Practical aims to maintain neonatal resuscitation skills

In this issue of the Journal of Paediatrics and Child Health, Boo and Pong1 report the results of a prospective observational study of the dissemination of a neonatal resuscitation program in Malaysia. In Malaysia, a train-the-trainer model was used where trainees become instructors running training courses. Program funding, including the purchase of mannequins, intubation heads and resuscitation equipment was borne by the Ministry of Health. The course was modelled on the format of the Neonatal Resuscitation Program (NRP), first developed by the American Heart Association and American Academy of Pediatrics in 1979 with frequent subsequent updates.2 Neonatal resuscitation programs are well established in the USA and Canada and taught in 25 countries worldwide. The Australian States and Territories are in their infancy in establishing NRP courses, however paediatric advanced life support courses have been successfully implemented for 5–10 years. The NRP contains an excellent education manual which follows a self-paced learning format. It begins with an introductory section including pathophysiology, followed by a series of lessons on the different activities associated with neonatal resuscitation.2 Each lesson building on the skills learnt in the previous one. Lessons include initial evaluation and management of newborns at risk, preparation and use of equipment for assisted ventilation, performance of chest compression and endotracheal intubation, and the use of drugs for severely ill infants. The goals of the NRP courses are that every newborn has a right to a resuscitation performed at a high level of competence. At least one person skilled in neonatal resuscitation should be in attendance at every delivery and an additional skilled person should be readily available if required. Appropriate equipment must be immediately available, well maintained and clinical staff must be familiar with its function. Finally, familiarity with the NRP will ensure that clinical staff will be capable of working effectively as a team. The universal problems of training courses, namely that the skills and training required for instructors, are not well defined and the retention of knowledge and skill, both for the provider and instructor, are not well documented. This was addressed in a systematic review of randomized trials.3 Boo and Pong stated that even though they reached their aim of training large numbers of clinical staff, the retention of skill and knowledge of some instructors was poor. There were less than four personnel per instructor a year, of whom many were not primarily involved in clinical neonatology.1 It was not possible to assess whether the introduction of the program had reduced perinatal mortality or morbidity. The introduction of a NRP has been documented to decrease neonatal mortality, hypothermia and meconium aspiration.4 The NRP emphasizes that the quicker the initial steps in resuscitation are, the less the need for CPR, intubation and medications. Most neonates respond to drying, warming, suctioning and tactile stimulation and over zealous and invasive resuscitation are unwarranted in most cases.5 Thorough suctioning of the nose, mouth and posterior pharynx before delivery of the body decreases the risk of meconium aspiration syndrome. The International Liaison Committee on Resuscitation, with representation from Australia, New Zealand and four other countries, was formed in 1992 to provide a forum for liaison between resuscitation organizations in the developed world.6 Recognition and immediate resuscitation of a distressed neonate requires an organized plan of action and the immediate availability of equipment and of qualified personnel. Preparation for resuscitation needs the availability of skilled personnel and equipment, communication with clinicians and parents, appropriate environmental conditions, practice of standard precautions and a concept of integrated assessment. Special resuscitation planning is required for multiple birth, prematurity, meconium stained liquor and surgical conditions.7 The introduction of a structured Neonatal Resuscitation Program in delivery and operating suites results in decreased instances of hypothermia and meconium aspiration syndrome, and increased use of free oxygen and effective bag and mask ventilation with consequent decreased need for intubation and positive pressure ventilation.

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