24.1 Newborn Life Support and Paediatric Life Support

24.1 Newborn Life Support and Paediatric Life Support

Why Newborns and Children Are Different

In adults, sudden cardiac arrest is usually caused by a primary arrhythmia. In children, arrest is usually the end point of hypoxia or shock, so the rhythm is often bradycardia progressing to asystole or pulseless electrical activity. This explains why airway opening and ventilation come first and why the initial breaths are emphasised.

Newborn Life Support (NLS)

Preparation and Initial Steps

• In uncompromised infants, delay cord clamping for at least 60 seconds; if immediate resuscitation is needed and delayed clamping is not possible, cord milking may be considered in infants of 28 weeks or more (follow local policy).
• Keep the baby warm: dry and wrap term babies; place preterm babies below about 32 weeks into a plastic bag or wrap without drying, under a radiant heater. Aim for a temperature of 36.5-37.5 °C.
• Assess tone, breathing and heart rate (heart rate by stethoscope; ECG gives a more reliable reading during resuscitation).

Algorithm

Birth --> Dry, warm, stimulate; assess tone, breathing, heart rate
   |
   +-- Not breathing or gasping:
   |     Open airway (neutral head position, jaw thrust)
   |     5 INFLATION BREATHS (2-3 s each; about 30 cmH2O term,
   |       about 25 cmH2O preterm below 32 weeks)
   |     Reassess heart rate
   |
   +-- No chest rise: re-position, two-person jaw thrust, suction under vision,
   |     consider supraglottic airway or tracheal tube, then repeat inflation breaths
   |
   +-- Chest moving: VENTILATION BREATHS 30 per minute
   |
   +-- Heart rate below 60/min after 30 s of effective ventilation:
         CHEST COMPRESSIONS 3:1 (about 15 cycles per 30 s), increase oxygen to 100%
         Consider drugs via umbilical venous catheter or intraosseous needle

Oxygen

Start with air (21%) for term and late preterm babies (35 weeks or more), about 21-30% at 32-34 weeks and 30% below 32 weeks, then titrate to target pre-ductal saturations measured on the right hand or wrist. Saturations rise gradually after birth (for example about 85% by 5 minutes and about 90% by 10 minutes in healthy term infants). Hyperoxia is harmful, especially in preterm infants.

Compressions and Drugs

• Technique: two-thumb encircling technique on the lower third of the sternum, depth one-third of the chest.
• Ratio: 3:1, about 90 compressions and 30 breaths per minute.
• Adrenaline: 20 $\mu\text{g/kg}$ (range 10-30 $\mu\text{g/kg}$) intravenously or intraosseously if the heart rate remains below 60/min despite effective ventilation and compressions; repeat every 3-5 minutes. Tracheal adrenaline (about 100 $\mu\text{g/kg}$) is used only if no other access exists.
• Glucose (about 250 mg/kg, 2.5 mL/kg of 10%) for hypoglycaemia; volume (10 mL/kg of crystalloid or blood) for suspected blood loss; sodium bicarbonate may be considered in prolonged arrest.

Meconium

Routine suctioning of the airway of a non-vigorous baby born through meconium-stained fluid is not recommended; focus on starting ventilation within the first minute. Suction under direct vision only if the airway is obstructed.

Paediatric Life Support (PLS)

Basic Life Support Sequence

1. Ensure safety, check responsiveness, shout for help.
2. Open the airway: head tilt and chin lift (neutral position in infants, "sniffing" in older children) or jaw thrust.
3. Look, listen and feel for breathing for up to 10 seconds.
4. If not breathing normally, give 5 rescue breaths.
5. If there are no signs of life, start chest compressions at 15:2 (healthcare providers), rate 100-120 per minute, depth at least one-third of the anterior-posterior chest diameter (about 4 cm in infants, 5 cm in children, no more than 6 cm).

A single lay rescuer without a phone should perform about 1 minute of CPR before going for help, because the arrest is likely to be hypoxic.

Advanced Life Support

• Maximum single doses: adrenaline 1 mg, amiodarone 300 mg (first dose).
• Intraosseous access (proximal tibia, distal femur, proximal humerus) is recommended if intravenous access is not achieved within about 1 minute.
• Treat reversible causes (4 Hs and 4 Ts), with emphasis on hypoxia and hypovolaemia.

Practical Calculations

The Seriously Ill Child

Use a structured ABCDE approach. Early warning signs include tachypnoea, increased work of breathing (recession, grunting, nasal flaring), tachycardia, prolonged capillary refill time (above 2 seconds), reduced consciousness and hypotension, which is a late sign of shock in children. Bradycardia in a hypoxic child is a pre-arrest sign.

Post-Resuscitation Care

Avoid hypoxaemia and hyperoxaemia (target saturations of about 94-98%), maintain normocapnia, avoid hypotension, treat fever, maintain normoglycaemia, and arrange transfer to paediatric intensive care.

Foreign Body Airway Obstruction

• Effective cough: encourage coughing and observe.
• Ineffective cough, conscious: up to 5 back blows then up to 5 chest thrusts (infants) or 5 abdominal thrusts (children over 1 year), alternating.
• Unconscious: open the airway, give 5 rescue breaths and start CPR.