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Instructor Update

Summary of the AAP/AHA ECC Guidelines

fter five years in the making, the 2010 International Liaison Committee on Resuscitation (ILCOR) Consensus on Science and Treatment Recommendations (CoSTR) and the American Heart Association's Guidelines for Emergency Cardiovascular Care (ECC) were published on October 18. The ECC Guidelines include the newly revised 2010 American Academy of Pediatrics/American Heart Association Guidelines for Neonatal Resuscitation, serving as the core of the NRP 6th Edition materials. The guidelines were developed by the NRP Steering Committee based on evidence from over 30 evidence-based worksheets, representing thousands of hours of preparation, review, and oftentimes spirited debates, among the members of the Neonatal ILCOR, which laid the foundation for the CoSTR and ECC Guidelines. Evidence evaluation was conducted in stages and followed a very organized, methodical, and rigorous process. First, key issues were defined and indepth reviews of literature were completed. Then, a series of ILCOR meetings were held worldwide and debates occurred over several issues related

In This Issue

1 ummary of the aaP/aHa S eCC Guidelines 1 NrP 6th edition Key Dates/ Keep in Mind 2 6th edition Materials Q&a 4 6th edition Online examination Q&a 5 welcome and farewell 6 rP 5th anniversary in China N 6 rP and PaLS N 7 onducting a 6th edition C instructor Update 7 011 NrP research Grant and 2 Young investigator award Call for application 8 elping Babies Breathe Update H 9 mproving NrP Simulations: i Meconium 12 ongratulations to C Cathy Cropley, rN, MSN, CNS and Bill Keenan, MD, faaP 12 Preparing NrP rosters for the 6th edition

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to neonatal resuscitation. Once consensus was reached on the scientific evidence compiled by ILCOR, the CoSTR statements were finalized. Based on these statements, the NRP Steering Committee developed specific practice guidelines for use by NRP providers and instructors.

"EvidEncEEvAluAtionwAs conductEdinstAgEsAndfollowEd AvEryorgAnizEd,mEthodicAl, AndrigorousprocEss."

It is from these scientific documents that the NRP Steering Committee developed the revisions that will appear in the Textbook of Neonatal Resuscitation, 6th Edition, scheduled for release in April 2011. The following summary reflects the major changes to the 2010 Guidelines for Neonatal Resuscitation, which were published in Pediatrics and will appear as a reprint in the 6th Edition textbook. A summary of the changes that resulted from the ILCOR review follow.

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NRP 6th Edition Key Dates

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Keep in Mind...

· Starting on January 1, 2012 all learners will be required to take and pass the online examination before meeting with an instructor to complete the NRP course. · With the 6th Edition, there will no longer be an official distinction between provider and renewal courses; instructors will adjust the time spent on skills practice and scenarios based on the level of experience among the members of each class. · The NRP Instructor DVD: An Interactive Tool for Facilitation of Simulation-based Learning must be completed by January 1, 2012.

March 2011 · Wall Chart/Code Cart Card/Pocket Card April 2011 · Textbook of Neonatal Resuscitation, 6th Edition · 6th Edition Online Examination through HealthStream · Instructor's Manual for Neonatal Resuscitation · SimplyNRP

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the Neonatal resuscitation ProgramTM (NrP) Steering Committee offers the NRPInstructorUpdate to all aaP/aHa Neonatal resuscitation Program instructors. editor Jane e. McGowan, MD, faaP Managing editors rachel Poulin, MPH wendy Marie Simon, Ma, Cae Contributor Deborah Bullwinkel NRPSteeringCommittee Louis P. Halamek, MD, faaP, Cochair Stanford University Palo alto, Ca Jane e. McGowan, MD, faaP, Cochair associate editor TextbookofNeonatalResuscitation,6thEdition Drexel University College of Medicine Philadelphia, Pa Christopher Colby, MD, faaP Mayo Clinic rochester, MN Kimberly D. ernst, MD, MSMi, faaP University of Oklahoma Health Sciences Center Oklahoma City, OK Karen fairchild, MD, faaP University of Virginia Health System Charlottesville, Va George a. Little, MD, faaP Dartmouth-Hitchcock Medical Center Lebanon, NH Steven ringer, MD, PhD, faaP Brigham & women's Hospital Boston, Ma Myra H. wyckoff, MD, faaP University of texas Southwestern Medical Center Dallas, tX NRPTextbookEditor John Kattwinkel, MD, faaP University of Virginia Charlottesville, Va NRPSteeringCommitteeLiaisons John Gallagher, rrt-NPS american association for respiratory Care rainbow Babies & Children's Hospital Cleveland, OH Khalid aziz, MD, frCPC, faaP Canadian Paediatric Society royal alexandra Hospital edmonton, aB, Canada Praveen Kumar, MD, faaP aaP Committee on fetus and Newborn Northwestern Memorial Hospital Chicago, iL Mildred ramirez, MD, faCOG american College of Obstetricians and Gynecologists University of texas Health Science Center ­ Houston Houston, tX Barbara Nightengale, rN, MSN, NNP-BC National association of Neonatal Nurses west Virginia University Morgantown, wV Jeffrey Perlman, MB, ChB iLCOr Science Director Liaison aHa Pediatric Subcommittee New York Presbyterian Hospital New York, NY NRPSteeringCommitteeConsultants Jerry Short, PhD University of Virginia Charlottesville, Va Gary M. weiner, MD, faaP Saint Joseph Mercy Hospital ann arbor, Mi Jeanette Zaichkin, rN, MN, NNP-BC Seattle Children's Hospital Seattle, wa AAPStaffLiaisons Kristy Crilly Nancy Gardner rory Hand, edM Melissa Marx Bonnie Molnar rachel Poulin, MPH wendy Simon, Ma, Cae Statements and opinions expressed in this publication are those of the authors and are not necessarily those of the american academy of Pediatrics or american Heart association. Commentsandquestionsarewelcome andshouldbedirectedto: Jane e. McGowan, MD, faaP editor, NRPInstructorUpdate 141 Northwest Point Blvd., PO Box 927 elk Grove Village, illinois 60009-0927 www.aap.org/nrp © american academy of Pediatrics/ american Heart association, 2010

