Birth Antenatal counseling Team briefing and equipment check Neonatal Resuscitation Algorithm. In newly born babies receiving resuscitation, if there is no heart rate and all the steps of resuscitation have been performed, cessation of resuscitation efforts should be discussed with the team and the family. After an uncomplicated term or late preterm birth, it is reasonable to delay cord clamping until after the baby is placed on the mother, dried, and assessed for breathing, tone, and activity. The guidelines form the basis of the AAP/American Heart Association (AHA) Neonatal Resuscitation Program (NRP), 8th edition, which will be available in June 2021. Monday - Friday: 7 a.m. 7 p.m. CT Reduce the inflation pressure if the chest is moving well. Teams and individuals who provide neonatal resuscitation are faced with many challenges with respect to the knowledge, skills, and behaviors needed to perform effectively. Reassess heart rate and breathing at least every 30 seconds. For nonvigorous newborns with meconium-stained fluid, endotracheal suctioning is indicated only if obstruction limits positive pressure ventilation, because suctioning does not improve outcomes. With the symptoms of The dose of epinephrine is .5-1ml/kg by ETT or .1-.3ml/kg in the concentration of 1:10,000 (0.1mg/ml), which is to be followed by 0.5-1ml flush of normal saline. Case series in preterm infants have found that most preterm infants can be resuscitated using PPV inflation pressures in the range of 20 to 25 cm H. An observational study including 1962 infants between 23 and 33 weeks gestational age reported lower rates of mortality and chronic lung disease when giving PPV with PEEP versus no PEEP. Epinephrine dosing may be repeated every three to five minutes if the heart rate remains less than 60 beats per minute. The heart rate should be re- checked after 1 minute of giving compressions and ventilations. As mortality and severe morbidities decline with biomedical advancements and improvements in healthcare delivery, there is decreased ability to have adequate power for some clinical questions using traditional individual patient randomized trials. The ILCOR task force review, when comparing PPV with sustained inflation breaths, defined PPV to have an inspiratory time of 1 second or less, based on expert opinion. The 2015 Neonatal Resuscitation Algorithm and the major concepts based on sections of the algorithm continue to be relevant in 2020 (Figure(link opens in new window)(link opens in new window)). Watch a recording of Innov8te NRP: An Introduction to the NRP 8th Edition: Three webinars hosted by RQI Partners to discuss changes to the 8 th edition NRP and the new RQI for NRP Posted 2/19/21. 1 minuteb. Supplemental oxygen: 100 vs. 21 percent (room air). This link is provided for convenience only and is not an endorsement of either the linked-to entity or any product or service. No type of routine suctioning is helpful, even for nonvigorous newborns delivered through meconium-stained amniotic fluid. Approximately 10% of newborns require assistance to breathe after birth.13,5,13 Newborn resuscitation requires training, preparation, and teamwork. The AAP released the 8th edition of the Neonatal Resuscitation Program in June 2021. None of these studies evaluate outcomes of resuscitation that extends beyond 20 minutes of age, by which time the likelihood of intact survival was very low. Compared with preterm infants receiving early cord clamping, those receiving delayed cord clamping were less likely to receive medications for hypotension in a meta-analysis of 6 RCTs. The following knowledge gaps require further research: For all these gaps, it is important that we have information on outcomes considered critical or important by both healthcare providers and families of newborn infants. June 2021 The NRP 8th Edition introduces a new educational methodology to better meet the needs of health care professionals who manage the newly born baby. Newer methods of chest compression, using a sustained inflation that maintains lung inflation while providing chest compressions, are under investigation and cannot be recommended at this time outside research protocols.12,13. Rescuer 2 verbalizes the need for chest compressions. When vascular access is required in the newly born, the umbilical venous route is preferred. It may be possible to identify conditions in which withholding or discontinuation of resuscitative efforts may be reasonably considered by families and care providers. Rapid and effective response and performance are critical to good newborn outcomes. Comprehensive disclosure information for peer reviewers is listed in Appendix 2(link opens in new window). Endotracheal suctioning for apparent airway obstruction with MSAF is based on expert opinion. Newly born infants who breathe spontaneously need to establish a functional residual capacity after birth.8 Some newly born infants experience respiratory distress, which manifests as labored breathing or persistent cyanosis. The importance of skin-to-skin care in