Neonatal Resuscitation Program™
and Helping Babies Breathe®
The past, present, and future of neonatal
resuscitation efforts worldwide
(and lessons learned along the way)
Errol R. Alden, MD, FAAP
AAP Executive Director/CEO
November 2011
• Provide an overview of the AAP’s
“Neonatal Resuscitation Program” and
“Helping Babies Breathe”
• Highlight the importance of working
with local authorities
• Demonstrate the translation of science
into practice
• Share lessons learned
Neonatal Resuscitation
• Of the 130 million babies born each
year, about 4 million die in the first
4 weeks of life. A quarter of these
deaths are due to asphyxia.
• It is estimated that an additional
million develop problems such as
cerebral palsy and other
World Health Report 2005
Neonatal Resuscitation
• The vast majority of newborn infants
do not require intervention from
intrauterine to extrauterine life.
• Approximately 10% of newborns
require some assistance to begin
breathing at birth.
• About 1% of newborns require
extensive resuscitation
Inverted Pyramid
of Neonatal Resuscitation
All infants
Assessment at Birth and
Simple Newborn Care
Initial Steps: Drying,
Warmth, Clearing the
Airway, Stimulation
Some infants
136 million
babies born
Approx 10
million babies
Approx 6
million babies
< 1.4 million
Few infants
Wall, Lee, Niermeyer et al. IJGO 2009
Pathophysiologic Cardio-Pulmonary
Consequences of Asphyxia
Dawes Foetal and Neonatal Physiology. Year Book Medical Publishers Inc; 1968.
Some Recommendations for
Resuscitation (1850-1950)
•Rectal stimulation
(stretching of the
rectum with
a corn cob)
•Tobacco smoke
blown into the rectum
•Immersion into cold water(+ alternating
with warm water)
Some Recommendations for
Resuscitation (1850-1950)
•Intragastric oxygen
•Rhythmic traction
of the tongue
•Rubbing, slapping,
and pinching
•Raising and lowering of the arms,
while an assistant compresses the
Consequences of Poor
Neonatal Resuscitation
Increased Death
Increased Disability
Emotional & Financial Burden
Direct Community Costs
Loss of Productivity
Neonatal Resuscitation Program
• mid-1970s: Dr Bloom and Cathy
Cropley receive NICHD award to
develop an initial simple way to focus
neonatal resuscitation teaching
• 1981: Dr George Peckham, an AHA
volunteer and AAP Perinatal Section
Chair, advocated for development of a
standardized core curriculum
Ron Bloom
• 1985: Dr Peckham and Dr Leon
Chameides discussed models and
outlined the “train the trainer” approach
for dissemination
Cathy Cropley
Neonatal Resuscitation Program
• 1986: Dr Peckham and Dr
Bill Keenan, AAP Perinatal
Section Leaders, began
seeking buy-in from
neonatology community
for such an endeavor
• First NRP textbook (1987):
based on consensus
opinions of leaders in
neonatology regarding
what was “accepted”
• First 2-day NRP course
occurred in November 1987
The Neonatal Resuscitation
American Academy of Pediatrics
American Heart Association
The NRP is designed to
guide resuscitation of the
newborn infant in the
critical few minutes during
and immediately following
NRP: Program Goal
To have at least one person
trained in neonatal resuscitation
present at every delivery in the
United States.
Early NRP
Mead Johnson Nutritionals: Neonatal Resuscitation
NRP: US Program History
In 24 years:
• 2.9 million providers have been
Currently in the United States:
• There are more than 27,000 active instructors.
• Approximately 130 courses are held each day.
Lesson #2: Convince others the
mission is their own
Edition Update
• Pulse oximetry
• Meconium
• Use of
oxygen during
NRP 6th Edition Update,
• Increase time between initiating chest
compressions and interrupting
compressions to assess heart rate
• Induced therapeutic hypothermia
• Simulation-based educational
Textbook of Neonatal Resuscitation, 6th Edition, 2011
NRP Outcomes
• Asphyxia decreased in 10 provinces
in China after training with NRP.
(Huishan et al 2008)
• In the first decade, deaths due to
birth asphyxia in the US decreased
42%. (Wegman 1991)
• Introduction of NRP in 10 hospitals in
India reduced overall neonatal
mortality by 7 per 1000. (Deorari 2000)
NRP Outcomes, Continued
Guyer B et al. Annual Summary of Vital Statistics - 1996
Pediatrics 1997; 100:90
NRP: Reach of Program
Although reporting of international NRP
courses is voluntary, training has been
reported in more than 125 countries and
translated into 26 languages.
Of all the educational material produced by the
American Academy of Pediatrics,
the NRP is the most widely used
around the world.
Lesson #3: Expertise doesn’t
necessarily equal ability to teach
Laos & Thailand
Lesson #4: Being an expert in
your own country doesn’t mean
you’re an expert in other
NRP Reach
Sites of NRP Implementation
Transferability….to more than 125 countries
Lesson #5: Humor may not
translate, but laughter is universal
NRP in Developing Countries
• While NRP has been embraced
internationally, the content and
format is routinely altered to meet
the needs of the learners in
developing countries.