6th Edition Materials Q&A

he last several editions of the NRP Instructor Update have prepped NRP instructors for the changes headed their way with the American Academy of Pediatrics NRP 6th Edition materials. The new NRP materials represent a shift in approach to the NRP education process, eliminating the slide and lecture format and emphasizing a hands-on, interactive, simulation-based learning environment. The NRP 6th Edition is scheduled to launch in phases beginning December 2010 with the NRP Instructor DVD, and the rollout of the 6th Edition materials is expected to prompt many questions from NRP Instructors. The following Q&A is a compilation of key questions NRP Instructors may ask during the transition to the 6th Edition. NRP Instructors are encouraged to use this list as a resource ­ take this information and share with your colleagues, post near your computer, on your bulletin board, or in another convenient location at your institution to help guide your way through the 6th Edition of NRP. What materials will I need for the NRP 6th Edition? NRP Instructors will be required to purchase the NRP Instructor DVD. Instructors should also have access to the Textbook of Neonatal Resuscitation, 6th Edition and the Instructor's Manual for Neonatal Resuscitation. · NRP Instructor DVD: An Interactive Tool for Facilitation of Simulation-based Learning. This flexible, interactive learning tool features 21 video clips that demonstrate how to perform various resuscitation interventions, including how to use a pulse oximeter and laryngeal mask airway. The DVD also includes segments on how to facilitate effective debriefings and offers tips for creating scenarios in a classroom setting. · All current NRP Instructors will be required to purchase and watch the NRP Instructor DVD by January 1, 2012. The same requirement will apply to those who achieve Instructor status for the first time after January 1, 2012. The DVD will be available in December 2010 and will cost $64.95 ($59.95 through December 31, 2010). For more information about the NRP Instructor DVD, check out the article that appeared in the Spring/Summer 2010 edition of NRP Instructor Update. · Textbook of Neonatal Resuscitation & DVD, 6th Edition. The 6th Edition textbook and accompanying DVD will reflect the 2010 American Academy of Pediatrics and American Heart Association Guidelines for Neonatal Resuscitation. The 6th Edition textbook will be available in Spring 2011. All NRP courses wil be required to use the 6th Edition materials beginning January 1, 2012. · Instructor's Manual for Neonatal Resuscitation : The manual includes updated information on instructor requirements, the online examination, and simulation and debriefing. The manual, which will be available in Spring 2011, contains many valuable tips and tricks for organizing course schedules, developing realistic scenarios for simulations, carrying out successful debriefings, and loads of other useful information for those planning and facilitating NRP courses. · Slides will no longer be a part of the NRP course. The NRP 6th Edition will focus on a flexible, self-study format. This will allow NRP Instructors to concentrate on valuable hands-on skills practice, case-based resuscitation scenarios, and team debriefing sessions in the classroom.

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What are the new requirements for NRP Instructors? NRP Instructors should note several new requirements as the NRP 6th Edition begins its launch later this year. Primary requirements include: · Eligibility: NRP Hospital-based Instructors (HBI) and Regional Trainers must be physicians, registered nurses (including advanced practice nurses), respiratory care practitioners, or physician assistants who have hospital experience in the care of newborns in the delivery room, newborn nursery, or newborn intensive care setting. Exceptions to the above requirements will no longer be granted. · Current NRP Instructors must complete and pass all nine lessons of the NRP online examination every two years based on their renewal date, beginning January 2013. The online exam will be provided at no charge to NRP instructors renewing their instructor status. Continuing education credit will be offered to NRP Instructors who take the online exam. · NRP Instructor candidates must take the online examination and pass Lessons 1 through 9 prior to taking an Instructor course. The cost of the exam must be paid by the Instructor candidate or his/her institution, and will be approximately $15-25, depending on your institution status and the number of people taking the exam at your institution. Once Instructor status is achieved, the online exam will be available at no cost every two years thereafter if Instructor status is maintained. · Every current NRP Instructor must purchase and watch the NRP Instructor DVD: An Interactive Tool for Facilitation of Simulation-based Learning by January 1, 2012. · NRP Instructor candidates who plan to take an Instructor course after January 1, 2012 are required to watch the NRP Instructor DVD as a prerequisite for attending the HBI or Regional Trainer course.

