This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid. Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed. All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published. Over 140 million babies are born annually worldwide ( https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100 ). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born.

The success rate and overall quality of neonatal intubations performed by neonatal and pediatric trainees in Canada did not meet NRP standards; in particular, the time taken to intubate by pediatric residents and neonatal fellows is concerning. Re-evaluation of training methods and the volume of formalized exposure to neonatal intubation in Canadian residency programs are required.

Objective: Despite completing accredited resuscitation training, neonatal trainees often feel unprepared to deal with real-life clinical emergencies. High-fidelity simulator (HFS) technology offers the potential of recreating a realistic stressful clinical environment to aid training and evaluation. To date, there are limited data examining the physiological impact of this training modality in comparison to less costly alternatives. The objective of this study was to compare the effects of low-fidelity simulator (LFS) versus HFS technology on performance levels, objective and subjective measures of stress in neonatal trainees.Study Design: Sixteen neonatal fellows were invited to participate in a prospective randomized study. Subjects were divided into pairs and randomized to LFS or HFS for completion of scenario I. After an interval of 1 month, fellow teams crossed over to complete scenario II using the alternative simulator technology. Technical and non-technical skills were assessed using validated resuscitation scoring tools. Participants recorded subjective stress at sequential time points before and after each simulation. Buccal cortisol was measured at each corresponding time point and comparison between HFS and LFS groups was made.Result: The mean overall resuscitation performance score was 75.8%±10, but there was no difference in performance between HFS and LFS groups. There was also no significant difference in non-technical skills performance between groups. Salivary cortisol increased over the duration of the simulated experience, but there were no differences between the two groups (P ¼ 0.001, two-way repeated measures analysis of variance). We also identified changes in subjective measures of stress (P<0.001, analysis of variance) over time, but again there were no differences between groups.Conclusion: Simulated neonatal resuscitations induce a significant stress response in neonatal trainees; however, we were unable to identify any difference in stress measures between HFS and LFS. These data suggest that HFS technology offers no additional stress-inducing benefit.

Objective: Neonatal intubation is a life-saving procedural skill required by pediatricians. Trainees receive insufficient clinical exposure to develop this competency. Traditional training comprises a Neonatal Resuscitation Program (NRP) complemented by clinical experience. More recently, simulation is being used in procedural skills training. The objective of this study is to examine the impact of a simulation session, which teaches the skill of neonatal intubation by comparing pre-and post-intervention performance, and examining transferability of skill acquisition to the clinical setting.Study Design: First-year pediatric residents with NRP training, but no previous neonatal experience, attended a 2-h intubation education session conducted by two experienced respiratory therapists. Individual components of the skill were taught, followed by practice on a highfidelity infant mannequin with concurrent feedback. Skills were assessed using a validated neonatal intubation checklist (CL) and a five-point global rating scale (GRS), pre-and immediately post-intervention, using the mannequin. Clinical intubations performed in the subsequent 8-week neonatal intensive-care unit (NICU) rotation were evaluated by documenting success rates, time taken to intubate, and CL and GRS scores. Performance was also compared with similar data collected on intubations performed by a historical cohort of first-year residents who did not receive the training intervention. Data were analyzed using descriptive statistics, Student's t-test and w 2 -test as appropriate, and analysis of variance.Result: Thirteen residents participated in the educational session. Mean pre-intervention CL score was 65.4 ± 18% (s.d.) and GRS was 3±0.7 (s.d.). Performance improved following the intervention with post-training CL score of 93 ± 5% (P<0.0001) and GRS of 3.92 ± 0.4 (P ¼ 0.0003). These trainees performed 40 intubations during their subsequent NICU rotation, with a success rate of 67.5% compared with 63.15% in the cohort group (NS). However, mean CL score for the study trainees during the NICU rotation was 64.6 ± 20%, significantly lower than their post-training CL score (P<0.001), and significantly lower than the historical cohort score of 82.5 ± 15.4% (P ¼ 0.001). In the intervention group, there were no significant differences between the pre-intervention and real-life CL scores of 65 ± 18% and 64.63 %, respectively, and the pre-intervention and real-life GRS of 3.0 ± 0.7 and 2.95 ± 0.86, respectively. Conclusion:Trainees showed significant improvement in intubation skills immediately post intervention, but this did not translate into improved-clinical performance, with performance returning to baseline. In fact, significantly higher CL scores were demonstrated by the cohort group. These data suggest that improved performance in the simulation environment may not be transferable to the clinical setting. They also support the evidence that although concurrent feedback may lead to improved performance immediately post training intervention, this do...

Bedside echocardiography, performed by trained neonatologists, has become an integral part of routine neonatal intensive care in many centers across all five major continents. The goal of these assessments is to obtain longitudinal physiologic information that enables enhanced diagnostic precision and facilitates an enriched approach to the management of cardiovascular problems in newborns and young infants. Although this clinical practice has become widely disseminated, formalized curriculum and structured training programs for neonatologists are lacking in many parts of the world. Four major published guidelines articulate the need for a welldefined training structure and the need for a standardized approach to clinical application, but there are regional variances in how these guidelines are applied. 1-4 Although variable terminology has been used to define the imaging component of these assessments including functional echocardiography, clinician-performed ultrasound, targeted neonatal echocardiography, and neonatologistperformed echocardiography (NPE), the philosophical goals of training and clinical utility are comparable, and for the purpose of this editorial we will use the generic term ''bedside echocardiography.'' Importantly, a key component of bedside echocardiography and one of the primary differences compared with traditional echocardiography is that performance of the imaging and study interpretation by the neonatologist enables enhanced integration within the intensive care context. As such, the value of the assessment is entirely dependent on the extent of the clinical evaluators' knowledge of cardiovascular physiology and pharmacotherapeutics, mechanical ventilation strategies, and fluid and electrolyte status and their ability to integrate this information over the course of an illness. We, therefore, propose the concept of a ''hemodynamic consultation'' as the recommended model for clinical practice. The latter refers to the performance of a comprehensive integrated assessment by a neonatologist with advanced echocardiography skills and a strong foundation in neonatal pathophysiology. In addition, we suggest the need for restructuring of training based on competencies relevant to routine clinical assessments performed by neonatologists, rather than arbitrary numbers of studies or a fixed duration of time. It is important to highlight that this commentary reflects the opinions and perspectives of the authors rather than any specific regulatory body or society.