Resusitasi Neonatus 2020 AAP

Prepublication Release
Part 5: Neonatal Resuscitation

2020 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care
Khalid Aziz, MBBS, MA, MEd(IT), Chair; Henry C. Lee, MD, Vice Chair; Marilyn B. Escobedo, MD
Amber V. Hoover, RN, MSN; Beena D. Kamath-Rayne, MD, MPH; Vishal S. Kapadia, MD, MSCS;
David J. Magid, MD, MPH; Susan Niermeyer, MD, MPH; Georg M. Schmölzer, MD, PhD; Edgardo
Szyld, MD, MSc Gary M. Weiner, MD; Myra H. Wyckoff, MD Nicole K. Yamada, MD, MS; Jeanette
Zaichkin, RN, MN, NNP-BC
DOI: 10.1542/peds.2020-038505E
Journal: Pediatrics
Article Type: Supplement Article
Citation: Aziz K, Lee HC, Escobedo MB, et al. Part 5: Neonatal Resuscitation 2020 American Heart
Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Pediatrics. 2020; doi: 10.1542/peds.2020-038505E
This article has been copublished in Circulation.

This is a prepublication version of an article that has undergone peer review and been accepted for
publication but is not the final version of record. This paper may be cited using the DOI and date of
access. This paper may contain information that has errors in facts, figures, and statements, and will be
corrected in the final published version. The journal is providing an early version of this article to
expedite access to this information. The American Academy of Pediatrics, the editors, and authors are not
responsible for inaccurate information and data described in this version.
©2020 American Academy of Pediatrics and American Heart Association, Inc.

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Part 5: Neonatal Resuscitation
2020 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care
Khalid Aziz, MBBS, MA, MEd(IT), Chair; Henry C. Lee, MD, Vice Chair; Marilyn B. Escobedo, MD Amber V.
Hoover, RN, MSN; Beena D. Kamath-Rayne, MD, MPH; Vishal S. Kapadia, MD, MSCS; David J. Magid, MD, MPH
Susan Niermeyer, MD, MPH; Georg M. Schmölzer, MD, PhD; Edgardo Szyld, MD, MSc; Gary M. Weiner, MD;
Myra H. Wyckoff, MD Nicole K. Yamada, MD, MS; Jeanette Zaichkin, RN, MN, NNP-BC
TOP 10 TAKE-HOME MESSAGES FOR NEONATAL LIFE

SUPPORT
1. Newborn resuscitation requires anticipation and preparation by providers
who train individually and as teams.
2. Most newly born infants do not require immediate cord clamping or resusci-
tation and can be evaluated and monitored during skin-to-skin contact with
their mothers after birth.
3. Inflation and ventilation of the lungs are the priority in newly born infants
who need support after birth.
4. A rise in heart rate is the most important indicator of effective ventilation and
response to resuscitative interventions.
5. Pulse oximetry is used to guide oxygen therapy and meet oxygen saturation goals.
Key Words: AHA Scientific Statements
6. Chest compressions are provided if there is a poor heart rate response to ■ cardiopulmonary resuscitation
ventilation after appropriate ventilation corrective steps, which preferably ■ neonatal resuscitation ◼ neonate
include endotracheal intubation. © 2020 American Heart Association,
7. The heart rate response to chest compressions and medications should be Inc., and American Academy of
monitored electrocardiographically. Pediatrics
This article has been copublished in
8. If the response to chest compressions is poor, it may be reasonable to provide Circulation.
epinephrine, preferably via the intravenous route.
9. Failure to respond to epinephrine in a newborn with history or examination
consistent with blood loss may require volume expansion.
10. If all these steps of resuscitation are effectively completed and there is no
heart rate response by 20 minutes, redirection of care should be discussed
with the team and family.
PREAMBLE
It is estimated that approximately 10% of newly born infants need help to begin
breathing at birth,1–3 and approximately 1% need intensive resuscitative measures
to restore cardiorespiratory function.4,5 The neonatal mortality rate in the United
States and Canada has fallen from almost 20 per 1000 live births6,7 in the 1960s to
the current rate of approximately 4 per 1000 live births. The inability of newly born
infants to establish and sustain adequate or spontaneous respiration contributes
significantly to these early deaths and to the burden of adverse neurodevelop-
mental outcome among survivors. Effective and timely resuscitation at birth could
therefore improve neonatal outcomes further.
Successful neonatal resuscitation efforts depend on critical actions that must occur in
rapid succession to maximize the chances of survival. The International Liaison Commit-
tee on Resuscitation (ILCOR) Formula for Survival emphasizes 3 essential components
for good resuscitation outcomes: guidelines based on sound resuscitation science,

effective education of resuscitation providers, and imple- for both vigorous and nonvigorous infants born with
mentation of effective and timely resuscitation.8 The 2020 meconium-stained amniotic fluid (MSAF). This guide-
neonatal guidelines contain recommendations, based on line reinforces initial steps and PPV as priorities.
the best available resuscitation science, for the most im- It is important to recognize that there are several
pactful steps to perform in the birthing room and in the significant gaps in knowledge relating to neonatal re-
neonatal period. In addition, specific recommendations suscitation. Many current recommendations are based
about the training of resuscitation providers and systems on weak evidence with a lack of well-designed human
of care are provided in their respective guideline Parts.9,10 studies. This is partly due to the challenges of perform-
ing large randomized controlled trials (RCTs) in the de-
livery room. The current guideline, therefore, concludes
INTRODUCTION with a summary of current gaps in neonatal research
Scope of Guideline and some potential strategies to address these gaps.
This guideline is designed for North American healthcare COVID-19 Guidance
providers who are looking for an up-to-date summary for Together with other professional societies, the AHA has
clinical care, as well as for those who are seeking more provided interim guidance for basic and advanced life sup-
in-depth information on resuscitation science and gaps port in adults, children, and neonates with suspected or
in current knowledge. The science of neonatal resuscita- confirmed coronavirus disease 2019 (COVID-19) infec-
tion applies to newly born infants transitioning from the tion. Because evidence and guidance are evolving with the
fluid-filled environment of the womb to the air-filled en- COVID-19 situation, this interim guidance is maintained
vironment of the birthing room and to newborns in the separately from the ECC guidelines. Readers are directed
days after birth. In circumstances of altered or impaired to the AHA website for the most recent guidance.12
transition, effective neonatal resuscitation reduces the
risk of mortality and morbidity. Even healthy babies who Evidence Evaluation and Guidelines
breathe well after birth benefit from facilitation of normal
Development
transition, including appropriate cord management and
thermal protection with skin-to-skin care. The following sections briefly describe the process of
The 2015 Neonatal Resuscitation Algorithm and the evidence review and guideline development. See “Part
major concepts based on sections of the algorithm con- 2: Evidence Evaluation and Guidelines Development”
tinue to be relevant in 2020 (Figure). The following sec- for more details on this process.11
tions are worth special attention.
• Positive-pressure ventilation (PPV) remains the Organization of the Writing Committee
main intervention in neonatal resuscitation. While The Neonatal Life Support Writing Group includes neo-
the science and practices surrounding monitoring natal physicians and nurses with backgrounds in clini-
and other aspects of neonatal resuscitation con- cal medicine, education, research, and public health.
tinue to evolve, the development of skills and prac- Volunteers with recognized expertise in resuscitation
tice surrounding PPV should be emphasized. are nominated by the writing group chair and selected
• Supplemental oxygen should be used judiciously, by the AHA ECC Committee. The AHA has rigorous
guided by pulse oximetry. conflict of interest policies and procedures to minimize
• Prevention of hypothermia continues to be an the risk of bias or improper influence during develop-
important focus for neonatal resuscitation. The ment of the guidelines.13 Before appointment, writing
importance of skin-to-skin care in healthy babies group members and peer reviewers disclosed all com-
is reinforced as a means of promoting parental mercial relationships and other potential (including in-
bonding, breast feeding, and normothermia. tellectual) conflicts. Disclosure information for writing
• Team training remains an important aspect of group members is listed in Appendix 1.
neonatal resuscitation, including anticipation,
preparation, briefing, and debriefing. Rapid and
effective response and performance are critical to Methodology and Evidence Review
good newborn outcomes. These 2020 AHA neonatal resuscitation guidelines are
• Delayed umbilical cord clamping was recommended based on the extensive evidence evaluation performed
for both term and preterm neonates in 2015. This in conjunction with the ILCOR and affiliated ILCOR
guideline affirms the previous recommendations. member councils. Three different types of evidence
• The 2015 American Heart Association (AHA) reviews (systematic reviews, scoping reviews, and evi-
Guidelines Update for Cardiopulmonary Resuscitation dence updates) were used in the 2020 process. Each
(CPR) and Emergency Cardiovascular Care (ECC) rec- of these resulted in a description of the literature that
ommended against routine endotracheal suctioning facilitated guideline development.14–17

Figure. Neonatal Resuscitation Algorithm.
CPAP indicates continuous positive airway pressure; ECG, electrocardiographic; ETT, endotracheal tube; HR, heart rate; IV, intravenous; O2, oxygen; Spo2, oxygen
saturation; and UVC, umbilical venous catheter.
Class of Recommendation and Level of 2020 ILCOR International Consensus on CPR and ECC
Evidence Science With Treatment Recommendations evidence
Each AHA writing group reviewed all relevant and cur- and recommendations21 to determine if current guide-
rent AHA guidelines for CPR and ECC18–20 and all relevant lines should be reaffirmed, revised, or retired, or if new
Table. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient
Care (Updated May 2019)*
recommendations were needed. The writing groups then clarifies the rationale and key study data supporting the
drafted, reviewed, and approved recommendations, as- recommendations. When appropriate, flow diagrams or
signing to each a Level of Evidence (LOE; ie, quality) and additional tables are included. Hyperlinked references
Class of Recommendation (COR; ie, strength) (Table).11 are provided to facilitate quick access and review.
Guideline Structure Document Review and Approval

The 2020 guidelines are organized into “knowledge Each 2020 AHA Guidelines for CPR and ECC document
chunks,” grouped into discrete modules of information was submitted for blinded peer review to 5 subject mat-
on specific topics or management issues.22 Each modu- ter experts nominated by the AHA. Before appointment,
lar knowledge chunk includes a table of recommenda- all peer reviewers were required to disclose relationships
tions using standard AHA nomenclature of COR and with industry and any other potential conflicts of inter-
LOE. A brief introduction or short synopsis is provided to est, and all disclosures were reviewed by AHA staff. Peer
put the recommendations into context with important reviewer feedback was provided for guidelines in draft
background information and overarching management format and again in final format. All guidelines were
or treatment concepts. Recommendation-specific text reviewed and approved for publication by the AHA
Science Advisory and Coordinating Committee and (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169:467–
473. doi: 10.7326/M18-0850
AHA Executive Committee. Disclosure information for 18. Kattwinkel J, Perlman JM, AzizK,Colby C,Fairchild K,Gallagher J, Hazinski MF,
peer reviewers is listed in Appendix 2. Halamek LP, Kumar P, Little G, et al. Part 15: neonatal resuscitation: 2010
American Heart Association Guidelines for Cardiopulmonary Resuscita-
tion and Emergency Cardiovascular Care. Circulation. 2010;122(suppl
REFERENCES 3):S909–S919. doi: 10.1161/CIRCULATIONAHA.110.971119
19. Wyckoff MH, Aziz K, Escobedo MB, Kapadia VS, Kattwinkel J, Perlman JM,
1. Little MP, Järvelin MR, Neasham DE, Lissauer T, Steer PJ. Factors associated Simon WM, Weiner GM, Zaichkin JG. Part 13: neonatal resuscitation:
with fall in neonatal intubation rates in the United Kingdom–prospective 2015 American Heart Association Guidelines Update for Cardiopulmo-
study. BJOG. 2007;114:156–164. doi: 10.1111/j.1471-0528.2006.01188.x nary Resuscitation and Emergency Cardiovascular Care. Circulation.
2. Niles DE, Cines C, Insley E, Foglia EE, Elci OU, Skåre C, Olasveengen T, 2015;132(suppl 2):S543–S560. doi: 10.1161/CIR.0000000000000267
Ades A, Posencheg M, Nadkarni VM, Kramer-Johansen J. Incidence and 20. Escobedo MB, Aziz K, Kapadia VS, Lee HC, Niermeyer S, Schmölzer GM,
characteristics of positive pressure ventilation delivered to newborns in Szyld E, Weiner GM, Wyckoff MH, Yamada NK, Zaichkin JG. 2019 Ameri-
a US tertiary academic hospital. Resuscitation. 2017;115:102–109. doi: can Heart Association Focused Update on Neonatal Resuscitation: An
10.1016/j.resuscitation.2017.03.035 Update to the American Heart Association Guidelines for Cardiopul-
3. Aziz K, Chadwick M, Baker M, Andrews W. Ante- and intra-partum fac- monary Resuscitation and Emergency Cardiovascular Care. Circulation.
tors that predict increased need for neonatal resuscitation. Resuscitation. 2019;140:e922–e930. doi: 10.1161/CIR.0000000000000729
2008;79:444–452. doi: 10.1016/j.resuscitation.2008.08.004 21. Wyckoff MH, Wyllie J, Aziz K, de Almeida MF, Fabres J, Fawke J,
4. Perlman JM, Risser R. Cardiopulmonary resuscitation in the delivery room. Guinsburg R, Hosono S, Isayama T, Kapadia VS, et al; on behalf of the
Associated clinical events. Arch Pediatr Adolesc Med. 1995;149:20–25. Neonatal Life Support Collaborators. Neonatal life support: 2020 Interna-
doi: 10.1001/archpedi.1995.02170130022005 tional Consensus on Cardiopulmonary Resuscitation and Emergency Car-
5. Barber CA, Wyckoff MH. Use and efficacy of endotracheal versus in- diovascular Care Science With Treatment Recommendations. Circulation.
travenous epinephrine during neonatal cardiopulmonary resuscita- 2020;142(suppl 1):S185–S221. doi: 10.1161/CIR.0000000000000895
tion in the delivery room. Pediatrics. 2006;118:1028–1034. doi: 22. Levine GN, O’Gara PT, Beckman JA, Al-Khatib SM, Birtcher KK, Cigarroa JE,
10.1542/peds.2006-0416 de Las Fuentes L, Deswal A, Fleisher LA, Gentile F, Goldberger ZD, Hlatky MA,
6. MacDorman MF, Rosenberg HM. Trends in infant mortality by cause of Joglar JA, Piano MR, Wijeysundera DN. Recent Innovations, Modifications,
death and other characteristics, 1960–88. Vital Health Stat 20. 1993:1–57. and Evolution of ACC/AHA Clinical Practice Guidelines: An Update for
7. Kochanek KD, Murphy SL, Xu JQ, Arias E; Division of Vital Statistics. Na- Our Constituencies: A Report of the American College of Cardiology/
tional Vital Statistics Reports: Deaths: Final Data for 2017 Hyattsville, MD: American Heart Association Task Force on Clinical Practice Guidelines. Cir-
National Center for Health Statistics; 2019(68). https://www.cdc.gov/ culation. 2019;139:e879–e886. doi: 10.1161/CIR.0000000000000651
nchs/data/nvsr/nvsr68/nvsr68_09-508.pdf. Accessed February 28, 2020.
8. Søreide E, Morrison L, Hillman K, Monsieurs K, Sunde K, Zideman D,
Eisenberg M, Sterz F, Nadkarni VM, Soar J, Nolan JP; Utstein Formula for
Survival Collaborators. The formula for survival in resuscitation. Resuscita- MAJOR CONCEPTS
tion. 2013;84:1487–1493. doi: 10.1016/j.resuscitation.2013.07.020
9. Cheng A, Magid DJ, Auerbach M, Bhanji F, Bigham BL, Blewer AL, Dain- These guidelines apply primarily to the “newly born”
ty KN, Diederich E, Lin Y, Leary M, et al. Part 6: resuscitation education baby who is transitioning from the fluid-filled womb to
science: 2020 American Heart Association Guidelines for Cardiopul-
the air-filled room. The “newly born” period extends
monary Resuscitation and Emergency Cardiovascular Care. Circulation.
2020;142(suppl 2):S551–S579. doi: 10.1161/CIR.0000000000000903 from birth to the end of resuscitation and stabilization
10. Berg KM, Cheng A, Panchal AR, Topjian AA, Aziz K, Bhanji F, Bigham BL, in the delivery area. However, the concepts in these
Hirsch KG, Hoover AV, Kurz MC, et al; on behalf of the Adult Basic and Ad-
guidelines may be applied to newborns during the neo-
vanced Life Support, Pediatric Basic and Advanced Life Support, Neonatal
Life Support, and Resuscitation Education Science Writing Groups. Part 7: natal period (birth to 28 days).
systems of care: 2020 American Heart Association Guidelines for Cardio- The primary goal of neonatal care at birth is to facili-
pulmonary Resuscitation and Emergency Cardiovascular Care. Circulation.
tate transition. The most important priority for newborn
2020;142(suppl 2):S580–S604. doi: 10.1161/CIR.0000000000000899
11. Magid DJ, Aziz K, Cheng A, Hazinski MF, Hoover AV, Mahgoub M, survival is the establishment of adequate lung inflation
Panchal AR, Sasson C, Topjian AA, Rodriguez AJ, et al. Part 2: evidence evalua- and ventilation after birth. Consequently, all newly born
tion and guidelines development: 2020 American Heart Association Guidelines
babies should be attended to by at least 1 person skilled
for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circu-
lation. 2020;142(suppl 2):S358–S365. doi: 10.1161/CIR.0000000000000898 and equipped to provide PPV. Other important goals in-
12. American Heart Association. CPR & ECC. https://cpr.heart.org/. Accessed clude establishment and maintenance of cardiovascular
June 19, 2020. and temperature stability as well as the promotion of
13. American Heart Association. Conflict of interest policy. https://www.heart.
org/en/about-us/statements-and-policies/conflict-of-interest-policy. Ac- mother-infant bonding and breast feeding, recognizing
cessed December 31, 2019. that healthy babies transition naturally.
14. International Liaison Committee on Resuscitation. Continuous evidence The Neonatal Resuscitation Algorithm remains un-
evaluation guidance and templates. https://www.ilcor.org/documents/
continuous-evidence-evaluation-guidance-and-templates. Accessed De- changed from 2015 and is the organizing framework for
cember 31, 2019. major concepts that reflect the needs of the baby, the
15. Institute of Medicine (US) Committee of Standards for Systematic Reviews family, and the surrounding team of perinatal caregivers.
of Comparative Effectiveness Research. Finding What Works in Health
Care: Standards for Systematic Reviews. Eden J, Levit L, Berg A, Morton S,
eds. Washington, DC: The National Academies Press; 2011.
16. PRISMA. Preferred Reporting Items for Systematic Reviews and Meta- Anticipation and Preparation
Analyses (PRISMA) website. http://www.prisma-statement.org/. Accessed
December 31, 2019. Every healthy newly born baby should have a trained and
17. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, equipped person assigned to facilitate transition. Identifica-
Moher D, Peters MDJ, Horsley T, Weeks L, Hempel S, Akl EA, Chang C,
tion of risk factors for resuscitation may indicate the need
McGowan J, Stewart L, Hartling L, Aldcroft A, Wilson MG, Garritty C, Lewin S,
Godfrey CM, Macdonald MT, Langlois EV, Soares-Weiser K, Moriarty J, for additional personnel and equipment. Effective team
Clifford T, Tunçalp Ö, Straus SE. PRISMA Extension for Scoping Reviews behaviors, such as anticipation, communication, briefing,

