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.
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Failure or delay to establish adequate ventilation soon after birth can lead to a hypoxic injury and neurodevelopmental sequelae.3
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.
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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,5
compared to 68 and 71 s in comparable populations in Uganda6
and Nepal7
(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.3
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.6
Table 1Time to obtain first ventilation with bag and mask.
| Author/year | Country | Seconds |
|---|---|---|
| Thallinger 2017 5 mean (SD) | Tanzania | 134 (84.5) |
| Pejovic 2018 6 mean (SD) | Uganda | 68 (36) |
| Andersson 2019 7 mean (SD) (early clamping) | Nepal | 71 (31) |
| Ersdal 2020 8 median (25th–75th percentiles) | Tanzania | 109 (77−152) |
McCarthy et al. noted the intervals included in the ILCOR algorithm are based on expert consensus and not on research data.
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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).
References
- Part 7: neonatal resuscitation: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations.Circulation. 2015; 132: S204-41
- Delivery room management of term and preterm newly born infants.Neonatology. 2015; 107: 365-371
- 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.Resuscitation. 2012; 83: 869-873
- Timing of interventions in the delivery room: does reality compare with neonatal resuscitation guidelines?.J Pediatr. 2013; 163: 1553-1557
- Born not breathing: a randomised trial comparing two self-inflating bag-masks during newborn resuscitation in Tanzania.Resuscitation. 2017; 116: 66-72
- Neonatal resuscitation using a laryngeal mask airway: a randomised trial in Uganda.Arch Dis Child. 2018; 103: 255-260
- 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.Matern Health Neonatol Perinatol. 2019; 5: 15
- Establishment of functional residual capacity at birth: observational study of 821 neonatal resuscitations.Resuscitation. 2020; 153: 71-78
Article info
Publication history
Published online: September 10, 2020
Received:
August 25,
2020
Identification
Copyright
© 2020 Elsevier B.V. All rights reserved.
