Neonatal R P Guidelines 2024 updated 28July2024.pptx

Discussion on Neonatal R P Guidelines 2024 updated July2024

1. Neonatal Resuscitation Revisited Crafting Country Specific NRP Guidelines for India Dr. Lalan Bharti Dr. Ravi Sachan Dr. Jai Kishore Dr. Vinay Rai Dr. Somashekhar Marutirao Nimbalkar

2. Name & Present Designations: Dr. LALAN K. BHARTI MD (Gold Medalist) ,FNNF ,FIAP, Fellow Afro -ADVAC (South Africa) HOD Pediatrics, JPC Hospital, Govt. of NCT of Delhi Affiliation: National Coordinator & Chair NNF NRP EB CIAP Delhi 2022,2023 President NNF Delhi 2022 President IAP East Delhi 23 Zonal Coordinator IAP NRP FGM Project National Coordinator IAP NTEP 2023 National joint Coordinator IAP U5MR”2022 Vice President NNF India 2021 Secretary General, NNF India 2019-20 Joint Secretary cum Treasurer 2017-18 Delhi State Academic Coordinator: IAP-NNF NRPFGM 2016-20 Major Achievements: (Honours) (Awards) (Publications) Executive Editor Journal of Neonatology 2019-20 More than 37 publications in National and International Journals. Contributed in NRP India Book and many others National Faculty & Master Trainer: HBS, NRP India, NRP FGM, FBNC, KMC, Preterm care package ,NSSK,NTEP,NC- ECD ,POINT etc Organizing chairperson NIPID 2022-23, Organizing chairperson Back to basics 2023

3. Name Dr. Ravi Sachan Qualifications MD,MBA, FNNF Designation Professor, Division Of Neonatology Affiliation UCMS & GTB Hospital, Delhi. Central Health Services ,MOHFW, Govt. of India Achievements & Awards National Executive Board Member, National Neonatology Forum of India Advisor & member of various standing committees of NNF Vice-President, National Neonatology Forum of Delhi. 2022 Secretary , National Neonatology Forum of Delhi, 2020-2021 Editor- Hand Book Of Neonatal Clinical Practices ( NeoClips ) National Co- ordinator , NNF PGs Quiz, 2021,2022,2023 National Faculty & Trainer NRP, NSSK, FBNC, KMC, NEOMAP, NeoQuip National Assessor for Neonatal Health Facility, NNF Delhi State Academic Co- ordinator for advance IAP-NNF FGM NRP Project Area of intrest quality improvement in maternal& neonatal health care.

4. Dr Jay Kishore M D (Pediatrics), DNB (Neonatology, Sir Ganga Ram Hospital ) Senior Consultant Neonatology and Pediatrics, Cloudnine Hospital, Patparganj, Delhi National Faculty in Neonatal Ventilation Workshop, Neocon, 2017 National trainer Advanced NRP Program National trainer Developmentally Supportive care Workshop Area of interest: Neonatal ventilation, Neonatal nutrition, Functional Echocardiography, Developmentally supportive care Formerly, Lecturer, PGIMS Rohtak NICU -in-Charge, Paras Hospital, Gurugram Principal consultant and NICU-In-Charge, Max Superspecialty Hospital, Patparganj Has got more than 20 publications in different journals and books

5. Insert Photograph Name & Present Designation: DR. VINAY KUMAR RAI MBBS, MD PEDIATRICS, DrNB NEONATOLOGY SENIOR CONSULTANT Affiliation: CLOUDNINE HOSPITAL KAILASH COLONY SOUTH DELHI Major Achievements: (Honours) (Awards) (Publications) - EB member NNF DELHI -VARIOUS PUBLICATION IN NATIONAL AND INETRNATIONAL JOURNALS -CONTRIBUTED VARIOUS CHAPTERS IN NEONATAL BOOKS - FACULTY NRP provider course

