2025+ILCOR科学治疗建议共识：新生儿生命支持

INTRODUCTION

# Resuscitation of the Newborn Infant

The physiological adaptations that take place during and immediately after birth are interdependent and critical to survival and good health. They include the establishment of air breathing, closure of fetal cardiovascular shunts,and functional adaptations to increase pulmonary blood flow while maintaining or increasing systemic flows and pressures. Additional adaptations that are critical to sur-vival of the immediate newborn period include the main-tenance of body temperature and of a consistent supply of glucose and substrates for metabolism of vital organs.The majority of newborns adapt to extrauterine life with-

<EndOfPara>out resuscitation, but interventions to support or achieve these adaptations can be critical to achieving survival and preventing morbidity.

National data from 2022 to 2023 from Australia indi-cated that among over 600 000 live-born infants, 10.3%received continuous positive airway pressure, 4.5%received positive-pressure ventilation, 0.8% were intu-bated, and 0.2% received chest compressions. ${ }^{1}$ However,although these results are from a country where neonatal resuscitation training is widely accessible and the neona-tal mortality rate is low $(2.3 / 1000)$ , the data reflect those who received various resuscitation interventions and do not define the optimal proportions who would benefit.The need for resuscitation interventions may be affected

Liley et al

Neonatal Life Support: CoSTR 2025

by various factors including maternal health, the quality of antenatal and intrapartum care, rates of prematurity,and other risk factors. Higher intervention rates may be needed to optimize survival without major morbidity when high-quality pregnancy and birth care are unavailable.

As consistently recommended by the Neonatal Life Support (NLS) Task Force,2,3 newborn infants who are breathing or crying and have good tone and an ade-quate heart rate may undergo deferred cord clamping and should be placed skin-to-skin with their mothers,using methods to maintain a normal body temperature.Ongoing observation is needed because the low oxygen saturations that are normal in the first few minutes after birth can persist or recur, apnea can occur, and breath-ing difficulties are common. When respiratory effort is inadequate, escalation should be undertaken by using the steps of the Neonatal Resuscitation Algorithm(Fig-ure 1), which is unchanged from 2015 and 2020.2,5

This NLS Task Force chapter of the 2025 International Liaison Committee on Resuscitation(ILCOR) Consensus on Science With Treatment Recommendations (CoSTR)includes 4 systematic reviews (SysRevs) and 2 scoping reviews (ScopRevs) conducted by the NLS Task Force in the previous year. Another 22 reviews conducted and published6-9 since the 2020 publication are also summa-rized to provide a single reference document for readers,along with evidence updates (EvUps) for these reviews and for 12 reviews conducted in 2020 or earlier. Thus,the NLS Task Force work presented here encompasses 40 PICOST(population, intervention, comparator, out-come, study design, time frame) questions. Draft CoSTRs for all topics evaluated with SysRevs were posted on a rolling basis on the ILCOR website, ${}^{10}$ with public com-ments accepted for at least 2 weeks after posting and considered before final versions were posted.

Although only SysRevs can generate a full CoSTR and new treatment recommendations, many other top-ics were evaluated with more streamlined processes,including ScopRevs and EvUps. Good practice state-ments, which represent the opinion of task force experts in light of very limited or no direct evidence,can be generated after ScopRevs and occasionally after EvUps in cases where the task force thinks pro-viding guidance is especially important. A separate arti-cle in this issue includes the full details of the evidence evaluation process. ${ }^{11}$

This summary statement contains the final wording of the treatment recommendations and good practice statements as approved by the ILCOR NLS Task Force.The year that treatment recommendations or good practice statements were generated or last updated by a SysRev is provided in parentheses. In cases where existing treatment recommendations have changed for 2025, the prior recommendations are also presented so the reader can easily see what has changed. SysRev include evidence-to-decision highlights and knowledge

gaps, and ScopRevs summarize task force insights on specific topics. Links to the published reviews and full online CoSTRs are provided in the corresponding sec-tions. Evidence-to-decision tables for SysRevs are pro-vided in Appendix A, and the complete EvUp worksheets are provided in Appendix B.

Topics are presented using the PICOST format.To minimize redundancy, PICOST wording has been removed from EvUps and reviews published previously,and the study designs have been removed from all reviews except in cases where the designs differed from the ILCOR standard criteria. The standard study designs included were randomized controlled trials (RCTs) and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, and cohort studies). Case series, case reports, animal studies, and unpublished studies (conference abstracts, trial proto-cols) were excluded. All languages were included pro-vided they had an English abstract.

The following topics are addressed in this NLS Task Force CoSTR summary. The order reflects the steps in the Neonatal Resuscitation Algorithm. Importance of all outcomes was in accord with Strand et al12 and (where stated) Webb et al,137 or by consensus of the task force for outcomes specifically to each review.

# Anticipation and Preparation

● Effect of briefing before neonatal resuscitation (NLS 5002: EvUp 2025)

# Umbilical Cord Management

● Umbilical cord management at birth for nonvigor-ous term and late preterm infants (NLS 5050[a]:SysRev 2025)

● Umbilical cord management at birth for vigorous term and late preterm infants(NLS 5050[b]: SysRev 2021, EvUp 2025)

● Umbilical cord management at birth for preterm infants(NLS 5051:SysRev 2024,EvUp 2025)

Initial Steps

● Maintaining normal temperature immediately after birth in term and late preterm infants (NLS 5100:SysRev 2022, EvUp 2025)

● Maintaining normal temperature immediately after birth in preterm infants (NLS 5101: SysRev 2023,EvUp 2025)

● Suctioning of clear amniotic fluid at birth (NLS 5120: SysRev 2022, EvUp 2025)

● Tracheal suctioning of meconium-stained amniotic fluid (NLS 5130: SysRev 2022, EvUp 2025)

● Tactile stimulation (NLS 5140: SysRev 2022, EvUp 2025)

Liley et al

Neonatal Life Support: CoSTR 2025

 Figure 1. Neonatal Resuscitation Algorithm.

CPAP indicates continuous positive airway pressure; ECG, electrocardiographic; HR, heart rate; IV, intravenous; PPV, positive-pressure ventilation;

Assessment of Heart Rate

● Heart rate assessment methods in the deliv-ery room-diagnostic characteristics (NLS 5200:SysRev 2023, EvUp 2025)

● Heart rate assessment methods in the delivery room-clinical outcomes(NLS 5201: SysRev 2022, EvUp 2025)

Ventilation and Oxygenation

● Devices for administering positive-pressure ventilation(NLS 5300: SysRev 2021, EvUp 2025)

● Continuous positive airway pressure versus positive-pressure ventilation for preterm infants(NLS 5310:SysRev 2015,EvUp 2025)

Liley et al

Neonatal Life Support: CoSTR 2025

● Continuous positive airway pressure for term and late preterm infants with respiratory distress (NLS 5312: SysRev 2022, EvUp 2025)

● Sustained inflations during newborn resuscitation(NLS 5320: EvUp 2025)

● Supraglottic airway device versus face mask (NLS 5340: SysRev 2022, EvUp 2025)

● Supraglottic airway device versus tracheal tube(NLS 5341: EvUp 2025)

● Use of a supraglottic airway device during chest compressions (NLS 5342: ScopRev 2025)

● Exhaled CO, monitoring to guide noninvasive venti-lation (NLS 5350: SysRev 2023, EvUp 2025)

● Video versus traditional laryngoscope(NLS 5351:SysRev 2025)

● Respiratory function monitoring during resuscitation at birth (NLS 5360: SysRev 2022, EvUp 2025)

● Near-infrared spectroscopy during positive-pressure ventilation (NLS 5362: SysRev 2025)

● Oxygen concentration for initiating resuscitation in preterm infants (NLS 5400: SysRev 2025)

● Oxygen concentration for initiating resuscitation in late preterm and term infants (NLS 5401: EvUp 2025)

Circulatory Support

• Heart rate for commencing chest compressions(NLS 5500: ScopRev 2023, EvUp 2025)

● Chest compressions with 2 thumbs versus other techniques (NLS 5501: ScopRev 2023, EvUp 2025)

● Supplemental oxygen during chest compressions(NLS 5503: ScopRev 2023, EvUp 2025)

● Compression-to-ventilation ratio (NLS 5504:ScopRev 2023, EvUp 2025)

● Use of feedback cardiopulmonary resuscitation(CPR) devices for neonatal cardiac arrest, are NLS 5505: ScopRev 2023, EvUp 2025)

● Depth of chest compressions (NLS 5506: ScopRev 2023, EvUp 2025)

● Chest compression location on sternum (NLS 5507:EvUp 2025)

Drug and Fluid Administration

● Epinephrine(adrenaline) for neonatal resuscitation(NLS 5600: EvUp 2025)

● Sodium bicarbonate during neonatal resuscitation(NLS 5601:EvUp 2025)

● Glucose management during or immediately after resuscitation (NLS 5602: ScopRev 2025)

● Blood volume expansion during neonatal resuscita-tion (NLS 5650: EvUp 2025)

● Intraoseous versus intravenous cannulation for emergency access (NLS 5652: EvUp 2025)

Postresuscitation Care

● Rate of rewarming hypothermic newborns (NLS 5700: SysRev 2024, EvUp 2025)

•Therapeutic hypothermia in limited-resource set-tings(NLS 5701: SysRev 2024, EvUp 2025)

Prognostication During CPR

● Impact of duration of intensive resuscitation (NLS 5800: EvUp 2025)

Family Presence

● Family presence during neonatal resuscitation(NLS 5900: SysRev 2021, EvUp 2025)

Readers are encouraged to monitor the ILCOR web-site 10 to provide feedback on planned SysRevs and to provide comments when additional draft reviews are posted.