healthy babies is reinforced as a means of promoting parental bonding, breast feeding, and normothermia. Additional personnel are necessary if risk factors for complicated resuscitation are present. Nearly 10 percent of the more than 4 million infants born in the United States annually need some assistance to begin breathing at birth, with approximately 1 percent needing extensive resuscitation1,2 and about 0.2 to 0.3 percent developing moderate or severe hypoxic-ischemic encephalopathy.3 Mortality in infants with hypoxic-ischemic encephalopathy ranges from 6 to 30 percent, and significant morbidity, such as cerebral palsy and long-term disabilities, occurs in 20 to 30 percent of survivors.4 The Neonatal Resuscitation Program (NRP), which was initiated in 1987 to identify infants at risk of respiratory depression and provide high-quality resuscitation, underwent major updates in 2006 and 2010.1,57, A 1987 study showed that nearly 78 percent of Canadian hospitals did not have a neonatal resuscitation team, and physicians were called into a significant number of community hospitals (69 percent) for neonatal resuscitation because they were not in-house.8 National guidelines in the United States and Canada recommend that a team or persons trained in neonatal resuscitation be promptly available for every birth.9,10 Actual institutional compliance with this guideline is unknown. Excessive chest wall movement should be avoided.2,6, In spontaneously breathing preterm infants with respiratory distress, either CPAP or endotracheal intubation with mechanical ventilation may be used.1,5,6, In preterm infants less than 32 weeks' gestation, an initial oxygen concentration of more than 21 percent (30 to 40 percent), but less than 100 percent should be used. Author disclosure: No relevant financial affiliations. See Part 2: Evidence Evaluation and Guidelines Development for more details on this process.11. Immediate, unlimited access to all AFP content, Immediate, unlimited access to this issue's content. The same study demonstrated that the risk of death or prolonged admission increases 16% for every 30-second delay in initiating PPV. Once return of spontaneous circulation (ROSC) is achieved, the supplemental oxygen concentration may be decreased to target a physiological level based on pulse oximetry to reduce the risks associated with hyperoxia.1,2. Positive-pressure ventilation should be started in newborns who are gasping, apneic, or with a heart rate below 100 beats per minute by 60 seconds of life. ECG provides the most rapid and accurate measurement of the newborns heart rate at birth and during resuscitation. If epinephrine is administered via endotracheal tube, a dose of 0.05 to 0.1 mg per kg (1:10,000 solution) is needed.1,2,57, Early volume expansion with crystalloid (10 mL per kg) or red blood cells is indicated for blood loss when the heart rate does not increase with resuscitation.5,6, Use of naloxone is not recommended as part of initial resuscitation of infants with respiratory depression in the delivery room.1,2,5,6, Very rarely, sodium bicarbonate may be useful after resuscitation.6, Term or near term infants with evolving moderate to severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia.57, Intravenous glucose infusion should be started soon after resuscitation to avoid hypoglycemia.5,6, It is recommended to cover preterm infants less than 28 weeks' gestation in polyethylene wrap after birth and place them under a radiant warmer. With secondary apnea, the heart rate continues to drop, and blood pressure decreases as well. Three out of seven (43%) and 12/15 (80%) lambs achieved ROSC after the rst dose of epinephrine with 1-mL and 2.5-mL ush respectively (p = 0.08). Hyperlinked references are provided to facilitate quick access and review. However, free radicals are generated when successful resuscitation results in reperfusion and restoration of oxygen delivery to organs.44 Use of 100 percent oxygen may increase the load of oxygen free radicals, which can potentially lead to end-organ damage. Initiate effective PPV for 30 seconds and reassess the heart rate. Please see updates below from RQI Partners, the company that is providing the NRP Learning Platform TM and RQI for NRP. One large retrospective review found that 0.04% of newborns received volume resuscitation in the delivery room, confirming that it is a relatively uncommon event. In preterm newly born infants, the routine use of sustained inflations to initiate resuscitation is potentially harmful and should not be performed. Neonatal resuscitation program Your team is resuscitating a newborn whose heart rate remains less than 60 bpm despite effective PPV and 60 seconds of chest compressions. Breathing: Assist breathing with PPV if baby apneic, gasping, or bradycardic. For nonvigorous newborns (presenting with apnea or ineffective breathing effort) delivered through MSAF, routine laryngoscopy with or without tracheal suctioning is not recommended. Physicians who provide obstetric care should be aware of maternal-fetal