6. Name & Present Designation: Prof. SOMASHEKHAR NIMBALKAR, MD, FNNF, FIAP MD, PGDPH, CPH, Fellowship (Neonatology) RGUHS Prof. and Head, Dept. of Neonatology, Pramukhswami Medical College, Bhaikaka University, GUJ Affiliation: Editor-in-Chief – Journal of Neonatology (NNF) Joint Secretary – KMC Foundation of India Chairperson 2023 IAP Medical Education Chapter National Coordinator - IAP NNF NRP Program (2020, 2021,2022, 2024) Member of the International Pediatric Association - Program Area Committee on Education & Pediatric Workforce for 2023-2025. Member of Content Expert Group – ILCOR Member of various university and ethics committees Major Achievements (Honours) (Awards) (Publications) Leads first & only DM course in Neonatology in Gujarat; PhD Guide (5 students) Member, Governing Body, NNF, New Delhi (2013, 2014, 2021) Associate Editor - International Journal of Pediatrics , Heliyon India- Giani Award 2014; James Flett Award 2012 and 2014, Best Research Paper Award 2012 and 2015 (Excellence in Pediatrics), Finalist BMJ Best paper Awards 2014, 2017; Dr Arun Parikh Endowment Lecture at Kutch – January 2019; Dr. Kamlesh Gandhi Oration [NNF Gujarat] – Oct 2023; Dr. Gaya Prasad Oration [IAP Bihar] – Dec 2023 137 PubMed Indexed Publications (total – 200+); 250+ Research Presentations (50+ In Pediatric Academic Societies; Multiple Book Chapters; Book on Communication.

7. Background of NRP and Guideline Formation Early iterations of NRP were based on established practice in late 1980’s, expert opinion and some data

8. Achieving Consensus on Resuscitation Science Since 2000, the AAP with the American Heart Association, participates with the International Liaison Committee on Resuscitation (ILCOR) for a complete review of resuscitation science every 5 years.

9. ILCOR The International Liaison Committee on Resuscitation (ILCOR) was formed in 1992  publication of consensus international advisory statements on resuscitation in 1997. IN 1999 ILCOR published an advisory statement summarising international consensus on resuscitation of the newly born infant at the time Publication of updated guidelines in 2000, December 2005, December 2010, October 2015 Newest Updated Guidelines in 2020

10. 1 st Edition General consensus, Delivery room experience, Best guesses of pediatricians and neonatologists across the country. USA Theoretical > Practical 8 th Edition Evidence based: Researching  Reporting  D eveloping an international consensus: CoSTR Multinational Practical > Theoretical

11. Development of NRP The National Academy of Sciences recommended guidelines for adult resuscitation in 1966 Catherine Cropley , RN, MSN, and Ron Bloom, MD, FAAP, developed the curriculum needed for programs to provide education regarding the fundamentals of neonatal care to community hospitals, which they called the Neonatal Educational Program (NEP) NEP formed the basis for what would become the Neonatal Resuscitation Program (NRP). George Peckham, MD, chaired a AAP group whose goal was to “address the adequacy of training for neonatal resuscitations.”

12. Development of NRP Bloom and Cropley based the first edition of the Textbook of Neonatal Resuscitation on accepted practice among senior neonatologists rather than on support from the literature – 1987 – was a joint AAP and AHA project The first two-day course of the NRP was presented to 23 national volunteers in November 1987 Resuscitation guidelines were published in the October 1992 Journal of the American Medical Association and would serve as the scientific basis for NRP practice through the 1990s. 2000 edition of the Textbook of Neonatal Resuscitation (4 th Edition) resulted from a three-year review of the scientific literature that supports current neonatal resuscitation practices.

