This guideline is designed for North American health care professionals seeking an up-to-date summary for clinical care, as well as for those looking for more in-depth information on resuscitation science and gaps in current knowledge. The science of neonatal resuscitation applies to infants at birth and in the days after birth. In circumstances of altered or impaired transition, effective neonatal resuscitation reduces the risk of mortality and morbidity. Even healthy babies who breathe well after birth benefit from the facilitation of normal transition, including appropriate umbilical cord management and thermal protection with skin-to-skin care.

The 2025 Neonatal Resuscitation Algorithm summarizes the sequence of assessments and actions contained in the guidelines (1Figure 2).

Neonatal resuscitation science continues to advance. Although major updates to the guidelines occur every 5 years, interim updates may occur in the form of focused updates, as further evidence emerges based on publications of new clinical trials and systematic reviews.¹⁶ Gaps in knowledge relating to neonatal resuscitation remain. Some recommendations are based on weak evidence with only a few well-designed human studies. Therefore, the guidelines conclude with a summary of current gaps in neonatal resuscitation research.

These guidelines apply primarily to the newborn infant who is transitioning from a fluid-filled to an air-filled environment. The concepts in these guidelines may also apply to infants during the neonatal period (birth to 28 days of age) and potentially older infants cared for in the neonatal intensive care unit, depending on patient pathophysiology and institutional practice.¹⁷ Institutional policies and practices should be established based on the predominant patient population profile (in terms of age and pathophysiology) and staff training. Resuscitation of infants and children is addressed in “Part 6: Pediatric Basic Life Support” and “Part 8: Pediatric Advanced Life Support.”^18,19

The following sections briefly describe the process of evidence review and guideline development. Refer to “Part 2: Evidence Evaluation and Guidelines Development” for more details on this process.²⁰

The Neonatal Life Support Writing Group includes physicians, nurses, and scientists with backgrounds in neonatology, obstetrics, education, research, and public health. A call for candidates was distributed to the American Heart Association (AHA) Emergency Cardiovascular Care (ECC) Committee and American Academy of Pediatrics (AAP) subject matter experts, and volunteers with recognized expertise in neonatal resuscitation were nominated by the writing group co-chairs. Writing group members were selected by the AHA ECC Science Subcommittee and the AAP Executive Committee and then approved by the AHA Manuscript Oversight Committee. The AHA and AAP have rigorous conflict of interest policies and procedures to minimize the risk of bias or improper influence during development of the guidelines.²¹ Before appointment, writing group members and peer reviewers disclosed all commercial relationships and other potential (including intellectual) conflicts. Comprehensive disclosure information for writing group members is listed in Appendix 1. Writing group members whose research led to changes in guidelines were required to declare those conflicts during discussions and abstain from voting on those specific recommendations. This process is described more fully in “Part 2: Evidence Evaluation and Guidelines Development.”²⁰

These 2025 AHA and AAP neonatal resuscitation guidelines are based on the extensive evidence evaluation performed in conjunction with the ILCOR and affiliated ILCOR member councils. Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2025 process. Each of these resulted in a description of the literature that facilitated guideline development.²² This process is described more fully in “Part 2: Evidence Evaluation and Guidelines Development.”²⁰

The writing group reviewed all relevant and current AHA guidelines for cardiopulmonary resuscitation and ECC^16,23 and all relevant ILCOR consensus on science with treatment recommendations evidence and recommendations to determine if current guidelines should be reaffirmed, revised, or retired, or if new recommendations were needed.^24-28 Supplemental reviews were performed by the writing groups to develop recommendations. The writing groups then drafted, reviewed, and approved recommendations, assigning to each a Level of Evidence (LOE; ie, quality) and Class of Recommendation (COR; ie, strength) (Table 1). Refer to “Part 2: Evidence Evaluation and Guidelines Development.”²⁰

The 2025 guidelines are organized into knowledge chunks, discrete modules of information on specific topics or management issues.³⁰ Each modular knowledge chunk includes a table of recommendations using standard AHA nomenclature of COR and LOE. A short synopsis is provided to put the recommendations into context with important background information and overarching management or treatment concepts. Recommendation-specific text clarifies the rationale and key study data supporting the recommendations. Hyperlinked references are provided to facilitate quick access and review.

Each 2025 Guidelines document was given guidance and reviewed by the AHA’s ECC Science Subcommittee leadership and submitted for blinded peer review to 16 subject matter experts nominated by the AHA and the AAP, when appropriate. Before appointment, all peer reviewers were required to disclose relationships with industry and any other potential conflicts of interest, and all disclosures were reviewed by AHA staff. Peer reviewer feedback was provided for guidelines in draft format and again in final format. All guidelines were reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee, the AAP Board of Directors, and the AHA Executive Committee. Comprehensive disclosure information for peer reviewers is listed in Appendix 2. These recommendations supersede the last full set of AHA recommendations for neonatal life support, made in 2020.²³ The writing group members voted on each individual recommendation and approved all guideline recommendations.

Anticipation and Preparation for Resuscitation

Every newborn infant should have a trained and equipped person, or team when appropriate, to facilitate transition after birth. Identification of risk factors may indicate the need for additional personnel and equipment. Team behaviors such as anticipation, communication, briefing, equipment checks, and role assignment result in improved performance and outcomes.

Umbilical Cord Management

The neonatal team can communicate and plan with the obstetric team to provide the most appropriate cord management, which in most cases will be deferring cord clamping for at least 60 seconds. This applies to both preterm and term newborn infants who do not require resuscitation.

Initial Steps

When possible, term newborn infants should be managed skin-to-skin with their parent. After birth, the newborn infant with cord intact can be placed directly skin-to-skin, with attention to warm coverings and maintenance of normal temperature, while receiving ongoing evaluation of respiratory transition. Radiant warmers and other warming adjuncts are suggested for newborn infants who require resuscitation at birth, especially those born very preterm.

Stimulation may be provided to facilitate respiratory effort. Suctioning may be considered for suspected airway obstruction but is not routinely recommended.

Assessment of Heart Rate

Heart rate is assessed initially by auscultation. Pulse oximetry and electrocardiography (ECG) are important adjuncts in babies requiring resuscitation.