NRP in Developing Countries
• The challenge has been to develop a
curriculum, based on the same
rigorous science of NRP, that is
culturally effective and meets the
needs of those who live in resource
limited settings.
NRP in Developing Countries
• Developing an effective curriculum
for limited resource settings would
impact Millennium Development Goal
#4, which is to reduce by two thirds,
the under-five mortality rate.
Helping Babies Breathe®
Global Causes of Neonatal Death
Lee, Wall, Cousens et al. Int J Epidemiol (in press)
Big Target of Helping Babies Breathe
1 million “stillbirths” due to
830,000 neonatal deaths
due to asphyxia
Lawn JE et al. IJGO 2009; 107:S5
Helping Babies Breathe Concept
• International Liaison Committee on
Resuscitation (ILCOR) Science
• Harmonious With NRP & WHO
Recommendation, if feasible
• Non-Profit, Inclusive
• Directed To Resource Limited
Conditions - Single Provider
Helping Babies Breathe
Curricular Concept
• Pictorial
• Limited Text
• Hands On Performance
• Frequent Skills Practice
• Simplest Steps “Possible”
• The Golden Minute
Hands on Practice
Educational Design
• Adult Learning -
TOT, Visual
Tool kit
Hands on
• Performance - OSCE
• Learner to Facilitator - 6:1
• Learning in Pairs
Paired Teaching/Learning
Neonatal Physiology
• Hypoxia-apnea, slow heart rate
• Breathing for the Baby-rapid
• Delays-increase mortality,
Field Testing
• Educational Approaches
Tanzania, Kenya, India, Pakistan
• Modified MCQ, Problem-Solving, OSCE
Tanzania, Kenya, India, Pakistan
• Simulator
• Implementation Studies
Kenya, India, Bangladesh
Educational Field Testing
Birth Attendants
• Increase Level of Skills Attained
• Testing OSCE
• Revision of MCQs
• Revision of Bag/Mask Instruction
• Revision of OSCEs
Implementation Field Testing
• Knowledge Acquisition improved
• Skills Testing – 98% Passed
• Resuscitation Required
↑ Stimulation
↓ BMV, Suction
• 6-12 Hours of Training
Clinical Outcomes
• ↓ death at 24 hours among babies not
breathing at birth (RR = 0.46) with no
change in stillbirths - Tanzania
– N=6928/7277 pre/post training
• ↓ stillbirths (RR = 0.73) with no change
in neonatal deaths – India
– N=4173/5427 pre/post training
Helping Babies Breathe Tool Kit
• Action Plan
• Learner Workbook
• Facilitator Flip Chart
• Multiple Choice Questions
• Simulator-Purpose Built
• Bag/Mask/Suction/Stethoscope
Routine Care
• Clearing the airway if
meconium present
• Drying infant
• Recognize crying
• Keeping warm
• Cutting the umbilical
• Encouraging
The Golden Minute®
• Recognizing infant not
• Positioning head
• Clearing the airway
• Stimulating
• Recognizing breathing
• Initiating ventilation by
1 minute
Global Development Alliance for
Country-Wide Implementation
• American Academy of Pediatrics
• US Agency for International Development
• Saving Newborn Lives/Save the Children
• Eunice Kennedy Shriver National Institute of
Child Health and Human Development
• Laerdal Global Health
Global Development Alliance
Overall Objective
•Reduce newborn mortality due to asphyxia
Guiding Principles
•Inclusiveness and collaboration
•Country-owned and country-led
•Integration with maternal and essential newborn
•Shared goal, results, and recognition
•Brand non-exclusivity
Global Development Alliance
The GDA continues to grow each day with
new partners:
• Johnson and Johnson
• Latter Day Saints Charities
Soon to be added:
• Columbia University Earth Institute
Millennium Villages/Cities Project
• International Pediatric Association
Ongoing Steps
• Global Development Alliance
• NICHD Studies
• Country-wide Implementation
• Facilitator Video
• Translations
• ENC (Essential Newborn Care) and
EMONC (Emergency Obstetric and
Neonatal Care)
Fit with Essential Newborn Care
• Thermal Protection
• Clean Delivery
• Cord Management
• Early Breast Feeding
• Resuscitation As Required
Hypothesis From Experience
Improving Skill in Neonatal
Resuscitation Spurs Improvements
in Other Components of Early
Neonatal Care.
Helping Babies Breathe
• Simple and evidencebased
• Low-cost and effective
• Easy to integrate with
other essential parts of
NB care
Big Hairy Audacious Goal
To have at least one person
trained in neonatal resuscitation
present at every delivery in the
Helping Babies Breathe
Lesson #6: A healthy first cry
represents a baby with unlimited

Neonatal Resuscitation ProgramTM and Helping Babies …