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Neonatal resuscitation: advances in training and practice

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Neonatal resuscitation: advances in training and

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Advances in Medical Education and Practice
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Taylor Sawyer Abstract: Each year in the US, some four hundred thousand newborns need help breath-
Rachel A Umoren ing when they are born. Due to the frequent need for resuscitation at birth, it is vital to have
Megan M Gray evidence-based care guidelines and to provide effective neonatal resuscitation training. Every
five years, the International Liaison Committee on Resuscitation (ILCOR) reviews the science
Department of Pediatrics, Division
For personal use only.

of Neonatology, Neonatal Education of neonatal resuscitation. In the US, the American Heart Association (AHA) develops treatment
and Simulation-based Training (NEST) guidelines based on the ILCOR science review, and the Neonatal Resuscitation Program (NRP)
Program, University of Washington
translates the AHA guidelines into an educational curriculum. In this report, we review recent
School of Medicine, Seattle, WA, USA
advances in neonatal resuscitation training and practice. We begin with a review of the new 7th
edition NRP training curriculum. Then, we examine key changes to the 2015 AHA neonatal
resuscitation guidelines. The four components of the NRP curriculum reviewed here include
eSim®, Performance Skills Stations, Integrated Skills Station, and Simulation and Debriefing.
The key changes to the AHA neonatal resuscitation guidelines reviewed include initial steps of
newborn care, positive-pressure ventilation, endotracheal intubation and use of laryngeal mask,
chest compressions, medications, resuscitation of preterm newborns, and ethics and end-of-life
care. We hope this report provides a succinct review of recent advances in neonatal resuscitation.
Keywords: neonatal resuscitation, Neonatal Resuscitation Program, NRP, simulation, deliber-
ate practice, debriefing, eSIM

Introduction
Approximately 4,000,000 babies will be born in US this year.1 Around 400,000 of these
babies will need help breathing and/or positive-pressure ventilation to successfully
transition to life outside the womb, and as many as 12,000 will need resuscitation with
chest compressions and cardiac medications to survive.2,3 Due to the frequent need for
resuscitation at birth, it is vital to have birth attendants who are trained to provide neonatal
resuscitation to babies in need. In the US, the Neonatal Resuscitation Program (NRP)
is the primary educational mechanism used to teach health care providers to perform
neonatal resuscitation. The goal of the NRP curriculum is to help neonatal care provid-
Correspondence: Taylor Sawyer ers acquire the cognitive, technical, and behavioral skills needed to successfully and
Department of Pediatrics, Division efficiently resuscitate babies at the time of birth.4
of Neonatology, Neonatal Education
and Simulation-based Training (NEST) The NRP educational curriculum is reviewed and revised in five years cycles in
Program, University of Washington coordination with the International Liaison Committee on Resuscitation (ILCOR)
School of Medicine, 1959 NE Pacific
Street, RR451 HSB, Box 356320, Seattle,
review of resuscitation science.5 Based on the ILCOR science review, the American
WA 98195-6320, USA Heart Association (AHA) developed neonatal resuscitation guidelines and treatment
Tel +1 206 543 3200
Fax +1 206 543 8926
recommendations.6 The NRP program then translates the AHA guidelines into an
Email [email protected] e­ducational curriculum and develops a NRP flow diagram, which is published in the

submit your manuscript | www.dovepress.com Advances in Medical Education and Practice 2017:8 11–19 11
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Textbook of Neonatal Resuscitation.7 This year marks the 7th Prove-Do-Maintain” (LSPPDM) pedagogy.8 The LSPPDM
edition of the NRP educational curriculum. pedagogy is a six-phase framework for teaching procedural
In this report, we review recent advances in neonatal skills, assessing competency, and maintaining competency
resuscitation training and practice. We begin by examining once acquired. When applied to the NRP curriculum, the LSP-
the new 7th edition NRP educational curriculum. Then, we PDM pedagogy is used as follows. The first phase, “Learn”, is
examine key changes to the 2015 AHA neonatal resuscitation facilitated by self-study of the Textbook of Neonatal Resusci-
Advances in Medical Education and Practice downloaded from https://www.dovepress.com/ by 24.16.23.65 on 30-Dec-2016

