Neonatal Resuscitation Program ™ and Helping Babies Breathe ®

1. Neonatal Resuscitation Program™ and Helping Babies Breathe® The past, present, and future of neonatal resuscitation efforts worldwide (and lessons learned along the way) Errol R. Alden, MD, FAAP AAP Executive Director/CEO November 2011

2. Objectives • Provide an overview of the AAP’s “Neonatal Resuscitation Program” and “Helping Babies Breathe” • Highlight the importance of working with local authorities • Demonstrate the translation of science into practice • Share lessons learned

3. Neonatal Resuscitation • Of the 130 million babies born each year, about 4 million die in the first 4 weeks of life. A quarter of these deaths are due to asphyxia. • It is estimated that an additional million develop problems such as cerebral palsy and other disabilities. World Health Report 2005

4. Neonatal Resuscitation • The vast majority of newborn infants do not require intervention from intrauterine to extrauterine life. • Approximately 10% of newborns require some assistance to begin breathing at birth. • About 1% of newborns require extensive resuscitation

5. Inverted Pyramidof Neonatal Resuscitation 136 million babies born Assessment at Birth and Simple Newborn Care All infants Initial Steps: Drying, Warmth, Clearing the Airway, Stimulation Approx 10 million babies Approx 6 million babies Some infants Positive-Pressure Ventilation Chest Compressions < 1.4 million babies Few infants Medications Wall, Lee, Niermeyer et al. IJGO 2009

6. Pathophysiologic Cardio-Pulmonary Consequences of Asphyxia Dawes Foetal and Neonatal Physiology. Year Book Medical Publishers Inc; 1968.

7. Some Recommendations for Resuscitation (1850-1950) • Rectal stimulation (stretching of the rectum with a corn cob) • Tobacco smoke blown into the rectum • Immersion into cold water(+ alternating with warm water)

8. Some Recommendations for Resuscitation (1850-1950) O2 O2 O2 • Intragastric oxygen • Rhythmic traction of the tongue • Rubbing, slapping, and pinching • Raising and lowering of the arms, while an assistant compresses the chest

9. Consequences of Poor Neonatal Resuscitation Increased Death Increased Disability Emotional & Financial Burden Direct Community Costs Loss of Productivity

10. Neonatal Resuscitation Program • mid-1970s: Dr Bloom and Cathy Cropley receive NICHD award to develop an initial simple way to focus neonatal resuscitation teaching • 1981: Dr George Peckham, an AHA volunteer and AAP Perinatal Section Chair, advocated for development of a standardized core curriculum • 1985: Dr Peckham and Dr Leon Chameides discussed models and outlined the “train the trainer” approach for dissemination Ron Bloom Cathy Cropley

11. Neonatal Resuscitation Program • 1986: Dr Peckham and Dr Bill Keenan, AAP Perinatal Section Leaders, began seeking buy-in from neonatology community for such an endeavor • First NRP textbook (1987): based on consensus opinions of leaders in neonatology regarding what was “accepted” practice • First 2-day NRP course occurred in November 1987

12. The Neonatal Resuscitation Program American Academy of Pediatrics American Heart Association The NRP is designed to guide resuscitation of the newborn infant in the critical few minutes during and immediately following birth.

13. NRP: Program Goal To have at least one person trained in neonatal resuscitation present at every delivery in the United States.

14. Early NRP Mead Johnson Nutritionals: Neonatal Resuscitation

15. NRP: US Program History In 24 years: • 2.9 million providers have been trained/retrained. Currently in the United States: • There are more than 27,000 active instructors. • Approximately 130 courses are held each day.

16. Lesson #2: Convince others the mission is their own Romania 1991

17. NRP 6th Edition Update • Pulse oximetry added • Meconium suctioning recommendations changed • Use of supplemental oxygen during resuscitation

18. NRP 6th Edition Update, Continued • Increase time between initiating chest compressions and interrupting compressions to assess heart rate • Induced therapeutic hypothermia • Simulation-based educational methodology

19. NRP Now Textbook of Neonatal Resuscitation, 6th Edition, 2011

20. NRP Outcomes • Asphyxia decreased in 10 provinces in China after training with NRP. (Huishan et al 2008) • In the first decade, deaths due to birth asphyxia in the US decreased 42%. (Wegman 1991) • Introduction of NRP in 10 hospitals in India reduced overall neonatal mortality by 7 per 1000. (Deorari 2000)

21. NRP Outcomes, Continued Guyer B et al. Annual Summary of Vital Statistics - 1996 Pediatrics 1997; 100:90

22. NRP: Reach of Program Although reporting of international NRP courses is voluntary, training has been reported in more than 125 countries and translated into 26 languages. Of all the educational material produced by the American Academy of Pediatrics, the NRP is the most widely used around the world.