Why is the written examination no longer available with the NRP 6th Edition materials? After much deliberation, the NRP Steering Committee decided that the NRP's objectives and educational goals would be best served by eliminating the written examination and replacing it with a mandatory online examination. Use of the online examination provides the opportunity for a selfpaced approach to learning that will allow the learners and instructors more flexibility. · Data from a national survey of Instructors indicated that instructors spend a majority of classroom time giving lectures and administering written exams; however, in the same survey, Instructors indicated that lectures were the least effective way to learn the NRP course material. The goal of the NRP Steering Committee is to shift the focus of Instructor-learner interactions in the classroom to handson training and simulation-based learning and debriefing exercises with the neonatal resuscitation team. How can I utilize the 2nd Edition SimplyNRP DVD? The 2nd Edition SimplyNRP DVD is a self-directed educational video designed to provide hands-on practice opportunities in a flexible learning environment. The DVD focuses on Lessons 1-4 from the Textbook of Neonatal Resuscitation, 6th Edition, based on the 2010 AAP/ AHA Guidelines for Neonatal Resuscitation. · This is an optional learning tool for NRP learners and can be purchased by institutions and loaned to Instructors and learners who seek self-directed learning opportunities.

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6th Edition Online Examination Q&A

As an NRP Instructor, when should I complete the online examination? Beginning January 1, 2013, NRP Instructors are required to take the 6th Edition online examination (Lessons 1 through 9) prior to their renewal date (free of charge). Even if other NRP Instructor requirements are complete, Instructors who fail to take the 6th Edition online exam by their renewal date after January 1, 2013 will lose their status as a Hospital-based Instructor or Regional Trainer. Instructors are encouraged to complete the 6th Edition NRP online examination beginning April 2011, but it is not an Instructor renewal requirement until the first renewal date after January 1, 2013. Will the online examination vendor change when the 6th Edition is released? The mandatory online examination for providers hosted by our new vendor, HealthStream, will be available when the 6th Edition materials are released. The optional online examination currently hosted by ExamWeb will continue to test knowledge of the 5th Edition NRP materials until 12/31/2011, after which all NRP courses must be taught with the 6th Edition educational materials. How will Instructors know if a student has completed the online examination? Each learner must print out a certificate of completion that will serve as their "ticket" for entry into an NRP course. Learners will also be able to print out any questions they missed on the online exam and show these to their instructors for additional guidance. Will the 5th Edition NRP online examination PINs be transferable to the 6th Edition NRP online examination? The 6th Edition online examination is hosted by a different vendor than the 5th Edition online examination, and, as such, PINs are not transferrable from one edition to the next. NRP courses are not required to utilize the 6th Edition educational materials until 1/1/2012. 5th Edition PINs will expire 12/31/2011.

Will my NRP learners have trouble understanding the material and passing the online examination without watching the slides and hearing the Instructor's explanation? NRP learners who work in a professional capacity in a healthcare setting are more than capable of reading and understanding the Textbook of Neonatal Resuscitation, 6th Edition. The Textbook of Neonatal Resuscitation, 6th Edition follows the same format that has earned the textbook critical acclaim for its simplicity and ease of use for many years. If learners prefer, they can use the DVDROM that accompanies each textbook to study instead of reading the textbook. Many learners enjoy the interactive components of the DVD more than reading the textbook. Many Instructors have voluntarily implemented self-study in preparation for taking the online examination requirement for courses based on the 5th Edition of the NRP Textbook, and, thus far, these requirements have not caused a problem for NRP learners or Instructors. In fact, most participants appreciate being able to self-study and take the online examination at their convenience instead of sitting through a lengthy set of lectures and waiting for fellow learners to finish their hard copy examinations.

"mostpArticipAntsApprEciAtEbEingAblEtosElf-studyAndtAkEthEonlinEExAminAtionAt thEirconvEniEncEinstEAdofsittingthroughAlEngthysEtoflEcturEsAndwAitingfor fEllowlEArnErstofinishthEirhArdcopyExAminAtions."

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Welcome and Farewell

transitionsinthenrpsteeringcommitteemembershipaccompanythe excitingchangesthatcharacterizetheAAp'sNeonatal Resuscitation Program, 6th Edition.inJuly,kimberlyd.Ernst,md,msmi,fAApbecamethe newestmemberofthecommitteeaftergaryweiner,md,fAApstepped downfollowingasix-yearstintonthenrpsteeringcommittee.

WelcomeKimberlyErnst,MD,MSMI,FAAP

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r Ernst, who holds a Master of Science degree in medical informatics from Northwestern University in Chicago in addition to the MD degree, said she is looking forward to applying her clinical background and knowledge of computer information technology to the many facets of NRP, including simulation-based training. "At my institution, I've gotten more involved with our simulation lab, particularly with a project that involves regularly training our third-year medical students in neonatal intubation," said Dr Ernst, Clinical Assistant Professor and Director of Education in NeonatalPerinatal Medicine at the University of Oklahoma College of Medicine in Oklahoma City. "I'd like to follow this group when they are 4th year medical students and observe their intubation skills at three month, six month, and one year intervals. I've gone back and reviewed evaluations from residents, and more of them have conveyed that they don't feel competent or comfortable enough with their resuscitation skills. This is a bit disturbing, especially since we spend so much time teaching neonatal intubation skills."