ANTICIPATION AND PREPARATION

Effect of Briefing Before Neonatal Resuscitation (NLS 5002: EvUp 2025)

Rationale for Review

A Scoprev addressed both briefing and debriefing to de-termine whether they improve outcomes for infants, fam-ilies, and health care professionals for the 2020 CoSTR and concluded that there was insufficient evidence to make a treatment recommendation.5,14 This EvUp only as-sessed briefing because debriefing has been addressed in a recent SysRev by the Education, Implementation,and Teams Task Force.15 The complete EvUp, including the full PICOST, can be found in Appendix B.

Time frame: December 1, 2019, to December 30,2024

Summary of Evidence

Four new studies including observational data from be-fore and after implementation of an intervention to in-crease or improve aspects of briefing before newborn resuscitation were identified. ${ }^{16-19}$ The studies were gen-erally supportive of the use of briefing, but there is insuf-ficient new evidence to justify a new SysRev.

Treatment Recommendation (2025)

There was no previous treatment recommendation on the topic. The task force considered that the following statement was justified:

Whenever the need for resuscitation of a newborn is anticipated, there should be a briefing of the neonatal team that includes communication with the obstetric and midwifery team to inform the neonatal management plan(good practice statement).

Liley et al

Neonatal Life Support: CoSTR 2025

UMBILICAL CORD MANAGEMENT

For umbilical cord management, the previous reviews for preterm and term infants used definitions that do not adequately reflect more recent research studies and routine definitions used in clinical practice. These terms have been replaced, as noted in Table 1, in the following 3 summaries of reviews of umbilical cord management.There is also some variation in how individual clinical tri-aists or previous reviews have used these terms. Where essential to interpretation of results, we will point this out.Adherence to the intended intervention may also vary be-tween the arms of different studies.

Umbilical Cord Management at Birth for Nonvigorous Term and Late Preterm Infants(NLS 5050[a]: SysRev 2025)

Rationale for Review

Clamping the umbilical cord at birth is a key event af-fecting adaptation to extrauterine life, particularly in the seconds and minutes immediately after birth. If cord clamping is deferred, umbilical venous return contrib-utes to hemodynamic stability for several minutes after birth.2021 Placental transfusion also reduces later need for red cell transfusion in preterm infants and helps to prevent anemia and iron deficiency in term infants.9

A 2021 SysRev conducted for ILCOR with the Cochrane Collaboration found substantial evidence to sup-port a recommendation suggesting deferred cord clamp-ing for $\geq 60$ seconds. ${}^{9,22}$ Because of a paucity of evidence at the time, this recommendation excluded the important subgroup of infants who are not vigorous at birth. Their treatment has traditionally involved immediate clamping

Table 1. Abbreviations and Definitions of Terms Related to Umbilical Cord Management

|Time-based decisions|Physiology-based decisions|Cord milking| |---|---|---| |ICC:Immediate cord(smually<15s) without initiation of respira-tory support|Intact cord resuscitation: Any time to cord clamping(usually≥60 s) but when respiratory support(eg,supplemental oxygen, high-flow,CPAP,PPV) is provided before cord clamping|I-UCM: Intact umbilical cord milking; repeated compression of the cord from the placental side toward the baby with the connection to the placenta intact| |ECC:Early cord clamping(usually<60 s) without initiation of respiratory support; may include infants who had ICC|PBCC: Physiologically based clamping; cord clamping not based on a specific time but on physiological observa- tions such as a defined duration of breathing or effective PPV|C-UCM: Cut umbilical cord milking; drainage of the cord by compression from the cut end toward the baby after clamping and cutting a long segment|

CPAP indicates continuous positive airway pressure; C-UCM, cut umbilical cord milking; DCC, deferred cord clamping; ECC, early cord clamping; I-UCM, in-tact umbilical cord milking; ICC, immediate cord clamping; PBCC, physiologically based cord clamping; and PPV, positive-pressure ventilation.

of the umbilical cord and transfer to a resuscitation trolley for the commencement of assisted ventilation. Alternative strategies to enable placental transfusion before or dur-ing resuscitation have since been investigated. The task force updated the previous SysRev for term and late pre-term infants for the specific subgroup of infants who are not vigorous at birth. The review was registered before initiation(PROSPERO 2024 CRD42024562012). The full online CoSTR can be found on the ILCOR website.23

Population, Intervention, Comparator, Outcome, and Time Frame

$\bullet$ Population: Term and late preterm infants(≥34 weeks' gestation) who are not vigorous at birth

$\bullet$ Intervention: Any cord management strategy designed to improve fetal to neonatal cardiorespi-ratory transition, including deferred cord clamping,intact cord resuscitation, intact umbilical cord milk-ing, and cut umbilical cord milking

● Comparator: Immediate cord clamping, early cord clamping, or between-intervention comparisons(eg,deferred cord clamping versus intact umbilical cord milking) or cut umbilical cord milking)

· Outcome:

Infant

- Neonatal mortality (critical)

- Moderate to severe neurodevelopmental impair-ment at 18 to 24 months(critical)

- Any component of neurodevelopmental impair-ment at 18 to 24 months(critical)(cerebral palsy,significant mental developmental delay, blind-ness as defined by the World Health Organization[<20/200 visual acuity] or the author's definition,hearing deficit [aided or<60 dB on audiometric testing])

- Moderate to severe hypoxic ischemic encepha-lopathy(Sarnat 2 or 324)(critical)

- Proportion of infants receiving chest compres-sions in the delivery room(important)

-Admission to a neonatal intensive care unit(NICU)(important)

- Jaundice: Treated with exchange transfusion(critical) or phototherapy(important)

- Hematologic outcomes including peak hemoglo-bin or hematocrit concentration during hospital admission(important) and anemia or iron defi-ciency at 4 to 6 months(important)

- Unintended hypothermia within the first hour of life(important)

Mother

-Postpartum hemorrhage, estimated as at least 1000 mL(critical), postpartum infection(critical),death or severe morbidity(composite),major sur-gery, organ failure, intensive care unit admission $\left(\right.$ critical)

● Time frame: January 1,2019,to July 10,2024

Liley et al

Neonatal Life Support: CoSTR 2025

Consensus on Science

Intact Umbilical Cord Milking Compared With Early Cord Clamping

One eligible cluster-randomized multicenter crossover trial including 1730 infants,25 of whom 971 were fol-lowed up to 2 years of age,26 was identified. Infants were eligible if they had poor tone, pallor, or were not breathing despite stimulation. For those in the intact umbilical cord milking arm, the infant was held below the level of the incision(for caesarean births) or on the mother's abdo-men(for vaginal births) while a 20 cm length of umbili-cal cord was milked for 2 seconds per time a total of 4 times before cord clamping. For those in the early cord clamping arm, the cord was clamped within 60 seconds after birth(median interquartile range, 20[10-30] s).Key outcomes are summarized in Table 2. For additional outcomes, see the full online CoSTR.23 Statistical results are reported conforming to analytical methods that were used in the study because of the cluster randomization(eg, modified odds ratio instead of relative risk).

Intact Cord Resuscitation Compared with Early Cord Clamping or Immediate Cord Clamping

Three studies were included,27-29 and 2-year follow-up data30 were available for one.28 In all 3 studies, the in-tervention group received respiratory support, if required,using a T-piece resuscitator27,29 or self-inflating bag28 with the umbilical cord intact. Two studies aimed for at least 180 seconds before cord clamping 27,28 and the oth-er at least 2 minutes and until≥60 seconds after change in color of a CO, detector placed between the face mask and T-piece.29 Timing of clamping of the umbilical cord in the control arm of each study was generally within 1 minute. From these studies, clinical benefit or harm could not be excluded for any of the critical or important short-and long-term outcomes.

Two other small single-arm studies examining resus-citation with an intact cord concluded that intact cord resuscitation was feasible in 12 nonvigorous infants≥32 weeks' gestation31 and 20 infants with congenital dia-phragmatic hernia.32

Prior Treatment Recommendations(2021; see NLS 5050[b])

There are none for this subgroup of nonvigorous term and late preterm infants.

Treatment Recommendations(2025)

Intact Umbilical Cord Milking Compared With Early Cord Clamping

In term and late preterm infants who remain nonvigor-ous despite stimulation, we suggest intact cord milking in preference to early cord clamping(weak recommenda-tion, low-certainty evidence).

Intact Cord Resuscitation Compared With Early Cord Clamping or Immediate Cord Clamping

There is currently insufficient evidence to recommend ei-ther for or against intact cord resuscitation for term and late preterm infants who are nonvigorous at birth.