guidelines that affect the practice of neonatal resuscitation. tation, passing the online examination, and doing the online
We hope this report provides a succinct review of recent eSim® module. During the NRP course, students “See” the
advances in neonatal resuscitation. techniques of neonatal resuscitation demonstrated by the
instructor, and “Practice” the skills using simulation during the
Advances in training Performance Skills Stations, and Simulation and Debriefing.
The following are six educational components of the NRP 7th During the Integrated Skills Station, the students “Prove” their
edition educational curriculum: 1) self-study of the Textbook proficiency in neonatal resuscitation. After course comple-
of Neonatal Resuscitation, 2) assessment of knowledge via tion, students go on to “Do” neonatal resuscitation as part of
online examination, 3) computer-based practice via NRP clinical care. Students “Maintain” neonatal resuscitation skill
eSim® (Laerdal Medical, Wappingers Falls, NY, USA), through clinical practice, supplemented by simulation-based
4) Performance Skills Stations, 5) Integrated Skills Station, training as needed and participation in an NRP course every
and 6) Simulation and Debriefing. Advances in the NRP two years. Figure 1 provides an overview of the LSPPDM
For personal use only.

educational curriculum from the sixth to the 7th edition are pedagogy applied to the NRP curriculum. The following are
summarized in Table 1. the four components of the NRP curriculum reviewed: eSim®,
The 7th edition NRP educational curriculum follows an Performance Skills Stations, Integrated Skills Station, and
evidence-based framework known as the “Learn-See-Practice- Simulation and Debriefing.
Table 1 Advances in the Neonatal Resuscitation Program (NRP)
educational curriculum from the 6th to the 7th edition NRP eSim®
Sixth edition NRP Seventh edition NRP
Before attending the 7th edition NRP course, students are
Pre-course Self-study of the Textbook Self-study of the Textbook of required to complete at least two simulated resuscitation sce-
of Neonatal Resuscitation Neonatal Resuscitation narios through the online eSim® platform. The NRP eSim®
Online examination Online examination is a screen-based simulator designed by Laerdal Medical in
NRP eSim®
collaboration with the American Academy of Pediatrics. NRP
During the Performance Skills Stations Performance Skills Stations
course eSim® allows a single user to resuscitate a virtual newborn in
Integrated Skills Station Integrated Skills Station order to learn the steps of neonatal resuscitation (Figure 2). The
Simulation and Debriefing Simulation and Debriefing simulated resuscitation can be performed by the student from

Learn See Practice Prove Do Maintain

Students learn Instructors Students practice Summative After the NRP course, Students maintain skill
about neonatal demonstrate technical and assessment is students perform through clinical practice
resuscitation via: technical and behavioral skills done during the neonatal resuscitation supplemented by
• Self-study of behavioral skills during Procedural Integrated Skills during clinical care simulation as needed and
Textbook of during Procedural Skills Stations and Station – this is attendance of a NRP
Neonatal Skills Stations Simulation and where students course every two years
Resuscitation Debriefing pass or fail the
• Taking NRP NRP course
online exam
• Completing
eSim® module

Cognitive phase Psychomotor phase

Figure 1 LSPPDM pedagogy applied to the Neonatal Resuscitation Program (NRP) curriculum.
Note: Sawyer T, White M, Zaveri P, et al. Learn, see, practice, prove, do, maintain: an evidence-based pedagogical framework for procedural skill training in medicine. Acad
Med. 2015;90(8):1025–1033. http://journals.lww.com/academicmedicine/Fulltext/2015/08000/Learn,_See,_Practice,_Prove,_Do,_Maintain___An.13.aspx.
Abbreviation: LSPPDM, Learn-See-Practice-Prove-Do-Maintain.

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 Dovepress Advances in neonatal resuscitation

Pause Reference Open End

scenario materials textbook scenario

Bulb syringe Towel Suction Meconum

catheter aspirator
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Stethoscope Pulse oximeter ECG leads Temperature

sensor probe

T-piece Self-inflating Flow inflating Free flow O2

resuscitator bag bag tube

Intubation Laryngeal mask Feeding tube Plastic bag

supplies

Umbilical Epinephrine Normal saline Thermal

catheter 1:10,000 mattress
For personal use only.

