guidelines are widely used and the recommended individual and team skills are thoroughly learned and rehearsed. Australia has thousands of locations where babies are born but lacks official standards of training and certification in neonatal resuscitation for all clinicians (medical, nursing and midwifery) involved in neonatal care. USA and Canada have such a standard in the AAP/AHA Neonatal Resuscitation Program (NRP), which has undergone four revisions (the most recent in 2006) since 1987. NRP is widely taught in Australia, as many instructors recognise the merits of the textbook,4 interactive DVD, self study and class teaching materials and assessment tools.

Queensland maternity hospitals were among the first in Australia to commence standardised use of the NRP and a Queensland NRP steering committee has formed. Its aims include achieving at least one clinician with current Queensland NRP certification available at every birth, and establishing at least biennial NRP certification as a Queensland standard for all who provide care around birth, with a state database of certified providers and instructors. The course has been highly popular among participants and hospitals. RANZCOG and RACGP have accredited NRP courses for their members. Course instructors from Queensland have been invited to NSW, SA and Victoria to demonstrate the course, thereby facilitating metastasis of the program in other states. Professor Heather Jeffery and colleagues devised a similar course and have taught it widely in NSW. Both courses promote self-education, multidisciplinary teamwork and anticipation. Both require self-study and a full day’s attendance for initial certification. Both courses were supported by a short-lived multidisciplinary national committee that included representatives from all states and territories. This committee agreed that such courses were needed and were not supplanted by the Advanced Paediatric Life Support course, which is compatible but less comprehensive in regard to neonatal resuscitation.

Barriers to promulgating the courses include heavy workload for instructors and secretariats, competition with other compulsory or desirable education programs, difficulties of providing good equipment for rehearsing practical skills and misconceptions about incompatibility with contemporary Australian guidelines and practices. Commercialising the course to provide revenue to attract instructors, pay for secretariat functions and optimise teaching equipment and locations might solve some of these problems. However, high fees could deter or preclude universal participation. Responsibility and support for universal, standardised instruction and certification will likely need to rest with state health departments and hospitals, and will require hard work at the state level. However, support from individuals and professional organisations is critical to success.

The misconceptions are easier to dispel; the courses offer far more concord than discord, and all are based on the ILCOR consensus. Trans-Pacific differences in spelling, stock drug concentrations and jargon, are easily amended.

Yeah, I’m a thrill seeker, but crikey, education’s the most important thing. (Steve Irwin)