Justification and Evidence-to-Decision Framework Highlights

The complete evidence-to-decision table is provided in Appendix A.

Intact Umbilical Cord Milking Compared With Early Cord Clamping

The use of intact umbilical cord milking in preference to early cord clamping in infants who remain nonvigorous despite stimulation is justified by the reduction in mod-erate or severe hypoxic ischemic encephalopathy and improvement in early hemoglobin, given that there was

Table 2. Milking of the Intact Umbilical Cord Compared With Early Cord Clamping: Critical and Important Outcomes

|Outcome(importance*)|Participants (studies),n|Certainty of evidence, GRADE|Relative effect (95% CI)|Anticipated absolute effect(95% CI)|| |---|---|---|---|---|---| |Outcome(importance*)|Participants (studies),n|Certainty of evidence, GRADE|Relative effect (95% CI)|Risk with ECC|Risk difference with I-UCM| |Mortality(critical)|1730(1 RCT)25(follow-up to hospital discharge)|Low|RR 0.11(0.01-2.03)|5/1000|4 fewer per 1000 (5 fewer to 5 more)| |Moderate or severe HIE(critical)|1634(1 RCT)25|Moderate|RR 0.49(0.25-0.97)|30/1000|15 fewer per 1000 (22 fewer to 1 fewer)| |Admission to NICU(important)|1730(1 RCT)25|Moderate|mOR,t 0.69(0.41-1.14)|279/1000|68 fewer per 1000 (142 fewer to 27 more)| |Hemoglobin(g/dL)(important)|1730(1 RCT)25|Moderate|-|Median hemoglobin (g/dL) was 17.3 g/L|mMDt 0.7 g/L higher (0.3 higher to 1.1 higher)| |Survival with typical development (ASQ domains normal range)|971(1 RCT)28(follow-up to 2 y of age)|Low|mOR,t 0.76(0.54-1.08)|829/1000|42 fewer per 1000 (105 fewer to 11 more)|

*Outcome importance according to Strand et al.12

t+Modeled odds ratios or modeled mean differences were as reported by study authors(modeling to account for the cluster-randomized study design).

ASQ indicates Ages& Stages Questionnaires; ECC, early cord amplling; GRADE, Grading of Recommendations Assessment, Development, and Evaluation; HIE,hypoxic ischemic encephalopathy; I-UCM, intact cord milking; mMD, modelled mean difference; mOR, modeled odds ratio; NICU, neonatal intensive care unit; RCT,randomized controlled trial; and RR, relative risk.

Liley et al

Neonatal Life Support: CoSTR 2025

<EndOfPara>no evidence of adverse effects. It also allows a uniform suggestion for intact cord milking as an alternative to early cord clamping for all infants $\geq$ 28 weeks' gestation,9 bearing in mind that deferred cord clamping is still the preferred option for all vigorous infants. The rationale differs depending on gestation, but the certainty of evi-dence and strength of recommendation are similar.9 The strategy is simple, does not require additional equipment,and appears safe and feasible. Although no formal cost-benefit analysis has been performed, any reduction in moderate or severe hypoxic ischemic encephalopathy is likely to result in cost savings both in relation to the costs of NICU care and the lifetime costs of adverse outcomes of this condition.

An additional observational study reported that in newborn infants who were not yet crying, providing tac-tile stimulation while the cord remained intact(deferred cord clamping) was associated with a higher proportion who breathed spontaneously, a decrease in use of bag-mask ventilation, fewer Apgar scores ≤3, and increased odds of spontaneous breathing than providing stimulation after early cord clamping,33 supporting the role of tactile stimulation during deferred cord clamping and indicating that the task force treatment recommendation for tactile stimulation to stimulate breathing should apply regard-less of the method of umbilical cord management.34

Intact Cord Resuscitation Compared with Early Cord

Clamping or Immediate Cord Clamping

The task force considered that because clinical ben-efit or harm cannot be excluded for any outcome, and certainty of evidence was low, no general or conditional treatment recommendation can be made at this time. Re-suscitation of infants still attached to the umbilical cord can be accomplished by using a variety of strategies and devices. These include purpose-built resuscitation tables that may include equipment to provide an external heat source, assisted ventilation, and monitoring. Given that in many cases, the finding that an infant is not vigorous at birth is unexpected, these devices may only be available for a small proportion of high-risk births, and potentially not in locations where resources are limited.

<BeginOfPara>No studies were found to inform a treatment recom-mendation about any other form of umbilical cord man-agement in late preterm and term infants who are not vigorous at birth, or to compare intact umbilical cord milk-ing to intact cord resuscitation.

Knowledge Gaps

● The need for large multicenter RCTs evaluating both intact umbilical cord milking and intact cord resus-citation, including high-quality follow-up with formal assessment of cognition, motor development, hear-ing, and vision

● The safety,useability, and cost-effectiveness of dif-ferent devices to support resuscitation with an intact cord

● The effect of other techniques to facilitate placental transfusion including milking of a long segment of clamped-and-cut umbilical cord

Umbilical Cord Management for Vigorous Term and Late Preterm Infants (NLS 5050(b): SysRev 2021, EvUp 2025)

Various methods of umbilical cord management for all term and late preterm infants were addressed by a 2021 SysRev and included in the 2021 CoSTR summary, al-though the studies found for inclusion included few in-fants who were nonvigorous.9,22 An EvUp was conducted for 2025 to determine whether, in vigorous infants, any of these methods compared with early cord clamping(or any other method) improved neonatal or infant outcomes without causing any harm to mothers. The complete EvUp,including the full PICOST, can be found in Appendix B.

● Time frame: July 26, 2019, to July 10, 2024

Summary of Evidence

Forty-two eligible RCTs or quasi RCTs reported in 43 arti-cles since the last SysRev were identified.35-77 The studies each compared two or more methods of umbilical cord man-agement including ECC, DCC of various durations, I-UCM,C-UCM and PBCC. Twenty-four trials focused on infant hematologic outcomes,37-39,41-43,45,47-51,53-56,60,61,66,70,71,74,76,778 on various physiological measurements.35,40,46,57,69,72,753 on risk of postpartum hemorrhage,58,62,65 3 on jaundice,phototherapy59,64,68 and 3 on neurodevelopmental or brain-imaging outcomes.36,52,63 One trial assessed breastfeeding scores.44 Seven of the trials examined specific subgroups of infants, including those at risk of Rh hemolytic disease,66 infants of mothers with diabetes or large-for-gestational age infants,48,59,76 and infants who were small for gesta-tional age, had fetal growth restriction, or whose mothers had preeclampsia.35,39,65

Based on the amount of evidence, the task force will prioritize an updated SysRev.

Treatment Recommendation (2021)

For term and late preterm infants born at ≥34 weeks'gestation who are vigorous or deemed not to require immediate resuscitation at birth, we suggest later (de-ferred) clamping of the cord at ≥60 seconds (weak rec-ommendation, very low-certainty evidence).

Umbilical Cord Management at Birth for Preterm Infants(NLS 5051: SysRev 2023, EvUp 2025)

Umbilical cord management for preterm infants was ad-dressed by a 2021 SysRev,9,78 which was updated for the 2024 CoSTR summary7 by adolescence of a large,individual patient data pairwise meta-analysis79 and net-work meta-analysis80-the iCOMP(Cord Management of

Liley et al

Neonatal Life Support: CoSTR 2025

Preterm Birth) study. An EvUp was conducted for 2025.The complete EvUp, including the full PICOST, can be found in Appendix B.

● Study design: The iCOMP individual patient data meta-analysis and network meta-analysis included RCTs comparing umbilical cord management strat-egies for which individual patient data were avail-able but excluded trials with missing data, integrity issues, those not fitting intervention categories, and cluster- and quasi-randomized trials. ${ }^{81}$ The updated search included RCTs whether or not individual patient data were available.

● Time frame: June 6,2023,to June 6,2024

Summary of Evidence

The search found 8 eligible RCTs35,82-88 and 1 SysRev.89 Most of the clinical trials had insufficient sample size for critical and important outcomes, but overall, they support-ed the use of deferred cord clamping or umbilical cord milking compared with early cord clamping or immediate cord clamping, with no new adverse effects reported. The task force concluded that they would not change the cur-rent treatment recommendations or justify updating the SysRev at this time.

Treatment Recommendations (2024)

In preterm infants born at<37 weeks' gestation who are deemed not to require immediate resuscitation at birth, we recommend deferring clamping of the umbilical cord for at least 60 seconds (strong recommendation,moderate-certainty evidence).

In preterm infants born at 28+ 0 to 36+ 6 weeks'gestation who do not receive deferred cord clamp-ing, we suggest umbilical cord milking as a reasonable alternative to immediate cord clamping to improve infant hematologic outcomes. Individual maternal and infant circumstances should be taken into account (conditional recommendation, low-certainty evidence).

We suggest against intact cord milking for infants born at <28 weeks' gestation (weak recommendation,low-certainty evidence). There is insufficient evidence to make a recommendation regarding cut-cord milking in this gestational age group.