Ventilation and Continuous Positive Airway Pressure

Ventilation, also referred to as positive pressure ventilation, remains the primary method for providing support for newborn infants who are apneic, bradycardic, or demonstrate inadequate respiratory effort. Most newborn infants will respond to this intervention. An improvement in heart rate and establishment of breathing or crying are all signs of effective ventilation, which may be aided by corrective steps. The laryngeal mask, also known as a supraglottic airway, can be an effective method for providing ventilation to the newborn infant. For preterm infants who are breathing spontaneously but having increased work of breathing or hypoxia, CPAP may be beneficial.

Oxygen Supplementation

Ventilation may be initiated with air (21% oxygen) in term and late preterm newborn infants, and 21% to 30% oxygen in preterm babies 32 to 35 weeks of gestation. Very preterm infants less than 32 weeks’ gestational age may require higher oxygen concentrations (30%–100%) to achieve target oxygen saturation goals guided by pulse oximetry.

Chest Compressions

If the heart rate remains less than 60/min despite 30 seconds of ventilation that moves the chest, preferably through an alternative airway (endotracheal tube or laryngeal mask), chest compressions should be provided. The suggested ratio is 3 chest compressions synchronized to 1 inflation (with 30 inflations per minute and 90 compressions per minute). The preferred method is the 2 thumb–encircling hands technique, not the 2-finger or other techniques.

Intravascular Access

When intravascular access is required in the newborn infant, the umbilical venous route is preferred. When intravenous access is not possible or feasible, the IO route may be considered.

Epinephrine

If the heart rate remains less than 60/min despite 60 seconds of chest compressions and adequate ventilation, epinephrine should be administered, ideally via an intravascular route. Endotracheal epinephrine may be considered while vascular access is being obtained.

Volume Expansion

When blood loss is known or suspected based on history and examination, and there is no response to intravascular epinephrine, volume expansion is indicated.

Postresuscitation Care

If prolonged ventilation or advanced resuscitation is required, newborn infants should be closely monitored after stabilization. This monitoring may identify complications that can impact short- and long-term outcomes.

Withholding and Discontinuing Resuscitation

It may be possible to identify conditions in which withholding or discontinuing resuscitative efforts may be reasonably considered by families and health care professionals. Appropriate and timely support for collaborative decision-making should be provided to all involved.

Training and Human Performance

To optimize performance, teams and individuals who provide neonatal resuscitation should acquire necessary knowledge, technical skills, and behaviors, and also ensure ongoing maintenance of these skills. Given the low frequency of advanced resuscitation and inconsistency of resuscitation team members, institutions should be intentional in creating opportunities for individual and team training. Such training should include ongoing booster training and the use of simulation and debriefing.

Terminology

Prior neonatal guidelines have used the term positive pressure ventilation to refer to providing assisting ventilation. In this update, we generally use the term ventilation or assisted ventilation in order to simplify terminology, to align with other guidelines, and with the recognition that ventilation in neonatal resuscitation only involves positive pressure, not negative pressure.

The broad categories of gestational age can be specified as term to encompass infants 37+0 to 41+6/7 weeks’ gestational age, while preterm describes infants born prior to 37 weeks’ gestational age. When term and preterm are used in isolation in the guidelines, the above categorization would apply. When the evidence applies to a more specific subgroup, those gestational ages are specified in the recommendation and supportive text.

Management of the umbilical cord and placental transfusion at the time of birth remains an area of robust investigation. Placental transfusion can be achieved either by delaying the clamping of the umbilical cord following delivery or by milking the umbilical cord. Milking is typically done by stripping 20 cm of cord from the placenta toward the infant 3 to 4 times, allowing the cord to refill from the placenta each time. The volume of blood transferred from the placenta to the newborn infant and the impact of this transfusion vary based on gestational age at birth, mode of delivery, the time from birth to cord clamping, any milking of the umbilical cord, and physiologic status of the newborn. Based on available literature, deferred cord clamping for at least 60 seconds can be beneficial compared to immediate cord clamping for term infants who do not require resuscitation. For term infants who require resuscitation at birth, there is limited evidence to guide timing of umbilical cord clamping. Several studies currently are underway to investigate the interaction between deferred cord clamping and resuscitation. Initial steps of resuscitation such as drying and tactile stimulation, if required, can be undertaken during deferred cord clamping.

Recommendation-Specific Supportive Text

1. For term newborns, evidence from 14 studies (n=2412)^1-14 reporting on hemoglobin, and 20 studies (n=3452)^{1,4-6,8,10,13,15-27} reporting on hematocrit showed that infants received deferred umbilical cord clamping beyond 30 seconds had improved hematologic indices early in the newborn period. In 5 trials studying 1199 term newborn infants, those who received early cord clamping had lower ferritin levels at 3 to 6 months of age compared to those who received deferred cord clamping.^1,6,18,28,29 There was no difference in mortality among term infants who received deferred or early cord clamping in 3 randomized controlled trials (RCTs) including 419 infants.^16,18,30 More recent studies have evaluated deferred clamping for at least 60 seconds^{3,11-13,15,18,23,25,31-34} and additional studies have evaluated longer durations of deferred umbilical cord clamping.^17,35-37 These studies have shown increases in hematological indices compared to shorter durations of deferred cord clamping.
2. One RCT including 1730 nonvigorous infants, limited to 35 to 42 weeks’ gestational age, compared intact umbilical cord milking to early cord clamping (within 60 seconds of birth).³⁸ The primary outcome, admission to neonatal intensive care unit, was not different between groups. However, compared to early cord clamping, intact umbilical cord milking in nonvigorous infants was associated with decreases in several secondary outcomes, including rate of cardiorespiratory support in the delivery room, moderate to severe hypoxic-ischemic encephalopathy (HIE), and use of therapeutic hypothermia.
3. The currently available evidence does not support intact cord milking compared to deferred cord clamping in vigorous term newborns.^31,32,39 Two RCTs including 275 term infants showed no difference between hematologic indices when measured between 6 and 48 hours after delivery.^31,39 One study followed subjects to 4 months of age and measured hemoglobin and ferritin. No difference was noted between the cord milking and delayed cord clamping groups.³¹ Two RCTs including 371 term infants did not demonstrate a difference in hyperbilirubinemia, administration of phototherapy, or need for exchange transfusions.^32,39