equipment checks, and assignment of roles, result in im- Vascular Access
proved team performance and neonatal outcome.
When vascular access is required in the newly born, the
umbilical venous route is preferred. When intravenous
Cord Management access is not feasible, the intraosseous route may be
After an uncomplicated term or late preterm birth, it is considered.
reasonable to delay cord clamping until after the baby is
placed on the mother, dried, and assessed for breathing, Medications
tone, and activity. In other situations, clamping and cut-
ting of the cord may also be deferred while respiratory, If the heart rate remains less than 60/min despite 60
cardiovascular, and thermal transition is evaluated and seconds of chest compressions and adequate PPV, epi-
initial steps are undertaken. In preterm birth, there are nephrine should be administered, ideally via the intra-
also potential advantages from delaying cord clamping. venous route.
Initial Actions Volume Expansion

When possible, healthy term babies should be man- When blood loss is known or suspected based on his-
aged skin-to-skin with their mothers. After birth, the tory and examination, and there is no response to epi-
baby should be dried and placed directly skin-to-skin nephrine, volume expansion is indicated.
with attention to warm coverings and maintenance of
normal temperature. There should be ongoing evalua-
Withholding and Discontinuing
tion of the baby for normal respiratory transition. Radi-
ant warmers and other warming adjuncts are suggested Resuscitation
for babies who require resuscitation at birth, especially It may be possible to identify conditions in which with-
very preterm and very low-birth-weight babies. holding or discontinuation of resuscitative efforts may
Stimulation may be provided to facilitate respiratory be reasonably considered by families and care provid-
effort. Suctioning may be considered for suspected air- ers. Appropriate and timely support should be provid-
way obstruction. ed to all involved.
Assessment of Heart Rate Human Factors and Systems

Heart rate is assessed initially by auscultation and/or Teams and individuals who provide neonatal resusci-
palpation. Oximetry and electrocardiography are impor- tation are faced with many challenges with respect
tant adjuncts in babies requiring resuscitation. to the knowledge, skills, and behaviors needed to
perform effectively. Neonatal resuscitation teams
Positive-Pressure Ventilation may therefore benefit from ongoing booster training,
PPV remains the primary method for providing support for briefing, and debriefing.
newborns who are apneic, bradycardic, or demonstrate
inadequate respiratory effort. Most babies will respond to Abbreviations
this intervention. An improvement in heart rate and estab-
lishment of breathing or crying are all signs of effective PPV. AHA American Heart Association
COR Class of Recommendation
Oxygen Therapy CPAP continuous positive airway pressure
PPV may be initiated with air (21% oxygen) in term and ECC emergency cardiovascular care
late preterm babies, and up to 30% oxygen in preterm ECG electrocardiogram/electrocardiographic

babies. Oximetry is used to target the natural range of H2O water
oxygen saturation levels that occur in term babies. HIE hypoxic-ischemic encephalopathy
ILCOR International Liaison Committee on Resuscitation
Chest Compressions LOE Level of Evidence
If the heart rate remains less than 60/min despite 30 MSAF meconium-stained amniotic fluid
seconds of adequate PPV, chest compressions should be PEEP positive end-expiratory pressure
provided. The suggested ratio is 3 chest compressions PPV positive pressure ventilation
synchronized to 1 inflation (with 30 inflations per minute
RCT randomized controlled trial
and 90 compressions per minute) using the 2 thumb–
ROSC return of spontaneous circulation
encircling hands technique for chest compressions.

ANTICIPATION OF RESUSCITATION reduced stillbirths and improved 7-day neonatal
survival in low-resource countries.3 A retrospec-
NEED
tive cohort study demonstrated improved Apgar
Recommendations for Anticipating Resuscitation Need scores among high-risk newborns after neonatal
COR LOE Recommendations
resuscitation training.16
2. A multicenter, case-control study identified 10
1. Every birth should be attended by at
least 1 person who can perform the perinatal risk factors that predict the need for
1 B-NR initial steps of newborn resuscitation and advanced neonatal resuscitation.7 An audit study
initiate PPV, and whose only responsibility
is the care of the newborn.1–4 done before the use of risk stratification showed
2. Before every birth, a standardized risk
that resuscitation was anticipated in less than
factors assessment tool should be used half of births requiring PPV.6 A prospective cohort
1 B-NR
to assess perinatal risk and assemble a study showed that risk stratification based on
qualified team on the basis of that risk.5–7
perinatal risk factors increased the likelihood of
3. Before every birth, a standardized skilled team attendance at high-risk births.5
equipment checklist should be used to
1 C-LD ensure the presence and function of 3. A multicenter quality improvement study demon-
supplies and equipment necessary for a
strated high staff compliance with the use of a neo-
complete resuscitation. 8,9
natal resuscitation bundle that included briefing
4. When anticipating a high-risk birth, a
preresuscitation team briefing should and an equipment checklist.8 A management bun-
1 C-LD be completed to identify potential dle for preterm infants that included team briefing
interventions and assign roles and and equipment checks resulted in clear role assign-
responsibilities.8,10–12
ments, consistent equipment checks, and improved
thermoregulation and oxygen saturation.9
Synopsis
4. A single-center RCT found that role confusion dur-
Approximately 10% of newborns require assistance to ing simulated neonatal resuscitation was avoided
breathe after birth.1–3,5,13 Newborn resuscitation requires and teamwork skills improved by conducting a
training, preparation, and teamwork. When the need team briefing.11 A statewide collaborative qual-
for resuscitation is not anticipated, delays in assisting a ity initiative demonstrated that team briefing
newborn who is not breathing may increase the risk of improved team communication and clinical out-
death.1,5,13 Therefore, every birth should be attended by comes.10 A single-center study demonstrated
at least 1 person whose primary responsibility is the new- that team briefing and an equipment checklist
born and who is trained to begin PPV without delay.2–4 improved team communication but showed no
A risk assessment tool that evaluates risk factors improvement in equipment preparation.12
present during pregnancy and labor can identify new-
borns likely to require advanced resuscitation; in these REFERENCES
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effective teamwork and communication, and support 2015;132(suppl 2):S543–S560. doi: 10.1161/CIR.0000000000000267
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Patient Saf. 2016;42:369–376. doi: 10.1016/s1553-7250(16)42052-0 after birth and better iron levels in infancy.9–21 While
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Sappenfield WM, Curran JS, Ashmeade TL. Promoting teamwork may assessed, iron deficiency is associated with impaired
improve infant care processes during delivery room management: Florida
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doi: 10.1038/jp.2017.27 able to delay cord clamping (longer than 30 seconds)
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Quality Care Golden Hour Project Team. Improving neonatal resuscita-
tion in Tennessee: a large-scale, quality improvement project. J Perinatol. pressure support and transfusion and may improve
2019;39:1676–1683. doi: 10.1038/s41372-019-0461-3 survival.1–8
11. Litke-Wager C, Delaney H, Mu T, Sawyer T. Impact of task-oriented There are insufficient studies in babies requiring PPV
role assignment on neonatal resuscitation performance: a simulation-
based randomized controlled trial. Am J Perinatol. 2020; doi: 10.1055/s- before cord clamping to make a recommendation.22
0039-3402751 Early cord clamping should be considered for cases
12. Katheria A, Rich W, Finer N. Development of a strategic process using when placental transfusion is unlikely to occur, such
checklists to facilitate team preparation and improve communication
during neonatal resuscitation. Resuscitation. 2013;84:1552–1557. doi: as maternal hemorrhage or hemodynamic instability,
10.1016/j.resuscitation.2013.06.012 placental abruption, or placenta previa.27 There is no
13. Niles DE, Cines C, Insley E, Foglia EE, Elci OU, Skåre C, Olasveengen T, evidence of maternal harm from delayed cord clamping
Ades A, Posencheg M, Nadkarni VM, Kramer-Johansen J. Incidence and
characteristics of positive pressure ventilation delivered to newborns in compared with early cord clamping.10–12,28–34 Cord milk-
a US tertiary academic hospital. Resuscitation. 2017;115:102–109. doi: ing is being studied as an alternative to delayed cord
10.1016/j.resuscitation.2017.03.035 clamping but should be avoided in babies less than 28
14. Brown T, Tu J, Profit J, Gupta A, Lee HC. Optimal Criteria Survey for Prere-
suscitation Delivery Room Checklists. Am J Perinatol. 2016;33:203–207. weeks’ gestational age, because it is associated with
doi: 10.1055/s-0035-1564064 brain injury.23
15. The Joint Commission. Sentinel Event Alert: Preventing infant death and
injury during delivery. 2004. https://www.jointcommission.org/resources/ Recommendation-Specific Supportive Text
patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/
1. Compared with preterm infants receiving early
sentinel-event-alert-issue-30-preventing-infant-death-and-injury-during-
delivery/. Accessed February 28, 2020. cord clamping, those receiving delayed cord
16. Patel D, Piotrowski ZH, Nelson MR, Sabich R. Effect of a statewide neonatal
resuscitation training program on Apgar scores among high-risk neonates
clamping were less likely to receive medications
in Illinois. Pediatrics. 2001;107:648–655. doi: 10.1542/peds.107.4.648 for hypotension in a meta-analysis of 6 RCTs1–6 and
receive transfusions in a meta-analysis of 5 RCTs.7
Among preterm infants not requiring resuscita-
UMBILICAL CORD MANAGEMENT tion, delayed cord clamping may be associated
with higher survival than early cord clamping is.8
Ten RCTs found no difference in postpartum hem-
Recommendations for Umbilical Cord Management
orrhage rates with delayed cord clamping versus
COR LOE Recommendations early cord clamping.10–12,28–34
1. For preterm infants who do not require
resuscitation at birth, it is reasonable to
2. Compared with term infants receiving early cord
2a B-R clamping, term infants receiving delayed cord
delay cord clamping for longer than 30
s.1–8 clamping had increased hemoglobin concen-
2. For term infants who do not require
tration within the first 24 hours and increased
resuscitation at birth, it may be ferritin concentration in the first 3 to 6 months
2b C-LD
reasonable to delay cord clamping for in meta-analyses of 12 and 6 RCTs,9–21 respec-
longer than 30 s.9–21
tively. Compared with term and late preterm
3. For term and preterm infants who require
infants receiving early cord clamping, those
resuscitation at birth, there is insufficient
2b C-EO
evidence to recommend early cord receiving delayed cord clamping showed no
clamping versus delayed cord clamping.22 significant difference in mortality, admission
4. For infants born at less than 28 wk to the neonatal intensive care unit, or hyper-
3: No Benefit B-R of gestation, cord milking is not bilirubinemia leading to phototherapy in meta-
recommended.23
analyses of 4,10,13,29,35 10,10,12,17,19,21,28,31,34,36,37
and 15 RCTs, respectively.9,12,14,18–21,28–30,32–34,38,39
Synopsis Compared with term infants receiving early
During an uncomplicated term or late preterm birth, cord clamping, those receiving delayed cord
it may be reasonable to defer cord clamping until af- clamping had increased polycythemia in meta-
ter the infant is placed on the mother and assessed analyses of 1310,11,13,14,17,18,21,29,30,33,39–41 and 8
for breathing and activity. Early cord clamping (within RCTs,9,10,13,19,20,28,30,34 respectively.