13. AAP History https:// www.aap.org / en / pedialink /neonatal-resuscitation-program/ nrp -history/ 7/28/24 14

14. Indian History 1986-1987 – Dr. Dharmapuri Vidyasagar – NRP – Neonatology Training NNF – Regular NRP Instructor courses during Neocon – 10-20 instructors created every year 2008 – IAP NRP trainings – Meerut – to trial program – Collaboration with AAP IAP – 2009 – 100 Instructors – Bengaluru Pedicon – Dr. Naveen Thacker – IAP President 2007 2009 – January – Kutch NRP 2009 – September – NSSK (First Edition) – Two day Program 2009 – December – 2010 – March --- IAP BNCRP ( Two day Program) 2010 – 2016 – IAP NNF NRP FGM program 2011 – IAP NNF meetings for Addendum to AAP Textbook 2014 – NRIndia – NNF Textbook – ran into three editions 2017 – NRP TOT without AAP Instructors 7/28/24 15

15. Indian History 2017-2020 – Yearly TOTs 2020 December – Updated Grant from J and J 2021 September – IAP NNF MOU Joint Progam –and Textbook 2023 – IAP NNF NRP Textbook released 2023 November – NNF TOT using new book 2024 January – IAP TOT using new book 7/28/24 16

16. ILCOR, AHA and ERC ILCOR 2020 used three types of evidence evaluations including systematic reviews, evidence updates, and scoping reviews ILCOR continued to utilize the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system for evaluating the certainty of evidence ( CoE ) supporting interventions . Whilst GRADE categorizes the CoE into 4 levels (high, moderate, low, very low), the strength of treatment recommendations made by ILCOR are classified as either strong or weak. ILCOR 2020 Consensus on Science and Treatment Recommendations ( CoSTR ) for Neonatal Life Support forms the framework on which other neonatal resuscitation councils base their recommendations .

17. Class of Recommendations and Level of Evidence 18 COR indicates the strength the writing group assigns the recommendation, and the LOE is assigned based on the quality of the scientific evidence . Class 1 , Strong recommendation for which the potential benefit greatly outweighs the risk ; Class 2a , Moderate recommendation for which benefit most likely outweighs the risk ; Class 2b , Weak recommendation for which it’s unknown whether benefit will outweigh the risk ; Class 3 : No Benefit, Moderate recommendation signifying that there is equal likelihood of benefit and risk; and Class 3 : Harm, Strong recommendation for which the risk outweighs the potential benefit.

18. 19 Level A are derived from High-quality evidence from more than 1 randomized clinical trial, or RCT; Meta-analyses of high-quality RCTs; One or more RCTs corroborated by high-quality registry studies Level B-R (randomized) are derived from Moderate-quality evidence from 1 or more RCTs; Meta-analyses of moderate-quality RCTs Level B-NR (nonrandomized) are derived from Moderate-quality evidence from 1 or more well-designed, well-executed nonrandomized studies, observational studies, or registry studies Meta-analyses of such studies

19. 20 Level C-LD (limited data) are derived from Randomized or nonrandomized observational or registry studies with limitations of design or execution Meta-analyses of such studies; Physiological or mechanistic studies in human subjects Level C-EO (expert opinion ) are derived from Consensus of expert opinion based on clinical experience COR and LOE are determined independently (any COR may be paired with any LOE). A recommendation with LOE C does not imply that the recommendation is weak.

20. AHA 2020 - AHA writing group collaborated with ILCOR for reviewing evidence. AHA used own terminology to classify CoE (level of evidence) and strength of recommendations. AHA level of evidence and strength of recommendation were classified into 5 levels. ERC members also collaborated with ILCOR. The level of evidence and strength of recommendations were adopted from the ILCOR 2020 CoSTR . For questions that were not addressed by ILCOR, recommendations of ERC were based on expert consensus, which in turn was based on focused literature reviews. The level of evidence or strength of recommendation was not explicitly stated for these recommendations of ERC.

21. AHA Algorithm - It is the Same 22 Training does not change much 8 th edition of AAP Book released this year. Emphasis on few things Apps based on algorithm do not need to change. More evidence based; more research available NRP Guidelines; Consensus on CPR and Emergency Cardiovascular Care Science With Rx Recommendations

22. ERC Algorithm - Few Changes 23 Delivery Temp are different Inspired Oxygen for Preterm is different Delayed cord clamping emphasized