risk factors1 and should assess the risk of respiratory depression with each delivery.19 The obstetric team should inform the neonatal resuscitation team of the risk status for each delivery and continue to focus on obstetric care. The heart rate is reassessed,6 and if it continues to be less than 60 bpm, synchronized chest compressions and PPV are initiated in a 3:1 ratio (three compressions and one PPV).5,6 Chest compressions can be done using two thumbs, with fingers encircling the chest and supporting the back (preferred), or using two fingers, with a second hand supporting the back.5,6 Compressions should be delivered to the lower one-third of the sternum to a depth of approximately one-third of the anteroposterior diameter.5,6 The heart rate is reassessed at 45- to 60-second intervals, and chest compressions are stopped once the heart rate exceeds 60 bpm.5,6, Epinephrine is indicated if the infant's heart rate continues to be less than 60 bpm after 30 seconds of adequate PPV with 100 percent oxygen and chest compressions. Prevention of hyperthermia (temperature greater than 38C) is reasonable due to an increased risk of adverse outcomes. Other important goals include establishment and maintenance of cardiovascular and temperature stability as well as the promotion of mother-infant bonding and breast feeding, recognizing that healthy babies transition naturally. Administer epinephrine, preferably intravenously, if response to chest compressions is poor. Each 2020 AHA Guidelines for CPR and ECC document was submitted for blinded peer review to 5 subject matter experts nominated by the AHA. When providing chest compressions with the 2 thumbencircling hands technique, the hands encircle the chest while the thumbs depress the sternum.1,2 The 2 thumbencircling hands technique can be performed from the side of the infant or from above the head of the newborn.1 Performing chest compressions with the 2 thumbencircling hands technique from above the head facilitates placement of an umbilical venous catheter. Oximetry and electrocardiography are important adjuncts in babies requiring resuscitation. Early cord clamping (within 30 seconds) may interfere with healthy transition because it leaves fetal blood in the placenta rather than filling the newborns circulating volume. External validity might be improved by studying the relevant learner or provider populations and by measuring the impact on critical patient and system outcomes rather than limiting study to learner outcomes. However, it may be reasonable to increase inspired oxygen to 100% if there was no response to PPV with lower concentrations. Suctioning may be considered if PPV is required and the airway appears obstructed. IV epinephrine every 3-5 minutes. In a retrospective review, early hypoglycemia was a risk factor for brain injury in infants with acidemia requiring resuscitation. If the baby is bradycardic (HR <60 per minute) after 90 seconds of resuscitation with a lower concentration of oxygen, oxygen concentration should be increased to 100% until recovery of a normal heart rate (Class IIb, LOE B). Most newly born infants do not require immediate cord clamping or resuscitation and can be evaluated and monitored during skin-to-skin contact with their mothers after birth. There are limited data comparing the different approaches to heart rate assessment during neonatal resuscitation on other neonatal outcomes. Various combinations of warming strategies (or bundles) may be reasonable to prevent hypothermia in very preterm babies. The updated guidelines also provide indications for chest compressions and for the use of intravenous epinephrine, which is the preferred route of administration, and recommend not to use sodium bicarbonate or naloxone during resuscitation. While vascular access is being obtained, it may be reasonable to administer endotracheal epinephrine at a larger dose (0.05 to 0.1 mg/kg). The 2 thumbencircling hands technique achieved greater depth, less fatigue, and less variability with each compression compared with the 2-finger technique. 0.5 mL Appropriate resuscitation must be available for each of the more than 4 million infants born annually in the United States. The decision to continue or discontinue resuscitative efforts should be individualized and should be considered at about 20 minutes after birth. No studies have examined PEEP vs. no PEEP when positive pressure ventilation is used after birth. Hand position is correct. Pulse oximetry with oxygen targeting is recommended in this population.3, Most newborns who are apneic or have ineffective breathing at birth will respond to initial steps of newborn resuscitation (positioning to open the airway, clearing secretions, drying, and tactile stimulation) or to effective PPV with a rise in heart rate and improved breathing. In preterm infants younger than 30 weeks' gestation, continuous positive airway pressure instead of intubation reduces bronchopulmonary dysplasia or death with a number needed to treat of 25. In newly born infants who require PPV, it is