"iEnJoyEdEvErymomEntofmytimEonthE nrpstEEringcommittEEAndwAsblEssEd withExtrAordinAryopportunitiEstomEEt lEAdErsAndtruE`giAnts'inrEsuscitAtion fromAllovErthEworld."

Although Dr Weiner is no longer a member of the NRP Steering Committee, he will continue his involvement in other capacities, including his role as Cochair of the Instructor Development Task Force. "I enjoyed every moment of my time on the NRP Steering Committee and was blessed with extraordinary opportunities to meet leaders and true `giants' in resuscitation from all over the world," said Dr Weiner, who made tremendous contributions to the 6th Edition materials. "I was overwhelmed by the commitment and achievements of colleagues I met through the NRP, and look forward to the opportunity to make new contributions to the NRP." The NRP and AAP are pleased to welcome Dr Ernst and applaud Dr Weiner for his efforts, commitment, and dedication to the mission of the NRP.

"Atmyinstitution,i'vEgottEnmorEinvolvEd withoursimulAtionlAb,pArticulArlywith AproJEctthAtinvolvEsrEgulArlytrAining ourthird-yEArmEdicAlstudEntsin nEonAtAlintubAtion."

Dr Ernst said the key is to practice, practice, and practice some more until students can prove they possess the skills necessary to perform neonatal resuscitation. "I'd like to gain a better understanding of how people learn skills and how much people need to practice their skills before neonatal intubation becomes second nature to them," Dr Ernst said. "One of my primary goals is to determine how we evaluate competency.

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AAP Celebrates 5th Anniversary of NRP in China

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inseptember,theAmericanAcademyofpediatrics(AAp) celebratedthefifthanniversaryofaninternationalpartnership thathastaughtessentialneonatalresuscitationskillstobirth attendantsinchina,savinganestimated90,000infantswho wouldhavediedorbeenseriouslyinjuredfrombirthasphyxia.

ccording to national statistics from five years ago, more than one in five infant deaths in China were a result of birth asphyxia, making it the leading cause of mortality among children younger than 5 in Chinese cities. At the time, many areas in China lacked both equipment and training and relied on older methods for resuscitation.

LearnerspracticebagmaskventilationduringanNRPChinaevent.

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Foundation of Life" project, a neonatal resuscitation program. It is modeled on the Neonatal Resuscitation Program curriculum developed by the AAP and the American Heart Association, which is the gold standard program for neonatal resuscitation and is taught in 124 countries. The goal was to have at least one person skilled in neonatal resuscitation present at each hospital delivery. After five years, that goal has been reached, and more than 100,000 medical professionals from more than 20 provinces have been trained. In studies conducted by the China Ministry of Health, birth asphyxia mortality declined by 53 percent in 360 surveyed hospitals. "During the past five years the professional and public health leadership in China conducted the largest implementation of neonatal resuscitation training in the world," said William Keenan, MD, FAAP, executive director of the International Pediatric Association. "The astoundingly successful

international partnership model of the China Neonatal Resuscitation Program has served as the example for implementation programs in India and Pakistan." The partners also created an approach for neonatal resuscitation education focused on more rural China, which informed the development of Helping Babies Breathe. In June, AAP launched a global effort to SM introduce Helping Babies Breathe to the 63 countries participating in Millennium Development Goal 4, which aims for a reduction in under-5 child mortality by twothirds from 1990 levels by the year 2015. "The objectives of Millennium Development Goal 4 cannot be achieved without significant progress in the care of the newly born baby," said Judith S. Palfrey, MD, FAAP, president of the AAP. "China's very successful investment in newborn health is the working model for the rest of the countries struggling to achieve this objective."

"morEthAn100,000mEdicAl profEssionAlsfrom morEthAn20provincEs hAvEbEEntrAinEd."

In 2003, the AAP formed a partnership with the China Ministry of Health, the National Center for Women and Children's Health, the Chinese Society of Perinatal Medicine, and the Johnson and Johnson Pediatric Institute to launch the "Freedom of Breath,

NRP and PALS

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What's the difference between the American Academy of Pediatrics Neonatal Resuscitation Program (NRP) and the American Heart Association's Pediatric Advanced Life Support (PALS) course? While both courses provide important hands-on educational training opportunities, they do have some distinct differences and similarities. Both courses offer a systematic approach to assessing infants and children (algorithms) as well as follow similar educational methodologies. NRP and PALS courses encompass a realistic active learning environment with hands-on skills practice, case-based resuscitation scenarios, and team debriefing sessions. According to AAP literature, the NRP is an educational program designed to teach the appropriate step-by-step approach to neonatal resuscitation of a newborn within the first few minutes of birth in the delivery room or upon transfer to the NICU. The NRP emphasizes the

importance of administering positive-pressure ventilation during a neonatal resuscitation. The PALS course is described as one used to teach the recognition and treatment of critically ill infants and children over six months old who are at risk for cardio-pulmonary arrest. Treatment is administered during the first few minutes of a life threatening crisis. This course also covers treatment of an infant beyond the first few minutes of an emergency (infants approaching or already in respiratory or cardiac arrest). Neonatal healthcare practitioners might consider taking both the NRP and PALS courses if they work in a setting in which they would care for both newborns and older children. The AAP recommends that all healthcare professionals (ie, OB/GYN nurses, NICU nurses, anesthesiologists, etc.) who may find themselves in a situation to perform neonatal resuscitation take the NRP course.