3. For infants requiring PPV at birth, there is currently 18. Ultee CA, van der Deure J, Swart J, Lasham C, van Baar AL. Delayed cord
clamping in preterm infants delivered at 34 36 weeks’ gestation: a ran-
insufficient evidence to recommend delayed cord domised controlled trial. Arch Dis Child Fetal Neonatal Ed. 2008;93:F20–
clamping versus early cord clamping. F23. doi: 10.1136/adc.2006.100354
4. A large multicenter RCT found higher rates of intra- 19. Vural I, Ozdemir H, Teker G, Yoldemir T, Bilgen H, Ozek E. Delayed
cord clamping in term large-for-gestational age infants: A prospec-
ventricular hemorrhage with cord milking in preterm tive randomised study. J Paediatr Child Health. 2019;55:555–560. doi:
babies born at less than 28 weeks’ gestational age.23 10.1111/jpc.14242
20. Yadav AK, Upadhyay A, Gothwal S, Dubey K, Mandal U, Yadav CP. Com-
parison of three types of intervention to enhance placental redistribution
in term newborns: randomized control trial. J Perinatol. 2015;35:720–
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31. Mohammad K, Tailakh S, Fram K, Creedy D. Effects of early umbilical
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Temperature Management for Newly
40. Grajeda R, Pérez-Escamilla R, Dewey KG. Delayed clamping of the umbili- Born Infants
cal cord improves hematologic status of Guatemalan infants at 2 mo of
age. Am J Clin Nutr. 1997;65:425–431. doi: 10.1093/ajcn/65.2.425 Additional Recommendations for Interventions to Maintain or
41. Saigal S, O’Neill A, Surainder Y, Chua LB, Usher R. Placental transfusion
Normalize Temperature
and hyperbilirubinemia in the premature. Pediatrics. 1972;49:406–419.
1. Placing healthy newborn infants who do

INITIAL ACTIONS 2a B-R
not require resuscitation skin-to-skin after
birth can be effective in improving breast-
Temperature at Birth feeding, temperature control and blood
glucose stability.8
Recommendations for Temperature Management 2. It is reasonable to perform all resuscitation

procedures, including endotracheal
COR LOE Recommendations intubation, chest compressions, and
2a C-LD
insertion of intravenous lines with
1. Admission temperature should be
1 B-NR temperature-controlling interventions in
routinely recorded.1,2
place.9
2. The temperature of newly born babies
should be maintained between 36.5°C 3. The use of radiant warmers, plastic bags
1 C-EO and wraps (with a cap), increased room
and 37.5°C after birth through admission
and stabilization.2 temperature, and warmed humidified
2a B-R
inspired gases can be effective in
3. Hypothermia (temperature less than preventing hypothermia in preterm babies
1 B-NR 36°C) should be prevented due to an in the delivery room.10,11
increased risk of adverse outcomes. 3–5
4. Exothermic mattresses may be effective
4. Prevention of hyperthermia (temperature 2b B-R in preventing hypothermia in preterm
2a B-NR greater than 38°C) is reasonable due to babies.11
an increased risk of adverse outcomes.4,6
5. Various combinations of warming
strategies (or “bundles”) may be
2b B-NR
reasonable to prevent hypothermia in very
Synopsis preterm babies.12
Temperature should be measured and recorded after 6. In resource-limited settings, it may be
birth and monitored as a measure of quality.1 The tem- reasonable to place newly born babies in
2b C-LD a clean food-grade plastic bag up to the
perature of newly born babies should be maintained level of the neck and swaddle them in
between 36.5°C and 37.5°C.2 Hypothermia (less than order to prevent hypothermia.13
36°C) should be prevented as it is associated with in-
creased neonatal mortality and morbidity, especially in Synopsis
very preterm (less than 33 weeks) and very low-birth- Healthy babies should be skin-to-skin after birth.8 For
weight babies (less than 1500 g), who are at increased preterm and low-birth-weight babies or babies requir-
risk for hypothermia.3–5,7 It is also reasonable to prevent ing resuscitation, warming adjuncts (increased ambient
hyperthermia as it may be associated with harm.4,6 temperature [greater than 23°C], skin-to-skin care, ra-
diant warmers, plastic wraps or bags, hats, blankets,
Recommendation-Specific Supportive Text exothermic mattresses, and warmed humidified in-
1. Hypothermia after birth is common worldwide, spired gases)10,11,14 individually or in combination may
with a higher incidence in babies of lower gesta- reduce the risk of hypothermia. Exothermic mattresses
tional age and birth weight.3–5 have been reported to cause local heat injury and hy-
2. There are long-standing worldwide recommenda- perthermia.15
tions for routine temperature management for When babies are born in out-of-hospital, resource-
the newborn.2 limited, or remote settings, it may be reasonable to pre-
3. In observational studies in both preterm (less than vent hypothermia by using a clean food-grade plastic
37 weeks) and low-birth-weight babies (less than bag13 as an alternative to skin-to-skin contact.8

Recommendation-Specific Supportive Text Recommendation-Specific Supportive Text
1. A systematic review (low to moderate certainty) 1. A meta-analysis of 8 RCTs19 (low certainty of evi-
of 6 RCTs showed that early skin-to-skin contact dence) suggest no benefit from routine suction-
promotes normothermia in healthy neonates.8 ing after birth.7 Subsequently, 2 additional studies
Two meta-analyses reviewed RCTs and observa- supported this conclusion.7
tional studies of extended skin-to-skin care after
Recommendations for Tactile Stimulation and Clearing the Airway
initial resuscitation and/or stabilization, some in
in Newly Born Infants With Ineffective Respiratory Effort
resource-limited settings, showing reduced mor-
tality, improved breastfeeding, shortened length
of stay, and improved weight gain in preterm 1. In babies who appear to have ineffective
2a B-NR respiratory effort after birth, tactile
and low-birth-weight babies (moderate quality stimulation is reasonable.20,21
evidence).16,17
2. Suctioning may be considered if PPV
2. Most RCTs in well-resourced settings would 2b C-EO is required and the airway appears
obstructed. 20
routinely manage at-risk babies under a radiant
warmer.11
3. RCTs and observational studies of warming Synopsis
If there is ineffective breathing effort or apnea after
adjuncts, alone and in combination, demonstrate
birth, tactile stimulation may stimulate breathing. Tac-
reduced rates of hypothermia in very preterm
tile stimulation should be limited to drying an infant
and very low-birth-weight babies.10,11 However,
and rubbing the back and soles of the feet.21,22 There
meta-analysis of RCTs of interventions that reduce
hypothermia in very preterm or very low-birth- may be some benefit from repeated tactile stimulation
weight babies (low certainty) show no impact on in preterm babies during or after providing PPV, but
neonatal morbidity or mortality.11 Two RCTs and this requires further study.23 If, at initial assessment,
expert opinion support ambient temperatures of there is visible fluid obstructing the airway or a con-
23°C and above.2,14,18 cern about obstructed breathing, the mouth and nose
4. One moderate quality RCT found higher rates of may be suctioned. Suction should also be considered
if there is evidence of airway obstruction during PPV.
hyperthermia with exothermic mattresses.15
5. Numerous nonrandomized quality improvement Recommendation-Specific Supportive Text
(very low to low certainty) studies support the use 1. Limited observational studies suggest that tactile
of warming adjunct “bundles.”12 stimulation may improve respiratory effort. One
6. One RCT in resource-limited settings found that RCT (low certainty of evidence) suggests improved
plastic coverings reduced the incidence of hypo- oxygenation after resuscitation in preterm babies
thermia, but they were not directly compared who received repeated tactile stimulation.23
with uninterrupted skin-to-skin care.13 2. Suctioning for suspected airway obstruction dur-
ing PPV is based on expert opinion.7
Clearing the Airway and Tactile
Recommendations for Clearing the Airway in Newly Born Infants
Stimulation in Newly Born Infants Delivered Through MSAF
Recommendation for Tactile Stimulation and Clearing the Airway in
Newly Born Infants 1. For nonvigorous newborns delivered
through MSAF who have evidence
COR LOE Recommendation 2a C-EO of airway obstruction during PPV,
1. Routine oral, nasal, oropharyngeal, or intubation and tracheal suction can
3: No Benefit C-LD endotracheal suctioning of newly born be beneficial.
babies is not recommended.7,19 2. For nonvigorous newborns
(presenting with apnea or ineffective
breathing effort) delivered through
Synopsis 3: No Benefit C-LD
MSAF, routine laryngoscopy with or
The immediate care of newly born babies involves an without tracheal suctioning is not
initial assessment of gestation, breathing, and tone. recommended.7
Babies who are breathing well and/or crying are cared
for skin-to-skin with their mothers and should not Synopsis
need interventions such as routine tactile stimulation Direct laryngoscopy and endotracheal suctioning are
or suctioning, even if the amniotic fluid is meconium not routinely required for babies born through MSAF
stained.7,19 Avoiding unnecessary suctioning helps pre- but can be beneficial in babies who have evidence of
vent the risk of induced bradycardia as a result of suc- airway obstruction while receiving PPV.7
tioning of the airway.
Recommendation-Specific Supportive Text plastic bags to prevent term neonatal hypothermia in a resource-poor
setting. Pediatrics. 2013;132:e656–e661. doi: 10.1542/peds.2013-0172
1. Endotracheal suctioning for apparent airway 14. Duryea EL, Nelson DB, Wyckoff MH, Grant EN, Tao W, Sadana N, Chalak LF,
obstruction with MSAF is based on expert opinion. McIntire DD, Leveno KJ. The impact of ambient operating room tempera-
2. A meta-analysis of 3 RCTs (low certainty of evi- ture on neonatal and maternal hypothermia and associated morbidities: a
randomized controlled trial. Am J Obstet Gynecol. 2016;214:505.e1–505.
dence) and a further single RCT suggest that non- e7. doi: 10.1016/j.ajog.2016.01.190
vigorous newborns delivered through MSAF have 15. McCarthy LK, Molloy EJ, Twomey AR, Murphy JF, O’Donnell CP. A random-
ized trial of exothermic mattresses for preterm newborns in polyethylene
the same outcomes (survival, need for respiratory bags. Pediatrics. 2013;132:e135–e141. doi: 10.1542/peds.2013-0279
support, or neurodevelopment) whether they are 16. Boundy EO, Dastjerdi R, Spiegelman D, Fawzi WW, Missmer SA, Lieberman E,
suctioned before or after the initiation of PPV.7 Kajeepeta S, Wall S, Chan GJ. Kangaroo mother care and neonatal out-
comes: a meta-analysis. Pediatrics. 2016;137 doi: 10.1542/peds.2015–2238
17. Conde-Agudelo A, Díaz-Rossello JL. Kangaroo mother care to reduce
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Subcommittees of the NICHD Neonatal Research Network. Admission
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Temperature and Associated Mortality and Morbidity among Moder-
tion of mortality effect. BMC Public Health. 2011;11(suppl 3):S12. doi:
ately and Extremely Preterm Infants. J Pediatr. 2018;192:53–59.e2. doi:
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22. World Health Organization. Guidelines on Basic Newborn Resuscita-
4. Lyu Y, Shah PS, Ye XY, Warre R, Piedboeuf B, Deshpandey A, Dunn M,
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Lee SK; Canadian Neonatal Network. Association between admission
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5. Lunze K, Bloom DE, Jamison DT, Hamer DH. The global burden of neo-
Repetitive versus standard tactile stimulation of preterm infants at birth
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10.1016/j.resuscitation.2018.03.030
6. Amadi HO, Olateju EK, Alabi P, Kawuwa MB, Ibadin MO,
Osibogun AO. Neonatal hyperthermia and thermal stress in low- and
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birthweight neonates. Paediatr Int Child Health. 2015;35:273–281. doi: ASSESSMENT OF HEART RATE DURING
10.1179/2046905515Y.0000000030
7. Wyckoff MH, Wyllie J, Aziz K, de Almeida MF, Fabres J, Fawke J,
NEONATAL RESUSCITATION
Guinsburg R, Hosono S, Isayama T, Kapadia VS, et al; on behalf of the After birth, the newborn’s heart rate is used to assess
Neonatal Life Support Collaborators. Neonatal life support: 2020 Interna-
tional Consensus on Cardiopulmonary Resuscitation and Emergency Car- the effectiveness of spontaneous respiratory effort,
diovascular Care Science With Treatment Recommendations. Circulation. the need for interventions, and the response to
2020;142(suppl 1):S185–S221. doi: 10.1161/CIR.0000000000000895 interventions. In addition, accurate, fast, and continu-
8. Moore ER, Bergman N, Anderson GC, Medley N. Early skin-to-skin contact
for mothers and their healthy newborn infants. Cochrane Database Syst ous heart rate assessment is necessary for newborns
Rev. 2016;11:CD003519. doi: 10.1002/14651858.CD003519.pub4 in whom chest compressions are initiated. Therefore,
9. Kattwinkel J, Perlman JM, AzizK,Colby C,Fairchild K,Gallagher J, Hazinski MF,
identifying a rapid and reliable method to measure the
Halamek LP, Kumar P, Little G, et al. Part 15: neonatal resuscitation: 2010
American Heart Association Guidelines for Cardiopulmonary Resuscita- newborn’s heart rate is critically important during
tion and Emergency Cardiovascular Care. Circulation. 2010;122(suppl neonatal resuscitation.
3):S909–S919. doi: 10.1161/CIRCULATIONAHA.110.971119
10. Meyer MP, Owen LS, Te Pas AB. Use of Heated Humidified Gases for
Early Stabilization of Preterm Infants: A Meta-Analysis. Front Pediatr. Recommendation for Assessment of Heart Rate
2018;6:319. doi: 10.3389/fped.2018.00319 COR LOE Recommendation
11. McCall EM, Alderdice F, Halliday HL, Vohra S, Johnston L. Interven-
tions to prevent hypothermia at birth in preterm and/or low birth 1. During resuscitation of term and preterm
weight infants. Cochrane Database Syst Rev. 2018;2:CD004210. doi: newborns, the use of electrocardiography
10.1002/14651858.CD004210.pub5 2b C-LD (ECG) for the rapid and accurate
12. Donnellan D, Moore Z, Patton D, O’Connor T, Nugent L. The effect of measurement of the newborn’s heart rate
thermoregulation quality improvement initiatives on the admission tem- may be reasonable.1–8
perature of premature/very low birth-weight infants in neonatal intensive
care units: a systematic review. J Spec Pediatr Nurs. 2020:e12286. doi: Synopsis
10.1111/jspn.12286 Auscultation of the precordium remains the preferred
13. Belsches TC, Tilly AE, Miller TR, Kambeyanda RH, Leadford A, Manasyan A,
Chomba E, Ramani M, Ambalavanan N, Carlo WA. Randomized trial of
physical examination method for the initial assessment