In preterm infants born at<37 weeks' gestation who are deemed to require immediate resuscitation at birth,there is insufficient evidence to make a recommendation with respect to cord management (weak recommenda-tion, low-certainty evidence).

There is insufficient evidence to make recommenda-tions on cord management for maternal, fetal, or placen-tal conditions that were considered exclusion criteria in many studies(monochorionic multiple fetuses, congeni-tal anomalies, placental abnormalities, alloimmunization,fetal anemia, fetal compromise, and maternal illness).In these situations, we suggest individualized decisions based on severity of the condition and assessment of

maternal and neonatal risk (weak recommendation, very low-certainty evidence).

Whenever circumstances allow, the plan for umbilical cord management should be discussed between mater-nity and neonatal providers and parents before delivery and should take into account individual maternal and infant circumstances (good practice statement).

INITIAL STEPS

Maintaining Normal Temperature Immediately After Birth in Term and Late Preterm Infants(NLS 5100: SysRev 2022, EvUp 2025)

A previous ILCOR SysRev reported a dose-responsive association between hypothermia and increased risk of mortality and other adverse outcomes, ${}^{2}$ and another SysRev found that hypothermia was very common in infants born in hospitals and homes, even in tropical environments. ${ }^{90}$ Hence, the effect of various interven-tions to maintain normal temperature immediately after birth on survival, on the response to resuscitation, and on temperature outcomes was addressed in a 2022 SysRev,91 details of which can be found in the 2022 CoSTR summary. ${ }^{8}$ An EvUp was conducted for 2025.The complete EvUp, including the full PICOST, can be found in Appendix B.

● Time frame: July 20,2022,to July 20,2024

Summary of Evidence

The update found 1 SysRev establishing a national guideline that had extensive overlap with the previous ILCOR SysRev,92 3 RCTs, 2 observational studies, and 1 quality improvement study. There was insufficient new evidence for most interventions to justify an updated SysRev. However, 1 cluster RCT comparing different am-bient temperatures in the operating room was thought to justify an updated SysRev for this specific intervention,which the task force will prioritize. ${ }^{93}$

Treatment Recommendations (2022)

In late preterm and term newborn infants (≥34 weeks'gestation), we suggest the use of room temperatures of 23 ${}^{\circ}C$ compared to 20 ${}^{\circ}C$ at birth in order to maintain normal temperature (weak recommendation, very low-certainty evidence).

In late preterm and term newborn infants (≥34 weeks'gestation) at low risk of needing resuscitation, we sug-gest the use of skin-to-skin care with a parent imme-diately after birth rather than no skin-to-skin care to maintain normal temperature (weak recommendation,very low-certainty evidence).

In some situations where skin-to-skin care is not pos-sible, it is reasonable to consider the use of a plastic bag or wrap, among other measures, to maintain normal

Liley et al

Neonatal Life Support: CoSTR 2025

temperature(weak recommendation, very low-certainty evidence).

In late preterm and term newborn infants $\geq$ 34 weeks'sgestation, for routine use of a plastic bag or wrap in addi-tion to skin-to-skin care immediately after birth compared with skin-to-skin care alone, the balance of desirable and undesirable effects was uncertain. Furthermore, the val-ues,preferences, and cost implications of the routine use of a plastic bag or wrap in addition to skin-to-skin care are not known; therefore, no treatment recommendation can be formulated.

Maintaining Normal Temperature Immediately After Birth in Preterm Infants(NLS 5101:SysRev 2023, EvUp 2025)

Recent observational studies94-97 confirm the associa-tion between hypothermia on admission to a neonatal unit and increased mortality and other adverse out-comes,$2$ and also suggest there is potential harm from hyperthermia on admission. Therefore, a SysRev on the effect of various methods for maintaining normal tem-perature immediately after birth on critical and import neonatal outcomes was conducted ${ }^{98}$ and included in the 2023 CoSTR summary. ${ }^{6}$ An EvUp was also conducted for 2025. The complete EvUp, including the full PICOST,can be found in Appendix B.

● Time frame: The literature search was updated from July 20,2022, to July 20,2024.

Summary of Evidence

One SysRev92 that addressed the PICOST had exten-sive overlap in included studies with the ILCOR Sys-Rev $^{98}$ and similar conclusions. In addition, 1 cluster RCT addressed ambient operating room temperature(24°C versus 20°C) at birth93 and 2 RCTs assessed aspects of plastic bag or wrap versus no plastic bag or wrap. ${}^{99,100}$ These studies do not warrant an updated SysRev.

Some additional studies provided evidence on admis-sion temperatures in relation to skin-to-skin care after delivery room resuscitation. ${ }^{101-104}$ These may justify a ScopRev or SysRev to consider the role of skin-to-skin care during transfer from delivery room to NICU after resuscitation.

Treatment Recommendations (2023)

In preterm infants(<34 weeks' gestation), as for late preterm and term infants(≥34 weeks' gestation), we suggest the use of room temperatures of≥23℃ com-pared with 20℃ at birth in order to maintain normal temperature(weak recommendation, very low-certainty evidence).

In preterm infants(<34 weeks' gestation) immediately after birth, where hypothermia on admission is identified as a problem, it is reasonable to consider the addition of

a thermal mattress, but there is a risk of hyperthermia(conditional recommendation, low-certainty evidence).

In preterm infants (<34 weeks' gestation) immedi-ately after birth, we recommend the use of a plastic bag or wrap to maintain normal temperature (strong recom-mendation, moderate-certainty evidence).

Temperature should be carefully monitored and man-aged to prevent hyperthermia (good practice statement).

In preterm infants (<34 weeks' gestation) immedi-ately after birth, we suggest the use of a head covering to maintain normal temperature (strong recommenda-tion, moderate-certainity evidence).

In preterm infants (<34 weeks' gestation) immedi-ately after birth, we suggest that heated and humidified gases for respiratory support in the delivery room can be used when an audit shows that admission hypothermia is a problem and resources allow(conditional recommen-dation, very low-certainty evidence).

In preterm infants (<34 weeks' gestation) immedi-ately after birth, there is insufficient published evidence to suggest for or against the use of a radiant warmer in servo-controlled mode compared with manual mode for maintaining normal temperature.

In preterm infants(<34 weeks' gestation), there is insufficient published evidence to suggest for or against the use of skin-to-skin care immediately after birth. Skin-to-skin care may be helpful for maintaining normal tem-perature when few other effective measures are available(good practice statement).

Suctioning of Clear Amniotic Fluid at Birth (NLS 5120: SysRev 2022, EvUp 2025)

Since 2010, ILCOR treatment recommendations and many guidelines have advised selective rather than routine oropharyngeal or nasopharyngeal upper airway suctioning, with use only if the airway appears obstruct-ed or when positive-pressure ventilation is required. ${}^{105}$ To update the assessment of evidence using Grading of Recommendations Assessment, Development, and Evaluation methods, the topic was prioritized for a Sys-Rev, ${}^{106}$ details of which can be found in the 2022 CoSTR summary. ${}^{8}$ An EvUp was conducted for 2025. The com-plete EvUp, including the full PICOST, can be found in Appendix B.

● Time frame: September 21,2021,to June 23,2024

Summary of Evidence

A new quality improvement study that focused on re-ducing unnecessary suctioning of clear amniotic fluid in the delivery room included 999 infants, of whom 12% received oropharyngeal suctioning in the first phase of the study and 4% in the second. ${ }^{107}$ The study found no disadvantages of the more selective suction-ing approach. An updated SysRev is not justified at this time.

Liley et al

Neonatal Life Support: CoSTR 2025

Treatment Recommendations (2022)

We suggest that suctioning of clear amniotic fluid from the nose and mouth should not be used as a routine step for newborn infants at birth (weak recommendation, very low-certainty evidence).

Airway positioning and suctioning should be consid-ered if airway obstruction is suspected (good practice statement).

Tracheal Intubation and Suctioning of Meconium-Stained Amniotic Fluid (NLS 5130:EvUp 2025)

ILCOR guidance has progressively changed for infants exposed to mesonium-stained amniotic fluid, from rec-ommending routine tracheal suctioning in all infants with depressed respirations and decreased muscle tone to prevent meconium aspiration syndrome and reduce risk of death, ${ }^{108}$ to concluding that there was insufficient evidence for this practice, ${ }^{4}$ to suggesting against it as a result of a 2020 ILCOR SysRev.8,109 An EvUp was con-ducted for 2025. The complete EvUp, including the full PICOST, can be found in Appendix B.

● Time frame: November 1,2018,to June 3,2024

Summary of Evidence

A meta-analysis of RCTs110 included the same studies as the previous ILCOR SysRev109 and supported its conclu-sions, as did a meta-analysis of observational studies.111 Eight single-center observational studies were identi-fied.112-119 All were retrospective or prospective with his-torical controls and were considered unlikely to change the existing treatment recommendation or to justify a new SysRev at this time.

Treatment Recommendations (2020)

For nonvigorous newborn infants delivered through meconium-stained amniotic fluid, we suggest against routine immediate direct laryngoscopy with or without tracheal suctioning when compared with immediate re-suscitation without direct laryngoscopy (weak recom-mendation, low-certainty evidence).