Timer Pulse oximeter Pre-ductal SpO2 ECG monitor Oxygen blender and Manometer Radiant warmer Wall suction
Targeted flowmeter

Figure 2 Screenshot of the Neonatal Resuscitation Program (NRP) eSim® module.

Note: From Weiner GM, editor. Textbook of Neonatal Resuscitation (NRP). 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2016:10. Copyright © 2016 American
Academy of Pediatrics. Reproduced with permission.
Abbreviation: ECG, electrocardiography.

any computer at a time in a convenient location. Each eSim® including positive-pressure ventilation, laryngeal mask place-
scenario starts with a brief case overview that provides perti- ment, tracheal intubation, chest compressions, placement
nent prenatal history. After the case introduction, students start of an emergency umbilical catheter, and administration of
the scenario with an equipment check that includes adjustment medications. They also demonstrate behavioral and teamwork
of the fraction of inspired oxygen, positive-pressure ventilation skills. After demonstration, the students deliberately practice
setting, and suction pressure. Once the equipment is prepared, with expert coaching by the instructor. Deliberate practice
students begin the simulation scenario. To simulate the steps continues until the students can perform the skills with
of resuscitation on the screen-based simulator, students “drag minimal coaching. Each skill builds on the next, and can be
and drop” equipment such as a towel, stethoscope, and T-piece integrated into brief training scenarios. By the end of the Per-
resuscitator over the infant. The infant responds to the student’s formance Skills Stations, the students have repeatedly prac-
actions based on a physiologic model. Each scenario requires ticed all the steps of the NRP flow diagram. This instructional
different resuscitation measures for effective resuscitation. methodology aligns well with Ericsson’s deliberate practice
Upon completion of the scenario, students receive automated paradigm that advocates for repeated practice combined with
feedback for self-reflection. There is no “pass” or “fail” in focused feedback.9 Advanced students are allowed to skip the
the eSim® module. Students can repeat any of the four eSim® Performance Skills Stations and start the NRP course with
scenarios as many times as they want. Figure 2 displays a the Integrated Skills Station, with the assumption that they
screenshot from the NRP eSim® module, showing the virtual have already mastered the skills of neonatal resuscitation and
neonate and the actions and equipment available to the student. are well-versed in the NRP flow diagram.

Performance Skills Stations Integrated Skills Station

The NRP course begins with Performance Skills Stations. Students are required to prove their proficiency in neonatal
At these stations, instructors demonstrate the correct perfor- resuscitation during the Integrated Skills Station. The Inte-
mance of the skills required during neonatal resuscitation, grated Skills Station consolidates learning by integrating the

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 Sawyer et al Dovepress

individual technical and behavioral skills of students for neo- summarizing the important learning points and a discussion
natal resuscitation into mini-simulation scenarios. The student of how they will change their performance in subsequent
being evaluated leads the resuscitation team during the sce- resuscitation scenarios. A suggested conversational struc-
nario, receiving minimal help or guidance from his/her team. ture for debriefing in the NRP course is available.10
During these scenarios, the student demonstrates that he/she According to the NRP flow diagram, post-event debrief-
can follow the NRP flow diagram in proper sequence. At this ing should occur after every neonatal resuscitation. These
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point, the NRP instructor determines if the student passes the post-event clinical debriefings can follow the same GAS
NRP course. It is important to note that completion of the NRP format and plus/delta method used in the NRP course.15
course does not imply that a student is competent to perform Using the same debriefing method during the NRP course
neonatal resuscitation. Each hospital and care organization is and during clinical care allows neonatal care providers to
required to determine the competency of its providers.7 gain familiarity and proficiency with post-event debriefing,
allowing debriefing to become a standard practice.
Simulation and Debriefing
After practicing the technical and behavioral skills in the Advances in practice
Performance Skills Stations, and proving their proficiency As mentioned earlier, the science that supports neonatal
in the Integrated Skills Station, students participate in team- resuscitation practice is reviewed every five years by the
based neonatal resuscitation Simulation and Debriefing. The ILCOR. The data are summarized in the International Con-
Simulation and Debriefing part of the course continues to sensus on Cardiopulmonary Resuscitation and Emergency
For personal use only.