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Conducting a 6th Edition Instructor Update

ow will you update your Instructors so that they are prepared and excited about beginning NRP 2012? Here is one example of how to conduct an Instructor update. Schedule your Instructor update to occur after your 6th Edition materials arrive. Ask each Instructor to prepare for the update by completing these activities before you meet as a group: 1. Watch the NRP Instructor DVD: An Interactive Tool for Facilitation of Simulation-based Learning and complete the educational activity. 2. Read the revised Instructor's Manual for Neonatal Resuscitation and answer the self-assessment questions in the manual. 3. Review the Textbook of Neonatal Resuscitation, 6th Edition and pass the online examination, Lessons 1 through 9 (current Instructors may take the examination at no cost). Requiring Instructors to complete these activities before the update reflects the same pre-course preparation expected of NRP providers. Most important, it reduces lecture time and allows Instructors more time for interactive, hands-on practice with new skills. When you meet as a group, spend a few minutes discussing your hospital's Neonatal Resuscitation Program. Do you need to re-organize any aspects of your program? Are there questions about Instructor roles and responsibilities? Review Instructor skills at Skill Stations. Ideally, there should be six or fewer people at each station at any one time. If there are more than six or seven people in the Instructor update session, another Instructor may be needed to work with a second team. Practice skills at the following stations and rotate teams to a new table about every 15 minutes:

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1. Create aids to enhance realism of scenarios (simulated blood, meconium, and vernix). 2. Demonstrate ways to give physiologic signals to learners if you are using a traditional mannequin for simulation and debriefing, and have Instructors practice using a metronome, a pulse oximeter made from a box, etc. to show heart rate and other vital signs. 3. Write a scenario using the template in the NRP Instructor DVD and Instructor Manual, or introduce a template that you prefer. 4. Review the basics of debriefing and distribute a tool (found in the NRP Instructor DVD and Instructor Manual) to help Instructors remember key questions. The only way to learn how to debrief is to actually practice it. 5. Practice facilitating Performance Skills Stations and asking reflective questions instead of giving feedback about the learner's performance. 6. Practice evaluating "learners" (your fellow Instructors) at the Integrated Skills Station. After practicing at the Skills Stations, ask each team of about 6 people to use a scenario they wrote at the Scenario Skill Station to conduct, film, facilitate, and debrief learners (the learners are other Instructors on a team or additional volunteers as needed). Film the scenario and practice setting it up for viewers. Practice using the film during debriefing. Film the debriefing, also. Using the debriefing tool you like from the NRP Instructor DVD or Instructor Manual, view the Instructors' techniques during the debriefing and "debrief the debriefers." This exercise quickly builds debriefing skills. A comprehensive Instructor update takes approximately 4 hours. Most of the time should be spent practicing simulation and debriefing, including analyzing the debriefing with the debriefers. Instructors who have had the opportunity to practice these skills before an actual provider course will be more confident and better prepared to facilitate a quality learning experience.

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2011 Call for Applications! NRP Research Grant and Young Investigator Award

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Any health care professional with an interest in neonatal resuscitation can submit a proposal for $20,000$50,000 through the NRP Research Grant Program.

Physicians-in-training or individuals within four years of completing fellowship training are eligible to apply for up to $10,000 through the NRP Young Investigator Award.

The American Academy of Pediatrics (AAP) Neonatal Resuscitation Program (NRP) Steering Committee and the Section on Perinatal Pediatrics are pleased to announce the availability of the 2010 Neonatal Resuscitation Program Research Grant and the NRP Young Investigator Award. The awards are designed to support basic science, clinical, educational, or epidemiological research pertaining to the broad area of neonatal resuscitation. Researchers from Canadian and US institutions are invited to apply. Potential applicants should submit an intent for application to the NRP Steering Committee by Friday, May 6, 2011. All intents will be reviewed and the committee will ask a select group to submit full proposals. Those selected to submit a full proposal will receive the formal application by Friday, June 24, 2011. Completed applications are due on Friday, August 19, 2011. To obtain the NRP Research Grant or NRP Young Investigator Award Program Guidelines and the Intent for Application, please contact: American Academy of Pediatrics, Division of Life Support Programs, 800/433-9016, Ext. 4798, www.aap.org/nrp.