Outcomes of interest and recommendations for cord management in preterm infants differ from term infants because of differences in the cardiovascular and cerebral vascular physiology of preterm infants. Transfer of blood from the placenta through the umbilical vein after birth has been shown to increase hemoglobin, increase circulating blood volume, improve organ perfusion and result in greater hemodynamic stability in preterm newborns after birth.^40-42 Based on available evidence for preterm infants who do not require resuscitation, deferred cord clamping for at least 60 seconds may result in improved outcomes. While deferred cord clamping is the preferred approach, an alternative approach is intact cord milking for infants born at 28+0 to 36+6 weeks’ gestational age in whom deferred cord clamping cannot be performed.⁴³ For infants born at less than 28 weeks’ gestational age, intact cord milking is associated with increased risk of intraventricular hemorrhage.^43,44 Some studies have shown an increased incidence of hypothermia on admission to the neonatal intensive care unit for preterm infants who received deferred cord clamping when compared to those who received immediate cord clamping. Attention to maintaining normothermia is an important aspect of care during resuscitation regardless of cord management strategy.

Recommendation-Specific Supportive Text

1. A recent pairwise individual participant data meta-analysis conducted by ILCOR included 21 studies enrolling 3292 newborns with a median gestational age of 29 weeks (IQR range 27–33 weeks) and compared deferred cord clamping (30 to ≥180 seconds) to immediate cord clamping (≤15 seconds).^22,43,45-62 Twenty trials enrolling 3263 infants showed a reduction in mortality before discharge with a number needed to treat of 40 (95% lCI 143 to 26 infants).^22,45-63 For all preterm infants, there is an increase in hematological indices,⁴³ while in those infants born at less than 32 weeks’ gestational age, there is a reduction in need for packed red blood cell transfusion during neonatal intensive care unit admission.^{22,46,48-50,52,53,55,57,59,61-63} In comparing durations of deferred cord clamping, long duration (≥120 seconds) was associated with the greatest reduction in mortality, but the number of extreme preterm infants included in these studies was low (n=121) and adherence to this duration (67%) was significantly lower compared to adherence for short and medium durations (30 seconds to less than120 seconds).⁴³ A post-hoc analysis by ILCOR demonstrated that newborn infants who received deferred cord clamping for 60 seconds or more (n=1316) had a reduction in mortality compared to those who had immediate cord clamping (less than15 seconds) (odds ratio [OR], 0.63 [95% lCI 0.44–0.88, p=0.01]).15^43,64 In 8 trials including 1995 preterm infants, hypothermia (defined as less than 36.5 °c) was increased on admission to the neonatal intensive care unit for infants less than 32 weeks of gestation who received deferred cord clamping compared to immediate cord clamping (mean difference -0.13 degrees, OR 1.28).⁴³
2. In preterm infants born at ≥28 weeks’ gestational age who received intact umbilical cord milking, pairwise individual participant data meta-analysis of 12 trials including 944 infants showed that hemoglobin levels in the first 24 hours after birth were higher compared with those who received immediate cord clamping.⁴³ Further, data from 15 studies including 1163 infants showed a reduction in the need for red blood cell transfusion for those infants who received intact cord milking compared with immediate cord clamping.⁴³ For infants who received intact umbilical cord milking compared with deferred cord clamping, data from 7 studies including 860 infants showed an increased risk of severe intraventricular hemorrhage in infants born at less than 32 weeks’ gestational age. This was primarily related to 1 RCT including 540 infants which showed an increased incidence of intraventricular hemorrhage in infants born at less than 28 weeks’ gestational age.⁴⁴ One RCT including 1019 infants delivered at 28 to 32 weeks of gestation showed no increased rate of severe intraventricular hemorrhage in the group receiving intact umbilical cord milking when compared with those receiving deferred cord clamping.⁶⁵
3. In a single study including 182 infants born between 23 and 27+6/7 weeks of gestation who did not require immediate resuscitation, the incidence of severe intraventricular hemorrhage was significantly higher in those who received umbilical cord milking compared with deferred cord clamping of 60 seconds.⁴⁴

Temperature after birth is an important measure of resuscitation quality.^1,2 The ideal temperature of newborn infants is between 36.5 °C and 37.5 °C.³ Hypothermia is associated with increased neonatal mortality and morbidity, especially in very preterm (less than 33 weeks’ gestational age) and very low-birth-weight infants (less than 1500 g), who are at increased risk for hypothermia.^4-7 Hyperthermia is associated with increased mortality and cerebral injury in both term and preterm infants.^5,8-10 Adverse outcomes are more frequent as temperature deviation on either side of the normal range increases.^4,5

Recommendation-Specific Supportive Text

1. There are long-standing worldwide recommendations for routine temperature management for the newborn infant.³ Monitoring of temperature after birth shows that hypothermia is common worldwide, with a higher incidence in newborn infants of lower gestational age and birth weight.^4-7,11 Hyperthermia may occur when warming interventions are provided in the delivery room without careful monitoring.¹²
2. In observational studies, the presence and degree of hypothermia after birth is strongly associated with increased neonatal mortality and morbidity, particularly in preterm (less than 37 weeks’ gestational age) and low-birth-weight infants (less than 2500 g).^4-7
3. Two observational studies found an association between hyperthermia and increased morbidity and mortality in very preterm and very low-birth-weight newborn infants.^5,10 Two observational studies showed an association between hyperthermia in preterm infants and major abnormalities on cranial ultrasound, neurodevelopmental impairment, and necrotizing enterocolitis.^8,13 Meta-analysis of 31 observational studies of epidural analgesia showed an association between intrapartum hyperthermia and adverse neonatal neurological outcome in both term and preterm infants.⁹

Placing healthy newborn infants skin-to-skin after birth can be beneficial for maintaining normothermia.¹⁴ For preterm and low-birth-weight infants or newborn infants requiring resuscitation, warming adjuncts (ambient temperature greater than 23 °C, skin-to-skin care, radiant warmers, plastic wraps or bags, hats, blankets, exothermic mattresses, and warmed humidified inspired gases)^15-17 individually or in combination may reduce the risk of hypothermia. However, exothermic mattresses have been reported to cause local heat injury and hyperthermia.¹⁸ Warming devices, especially when used in combination with other interventions to minimize heat loss, can result in hyperthermia.