reinforce cognitive and technical skills, but mainly focuses Cardiovascular Care Science with treatment recommenda-
on the 10 NRP key behavioral skills.7 The simulation sce- tions and translated into AHA neonatal resuscitation guide-
narios mimic clinical cases that resuscitation team members lines in the US.5,6 A summary of the advances in neonatal
are expected to manage and challenge the students to work resuscitation practice with the 2015 guidelines is provided
together as a team to follow the NRP flow diagram. below and summarized in Table 2. These changes become
Debriefing is the most important part of the Simulation the standard of care in the US from January 2017.
and Debriefing process of the NRP course.10 Debriefing pro-
vides a method of reflection on action and is a form of what Initial steps of newborn care
Schön calls “reflective practice”.11 Kolb experiential learning Every neonatal resuscitation should begin with a team brief-
theory, which describes how experience results in learning ing and equipment check.7 During the briefing, the reason
and personal development, relies on reflection on action as for delivery attendance is reviewed, team members introduce
a core principle.12 The central theme of both reflective prac- themselves and are assigned roles by the team leader. All the
tice and experiential learning is that experience alone does pieces of equipment are then checked to ensure they work,
not lead to learning, but rather a deliberate reflection on the and settings for positive-pressure ventilation, fraction of
experience leads to learning. inspired oxygen and suction are confirmed.
There are many methods for conducting simulation Delaying umbilical cord clamping for 30–60 seconds is
and debriefing.13 Debriefing in the NRP course uses a recommended in all vigorous term and preterm newborns.5,6
method known as facilitator-guided post-event debriefing. In cases where placental circulation is not intact, delayed
Using this method the debriefing conversation occurs after cord clamping is not recommended. Such cases include cord
completion of the simulation scenario, and is guided by the avulsion, placental abruption, and bleeding placenta previa or
instructor who acts as the debriefing facilitator. A suggested vasa previa. If the infant is not vigorous and requires resuscita-
structure for the debriefing conversations is the “Gather, tion at birth, it is unclear whether or not clamping of the cord
Analyze, and Summarize” (GAS) format developed by should be delayed. In these cases, the decision to delay cord
Phrampus et al.14 Using the GAS format, the debriefing clamping, or clamp immediately and start resuscitation, is
process starts with a quick review of resuscitation events left to the neonatal care providers and to hospital authorities.
to gather data and establish a shared mental model among Intubation and suction of the airway with an endotracheal
the team members. Next, the events of the resuscitation are tube are no longer recommended for non-vigorous infants
analyzed using a “plus-delta” method in which students born through meconium-stained amniotic fluid.6 After a
first review what went well (plus), and then what could review of resuscitation science, ILCOR determined there
be improved (delta). Debriefing concludes with students is insufficient evidence to continue this practice.5 Gentle

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 Dovepress Advances in neonatal resuscitation

Table 2 Advances in neonatal resuscitation practice with the 2015 guidelines

Initial steps of newborn care • Begin every resuscitation with a team briefing and equipment check
• Delay umbilical cord clamping for 30–60 seconds in vigorous term and preterm newborns
• Do not intubate and suction the airway in non-vigorous infants born through meconium-stained fluids
• Assess heart rate via auscultation with a stethoscope
Positive-pressure ventilation (PPV) • Ensure PPV results in visible “chest movement”
• Use a rising heart rate as the physiologic indicator of effective PPV
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Endotracheal intubation and laryngeal • Perform endotracheal intubation prior to starting chest compressions
mask • Use “Initial Endotracheal Tube Insertion Depth” table or the newborn’s nasal-tragus length (NTL) + 1 cm
to determine proper endotracheal tube depth
• Use a laryngeal mask if tracheal intubation is not successful or not feasible due to lack of trained personnel
Chest compressions • Use electrocardiography (ECG) to accurately assess heart rate
• Continue chest compressions for 60 seconds before stopping to check the heart rate
Medications • Do not use Lactated Ringers or sodium bicarbonate
• Give epinephrine if the heart rate remains less than 60 bpm despite 30 seconds of effective PPV that
moves the chest, and another 60 seconds of coordinated chest compression and ventilations using
100% oxygen
• If an endotracheal dose of epinephrine is used, give a repeat intravenous dose as soon as vascular access is
obtained; do not wait 3–5 minutes after the endotracheal dose
Resuscitation of preterm newborns • Delivery room temperature should be set at ~23°C–25°C (74°F–77°F)
• A thermal mattress, plastic wrap or bag, and a hat should be used for premature newborns less than
32 weeks’ gestation
For personal use only.

