Neonatal stabilization in Canada: Updates to Acute Care of at-Risk Newborns (ACoRN) practices and programming

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BACKGROUND

Clinical gaps

Out of an estimated 374,000 live births in Canada in 2018, almost 30,000 infants (8%) were born preterm, and more than 15,000 were admitted for care in a level 2 or 3 nursery ^[1][2]. Of these, 22% required on-site stabilization before being transferred, and 14% were outborn infants <33 weeks gestational age (GA) requiring higher level care ^[3]. Preterm birth rates were highest in the three territories (up to 13.7%) compared with the national average (7.9%) ^[4]. Neonatal mortality rates varied considerably by region, with Nunavut’s rate being 2.4 times higher than elsewhere in Canada ^[5]. In part, such disparities are the result of insufficient training in newborn resuscitation and stabilization, and inconsistent adherence to best practices ^[6]-[8].

Health care professionals (HCPs) in a range of practice settings, with varying degrees of experience or training in neonatal emergencies, may be called upon to care for an ill newborn. This can be challenging and stressful when an HCP or facility is unfamiliar with or unprepared for such encounters ^[6]-[8].

ACoRN is an established Canadian neonatal stabilization program that first launched in 2005 to bridge gaps in the care continuum between newborn resuscitation (for which the neonatal resuscitation program (NRP) is standard care) and stabilization, during an unwell or at-risk infant’s first hours and days post-birth. Based on an initial, prioritized Primary Survey used for every newborn and followed by corresponding systems-based algorithms (Sequences), the ACoRN process guides assessment, essential care, and management pathways that ensure physiologic stability and optimal outcomes ^[9].

A new phase in ACoRN education began when the program transferred to the Canadian Paediatric Society (CPS) in 2015. Development of a revised and updated second edition of the ACoRN textbook was a process informed by several rich sources over a period of years: evidence-based guidelines from the International Liaison Committee on Resuscitation (ILCOR) ^[10], standard and consensus-based best practices, the current literature, and input from a host of clinical experts from the multidisciplinary ACoRN Neonatal Society or involved in text review. The CPS partnered with Oxford University Press in 2018 to publish the book in the spring of 2021. A revitalized educational program is to roll out simultaneously, enabling registered ACoRN instructors to deliver core content and site-specific enhanced learning using interactive, case-based modules, simulations, and other targeted training modalities.

Key changes to clinical practice include:

• The early identification and management of shock
• Screening for critical congenital heart disease (CCHD)
• Early identification and management of infants with hypoxic-ischemic encephalopathy (HIE), jaundice, or a neural tube defect (NTD); and
• Updated management of hypoglycemia.

The following case studies highlight two of these changes. 

1. Early recognition and management of HIE

Your level 2 facility team is stabilizing a post-term male infant after prolonged resuscitation. His Apgar scores were 3¹, 4⁵ and 5¹⁰, and cord pH was 6.98. The team is concerned about HIE and refer to ACoRN upon completing NRP, for further guidance.

New ACoRN guidance reflects the most current evidence of benefit for treating certain infants with HIE using therapeutic hypothermia (TH) ^[11], including strict criteria and procedures outlined in a 2018 CPS position statement ^[12].

‘At-risk for HIE’ and ‘HIE management’ are two new ACoRN Alerting Signs in the Neurology and Thermoregulation Sequences that assist early identification, and sequences have been adjusted to direct current, evidence-based management for these infants. Entering the Neurology Sequence, you complete the Encephalopathy Assessment (EA) Table as the essential Core Step to evaluate for the presence and degree of encephalopathy ^[12].

You monitor this infant closely because TH should be initiated within the first 6 h post-birth. The infant’s cord pH was ≤7.0, and there is no evidence, as yet, of moderate-to-severe encephalopathy (i.e., seizures, or signs from the EA’s ‘moderate’ or ‘severe’ columns).

Strict normothermia (axillary temperature: 36.5^oC to 37.0^oC) is initiated, as directed by the Thermoregulation Sequence, while decisions about TH are pending. The Thermoregulation chapter guides further monitoring of vital signs and temperature. As per the Fluid and Glucose chapter, an infusion of D10W is initiated at 3 mL/kg/h. The ACoRN program guides HCPs to continuously monitor this infant for ventilation, oxygenation, and cardiovascular status.

When assessing the infant’s temperature at 2 hours of age, seizure activity is noted.

The tertiary referral centre is updated and they recommend following the Neurology Sequence recommendation to administer phenobarbital (20 mg/kg IV) and the Thermoregulaton Sequence to initiate passive hypothermia. Your team turns off the overbed warmer and monitors the infant’s core temperature closely to ensure it stays within the target range of 33^oC to 34^oC, as directed in the HIE management arm of the Thermoregulation Sequence.

While awaiting the transport team, ACoRN continues to provide HCPs the guidance needed to monitor and intervene to optimize care.

2.  Identifying and managing a newborn with jaundice

You are assessing a 12-hour-old late preterm female infant (35⁵ weeks GA) with hypotonia and visible jaundice. You refer to ACoRN, which now includes a new chapter on jaundice based on nomograms developed by the American Academy of Paediatrics and adapted for Canadian use in a 2007 CPS position statement^[13].