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1. RCTs and observational studies of warming adjuncts, alone and in combination, demonstrate reduced rates of hypothermia in very preterm and very low-birth-weight infants.^15,16,19 However, meta-analysis of RCTs of interventions that reduce hypothermia in very preterm or very low-birth-weight infants show no impact on neonatal morbidity or mortality.¹⁶ Two RCTs and expert opinion support ambient temperatures of 23 °C and above.^3,17,20
2. Two meta-analyses of RCTs showed that early skin-to-skin contact promotes normothermia in healthy newborn infants.^2,14 A single-center RCT comparing immediate skin-to-skin contact during and after elective cesarean delivery with conventional management showed elimination of hypothermia and hypoglycemia in the intervention group, as well as improved breastfeeding outcomes.²¹ Two meta-analyses reviewed RCTs and observational studies of extended skin-to-skin care after initial resuscitation or stabilization, some in resource-limited settings, showing reduced mortality, improved breastfeeding and blood glucose stability, shortened length of stay, and improved weight gain in preterm and low-birth-weight infants.^22,23
3. Most RCTs in well-resourced settings routinely manage at-risk babies and those requiring resuscitation under a radiant warmer.^15,16 Other warming adjuncts are utilized when resuscitation is initiated with the cord intact.¹²
4. Several RCTs suggest that exothermic mattresses (combined with other measures) prevent hypothermia in preterm infants.¹⁹ One RCT found higher rates of hyperthermia with exothermic mattresses.¹⁸
5. Numerous nonrandomized quality improvement studies support the combined use of multiple warming adjuncts (“bundles”).²⁴ The use of radiant warmers in manual mode or exothermic mattresses in combination with other interventions to conserve heat effectively maintains temperature but increases the risk of hyperthermia.¹⁹

The immediate care of newborn infants involves an initial assessment of breathing and muscle tone. Infants who are breathing well or crying are cared for skin-to-skin with their mothers and do not need interventions such as routine tactile stimulation.²⁵ Tactile stimulation is defined as drying an infant and rubbing the back and soles of the feet.²⁵ If there is ineffective breathing effort or apnea after birth, tactile stimulation may improve or initiate breathing. There may be some benefit from repeated tactile stimulation in preterm infants during or after providing ventilation, but this requires further study.²⁶ Prolonged tactile stimulation should not delay the provision of ventilation.

Recommendation-Specific Supportive Text

1. Limited observational studies suggest that tactile stimulation may improve respiratory effort. In an observational study of video recordings of neonatal resuscitations among 245 infants born prior to 32 weeks of gestation, those who received tactile stimulation had lower rates of endotracheal intubation than those who did not receive stimulation.²⁷ One RCT found improved oxygenation after resuscitation in preterm infants who received repeated tactile stimulation.²⁶ This study concerned only preterm infants 27 to 32 weeks’ gestational age. In an observational study of 3073 noncrying newborn infants 34 weeks or more of gestation, 83% received stimulation, of whom 81% breathed after stimulation when cord was intact, while 69% breathed after stimulation with cord clamped.²⁸

Newborn infants who are breathing well or crying are cared for skin-to-skin with their mothers and should not need interventions such as suctioning, whether the amniotic fluid is clear or meconium-stained.²⁹ Avoiding unnecessary suctioning helps prevent the risk of induced bradycardia, apnea, desaturation, and airway injury.²⁹ If, at initial assessment, there is visible fluid obstructing the airway or a concern about obstructed breathing, the mouth and nose may be suctioned. Suctioning is reserved for when there is evidence of airway obstruction during ventilation. Direct laryngoscopy and endotracheal suctioning had been practiced in the past for newborn infants with meconium-stained amniotic fluid. However, this practice has not been shown as beneficial, whether the infant is vigorous or nonvigorous.³⁰ The practice of suctioning may delay assisted ventilation. When ventilation appears ineffective after corrective measures, airway obstruction may be present from blood, mucous, amniotic fluid, or meconium. In those instances, providing suction to relieve the obstruction may facilitate more effective ventilation.

Recommendation-Specific Supportive Text

1. Suctioning for suspected airway obstruction during ventilation is based on expert opinion. When ventilation is indicated and the airway appears obstructed, use of a bulb syringe or other suction device can clear the airway. There is no evidence or consensus to support the use of deep suctioning of the stomach.
2. Endotracheal suctioning for apparent airway obstruction is based on expert opinion. Regardless of the presence of meconium, when ventilation corrective steps do not lead to an increase in heart rate or to chest rise, endotracheal suctioning may help to relieve an obstruction. Obstruction may be caused by meconium, mucous plug, blood, or amniotic fluid.
3. A meta-analysis of 7 RCTs found no benefit from routine upper airway suctioning after birth in infants born through clear amniotic fluid.²⁹ Two RCTs and 2 prospective observational studies found lower oxygen saturations in infants who received suctioning within the first 10 minutes, while 2 RCTs did not find significant differences.²⁹ A meta-analysis of 4 RCTs found no benefit of endotracheal suction for infants born through meconium-stained amniotic fluid.³⁰ A large quality improvement trial found that avoiding suction prior to spontaneous breathing, but only wiping the mouth of nonvigorous infants with a towel, was associated with decreased exposure to oxygen in the delivery room (12.4% versus 4.4%) but no differences in Apgar scores, use of ventilation or CPAP, or neonatal intensive care unit admission.³¹

After birth, the newborn infant’s heart rate is used to assess the effectiveness of spontaneous respiratory effort, the need for interventions, and the response to interventions. Auscultation of the precordium remains the preferred physical examination method for the initial assessment of the heart rate, although assessment by auscultation (or palpation) may be unreliable and inaccurate. ECG provides the most rapid and accurate measurement of the newborn infant’s heart rate at birth and during resuscitation.¹ Compared to ECG, pulse oximetry is both slower in detecting the heart rate and tends to be inaccurate during the first few minutes after birth. Several emerging technologies show potential for fast and accurate heart rate assessment, but insufficient clinical data exists for inclusion in these recommendations. Underestimation of heart rate can lead to potentially unnecessary interventions. Alternatively, overestimation of heart rate when a newborn infant is bradycardic may delay necessary interventions. Limited data are available comparing the different approaches to heart rate assessment during neonatal resuscitation on other neonatal outcomes. Use of ECG for heart rate detection does not replace the need for pulse oximetry to evaluate oxygen saturation to assess the need for supplemental oxygen. Pulse oximetry can be placed in anticipation of resuscitation or when assisted ventilation is initiated. ECG can be considered when assisted ventilation is initiated and placed by the time that an alternative airway is being considered for bradycardia (Figure 2).