• CPAP can be used immediately after birth in premature newborns with respiratory distress syndrome as
an alternative to routine intubation and prophylactic surfactant administration
Ethics and end-of-life care • In cases of birth at less than 22 weeks’ gestation, and some chromosomal anomalies and congenital
malformations where there is no chance for survival, neonatal resuscitation is not ethical and should not
be offered
• In cases where survival is uncertain and there is a high risk of morbidity, such as birth between 22 and 24
weeks’ gestation and some chromosomal anomalies and congenital malformations, the parents should be
included in decisions regarding resuscitation plans
Abbreviations: CPAP, continuous positive airway pressure; bpm, beats per minute.

suctioning of the mouth and nose with a bulb syringe can be ensure that it is being given effectively. Providers should con-
done for infants born through meconium.7 sider using ECG when positive-pressure ventilation begins
Assessment of the heart rate in a newborn is most accu- in order to accurately follow the heart rate.
rately done via auscultation with a stethoscope.5 Palpation To determine whether or not positive-pressure ventilation
of the umbilical cord is less accurate and may lead to an is effective, one team member should auscultate the heart
underestimation of the actual heart rate. If the heart rate rate during the first 15 seconds of positive-pressure ventila-
cannot be determined by auscultation, then a pulse oximeter tion. If the chest is moving and the heart rate is increasing
or electrocardiography (ECG) should be used.5 or stable, then positive-pressure ventilation will continue for
another 15 seconds, after which the heart rate is reassessed.
Positive-pressure ventilation If the chest is not moving and the heart rate is not increas-
The most critical action in neonatal resuscitation is ventila- ing, ventilation corrective steps should be followed until the
tion of the baby’s lungs.5–7 Positive-pressure ventilation is chest moves with ventilation. The order of ventilation cor-
indicated in apneic and gasping newborns, and those with rective steps is as follows: 1) reapplication of the mask, 2)
a heart rate less than 100 beats per minute (bpm). An initial repositioning of the head, 3) suctioning of the airway with
peak inspiratory pressure (PIP) of 20–25 cm H2O and a peak a bulb syringe, 4) opening of the mouth, 5) increase in PIP,
end-expiratory pressure of 5 cm H2O are recommended when and 6) placement of an alternative airway. The pneumonic
administering positive-pressure ventilation.7 Movement of the “MR. SOPA” is used to remember these six steps.7 These
chest is the preferred method to confirm ventilation of the maneuvers should be performed in a stepwise manner with
lungs.6 A rising heart rate is the best physiologic indicator of reapplication of the mask and repositioning of the head first,
effective positive-pressure ventilation.6 The heart rate should followed by several breaths and auscultation of the heart rate.
be followed closely during positive-pressure ventilation to If the chest is not moving, then suctioning and opening of the

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mouth should be performed, and PIP should be titrated up Table 3 Endotracheal tube and laryngeal mask sizes for newborns
to a maximum of 40 cm H2O as needed in order to achieve Gestational age Weight (g) Endotracheal Laryngeal
chest rise. (weeks) tube size (mm) mask size

After completion of any needed ventilation corrective <28 <1,000 2.5 N/A
28–34 1,000–2,000 3.0 1
steps, 30 seconds of positive-pressure ventilation that moves
>34 >2,000 3.5 1
the chest should be given and the heart rate should be reas-
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Note: Data from Weiner et al.7

sessed. If the heart rate is at least 100 bpm, then positive- Abbreviation: N/A, not applicable.

