One of the things that is done in neonatal resuscitation that isn’t part of resuscitating older patients is tactile stimulation. Babies who are apneic and/or floppy often receive stimulation in the form of rubbing the back, patting or flicking the feet, or, in the old days, slapping the butt (sometimes while held upside down by the feet!)
I have never been quite convinced of the efficacy of this, but haven’t thought much about how you would prove if it works or not, or even what “works” would mean. Does tactile stimulation actually start babies breathing sooner? Does it delay effective ventilation? In babies who are bradycardic is there any benefit?
I have seen babies receiving prolonged stimulation with little response, and have even been pushed aside by older nurses while I was trying to ventilate a baby so that they could give a really good rub of the babies back! It is such an ingrained practice that it is accepted uncritically in the initial steps of NRP.
I think it is possible that stimulation has no effect at all, and that the common observation of babies starting breathing after stimulation promotes a confirmation bias, “because they started breathing after being stimulated it must have been because of the stimulation”.
I think it is also possible that stimulation causes reflex respiratory effort, but only in babies that would have started breathing a few seconds later in any case, with no overall benefit.
I think it is also possible that there is enough impact that babies with moderate depression at birth might have a benefit, starting to breathe effectively earlier and even perhaps having an increasing heart rate if mildly bradycardic.
I think it is unlikely that a seriously depressed baby has a benefit, and that, for such a baby, stimulation runs a risk of delaying effective interventions.
How would you prove any of this? It would be difficult to do a prospective RCT, you would have to randomize babies to 2 different NRP type protocols, one with stimulation and one without, you’d need enough babies to include a substantial number who actually need intervention, and then you could look at time to effective ventilation, time to a stable heart rate, or something like that, as the outcome criterion. Could you ethically randomize babies to a no stimulation protocol? Could you get enough people to refrain from stimulation for the study to work?
I think the first thing should be to collect some reliable observational information about the impacts of stimulation. This new study has done just that: Baik-Schneditz N, et al. Tactile stimulation during neonatal transition and its effect on vital parameters in neonates during neonatal transition. Acta Paediatr. 2018 Video recordings and pulse oximeter recordings of babies during transition were analyzed. There were just over 50 term and 50 preterm babies included in the analysis. 18 of the preterms and 25 of the term babies were stimulated at some point. In the preterm group babies were often given respiratory assistance without stimulation, which rarely happened in the term babies, for whom most of the non-stimulated babies did not need any intervention. They weren’t able to measure direct respiratory impacts of stimulation, but they did show in the term babies that there was no change in the saturation or heart rate before and after the stimulation, (comparing the averages for 30 second periods). In the preterm babies heart rate did not change, but saturations increased (which of course might have happened anyway…).
Another study Dekker J, et al. Tactile Stimulation to Stimulate Spontaneous Breathing during Stabilization of Preterm Infants at Birth: A Retrospective Analysis. Frontiers in Pediatrics. 2017;5(61) analyzed practice regarding stimulation among preterm babies. The basic message is that practice was extremely variable. Which to my mind is completely appropriate, as there is really no evidence base for tactile stimulation at term, and even less (if you can have less than zero without becoming negative) after preterm delivery, then variability in practice should be expected, and should give room for observational studies, and then prospective studies.
Millions of babies are born every year who receive some sort of intervention after birth, failure to adequately adapt to life outside of the womb is a major cause of death and long term disability in the world. Our review of standardized training programs showed that such programs seem to improve survival, and that most survivors have good outcomes.
While awaiting good prospective studies what should we do? I think that, for a term baby with a good heart rate who does not breathe quickly after birth, rubbing the back or flicking their feet is probably harmless and might stimulate an increase in respiratory drive. If the baby is bradycardic or fails to respond within a very short interval (perhaps 20 seconds) then tactile stimulation should quickly be abandoned in favor of positive pressure ventilation.
I agree with you that we need more studies to see how the effective tactile stimulation is, but at the same time I think that giving 20 seconds for this stimulation is too much.
My view is based on the Neonatal Resuscitation Program issued by the American Academy of Pediatrics, whereas during the first 30 seconds, initial steps to be taken, which include (dry, warm, clear airway and stimulate)……so initial steps take 30 seconds and checking heart rate will come after this period.
what you think about stimulation before cord clamping and if that doesnt work start ventilation inmediatly
Why isn’t there already more studies about this? Hitting babies on the back while holding them upside down is a common thing in many countries. Research on this needs to be done soon otherwise many people might be at harm!
Anyway, great share Keith!