Recommendation-Specific Supportive Text

1. In 1 RCT and 1 observational study including 70 infants, there were no reports of technical difficulties with ECG monitoring during neonatal resuscitation, supporting its feasibility as a tool for monitoring heart rate during neonatal resuscitation.^2,3 One observational study including 630 infants compared neonatal outcomes before (historical cohort) and after implementation of ECG monitoring in the delivery room.⁴ Compared with the newborn infants in the historical cohort, newborn infants with ECG monitoring had lower rates of endotracheal intubation and higher 5-minute Apgar scores. Newborn infants in that study with ECG monitoring had higher odds of receiving chest compressions in the delivery room with appropriateness of compressions not assessed. Evidence from 11 nonrandomized studies^2,5-14 enrolling 452 newborn infants and 3 RCTs^15-17 enrolling 187 newborn infants suggest that at birth, ECG is faster and more accurate for newborn heart assessment compared with pulse oximetry. Data from 4 nonrandomized studies enrolling 156 newborns and 1 RCT enrolling 45 newborn infants show that auscultation is not as accurate as ECG for heart rate assessment during stabilization immediately after birth.^6,18-21
2. In the absence of ECG, studies demonstrate auscultation and pulse oximetry are faster or more accurate than palpation for heart rate assessment.^1,18 When ECG is unavailable or not functional, auscultation or pulse oximetry are reasonable alternatives and adjuncts for heart rate assessment.

When chest compressions are initiated, ECG monitoring can confirm heart rate. The placement of ECG leads can facilitate a continuous assessment of heart rate without the need for a team member auscultating the heart intermittently. During chest compressions, the ECG signal may not be reliable due to artifact. When ECG heart rate is greater than 60/min, a palpable pulse or audible heart rate rules out pulseless electrical activity.^22-26

Recommendation-Specific Supportive Text

1. Given its reliability in heart rate assessment compared to other modalities prior to beginning chest compressions in term and preterm infants, expert opinion is that ECG should be used when providing chest compressions despite the lack of direct evidence supporting the practice during chest compressions.¹

Most newborn infants start breathing spontaneously within 30 to 60 seconds after birth, sometimes with the help of drying and gentle stimulation.¹ If a newborn infant does not breathe spontaneously or has a persistent heart rate below 100/min despite initial efforts including tactile stimulation, ventilation is required at a rate of 30 to 60 inflations per minute. Delay in providing ventilation can increase the risk of death.¹ The effectiveness of ventilation is assessed by increase in heart rate and, to a lesser extent, by chest movement. For newborn infants, initial peak inflation pressures of 20 to 30 cm H₂O are generally sufficient to inflate the lungs. In some cases, higher peak inflation pressures may be necessary.^2,3 However, excessive tidal volumes have been associated with lung and brain injury in preterm newborns.^4,5 As tidal volumes can be both insufficient for effective ventilation if too low, or injurious if too high, titration of peak inflation pressure can be considered during neonatal resuscitation.

Lungs of sick or preterm infants are prone to collapse due to immaturity or inflammation. PEEP improves lung function and oxygenation, and maintains lung inflation during expiration. While PEEP may be advantageous, human studies in neonates are limited, and the optimal level of PEEP remains undetermined.^6,7

Recommendation-Specific Supportive Text

1. Most nonvigorous newborn infants respond to stimulation and ventilation. The risk of death or prolonged hospitalization increases by 16% for every 30-second delay in initiating ventilation.¹
2. An observational study in 129 term newborn infants using a T-piece resuscitator (refer to the Devices for Ventilation section) reported that during ventilation, median (iIQR) peak inflation pressures of 30.6 (28.6–31.6) cm H₂O resulted in a tidal volume of 4.5 (1.6–7.8) mL/kg.² Similarly, an observational study in 821 term newborn infants using a self-inflating bag reported that during ventilation, median peak inflation pressure of 37.7 (32.6–40.8) cm H₂O resulted in a tidal volume of 5.2 (2.3–8.6) mL/kg.³ Furthermore, a multicenter cluster-crossover trial randomized preterm infants greater than 26 weeks’ gestational age and term infants to ventilation with either a self-inflating bag with or without a PEEP valve or a T-piece with PEEP and reported a mean (standard deviation) maximum peak inflation pressure of 26 (2) cm H₂O with the T-piece versus 28 (5) cm H₂O with the self-inflating bag.⁸ Observational studies in preterm newborn infants reported that a peak inflation pressure of 20 to 25 cm H₂O delivered a median (IQR) tidal volume of 9 (3–15.7) mL/kg during ventilation, but higher initial pressures may sometimes be required.^9-14 After initiation of assisted ventilation, titrating peak inflation pressures both up and down during resuscitation may be needed to achieve effective, but not excessive ventilation.
3. A cohort study of 1962 infants born between 23 and 33 weeks’ gestational age reported lower rates of mortality and chronic lung disease during ventilation with PEEP versus ventilation with no PEEP.⁶ Furthermore, using logistic regression with adjustment for maternal and neonatal characteristics, use of the T-piece resuscitator with PEEP compared with self-inflating bag without PEEP increased the chance of survival to hospital discharge without major morbidities (OR, 1.38; 95% CI, 1.06–1.80).⁶
   
   In preterm animal models, PEEP facilitates lung aeration and development of functional residual capacity, prevents distal airway collapse, increases lung surface area and compliance, decreases expiratory resistance, conserves surfactant, and reduces hyaline membrane formation, alveolar collapse, and the expression of proinflammatory mediators.^15-17
4. Animal studies reported that ventilation with high volumes initiates inflammatory cascades, which result in lung and brain injury in immature animals.^18,19 The 2 pathways (cerebral blood flow instability and cerebral inflammatory cascade) increase the risk of brain injury and potential life-long adverse neurodevelopmental outcomes.¹⁸

During ventilation, an inflation time of 0.5 to 1 second during ventilation aligns with the natural breathing patterns of both term and preterm newborn infants.^2,20,21 It is appropriate to provide ventilation at a rate of 30 to 60 inflations per minute for newborn infants who are not breathing effectively.^1,2 Studies that explored the effects of sustained inflations greater than 5 seconds reported higher risks for preterm newborns.²² The potential benefits or risks of sustained inflations lasting between 1 and 5 seconds remain unclear.