23. Transitions (ERC) ERC defines 3 levels of transitions based on Initial Assessment (not defined by AHA) 24 Satisfactory Transition Good tone Vigorous breathing or crying Heart rate – fast (≥100 min−1) Assessment: Satisfactory transition – Breathing does not require support. Heart rate is acceptable Incomplete Transition Reduced tone Breathing inadequately (or apnoeic ) Heart rate – slow (<100 min−1) Assessment: Incomplete transition – Breathing requires support, slow heart rate may indicate hypoxia Poor/failed transition Floppy ± Pale Breathing inadequately or apnoeic Heart rate – very slow (<60 min−1) or undetectable Assessment: Poor/Failed transition – Breathing requires support, heart rate suggestive of significant hypoxia

24. Dr. Lalan Dr. Lalan – ILCOR and other National bodies mandate that Saturation Monitor and Blender be part of Neonatal Equipment as there is evidence for its utility. Can you discuss the pros and cons or issues that India needs to address and what the position of our guidelines should be?

25. Dr. Ravi Sachan The latest guidelines released by ILCOR and AAP recommend using T-piece for all deliveries over Bag and Mask based on evidence. “Using a T-piece resuscitator to deliver positive-pressure ventilation is preferred to the use of a self-inflating bag. (Dec 2023 Update)” What should our position?

26. Dr. Vinaykumar ECG has been recommended for long in the NRP guidelines (since 2015). Why do we not have it in Indian guidelines? Should we have it?

27. HR monitoring during neonatal resuscitation Most important vital parameter to assess the neonatal condition at the time of birth To decide about the need of chest compression and medication Guide us about the response to resuscitative measures like PPV and chest compression It also tell us about when to deescalate the resuscitative measures

28. How to assess HR in the delivery room Use stethoscope Through pulse oximetry ECG Which is the best for HR assessment?

29. ECG Faster in acquiring HR as compared to Pulse oximeter More accurate(nearly 10 beats/min difference) during initial 2-3 minutes of life(especially during low cardiac output status) as compared to other devices Provide continuous HR information Evidence – Decrease in delivery room tracheal intubation with ECG USE(OR-0.65,CI-0.45-0.94) Better APGAR score in those babies where ECG was used for HR monitoring

30. What is level of evidence and grade of recommendation regarding DR room use of ECG COR-2b,LOE-C-LD So its is weak recommendation based on limited data available till date

31. Is it useful in resource poor countries? There is no data available regarding its clinical utility significance in resource poor countries like India Even in western countries ,its use is not universal because of weak recommendation Needs a lot of resources and training So where resources permits and there is availability of enough trained health care personnel's , ECG is recommended for heart rate assessment in DR In our set up, pulse oximetry is a reasonable alternative over ECG for heart rate assessment in DR

32. Dr. Jay Kishore “Use of a supraglottic airway may be considered as the primary interface to administer positive-pressure ventilation instead of a face mask for newborn infants delivered at ≥34 0/7 weeks’ gestation. (Dec 2023)” – What should we do?

33. Is there a use of supraglottic airways in neonatal resuscitation ? Newborn infants >34 0/7 weeks’ receiving during resuscitation at birth Supraglottic airway Vs face mask. 5 RCT, 1 Quasi RCT, Non RCT’s, 2 retrospective cohort Overall risk of bias – ↑ 1 ) Failure to improve with the device   ( moderate certainty evidence ) Probable benefit  - (risk ratio (RR) 0.24; 95% confidence interval (CI) 0.17 to 0.36; p <0.001; NNT= 10). 2) Endotracheal intubation, (low certainty) Possible benefit  ( RR 0.34, 95% CI 0.20 to 0.56; p <0.001; I 2 =78%; NNT 20) Supraglottic Airways for Neonatal Resuscitation NLS #5340, Jan 29-2022 CoSTR . Neonatal Resuscitation Revolution: What's on the Horizon? 28/07/24 36