23. Lesson #3: Expertise doesn’t necessarily equal ability to teach Laos & Thailand

24. Lesson #4: Being an expert in your own country doesn’t mean you’re an expert in other countries.

25. NRP Reach Sites of NRP Implementation Transferability….to more than 125 countries

26. Lesson #5: Humor may not translate, but laughter is universal

27. NRP in Developing Countries • While NRP has been embraced internationally, the content and format is routinely altered to meet the needs of the learners in developing countries.

28. NRP in Developing Countries • The challenge has been to develop a curriculum, based on the same rigorous science of NRP, that is culturally effective and meets the needs of those who live in resource limited settings.

29. NRP in Developing Countries • Developing an effective curriculum for limited resource settings would impact Millennium Development Goal #4, which is to reduce by two thirds, the under-five mortality rate.

30. Helping Babies Breathe®

31. Global Causes of Neonatal Death UNICEF 2007 Lee, Wall, Cousens et al. Int J Epidemiol (in press)

32. Big Target of Helping Babies Breathe 1 million “stillbirths” due to asphyxia 830,000 neonatal deaths due to asphyxia Lawn JE et al. IJGO 2009; 107:S5

33. Helping Babies Breathe Concept • International Liaison Committee on Resuscitation (ILCOR) Science • Harmonious With NRP & WHO Recommendation, if feasible • Non-Profit, Inclusive • Directed To Resource Limited Conditions - Single Provider

34. Helping Babies Breathe Curricular Concept Pictorial Limited Text Hands On Performance Frequent Skills Practice Simplest Steps “Possible” The Golden Minute

35. Hands on Practice

36. Educational Design • Adult Learning - TOT, Visual Tool kit Hands on • Performance - OSCE Evidence-Based • Learner to Facilitator - 6:1 • Learning in Pairs

37. Paired Teaching/Learning

38. Neonatal Physiology Hypoxia-apnea, slow heart rate Breathing for the Baby-rapid reversal Delays-increase mortality, morbidity

39. Field Testing • Educational Approaches Tanzania, Kenya, India, Pakistan • Modified MCQ, Problem-Solving, OSCE Tanzania, Kenya, India, Pakistan • Simulator India • Implementation Studies Kenya, India, Bangladesh

40. Educational Field TestingBirth Attendants • Increase Level of Skills Attained • Testing OSCE • Revision of MCQs • Revision of Bag/Mask Instruction • Revision of OSCEs

41. Implementation Field Testing • Knowledge Acquisition improved • Skills Testing – 98% Passed • Resuscitation Required ↑ Stimulation↓ BMV, Suction • 6-12 Hours of Training

42. Clinical Outcomes • ↓ death at 24 hours among babies not breathing at birth (RR = 0.46) with no change in stillbirths - Tanzania • N=6928/7277 pre/post training • ↓ stillbirths (RR = 0.73) with no change in neonatal deaths – India • N=4173/5427 pre/post training

43. Helping Babies Breathe Tool Kit • Action Plan • Learner Workbook • Facilitator Flip Chart • Multiple Choice Questions • OSCE • Simulator-Purpose Built • Bag/Mask/Suction/Stethoscope

44. Flipchart Simulator Workbook

45. Routine Care Clearing the airway if meconium present Drying infant Recognize crying Keeping warm Cutting the umbilical cord Encouraging breastfeeding

46. The Golden Minute® Recognizing infant not crying Positioning head Clearing the airway Stimulating Recognizing breathing Initiating ventilation by 1 minute

47. Global Development Alliance for Country-Wide Implementation • American Academy of Pediatrics • US Agency for International Development • Saving Newborn Lives/Save the Children • Eunice Kennedy Shriver National Institute of Child Health and Human Development • Laerdal Global Health

48. Global Development Alliance • Overall Objective • Reduce newborn mortality due to asphyxia • Guiding Principles • Inclusiveness and collaboration • Country-owned and country-led • Integration with maternal and essential newborn care • Shared goal, results, and recognition • Brand non-exclusivity

49. Global Development Alliance The GDA continues to grow each day with new partners: • Johnson and Johnson • Latter Day Saints Charities Soon to be added: • Columbia University Earth Institute Millennium Villages/Cities Project • International Pediatric Association

50. Ongoing Steps • Global Development Alliance • NICHD Studies • Country-wide Implementation • Facilitator Video • Translations • ENC (Essential Newborn Care) and EMONC (Emergency Obstetric and Neonatal Care)