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1. An observational study of 129 term newborn infants reported that ventilation using inflation time of approximately 0.5 seconds with a rate 30 to 60/min resulted in delivered tidal volumes between 5 and 10 mL/kg.² An observational study of 434 late preterm and term newborns reported that an inflation rate of 30/min was associated with the highest carbon dioxide clearance and the shortest time to reach exhaled carbon dioxide greater than 2%.²³
2. Observational studies including 950 term newborn infants reported that median inflation time of 0.46 seconds (IQR, 0.35–0.59 seconds) was associated with adequate tidal volume delivery.^1,2 Furthermore, increased inflation times were associated with a rise in tidal volume.²
3. An ILCOR task force review reported no benefit in using 1 or more sustained inflations of >5 seconds for preterm infants at birth.²² Sustained inflations may increase mortality among the subgroup of preterm newborns less than 28 weeks of gestation.²² The Sustained Aeration for Infant Lungs trial included 426 newborn infants 23 to 26 weeks’ gestational age and compared ventilation with up to 2 initial sustained inflations using a peak inflation pressure of 25 cm H₂O for 15 seconds (intervention) to standard ventilation (control) and reported significantly higher early mortality with sustained inflation compared to standard ventilation.²⁴

Effective ventilation is difficult to perform in newborn infants due to problems such as leak around the facemask, airway obstruction, and insufficient inflating pressures.^25-28 Neonatal manikin studies have shown that large leaks around the facemask can occur during ventilation,^29-32 and these findings have been replicated in clinical studies of term and preterm infants receiving mask ventilation.^13,28,33-35 Ventilation corrective maneuvers to overcome common challenges to effective ventilation include airway repositioning, mask adjustment or use of the 2-handed mask hold, suctioning, increasing peak inflation pressure, and placement of an alternative airway.³⁷

Direct laryngoscopy has been the traditional method of placing an endotracheal tube. As video laryngoscopes have been used both in the delivery room and in the neonatal intensive care unit, evidence has shown potential benefit including increased rates of first attempt success and overall success.^38-43 As video laryngoscopy may not be feasible across all settings due to cost and training requirements, traditional laryngoscopy continues to be a reasonable alternative.

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1. In an infant manikin study of 48 subjects and a pilot RCT of 30 preterm infants, mask leak was significantly reduced when using a 2-handed mask hold technique compared to a single operator holding the mask and providing the ventilation.^44,45 In an observational study of ventilation corrective maneuvers on the impact of tidal volume delivery during ventilation in 30 preterm infants, performing ventilation corrective steps led to improved tidal volume delivery in about one third of patients but resulted in ineffective or excessive tidal volumes in others. The number, sequence, and combination of maneuvers varied across resuscitations.⁴⁶ In an observational study of physiological response to ventilation corrective maneuvers in 28 preterm infants, mask adjustment, airway repositioning, and increasing peak inflation pressure led to improved oxygen saturation. Mask adjustment and increasing peak inflation pressure were also observed to increase expired tidal volume, although excessive tidal volumes were seen in this study.⁴⁷ An observational study of 58 term and 76 preterm infants reported a total of 427 maneuvers to improve noninvasive respiratory support. Cerebral regional tissue oxygen saturation measured by near infrared spectroscopy increased after the first ventilation corrective maneuver. There were nonsignificant improvements in heart rate, oxygen saturation, and facemask leak.⁴⁸
2. In a meta-analysis of 6 RCTs involving 862 intubations, video laryngoscopy compared to traditional laryngoscopy led to increased endotracheal intubation success.^38-43,49 In a meta-analysis of 4 RCTs involving 610 intubations, video laryngoscopy compared to traditional laryngoscopy led to increased likelihood of endotracheal intubation on first attempt.^39,41-43 In a meta-analysis of 4 RCTs involving 555 intubations, video laryngoscopy compared to traditional laryngoscopy led to decreased number of intubation attempts.^38-40,43 Adverse outcomes such as airway trauma, bradycardia, oxygen desaturation, esophageal intubation, and pneumothorax were not increased in 5 comparative RCTs.^39-43 In 4 observational studies involving 3342 intubations, video laryngoscopy compared to traditional laryngoscopy was associated with increased likelihood of endotracheal intubation on first attempt.^50-53 While traditional laryngoscopy remains a reasonable method to achieve an alternative airway, video laryngoscopy may be preferable when resources and training allow.

Available interfaces for delivery of ventilation during newborn resuscitation include face masks, nasal prongs, and laryngeal masks (also known as supraglottic airways). While face masks have historically been the most used and most studied interface in neonatal resuscitation, there is a growing body of evidence for the role of laryngeal masks as either primary or secondary interfaces for newborn ventilation.

Based on available evidence, these recommendations are limited to newborn infants greater than 34+0/7 weeks of gestation as this reflects the gestational age of the infants studied. Many manufacturers of laryngeal masks also state a lower weight limit of 2 kg, but smaller devices are now being made for infants weighing less than 2 kg. There is a lack of evidence for a lower weight limit or gestational age at which these smaller devices may be safely and effectively used.