of the heart rate.9 Pulse oximetry and ECG remain im- Recommendation-Specific Supportive Text
portant adjuncts to provide continuous heart rate as- 1. Given the evidence for ECG during initial steps of
sessment in babies needing resuscitation. PPV, expert opinion is that ECG should be used
ECG provides the most rapid and accurate measure- when providing chest compressions.
ment of the newborn’s heart rate at birth and during re-
suscitation. Clinical assessment of heart rate by auscul-
tation or palpation may be unreliable and inaccurate.1–4 REFERENCES
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Compared to ECG, pulse oximetry is both slower in de-
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the first few minutes after birth.5,6,10–12 Underestimation training and technology design. Resuscitation. 2013;84:369–372. doi:
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ventions. On the other hand, overestimation of heart clinical assessment of infant heart rate in the delivery room. Resuscitation.
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Use of ECG for heart rate detection does not replace tion. 2010;81:1000–1003. doi: 10.1016/j.resuscitation.2010.03.021
5. Kamlin CO, Dawson JA, O’Donnell CP, Morley CJ, Donath SM, Sekhon J,
the need for pulse oximetry to evaluate oxygen satura- Davis PG. Accuracy of pulse oximetry measurement of heart rate of new-
tion or the need for supplemental oxygen. born infants in the delivery room. J Pediatr. 2008;152:756–760. doi:
10.1016/j.jpeds.2008.01.002
Recommendation-Specific Supportive Text 6. Katheria A, Rich W, Finer N. Electrocardiogram provides a continuous
1. In one RCT and one observational study, there heart rate faster than oximetry during neonatal resuscitation. Pediatrics.
2012;130:e1177–e1181. doi: 10.1542/peds.2012-0784
were no reports of technical difficulties with 7. Katheria A, Arnell K, Brown M, Hassen K, Maldonado M, Rich W, Finer N.
A pilot randomized controlled trial of EKG for neonatal resuscitation. PLoS
ECG monitoring during neonatal resuscitation,
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supporting its feasibility as a tool for monitoring 8. Shah BA, Wlodaver AG, Escobedo MB, Ahmed ST, Blunt MH, Anderson MP,
heart rate during neonatal resuscitation.6,7 Szyld EG. Impact of electronic cardiac (ECG) monitoring on delivery room
resuscitation and neonatal outcomes. Resuscitation. 2019;143:10–16.
2. One observational study compared neonatal out-
doi: 10.1016/j.resuscitation.2019.07.031
comes before (historical cohort) and after imple- 9. Wyckoff MH, Aziz K, Escobedo MB, Kapadia VS, Kattwinkel J, Perlman JM,
mentation of ECG monitoring in the delivery Simon WM, Weiner GM, Zaichkin JG. Part 13: neonatal resuscitation:
room.8 Compared with the newborns in the histori- 2015 American Heart Association Guidelines Update for Cardiopulmo-
nary Resuscitation and Emergency Cardiovascular Care. Circulation.
cal cohort, newborns with the ECG monitoring had 2015;132(suppl 2):S543–S560. doi: 10.1161/CIR.0000000000000267
lower rates of endotracheal intubation and higher 10. Mizumoto H, Tomotaki S, Shibata H, Ueda K, Akashi R, Uchio H, Hata D.
5-minute Apgar scores. However, newborns with Electrocardiogram shows reliable heart rates much earlier than pulse ox-
imetry during neonatal resuscitation. Pediatr Int. 2012;54:205–207. doi:
ECG monitoring also had higher odds of receiving 10.1111/j.1442-200X.2011.03506.x
chest compressions in the delivery room. 11. Narayen IC, Smit M, van Zwet EW, Dawson JA, Blom NA, te Pas AB. Low
3. Very low-quality evidence from 8 nonrandomized signal quality pulse oximetry measurements in newborn infants are reli-
able for oxygen saturation but underestimate heart rate. Acta Paediatr.
studies2,5,6,10,12–15 enrolling 615 newborns and 2 2015;104:e158–e163. doi: 10.1111/apa.12932
small RCTs7,16 suggests that at birth, ECG is faster 12. van Vonderen JJ, Hooper SB, Kroese JK, Roest AA, Narayen IC,
and more accurate for newborn heart assessment van Zwet EW, te Pas AB. Pulse oximetry measures a lower heart rate at
birth compared with electrocardiography. J Pediatr. 2015;166:49–53. doi:
compared with pulse oximetry. 10.1016/j.jpeds.2014.09.015
4. Very low-quality evidence from 2 nonrandomized 13. Dawson JA, Saraswat A, Simionato L, Thio M, Kamlin CO, Owen LS,
Schmölzer GM, Davis PG. Comparison of heart rate and oxygen saturation
studies and 1 randomized trial show that auscul- measurements from Masimo and Nellcor pulse oximeters in newly born
tation is not as accurate as ECG for heart rate term infants. Acta Paediatr. 2013;102:955–960. doi: 10.1111/apa.12329
assessment during newborn stabilization immedi- 14. Gulati R, Zayek M, Eyal F. Presetting ECG electrodes for earlier heart
rate detection in the delivery room. Resuscitation. 2018;128:83–87. doi:
ately after birth.2–4 10.1016/j.resuscitation.2018.03.038
15. Iglesias B, Rodrí Guez MAJ, Aleo E, Criado E,
Recommendation for Assessment of Heart Rate Martí Nez-Orgado J, Arruza L. 3-lead electrocardiogram is more reliable
than pulse oximetry to detect bradycardia during stabilisation at birth of
COR LOE Recommendation very preterm infants. Arch Dis Child Fetal Neonatal Ed. 2018;103:F233–
1. During chest compressions, an ECG F237. doi: 10.1136/archdischild-2016-311492
1 C-EO should be used for the rapid and accurate 16. Murphy MC, De Angelis L, McCarthy LK, O’Donnell CPF. Randomised
assessment of heart rate.1–7,10,12–16 study comparing heart rate measurement in newly born infants using a
monitor incorporating electrocardiogram and pulse oximeter versus pulse
Synopsis oximeter alone. Arch Dis Child Fetal Neonatal Ed. 2019;104:F547–F550.
doi: 10.1136/archdischild-2017-314366
When chest compressions are initiated, an ECG should 17. Luong D, Cheung PY, Barrington KJ, Davis PG, Unrau J, Dakshinamurti S,
be used to confirm heart rate. When ECG heart rate is Schmölzer GM. Cardiac arrest with pulseless electrical activity rhythm
greater than 60/min, a palpable pulse and/or audible in newborn infants: a case series. Arch Dis Child Fetal Neonatal Ed.
2019;104:F572–F574. doi: 10.1136/archdischild-2018-316087
heart rate rules out pulseless electric activity.17–21
18. Luong DH, Cheung PY, O’Reilly M, Lee TF, Schmolzer GM. Electrocardiog- Synopsis
raphy vs. Auscultation to Assess Heart Rate During Cardiac Arrest With
Pulseless Electrical Activity in Newborn Infants. Front Pediatr. 2018;6:366.
The adequacy of ventilation is measured by a rise in
doi: 10.3389/fped.2018.00366 heart rate and, less reliably, chest expansion. Peak infla-
19. Patel S, Cheung PY, Solevåg AL, Barrington KJ, Kamlin COF, tion pressures of up to 30 cm H2O in term newborns
Davis PG, Schmölzer GM. Pulseless electrical activity: a misdiagnosed en-
tity during asphyxia in newborn infants? Arch Dis Child Fetal Neonatal Ed. and 20 to 25 cm H2O in preterm newborns are usu-
2019;104:F215–F217. doi: 10.1136/archdischild-2018-314907 ally sufficient to inflate the lungs.5–7,9,11–14 In some cases,
20. Sillers L, Handley SC, James JR, Foglia EE. Pulseless Electrical Activity Com- however, higher inflation pressures are required.5,7–10
plicating Neonatal Resuscitation. Neonatology. 2019;115:95–98. doi:
10.1159/000493357
Peak inflation pressures or tidal volumes greater than
21. Solevåg AL, Luong D, Lee TF, O’Reilly M, Cheung PY, Schmölzer GM. Non- what is required to increase heart rate and achieve
perfusing cardiac rhythms in asphyxiated newborn piglets. PLoS One. chest expansion should be avoided.24,26–28
2019;14:e0214506. doi: 10.1371/journal.pone.0214506
The lungs of sick or preterm infants tend to collapse
because of immaturity and surfactant deficiency.15 PEEP
VENTILATORY SUPPORT AFTER BIRTH: provides low-pressure inflation of the lungs during expira-
tion. PEEP has been shown to maintain lung volume dur-
PPV AND CONTINUOUS POSITIVE ing PPV in animal studies, thus improving lung function
AIRWAY PRESSURE and oxygenation.16 PEEP may be beneficial during neona-
Initial Breaths (When and How to tal resuscitation, but the evidence from human studies is
limited. Optimal PEEP has not been determined, because
Provide PPV)
all human studies used a PEEP level of 5 cm H2O.18–22
The vast majority of newborns breathe spontaneously
within 30 to 60 seconds after birth, sometimes after dry- Recommendation-Specific Supportive Text
ing and tactile stimulation.1 Newborns who do not breathe 1. A large observational study showed that most
within the first 60 seconds after birth or are persistently
bradycardic (heart rate less than 100/min) despite appropri- nonvigorous newly born infants respond to stim-
ate initial actions (including tactile stimulation) may receive ulation and PPV. The same study demonstrated
PPV at a rate of 40 to 60/min.2,3 The order of resuscitative that the risk of death or prolonged admission
procedures in newborns differs from pediatric and adult increases 16% for every 30-second delay in initi-
resuscitation algorithms. On the basis of animal research, ating PPV.1
the progression from primary apnea to secondary apnea 2. Animal studies in newborn mammals show that
in newborns results in the cessation of respiratory activ- heart rate decreases during asphyxia. Ventilation
ity before the onset of cardiac failure.4 This cycle of events of the lungs results in a rapid increase in heart
differs from that of asphyxiated adults, who experience rate.3,4 Several case series found that most term
concurrent respiratory and cardiac failure. For this reason, newborns can be resuscitated using peak infla-
tion pressures of 30 cm H O, delivered without
2
neonatal resuscitation should begin with PPV rather than PEEP.5–8 Occasionally, higher peak pressures are
with chest compressions.2,3 Delays in initiating ventilatory required.5,7–10
support in newly born infants increase the risk of death.1 3. Case series in preterm infants have found that
Recommendations About Pressure for Providing PPV
most preterm infants can be resuscitated using
PPV inflation pressures in the range of 20 to 25 cm
H2O,11–14 but higher pressures may be required.10,11
1. In newly born infants who are gasping or
apneic within 60 s after birth or who are
4. An observational study including 1962 infants
persistently bradycardic (heart rate less between 23 and 33 weeks’ gestational age reported
1 B-NR
than 100/min) despite appropriate initial lower rates of mortality and chronic lung disease
actions (including tactile stimulation), PPV
should be provided without delay.1
when giving PPV with PEEP versus no PEEP.19
5. Two randomized trials and 1 quasi-randomized trial
2. In newly born infants who require PPV, it is
reasonable to use peak inflation pressure
(very low quality) including 312 infants compared
to inflate the lung and achieve a rise in PPV with a T-piece (with PEEP) versus a self-inflating
2a C-LD heart rate. This can usually be achieved bag (no PEEP) and reported similar rates of death
with a peak inflation pressure of 20 to 25
cm water (H2O). Occasionally, higher peak and chronic lung disease.20–22 One trial (very low
inflation pressures are required.5–14 quality) compared PPV using a T-piece and PEEP of
3. In newly born infants receiving PPV, it 5 cm H2O versus 0 cm H2O and reported similar
2b C-LD may be reasonable to provide positive rates of death and chronic lung disease.23
end-expiratory pressure (PEEP).15–23 6. Studies of newly born animals showed that PEEP
4. Excessive peak inflation pressures are facilitates lung aeration and accumulation of
3: Harm C-LD potentially harmful and should be
avoided.24,25
functional residual capacity, prevents distal air-
way collapse, increases lung surface area and

compliance, decreases expiratory resistance, con- received sustained inflations; no significant differ-
serves surfactant, and reduces hyaline membrane ence was found in the primary outcome of death
formation, alveolar collapse, and the expression or bronchopulmonary dysplasia.
of proinflammatory mediators.16,18
7. One observational study in newly born infants
Continuous Positive Airway Pressure
associated high tidal volumes during resuscitation Administration
with brain injury.25
8. Several animal studies found that ventilation with Recommendation for Providing CPAP
high volumes caused lung injury, impaired gas COR LOE Recommendation
exchange, and reduced lung compliance in imma- 1. For spontaneously breathing preterm
ture animals.24,26–28 2a A
infants who require respiratory support
immediately after delivery, it is reasonable
Recommendations for Rate and Inspiratory Time During PPV to use CPAP rather than intubation.32