reasonable to use peak inflation pressure to inflate the lung and achieve a rise in heart rate. A team or persons trained in neonatal resuscitation should be promptly available to provide resuscitation. Copyright 2023 American Academy of Family Physicians. Clinical assessment of heart rate by auscultation or palpation may be unreliable and inaccurate.14 Compared to ECG, pulse oximetry is both slower in detecting the heart rate and tends to be inaccurate during the first few minutes after birth.5,6,1012 Underestimation of heart rate can lead to potentially unnecessary interventions. When feasible, well-designed multicenter randomized clinical trials are still optimal to generate the highest-quality evidence. The following sections are worth special attention. The baby could attempt to breathe and then endure primary apnea. A meta-analysis of 3 RCTs (low certainty of evidence) and a further single RCT suggest that nonvigorous newborns delivered through MSAF have the same outcomes (survival, need for respiratory support, or neurodevelopment) whether they are suctioned before or after the initiation of PPV. The effect of briefing and debriefing on longer-term and critical outcomes remains uncertain. The International Liaison Committee on Resuscitation (ILCOR) Formula for Survival emphasizes 3 essential components for good resuscitation outcomes: guidelines based on sound resuscitation science, effective education of resuscitation providers, and implementation of effective and timely resuscitation.8 The 2020 neonatal guidelines contain recommendations, based on the best available resuscitation science, for the most impactful steps to perform in the birthing room and in the neonatal period. One moderate quality RCT found higher rates of hyperthermia with exothermic mattresses. Most babies will respond to this intervention. *Red Dress DHHS, Go Red AHA ; National Wear Red Day is a registered trademark. If resuscitation is required, heart rate should be monitored by electrocardiography as early as possible. Administration of epinephrine via a low-lying umbilical venous catheter provides the most rapid and reliable medication delivery. During resuscitation of term and preterm newborns, the use of electrocardiography (ECG) for the rapid and accurate measurement of the newborns heart rate may be reasonable. High oxygen concentrations are recommended during chest compressions based on expert opinion. Although current guidelines recommend using 100% oxygen while providing chest compressions, no studies have confirmed a benefit of using 100% oxygen compared to any other oxygen concentration, including air (21%). Consequently, all newly born babies should be attended to by at least 1 person skilled and equipped to provide PPV. Approximately 10% of infants require help to begin breathing at birth, and 1% need intensive resuscitation. If the heart rate is less than 60 bpm, begin chest compressions. Birth 1 minute If HR remains <60 bpm, Consider hypovolemia. However, if heart rate remains less than 60/min after ventilating with 100% oxygen (preferably through an endotracheal tube) and chest compressions, administration of epinephrine is indicated. All Rights Reserved. Infants with unintentional hypothermia (temperature less than 36C) immediately after stabilization should be rewarmed to avoid complications associated with low body temperature (including increased mortality, brain injury, hypoglycemia, and respiratory distress). Very low-quality evidence from 8 nonrandomized studies. This is partly due to the challenges of performing large randomized controlled trials (RCTs) in the delivery room. Newborn temperature should be maintained between 97.7F and 99.5F (36.5C and 37.5C), because mortality and morbidity increase with hypothermia, especially in preterm and low birth weight infants. Cord milking in preterm infants should be avoided because of increased risk of intraventricular hemorrhage. This article has been copublished in Pediatrics. Contact Us, Hours The frequency and format of booster training or refresher training that best supports retention of neonatal resuscitation knowledge, technical skills, and behavioral skills, The effects of briefing and debriefing on team performance, Optimal cord management strategies for various populations, including nonvigorous infants and those with congenital heart or lung disease, Optimal management of nonvigorous infants with MSAF, The most effective device(s) and interface(s) for providing PPV, Impact of routine use of the ECG during neonatal resuscitation on resuscitation, Feasibility and effectiveness of new technologies for rapid heart rate measurement (such as electric, ultrasonic, or optical devices), Optimal oxygen management during and after resuscitation, Novel techniques for effective delivery of CPR, such as chest compressions accompanied by sustained inflation, Optimal timing, dosing, dose interval, and delivery routes for epinephrine or other vasoactive drugs, including earlier use in very depressed newly born infants, Indications for volume expansion, as