{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T11:58:04Z","timestamp":1789559884752,"version":"build-2803163510"},"reference-count":36,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2025,8,18]],"date-time":"2025-08-18T00:00:00Z","timestamp":1755475200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Laerdal Foundation","award":["5007"],"award-info":[{"award-number":["5007"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Children"],"abstract":"<jats:p>Background\/Objectives: Newborn heart rate is an integral part of resuscitation algorithms, but the impact of ECG monitoring on resuscitative interventions and clinical outcomes has been identified as a knowledge gap. The objective was to evaluate the impact of routine use of dry-electrode ECG in all newborns immediately after birth on time to start positive pressure ventilation (PPV) when indicated. Methods: We conducted a randomized clinical trial from June 2019 to November 2021 at Stavanger University Hospital, Norway. Dry-electrode ECG sensors were applied immediately after birth to all newborns \u2265 34 weeks\u2019 gestation. Randomization determined whether the heart rate display was visible or masked. Time of birth was registered in an observation app. Time to start ventilation was calculated from video recordings. Results: In total, 7343 newborns \u2265 34 weeks\u2019 gestation were enrolled, 4284 in the intervention and 3059 in the control group, and 3.7% and 3.8% received ventilation, respectively. In 171\/275 (62%) of the newborns the exact time of birth and a video of the resuscitation were available, for 98 in the intervention and 73 in the control group. Ventilation was provided within 60 s to 44\/98 (45%) in the intervention and 24\/73 (33%) in the control group, p = 0.12. Time from birth to start of PPV was a median of 66 (44, 102) s in the intervention and 84 (49, 148) s in the control group, p = 0.058. Resuscitated newborns were apneic (74%) or breathing ineffectively (26%) at the start of PPV, and only 36% had a heart rate &lt; 100 beats per minute. Conclusions: The use of dry-electrode ECG heart rate monitoring did not change the proportion of newborns that received ventilation within 60 s after birth, but early termination due to employee protests to video recordings rendered the trial inadequately powered to detect a difference. Breathing status was likely a more important determinant of starting ventilation than bradycardia.<\/jats:p>","DOI":"10.3390\/children12081082","type":"journal-article","created":{"date-parts":[[2025,8,18]],"date-time":"2025-08-18T11:31:37Z","timestamp":1755516697000},"page":"1082","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Impact of Heart Rate Monitoring Using Dry-Electrode ECG Immediately After Birth on Time to Start Ventilation: A Randomized Trial"],"prefix":"10.3390","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4305-141X","authenticated-orcid":false,"given":"Siren","family":"Rettedal","sequence":"first","affiliation":[{"name":"Department of Simulation-Based Learning, Stavanger University Hospital, 4068 Stavanger, Norway"},{"name":"Faculty of Health Sciences, University of Stavanger, 4036 Stavanger, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amalie","family":"Kibsgaard","sequence":"additional","affiliation":[{"name":"Department of Simulation-Based Learning, Stavanger University Hospital, 4068 Stavanger, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Frederikke","family":"Buskov","sequence":"additional","affiliation":[{"name":"Department of Simulation-Based Learning, Stavanger University Hospital, 4068 Stavanger, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4607-2689","authenticated-orcid":false,"given":"Joar","family":"Eilevstj\u00f8nn","sequence":"additional","affiliation":[{"name":"Strategic Research, Laerdal Medical, 4002 Stavanger, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-7981-6968","authenticated-orcid":false,"given":"Vilde","family":"Kolstad","sequence":"additional","affiliation":[{"name":"Department of Simulation-Based Learning, Stavanger University Hospital, 4068 Stavanger, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8829-6250","authenticated-orcid":false,"given":"Jan Terje","family":"Kval\u00f8y","sequence":"additional","affiliation":[{"name":"Department of Research, Section of Biostatistics, Stavanger University Hospital, 4068 Stavanger, Norway"},{"name":"Department of Mathematics and Physics, University