Meonium-stained amniotic fluid remains a signifi-cant risk factor for receiving advanced resuscitation in the delivery room. Rarely, an infant may require intuba-tion and tracheal sactioning to relieve airway obstruction(good practice statement).

Tactile Stimulation(NLS 5140: SysRev 2022,EvUp 2025)

Tactile stimulation as an initial step in resuscitation im-mediately after birth was included in ILCOR neonatal resuscitation treatment recommendations since 1999,largely based on expert opinion. $^{5,105,120,121}$ A SysRev ${}^{124}$

was conducted for 2022 examining whether-in infants with absent, intermittent, or shallow breathing immedi-ately after birth-tactile stimulation improved survival or other critical and important outcomes,including response to resuscitation. Details can be found in the 2022 CoSTR summary.8 An EvUp was conducted for 2025. The com-plete EvUp, including the full PICOST, can be found in Appendix B.

● Time frame: September 17,2021,to June 30,2024

Summary of Evidence

One narrative review ${ }^{125}$ and 4 observational stud-ies ${ }^{33,126-128}$ were identified. All the observational studies supported use of tactile stimulation to promote spon-taneous breathing, but none specifically addressed the PICOST. There is insufficient new evidence to justify up-dating the SysRev.

Treatment Recommendations (2022)

We suggest it is reasonable to apply tactile stimulation in addition to routine handling with measures to maintain temperature in newborn infants with absent, intermittent,or shallow respirations during resuscitation immediately after birth (weak recommendation, very low-certainty evidence).

Tactile stimulation should not delay the initiation of positive-pressure ventilation for newborn infants who continue to have absent, intermittent, or shallow respira-tions after birth (good practice statement).

ASSESSMENT OF HEART RATE AT BIRTH

Heart Rate Assessment Methods in the Delivery Room-Diagnostic Characteristics (NLS 5200:SysRev2023, EvUp 2025)

The diagnostic characteristics of methods to assess heart rate were addressed in a SysRev $^{129}$ that was included in the 2023 CoSTR summary. ${ }^{6}$ Note that the treatment recommendations for NLS 5200 are combined with and supersede those of NLS 5201. A companion review(NLS 5201) examined the effects of different methods of heart rate measurement on survival and other critical and important outcomes. ${ }^{130}$ For this review of diagnostic characteristics, heart rate measured by electrocardiog-raphy (ECG) was considered the gold standard against which the relative accuracy and precision of other meth-ods were assessed. The time to first heart rate assess-ment from the device placement and from birth was also compared. An EvUp was conducted for 2025. The com-plete EvUp, including the full PICOST, can be found in Appendix B.

● Time frame: August 16,2023, to June 30,2024

Summary of Evidence

No new studies were identified.

Liley et al

Neonatal Life Support: CoSTR 2025

Treatment Recommendations (2023)

Where accurate heart rate estimation is needed for a newborn infant immediately after birth and resources permit, we suggest that the use of ECG is reasonable(conditional recommendation, low-certainty evidence).

Pulse oximetry and auscultation may be reasonable alternatives to ECG for heart rate assessment, but the limitations of these modalities should be kept in mind(conditional recommendation, low-certainty evidence).

There is insufficient evidence to make a treatment recommendation regarding use of any other device for heart rate assessment of a newborn infant immediately after birth.

Auscultation with or without pulse oximetry should be used to confirm the heart rate when ECG is unavailable,not functioning, or when pulseless electrical activity is suspected (good practice statement).

Heart Rate Assessment Methods in the Delivery Room-Clinical Outcomes(NLS 5201: SysRev 2022, EvUp 2025)

Because heart rate is considered a critical indicator of both the need for and the response to resuscitation in newborn infants, fast and accurate measurement is de-sirable.129 However, heart rate should be considered in the context of other characteristics, such as tone and breathing effort, and with an awareness of the time it takes for the heart rate to improve after any interven-tion. Fixation on heart rate alone could lead to too many or too few resuscitation interventions. Because evalu-ation of test characteristics and the effects on clinical outcomes required different methods, clinical outcomes were addressed by a separate SysRev130 included in the 2022 CoSTR summary,8 and an EvUp was conducted for 2025. The complete EvUp, including the full PICOST, can be found in Appendix B.

● Time frame: August 16,2023, to June 30,2024

Summary of Evidence

One new retrospective observational study compared the frequency of resuscitation interventions before and after implementation of ECG in the delivery room and reported an initial increase in the use of chest compressions at birth and a decrease in frequency of tracheal intubation.These changes were reversed by a focused educational intervention highlighting the importance of achieving ef-fective ventilation. ${ }^{131}$ This study was not deemed to jus-tify a new SysRev.

Treatment Recommendations (2022, Superseded-See NLS 5200)

<BeginOfPara>Recommendations for NLS 5201 were superseded in 2023 by those for heart rate assessment methods-diagnostic characteristics(NLS 5200, see previous sec-tion), which reflect conclusions of both reviews.

VENTILATION AND OXYGENATION

Devices for Administering Positive-Pressure Ventilation (NLS 5300: SysRev 2021, EvUp 2025)

Establishing lung aeration and tidal ventilation is essential in newborn infants who remain apneic or are not breath-ing effectively. A 2021 ILCOR ScopRev identified possi-ble differences in the effectiveness and safety of T-piece resuscitators versus self-inflating bags for administering positive-pressure ventilation.132 A subsequent SysRev in the same year addressed this question.133 Details of this review can be found in the 2021 CoSTR summary.9 An EvUp was conducted for 2025. The complete EvUp, in-cluding the full PICOST, can be found in Appendix B.

● Time frame: December 30,2020,to July 1,2024

Summary of Evidence

Two new SysRevs were identified that included RCTs and cohort studies, most of which were already included in the 2021 ILCOR review, ${ }^{134,135}$ and which, in general,concurled with the previous ILCOR SysRev. ${ }^{133}$ Two addi-tional small RCTs ${ }^{136,137}$ provide insufficient new evidence to justify a new SysRev.

Treatment Recommendations (2021)

Where resources permit, we suggest the use of a T-piece resuscator over the use of a self-inflating bag in infants receiving positive-pressure ventilation at birth (weak rec-ommation, very low-certainty evidence).

However, a self-inflating bag should be available as a backup device for the T-piece resuscitator in case of gas-supply failure(technical remark).

There are no data to make a treatment recommenda-tion for use of a T-piece resuscitator compared with a flow-inflating bag.

There are no data to make a treatment recommen-dation for use of a flow-inflating bag compared with a self-inflating bag.

The confidence in effect estimates is so low that any recommendation for the use of self-inflating bags fitted with positive end-expiratory pressure valves compared to those without them would be speculative.

Continuous Positive Airway Pressure Versus Positive-Pressure Ventilation for Preterm Infants(NLS 5310: EvUp 2025)

Continuous positive airway pressure is a well-established method of respiratory support during NICU care for pre-term infants whose breathing is spontaneous but labored because of lung immaturity, or as part of treatment for apnea of prematurity. A 2015 SysRev2 addressed the use of continuous positive airway pressure compared with tracheal intubation and positive-pressure ventila-tion immediately after birth for mortality and critical and

Liley et al

Neonatal Life Support: CoSTR 2025

important neonatal morbidity outcomes. An EvUp was undertaken for the 2020 CoSTR ${ }^{5}$ and again in 2025.The complete EvUp, including the full PICOST, can be found in Appendix B.

● Time frame: November 1,2019, to September 30,2024

Summary of Evidence

No new studies were identified. A new SysRev conclud-ed that in spontaneously breathing, very preterm infants,nasal continuous positive airway pressure(within the first 15 minutes) compared with mechanical ventilation reduces the incidence of bronchopulmonary dysplasia,the combined outcome of death and bronchopulmonary dysplasia, and mechanical ventilation but does not affect neurodevelopmental impairment at 18 to 22 months of age.138 In the absence of new evidence, there is no justi-fication for an updated SysRev.

Treatment Recommendation (2015)

For spontaneously breathing preterm infants with re-spiratory distress requiring respiratory support in the delivery room, we suggest initial use of continuous posi-tive airway pressure rather than tracheal intubation and positive-pressure ventilation (weak recommendation,moderate-certainty evidence).

Continuous Positive Airway Pressure for Term and Late Preterm Infants With Respiratory Distress (NLS 5312: SysRev 2022, EvUp 2025)

Although it has become increasingly common to use continuous positive airway pressure for respiratory dis-tress immediately after birth in late preterm and term in-fants, the evidence for it is not as well established as for preterm infants. The effect of continuous positive airway pressure for late preterm and term infants with respira-tory distress on mortality, major neonatal morbidity, and response to resuscitation was addressed in a SysRev139 included in the 2022 CoSTR summary.8 An EvUp was conducted for 2025. The complete EvUp, including the full PICOST, can be found in Appendix B.

● Time frame: October 8,2021, to August 28,2024

Summary of Evidence

One new retrospective observational study compared outcomes before and after introduction of local guide-lines to avoid the use of continuous positive airway pressure in certain late preterm and term infants. It suggested no harm and a possible benefit from reduc-ing the use of continuous positive airway pressure for term and late preterm infants immediately after birth who have signs of respiratory distress(eg, grunting, re-tractions or tachypnea) but whose blood oxygen satu-rations are reaching target ranges. ${ }^{140}$ Given the limited new evidence, there is no justification for an updated SysRev.