well as optimal dosing, timing, and type of volume, The management of pulseless electric activity, Management of the preterm newborn during and after resuscitation, Management of congenital anomalies of the heart and lungs during and after resuscitation, Resuscitation of newborns in the neonatal unit after the newly born period, Resuscitation of newborns in other settings up to 28 days of age, Optimal dose, route, and timing of surfactant in at-risk newborns, including less-invasive administration techniques, Indications for therapeutic hypothermia in babies with mild HIE and in those born at less than 36 weeks' gestational age, Adjunctive therapies to therapeutic hypothermia, Optimal rewarming strategy for newly born infants with unintentional hypothermia. The dose of Epinephrine via the UVC is 0.1 mg/kg - 0.5 mg/kg It may be easier for you to use 0.1 mg/kg for the UVC access.. For an infant weighing 1 kg the dose becomes 0.1 ml. Team briefings promote effective teamwork and communication, and support patient safety.8,1012, During an uncomplicated term or late preterm birth, it may be reasonable to defer cord clamping until after the infant is placed on the mother and assessed for breathing and activity. Given the evidence for ECG during initial steps of PPV, expert opinion is that ECG should be used when providing chest compressions. The impact of therapeutic hypothermia on infants less than 36 weeks gestational age with HIE is unclear and is a subject of ongoing research trials. These 2020 AHA neonatal resuscitation guidelines are based on the extensive evidence evaluation performed in conjunction with the ILCOR and affiliated ILCOR member councils. In other situations, clamping and cutting of the cord may also be deferred while respiratory, cardiovascular, and thermal transition is evaluated and initial steps are undertaken. 7272 Greenville Ave. In term and late preterm newborns (35 wk or more of gestation) receiving respiratory support at birth, 100% oxygen should not be used because it is associated with excess mortality. Coordinate chest compressions with ventilations at a ratio of 3:1 and a rate of 120 events per minute to achieve approximately 90 compressions and 30 breaths per minute. Numerous nonrandomized quality improvement (very low to low certainty) studies support the use of warming adjunct bundles.. The use of radiant warmers, plastic bags and wraps (with a cap), increased room temperature, and warmed humidified inspired gases can be effective in preventing hypothermia in preterm babies in the delivery room. Before giving PPV, the airway should be cleared by gently suctioning the mouth first and then the nose with a bulb syringe. Readers are directed to the AHA website for the most recent guidance.12, The following sections briefly describe the process of evidence review and guideline development. Delayed cord clamping is associated with higher hematocrit after birth and better iron levels in infancy.921 While developmental outcomes have not been adequately assessed, iron deficiency is associated with impaired motor and cognitive development.2426 It is reasonable to delay cord clamping (longer than 30 seconds) in preterm babies because it reduces need for blood pressure support and transfusion and may improve survival.18, There are insufficient studies in babies requiring PPV before cord clamping to make a recommendation.22 Early cord clamping should be considered for cases when placental transfusion is unlikely to occur, such as maternal hemorrhage or hemodynamic instability, placental abruption, or placenta previa.27 There is no evidence of maternal harm from delayed cord clamping compared with early cord clamping.1012,2834 Cord milking is being studied as an alternative to delayed cord clamping but should be avoided in babies less than 28 weeks gestational age, because it is associated with brain injury.23, Temperature should be measured and recorded after birth and monitored as a measure of quality.1 The temperature of newly born babies should be maintained between 36.5C and 37.5C.2 Hypothermia (less than 36C) should be prevented as it is associated with increased neonatal mortality and morbidity, especially in very preterm (less than 33 weeks) and very low-birthweight babies (less than 1500 g), who are at increased risk for hypothermia.35,7 It is also reasonable to prevent hyperthermia as it may be associated with harm.4,6, Healthy babies should be skin-to-skin after birth.8 For preterm and low-birth-weight babies or babies requiring resuscitation, warming adjuncts (increased ambient temperature [greater than 23C], skin-to-skin care, radiant warmers, plastic wraps or bags, hats, blankets, exothermic mattresses, and warmed humidified inspired gases)10,11,14 individually or in combination may reduce the risk of hypothermia. The American Heart Association requests that this document be cited as follows: Aziz K, Lee HC, Escobedo MB, Hoover AV, Kamath-Rayne BD, Kapadia VS, Magid DJ, Niermeyer S, Schmolzer GM, Szyld E, Weiner GM, Wyckoff MH, Yamada NK, Zaichkin