of Stavanger, 4036 Stavanger, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6965-8263","authenticated-orcid":false,"given":"Peder Aleksander","family":"Bjorland","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Stavanger University Hospital, 4068 Stavanger, Norway"},{"name":"Department of Clinical Science, University of Bergen, 5021 Bergen, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-9458-8991","authenticated-orcid":false,"given":"Hanne","family":"Pike","sequence":"additional","affiliation":[{"name":"Faculty of Health Sciences, University of Stavanger, 4036 Stavanger, Norway"},{"name":"Department of Pediatrics, Stavanger University Hospital, 4068 Stavanger, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joanna","family":"Haynes","sequence":"additional","affiliation":[{"name":"Department of Simulation-Based Learning, Stavanger University Hospital, 4068 Stavanger, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1305-0408","authenticated-orcid":false,"given":"Thomas Bailey","family":"Tysland","sequence":"additional","affiliation":[{"name":"Department of Neurology, Stavanger University Hospital, 4068 Stavanger, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6742-7314","authenticated-orcid":false,"given":"Peter G.","family":"Davis","sequence":"additional","affiliation":[{"name":"The Royal Women\u2019s Hospital, University of Melbourne, Parkville, Melbourne, VIC 3052, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2795-8564","authenticated-orcid":false,"given":"Hege","family":"Ersdal","sequence":"additional","affiliation":[{"name":"Department of Simulation-Based Learning, Stavanger University Hospital, 4068 Stavanger, Norway"},{"name":"Faculty of Health Sciences, University of Stavanger, 4036 Stavanger, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,8,18]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"S185","DOI":"10.1161\/CIR.0000000000000895","article-title":"Neonatal Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations","volume":"142","author":"Wyckoff","year":"2020","journal-title":"Circulation"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"208","DOI":"10.1016\/j.resuscitation.2022.10.005","article-title":"2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces","volume":"181","author":"Wyckoff","year":"2022","journal-title":"Resuscitation"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"e187","DOI":"10.1161\/CIR.0000000000001179","article-title":"2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces","volume":"148","author":"Berg","year":"2023","journal-title":"Circulation"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"291","DOI":"10.1016\/j.resuscitation.2021.02.014","article-title":"European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth","volume":"161","author":"Madar","year":"2021","journal-title":"Resuscitation"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"S524","DOI":"10.1161\/CIR.0000000000000902","article-title":"Part 5: Neonatal Resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care","volume":"142","author":"Aziz","year":"2020","journal-title":"Circulation"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"110156","DOI":"10.1016\/j.resuscitation.2024.110156","article-title":"Newborn resuscitation timelines: Accurately capturing treatment in the delivery room","volume":"197","author":"Pike","year":"2024","journal-title":"Resuscitation"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"175","DOI":"10.1159\/000506772","article-title":"Compliance with Guidelines and Efficacy of Heart Rate Monitoring during Newborn Resuscitation: A Prospective Video Study","volume":"117","author":"Bjorland","year":"2020","journal-title":"Neonatology"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"102","DOI":"10.1016\/j.resuscitation.2017.03.035","article-title":"Incidence and characteristics of positive pressure ventilation delivered to newborns in a US tertiary academic hospital","volume":"115","author":"Niles","year":"2017","journal-title":"Resuscitation"},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Rettedal, S., Eilevstjonn, J., Kibsgaard, A., Kvaloy, J.T., and Ersdal, H. (2021). Comparison of Heart Rate Feedback from Dry-Electrode ECG, 3-Lead ECG, and Pulse Oximetry during Newborn Resuscitation. Children, 8.","DOI":"10.3390\/children8121092"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"49","DOI":"10.1016\/j.jpeds.2014.09.015","article-title":"Pulse oximetry measures a lower heart rate at birth compared with electrocardiography","volume":"166","author":"Hooper","year":"2015","journal-title":"J. Pediatr."