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Helping Babies Breathe Update

seizingthe"goldenminute"afterbirthcanmeanthedifferencebetweenlifeanddeathforinfants. Anewprogramcalledhelpingbabiesbreatheissettingouttoimprovebirthratesindevelopingcountries, focusingonwhathappensduringthosefirst60secondsoflifewhenanewbornisnotbreathing.

very year, 940,000 die of intrapartumrelated neonatal deaths, 99% in developing countries without medical assistance, according to the World Health Organization (WHO). Helping Babies Breathe is working to change that statistic and achieve a WHO goal to reduce child mortality worldwide by two-thirds by 2015. The program, which launched during the International Conference on Global Health June 13 in Washington, DC, is a collaboration of the Academy, the US Agency for International Development, the Saving Newborn Lives initiative of Save the Children, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), with materials provided by Laerdal Medical AS. These organizations have committed to reducing the newborn mortality rate across the globe by training birth attendants in developing countries in the essential skills of newborn resuscitation. "There's a high level of enthusiasm because (Helping Babies Breathe) fills a gap in education and a gap in services provided to newborn babies," said William Keenan, MD, FAAP, Cochair of the Helping Babies Breathe Global Implementation Task Force and the AAP medical director, International Affairs. Helping Babies Breathe trains birth attendants to use just a few simple tools and techniques to assess a newborn in the first minute of life (Golden MinuteTM), to determine if the baby is breathing well or must be ventilated with a bag-and-mask. The aim of the program is to have at least one person skilled in neonatal resuscitation at the birth of every baby.

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A durable, easy-to-use training simulator was developed by Laerdal to complement educational materials, and it will be provided at a very low cost to developing countries. Successful pilot testing was completed in Bangladesh, India, Kenya, Pakistan and Tanzania. The next goal is to roll out the program to between 15 and 20 countries globally, by using established links with a core planning team in each of the governments, ministries of health and other contacts in developing countries.

said AAP President Judith S. Palfrey, MD, FAAP, who was among the 100 people from around the world who completed the Master Trainer program in Washington, DC. The evidence-based curriculum is adaptable to clinical and training use wherever babies are born and is based on the 2005 International Liaison Committee on Resuscitation Consensus on Science and Treatment Recommendations. "There is a major emphasis on scaling up the program to benefit as many people and support policy and program development on a lasting and sustainable basis," said Steve Wall, MD, FAAP senior advisor of Saving Newborn Lives at Save the Children, which assisted in technical review of the educational materials. What makes the teaching materials unique is their ease of use. Birth attendants can follow a pictorial action plan algorithm step-by-step. Previous programs were too complex and required a high level of advanced skills, Dr Wall said. "Physicians attend very few deliveries and are not the major provider in low resource settings in countries where there's high neonatal mortality," he said. Experts working in low resource countries have adapted the Neonatal Resuscitation Program materials with varying levels of success, said Dr Keenan. "We had the opportunity to take all of that expertise and (those) international experiences to make a program tailored to the resource limited parts of the world," he said.

"thErE'sAhighlEvElof EnthusiAsmbEcAusE (hElpingbAbiEsbrEAthE) fillsAgApinEducAtionAnd AgApinsErvicEsprovidEd tonEwbornbAbiEs,"

Master trainers designated in each country will train others, oversee data collection and act as a liaison between the country and the core planning team. New facilitators (birth attendants trained to train others) teach the program to other birth attendants in the community. "Helping Babies Breathe is a natural outgrowth of the highly successful Neonatal Resuscitation Program that has saved so many children around the world. The AAP is continuing its great tradition in intervening in a major problem that claims the lives of between 1 and 2 million infants a year,"

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Helping Babies Breathe will be one of the first well-monitored worldwide interventions, according to Linda Wright, MD, FAAP, deputy director, Center for Research for Mothers and Children and director, Global Network for Women's and Children's Health Research at NICHD. NICHD is developing a framework to track outcomes and monitor quality of the program.

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"It is very cutting edge because we are using new materials, we're resuscitating with room air ­ which has increasingly gotten favorable reviews from neonatologists in the United States ­ and we're primarily using stimulation first," said Dr Wright. What's being applied overseas can also help educators in the United States, said Dr Wright. "We've taken a practice that's worked and improved it more so by simplifying it. We should all be really proud as pediatricians that we have made this possible."

ReprintedwithPermissionfromAAPNews,Vol31,Num8,August31,2010.

JeffreyM.Perlman,MB,ChB,FAAP(left),HelpingBabiesBreatheGlobal ImplementationTaskForcemember,andAUdayaThomasofJhpiego­Innovating toSaveLives,Baltimore,observeasArthurMunfungwaNgoy,ofStJosephHospital, DominicanRepublicoftheCongo,appliesamaskanddeliversroomairtothe newbornsimulatorduringtheMasterTrainerprograminWashington,DC.

Improving NRP Simulations: Meconium

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Model

Simulated meconium can be created using pea soup, oatmeal and food coloring. Learners will be able to practice their recognition and treatment of newborns with meconium staining. (Figures 1 & 2)

Figure1

Materials

· Pea soup · Oatmeal · Disposable cup · Gloves · Tongue depressor · Green food coloring · Water

Method

Mix 2 tablespoons pea soup, 4 tablespoons oatmeal, and just enough water for the oatmeal to bind up. A very small drop of green food coloring can help if your soup is not sufficiently green. Lightly smear the mixture onto your manikin. (Figure 3)

Figure2

Discussion

Do not place anything in the manikin that you are not confident you can emove. Create scenarios where the newborn has meconium staining and is either vigorous or limp. This will encourage learners to think about the different resuscitation steps dictated by the NRP algorithm.