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1. In 2 separate meta-analyses of the same 3 RCTs (158 infants born at greater than 34+0/7 weeks’ gestational age), there was no significant difference in insertion time, failure to correctly place the device, or first attempt success when a laryngeal mask was used as a secondary device instead of endotracheal intubation after face mask ventilation was unsuccessful.^54,55 In 1 RCT (68 infants born at greater than 34+0/7 weeks’ gestational age) that was not included in these meta-analyses, there was no significant difference in insertion time, first attempt success, or duration of ventilation.⁵⁶ In 1 observational study (86 infants born at 34+0/7 to 36+6/7 weeks’ gestational age) that was not included in these meta-analyses, use of a laryngeal mask instead of an endotracheal tube was associated with decreased likelihood of admission to the neonatal intensive care unit.⁵⁷ There were insufficient subjects to determine statistical difference in important outcomes such as incidence of pneumothorax or mortality.
2. A meta-analysis of 6 RCTs (1823 infants born at greater than 34+0/7 weeks’ gestational age) found that use of a laryngeal mask decreased the probability of failure to improve with the assigned device and the rate of endotracheal intubation in the delivery room when compared to use of a face mask.⁵⁸ These studies had heterogeneity in regard to subjects in their resuscitation experience for face mask ventilation and tended to be conducted in low- and middle-income countries. The duration of ventilation and time until heart rate reached greater than 100/min were also shorter with the laryngeal mask. Similarly, a quasi-randomized study of 67 infants born at greater than 36 weeks’ gestational age that was not captured in the above meta-analysis found that infants who received ventilation using a laryngeal mask required shorter duration of ventilation and were less likely to require intubation when compared to infants who were ventilated using a face mask.⁵⁹

Several devices are available to administer ventilation, including self-inflating bags, flow-inflating bags, and T-piece resuscitators. The choice of ventilation device depends upon factors reflecting the context at a birthing site: the number of births, the case mix, availability of a compressed gas source, familiarity with the different devices, amount of training required to use each device, and device cost. Because both T-piece resuscitators and flow-inflating bags require a compressed gas source to function, a self-inflating bag can serve as a backup in the event of compressed gas failure when using either of these devices.

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1. A meta-analysis of 4 RCTs (1247 infants) found that resuscitation with a T-piece resuscitator compared with a self-inflating bag reduced the duration of assisted ventilation and decreased risk of bronchopulmonary dysplasia.⁷ A more recent meta-analysis of 5 RCTs (1271 infants) comparing “fixed pressure devices” (ie, T-piece resuscitators and mechanical ventilators) to “hand pressure devices” (ie, self-inflating bags and flow-inflating bags) similarly found that fixed pressure devices were associated with decreased bronchopulmonary dysplasia, intubation in the delivery room, requirement and duration of mechanical ventilation, and surfactant administration.⁶⁰ Neither meta-analysis showed a difference in mortality between groups. Although subgroup analyses by gestational age were not feasible⁷ or not significant,⁶⁰ bronchopulmonary dysplasia is an outcome that affects preterm infants and the use of a T-piece resuscitator may provide the greatest benefit to preterm infants. Since these meta-analyses, 2 additional RCTs (92 preterm infants) comparing the use of a self-inflating bag and T-piece resuscitator have been published. Ventilation provided by a T-piece resuscitator delivered tidal volumes within goal range more consistently when compared to a self-inflating bag,⁶¹ but there was no significant difference in duration of assisted ventilation or other outcomes.^61,62 There were no new studies identified that evaluated the use of flow-inflating bags.

Newborn transition is dependent on lung inflation and establishing functional residual capacity.⁶³ Most spontaneously breathing term and late-preterm newborn infants will achieve this goal independently. However, some infants, particularly preterm infants, will need assistance to establish functional residual capacity even while spontaneously breathing. These infants can have signs of respiratory distress (grunting, nasal flaring, retractions) or persistent hypoxia if they have not been independently successful in adequate pulmonary recruitment. CPAP can provide noninvasive support to infants to recruit alveoli for respiration and aid in transition.

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1. Four RCTs and 1 meta-analysis^64-68 showed reduction in the combined outcome of death and bronchopulmonary dysplasia when starting treatment with CPAP compared with intubation and ventilation in preterm infants less than 30 weeks of gestation with respiratory distress. The meta-analysis reported no differences in the individual outcomes of mortality, bronchopulmonary dysplasia, pneumothorax, intraventricular hemorrhage, necrotizing enterocolitis, or retinopathy of prematurity.⁶⁸
2. One randomized trial enrolling 124 preterm infants (28 to 36 weeks of gestation) compared CPAP to high-flow nasal cannula as primary respiratory support in the delivery room.⁶⁹ There was no difference in “treatment failure” within 24 hours between groups. Treatment failure was defined as oxygen concentration greater than 40%, failure of immediate extubation following surfactant administration by the Intubation-Surfactant-Extubation technique, predefined levels of acidosis or hypercarbia, apnea with predefined criteria of severity, or subsequent mechanical ventilation.
3. Two RCTs,^70,71 2 observational studies,^72,73 and 1 meta-analysis⁷⁴ inform the use of CPAP in the delivery room. The studies included both prophylactic use of CPAP for prevention of and treatment of respiratory distress. The use of CPAP for spontaneously breathing term and late preterm infants ≥34 weeks’ gestational age in the delivery room may decrease neonatal intensive care unit admission or respiratory support in the neonatal intensive care unit, though the incidence of pneumothorax may be increased.

    

Most newborn infants who require resuscitation at birth respond to initial steps of resuscitation or to ventilation that inflates the lungs. Effective ventilation is indicated by a rise in heart rate. Ventilation must be optimized before starting chest compressions, including placement of an alternative airway, if possible (intubation or laryngeal mask), as chest compressions compete with delivery of effective ventilation.¹

Oxygen is essential for organ function; however, excess inspired oxygen during resuscitation may be harmful.² Although current guidelines recommend using 100% oxygen during chest compressions,³ no studies have confirmed a benefit of using 100% oxygen compared to any other concentration, including air (21%).⁴ When providing chest compressions, the inspired oxygen can be increased to 100% and titrated to meet saturation targets once return of spontaneous circulation (ROSC) is achieved.

