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The first golden minute — Is it relevant?

  • Tonia Branche
    Affiliations
    Division of Neonatology, Stanley Manne Children’s Research Institute, Ann and Robert H. Lurie Children’s Hospital, 225 E. Chicago Ave, Chicago, IL 60611, United States

    Department of Pediatrics, Northwestern University, Feinberg School of Medicine, 420 E. Superior St, Chicago, IL 60611, United States
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  • Marta Perez
    Affiliations
    Division of Neonatology, Stanley Manne Children’s Research Institute, Ann and Robert H. Lurie Children’s Hospital, 225 E. Chicago Ave, Chicago, IL 60611, United States

    Department of Pediatrics, Northwestern University, Feinberg School of Medicine, 420 E. Superior St, Chicago, IL 60611, United States
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  • Ola D. Saugstad
    Correspondence
    Corresponding author at: Department of Pediatric Research, Oslo University Hospital, PB 4965 Nydalen, 0424 Oslo, Norway.
    Affiliations
    Department of Pediatrics, Northwestern University, Feinberg School of Medicine, 420 E. Superior St, Chicago, IL 60611, United States

    Department of Pediatric Research, University of Oslo, Oslo University Hospital, Pb 4950 Nydalen, 0424 Oslo, Norway
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      To the Editor
      The first Golden Minute after birth has been identified as a critical window for establishing ventilation in a newborn. According to the International Liaison Committee on Resuscitation (ILCOR) algorithm, key interventions of drying, warming, wrapping in plastic (<28 weeks gestational age), airway positioning, stimulating, and auscultating the heart and respiratory rates should be quickly completed. If those interventions are unsuccessful in achieving spontaneous respiration, resuscitators should set up a pulse oximeter and provide respiratory support within The Golden Minute timeframe, which starts when the whole body is delivered.
      • Perlman J.M.
      • Wyllie J.
      • Kattwinkel J.
      • et al.
      Part 7: neonatal resuscitation: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations.
      • Saugstad O.D.
      Delivery room management of term and preterm newly born infants.
      Failure or delay to establish adequate ventilation soon after birth can lead to a hypoxic injury and neurodevelopmental sequelae.
      • Ersdal H.L.
      • Mduma E.
      • Svensen E.
      • Perlman J.M.
      Early initiation of basic resuscitation interventions including face mask ventilation may reduce birth asphyxia related mortality in low-income countries: a prospective descriptive observational study.
      Thus, timely assessment and intervention is paramount in delivery room resuscitation.
      Neonatal resuscitators in a variety of settings use the ILCOR algorithm to guide delivery room management, including countries implementing the Helping Babies Breathe (HBB) program, which provides resuscitation training and standardized guidelines to medical teams in low-resource settings. Algorithms such as the Neonatal Resuscitation Program apply the same timeline.
      Providers across a variety of settings agree it is challenging to complete the initial resuscitation steps, particularly assessing a heart rate and subsequently providing ventilation, within the Golden Minute regardless of access to resources. McCarthy et al. showed it might be difficult to achieve these fundamental steps within the first minute of life.
      • McCarthy L.K.
      • Morley C.J.
      • Davis P.G.
      • et al.
      Timing of interventions in the delivery room: does reality compare with neonatal resuscitation guidelines?.
      We therefore explored the feasibility of Golden Minute resuscitation by examining studies from different countries in which exact timing of initiation of bag and mask ventilation was described. Table 1 shows it is possible to provide first ventilation at or around 1 min of age; however, a wide range exists, with one study from Tanzania starting ventilation at a mean of 134 s after birth,
      • Thallinger M.
      • Ersdal H.L.
      • Francis F.
      • et al.
      Born not breathing: a randomised trial comparing two self-inflating bag-masks during newborn resuscitation in Tanzania.
      compared to 68 and 71 s in comparable populations in Uganda
      • Pejovic N.J.
      • Trevisanuto D.
      • Lubulwa C.
      • et al.
      Neonatal resuscitation using a laryngeal mask airway: a randomised trial in Uganda.
      and Nepal
      • Andersson O.
      • Rana N.
      • Ewald U.
      • et al.
      Intact cord resuscitation versus early cord clamping in the treatment of depressed newborn infants during the first 10 minutes of birth (Nepcord III) — a randomized clinical trial.
      (personal communication) respectively. This difference is concerning since Ersdal et al. demonstrated that every 30 s delay in intervention leads to increased mortality and poor outcomes.
      • Ersdal H.L.
      • Mduma E.
      • Svensen E.
      • Perlman J.M.
      Early initiation of basic resuscitation interventions including face mask ventilation may reduce birth asphyxia related mortality in low-income countries: a prospective descriptive observational study.
      Of note, in the Tanzania study, the mean heart rate was 102 bpm before the mean start time of bag and mask ventilation compared to the accepted practice in the Uganda study, where the heart rate was <100 bpm before ventilation was initiated.
      • Pejovic N.J.
      • Trevisanuto D.
      • Lubulwa C.
      • et al.
      Neonatal resuscitation using a laryngeal mask airway: a randomised trial in Uganda.
      Table 1Time to obtain first ventilation with bag and mask.
      Author/yearCountrySeconds
      Thallinger 2017
      • Thallinger M.
      • Ersdal H.L.
      • Francis F.
      • et al.
      Born not breathing: a randomised trial comparing two self-inflating bag-masks during newborn resuscitation in Tanzania.
      mean (SD)
      Tanzania134 (84.5)
      Pejovic 2018
      • Pejovic N.J.
      • Trevisanuto D.
      • Lubulwa C.
      • et al.
      Neonatal resuscitation using a laryngeal mask airway: a randomised trial in Uganda.
      mean (SD)
      Uganda68 (36)
      Andersson 2019
      • Andersson O.
      • Rana N.
      • Ewald U.
      • et al.
      Intact cord resuscitation versus early cord clamping in the treatment of depressed newborn infants during the first 10 minutes of birth (Nepcord III) — a randomized clinical trial.
      mean (SD) (early clamping)
      Nepal71 (31)
      Ersdal 2020
      • Ersdal H.L.
      • Eilevstjonn J.
      • Perlman J.
      • et al.
      Establishment of functional residual capacity at birth: observational study of 821 neonatal resuscitations.
      median (25th–75th percentiles)
      Tanzania109 (77−152)
      McCarthy et al. noted the intervals included in the ILCOR algorithm are based on expert consensus and not on research data.
      • McCarthy L.K.
      • Morley C.J.
      • Davis P.G.
      • et al.
      Timing of interventions in the delivery room: does reality compare with neonatal resuscitation guidelines?.
      While acknowledging the difficulty in completing all of the recommended interventions, especially initiation of ventilation, in the first 60 s of life, the question arises of whether there is benefit in ascribing to the guideline times as written, if they are consistently difficult to achieve. Infants can, however, still benefit from intervention outside of that window. Striving toward a goal of establishing adequate ventilation in the first minute of life seems to be possible, minimizing the risks of delayed care. Simulation and ongoing education of resuscitation team members may play a key role in reinforcing intervention timing and quick decision-making in the delivery room.

      Declaration of interests

      The authors Tonia Branche, Marta Perez, and Ola D. Saugstad have no financial interests to declare.

      Acknowledgment

      This work has received support from NIH grant K08HL124295 (MP).

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