Overview of Pediatric and Neonatal Resuscitation
Resuscitation in children and newborns, which means reviving someone who’s unconscious or not breathing, follows a specific set of steps. These steps are similar to those used for adults but require some special attention to certain factors. This is because children and newborns aren’t just smaller adults – their bodies work a little differently, so their health conditions and their treatments are different, too.
In 2020, the American Heart Association released an updated guide on how to perform resuscitation for children and newborns. This guide informs emergency care providers on how to respond effectively during a cardiovascular emergency with kids.
The American Academy of Pediatricians also offers a Neonatal Resuscitation Program. This means they have a specific guide for saving newborn babies who are having trouble breathing at birth. This guide covers everything from what could cause a baby to need help breathing at birth, how to give the right dose of medicine, what medical procedures to use, and how to provide care after the baby has been stabilized.
Anatomy and Physiology of Pediatric and Neonatal Resuscitation
Babies and children have different body structures and functions compared to adults, which can impact the approach to emergency medical help or resuscitation. For instance, a child’s jaw is noticeably shorter, providing less space for doctors to work with. Their voice box (or vocal cords) is positioned more to the front, making it harder to reach, and this is further complicated by their relatively larger head size.
Additionally, children often have larger tonsils and adenoids, which can obstruct the view for doctors during medical procedures. If the child was born prematurely, has birth defects, or was influenced by the mother’s health factors, these can all increase the difficulty of resuscitation.
In an emergent situation, common causes of a sudden heart attack in a child such as physical injuries, fluid collecting around the heart (tamponade), a collapsed lung (pneumothorax), or shock from significant blood loss or infection, should all be considered and treated promptly. Other potential conditions include diseases of the heart muscle (cardiomyopathies), inflammation of the heart (myocarditis), which might not have shown any noticeable symptoms before.
Disruptions in the body’s metabolism caused by internal diseases like severe infections (sepsis), or ingesting poisonous substances, could also lead to irregular heartbeat. In such cases, doctors will not only perform cardiopulmonary resuscitation (CPR), but also try to treat the underlying cause.
In certain cases, conditions causing abnormal heart rhythm, referred to as ‘channelopathies’, are a common cause for emergency heart situations and even sudden, unexpected death in infants (known as SIDS). Known or unknown channelopathies account for 2% to 10% of SIDS cases. Hence, once other common reasons are ruled out, doctors might consider this diagnosis.
Why do People Need Pediatric and Neonatal Resuscitation
If someone turns blue (known as becoming cyanotic), their heart stops (asystolic), or they stop breathing (respiratory arrest), measures to help them should be started straight away. Even if their heart rate is under 60 beats per minute and they seem very unwell, help can be started. If the person still has a heartbeat, they might be given breaths to help them breathe if it looks like they might soon stop breathing.
About 1 in 10 babies needs some medical help to start breathing when they’re born. And around 1 in 100 needs a lot of support. While help should be given immediately, it’s normal for all newborn babies to not have enough oxygen (known as being hypoxic) in their bodies right after birth. Oxygen levels should be about 60% right after birth and then go up by about 10% every two minutes.
When a Person Should Avoid Pediatric and Neonatal Resuscitation
Although every effort is made to protect the life of a newborn or an infant, sometimes certain birth defects or diseases can greatly decrease their quality of life or how long they might live. In such instances, it’s often considered reasonable not to attempt resuscitation. This might include babies born very prematurely; for example, statistics from 2013-2015 in the US showed that only about 9% of babies born at 22 weeks survived until they could leave the hospital. However, survival rates increase significantly even one week later, with roughly half of babies born at 23 weeks and almost 80% of babies born at 25 weeks surviving.
In situations where an illness is considered unsurvivable, it’s generally accepted that no extraordinary efforts need to be made to resuscitate the child. Ethically, there are no hard and fast rules about when to stop resuscitative efforts in children. However, in newborns, studies have found little sign of significant survival rates after 20 minutes of resuscitation, making it acceptable to consider stopping at any point after this time.
Facing end-of-life decisions is always difficult, and it’s important to include the family and appropriate medical staff, like palliative care specialists, in deciding the best plan. They can help make these tough decisions in a way that respects both medical ethics and the family’s wishes and comfort.
Equipment used for Pediatric and Neonatal Resuscitation
When a child requires assistance to breathe, doctors may place a special tube called a cuffed endotracheal tube (ETT) into their throat. The size of this tube is determined using an equation – add 3.5 to the child’s age divided by 4. If a different type of tube, an uncuffed ETT, is used, the equation changes slightly to add 4 instead of 3.5. In babies under 3 months, a size 3.0 tube might be needed. In some cases, the tube’s size can be calculated using the same size as the child’s pinky finger.