Figure3

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ECC Guidelines

Changes in the NRP Algorithm "The new algorithm will look quite different. The purpose was to try to simplify the information, highlight the importance of using a pulse oximeter whenever supplemental oxygen, positive pressure ventilation or continuous positive airway pressure are necessary, and to encourage a greater focus on assuring adequate positive pressure ventilation before starting chest compressions," said Dr Kattwinkel. Elimination of Evaluation of Amniotic Fluid in Initial Rapid Assessment There were lengthy discussions about meconium during the evidence evaluation process and in the end, the guidelines didn't change too much for the 6th Edition. This is primarily due to the limited new data available regarding management strategies to prevent meconium aspiration. A randomized controlled study conducted by Thomas E. Wiswell, MD, FAAP, former member of the NRP Steering Committee, found that endotracheal suctioning of meconium from an active baby following birth did not reduce the incidence of meconium aspiration syndrome. Therefore, if the baby is crying and breathing well, there is no reason to treat a meconium-stained baby any differently than a baby born through clear fluid, except for continuing to evaluate the baby carefully for evidence of compromise. That evaluation should be able to take place while the baby remains with the mother. "Meconium has been removed from the rapid assessment algorithm regarding the four questions to ask when deciding whether or not to begin resuscitation, but that's because we want to be able to keep an active meconium-stained newborn with his mother," Dr Kattwinkel said. "We still tell people to bring the baby to the resuscitation table and intubate and suction the meconiumstained baby's trachea if he's floppy and bradycardic, but if the baby has good tone and is breathing well despite the presence of meconium, we prefer to leave the baby with his mother." Use of Supplemental Oxygen During Neonatal Resuscitation Over the past 10 years, six randomized controlled clinical studies have been completed that demonstrate that, in most infants, beginning resuscitation with 100% supplemental oxygen offers no apparent advantage over beginning resuscitation with 21% oxygen. In addition, some of those studies suggest that using room air may be associated with slightly lower mortality rates and some additional studies suggest that using 100% oxygen may result in some degree of measurable tissue injury. "We spent a considerable amount of time debating this issue and found through the latest available scientific evidence that the concept of increasing a newborn's oxygen level as fast as possible with 100% supplemental oxygen is probably not the best approach," explained John Kattwinkel, MD, FAAP, editor of the revised Textbook of Neonatal Resuscitation, 5th Edition and Professor of Pediatrics at the University of Virginia in Charlottesville. "Rather, starting resuscitation of term babies with room air (ie, no supplemental oxygen) and carefully assessing the amount of oxygen needed for both term and preterm babies will be the recommendation." Additional epidemiologic studies suggest that exposure to supplemental oxygen in the delivery room can cause short- and long-term issues, added Jane McGowan, MD, FAAP, Cochair of the NRP Steering Committee. However, further prospective studies are needed to confirm this observation."

"AnytimEyou'rEplAnningtousEsupplEmEntAl oxygEn,youshouldconsidErusingApulsE oximEtEr.or,ifchAncEsArEhighthAtyou'rE goingtodElivErAprEtErminfAnt,thE guidElinEsrEcommEndhAvingAnoximEtEr immEdiAtElyAvAilAblEforApplicAtion."

Use of Pulse Oximetry "Pulse oximetry and oxygen use are probably the biggest changes in the 6th Edition," said Dr Kattwinkel, adding that having pulse oximeters available in delivery areas is encouraged and is highly recommended for use whenever supplemental oxygen, positive pressure ventilation, or continuous positive airway pressure are considered necessary. "Anytime you're planning to use supplemental oxygen, you should consider using a pulse oximeter. Or, if chances are high that you're going to deliver a preterm infant, the guidelines recommend having an oximeter immediately available for application," said Dr Kattwinkel. Chest Compressions In the 6th Edition, the chest compression to ventilation ratio will remain the same as the 5th Edition recommendation of three chest compressions to one ventilation (3:1), although the guidelines for older children and adults recommend more compressions and less PPV breaths. ILCOR and the NRP Steering Committee also strongly recommend performing endotracheal intubation, whenever possible, if chest compressions are started.

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"Keeping track of the NRP recommendations will be particularly confusing for people involved with PALS, ALS, and BLS courses because a much stronger emphasis will be placed on chest compressions for older children and adults," said Dr Kattwinkel. In contrast, the NRP focuses on ventilation, because respiratory problems are the most common reason that resuscitation is needed in the newborn.

Induced Therapeutic Hypothermia Scientific evidence now supports the use of early induced hypothermia as an effective therapy to reduce the incidence and severity of hypoxic-ischemic encephalopathy, whether induced by whole-body or selective head cooling. The 2010 Guidelines call for using induced therapeutic hypothermia in a tertiary care center where it can be implemented using well-defined protocols and where appropriate follow-up is available. "I'm concerned that some institutions, including smaller NICUs, may be tempted to institute therapeutic whole-body cooling independently because it's not very complicated. All you have to do is place the newborn on the cooling blanket and monitor," said Dr Kattwinkel. "We're concerned that the proper technique for maintaining the temperature in a narrow range and for the appropriate duration, and the necessary neurologic evaluation pre- and post-cooling may not be optimum in all facilities. We emphasize unless your institution has multispecialty expertise on staff to evaluate and care for the baby, you should consult with a regional perinatal center immediately after the resuscitation so that the appropriate protocol can be instituted." Teaching Methodologies for Encouraging Simulation and Debriefing Based on available evidence demonstrating the value of incorporating simulation-based exercises to teach neonatal resuscitation, the NRP Steering Committee suggests utilizing simulation, along with briefing and debriefing techniques, in designing an effective NRP education program. A number of studies demonstrate that the use of simulation-based learning methodologies enhances learner performance in simulated resuscitations in laboratory and classroom settings, and may improve resuscitation quality in real-life clinical situations. In part based on these data, the lecture and slide presentation format NRP Instructors have grown accustomed to will be a thing of the past with the new 6th Edition. In the classroom setting, the primary focus of the new NRP will encompass a realistic active learning environment with handson skills practice, case-based resuscitation scenarios, and team briefing and debriefing sessions following these hands-on training exercises. "This is about whether people can suspend disbelief and treat a simulated neonatal resuscitation scenario playing out in the classroom the same as they would a real resuscitation situation in the delivery room," explained Dr McGowan.