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Johnson, P.A., and Schmolzer, G.M. (2020). Heart Rate Assessment during Neonatal Resuscitation. Healthcare, 8.","DOI":"10.3390\/healthcare8010043"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"550","DOI":"10.1136\/archdischild-2020-320901","article-title":"NeoBeat offers rapid newborn heart rate assessment","volume":"106","author":"Bush","year":"2021","journal-title":"Arch. Dis. Child. Fetal Neonatal Ed."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"311","DOI":"10.1136\/archdischild-2020-320179","article-title":"Changes in heart rate from 5 s to 5 min after birth in vaginally delivered term newborns with delayed cord clamping","volume":"106","author":"Bjorland","year":"2020","journal-title":"Arch. Dis. Child. Fetal Neonatal Ed."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1137","DOI":"10.1111\/apa.16242","article-title":"Comparing pulse rate measurement in newborns using conventional and dry-electrode ECG monitors","volume":"111","author":"Salverda","year":"2022","journal-title":"Acta Paediatr."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Pike, H., Eilevstjonn, J., Bjorland, P., Linde, J., Ersdal, H., and Rettedal, S. (2021). Heart rate detection properties of dry-electrode ECG compared to conventional 3-lead gel-electrode ECG in newborns. BMC Res. Notes, 14.","DOI":"10.1186\/s13104-021-05576-x"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e061839","DOI":"10.1136\/bmjopen-2022-061839","article-title":"Impact of immediate and continuous heart rate feedback by dry electrode ECG on time to initiation of ventilation after birth: Protocol for a randomised controlled trial","volume":"12","author":"Rettedal","year":"2022","journal-title":"BMJ Open"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"e000592","DOI":"10.1136\/bmjpo-2019-000592","article-title":"Incidence of newborn resuscitative interventions at birth and short-term outcomes: A regional population-based study","volume":"3","author":"Bjorland","year":"2019","journal-title":"BMJ Paediatr. Open"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"549","DOI":"10.2307\/2530245","article-title":"A multiple testing procedure for clinical trials","volume":"35","author":"Fleming","year":"1979","journal-title":"Biometrics"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"869","DOI":"10.1016\/j.resuscitation.2011.12.011","article-title":"Early initiation of basic resuscitation interventions including face mask ventilation may reduce birth asphyxia related mortality in low-income countries: A prospective descriptive observational study","volume":"83","author":"Ersdal","year":"2012","journal-title":"Resuscitation"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.resuscitation.2018.05.026","article-title":"Predictors of 24-h outcome in newborns in need of positive pressure ventilation at birth","volume":"129","author":"Linde","year":"2018","journal-title":"Resuscitation"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"271","DOI":"10.1097\/SIH.0000000000000740","article-title":"Increase in Newborns Ventilated Within the First Minute of Life and Reduced Mortality After Clinical Data-Guided Simulation Training","volume":"19","author":"Vadla","year":"2023","journal-title":"Simul. Healthc."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Patterson, J.K., Ishoso, D., Eilevstjonn, J., Bauserman, M., Haug, I., Iyer, P., Kamath-Rayne, B.D., Lokangaka, A., Lowman, C., and Mafuta, E. (2023). Delayed and Interrupted Ventilation with Excess Suctioning after Helping Babies Breathe with Congolese Birth Attendants. Children, 10.","DOI":"10.3390\/children10040652"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"245","DOI":"10.1016\/j.jpeds.2021.10.037","article-title":"A Pilot Randomized Trial of Heart Rate Monitoring Using Conventional Versus a New Electrocardiogram Algorithm during Neonatal Resuscitation at Birth","volume":"242","author":"Katheria","year":"2022","journal-title":"J. Pediatr."},{"key":"ref_24","unstructured":"Kapadia VS, K.M., Strand, M., Gately, C., Costa-Nobre, D.T., Davis, P.G., de Almeida, M.F., El-Naggar, W., Fabres, J.G., Fawke, J., and Finan, E. (2025, August 13). Methods of Heart Rate Monitoring in the Delivery Room and Neonatal Outcomes (NLS #5201). International Liaison Committee on Resuscitation (ILCOR) Neonatal Life Support Task Force 2022. Available online: http:\/\/ilcor.org."