J. Researchers studying these gaps may need to consider innovations in clinical trial design; examples include pragmatic study designs and novel consent processes. If the heart rate is less than 100 bpm and/or the infant has apnea or gasping respiration, positive pressure ventilation (PPV) via face mask is initiated with 21 percent oxygen (room air) or blended oxygen, and the pulse oximeter probe is applied to the right hand/wrist to monitor heart rate and oxygen saturation.5,6 The heart rate is reassessed after 30 seconds, and if it is less than 100 bpm, PPV is optimized to ensure adequate ventilation, and heart rate is checked again in 30 seconds.57 If the heart rate is less than 60 bpm after 30 seconds of effective PPV, chest compressions are started with continued PPV with 100 percent oxygen (3:1 ratio of compressions to ventilation; 90 compressions and 30 breaths per minute) for 45 to 60 seconds.57 If the heart rate continues to be less than 60 bpm despite adequate ventilation and chest compressions, epinephrine is administered via umbilical venous catheter (or less optimally via endotracheal tube).57, Depending on the skill of the resuscitator, the infant can be intubated and PPV delivered via endotracheal tube if chest compressions are needed or if bag and mask ventilation is prolonged or ineffective (with no chest rise).5 Heart rate, respiratory effort, and color are reassessed and verbalized every 30 seconds as PPV and chest compressions are performed. Exhaled carbon dioxide detectors to confirm endotracheal tube placement. The dose of epinephrine can be re-peated after 3-5 minutes if the initial dose is ineffective or can be repeated immediately if initial dose is given by endo-tracheal tube in the absence of an intravenous access. A team or persons trained in neonatal resuscitation should be promptly available at all deliveries to provide complete resuscitation, including endotracheal intubation and administration of medications. (Heart rate is 50/min.) Before appointment, all peer reviewers were required to disclose relationships with industry and any other potential conflicts of interest, and all disclosures were reviewed by AHA staff. CPAP, a form of respiratory support, helps newly born infants keep their lungs open. For neonatal resuscitation providers, it may be reasonable to brief before delivery and debrief after neonatal resuscitation. Hyperthermia should be avoided.1,2,6, Delivery room temperature should be set at at least 78.8F (26C) for infants less than 28 weeks' gestation.6. History and physical examination findings suggestive of blood loss include a pale appearance, weak pulses, and persistent bradycardia (heart rate less than 60/min). Similarly, meta-analysis of 2 quasi-randomized trials showed no difference in moderate-to-severe neurodevelopmental impairment at 1 to 3 years of age. Effective team behaviors, such as anticipation, communication, briefing, equipment checks, and assignment of roles, result in improved team performance and neonatal outcome. When providing chest compressions to a newborn, it may be reasonable to choose the 2 thumbencircling hands technique over the 2-finger technique, as the 2 thumbencircling hands technique is associated with improved blood pressure and less provider fatigue. Because evidence and guidance are evolving with the COVID-19 situation, this interim guidance is maintained separately from the ECC guidelines. Every birth should be attended by at least 1 person who can perform the initial steps of newborn resuscitation and initiate PPV, and whose only responsibility is the care of the newborn. increase in the newborn's heart rate is the most sensitive indicator of a successful response to resuscitation. CPAP indicates continuous positive airway pressure; ECG, electrocardiographic; ETT, endotracheal tube; HR, heart rate; IV, intravenous; O2, oxygen; Spo2, oxygen saturation; and UVC, umbilical venous catheter. Important aspects of neonatal resuscitation are the hospital policy and planning that ensure necessary equipment and personnel are present before delivery.1 Anticipation and preparation are essential elements for successful resuscitation,18 and this requires timely and accurate communication between the obstetric team and the neonatal resuscitation team. During The initiation of chest compressions in newborn babies with a heart rate less than 60/min is based on expert opinion because there are no clinical or physiological human studies addressing this question. The reduced heart rate that occurs in this situation can be reversed with tactile stimulation. Team debrieng. This content is owned by the AAFP. Variables to be considered may include whether the resuscitation was considered optimal, availability of advanced neonatal care (such as therapeutic hypothermia), specific circumstances before delivery, and wishes expressed by the family.3,6, Some babies are so sick or immature at birth that survival is unlikely, even if neonatal resuscitation and intensive care are provided.
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