Once a child has been intubated (tube inserted), the amount of air pumped into the lungs (tidal volume), should be less than normal to prevent lung damage. It’s recommended to set it around 6 mL for each kilogram of their ideal body weight. The air pressure control (PEEP) doesn’t need to be adjusted. The tube shouldn’t be inflated too high (over 30 cm H20, or 25 for premature babies) because this could hurt the surrounding tissue and lead to a narrowing of the airway below the voice box (subglottic stenosis).
To put the tube in, doctors might use specific tools like the Miller blade or Mac blade to lift up the U-shaped skin flap at the back of the throat (epiglottis) and reveal the vocal cords. Alternatively, video tools like laryngoscopy and bronchoscopy can also be used.
If the child’s heart needs to be reset due to a problem with its rhythm, doctors could use a special tool called a defibrillator. The preferred devices can adjust the energy output depending on the child’s size (biphasic attenuated defibrillators), but adult devices can be used if necessary. The energy settings are usually 2 to 4 joules per kilogram of the child’s weight, but the first shock should be set at a lower dose. If the heart is beating too fast (tachyarrhythmias), the energy setting should be started at 0.5 joules/kg and increased to 2 joules/kg as necessary.
It’s very important that these shocks are timed with the heart’s rhythm. If they’re not, it could disrupt the heart rhythm and cause a serious condition called ventricular fibrillation or Torsades de Pointes, where the use of shocks fail to return the heart to its normal rhythm.
Who is needed to perform Pediatric and Neonatal Resuscitation?
If you’re in a medical facility, it’s important to always seek help when you need it. The help could be from a special section of the hospital called the Neonatal Intensive Care Unit (NICU), which treats newborn babies with health issues. It could also be from a pediatrician who specializes in your child’s specific condition, or it could be from a neonatologist (a doctor who specializes in newborn care) at another hospital.
If your child has recently come home from the NICU and is still not well, you’re going to need to get in touch with a Pediatric Intensive Care Unit (PICU). Calling a PICU doesn’t mean you can’t also talk to a neonatologist about your child’s condition.
Making these calls can help plan the next steps for your child’s care. Studies have found that it can be good for family members to be in the room when their loved ones are being treated. But keep in mind, family members need to be cooperative and not cause disruptions.
The American Heart Association (AHA) suggests that families should be given the choice to be present, and if there are enough staff, one should be made the main person to answer the family’s questions and share updates.
Remember, everyone’s safety is important. If your child has a serious infectious disease like COVID-19, steps should be taken to prevent others, including family members and medical staff, from getting sick.
Preparing for Pediatric and Neonatal Resuscitation
In case of an incoming health emergency for a child, it’s very important to let the teams at your hospital’s Pediatric or Neonatal Intensive Care Unit (PICU or NICU) know as soon as possible. These expert teams have special training to handle such critical situations smoothly and quickly. If the child already has known health issues from birth, their designated specialists can help give the best care and arrange for the child to be transferred to another hospital if needed.
The anesthesia team should also be informed if there’s a chance the child may struggle to breathe soon. It’s also crucial to have an emergency (code) cart and an airway cart at hand, with tools and devices that are sized right for children. These prepared measures greatly help to handle a high-stress situation in an effective way.
How is Pediatric and Neonatal Resuscitation performed
When a baby is born, it’s very important to keep them warm to prevent a condition called hypothermia, where the body gets too cold. The most common way to do this is by placing the baby skin-to-skin with the mother right after birth. This helps with feeding and helps the baby maintain the right body temperature. If the baby needs more help staying warm, there are several tools we can use like wraps, heat lamps, warm rooms, or heated and humid air. If the birth happens in a place without a lot of medical resources, a simple plastic bag (not covering the head) can be used to keep the baby warm.
Another important step right after birth involves the baby’s umbilical cord. Doctors usually wait at least 30 to 60 seconds after birth before clamping the umbilical cord, which can help the baby’s heart and lungs work better. This is a simple step that can prevent problems later. But if the baby needs immediate medical care, doctors won’t wait to clamp the cord.
The advice about when to clamp the cord can change in different situations. For example, researchers are still studying whether the risk of COVID-19 is different for babies born to mothers who have the virus. In some countries, this might affect the recommendations for skin-to-skin contact and cord clamping, but the evidence so far is not clear.