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1. Initiation of chest compressions in newborn infants with a heart rate less than 60/min is based on expert opinion because there are no clinical or physiological human studies addressing this question. A review article regarding strategies to prevent progression of bradycardia and the role of chest compressions for persistent neonatal bradycardia in the delivery room included some potentially useful animal data.⁵ Fetal lambs (n=14) were asphyxiated until cardiac arrest. Heart rates were continuously monitored and coronary, carotid, and pulmonary flows recorded and compared during asphyxia at different levels of bradycardia. Peak systolic carotid flows were significantly lower for heart rates Peak systolic carotid flows were significantly lower for heart rates less than 60/min compared to baseline.⁵
2. In a neonatal simulation study, once chest compressions were initiated, health care professionals (n=30) were unable to recognize changing lung compliance and thus made little effort to optimize ventilation.¹ Based on expert opinion, intubation is suggested during chest compressions in order to assure efficacy of ventilation, which is a priority for neonatal resuscitation.
3. A recent ILCOR scoping review examined the evidence for using a laryngeal mask during chest compressions in newborn infants.⁶ Two animal studies suggest that ventilation via a laryngeal mask during chest compressions provides similar rates and time to ROSC compared to ventilation through an endotracheal tube.^7,8 Animal and manikin data suggest that laryngeal masks can deliver comparable ventilation to that provided through an endotracheal tube during chest compressions.^7-9
4. A recent scoping review⁴ identified that to date there are no human studies comparing air, 100% oxygen, or any other oxygen concentration during newborn infant chest compressions. Animal studies have not found any difference in rates of ROSC, mortality, markers of injury or oxidative stress, hemodynamics or oxygen delivery.^4,10-12 None of the animal studies examined any longer-term outcomes. Based on expert opinion, 100% oxygen during chest compressions is suggested. Once ROSC is achieved, oxygen should be weaned to meet goal saturations, as hyperoxia following resuscitation is associated with morbidity.^13-15

The need for chest compressions is uncommon for newborn infants.^16,17 When compressions are indicated, the preferred compression to ventilation ratio is 3:1 in synchrony. The 2 thumb–encircling hands compression technique may have benefit over the 2-finger technique with respect to blood pressure generation and clinician fatigue. When providing chest compressions with the 2 thumb–encircling technique, the hands encircle the chest while the thumbs depress the sternum.¹⁸ Performing chest compressions with this technique at the head of the bed facilitates placement of an umbilical venous catheter and has ergonomic advantages over compressing from the side of the infant.¹⁹

Optimal blood flow during chest compressions is achieved by compressing the chest to one third the anteroposterior diameter over the lower third of the sternum, with care to avoid the xiphoid process to avoid liver injury. Compressor fatigue may be minimized through routine role rotation among team members, preferably during heart rate assessments to limit interruptions in compressions.

Recommendation-Specific Supportive Text

1. In animal studies, the use of compression-to-ventilation ratios different from 3:1 (eg, 2:1, 4:1, 5:1, 9:3, 15:2) is associated with similar times to ROSC and mortality rates.^20-25 The use of chest compressions with asynchronous ventilations compared to a ratio of 3:1 has varied results with inconsistencies between studies with some reporting improvements in ROSC and survival, others showing no difference and some showing deteriorations in depth of compression and compressor fatigue.⁴ A new technique of providing continuous compressions during a sustained inflation has been studied in animals^4,11,26,27 as well as in a small pilot trial in newborn infants.²⁸ The majority of studies suggest potential benefit with faster time to ROSC but inconsistent survival results. A larger clinical trial found no differences but was underpowered.²⁹ Providing continuous compressions during a sustained inflation remains an interesting area of research but is not ready for clinical application.
2. Animal and manikin studies frequently demonstrate greater chest compression depth, improved carotid blood flow, lower fatigue, and higher proportion of correct hand placement with the 2 thumb–encircling hands technique compared with the 2-finger and othertechniques.^4,30 In 2 newborn infants with indwelling catheters, the 2 thumb–encircling hands technique generated higher systolic and mean blood pressures compared with the 2-finger technique.³¹
3. In a randomized animal trial, time to ROSC was similar with chest compression depths of 25%, 33%, and 40% of the anteroposterior chest diameter. A chest compression depth of only 12.5% did not achieve ROSC.³² The same group also reported on hemodynamic parameters, with the highest carotid blood flow and systemic mean blood pressure being achieved with 40% chest compression depth.³² A retrospective clinical study examined chest computed tomography scans of 54 neonates and concluded that the recommended one third anteroposterior diameter would be more effective than one fourth anteroposterior diameter compression and safer than one half anteroposterior diameter compressions.³³ No neonatal survival outcomes or long-term outcomes of newborn infants who received varying depths of compression are available.
4. One of the earliest reports of newborn infant chest compressions compared abdominal versus xiphoid versus middle sternum versus simultaneous chest/abdominal compression. Fresh cadavers of infants and young children (n=15) were used with subsequent autopsy examination. No rupture of the liver was produced when pressure was applied to the chest alone at mid-sternum. Superficial tears of the liver capsule were produced when pressure was applied to the xiphoid process and all patients with simultaneous chest/abdominal or abdominal compressions alone had liver rupture. Compression of the middle part of the sternum (above the xiphoid) produced effective circulatory pressures.³⁴ Chest radiograph studies with markers at the sternal notch and xiphoid process prior to taking the film subsequently identified that for the majority of infants, the heart lies under the lower one third of the sternum.^35-37 Additional studies found that the nipple line is not a good landmark for determining compression position.^38,39 Review of infant chest computed tomography scans to evaluate the optimal chest compression site found that the left ventricle was located beneath the lower quarter of the sternum the majority of the time.⁴⁰ Due to the safety concerns from the older cadaveric studies, it is important to make sure the compression is above the xiphoid on the lower one thirdof the sternum.³³
5. High-quality chest compressions encompass multiple factors including optimal compression to ventilation ratio, adequate rate, depth of compression and full recoil between compressions. If the compressor experiences fatigue, the quality of the compressions declines.^41,42 Neonatal manikin studies demonstrate that compression quality can diminish by 2 to 5 minutes when a single clinician performs compressions.^43-46

• Henry C. Lee, MD, Co-Chair
• Marya L. Strand, MD, MS
• Emer Finan, MD
• Jessica Illuzzi, MD
• Beena D. Kamath-Rayne, MD, MPH
• Vishal Kapadia, MD, MSCS
• Melissa Mahgoub, PhD
• Susan Niermeyer, MD, MPH
• Stephen M. Schexnayder, MD
• Georg M. Schmölzer, MD
• Jessica Weglarz, MBA
• Amanda L. Williams, RN
• Gary M. Weiner, MD
• Myra Wyckoff, MD
• Nicole K. Yamada, MD, MS
• Edgardo Szyld, MD, MSc, Co-Chair