Study identifies challenges to neonatal resuscitation outside of hospitals

NEW ORLEANS – With about 62,000 babies born outside of hospitals each year, and 1 in 10 newborns needing help to start breathing, emergency medical services (EMS) responders must be ready to give expert newborn resuscitation care. However, new research being presented at the American Academy of Pediatrics (AAP) 2019 National Conference & Exhibition found many responders lack recent training in resuscitation techniques for infants and experience in caring for newborns.

The research abstract, “When Seconds Matter: Neonatal Resuscitation in the Prehospital Setting,” will be presented on Friday, Oct. 25, at the Ernest N. Morial Convention Center in New Orleans.

“Actions taken during the first seconds to minutes after a child’s birth can make the difference between life, death, and lifelong disability,” said abstract author Trang Huynh, MD, FAAP, Assistant Professor of Pediatrics and Director of Neonatal Telemedicine at Oregon Health & Science University.

“When EMS responders are called to help with an out-of-hospital birth, they need to be able to act decisively and effectively if the baby isn’t breathing,” Dr. Huynh said. However, Dr. Huynh said her team’s research shows that the effectiveness of neonatal resuscitation by EMS responders may be limited because pediatric EMS calls are infrequent, age-appropriate pediatric equipment is sparse, and first responders face unpredictable settings.

For the study, funded by the National Institutes of Health’s National Institute for Child Health and Human Development, 45 EMS teams consisting of 262 paramedics and emergency medical technicians (EMTs) were recruited from public fire and private transport agencies in Oregon. Participants responded to questions about neonatal resuscitation training, which determined that:

66% either never had the training or completed it more than 2 years ago.

16% reported feeling very or extremely comfortable caring for children under 1 month (compared with 71% for children aged 12-18 years), and 8% were not comfortable at all (compared with 1% for children aged 12-18 years).

half of the EMTs had not provided cared for a newborn for more than a total 30 days in the last year.

The researchers also analyzed videos of EMS teams responding to out-of-hospital neonatal simulations, in which the team responded to a simulated 911 dispatch to a home for a birth in progress. Neonatal Resuscitation Program (NRP) guidelines, she said, recommend maintaining body temperature by drying and warming the baby, and using a bag valve mask within the first minute after delivery if the baby is not breathing.

The video analysis showed that 20% of the teams dried and 2% of them warmed the newborn within the first 30 seconds, as according to NRP recommendations. While 100% of teams used bag valve breathing assistance, only 9% of the teams provided it within 60 seconds, as recommended by NRP.

None of the teams had neonatal bags; all had either pediatric or adult bags. In addition, 88% of the teams bagged at a rate that was too slow (less than 40 breaths per minute), and 96% bagged with too much volume. Only 59% evaluated for adequate ventilation with a bag valve mask.

Dr. Huynh said the findings highlight the importance of including the needs of prehospital EMS in efforts to improve neonatal resuscitation. She said potential improvement interventions include EMS-specific neonatal training, refresher trainings and simulations, and EMS equipment specific for the neonatal population.

Dr. Huynh will present an abstract of the study, available below, at 6 p.m. in rooms 343-345 at the Ernest N. Morial Convention Center.

In addition, Dr. Huynh will be among highlighted abstract authors who will give brief presentations and be available for interviews during a press conference starting at 12:30 p.m. on Saturday, Oct. 26, in rooms 208-209 (Press Office) of the Ernest N. Morial Convention Center. During the meeting, you may reach AAP media relations staff in the National Conference Press Room at 504-670-5406.

Please note: only the abstract is being presented at the meeting. In some cases, the researcher may have more data available to share with media, or may be preparing a longer article for submission to a journal.

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The American Academy of Pediatrics is an organization of 67,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well-being of infants, children, adolescents and young adults. For more information, visit

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Editor’s note: The abstract below contains an updated figures for annual U.S. out-of-hospital births and percentages of teams studied that dried, warmed and provided valve breathing assistance in accordance with NRP guidelines.

Title: When Seconds Matter: Neonatal Resuscitation in the Prehospital Setting

Trang Huynh, MD, FAAP

Background: There are approximately 62,000 out-of-hospital births per year in the United States. Up to
10% of newborns require some assistance to establish breathing at birth. Neonatal Resuscitation
Program (NRP) guidelines recommend maintaining normothermia by drying and warming and initiating
bag valve mask within the first minute after delivery. Emergency medical services (EMS) responders
must be prepared to provide expert resuscitative measures immediately after birth, but their
effectiveness may be limited because pediatric calls are infrequent, age-appropriate pediatric
equipment is sparse, and first responders face unpredictable settings. Objective: To assess comfort in
neonatal resuscitation and NRP compliance in the out-of-hospital EMS setting. Methods: We conducted
a structured, independent analysis for technical performance on videos of EMS teams responding to
out-of-hospital neonatal simulations. Teams completed a baseline survey assessing experience and
comfort with the material. Clinical scenario included EMS team responding to a simulated 911 dispatch
to a home for a birth in progress. Team performance was assessed using the Clinical Teamwork Scale
(CTS™). NRP skills were assessed using a structured technical performance tool. Results: 45 EMS teams
consisting of 262 paramedics and Emergency Medical Technicians (EMTs) were recruited from public fire
and private transport agencies in Oregon. 230 responded to questions about NRP training: 66% either
never had NRP training or completed NRP training more than 2 years ago. 16% reported feeling very or
extremely comfortable caring for children under 1 month (compared with 71% for children aged 12-18
years), and 8% were not comfortable at all (compared with 1% for children aged 12-18 years). Of 45 EMS
teams, 20%(n=9) dried and 2%(n=1) warmed the newborn within the first 30 seconds and 9%(n=4)
provided BVM within 60 seconds, as recommended by NRP. All teams performed BVM with a mean time
of BVM at 114 seconds (SD 53s). Only 73% ever dried the baby, with average time of 120 seconds (SD
147s), and 44% warmed the baby, with a mean time among those who performed of 327 seconds (SD
190s). No teams had neonatal bags; all used either pediatric or adult bags. Looking specifically at BVM
techniques, 88% bagged at a rate that was too slow (<40 breaths/min) and 96% bagged with too much
volume. Only 59% evaluated for adequate ventilation with BVM. Conclusions: EMS personnel have
limited comfort in neonatal resuscitation. Maintaining normothermia by warming and drying and
initiating BVM are critical but were often delayed or absent. Potential improvement interventions
include EMS-specific neonatal training, refresher trainings and simulations, and EMS equipment specific
for the neonatal population.

AAP media contacts: Laura Alessio, 630-626-6276,

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Lisa Black, 630-626-6084,

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