pressure ventilation could be continued at 40–60 breaths/

minute until spontaneous breathing starts. If the heart rate With the new guidelines, correct endotracheal tube depth is
is less than 60 bpm or between 60 and 99 bpm, then the determined using the “Initial Endotracheal Tube Insertion
effectiveness of ventilation is reassessed, including repeat- Depth” table or by measuring the newborn’s nasal-tragus
ing ventilation corrective steps if necessary. If the heart rate length (NTL) and adding 1 cm.7 The NTL is the distance
remains less than 60 bpm with positive-pressure ventilation from the base of the nasal septum to the tip of the tragus of
that moves the chest, then an alternative airway (endotracheal the ear. These two methods are considered more accurate
tube or laryngeal mask) should be inserted. If the heart rate than previous methods. However, they are still only esti-
does not increase with an advanced airway in place, then mates of correct insertion depth. After the endotracheal tube
chest compressions should be started. is placed, auscultation of breath sounds and use of a CO2
Positive-pressure ventilation in newborns at 35 weeks’ detector are recommended to confirm correct endotracheal
For personal use only.

gestation or greater should begin with 21% oxygen. 5,6 tube placement.
Positive-pressure ventilation in newborns born earlier than If tracheal intubation is not successful after several
35 weeks’ gestation should begin with oxygen levels between attempts or not feasible due to lack of trained personnel,
21% and 30%, depending on local practice. Supplemental then a laryngeal mask should be used. A laryngeal mask is
oxygen can be started at 30%, and titrated as needed, in recommended during resuscitation of newborns at 34 weeks’
newborns who are breathing but not maintaining oxygen gestation or greater and weighing 2,000 g or more.7 Data on
saturation levels within the target range. Supplemental oxy- laryngeal mask use in preterm infants less than 34 weeks’
gen concentration should be titrated to keep oxygen satura- gestation are limited; however, several reports describe their
tion in the target range found in the NRP flow diagram.7 A successful use in infants weighing less than 1,500 g.16,17 A
trial of continuous positive airway pressure (CPAP) can be recent study of the effectiveness of laryngeal mask by Trev-
considered in newborns with labored breathing and those not isanuto et al found that in newborns with a gestational age
maintaining oxygen saturation within the target range with of 34 weeks and/or expected birth weight of 1,500 g needing
100% supplemental oxygen. positive-pressure ventilation at birth, the laryngeal mask was
more effective than the face mask to prevent endotracheal
Endotracheal intubation and laryngeal intubation.18 Additionally, the laryngeal mask was effectively
mask implemented in clinical practice after only a short educational
Placement of an endotracheal tube into the trachea is the intervention.18 Laryngeal mask use has not been evaluated
definitive method to secure the airway in a newborn who during chest compressions. However, if it is not feasible to
is persistently apneic, has significant respiratory distress, intubate or intubation is unsuccessful after several attempts,
or remains bradycardic with a heart rate less than 60 bpm it is reasonable to start compressions with the laryngeal
despite providing positive-pressure ventilation via face mask mask in place.7
that moves the chest. Intubation is recommended before
beginning chest compressions in order to ensure that effec- Chest compressions
tive ventilation is being provided.6 The steps of performing The preferred method to administer chest compressions in
neonatal intubation are outlined in the Textbook of Neonatal a newborn is the two-thumb technique, where the person
Resuscitation.7 Recommended sizes of endotracheal tubes performing compressions wraps his/her hands around the
and laryngeal masks for newborns are provided in Table 3. newborn’s chest and compresses the sternum with both
In the past, correct endotracheal tube depth was estimated thumbs. Once started, chest compressions should continue for
using the vocal cord guide on the endotracheal tube, or the 60 seconds before the team pauses compressions and checks
formula “6 + the weight in kilograms” (e.g. for a 3 kg baby the heart rate again. This limits interruptions in compres-
the estimated correct depth was 9 cm at the lip [6 + 3 = 9]). sions and may improve coronary artery perfusion.19 Once an

