Standardised formal neonatal resuscitation training (SFNRT) programmes for reducing mortality and morbidity in newborn infants

Newborn baby lying on table in maternity ward

Standardised formal neonatal resuscitation training (SFNRT) programmes for reducing mortality and morbidity in newborn infants

RHL Summary

Key findings

The review assessed whether SNFRT programmes can reduce neonatal mortality and morbidity, improve knowledge and skills, or change teamwork and resuscitation behaviour (compared to no SNFRT).

  • SFNRT (compared to basic newborn care or resuscitation) in developing country settings can maydecrease early and late neonatal mortality.
  • In addition, teaching teamwork in addition to resuscitation training may improve team behavior and decrease time for resuscitation.
  • Simulation training in neonatal resuscitation may enhance knowledge acquisition and retention. However, it is uncertain whether it will translate into an improved patient outcome in the clinical settings.

Evidence included in this review

Fourteen trials evaluating the effectiveness of formal newborn resuscitation training programmes were included. Of these, five were community-based trials involving 187,080 deliveries and nine were mannequin-based trials involving 626 newborns. All of these studies were conducted in developing countries.

  • Five trials assessed the effect of SFNRT compared with no SFNRT
  • Three trials compared SFNRT with basic resuscitation training
  • Two trials compared SFNRT with team training, to SFNRT alone
  • Two trials compared SFNRT with booster course, to SFNRT alone
  • Four trials examined decision support tools (2 trials), a cognitive aid (1 trial) and an electronic decision support tool (1 trial ) for newborn resuscitation care

Quality assessment

There was high heterogeneity among the studies; study quality was often downgraded due to lack of blinding of participants, lack of or unclear allocation concealment and high risk of attrition bias. However, moderate quality evidence from the three trials on training in newborn resuscitation indicated that early newborn deaths may be reduced.

 

Clinical implications

SFNRT in developing countries appears to confer benefit in reducing newborn mortality. Since all the studies were performed in the developing countries, the findings may have limited applicability in high-income settings.

 

Further research

Future studies are needed to report on newborn morbidity outcomes related to long-term health and development.Cochrane review


Cochrane review

Citation: M, Ryan AC, Barrington KJ . Standardised formal resuscitation training programmes for reducingmortality and morbidity in newborn infants. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD009106. DOI:10.1002/14651858.CD009106.pub2.

Abstract

Approximately 10% of all newborns require resuscitation at birth. Training healthcare providers in standardised formal neonatal resuscitation training (SFNRT) programmes may improve neonatal outcomes. Substantial healthcare resources are expended on SFNRT.

 

To determine whether SFNRT programmes reduce neonatal mortality and morbidity, improve acquisition and retention of knowledge and skills, or change teamwork and resuscitation behaviour.

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PREMEDLINE, EMBASE, CINAHL, Web of Science and the Oxford Database of Perinatal Trials, ongoing trials and conference proceedings in April 2014 and updated in March 2015.

Randomised or quasi-randomised trials including cluster-randomised trials, comparing a SFNRT with no SFNRT, additions to SFNRT or types of SFNRT, and reporting at least one of our specified outcomes.

 

Two authors extracted data independently and performed statistical analyses including typical risk ratio (RR), risk difference (RD), mean difference (MD), and number needed to treat for an additional beneficial outcome (NNTB) or an additional harmful outcome (NNTH) (all with 95% confidence intervals (CI)). We analysed cluster-randomised trials using the generic inverse variance and the approximate analysis methods.

We identified two community-based and three manikin-based trials that assessed the effect of SFNRT compared with no SFNRT. Very low quality evidence from one study suggested improvement in acquisition of knowledge (RR 5.96, 95% CI 3.60 to 9.87) and skills (RR 170, 95% CI 10.8 to 2711) and retention of knowledge (RR 3.60, 95% CI 2.43 to 5.35) and the other study suggested improvement in resuscitation and behavioural scores.

We identified three community-based cluster-randomised trials in developing countries comparing SFNRT with basic resuscitation training (Early Newborn Care). In this setting, there was moderate quality evidence that SFNRT decreased early neonatal mortality (typical RR 0.88, 95% CI 0.78 to 1.00; 3 studies, 66,162 neonates) and when analysed by the approximate analysis method (typical RR 0.85, 95% CI 0.75 to 0.96; RD -0.0044, 95% CI -0.0082 to -0.0006; NNTB 227, 95% CI 122 to 1667). Low quality evidence from one trial showed that SFNRT may decrease 28-day mortality (typical RR 0.55, 95% CI 0.33 to 0.91) but the effect on late neonatal mortality was more uncertain (typical RR 0.47, 95% CI 0.20 to 1.11). None of our a priori defined neonatal morbidities were reported. We did not identify any randomised studies in the developed world.

We identified two trials that compared SFNRT with team training to SFNRT. Teamwork training of physician trainees with simulation may increase any teamwork behaviour (assessed by frequency) (MD 2.41, 95% CI 1.72 to 3.11) and decrease resuscitation duration (MD -149.54, 95% CI -214.73 to -84.34) but may lead to little or no difference in Neonatal Resuscitation Program (NRP) scores (MD 1.40, 95% CI -2.02 to 4.82; 98 participants, low quality evidence).

We identified two trials that compared SFNRT with booster courses to SFNRT. It is uncertain whether booster courses improve retention of resuscitation knowledge (84 participants, very low quality evidence) but may improve procedural and behavioural skills (40 participants, very low quality evidence).

We identified two trials on decision support tools, one on a cognitive aid that did not change resuscitation scores and the other on an electronic decision support tool that improved the frequency of correct decision making on positive pressure ventilation, cardiac compressions and frequency of fraction of inspired oxygen (FiO2) adjustments (97 participants, very low quality evidence).

 

 

SFNRT compared to basic newborn care or basic newborn resuscitation, in developing countries, results in a reduction of early neonatal and 28-day mortality. Randomised trials of SFNRT should report on neonatal morbidity including hypoxic ischaemic encephalopathy and neurodevelopmental outcomes. Innovative educational methods that enhance knowledge and skills and teamwork behaviour should be evaluated.