Treatment Recommendation (2022)

For spontaneously breathing late preterm and term new-born infants in the delivery room with respiratory distress,there is insufficient evidence to suggest for or against routine use of continuous positive airway pressure com-pared with no continuous positive airway pressure.

Sustained Inflations During Newborn Resuscitation (NLS 5320: EvUp 2025)

Whether initial sustained inflations, with longer inspiratory times than those used for subsequent positive-pressure ventilation, improve critical or important outcomes from resuscitation of newborn infants was addressed with a SysRev included in the 2020 CoSTR. ${ }^{5,141}$ An EvUp was undertaken for 2025. The complete EvUp, including the full PICOST, can be found in Appendix B.

● Time frame: January 1,2020,to July 2,2024

Summary of Evidence

One RCT including 160 participants found no differ-ences in outcomes. ${ }^{142}$ The task force concluded that this single new study did not justify updating the SysRev at this time.

Treatment Recommendation (2020)

For preterm newborn infants who receive positive-pressure ventilation due to bradycardia or ineffective respirations at birth, we suggest against the routine use of initial sustained inflation(s)>5 seconds (weak recom-mendation, low-certainity evidence). A sustained inflation may be considered in research settings. ${ }^{5}$

For term or late preterm infants who receive positive pressure ventilation due to bradycardia or ineffective respirations at birth, it is not possible to recommend any specific duration for initial inflations due to the very low confidence in the estimates of effect.

Supraglottic Airway Device Versus Face Mask(NLS 5340: SysRev 2022, EvUp 2025)

Positive-pressure ventilation administered via a face mask may be ineffective because of mask leak or fail-ure to achieve airway patency. The effect of the use of supraglottic airway devices compared with face masks for administering positive-pressure ventilation on mortality, morbidity, and response to resuscitation was assessed by a SysRev $^{143}$ included in the 2022 CoSTR summary. ${ }^{8}$ An EvUp was conducted for 2025.The complete EvUp, including the full PICOST, can be found in Appendix B.

● Time frame: December 9,2021,to July 2,2024

Summary of Evidence

One new quasi-RCT (67 participants) was found, ${ }^{144}$which provided insufficient evidence to justify updating the SysRev at this time.

Liley et al

Neonatal Life Support: CoSTR 2025

Treatment Recommendation (2022)

Where resources and training permit, we sug-gest that a supraglottic airway device may be used in place of a face mask for newborn infants $\geq 34$ weeks' gestation receiving intermittent positive-pressure ventilation during resuscitation immediate-ly after birth (weak recommendation, low-certainty evidence).

Supraglottic Airway Device Versus Tracheal Tube (NLS 5341: EvUp 2025)

Tracheal intubation can be a lifesaving intervention during resuscitation of newborn infants, but it is a difficult, complex task. There are limited opportuni-ties and a lack of well-defined pathways for health care professionals to consolidate simulation-based training with guided clinical practice. ${}^{145}$ Supraglottic airway devices do not require laryngoscopy and are used in resuscitation in other age groups, albeit with low certainty of evidence. ${ }^{146,147}$ Until recently, devices small enough for infants <34 weeks' gestation were not available. The effect of the use of supraglottic air-way devices in newborns as an alternative to tracheal intubation on mortality, major morbidity, and response to resuscitation was last assessed by the NLS Task Force in 2015.2 An EvUp, was undertaken for 2025.The complete EvUp, including the full PICOST, can be found in Appendix B.

● Time frame: January 1,2014,to November 4,2024

Summary of Evidence

Two SysRevs, ${ }^{148,149}$ 3 new RCTs (2 of which were in-cluded in the SysRevs, together enrolling 223 partici-pants), ${ }^{150-152}$ and 1 observational study of 86 infants ${ }^{153}$ addressed the comparison for this PICOST.

The evidence was considered unlikely to change the current treatment recommendation but may jus-tify updating the SysRev to reevaluate the certainty of evidence. The terms laryngeal mask and low-quality evidence have been updated to reflect current termi-nology (supraglottic airway device and low-certainty evi-dence, respectively).

Treatment Recommendations (2015, Updated to Reflect Current Terminology)

We suggest using a supraglottic airway device as an al-ternative to tracheal intubation during resuscitation of the late preterm and term newborn (≥34 weeks) if face mask ventilation is unsuccessful (weak recommendation,low-certainty evidence).

A supraglottic airway device should be considered during newborn resuscitation if face mask ventilation is unsuccessful and tracheal intubation is unsuccessful or not feasible (good practice statement).

Use of a Supraglottic Airway Device During Chest Compressions (NLS 5342: ScopRev 2025)

Rationale for Review

Despite being one of the most common neonatal resus-citation interventions, positive-pressure ventilation via a face mask can be compromised by leaks around the mask or upper airway obstruction leading to inadequate tidal volume. ${ }^{143}$ Reduced tidal volume and minute volume with positive-pressure ventilation via a face mask during chest compressions have been reported. ${ }^{155}$ Because im-mediate availability of a clinician with skills to intubate the trachea cannot be assured in all locations where advanced resuscitation is needed, the task force prioritized a new ScopRev addressing whether a supraglottic airway de-vice would provide an effective alternative to face mask positive-pressure ventilation during chest compressions.The full review is available on the ILCOR CoSTR website. ${ }^{23}$

Population, Intervention, Comparator, Outcome, and Time Frame

● Population: Newborn infants of≥34 weeks' gesta-tion receiving chest compressions despite optimized positive-pressure ventilation

● Intervention: Positive-pressure ventilation with a supraglottic airway device

● Comparator: Positive-pressure ventilation with a face mask or traceal tube

• Outcome:

- Delivery room outcomes:

● Death in the delivery room (critical)

● Time to heart rate ≥60 beats per minute (bpm)and time to heart rate ≥100 bpm (important)

● Duration of advanced airway placement attempt and duration of interruption of CPR(important)

● Number of attempts to insert advanced airway(important)

● Epinephrine (adrenaline) administration(important)

● Team preference (important)

● Failure of primary device (important)

● Physiologic pulmonary outcomes (eg, tidal vol-ume, peak inspiratory pressure) (important)

- NICU outcomes:

● Survival to hospital discharge (critical)

● Incidence of hypoxic ischemic encephalopathy(critical)

● Air leak(eg, pneumothorax, pneumomediasti-num) during first 48 hours of life(important)

● Airway injury (important)

● Length of hospital stay (important)

—— Long-term outcomes:

● Neurodevelopmental impairment at $\geq 18$ months (critical)

● Time frame: All years to July 15, 2024

Liley et al

Neonatal Life Support: CoSTR 2025

Summary of Evidence

Neonatal or Infant Studies

No studies addressed the PICOST in human infants in the delivery room or during the neonatal period. Indirect evidence was available from 2 studies that addressed the use of supraglottic airway devices during chest compres-sions in newborn animals, ${}^{156,157}$ 2 in adult animals, ${}^{158,159}$ and 1 assessing resuscitor performance in a neonatal manikin study. ${}^{160}$

In lambs that were asphyxiated before the transi-tion from intrauterine to extraterine life, similar rates of return of spontaneous circulation(ROSC) were achieved within similar time frames with a supraglottic airway device and a tracheal tube. ${ }^{156}$ No differences in peak inspiratory pressure, positive end-expiratory pressure,tidal volume, or mean airway pressure were found, lead-ing the authors to conclude that use of the supraglottic airway device is noninferior to the use of a tracheal tube during chest compressions. In piglets asphyxiated after the transition to air breathing, similar tidal volumes and peak inspiratory pressures were achieved during venti-lation with a supraglottic airway device or tracheal tube during neonatal chest compressions. ${ }^{157}$

A crossover manikin study evaluating single-rescuer CPRD found that peak inspiratory pressures much closer to the pressure that was set for the T-piece resuscita-tor were achieved with the supraglottic airway compared with a face mask.160 The time taken to complete 30 compression-to-ventilation cycles was shorter with the supraglottic airway device than with a face mask (60.6 ±3.4 s versus 66.2 ±6.1 s; [mean ± SD] P<0.0001),which enabled better adherence to recommendations for completing 120 events in 60 seconds. ${ }^{161}$

Because of the paucity of human infant evidence, indi-rect evidence from other age groups was also evaluated.