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 Dovepress Advances in neonatal resuscitation

endotracheal tube or laryngeal mask is inserted and secured, of endotracheal tube.5 However, one dose of endotracheal
the person performing compressions should administer epinephrine may be considered while intravenous access is
chest compressions from the head of the newborn to free up being obtained. If an endotracheal dose of epinephrine is
space over the newborn’s abdomen for another provider to given, a repeat intravenous dose should be given as soon as
place an emergency umbilical catheter (Figure 3). During vascular access is obtained.6 In such a case, there is no need
neonatal resuscitation, chest compression should always be to wait 3–5 minutes after the endotracheal dose. The pre-
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synchronized with ventilation in a 3:1 ratio, regardless of the ferred method to establish vascular access during neonatal
presence of an advanced airway. The goal chest compression resuscitation is to place an emergency umbilical catheter,
rate is 90 compressions per minute synchronized with 30 bpm although an intraosseous needle can also be considered.6 If
and given with a cadence of “one-and-two-and-three-and- there are concerns of acute hypovolemia, a normal saline
breath”. With the start of chest compressions, supplemental bolus of 10 ml/kg can be administered using the emergency
oxygen should be increased to 100% in order to maximize umbilical catheter or intraosseous needle.6 In cases of sig-
systemic oxygen delivery.5 An ECG is the preferred method nificant blood loss, uncrossmatched type-O negative blood
for assessing the heart rate during chest compressions, and can be used to emergently treat acute anemia.
ECG leads should be placed on the newborn’s chest when
compressions begin. Resuscitation of preterm newborns
In preparation for resuscitation of a premature newborn,
Medications the temperature in the delivery room should be increased
For personal use only.

The only two medications included in the neonatal resusci- to 23°C–25°C (74°F–77°F).5 For premature newborns born
tation guidelines are epinephrine and normal saline (0.9% before 32 weeks’ gestation, the resuscitation team should
NaCl).6 Neither sodium bicarbonate nor Ringer’s Lactate is ensure normothermia by 1) placing a thermal mattress under
recommended during neonatal resuscitation. Epinephrine the newborn, 2) using plastic wrap or a bag to cover the new-
should be given if the heart rate stays less than 60 bpm born, and 3) placing a hat on the newborn’s head immediately
despite providing 30 seconds of effective positive-pressure after delivery.7 The goal axillary temperature in a newborn
ventilation that moves the chest, and another 60 seconds during resuscitation is between 36.5°C and 37.5°C.5
of coordinated chest compressions and ventilations using Many premature newborns have respiratory distress at
100% oxygen. Epinephrine should not be given before delivery due to lung immaturity and surfactant deficiency. If
effective ventilation that moves the chest has been estab- positive-pressure ventilation is given during the resuscitation
lished. Once given, epinephrine can be administered every of a preterm newborn, a T-piece device that can deliver CPAP
3–5 minutes if the heart rate remains less than 60 bpm. The is preferred. Using CPAP keeps the newborn’s lungs inflated
recommended intravenous dose of epinephrine is 0.01–0.03 and helps to establish functional residual capacity. CPAP can
mg/kg, or 0.1–0.3 ml/kg, of a 1:10,000 concentration.6 The be used immediately after birth in premature newborns with
recommended endotracheal dose is 0.05–0.1 mg/kg, or respiratory distress syndrome as an alternative to routine
0.5–1 ml/kg, of a 1:10,000 concentration.6 The preferred intubation and prophylactic surfactant administration.5 The
route for epinephrine is intravenous due to the concerns use of early CPAP may avoid the need for intubation and
regarding absorption from the lungs after administration mechanical ventilation in many cases.20

A B

Figure 3 Chest compression administered from the foot of the bed (A) and the head of the bed (B).

