# Pediatric Medicine/Resuscitation/Preparation

The goal of resuscitation is to ensure that air goes into the body, to the lungs, and then through the blood to the body to give the baby the oxygen needed for life. A successful newborn resuscitation requires preparation.
Trained personnel and equipment to warm the baby, establish an airway, and give medicines should be available at the time of birth.

## Step 1: Warming

* Heat loss occurs through:
** radiant loss (heat loss directly into the air),
** conduction (direct loss from contact between two solids), and
** convection (the loss of heat as water evaporates).
* A radiant heat source and warm blankets or towels are needed to warm and dry the baby.
* Premature babies with immature skin need to be gently wrapped in a watertight layer such as sterile plastic wrap to prevent convective heat loss. If a newborn is vigourous, the mother's body and warmed blankets can be used to keep the baby warm.

## Step 2: Clear the Airway

* Babies need to breathe air when they are born.
* While most babies will cough, cry, or breathe on their own, many need to have liquid cleared from their airway first.
* A rubber bulb suction or vacuum suction can be used to suck liquid from the moth and nostrils. A tube connecting to external wall suction should be set to less than 100 mm Hg to prevent damage to the baby's mouth tissue.
* The baby should be positioned with the head midline, slightly extended, to open the airway.

## Step 3: Breathing

Most babies can safely breathe on their own or be ventilated with a face mask.
Once the airway is cleared, most babies breathe spontaneously. If a baby does not breathe, the baby will need assisted ventilation to inflate the lungs. Most babies can be easily ventilated with positive pressure bag-mask ventilation. This requires a face mask that goes over the baby's mouth and nose. The mask should be connected to an air source with supplemental oxygen. It is currently not known how much oxygen is best to give to babies after delivery. It is a topic of current neonatal research.
There are two situations, however, when it is safer to place a breathing tube into the baby's trachea.
* Meconium
** A baby who is born through meconium needs to be assessed immediately.
** According to NRP guidelines, if the baby is not vigorous-- crying, with good tone, and with heart rate over 100-- the baby should be intubated and the trachea should be suctioned to clear meconium. Once meconium is cleared, the tube can be removed. Then the baby can be stimulated to breath on it's own.
* Congenital_diaphragmatic_hernia
** In babies born with diaphragmatic hernias, an endotracheal tube should be placed so that the stomach does not fill with air. This would put pressure on the lungs and make ventilation difficult.
The baby's efforts to breath should be assessed at least every 15-30 seconds. If the baby shows no effort, positive pressure breaths should be given to ensure that air is getting to the lungs. The breaths should be about once per second. The pressure should be high enough to inflate the lungs and see the chest wall rise and fall. Usually full term babies require a maximum pressure of 30 cm H2O.
Babies who do not breathe on their own need to be carefully evaluated. They may have a problem with their respiratory drive, or be effected by maternal medications, such as anesthesia or other drugs. They may be septic, asphyxiated, or have neuromuscular problems.

## Step 4: Heart Rate

The baby's heart rate should be monitored continuously. If the heart rate drops below 80 beats per minute, it is important to ensure that the baby is being ventilated. If the baby has a heart rate under 80 and has had adequate ventilation for 30 seconds, chest compressions should be started to help circulate the blood. If after 30 seconds of chest compressions and assisted ventilation the heart rate is still under 80, the baby would require epinephrine to increase the heart rate.
Ventilation and circulation are essential for life. Without ventilation and circulation of blood, a baby can have brain damage and may ultimately die. The goal of resuscitation is to prevent brain damage and death. Adequate preparation and training are essential for anyone who will be involved in the care of newborn babies.

## References

* comprehensive eMedicine reference
* NRP