Indirect Evidence From Studies in Children or Adolescents A registry study reported improved 30-day survival when sup alogrulitic airway device was used compared with a tracheal tube.162 Other pediatric studies have also re-ported worse outcomes with tracheal intubation during CPR.163,164

Indirect Evidence From Studies in Adults

A 2020 SysRev and network meta-analysis (of 11 stud-ies including 8 RCTs) compared effectiveness of different airway interventions for out-of-hospital cardiac arrest.165 The study reported increased ROSC with the use of a supraglottic airway device compared with a tracheal tube(odds ratio, 1.11; 95% CI, 1.03-1.20) or compared with bag-mask ventilation (odds ratio, 1.35; 95% CI, 1.11-1.63). No differences in survival or long-term neurological outcomes were found. A later SysRev and meta-analysis comparing the use of a supraglottic airway with tracheal intubation in adults with out-of-hospital cardiac arrest concluded that it took less time to place a supraglottic airway device (mean difference 2.5 min less; 95% CI,

1.6-3.4 min less; high certainty), and the use of a supra-glottic airway device likely led to more ROSC(relative risk,1.09;95% CI,1.02-1.15; moderate certainty).166

Epinephrine Administration During CPR

For the outcome of epinephrine administration, no stud-ies addressed whether epinephrine use was reduced by using a supraglottic airway device during chest compres-sions. For efficacy of epinephrine via supraglottic airway devices, 2 studies in adult pigs (not in cardiac arrest)concluded that epinephrine administration via a catheter passed through the supraglottic airway device had simi-lar effects to epinephrine administration via tracheal tube.But if administering epinephrine from the top of the su-praglottic airway devices, higher doses would be needed.

In the same model, 5 different routes and doses of epinephrine were compared.159 The authors again con-cluded that higher doses of epinephrine may be needed if administering the epinephrine at the top of the supra-glottic air device to produce an equivalent effect to epinephrine administered via tracheal tube.

Task Force Insights

The task force noted that the lack of studies in newborn in- fans but concluded that the few animal studies suggest that the use of a supraglottic airway device compared with a tracheal tube achieves similar rates of ROSC and that ventilation of the lungs is not compromised. The pediat-ric and adult(human) studies suggest benefits including reduced time to airway placement and increased rates of ROSC, without evidence of any adverse effects attribut-able to supraglottic airway devices. The animal studies of epinephrine administration suggest that doses given via a catheter down a supraglottic airway device may be as effective as administration via a tracheal tube. However,no human infant studies are available, and the task force noted that intravascular administration remains the pre-ferred route for epinephrine. 5,167 The task force concluded that there was insufficient evidence to justify a SysRev but that it was reasonable to generate a new good prac-tice statement based on the results of this ScopRev.

Treatment Recommendations (2025)

In newborn infants $\geq$ 34 weeks' gestation who are re-ceiving chest compressions despite optimized positive-pressure ventilation, if placement of a tracheal tube is not possible or is unsuccessful, ventilation via a supraglottic airway device during compressions is reasonable (good practice statement).

Exhaled CO, Monitoring to Guide Noninvasive Ventilation (NLS 5350: SysRev 2023, EvUp 2025)

The effectiveness of noninvasive positive-pressure ven-ilation can be difficult to judge objectively. There may be

Liley et al

Neonatal Life Support: CoSTR 2025

a delay in improvement in heart rate and blood oxygen saturation, even after positive-pressure ventilation is es-tablished. ${}^{168}$ Therefore, the effect of exhaled $CO_{2}$ moni-toring to guide noninvasive positive-pressure ventilation on survival, major morbidity, and response to resuscita-tion was addressed by a SysRev ${}^{169}$ included in the 2023 CoSTR summary. ${}^{6}$ An EvUp, was undertaken for 2025.The complete EvUp, including the full PICOST, can be found in Appendix B.

● Time frame: August 1,2022, to July 3,2024

Summary of Evidence

One small pilot RCT addressed the PICOST, providing insufficient evidence to justify updating the SysRev.

Treatment Recommendation (2023)

There is insufficient evidence to suggest for or against the use of exhaled $CO_{2}$ to guide noninvasive intermit-tent positive-pressure ventilation using interfaces, such as face masks, supraglottic airways, and nasal cannulas in infants immediately after birth.

Video Versus Traditional Laryngoscope(NLS 5351: SysRev 2025)

Rationale for Review

Aspects of neonatal anatomy(including the small mouth and airway, the large tongue, epiglottis, and arytenoids, and appearance of the glottis) make tracheal intubation diffi-cult, especially in preterm infants. Delivery room intubation for resuscitation is a time-critical procedure with a relatively low first-attempt success rate.170 Video laryngoscopes pro-vide indirect visualization of the glottis using a screen that(depending on the device) may also be visible to an instruc-tor or assistant. Some video laryngoscopes also may be used for direct visualization. In contrast, traditional laryngo-scopes enable only a direct view, which may be impeded by airway anatomy. Performance of and training in neonatal intubation may be improved by using video laryngoscopes instead of traditional laryngoscopes.145,171 Therefore, the NLS Task Force prioritized a SysRev,172 of which full details are available on the CoSTR website.23 The protocol was registered on PROSPERO CRD42023467940.

● Population: Infants receiving tracheal intubation at birth or on a neonatal unit

$\begin{array}{l}\text{ Intervention:}\quad\text{ Tracheal intubation}\quad\text{ using}\quad\text{ video}\\ \text{ laryngoscopy}\end{array}$ laryngoscopy

● Comparator: Tracheal intubation using traditional laryngoscopy

• Outcome:

- Mortality in-hospital(critical)

- Successful tracheal intubation(important)

- Successful tracheal intubation at the first attempt(important)

- Number of attempts to achieve successful tra-cheal intubation(important)

- Time taken to successfully intubate(important)

- Adverse events around the time of laryngoscopy,eg, airway trauma, bradycardia, desaturation,esophageal intubation, pneumothorax(important)

- Perception of intubating clinician, eg, intubation difficulty(as defined by the author)(important)

- Any intraventricular hemorrhage(IVH)(preterm only)(important)

● Time frame: All years to August 22, 2024

Consensus on Science

The SysRev identified 6 RCTs including 817 infants and 862 tracheal intubations,$^{173-178}$ as well as 4 observational studies involving 3289 infants who received 3342 tra-chal intubations.$^{175-177,179}$ The evidence was considered indirect because approximately 80% of the infants were intubated in the NICU, not the delivery room. Outcomes were described by intubation, not by infant.

Key results from RCTs are summarized in Table 3. The full online CoSTR can be found on the ILCOR website. ${}^{23}$

For the number of attempts to intubate and time to successful intubation, meta-analysis was not performed because of heterogeneity in how these results were reported. For other critical and important outcomes for which data were available, clinical benefit or harm could not be excluded.

Treatment Recommendations

Where resources and training allow, in infants being intu-bated at birth or on a neonatal unit, we suggest the use of video laryngoscopy in comparison to traditional laryn-goscopy, especially in settings where less-experienced clinicians are intubating(conditional recommendation,moderate-certainty evidence).

Table 3. Video Laryngoscopy Compared With Traditional Laryngoscopy for Tracheal Intubation at Birth or in a Neonatal Unit: RCTs

|Outcomes (importance*)|Intubations,n (studies)|Certainty of evidence, GRADE|Relative effect (95% CI)|Anticipated absolute effect(95% CI)|| |---|---|---|---|---|---| |Outcomes (importance*)|Intubations,n (studies)|Certainty of evidence, GRADE|Relative effect (95% CI)|Risk with traditional laryngoscopy|Risk difference with video laryngoscopy| |Successful intubation- overall(%)(important)|567 (4 RCTs)173-175,178|Moderate|RR 1.43 (1.15-1.7)|513/1000|220 more intubations per 1000 (77 more to 395 more)| |Successful intubation-first attempt(%)(important)|610 (4 RCTs)175-178|High|RR 1.57 (1.33-1.85)|394/1000|225 more intubations per 1000 (130 more to 335 more)|

*Outcome importance according to task force consensus.

GRADE indicates Grading of Recommendations Assessment, Development, and Evaluation; RCT, randomized controlled trial; and RR; relative risk.

Liley et al

Neonatal Life Support: CoSTR 2025

Traditional laryngoscopy remains a reasonable option,as no increased harm was shown compared with video laryngoscopy (weak recommendation, very low-certainty evidence).

A traditional laryngoscope should always be available as a backup device (good practice statement).

Justification and Evidence-to-Decision Framework Highlights

The complete evidence-to-decision table is provided in Appendix A.

The task force noted the moderate-certainty evi-dence for successful intubation overall and high-cer-tainty evidence for first attempts. Although the RCT evidence was used to formulate the treatment recom-mendations, the observational studies were broadly consistent. For adverse effects, from RCTs, there were either no data or clinical benefit or harm could not be excluded(low- to very low-certainty evidence).Of note, for the critical outcomes of mortality and IVH, the combined sample size was well below the optimal information size to detect clinical benefit or harm. The RCTs mainly included infants without airway anomalies,and they were intubated by trainees or other relatively inexperienced clinicians. In previous studies, success rates using traditional laryngoscopes were proportional to experience.180-183 So, for clinicians who are already very experienced, benefits may be smaller. The cost of video laryngoscopes is higher than for traditional laryn-goscopes(although no studies have assessed cost-effectiveness), and they are unlikely to be available in all locations where infants needing resuscitation are born.Therefore, there is a potential to decrease health equity.