An infant with one or more of the following Alerting Signs: ‘At risk for jaundice’, ‘Visible jaundice’, or ‘Bilirubin at treatment level’ enters the Jaundice Sequence. Because the infant has low tone and displays visible jaundice, you complete the Primary Survey and Consolidated Core Steps (CCS) and obtain a blood glucose (3 mmol/L) and a total serum bilirubin (TSB) of 115 μmol/L. The Neurology Sequence directs you to assess for signs of encephalopathy, of which there are none, and to ensure a normal blood glucose before moving to the Jaundice Sequence, which directs you to plot this result on the Phototherapy Thresholds and Exchange Transfusion Thresholds nomograms. This infant’s TSB is at treatment level. She requires phototherapy but does not need an exchange transfusion.

Key changes in ACoRN’s approach to stabilization are summarized below in Table 1.

Table 1. New ACoRN text and program components
Topic	New Content/Recommendations
Overview	A new opening chapter on the physiology of transition as the basis of ACoRN’s approach to neonatal stabilization, and a new Jaundice chapter 7 new Alerting Signs A Level of Risk assessment for each chapter, based on infant condition, anticipated clinical course, and site capacity to provide and sustain care. A series of initial actions (Consolidated Core Steps (CCS)) to evaluate, stabilize unwell or at-risk newborns. CCS are completed alongside the Primary Survey. Learning points to highlight key concepts and content
Transition chapter	Highlights the interrelated systemic processes occurring during the transition from intrauterine to extrauterine life and the clinical impact of interruptions to, or deviations from, normal transition
ACoRN Process	CCS, Level of Risk, and the Golden Hour are described Jaundice and new Alerting Signs added to the Primary Survey A new clinical case highlights first steps in the ACoRN Process
Respiratory	Organization of Care and Next Steps are reorganized and more detailed Mild respiratory distress is reassessed, if no improvement, after 6 h
Cardiovascular	New Alerting Sign: ‘Failed CCHD screening’ Clinical Assessment of Circulation Table Organization of Care is based on Alerting Signs and includes differentiation of shock versus cardiac instability without shock
Neurology	New Alerting Sign: ‘At-risk for HIE’ Completing the Encephalopathy Assessment Table is the essential Core Step Both glucose level and abnormal movements are key indicators for Organization of Care Neonatal abstinence syndrome and Neonatal opioid withdrawal syndrome (NAS/NOWS)
Surgical Conditions	New Alerting Sign: ‘Neural tube defect’ Next Steps: Specific bloodwork, antibiotic therapy for open lesions, and initiating intravenous fluids
Fluid and Glucose	Management of infants with persistent or refractory hypoglycemia reflects CPS statement Glucose infusion rate (GIR) as basis for treatment Response based on simplified glucose values and introduces treatment with glucose gel
Jaundice	New Alerting Signs: ‘At risk for jaundice’, ‘Visible jaundice’, and ‘Bilirubin at treatment level’ Evaluating infants at risk for developing hyperbilirubinemia Plotting and interpreting nomograms Bilirubin-induced Neurologic Dysfunction (BIND) Score
Thermoregulation	‘HIE management’ is a new Alerting Sign and Sequence pathway Revised temperature ranges (<36.5oC or >37.5oC axillary) and the introduction of strict normothermia (36.5oC to 37.0oC axillary)
Infection	New Infection Assessment Table (Core Step) to evaluate risk and direct Organization of Care and Response Enhanced discussion of Alerting Signs, intrapartum prophylaxis, early- and late-onset sepsis, and management of bacterial, viral, and fungal infections
Transport	Level of Risk as determining consultation/transfer for higher level care Standardized communication tool (SBARR) Sample forms: NICU Telephone Consult and Neonatal Transport Record
Support	New emphasis on positional and developmentally appropriate care, strategies to reduce infant pain and stress, family-centred approaches, palliative care, and health care team support New tools for debriefing
Appendices	Revised and updated medications list, initial ventilation parameters and procedures

Conclusion                    

The revitalized 2021 ACoRN program provides an evidence-based, standardized approach to neonatal stabilization in Canada that, if universally adopted, will close gaps in neonatal care, enhance HCP confidence and competence in caring for at-risk or unwell newborns, and improve neonatal outcomes across the country. The CPS recommends the universal adoption of ACoRN as the standardized approach to neonatal stabilization in Canada.

Acknowledgements

This practice point has been reviewed by the Acute Care, Community Paediatrics, Fetus and Newborn, and First Nations, Inuit and Metis Health Committees of the Canadian Paediatric Society.

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CANDIAN PAEDIATRIC SOCIETY ACoRN STEERING COMMITTEE (2020-2021)

Executive members: Khalid Aziz MD, Jill Boulton MD (Past Chair), Kevin Coughlin MD, MHSc, FRCPC (Chair), Deepak Manhas MD

Principal authors: Deborah Aylward, RN, BScN, MScN; Kevin Coughlin MD, MHSc, FRCPC

For a full list of ACoRN Steering Committee members, visit www.cps.ca/en/acorn/steering-committee

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References

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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.