If a baby isn’t getting enough oxygen, we can give extra oxygen through a small plastic tube that fits into the baby’s nose. We start with a lower level of extra oxygen and can adjust it up as needed. If the baby still isn’t doing well, doctors will check for other problems that can happen at birth, like heart defects or lung abnormalities. In these cases, the baby might need more help with breathing, like breathing treatments or even a breathing tube.
Doctors use a standard method to cover the baby’s airway when putting in a breathing tube. If they need to be careful about the baby’s spine, they will use a different approach.
In a serious situation where the baby’s heart stops or the baby isn’t breathing, doctors will do chest compressions and give breaths – a process known as CPR. There are different methods for doing the compressions and different ratios of compressions to breaths depending on whether one person or two are doing the CPR. One important thing to watch during CPR is the baby’s blood pressure, because keeping it at the right level can greatly improve the baby’s chance of survival and of being okay afterwards. Fluids are important, too, and we can give them through a needle or tube.
Doctors use different medicines in different situations, depending on the baby’s weight and other factors. Some medicines can be given in different ways. For example, some can be given through a tube into the baby’s trachea (windpipe) if needed, but usually doctors prefer to give them through a vein or mouth. Certain heart medicines can be given through a smaller vein if needed at first, but usually doctors will want to put a tube into a larger vein as soon as they can.
If a baby’s heart rhythm is abnormal and doesn’t get better after treatments to shock the heart, doctors will use special medicines to try to correct the problem. They will keep monitoring the baby carefully after these treatments just like with adults.
There are special situations when doctors will use different treatments. For example, if they think a baby might have taken in drugs that slow breathing, they might give a medicine called naloxone. If a baby has heart failure or high blood pressure in the lungs, they might use medicines that can open up the blood vessels. If a baby was born with a heart problem that causes high blood pressure in the lungs, they might use blood thinners to keep certain passages in the heart open.
One common way babies can get sick is by choking on something or swallowing something they shouldn’t. If a baby is choking and making noise, there’s probably still some air getting through, but if they turn blue or don’t make noise, the airway might be completely closed off. If doctors see something stuck in the airway during an exam, they’ll try to remove it. If they can’t see the object or remove it, they might try other methods to help the baby’s body push it out. In this case, they’ll need to bring in other specialists like ear, nose and throat doctors, lung specialists, or possibly surgeons. Blindly sticking fingers into the throat to try and find the object is not advised, as this could push the object further down.
Possible Complications of Pediatric and Neonatal Resuscitation
While immediate treatment can be offered at most local healthcare facilities, long-term care or final treatments are normally provided at larger hospitals or those tailored for children. It’s crucial to begin arranging the required team of doctors as early as possible in the healing process. Depending on its availability, a treatment known as ECMO/ECPR (a machine that takes over the work of the heart and lungs) should be thought about early on when dealing with a cardiac arrest in hospital. This has not been confirmed as beneficial for incidents outside hospital. But, if the doctors’ judgement suggests it might be helpful, and certain conditions are met, this option should not be dismissed completely.
Usually, younger patients have better outcomes after a cardiac arrest. However, brain injury caused after the cardiac arrest continues to be a reason for serious illness or death, even among younger age groups. For that reason, tests such as EEGs (which measure brain activity) and treatments to prevent seizures are recommended for patients at risk after they recover a pulse following a cardiac arrest. For patients who die without a known cause, an autopsy (examination of a body after death) followed by possible genetic testing should be carried out.
This is not mandatory, but it’s important to stress to the family that this could help prevent any future family deaths if they discover the cause was genetic.
What Else Should I Know About Pediatric and Neonatal Resuscitation?
Recent research suggests that around 20,000 kids in the U.S. experience a ‘cardiac arrest’, or a sudden stop in heart function, each year. Out of these, about 7,000 cases happen outside hospital premises in 2015. The arrests occurring outside hospitals are mostly due to breathing difficulties, while inside hospitals, they are more often due to heart-related issues. This is because hospitals are more likely to have patients with uncommon heart conditions concentrated in one place.
But there is some good news. Almost 40% of kids suffering cardiac arrests within hospitals were able to overcome their condition and get discharged. On the other hand, about 11% of cardiac arrests happening outside hospitals saw the same favourable outcome. This aligns with data from adults, where longer durations without natural heart activity often lead to worse results. This data underscores the importance of medical staff being aware and capable of delivering the best possible care based on the most reliable evidence.
An interesting finding is that survival rates from cardiac arrest also varied with age, with younger children generally having a lower chance of survival.