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Patterson, J.K., Ishoso, D., Lokangaka, A., Iyer, P., Lowman, C., Eilevstjonn, J., Haug, I., Kamath-Rayne, B.D., Mafuta, E., and Myklebust, H. (2025). Neonatal outcomes and resuscitation practices following the addition of heart rate-guidance to basic resuscitation. PLoS ONE, 20.","DOI":"10.1371\/journal.pone.0317199"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1016\/j.resuscitation.2021.12.020","article-title":"Effect of resuscitation training and implementation of continuous electronic heart rate monitoring on identification of stillbirth","volume":"171","author":"Patterson","year":"2022","journal-title":"Resuscitation"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"171","DOI":"10.1002\/ijgo.12430","article-title":"Fresh stillborn and severely asphyxiated neonates share a common hypoxic-ischemic pathway","volume":"141","author":"Ersdal","year":"2018","journal-title":"Int. J. Gynaecol. Obstet."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1016\/j.resuscitation.2019.07.031","article-title":"Impact of electronic cardiac (ECG) monitoring on delivery room resuscitation and neonatal outcomes","volume":"143","author":"Shah","year":"2019","journal-title":"Resuscitation"},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Katheria, A., Arnell, K., Brown, M., Hassen, K., Maldonado, M., Rich, W., and Finer, N. (2017). A pilot randomized controlled trial of EKG for neonatal resuscitation. PLoS ONE, 12.","DOI":"10.1371\/journal.pone.0187730"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1445","DOI":"10.1038\/s41390-021-01731-z","article-title":"Electrocardiogram for heart rate evaluation during preterm resuscitation at birth: A randomized trial","volume":"91","author":"Abbey","year":"2022","journal-title":"Pediatr. Res."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"231","DOI":"10.1159\/000445930","article-title":"Normal Newborn Heart Rate in the First Five Minutes of Life Assessed by Dry-Electrode Electrocardiography","volume":"110","author":"Linde","year":"2016","journal-title":"Neonatology"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"697","DOI":"10.1111\/apa.16659","article-title":"Newborns requiring resuscitation: Two thirds have heart rate >\/=100 beats\/minute in the first minute after birth","volume":"112","author":"Kibsgaard","year":"2023","journal-title":"Acta Paediatr."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"371","DOI":"10.1136\/archdischild-2023-325878","article-title":"Prevalence of bradycardia in 4876 newborns in the first minute after birth and association with positive pressure ventilation: A population-based cross-sectional study","volume":"109","author":"Rettedal","year":"2023","journal-title":"Arch. Dis. Child. Fetal Neonatal Ed."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"346","DOI":"10.1136\/archdischild-2023-326398","article-title":"Delayed cord clamping and the response to bradycardia immediately after birth","volume":"109","author":"Patterson","year":"2024","journal-title":"Arch. Dis. Child. Fetal Neonatal Ed."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"100","DOI":"10.1159\/000431075","article-title":"Incidence of Newborn Stabilization and Resuscitation Measures and Guideline Compliance during the First Minutes of Life in Norway","volume":"108","author":"Skare","year":"2015","journal-title":"Neonatology"},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Kolstad, V., Garcia-Torres, J., Brunner, S., Johannessen, A., Foglia, E., Ersdal, H., Meinich-Bache, O., and Rettedal, S. (2024). Detection of time of birth and cord clamping using thermal video in the delivery room. Front. Pediatr., 12.","DOI":"10.3389\/fped.2024.1342415"}],"container-title":["Children"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2227-9067\/12\/8\/1082\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T18:29:42Z","timestamp":1760034582000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2227-9067\/12\/8\/1082"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,8,18]]},"references-count":36,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2025,8]]}},"alternative-id":["children12081082"],"URL":"https:\/\/doi.org\/10.3390\/children12081082","relation":{},"ISSN":["2227-9067"],"issn-type":[{"value":"2227-9067","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,8,18]]}}}