"nrpinstructorswillnEEdtoEmphAsizE thAtthEtwo-thumbtEchniquEcAnbEusEd fromdiffErEntAnglEs,suchAswhEnthE rEsuscitAtorgivingppvmAynEEdtomovEto thEhEAdofthEbEdtopErmitAcollEAguEto insErtAnumbilicAlvEnouscAthEtEr."

The new guidelines strongly encourage using the two-thumb versus the two-finger technique. "NRP Instructors will need to emphasize that the two-thumb technique can be used from different angles, such as when the resuscitator giving PPV may need to move to the head of the bed to permit a colleague to insert an umbilical venous catheter," said Dr Kattwinkel. "Although it's still acceptable to use the two-finger technique, this should be the exception rather than the rule." Another recommendation from the NRP Steering Committee is to increase the time between initiating chest compressions and interrupting compressions to assess heart rate from 30 seconds to 45-60 seconds or longer. "This recommendation is based on data from animal studies showing that longer than 30 seconds may be required after the compressions have started to establish effective coronary perfusion," explained Dr Kattwinkel.

N r P iN S t rUC tO r UPD ate

11

CONGRAtULAtIONS!

Cathy Cropley, RN, MSN, CNS and Bill Keenan, MD, FAAP

c

athy Cropley, RN, MSN, CNS received the Neonatal Resuscitation Program Lifetime Achievement Award during the 2010 AAP National Conference and Exhibition (NCE). The award recognizes Ms Cropley's vision, untiring efforts, and nursing expertise in developing the Neonatal Resuscitation Program. Ms Cropley has devoted her career to the care of neonates in various clinical, administrative, and educational positions. She trained at the University of Washington and assisted in developing the hospital's neonatal intensive care unit. She was head nurse and clinical nurse specialist (CNS) at Children's Hospital Los Angeles. At the Charles R. Drew Postgraduate Medical School she collaborated with Dr. Ronald Bloom in co-authoring the initial Neonatal Resuscitation Program text and participated in disseminating the program in the US, Canada, Poland, and Romania.

ill Keenan, MD, FAAP received the Virginia Apgar Award during the 2010 NCE in San Francisco California. The Virginia Apgar Award is given annually by the Section on Perinatal Pediatrics of the American Academy of Pediatrics to an individual whose career has had a continuing influence on the well-being of newborn infants. Dr Keenan has previously served on the NRP Steering Committee. As Cochair of the NRP Steering Committee, he was one of the initiators of the now well-established national and international training curriculum to teach neonatal resuscitation. He participated in the writing and editing of the first and several subsequent editions of the NRP Textbook and Instructor Manual. He initiated the effort to establish the scientific evidence base for resuscitation guidelines and emphasized the need for funding research in this area. Over the past four years, Dr Keenan has served as Helping Babies Breathe Cochair, and continues his dedication to implementing the program around the world.

b

BillKeenan,MD,FAAP(L),CathyCropley,RN,MN(C),andErrolAlden,MD,FAAP (R)atthe2010NRPCurrentIssuesSeminar.MsCropleyreceivedtheNRP LifetimeAchievementAward.

JohnKattwinkel,MD,FAAP(L)andBillKeenan,MD,FAAP(R)posingwiththeVirginiaApgarawardplaque.

Preparing NRP Rosters for the 6th Edition

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In preparation for the NRP 6th Edition, changes to the NRP roster are taking effect in November 2010. As of November 1, 2010, there will be no provider renewal courses; therefore, the Renewal course option has been removed from the course name field on the roster. All courses, even Provider Renewal courses taught prior to the change to the 6th Edition course, will be posted as provider courses. Additionally, the hospital ID field and the question "Is it Taught in A Hospital?" have been removed, so the hospital name and address must be entered by the Instructor.

The "Lessons Offered" section has been moved from the main roster page to the student information page. Instructors will mark the lessons each student has completed. This allows the Instructor to include students with different levels of responsibilities within the hospital in the same class, as well as those who are new to the program, and those who have been previously educated in the NRP. The changes to the roster apply to both 5th and 6th Editions; thus, after November 1, 2010, all 5th Edition rosters will be processed under the new format. Please visit the "What's New" section on the NRP Homepage at www.aap.org/nrp for further information, or email [email protected] with questions.

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