Synopsis
1. It is reasonable to provide PPV at a rate of
2a C-EO Newly born infants who breathe spontaneously need to
40 to 60 inflations per minute.
establish a functional residual capacity after birth.8 Some
2. In term and preterm newly born infants,
2a C-LD it is reasonable to initiate PPV with an
newly born infants experience respiratory distress, which
inspiratory time of 1 s or less.2 manifests as labored breathing or persistent cyanosis.
3. In preterm newly born infants, the CPAP, a form of respiratory support, helps newly born in-
3: Harm B-R
routine use of sustained inflations to fants keep their lungs open. CPAP is helpful for preterm
initiate resuscitation is potentially harmful
and should not be performed.29
infants with breathing difficulty after birth or after resus-
citation33 and may reduce the risk of bronchopulmonary
Synopsis dysplasia in very preterm infants when compared with
It is reasonable to initiate PPV at a rate of 40 to 60/min endotracheal ventilation.34–36 CPAP is also a less invasive
to newly born infants who have ineffective breathing, form of respiratory support than intubation and PPV are.
are apneic, or are persistently bradycardic (heart rate Recommendation-Specific Supportive Text
less than 100/min) despite appropriate initial actions 1. Four RCTs and 1 meta-analysis32,34–37 (high quality)
(including tactile stimulation).1 showed reduction in the combined outcome of
To match the natural breathing pattern of both term death and bronchopulmonary dysplasia when start-
and preterm newborns, the inspiratory time while de- ing treatment with CPAP compared with intubation
livering PPV should be 1 second or less. While there and ventilation in very preterm infants (less than 30
has been research to study the potential effectiveness weeks of gestation) with respiratory distress (the
of providing longer, sustained inflations, there may be number needed to prevent was 25). The meta-anal-
potential harm in providing sustained inflations greater ysis reported no differences in the individual out-
than 10 seconds for preterm newborns. The potential comes of mortality, bronchopulmonary dysplasia,
benefit or harm of sustained inflations between 1 and pneumothorax, interventricular hemorrhage, necro-
10 seconds is uncertain.2,29 tizing enterocolitis, or retinopathy of prematurity.32
Recommendation-Specific Supportive Text
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Crossley K, Harding R, Morley CJ. Positive end expiratory pressure during O’Conor J, Soll RF; Vermont Oxford Network DRM Study Group. Randomized
resuscitation of premature lambs rapidly improves blood gases without trial comparing 3 approaches to the initial respiratory management of preterm
adversely affecting arterial pressure. Pediatr Res. 2004;56:198–204. doi: neonates. Pediatrics. 2011;128:e1069–e1076. doi: 10.1542/peds.2010-3848
10.1203/01.PDR.0000132752.94155.13 35. Morley CJ, Davis PG, Doyle LW, Brion LP, Hascoet JM, Carlin JB; COIN Trial
19. Guinsburg R, de Almeida MFB, de Castro JS, Gonçalves-Ferri WA, Investigators. Nasal CPAP or intubation at birth for very preterm infants. N
Marques PF, Caldas JPS, Krebs VLJ, Souza Rugolo LMS, de Almeida JHCL, Engl J Med. 2008;358:700–708. doi: 10.1056/NEJMoa072788
Luz JH, Procianoy RS, Duarte JLMB, Penido MG, Ferreira DMLM, Alves Filho N, 36. SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Re-
DinizEMA,SantosJP,AcquestaAL,SantosCND,GonzalezMRC,daSilvaRPVC, search Network. Early CPAP versus surfactant in extremely preterm infants.
Meneses J, Lopes JMA, Martinez FE. T-piece versus self-inflating bag ven- N Engl J Med. 2010;362:1970–1979. doi: 10.1056/NEJMoa0911783
tilation in preterm neonates at birth. Arch Dis Child Fetal Neonatal Ed. 37. Sandri F, Plavka R, Ancora G, Simeoni U, Stranak Z, Martinelli S,
2018;103:F49–F55. doi: 10.1136/archdischild-2016-312360 Mosca F, Nona J, Thomson M, Verder H, Fabbri L, Halliday H; CURPAP
20. Dawson JA, Schmölzer GM, Kamlin CO, Te Pas AB, O’Donnell CP, Donath SM, Study Group. Prophylactic or early selective surfactant combined with
Davis PG, Morley CJ. Oxygenation with T-piece versus self-inflating bag for nCPAP in very preterm infants. Pediatrics. 2010;125:e1402–e1409. doi:
ventilation of extremely preterm infants at birth: a randomized controlled 10.1542/peds.2009-2131
trial. J Pediatr. 2011;158;912–918.e1-2 doi: 10.1016/j.jpeds.2010.12.003
21. Szyld E, Aguilar A, Musante GA, Vain N, Prudent L, Fabres J, Carlo WA;
Delivery Room Ventilation Devices Trial Group. Comparison of devices for
newborn ventilation in the delivery room. J Pediatr. 2014;165:234–239.
OXYGEN ADMINISTRATION
e3. doi: 10.1016/j.jpeds.2014.02.035 Recommendations for Oxygen Administration During Neonatal
22. Thakur A, Saluja S, Modi M, Kler N, Garg P,Soni A, Kaur A, Chetri S. T-piece or self in- Resuscitation
flating bag for positive pressure ventilation during delivery room resuscitation: an
RCT. Resuscitation. 2015;90:21–24. doi: 10.1016/j.resuscitation.2015.01.021 COR LOE Recommendations
23. Finer NN, Carlo WA, Duara S, Fanaroff AA, Donovan EF, Wright LL, Kandefer S,
1. In term and late preterm newborns
Poole WK; National Institute of Child Health and Human Development Neo-
(35 wk or more of gestation) receiving
natal Research Network. Delivery room continuous positive airway pressure/ 2a B-R
respiratory support at birth, the initial use
positive end-expiratory pressure in extremely low birth weight infants: a fea-
of 21% oxygen is reasonable.1
sibility trial. Pediatrics. 2004;114:651–657. doi: 10.1542/peds.2004-0394
24. Hillman NH, Moss TJ, Kallapur SG, Bachurski C, Pillow JJ, Polglase GR, 2. In preterm newborns (less than 35 wk of
Nitsos I, Kramer BW, Jobe AH. Brief, large tidal volume ventilation initiates gestation) receiving respiratory support at
lung injury and a systemic response in fetal sheep. Am J Respir Crit Care 2b C-LD birth, it may be reasonable to begin with
Med. 2007;176:575–581. doi: 10.1164/rccm.200701-051OC 21% to 30% oxygen with subsequent
25. Mian Q, Cheung PY, O’Reilly M, Barton SK, Polglase GR, Schmölzer GM. oxygen titration based on pulse oximetry.2,3
Impact of delivered tidal volume on the occurrence of intraventricular
3. In term and late preterm newborns
haemorrhage in preterm infants during positive pressure ventilation in the
(35 wk or more of gestation) receiving
delivery room. Arch Dis Child Fetal Neonatal Ed. 2019;104:F57–F62. doi:
3: Harm B-R respiratory support at birth, 100%
10.1136/archdischild-2017–313864
oxygen should not be used because it is
26. Björklund LJ, Ingimarsson J, Curstedt T, John J, Robertson B,
associated with excess mortality.1
Werner O, Vilstrup CT. Manual ventilation with a few large breaths at

Synopsis reflects a preference to avoid exposing preterm
During an uncomplicated delivery, the newborn transi- newborns to additional oxygen (beyond what is
tions from the low oxygen environment of the womb necessary to achieve the predetermined oxygen
to room air (21% oxygen) and blood oxygen levels rise saturation target) without evidence demonstrat-
over several minutes. During resuscitation, supplemen- ing a benefit for important outcomes.3
tal oxygen may be provided to prevent harm from inad- 3. Meta-analysis of 7 randomized and quasi-ran-
equate oxygen supply to tissues (hypoxemia).4 However, domized trials enrolling term and late preterm
overexposure to oxygen (hyperoxia) may be associated newborns showed decreased short-term mor-
with harm.5 tality when using 21% oxygen compared with
Term and late preterm newborns have lower short- 100% oxygen for delivery room resuscitation.1
term mortality when respiratory support during resusci- No studies looked at starting with intermediate
tation is started with 21% oxygen (air) versus 100% ox- oxygen concentrations (ie, 22% to 99% oxygen).
ygen.1 No difference was found in neurodevelopmental
outcome of survivors.1 During resuscitation, pulse ox-
REFERENCES
imetry may be used to monitor oxygen saturation levels
1. Welsford M, Nishiyama C, Shortt C, Isayama T, Dawson JA, Weiner G,
found in healthy term infants after vaginal birth at sea Roehr CC, Wyckoff MH, Rabi Y; on behalf of the International Liaison
level.3 Committee on Resuscitation Neonatal Life Support Task Force. Room air
In more preterm newborns, there were no differ- for initiating term newborn resuscitation: a systematic review with meta-
analysis. Pediatrics. 2019;143. doi: 10.1542/peds.2018-1825
ences in mortality or other important outcomes when 2. Welsford M, Nishiyama C, Shortt C, Weiner G, Roehr CC, Isayama T,
respiratory support was started with low (50% or less) Dawson JA, Wyckoff MH, Rabi Y; on behalf of the International Liaison
versus high (greater than 50%) oxygen concentra- Committee on Resuscitation Neonatal Life Support Task Force. Initial
oxygen use for preterm newborn resuscitation: a systematic review with
tions.2 Given the potential for harm from hyperoxia, it meta-analysis. Pediatrics. 2019;143 doi: 10.1542/peds.2018-1828
may be reasonable to start with 21% to 30% oxygen. 3. Escobedo MB, Aziz K, Kapadia VS, Lee HC, Niermeyer S, Schmölzer GM,
Szyld E, Weiner GM, Wyckoff MH, Yamada NK, Zaichkin JG. 2019 Ameri-
Pulse oximetry with oxygen targeting is recommended
can Heart Association Focused Update on Neonatal Resuscitation: An
in this population.3 Update to the American Heart Association Guidelines for Cardiopul-
monary Resuscitation and Emergency Cardiovascular Care. Circulation.
Recommendation-Specific Supportive Text 2019;140:e922–e930. doi: 10.1161/CIR.0000000000000729
1. A meta-analysis of 5 randomized and quasi- 4. Saugstad OD. Resuscitation of newborn infants: from oxygen to room air.
Lancet. 2010;376:1970–1971. doi: 10.1016/S0140-6736(10)60543-0
randomized trials enrolling term and late pre- 5. Weinberger B, Laskin DL, Heck DE, Laskin JD. Oxygen toxic-
term newborns showed no difference in rates ity in premature infants. Toxicol Appl Pharmacol. 2002;181:60–67. doi:
10.1006/taap.2002.9387
of hypoxic-ischemic encephalopathy (HIE).
Similarly, meta-analysis of 2 quasi-randomized tri-
als showed no difference in moderate-to-severe CHEST COMPRESSIONS
neurodevelopmental impairment at 1 to 3 years
of age1 for newborns administered 21% versus CPR Timing
100% oxygen.1 Recommendations for Initiating CPR
2. Meta-analysis of 10 randomized trials enrolling
preterm newborns, including subanalysis of 7 tri-
1. If heart rate after birth remains at less
als reporting outcomes for newborns 28 weeks’ than 60/min despite adequate ventilation
gestational age or less, showed no difference in 2a C-EO
for at least 30 s, initiating chest
short-term mortality when respiratory support compressions is reasonable.1,2
was started with low compared with high oxy- 2. The benefit of 100% oxygen compared
gen.2 In the included studies, low oxygen was gen- with 21% oxygen (air) or any other oxygen
concentration for ventilation during chest
erally 21% to 30% and high oxygen was always 2b C-EO
compressions is uncertain. It may be
60% to 100%. Furthermore, no differences were reasonable to use higher concentrations of
found in long-term mortality, neurodevelopmen- oxygen during chest compressions.1,2
tal outcome, retinopathy of prematurity, bron-

chopulmonary dysplasia, necrotizing enterocolitis, Synopsis
or major cerebral hemorrhage.2 In a systematic Most newborns who are apneic or have ineffective
review of 8 trials that used oxygen saturation breathing at birth will respond to initial steps of newborn
targeting as a cointervention, all preterm babies resuscitation (positioning to open the airway, clearing se-
in whom respiratory support was initiated with cretions, drying, and tactile stimulation) or to effective
21% oxygen (air) required supplemental oxygen PPV with a rise in heart rate and improved breathing. If
to achieve the predetermined oxygen saturation the heart rate remains less than 60/min despite these in-
target.2 The recommendation to initiate respira- terventions, chest compressions can supply oxygenated
tory support with a lower oxygen concentration blood to the brain until the heart rate rises. Ventilation

should be optimized before starting chest compressions, Alternative compression-to-ventilation ratios to 3:1,
with endotracheal intubation if possible. Chest compres- as well as asynchronous PPV (administration of infla-
sions should be started if the heart rate remains less than tions to a patient that are not coordinated with chest
60/min after at least 30 seconds of adequate PPV.1 compressions), are routinely utilized outside the new-
Oxygen is essential for organ function; however, born period, but the preferred method in the newly
excess inspired oxygen during resuscitation may be born is 3:1 in synchrony. Newer methods of chest com-
harmful. Although current guidelines recommend us- pression, using a sustained inflation that maintains lung
ing 100% oxygen while providing chest compressions, inflation while providing chest compressions, are under
no studies have confirmed a benefit of using 100% investigation and cannot be recommended at this time
oxygen compared to any other oxygen concentration, outside research protocols.12,13
including air (21%). However, it may be reasonable to When providing chest compressions to a newborn,
increase inspired oxygen to 100% if there was no re- the 2 thumb–encircling hands technique may have ben-
sponse to PPV with lower concentrations. Once return efit over the 2-finger technique with respect to blood
of spontaneous circulation (ROSC) is achieved, the sup- pressure generation and provider fatigue. When pro-
plemental oxygen concentration may be decreased to viding chest compressions with the 2 thumb–encircling
target a physiological level based on pulse oximetry to hands technique, the hands encircle the chest while the
reduce the risks associated with hyperoxia.1,2 thumbs depress the sternum.1,2 The 2 thumb–encircling
hands technique can be performed from the side of the
infant or from above the head of the newborn.1 Per-
1. The initiation of chest compressions in newborn
forming chest compressions with the 2 thumb–encir-
babies with a heart rate less than 60/min is based on
cling hands technique from above the head facilitates
expert opinion because there are no clinical or physi-
placement of an umbilical venous catheter.
ological human studies addressing this question.
2. A meta-analysis (very low quality) of 8 animal Recommendation-Specific Supportive Text
studies (n=323 animals) that compared air with 1. In animal studies (very low quality), the use of alter-
100% oxygen during chest compressions showed ative compression-to-inflation ratios to 3:1 (eg, 2:1,
equivocal results.3 Two animal studies (very low 4:1, 5:1, 9:3, 15:2, and continuous chest compres-
quality) compared the tissue oxidative stress or sions with asynchronous PPV) are associated with
damage between air (21%) and 100% oxygen similar times to ROSC and mortality rates.4–8
and reported no difference in brain or lung inflam- 2. In a small number of newborns (n=2) with indwell-
matory markers.3 The use of 100% oxygen during
chest compressions is therefore expert opinion. ing catheters, the 2 thumb–encircling hands tech-
nique generated higher systolic and mean blood
pressures compared with the 2-finger technique.9
Compression-to-Ventilation Ratio and 3. One small manikin study (very low quality), com-
Techniques (Newborn) pared the 2 thumb–encircling hands technique
and 2-finger technique during 60 seconds of unin-
Recommendations for Providing Chest Compressions
terrupted chest compressions. The 2 thumb–encir-
cling hands technique achieved greater depth, less
1. When providing chest compressions fatigue, and less variability with each compression
in a newborn, it may be reasonable
2b C-EO
to repeatedly deliver 3 compressions
compared with the 2-finger technique.10
followed by an inflation (3:1 ratio).4–8
2. When providing chest compressions to a

