702 - Heart-rate guided resuscitation with Helping Babies Breathe: Neonatal outcomes and resuscitation practices in the Democratic Republic of the Congo

Monday, May 1, 2023

9:30 AM – 11:30 AM ET

Poster Number: 702
Publication Number: 702.445

Jackie Patterson, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States; Daniel Ishoso, Kinshasa School of Public Health, Kinshasa, Kinshasa, Congo, (Congo Â– Kinshasa); Pooja Iyer, University of North Carolina at Chapel Hill School of Medicine, San Francisco, CA, United States; Joar Eilevstjønn, Laerdal Medical, Sandnes, Rogaland, Norway; Beena D. Kamath-Rayne, American Academy of Pediatrics, Itasca, IL, United States; Eric Musalu. Mafuta, Ecole de Santé Publique de Kinshasa, Kinshasa, Kinshasa, Congo, (Congo Â– Kinshasa); Helge Myklebust, Laerdal Medical, STAVANGER, Rogaland, Norway; Carl Bose, University of North Carolina at Chapel Hill School of Medicine, Pittsboro, NC, United States; Sara Berkelhamer, University of Washington School of Medicine, Seattle, WA, United States

Presenting Author(s)

Jacquelyn Patterson, MD MPH

Assistant Professor
University of North Carolina at Chapel Hill School of Medicine
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina, United States

Background:

Ventilation of the neonatal lungs is critical to cardiorespiratory transition at birth. Heart rate (HR) is a sensitive indicator of the adequacy of spontaneous respiratory effort and thus need for ventilation, and the response to resuscitation. Lack of HR monitoring during resuscitation may contribute to delayed and ineffective ventilation, and worse outcomes.

Objective:

To evaluate the impact of training in HR-guided resuscitation (HRGR) compared to Helping Babies Breathe (HBB) on neonatal outcomes and resuscitation practices in the Democratic Republic of the Congo (DRC).

Design/Methods:

We conducted a pre-post clinical trial of resuscitation training with continuous electronic HR monitoring in three health facilities, enrolling in-born neonates ≥28 weeks gestation (ClinicalTrials.gov: NCT03799861). We developed a HRGR action plan and training program by adapting HBB to include assessment of HR to prompt both initiation and improvement of bag-mask ventilation (BMV; Figure 1). We abstracted demographic/outcome data from delivery registers, and observed a convenience sample of resuscitations to document provider practices, newborn breathing and HR. We evaluated our primary outcome of effective breathing at three minutes after birth among newborns not breathing well at 30 seconds (s) after birth using a method of least squares to fit general linear models.

Results:

Among the 1,284 newborns with observational data, there was no difference in the proportion of newborns effectively breathing (aRR 1.08 [95%CI 0.81, 1.45]), the time to effective breathing, or HR≥100 at three minutes (Table 1). Among 145 receiving BMV, there was no change in time to effective breathing (p=0.122; Table 2); however, time to BMV decreased 64.3s during HRGR (p< 0.001). Providers initiated both stimulation and suctioning earlier during HRGR (-6.3s, p=0.009 and -27.2s, p=0.03, respectively). Among 10,906 enrolled in the trial, perinatal mortality was unchanged (aRR 1.19 [95%CI 0.96, 1.48]) and death before discharge increased (aRR 1.43 [95% CI 1.03, 1.99]). Expert review of stillborn cases demonstrated a misclassification rate of 33.3% during HBB (n=6 of 18 cases) compared to 5.9% in HRGR (n=1 of 17).

Conclusion(s):

HRGR reduced time to BMV by greater than one minute compared to HBB. The increase in death before discharge and unchanged perinatal mortality may be due to resuscitation of newborns with a higher risk of mortality who were previously presumed stillborn. A cluster-randomized trial of HRGR is needed to evaluate its impact on neonatal mortality in low-resource settings.