34. Is there a use of supraglottic airways in neonatal resuscitation ? Chest compressions during resuscitation, - (Low certainty) Could not exclude benefit or harm  RR 0.97, 95% CI 0.57 - 1.65; p=0.91 Epinephrine administration ( low certainty) – Could not exclude benefit or harm  (RR 0.67, 95% CI 0.11 to 3.87; p=0.65; Time to heart rate >100 bpm, (low certainty)- Possible benefit  (mean difference -66 s, 95% CI -100 s to -31 s; p<0.001) Duration of positive-pressure ventilation, ( low certainty) - Possible benefit  (mean difference -18 s, 95% CI -24 s to -13 s; p < 0.001 Admission to the NICU, (very low certainty) - Possible benefit and no likely harm  (RR 0.97, 95% CI 0.94 to 1.00; p=0.07) Neonatal Resuscitation Revolution: What's on the Horizon? 28/07/24 37

35. Is there a use of supraglottic airways in neonatal resuscitation ? Air leak during initial hospital stay (very low certainty) Could not exclude benefit or harm  (RR not estimable due to no events; I 2 =0%; ARD 0%, ) Air leak during initial hospital stay (very low certainty) - Could not exclude benefit or harm  (RR 0.32, 95% CI 0.05 to 1.99; p=0.22) Soft tissue injury, (low certainty) Could not exclude benefit or harm  ( RR 1.05, 95% CI 0.15 to 7.46; p=0.96) Survival to hospital discharge, (low certainty) Could not exclude benefit or harm  (RR 0.99; 95% CI 0.96 to 1.02; p=0.58 Neonatal Resuscitation Revolution: What's on the Horizon? 28/07/24 38

36. Is there a use of supraglottic airways in neonatal resuscitation ? Conclusion : Where resources and training permit, suggest that a supraglottic airway may be used in place of a face mask for newborn infants >34 0/7 weeks’ receiving IPPV during resuscitation immediately after birth (weak recommendation, low certainty of evidence) Supraglottic airway in DR –Feasible, even resource-limited setting, even though the certainty of evidence remains low Knowledge gaps- The training to maintain competency The effectiveness and safety during chest compressions, as the initial device for PPV high resource settings, orofacial anomalies, < 34 weeks Neonatal Resuscitation Revolution: What's on the Horizon? 28/07/24 39

37. SAGA of Neonatal Hypothermia 2007 – Evidence for Neonatal Hypothermia Standard of Care Developing World – no trials 2021 – Therapeutic Hypotermia not beneficial – rather harmful – HELIX trials 2021 – NNF Guidelines for Therapeutic Hypothermia

38. What is the status of Respiratory Function Monitoring for Neonatal Resuscitation Neonatal Resuscitation Revolution: What's on the Horizon? 28/07/24 41

39. We have some data – Can we use a RFM? There is insufficient evidence to make a recommendation for or against the use of a respiratory function monitor in newborn infants receiving respiratory support at birth (low certainty evidence). Neonatal Resuscitation Revolution: What's on the Horizon? 28/07/24 42

40. Expired CO 2 and Near-infrared spectroscopy Expired CO 2 Expired CO 2 (ECO 2 ) can reassure a resuscitator that gas exchange is occurring, regardless of the tidal volume Near-infrared spectroscopy Current evidence to use NIRS during neonatal resuscitation is limited to observational studies and a small pilot trial comparing supplemental oxygen delivery guided by CrSO2 + SpO2 compared to SpO2 alone reported that the burden of cerebral hypoxia was halved, with a trend to lower mortality and/or cerebral injury (13vs. 20%) in the CrSO2 + SpO2.

41. Practical Considerations of NRIC Physiology-based cord clamping and intact cord resuscitation

42. AI in the DR Image training data set manually labelled, categorising actions for the algorithm. New data set (video) is inputted into the AI algorithm for analysis. The algorithm pixelates items to label and track them. Output allows quantification of important actions, their timing, duration, and frequency. Neonatal Resuscitation Revolution: What's on the Horizon? 28/07/24 45 Running in real time has the potential to support stabilisation /resuscitation algorithms to avoid deviations or errors especially in settings lacking experienced support.

43. Eye-tracking Example heat map after analysis of providers’ gaze behaviour in a simulated resuscitation scenario. Neonatal Resuscitation Revolution: What's on the Horizon? 28/07/24 46