newborn, it may be reasonable to choose
REFERENCES
the 2 thumb–encircling hands technique 1. Wyckoff MH, Aziz K, Escobedo MB, Kapadia VS, Kattwinkel J, Perlman JM,
2b C-LD over the 2-finger technique, as the 2 Simon WM, Weiner GM, Zaichkin JG. Part 13: neonatal resuscitation:
thumb–encircling hands technique is 2015 American Heart Association Guidelines Update for Cardiopulmo-
associated with improved blood pressure nary Resuscitation and Emergency Cardiovascular Care. Circulation.
and less provider fatigue.9,10 2015;132(suppl 2):S543–S560. doi: 10.1161/CIR.0000000000000267
2. Perlman JM, Wyllie J, Kattwinkel J, Wyckoff MH, Aziz K,
Guinsburg R, Kim HS, Liley HG, Mildenhall L, Simon WM, et al; on be-
Synopsis half of the Neonatal Resuscitation Chapter Collaborators. Part 7: neo-
Chest compressions are a rare event in full-term new- natal resuscitation: 2015 International Consensus on Cardiopulmonary
borns (approximately 0.1%) but are provided more fre- Resuscitation and Emergency Cardiovascular Care Science With Treat-
ment Recommendations. Circulation. 2015;132(suppl 1):S204–S241. doi:
quently to preterm newborns.11 When providing chest 10.1161/CIR.0000000000000276
compressions to a newborn, it may be reasonable to 3. Garcia-Hidalgo C, Cheung PY, Solevåg AL, Vento M, O’Reilly M, Saugstad
deliver 3 compressions before or after each inflation: O, Schmölzer GM. A Review of Oxygen Use During Chest Com- pressions
in Newborns-A Meta-Analysis of Animal Data. Front Pediatr. 2018;6:400.
providing 30 inflations and 90 compressions per minute doi: 10.3389/fped.2018.00400
(3:1 ratio for 120 total events per minute). 4. Solevåg AL, Schmölzer GM, O’Reilly M, Lu M, Lee TF, Hornberger LK,
Nakstad B, Cheung PY. Myocardial perfusion and oxidative stress after
21% vs. 100% oxygen ventilation and uninterrupted chest compres- 3. Practitioners outside of the delivery room setting,
sions in severely asphyxiated piglets. Resuscitation. 2016;106:7–13. doi:
and when umbilical venous catheterization is
5. Schmölzer GM, O’Reilly M, Labossiere J, Lee TF, Cowan S, Nicoll J, not feasible, may secure vascular access with the
Bigam DL, Cheung PY. 3:1 compression to ventilation ratio versus con- intraosseous route.
tinuous chest compression with asynchronous ventilation in a porcine
model of neonatal resuscitation. Resuscitation. 2014;85:270–275. doi:
10.1016/j.resuscitation.2013.10.011 REFERENCES
6. Solevåg AL, Dannevig I, Wyckoff M, Saugstad OD, Nakstad B. Extended series of 1. Wyckoff MH, Wyllie J, Aziz K, de Almeida MF, Fabres J, Fawke J,
cardiac compressions during CPR in a swine model of perinatal asphyxia. Re- Guinsburg R, Hosono S, Isayama T, Kapadia VS, et al; on behalf of the
suscitation. 2010;81:1571–1576. doi: 10.1016/j.resuscitation.2010.06.007 Neonatal Life Support Collaborators. Neonatal life support: 2020 Interna-
7. Solevag AL, Dannevig I, Wyckoff M, Saugstad OD, Nakstad B. Return of tional Consensus on Cardiopulmonary Resuscitation and Emergency Car-
spontaneous circulation with a compression:ventilation ratio of 15:2 ver- diovascular Care Science With Treatment Recommendations. Circulation.
sus 3:1 in newborn pigs with cardiac arrest due to asphyxia. Arch Dis Child 2020;142(suppl 1):S185–S221. doi: 10.1161/CIR.0000000000000895
Fetal Neonatal Ed. 2011;96:F417–F421. doi: 10.1136/adc.2010.200386 2. Niermeyer S, Kattwinkel J, Van Reempts P, Nadkarni V, Phillips B, Zideman D,
8. Pasquin MP, Cheung PY, Patel S, Lu M, Lee TF, Wagner M, O’Reilly M, Azzopardi D, Berg R, Boyle D, Boyle R, Burchfield D, Carlo W, Chameides L,
Schmolzer GM. Comparison of Different Compression to Ventilation Ratios (2: Denson S, Fallat M, Gerardi M, Gunn A, Hazinski MF, Keenan W, Knaebel S,
1, 3: 1, and 4: 1) during Cardiopulmonary Resuscitation in a Porcine Model of Milner A, Perlman J, Saugstad OD, Schleien C, Solimano A, Speer M, Toce S,
Neonatal Asphyxia. Neonatology. 2018;114:37–45. doi: 10.1159/000487988 Wiswell T, Zaritsky A. International Guidelines for Neonatal Resuscitation: An
9. David R. Closed chest cardiac massage in the newborn infant. Pediatrics. excerpt from the Guidelines 2000 for Cardiopulmonary Resuscitation and
1988;81:552–554. Emergency Cardiovascular Care: International Consensus on Science. Con-
10. Christman C, Hemway RJ, Wyckoff MH, Perlman JM. The two-thumb tributors and Reviewers for the Neonatal Resuscitation Guidelines. Pediatrics.
is superior to the two-finger method for administering chest compres- 2000;106:E29. doi: 10.1542/peds.106.3.e29
sions in a manikin model of neonatal resuscitation. Arch Dis Child Fetal 3. Vidal R, Kissoon N, Gayle M. Compartment syndrome following intraosse-
Neonatal Ed. 2011;96:F99–F101. doi: 10.1136/adc.2009.180406 ous infusion. Pediatrics. 1993;91:1201–1202.
11. Handley SC, Sun Y, Wyckoff MH, Lee HC. Outcomes of extremely preterm 4. Katz DS, Wojtowycz AR. Tibial fracture: a complication of in-
infants after delivery room cardiopulmonary resuscitation in a population- traosseous infusion. Am J Emerg Med. 1994;12:258–259. doi:
based cohort. J Perinatol. 2015;35:379–383. doi: 10.1038/jp.2014.222 10.1016/0735-6757(94)90261-5
12. Schmölzer GM, M OR, Fray C, van Os S, Cheung PY. Chest compres- 5. Ellemunter H, Simma B, Trawöger R, Maurer H. Intraosseous lines in
sion during sustained inflation versus 3:1 chest compression:ventilation preterm and full term neonates. Arch Dis Child Fetal Neonatal Ed.
ratio during neonatal cardiopulmonary resuscitation: a randomised fea- 1999;80:F74–F75. doi: 10.1136/fn.80.1.f74
sibility trial. Arch Dis Child Fetal Neonatal Ed. 2018;103:F455–F460. doi: 6. Carreras-González E, Brió-Sanagustín S, Guimerá I, Crespo C. Complica-
10.1136/archdischild-2017–313037 tion of the intraosseous route in a newborn infant [in Spanish]. Med In-
13. Schmölzer GM, O’Reilly M, Labossiere J, Lee TF, Cowan S, Qin S, Bigam DL, tensiva. 2012;36:233–234. doi: 10.1016/j.medin.2011.05.004
Cheung PY. Cardiopulmonary resuscitation with chest compressions dur- 7. Oesterlie GE, Petersen KK, Knudsen L, Henriksen TB. Crural amputa-
ing sustained inflations: a new technique of neonatal resuscitation that tion of a newborn as a consequence of intraosseous needle inser-
improves recovery and survival in a neonatal porcine model. Circulation. tion and calcium infusion. Pediatr Emerg Care. 2014;30:413–414. doi:
2013;128:2495–2503. doi: 10.1161/circulationaha.113.002289 10.1097/PEC.0000000000000150
8. Suominen PK, Nurmi E, Lauerma K. Intraosseous access in neonates and
infants: risk of severe complications - a case report. Acta Anaesthesiol
INTRAVASCULAR ACCESS Scand. 2015;59:1389–1393. doi: 10.1111/aas.12602
Recommendations for Vascular Access

MEDICATIONS (EPINEPHRINE) IN
NEONATAL RESUSCITATION
1. For babies requiring vascular access at
1 C-EO the time of delivery, the umbilical vein is Recommendations for Epinephrine Administration in Neonatal
the recommended route.1 Resuscitation
2. If intravenous access is not feasible, COR LOE Recommendations

2b C-EO it may be reasonable to use the
1. If the heart rate has not increased to 60/
intraosseous route.1
min or more after optimizing ventilation
2b C-LD and chest compressions, it may be
Synopsis reasonable to administer intravascular*
Babies who have failed to respond to PPV and chest epinephrine (0.01 to 0.03 mg/kg).1–3
compressions require vascular access to infuse epineph- 2. While vascular access is being obtained,
rine and/or volume expanders. In the delivery room set- 2b C-LD
it may be reasonable to administer
ting, the primary method of vascular access is umbilical endotracheal epinephrine at a larger dose
(0.05 to 0.1 mg/kg).1–3
venous catheterization. Outside the delivery room, or if
3. If endotracheal epinephrine is given
intravenous access is not feasible, the intraosseous route before vascular access is available and
may be a reasonable alternative, determined by the local response is inadequate, it may be
2b C-LD
availability of equipment, training, and experience. reasonable to give an intravascular* dose
as soon as access is obtained, regardless
Recommendation-Specific Supportive Text of the interval.1,2
1. Umbilical venous catheterization has been the 4. It may be reasonable to administer

further doses of epinephrine every 3
accepted standard route in the delivery room for 2b C-LD to 5 min, preferably intravascularly,*
decades.2 There are no human neonatal studies if the heart rate remains less than 60/
min.2,3
to support one route over others.1
2. There are 6 case reports indicating local complica- *In this situation, “intravascular” means intravenous or intraosseous.
Intra-arterial epinephrine is not recommended.
tions of intraosseous needle placement.3–8
Synopsis 4. In one very limited observational study, many
Medications are rarely needed in resuscitation of the infants received multiple doses of epinephrine
newly born infant because low heart rate usually results before ROSC.2 The perinatal model of cardiac
from a very low oxygen level in the fetus or inadequate arrest documented peak plasma epinephrine con-
lung inflation after birth. Establishing ventilation is the centrations at 1 minute after intravenous adminis-
most important step to correct low heart rate. However, tration, but not until 5 minutes after endotracheal
if heart rate remains less than 60/min after ventilating administration.3
with 100% oxygen (preferably through an endotra-
cheal tube) and chest compressions, administration of
epinephrine is indicated. REFERENCES
Administration of epinephrine via a low-lying umbili- 1. Barber CA, Wyckoff MH. Use and efficacy of endotracheal versus in-
travenous epinephrine during neonatal cardiopulmonary resuscita-
cal venous catheter provides the most rapid and reliable
tion in the delivery room. Pediatrics. 2006;118:1028–1034. doi:
medication delivery. The intravenous dose of epineph- 10.1542/peds.2006-0416
rine is 0.01 to 0.03 mg/kg, followed by a normal saline 2. Halling C, Sparks JE, Christie L, Wyckoff MH. Efficacy of Intravenous
flush.4 If umbilical venous access has not yet been ob- and Endotracheal Epinephrine during Neonatal Cardiopulmonary Re-
suscitation in the Delivery Room. J Pediatr. 2017;185:232–236. doi:
tained, epinephrine may be given by the endotrache- 10.1016/j.jpeds.2017.02.024
al route in a dose of 0.05 to 0.1 mg/kg. The dosage 3. Vali P, Chandrasekharan P, Rawat M, Gugino S, Koenigsknecht C,
interval for epinephrine is every 3 to 5 minutes if the Helman J, Jusko WJ, Mathew B, Berkelhamer S, Nair J, et al. Evaluation of
timing and route of epinephrine in a neonatal model of asphyxial arrest. J
heart rate remains less than 60/min, although an intra- Am Heart Assoc. 2017;6:e004402. doi: 10.1161/JAHA.116.004402
venous dose may be given as soon as umbilical access 4. Vali P, Sankaran D, Rawat M, Berkelhamer S, Lakshminrusimha S. Epi-
is obtained if response to endotracheal epinephrine has nephrine in neonatal resuscitation. Children (Basel). 2019;6:E51. doi:
10.3390/children6040051
been inadequate. 5. Perondi MB, Reis AG, Paiva EF, Nadkarni VM, Berg RA. A comparison of
high-dose and standard-dose epinephrine in children with cardiac arrest.
Recommendation-Specific Supportive Text N Engl J Med. 2004;350:1722–1730. doi: 10.1056/NEJMoa032440
1. The very limited observational evidence in human 6. Vandycke C, Martens P. High dose versus standard dose epinephrine in
infants does not demonstrate greater efficacy of cardiac arrest - a meta-analysis. Resuscitation. 2000;45:161–166. doi:
10.1016/s0300-9572(00)00188-x
endotracheal or intravenous epinephrine; how- 7. Berg RA, Otto CW, Kern KB, Hilwig RW, Sanders AB, Henry CP, Ewy GA. A
ever, most babies received at least 1 intravenous randomized, blinded trial of high-dose epinephrine versus standard-dose
dose before ROSC.1,2 In a perinatal model of car- epinephrine in a swine model of pediatric asphyxial cardiac arrest. Crit Care
Med. 1996;24:1695–1700. doi: 10.1097/00003246-199610000-00016
diac arrest using term lambs undergoing transi-
8. Burchfield DJ, Preziosi MP, Lucas VW, Fan J. Effects of graded doses of
tion with asphyxia-induced cardiopulmonary epinephrine during asphxia-induced bradycardia in newborn lambs. Re-
arrest, central venous epinephrine was associ- suscitation. 1993;25:235–244. doi: 10.1016/0300-9572(93)90120-f
ated with shorter time to ROSC and higher rates
of ROSC than endotracheal epinephrine was.3
Intravenous epinephrine followed by a normal VOLUME REPLACEMENT
saline flush improves medication delivery.4
2. One very limited observational study (human) Recommendations for Volume Resuscitation
showed 0.03 mg/kg to be an inadequate endo-
tracheal dose.1 In the perinatal model of cardiac 1. It may be reasonable to administer a
volume expander to newly born infants
arrest, peak plasma epinephrine concentrations in with suspected hypovolemia, based
animals were higher and were achieved sooner 2b C-EO on history and physical examination,
after central or low-lying umbilical venous admin- who remain bradycardic (heart rate less
than 60/min) despite ventilation, chest
istration compared with the endotracheal route, compressions, and epinephrine.1–3
despite a lower intravenous dose (0.03 mg/
2. It may be reasonable to provide volume
kg intravenous versus 0.1 mg/kg endotracheal 2b C-EO expansion with normal saline (0.9% sodium
route).3 chloride) or blood at 10 to 20 mL/kg.4,5
3. In one very limited observational study, most
Synopsis
infants who received an endotracheal dose A newly born infant in shock from blood loss may re-
achieved ROSC after a subsequent intravenous spond poorly to the initial resuscitative efforts of venti-
dose.2 Although the more rapid response to lation, chest compressions, and/or epinephrine. History
intravenous epinephrine warrants its immediate and physical examination findings suggestive of blood
administration once umbilical access is obtained,
loss include a pale appearance, weak pulses, and per-
repetitive endotracheal doses or higher intra-
sistent bradycardia (heart rate less than 60/min). Blood
venous doses may result in potentially harmful
may be lost from the placenta into the mother’s circula-
plasma levels that lead to associated hypertension
tion, from the cord, or from the infant.
and tachycardia.5–8