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Ethics and end-of-life care References

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cases include birth at less than 22 weeks’ gestation, some 3. Barber CA, Wyckoff MH. Use and efficacy of endotracheal versus
intravenous epinephrine during neonatal cardiopulmonary resuscitation
chromosomal anomalies, and congenital malformations.7 This
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is a change from earlier guidelines which suggested a lower 4. Halamek LP. Educational perspectives: the genesis, adaptation,
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2008;9(4):e142–e149.
weight of less than 400 g.21 In cases where survival is uncer- 5. Perlman JM, Wyllie J, Kattwinkel J, et al; Neonatal Resuscitation Chap-
tain or there is a high risk of morbidity, the parents should ter Collaborators. Part 7: Neonatal Resuscitation: 2015 International
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Conclusion Pediatrics and American Heart Association; 2016.
8. Sawyer T, White M, Zaveri P, et al. Learn, see, practice, prove, do,
In this report, we reviewed recent advances in neonatal
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maintain: an evidence-based pedagogical framework for procedural

resuscitation training and practice including the 7th edition skill training in medicine. Acad Med. 2015;90(8):1025–1033.
NRP educational curriculum and the 2015 AHA neonatal 9. Ericsson KA. Deliberate practice and the acquisition and maintenance
of expert performance in medicine and related domains. Acad Med.
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sary of the NRP. The 7th edition NRP curriculum continues 10. Sawyer T, Ades A, Ernst K, Colby C. Simulation and the neonatal
resuscitation program 7th edition curriculum. NeoReviews. 2016;17(8):
a long tradition of improving the cognitive, technical, and e447–e453.
behavioral skills of providers responsible for resuscitating 11. Schön DA. The Reflective Practitioner: How Professionals Think In
newborns. We hope that these changes in the educational Action. New York: Basic Books; 1983.
12. Kolb DA. Experiential Learning: Experience as The Source Of Learning
curriculum and the resuscitation guidelines will help to and Development. Englewood Cliffs, NJ: Prentice Hall; 1984.
save the lives of many newborns. Continued advances in 13. Sawyer T, Eppich W, Brett-Fleegler M, Grant V, Cheng A. More than
one way to debrief: a critical review of healthcare simulation debriefing
neonatal resuscitation training and practice will occur over methods. Simul Healthc. 2016;11(3):209–217.
the next five years in anticipation of the 8th edition NRP 14. Phrampus P, O’Donnell J. Debriefing using a structured and supported
educational curriculum and 2020 AHA neonatal resuscita- approach. In: Levine A, Demaria S, Schwarz A, editors. The Compre-
hensive Textbook of Healthcare Simulation. 1st ed. New York, NY:
tion guidelines. As with the release of the 2015 guidelines, Springer; 2013:73–84.
release of the 2020 guidelines will mark the continued efforts 15. Sawyer T, Loren D, Halamek LP. Post-event debriefings during neonatal
care: why are we not doing them, and how can we start? J Perinatol.
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Acknowledgments 17. Velankar P, Joshi M, Sahu P. Use of laryngeal mask airway in premature
infant. Indian J Anaesth. 2013;57(6):634–635.
Dr. Sawyer acknowledges his collaborators in the Interna-
18. Trevisanuto D, Cavallin F, Nguyen LN, et al. Supreme laryngeal mask
tional Network for Simulation-based Pediatric Innovation, airway versus face mask during neonatal resuscitation: a randomized
Research, and Education (INSPIRE) for their work in devel- controlled trial. J Pediatr. 2015;167(2):286–291.
19. Kapadia V, Wyckoff MH. Chest compressions for bradycardia or asystole
oping the LSPPDM pedagogy, and the help of Dr. Louis Hal- in neonates. Clin Perinatol. 2012;39(4):833–842.
amek in delineating the post-event debriefing conversational 20. Papile LA, Polin RA, Carlo WA, et al; Committee on Fetus and New-
born; American Academy of Pediatrics. Respiratory support in preterm
method referenced here.
infants at birth. Pediatrics. 2014;133(1):171–174.
21. Kattwinkel J, Perlman JM, Aziz K, et al. Part 15: Neonatal resuscitation:
Disclosure 2010 American Heart Association guidelines for cardiopulmonary resus-
citation and emergency cardiovascular care. Circulation. 2010;122(18
The authors report no conflicts of interest in this work. Suppl 3):S909–S919.

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