When blood loss is suspected in a newly born infant fluid bolus therapy in neonates. J Paediatr Child Health. 2019;55:632–
639. doi: 10.1111/jpc.14260
who responds poorly to resuscitation (ventilation, chest
compressions, and/or epinephrine), it may be reason-
able to administer a volume expander without delay. POSTRESUSCITATION CARE
Normal saline (0.9% sodium chloride) is the crystalloid
fluid of choice. Uncrossmatched type O, Rh-negative Recommendations for Postresuscitation Care
blood (or crossmatched, if immediately available) is COR LOE Recommendations
preferred when blood loss is substantial.4,5 An initial 1. Newly born infants born at 36 wk or
volume of 10 mL/kg over 5 to 10 minutes may be rea- more estimated gestational age with
1 A evolving moderate-to-severe HIE should
sonable and may be repeated if there is inadequate re- be offered therapeutic hypothermia
sponse. The recommended route is intravenous, with under clearly defined protocols.1
the intraosseous route being an alternative. 2. Newly born infants who receive
prolonged PPV or advanced resuscitation
Recommendation-Specific Supportive Text (intubation, chest compressions, or
1 C-EO
1. There is no evidence from randomized trials to epinephrine) should be maintained in
or transferred to an environment where
support the use of volume resuscitation at deliv- close monitoring can be provided.2–7
ery. One large retrospective review found that 3. Glucose levels should be monitored
0.04% of newborns received volume resuscita- 1 C-LD
as soon as practical after advanced
tion in the delivery room, confirming that it is a resuscitation, with treatment as
indicated.8–14
relatively uncommon event.1 Those newborns
4. For newly born infants who are
who received volume resuscitation in the delivery unintentionally hypothermic (temperature
room had lower blood pressure on admission to less than 36°C) after resuscitation, it
2b C-LD
the neonatal intensive care unit compared with may be reasonable to rewarm either
rapidly (0.5°C/h) or slowly (less than
those who did not, indicating that factors other 0.5°C/h).15–19
than blood loss may be important.1
2. There is insufficient clinical evidence to determine Synopsis
what type of volume expander (crystalloid or Newly born infants who receive prolonged PPV or ad-
blood) is more beneficial during neonatal resusci- vanced resuscitation (eg, intubation, chest compres-
tation. Extrapolation from studies in hypotensive sions ± epinephrine) should be closely monitored af-
newborns shortly after birth6–8 and studies in ani- ter stabilization in a neonatal intensive care unit or a
mals (piglets) support the use of crystalloid over monitored triage area because these infants are at risk
albumin expanders5 and blood over crystalloid for further deterioration.
solutions.4 One review discussed recommenda- Infants 36 weeks’ or greater estimated gestational
tions for the use of volume expanders.2 age who receive advanced resuscitation should be ex-
amined for evidence of HIE to determine if they meet
REFERENCES criteria for therapeutic hypothermia. Therapeutic hypo-
1. Wyckoff MH, Perlman JM, Laptook AR. Use of volume expansion dur- thermia is provided under defined protocols similar to
ing delivery room resuscitation in near-term and term infants. Pediatrics. those used in published clinical trials and in facilities ca-
2005;115:950–955. doi: 10.1542/peds.2004-0913 pable of multidisciplinary care and longitudinal follow-
2. Finn D, Roehr CC, Ryan CA, Dempsey EM. Optimising intravenous vol-
ume resuscitation of the newborn in the delivery room: practical consid- up. The impact of therapeutic hypothermia on infants
erations and gaps in knowledge. Neonatology. 2017;112:163–171. doi: less than 36 weeks’ gestational age with HIE is unclear
10.1159/000475456
and is a subject of ongoing research trials.
3. Conway-Orgel M. Management of hypotension in the very low-birth-
weight infant during the golden hour. Adv Neonatal Care. 2010;10:241– Hypoglycemia is common in infants who have re-
5; quiz 246. doi: 10.1097/ANC.0b013e3181f0891c ceived advanced resuscitation and is associated with
4. Mendler MR, Schwarz S, Hechenrieder L, Kurth S, Weber B, Hofler S,
poorer outcomes.8 These infants should be monitored
Kalbitz M, Mayer B, Hummler HD. Successful resuscitation in a model of
asphyxia and hemorrhage to test different volume resuscitation strategies. for hypoglycemia and treated appropriately.
a study in newborn piglets after transition. Front Pediatr. 2018;6:192. doi: Infants with unintentional hypothermia (tempera-
10.3389/fped.2018.00192
5. Wyckoff M, Garcia D, Margraf L, Perlman J, Laptook A. Randomized trial
ture less than 36°C) immediately after stabilization
of volume infusion during resuscitation of asphyxiated neonatal piglets. should be rewarmed to avoid complications associ-
Pediatr Res. 2007;61:415–420. doi: 10.1203/pdr.0b013e3180332c45 ated with low body temperature (including increased
6. Niermeyer S. Volume resuscitation: crystalloid versus colloid. Clin Perina-
tol. 2006;33:133–140. doi: 10.1016/j.clp.2005.12.002
mortality, brain injury, hypoglycemia, and respiratory
7. Shalish W, Olivier F, Aly H, Sant’Anna G. Uses and misuses of albumin distress). Evidence suggests that warming can be done
during resuscitation and in the neonatal intensive care unit. Semin Fetal rapidly (0.5°C/h) or slowly (less than 0.5°C/h) with no
Neonatal Med. 2017;22:328–335. doi: 10.1016/j.siny.2017.07.009
8. Keir AK, Karam O, Hodyl N, Stark MJ, Liley HG, Shah PS, Stanworth SJ;
significant difference in outcomes.15–19 Caution should
NeoBolus Study Group. International, multicentre, observational study of be taken to avoid overheating.
Recommendation-Specific Supportive Text 10. Nadeem M, Murray DM, Boylan GB, Dempsey EM, Ryan CA. Early blood
glucose profile and neurodevelopmental outcome at two years in neo-
1. In a meta-analysis of 8 RCTs involving 1344 term natal hypoxic-ischaemic encephalopathy. BMC Pediatr. 2011;11:10. doi:
and late preterm infants with moderate-to-severe 10.1186/1471-2431-11-10
11. McKinlay CJ, Alsweiler JM, Ansell JM, Anstice NS, Chase JG, Gamble GD,
encephalopathy and evidence of intrapartum Harris DL, Jacobs RJ, Jiang Y, Paudel N, Signal M, Thompson B, Wouldes TA,
asphyxia, therapeutic hypothermia resulted in a Yu TY, Harding JE; CHYLD Study Group. Neonatal Glycemia and Neurode-
significant reduction in the combined outcome of velopmental Outcomes at 2 Years. N Engl J Med. 2015;373:1507–1518.
doi: 10.1056/NEJMoa1504909
mortality or major neurodevelopmental disability 12. Tan JKG, Minutillo C, McMichael J, Rao S. Impact of hypoglycaemia on
to 18 months of age (odds ratio 0.75; 95% CI, neurodevelopmental outcomes in hypoxic ischaemic encephalopathy: a
0.68–0.83).1 retrospective cohort study. BMJ Paediatr Open. 2017;1:e000175. doi:
10.1136/bmjpo-2017-000175
2. Newly born infants who required advanced resus- 13. Shah BR, Sharifi F. Perinatal outcomes for untreated women with ges-
tational diabetes by IADPSG criteria: a population-based study. BJOG.
citation are at significant risk of developing mod-
2020;127:116–122. doi: 10.1111/1471-0528.15964
erate-to-severe HIE2–4 and other morbidities.5–7 14. Pinchefsky EF, Hahn CD, Kamino D, Chau V, Brant R, Moore AM, Tam EWY.
3. Newly born infants with abnormal glucose levels Hyperglycemia and Glucose Variability Are Associated with Worse Brain
Function and Seizures in Neonatal Encephalopathy: A Prospective Cohort
(both low and high) are at increased risk for brain Study. J Pediatr. 2019;209:23–32. doi: 10.1016/j.jpeds.2019.02.027
injury and adverse outcomes after a hypoxic-isch- 15. Feldman A, De Benedictis B, Alpan G, La Gamma EF, Kase J. Morbidity and mor-
tality associated with rewarming hypothermic very low birth weight infants. J
emic insult.8–14 Neonatal Perinatal Med. 2016;9:295–302. doi: 10.3233/NPM-16915143
4. Two small RCTs16,19 and 4 observational stud- 16. Motil KJ, Blackburn MG, Pleasure JR. The effects of four different radiant
warmer temperature set-points used for rewarming neonates. J Pediatr.
ies15,17,18,20 of infants with hypothermia after 1974;85:546–550. doi: 10.1016/s0022-3476(74)80467-1
delivery room stabilization found no difference 17. Rech Morassutti F, Cavallin F, Zaramella P, Bortolus R, Parotto M,
between rapid or slow rewarming for outcomes Trevisanuto D. Association of Rewarming Rate on Neonatal Outcomes
in Extremely Low Birth Weight Infants with Hypothermia. J Pediatr.
of mortality,15,17 convulsions/seizures,19 intraven- 2015;167:557–61.e1. doi: 10.1016/j.jpeds.2015.06.008
tricular or pulmonary hemorrhage,15,17,19,20 hypo- 18. Sofer S, Yagupsky P, Hershkowits J, Bearman JE. Improved outcome of
glycemia,16,17,19 or apnea.16,17,19 One observational hypothermic infants. Pediatr Emerg Care. 1986;2:211–214. doi:
10.1097/00006565-198612000-00001
study found less respiratory distress in infants 19. Tafari N, Gentz J. Aspects of rewarming newborn infants with severe
who were slowly rewarmed,18 while a separate accidental hypothermia. Acta Paediatr Scand. 1974;63:595–600. doi:
study found less respiratory distress syndrome in 10.1111/j.1651-2227.1974.tb04853.x
20. Racine J, Jarjoui E. Severe hypothermia in infants. Helv Paediatr Acta.
infants who were rapidly rewarmed.17 1982;37:317–322.
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WITHHOLDING AND DISCONTINUING
1. Jacobs SE, Berg M, Hunt R, Tarnow-Mordi WO, Inder TE, Davis PG. Cooling
for newborns with hypoxic ischaemic encephalopathy. Cochrane Database RESUSCITATION
Syst Rev. 2013:CD003311. doi: 10.1002/14651858.CD003311.pub3
2. Laptook AR, Shankaran S, Ambalavanan N, Carlo WA, McDonald SA, Recommendations for Withholding and Discontinuing Resuscitation
Higgins RD, Das A; Hypothermia Subcommittee of the NICHD Neo- COR LOE Recommendations
natal Research Network. Outcome of term infants using apgar scores
at 10 minutes following hypoxic-ischemic encephalopathy. Pediatrics. 1. Noninitiation of resuscitation and
2009;124:1619–1626. doi: 10.1542/peds.2009-0934 discontinuation of life-sustaining treatment
1 C-EO
3. Ayrapetyan M, Talekar K, Schwabenbauer K, Carola D, Solarin K, during or after resuscitation should be
McElwee D, Adeniyi-Jones S, Greenspan J, Aghai ZH. Apgar scores at 10 considered ethically equivalent.1,2
minutes and outcomes in term and late preterm neonates with hypoxic-
2. In newly born babies receiving resuscitation,
ischemic encephalopathy in the cooling era. Am J Perinatol. 2019;36:545–
if there is no heart rate and all the steps
554. doi: 10.1055/s-0038-1670637
of resuscitation have been performed,
4. Kasdorf E, Laptook A, Azzopardi D, Jacobs S, Perlman JM. Improving in-
1 C-LD cessation of resuscitation efforts should be
fant outcome with a 10 min Apgar of 0. Arch Dis Child Fetal Neonatal Ed.
discussed with the team and the family. A
2015;100:F102–F105. doi: 10.1136/archdischild-2014-306687
reasonable time frame for this change in
5. Barber CA, Wyckoff MH. Use and efficacy of endotracheal versus in- goals of care is around 20 min after birth.3
travenous epinephrine during neonatal cardiopulmonary resuscita-
tion in the delivery room. Pediatrics. 2006;118:1028–1034. doi: 3. If a birth is at the lower limit of viability
10.1542/peds.2006-0416 or involves a condition likely to result
6. Harrington DJ, Redman CW, Moulden M, Greenwood CE. The long-term in early death or severe morbidity,
outcome in surviving infants with Apgar zero at 10 minutes: a systematic 2a C-EO noninitiation or limitation of neonatal
review of the literature and hospital-based cohort. Am J Obstet Gynecol. resuscitation is reasonable after expert
2007;196:463.e1–463.e5. doi: 10.1016/j.ajog.2006.10.877 consultation and parental involvement in
7. Wyckoff MH, Salhab WA, Heyne RJ, Kendrick DE, Stoll BJ, Laptook AR; decision-making.1,2,4,5
National Institute of Child Health and Human Development Neona-
tal Research Network. Outcome of extremely low birth weight infants Synopsis
who received delivery room cardiopulmonary resuscitation. J Pediatr. Expert neonatal and bioethical committees have agreed
2012;160:239–244.e2. doi: 10.1016/j.jpeds.2011.07.041
8. Salhab WA, Wyckoff MH, Laptook AR, Perlman JM. Initial hypoglycemia that, in certain clinical conditions, it is reasonable not
and neonatal brain injury in term infants with severe fetal acidemia. Pedi- to initiate or to discontinue life-sustaining efforts while
atrics. 2004;114:361–366. doi: 10.1542/peds.114.2.361 continuing to provide supportive care for babies and
9. Castrodale V, Rinehart S. The golden hour: improving the stabilization of
the very low birth-weight infant. Adv Neonatal Care. 2014;14:9–14; quiz
families.1,2,4
15. doi: 10.1097/ANC.0b013e31828d0289
If the heart rate remains undetectable and all steps of Neonatal Life Support Collaborators. Neonatal life support: 2020 Interna-
tional Consensus on Cardiopulmonary Resuscitation and Emergency Car-
resuscitation have been completed, it may be reasonable diovascular Care Science With Treatment Recommendations. Circulation.
to redirect goals of care. Case series show small numbers 2020;142(suppl 1):S185–S221. doi: 10.1161/CIR.0000000000000895
of intact survivors after 20 minutes of no detectable heart 4. American College of Obstetricians and Gynecologists; Society for Mater-
nal-Fetal M. Obstetric Care Consensus No. 6: periviable birth. Obstet Gy-
rate. The decision to continue or discontinue resuscitative necol. 2017;130:e187–e199. doi: 10.1097/AOG.0000000000002352
efforts should be individualized and should be considered 5. Lemyre B, Moore G. Counselling and management for anticipated ex-
at about 20 minutes after birth. Variables to be considered tremely preterm birth. Paediatr Child Health. 2017;22:334–341. doi:
10.1093/pch/pxx058
may include whether the resuscitation was considered 6. Wyckoff MH, Aziz K, Escobedo MB, Kapadia VS, Kattwinkel J, Perlman JM,
optimal, availability of advanced neonatal care (such as Simon WM, Weiner GM, Zaichkin JG. Part 13: neonatal resuscitation:
therapeutic hypothermia), specific circumstances before 2015 American Heart Association Guidelines Update for Cardiopulmo-
nary Resuscitation and Emergency Cardiovascular Care. Circulation.
delivery, and wishes expressed by the family.3,6 2015;132(suppl 2):S543–S560. doi: 10.1161/CIR.0000000000000267
Some babies are so sick or immature at birth that 7. Guillén Ú, Weiss EM, Munson D, Maton P, Jefferies A, Norman M,
survival is unlikely, even if neonatal resuscitation and in- Naulaers G, Mendes J, Justo da Silva L, Zoban P, Hansen TW, Hallman M,
Delivoria-Papadopoulos M, Hosono S, Albersheim SG, Williams C, Boyle E,
tensive care are provided. In addition, some conditions Lui K, Darlow B, Kirpalani H. Guidelines for the Management of Extremely
are so severe that the burdens of the illness and treat- Premature Deliveries: A Systematic Review. Pediatrics. 2015;136:343–
ment greatly outweigh the likelihood of survival or a 350. doi: 10.1542/peds.2015-0542
healthy outcome. If it is possible to identify such condi-

tions at or before birth, it is reasonable not to initiate re-
suscitative efforts. These situations benefit from expert HUMAN AND SYSTEM PERFORMANCE
consultation, parental involvement in decision-making, Training Frequency
and, if indicated, a palliative care plan.1,2,4–6
Recommendation for Training Frequency
COR LOE Recommendation
1. It is the expert opinion of national medical societ-
1. For participants who have been trained
ies that conditions exist for which it is reasonable in neonatal resuscitation, individual or
to not initiate resuscitation or to discontinue resus- 1 C-LD
team booster training should occur more
frequently than every 2 yr at a frequency
citation once these conditions are identified.1,2,4,5 that supports retention of knowledge,
2. Randomized controlled studies and observational skills, and behaviors.1–5
studies in settings where therapeutic hypothermia

is available (with very low certainty of evidence) Synopsis
describe variable rates of survival without mod- To perform neonatal resuscitation effectively, individ-
erate-to-severe disability in babies who achieve ual providers and teams need training in the required
ROSC after 10 minutes or more despite continued knowledge, skills, and behaviors. Historically, the repeat
resuscitation. None of these studies evaluate out- training has occurred every 2 years.6–9 However, adult,
comes of resuscitation that extends beyond 20 pediatric, and neonatal studies suggest that without
minutes of age, by which time the likelihood of practice, CPR knowledge and skills decay within 3 to
intact survival was very low. The studies were too 12 months10–12 after training. Short, frequent practice
heterogeneous to be amenable to meta-analysis.3 (booster training) has been shown to improve neona-
3. Conditions in which noninitiation or discontinu- tal resuscitation outcomes.5 Educational programs and
perinatal facilities should develop strategies to ensure
ation of resuscitation may be considered include that individual and team training is frequent enough to
extremely preterm birth and certain severe congeni- sustain knowledge and skills.
tal anomalies. National guidelines recommend indi-
vidualization of parent-informed decisions based Recommendation-Specific Supportive Text
on social, maternal, and fetal/neonatal factors.1,2,4 1. In a randomized controlled simulation study,
A systematic review showed that international medical students who underwent booster train-
guidelines variably described periviability between ing retained improved neonatal intubation skills
22 and 24 weeks’ gestational age.7 over a 6-week period compared with medical
students who did not receive booster training.
There was no difference in neonatal intubation
REFERENCES
performance after weekly booster practice for 4
1. American Academy of Pediatrics Committee on Fetus and Newborn,
Bell EF. Noninitiation or withdrawal of intensive care for high-risk new-
weeks compared with daily booster practice for 4
borns. Pediatrics. 2007;119:401–403. doi: 10.1542/peds.2006–3180 consecutive days.1
2. Cummings J; and the Committee on Fetus and Newborn. Antenatal Coun- In a randomized controlled simulation study,
seling Regarding Resuscitation and Intensive Care Before 25 Weeks of
Gestation. Pediatrics. 2015;136:588–595. doi: 10.1542/peds.2015-2336
pediatric and family practice residents who un-
3. Wyckoff MH, Wyllie J, Aziz K, de Almeida MF, Fabres J, Fawke J, derwent booster training 9 months after an initial
Guinsburg R, Hosono S, Isayama T, Kapadia VS, et al; on behalf of the
Neonatal Resuscitation Program course demon- Briefing and Debriefing
strated better procedural skills and teamwork be-
haviors at a follow-up assessment at 16 months Recommendation for Training Frequency
compared with residents who did not receive COR LOE Recommendation
booster training.2 1. For neonatal resuscitation providers, it
In a prospective cohort study, physicians and 2b C-LD may be reasonable to brief before delivery
and debrief after neonatal resuscitation.1–3
nurses trained in Helping Babies Breathe dem-
onstrated a rapid loss of resuscitation skills by
1 month after training. Subjects who received Synopsis
monthly practice sessions were more likely to pass Briefing has been defined as “a discussion about an
an objective structured clinical evaluation than event that is yet to happen to prepare those who will
those who practiced less frequently.3 be involved and thereby reduce the risk of failure or
In a prospective observational study, imple- harm.”4 Debriefing has been defined as “a discus-
mentation of weekly, brief Helping Babies Breathe sion of actions and thought processes after an event
simulation training after a 1-day Helping Babies to promote reflective learning and improve clinical
Breathe training course resulted in increased fre- performance” 5 or “a facilitated discussion of a clini-
quency of stimulation of newborns, decrease in cal event focused on learning and performance im-
bag-mask ventilation, and decreased neonatal provement.”6 Briefing and debriefing have been rec-
mortality at 24 hours.4 ommended for neonatal resuscitation training since
20107 and have been shown to improve a variety of
educational and clinical outcomes in neonatal, pedi-
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diopulmonary resuscitation quality and resuscitation training by combin-
• Impact of routine use of the ECG during neonatal
ing audiovisual feedback and debriefing. Crit Care Med. 2008;36:2817–
2822. doi: 10.1097/CCM.0b013e318186fe37 resuscitation on resuscitation
12. Wolfe H, Zebuhr C, Topjian AA, Nishisaki A, Niles DE, • Feasibility and effectiveness of new technologies
Meaney PA, Boyle L, Giordano RT, Davis D, Priestley M, Apkon M, Berg RA, for rapid heart rate measurement (such as electric,
Nadkarni VM, Sutton RM. Interdisciplinary ICU cardiac arrest debriefing
improves survival outcomes*. Crit Care Med. 2014;42:1688–1695. doi: ultrasonic, or optical devices)
10.1097/CCM.0000000000000327 • Optimal oxygen management during and after
resuscitation
KNOWLEDGE GAPS Advanced Resuscitation

Neonatal resuscitation science has advanced signifi-
• Novel techniques for effective delivery of CPR,
cantly over the past 3 decades, with contributions by
such as chest compressions accompanied by sus-
many researchers in laboratories, in the delivery room,
tained inflation
and in other clinical settings. While this research has
• Optimal timing, dosing, dose interval, and delivery
led to substantial improvements in the Neonatal Resus-
routes for epinephrine or other vasoactive drugs,
citation Algorithm, it has also highlighted that we still
including earlier use in very depressed newly born
have more to learn to optimize resuscitation for both
infants
preterm and term infants. With growing enthusiasm for
• Indications for volume expansion, as well as opti-
clinical studies in neonatology, elements of the Neona-
mal dosing, timing, and type of volume
tal Resuscitation Algorithm continue to evolve as new
• The management of pulseless electric activity
evidence emerges.
The current guidelines have focused on clinical ac-
tivities described in the resuscitation algorithm, rather Specific Populations
than on the most appropriate devices for each step. • Management of the preterm newborn during and
Reviews in 2021 and later will address choice of de- after resuscitation
vices and aids, including those required for ventilation • Management of congenital anomalies of the heart
(T-piece, self-inflating bag, flow-inflating bag), ventila- and lungs during and after resuscitation
tion interface (face mask, laryngeal mask), suction (bulb • Resuscitation of newborns in the neonatal unit
syringe, meconium aspirator), monitoring (respiratory after the newly born period
function monitors, heart rate monitoring, near infrared • Resuscitation of newborns in other settings up to
spectroscopy), feedback, and documentation. 28 days of age

Postresuscitation Care advancements and improvements in healthcare delivery,
there is decreased ability to have adequate power for
• Optimal dose, route, and timing of surfactant in
some clinical questions using traditional individual patient
at-risk newborns, including less-invasive adminis-
randomized trials. Another barrier is the difficulty in ob-
tration techniques
taining antenatal consent for clinical trials in the delivery
• Indications for therapeutic hypothermia in babies room. Adaptive trials, comparative effectiveness designs,
with mild HIE and in those born at less than 36 and those using cluster randomization may be suitable for
weeks’ gestational age some questions, such as the best approach for MSAF in
• Adjunctive therapies to therapeutic hypothermia nonvigorous infants. High-quality observational studies of
• Optimal management of blood glucose large populations may also add to the evidence. When fea-
• Optimal rewarming strategy for newly born infants sible, well-designed multicenter randomized clinical trials
with unintentional hypothermia are still optimal to generate the highest-quality evidence.
For all these gaps, it is important that we have informa- Finally, we wish to reinforce the importance of ad-
tion on outcomes considered critical or important by both dressing the values and preferences of our key stake-
healthcare providers and families of newborn infants. holders, the families and teams who are involved in the
The research community needs to address the pau- process of resuscitation. Gaps in this domain, whether
city of educational studies that provide outcomes with perceived or real, should be addressed at every stage in
a high level of certainty. Internal validity might be bet- our research, educational, and clinical activities.
ter addressed by clearly defined primary outcomes, ap-
propriate sample sizes, relevant and timed interventions ARTICLE INFORMATION
and controls, and time series analyses in implementation
The American Heart Association requests that this document be cited as fol-
studies. External validity might be improved by study- lows: Aziz K, Lee HC, Escobedo MB, Hoover AV, Kamath-Rayne BD, Kapadia
ing the relevant learner or provider populations and by VS, Magid DJ, Niermeyer S, Schmölzer GM, Szyld E, Weiner GM, Wyckoff MH,
Yamada NK, Zaichkin J. Part 5: neonatal resuscitation: 2020 American Heart
measuring the impact on critical patient and system out- Association Guidelines for Cardiopulmonary Resuscitation and Emergency Car-
comes rather than limiting study to learner outcomes. diovascular Care. Circulation. 2020;142(suppl 2):S524–S550. doi: 10.1161/
Researchers studying these gaps may need to con- CIR.0000000000000902
This article has been copublished in Pediatrics.
sider innovations in clinical trial design; examples include
pragmatic study designs and novel consent processes. As Acknowledgment
mortality and severe morbidities decline with biomedical We thank Dr Abhrajit Ganguly for assistance in manuscript preparation.
Disclosures
Appendix 1. Writing Group Disclosures
Other Speakers’ Consultant/

Writing Group Research Research Bureau/ Expert Ownership Advisory
Member Employment Grant Support Honoraria Witness Interest Board Other
Khalid Aziz University of Alberta None None None None None None Salary: University
Pediatrics of Alberta†
Henry C. Lee Stanford University NICHD (PI of R01 None None None None None None
grant examining
intensive care
for infants born
at extremely
early gestational
age)*
Marilyn B University of Oklahoma None None None None None None None
Escobedo Medical School
Pediatrics
Amber V. Hoover American Heart None None None None None None None
Association
Beena D. American Academy of None None None None None None None
Kamath-Rayne Pediatrics
Vishal S. UT Southwestern NIH, NICHD† None None None None None None
Kapadia Pediatrics
David J. Magid University of Colorado NIH†; NHLBI†; None None None None None American Heart
CMS†; AHA† Association (Senior
Science Editor)†
(Continued )

Appendix 1. Continued

Writing Group Research Research Bureau/ Expert Ownership Advisory
Member Employment Grant Support Honoraria Witness Interest Board Other
Susan Niermeyer University of Colorado None None None None None None None
Pediatrics
Georg M. University of Alberta Heart and Stroke None None None Owner of None None
Schmölzer Pediatrics Foundation RETAIN LABS
Canada*; Medical Inc*
Canadian
Institute
of Health
Research*;
THRASHER
Foundation*;
Canadian
Institute
of Health
Research*
Edgardo Szyld University of Oklahoma None None None None None None None
Gary M. Weiner University of Michigan None None None None None None None
Pediatrics-Neonatology
Myra H. Wyckoff UT Southwestern None None None None None None None
Pediatrics
Nicole K. Stanford University AHRQ† None None None None None None
Yamada
Jeanette Self used None None None None None American None
Zaichkin Academy of
Pediatrics
Neonatal
Resuscitation
Program†
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on
the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if
(a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the
voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than
“significant” under the preceding definition.
*Modest.
†Significant.
Appendix 2. Reviewer Disclosures

Research Research Bureau/ Expert Ownership Advisory
Reviewer Employment Grant Support Honoraria Witness Interest Board Other
Christoph Bührer Charité University None None University of None None None None
Medical Center Tübingen*
(Germany)
Praveen SUNY Buffalo None None None None None None None
Chandrasekharan
Krithika Lingappan Baylor College of None None None None None None None
Medicine
Ju-Lee Oei Royal Hospital for None None None None None None None
Women (Australia)
Birju A. Shah The University of None None None None None None None
Oklahoma
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure
Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10000 or more
during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns
$10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.

2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care
Khalid Aziz, Henry C. Lee, Marilyn B. Escobedo, Amber V. Hoover, Beena D.
Kamath-Rayne, Vishal S. Kapadia, David J. Magid, Susan Niermeyer, Georg M.
Schmölzer, Edgardo Szyld, Gary M. Weiner, Myra H. Wyckoff, Nicole K. Yamada and
Jeanette Zaichkin
Pediatrics originally published online October 21, 2020;
Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/early/2020/10/19/peds.2020-03
8505E.citation
Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its
entirety can be found online at:
http://www.aappublications.org/site/misc/Permissions.xhtml
Reprints Information about ordering reprints can be found online:
http://www.aappublications.org/site/misc/reprints.xhtml

2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care
Khalid Aziz, Henry C. Lee, Marilyn B. Escobedo, Amber V. Hoover, Beena D.
Kamath-Rayne, Vishal S. Kapadia, David J. Magid, Susan Niermeyer, Georg M.
Schmölzer, Edgardo Szyld, Gary M. Weiner, Myra H. Wyckoff, Nicole K. Yamada and
Jeanette Zaichkin
Pediatrics originally published online October 21, 2020;
The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pediatrics.aappublications.org/content/early/2020/10/19/peds.2020-038505E.citation
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has
been published continuously since 1948. Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2020 by the
American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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Prepublication Release

Part 5: Neonatal Resuscitation

This article has been copublished in Circulation.

©2020 American Academy of Pediatrics and American Heart Association, Inc.

TOP 10 TAKE-HOME MESSAGES FOR NEONATAL LIFE

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Guideline Structure Document Review and Approval

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Initial Actions Volume Expansion

Assessment of Heart Rate Human Factors and Systems

Oxygen Therapy CPAP continuous positive airway pressure

late preterm babies, and up to 30% oxygen in preterm ECG electrocardiogram/electrocardiographic

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1. Placing healthy newborn infants who do

Recommendations for Temperature Management 2. It is reasonable to perform all resuscitation

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COR LOE Recommendations

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tal outcome, retinopathy of prematurity, bron-

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2. When providing chest compressions to a

Recommendations for Vascular Access

2. If intravenous access is not feasible, COR LOE Recommendations

1. Umbilical venous catheterization has been the 4. It may be reasonable to administer

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healthy outcome. If it is possible to identify such condi-

studies in settings where therapeutic hypothermia

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KNOWLEDGE GAPS Advanced Resuscitation

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Other Speakers’ Consultant/

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Other Speakers’ Consultant/

Appendix 2. Reviewer Disclosures

Other Speakers’ Consultant/

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