Knowledge Gaps

● Efficacy,effectiveness, and safety of video laryn-goscopy compared with traditional laryngoscopy in different gestational ages, in emergency intu-bation(including for infants immediately after birth), and in the delivery room compared with other settings

● The usability, feasibility, comparative effectiveness,and cost-effectiveness of different types of video laryngoscopes

● Effect of video laryngoscopy in those who are already experienced in intubation, compared with the effect in less-experienced practitioners and in training settings

Respiratory Function Monitoring During Resuscitation at Birth (NLS 5360: SysRev 2022,EvUp 2025)

<BeginOfPara>Respiratory function monitors have the potential to help resuscitation teams to recognize problems that cause

insufficient or excessive tidal volumes during resuscita-tion, such as airway obstruction or ventilation pressures that are too high or too low for the respiratory mechan-ics of the infant's lungs. Therefore, the effect of the use of respiratory function monitors during neonatal resus-citation on mortality, neonatal morbidity, and response to resuscitation was addressed by a SysRev ${ }^{184}$ included in the 2022 CoSTR summary. ${ }^{8}$ An EvUp was conducted for 2025.The complete EvUp, including the full PICOST,can be found in Appendix B.

● Time frame: December 31,2021,to September 30,2024

Summary of Evidence

No new studies were found to alter the current treat-ment recommendation or to justify a new SysRev. The task force is currently undertaking a SysRev of the use of respiratory function monitors during simulation-based training.

Treatment Recommendation (2022)

There is insufficient evidence to make a recommenda-tion for or against the use of a respiratory function moni-tor in newborn infants receiving respiratory support at birth (low-certainty evidence).

Near-Infrared Spectroscopy During Positive-Pressure Ventilation (NLS 5362: SysRev 2025)

Rationale for Review

Oxygenation is a determinant of morbidity and mortality in preterm infants. Evidence suggests that even when preterm infants reach early peripheral oxygen satura-tion targets, cerebral regional oxygen saturation (crSo$_{2}$ )measured with near-infrared spectroscopy may remain low. A low crSo$_{2}$ may be a risk factor for IVH. ${ }^{185}$ Re-cent studies have addressed whether the use of near-infrared spectroscopy accompanied by a treatment guideline that suggests adjustments to inspired oxy-gen or positive-pressure ventilation for out-of-range crSo$_{2}$ values, compared with standard care, improves outcomes for infants receiving positive-pressure ven-tilation for resuscitation in the delivery room. This SysRev ${ }^{186}$ was registered on PROSPERO 2024 CRD42024511496. The full online CoSTR can be found on the ILCOR website. ${ }^{10}$

Population, Intervention, Comparator, Outcome, and Time Frame

● Population: Newborn infants receiving continuous positive airway pressure, positive-pressure ventila-tion, or both (any interface) during stabilization or resuscitation at birth

Liley et al

Neonatal Life Support: CoSTR 2025

● Intervention: Delivery room monitoring of $crS_{o 2}$ with a dedicated treatment guideline in addition to clini-cal assessment, pulse oximetry, or ECG

● Comparator: Clinical assessment, pulse oximetry, or ECG only

• Outcome:

- Survival without neurodevelopmental impairment(critical)

- Survival(critical)

- Neurodevelopmental impairment(critical)

- Response to resuscitation(important): crSo_{2} <10th or>90th centile, maximum fraction of inspired oxygen(Fio_{2}) used, total oxygen exposure

- Morbidity outcomes in infants<34 weeks(criti-cal): Severe IVH(Papile grade III or IV),187 peri-ventricular leukomalacia

● Time frame: All years to November 5,2024

- Potential subgroups were defined a priori: meth-ods of near-infrared spectroscopy(including brand, manufacturer); continuous positive air-way pressure versus positive-pressure ventila-tion; cord management strategy, ie, immediate or deferred cord clamping or cord milking; sex, ges-tation at birth:<28 weeks; 28 to 33 weeks; and≥34 weeks' gestation.

Consensus on Science

Two RCTs ${}^{188,189}$ reporting outcomes for a total of 667 in-fants were included, and additional follow-up data were available for one. ${ }^{190}$ The studies examined a similar inter-vention, but there were some differences in which out-comes were reported. Key results from included RCTs are summarized in Table 4. Additional details can be found on the ILCOR website. ${ }^{23}$

For all other critical and important outcomes, there were either no data or clinical benefit or harm could not be excluded. For the preplanned subgroup analysis by gestation, there were no significant differences in effect size by gestation groups<28 weeks versus 28+

0 to 32+ 6 weeks gestation for the outcomes of sur-vival, severe IVH, or periventricular leukomalacia. There were insufficient data for other preplanned subgroup analyses.

Treatment Recommendation(2025)

In newborn infants receiving continuous positive airway pressure or positive-pressure ventilation immediately af-ter birth, there is insufficient evidence to recommend for or against use of delivery room monitoring of regional cerebral oxygen saturation with a dedicated treatment guideline in addition to(and compared with) clinical as-sessment and pulse oximetry with or without ECG(very low-certainty evidence).

Justification and Evidence-to-Decision Framework Highlights

The complete evidence-to-decision table is provided in Appendix A.

Concerns about clinical effectiveness, resources,equity, acceptability, and feasibility led the task force to conclude that in the absence of evidence of benefit or harm, delivery room monitoring of $crSO_{2}$ with a dedicated treatment guideline should only be considered where resources permit and ideally in the context of a research trial to close knowledge gaps.

Knowledge Gaps

● The effectiveness of interventions in response to out-of-range $crS_{o_{2}}$ values

● Prioritized research that includes human factors,opportunities to reduce inequity, and cost-benefit analysis

● The training requirements needed to achieve and maintain competency in interpretation of and response to monitoring of $crSo_{2}$ during neonatal resuscitation

● Cost-benefit analysis of monitoring of $crSo_{2}$ , taking into account both critical short-term outcomes and also long-term neurodevelopmental disability

Table 4. Comparison of the Use of Near Infrared Spectroscopy With a Dedicated Treatment Guideline Versus Standard Care During PPV in the Delivery Room: RCTs

|Outcomes (importance*)|Participants, n (studies) follow-up|Certainty of evidence, GRADE|Relative effect (95% CI)|Anticipated absolute effect (95% CI)|| |---|---|---|---|---|---| |Outcomes (importance*)|Participants, n (studies) follow-up|Certainty of evidence, GRADE|Relative effect (95% CI)|Risk with clinical assessment|Risk difference with NIRS plus a dedicated treatment guideline| |Survival (critical)|667 (2 RCTs)188,189|Low|RR 1.02 (0.99-1.05)|946/1000|19 more infants per 1000 (9 fewer to 47 more)| |In infants <34 wk-seiventricular (critical)|667 (2 RCTs)188,189|Very low|RR 0.76 (0.3-1.54)|51/1000|12 fewer infants per 1000 (32 fewer to 28 more)| |In infants <34 wk-quentricular (critical)|667 (2 RCTs)188,189|Very low|RR 1.93 (0.66-5.70)|15/1000|14 more infants per 1000 (5 fewer to 71 more)| |Regional cerebral tissue oxygenation (crSo2<10th centile)(important)|60 (1 RCT)188|Very low|RR 1.00 (0.78-1.29)|800/1000|0 fewer infants per 1000 (176 fewer to 232 more)|

*Outcome importance according to Strand et al12' or task force consensus.

crSo,indicates cerebral regional oxygen saturation; GRADE, Grading of Recommendations Assessment, Development, and Evaluation; IVH, intraventricular hemor-rhage; NIRS, near-infrared spectroscopy; PPV, positive-pressure ventilation; RCT, randomized controlled trial; and RR, relative risk.

Liley et al

Neonatal Life Support: CoSTR 2025

Oxygen Concentration for Initiating Resuscitation in Preterm Infants (NLS 5400: SysRev 2025)

Rationale for Review

A 2019 ILCOR SysRev reviewed 10 RCTs and 4 cohort studies including 5697 participants and con-cluded that there were no clear benefits or harms from starting with lower compared with higher Fio2 for short-term mortality, long-term mortality, neurodevel-opmental impairment, or key preterm morbidities.191 As a result of these findings, the task force suggested starting with a lower oxygen concentration(Fio2,0.21-0.30) compared with a higher concentration (0.60-1.00) for preterm infants <35 weeks' gestation, with subsequent titration of oxygen concentration using pulse oximetry.192

Recently, an individual patient data network meta-analysis (NetMotion)193 obtained individual patient data for 1055 infants included in 8194-201 of the 12 RCTs included in the previous ILCOR SysRev191 and 4 addi-tional trials.202-205 The authors concluded that "high initial F102(≥0.90) may be associated with reduced mortality in preterm infants born at <32 weeks' gestation com-pared to low initial F102(low certainty). High initial F102 is possibly associated with reduced mortality compared to intermediate initial F102(very low certainty), but more evidence is required."

Given the discordance between the conclusions of these 2 SysRevs, the task force concluded that an updated ILCOR SysRev was required to consider the fol-lowing:

● Evidence from study-level meta-analysis of eligible RCTs, including those in the previous SysRev191 plus any published since the last search date

● Evidence from large observational studies judged to provide similar or higher certainty of evidence to the RCTs

● Results of the NetMotion individual patient data network meta-analysis,193 by adoptiond. Key results from NetMotion and of the study-level meta-analysis of RCTs are described in text. The full online CoSTR can be found on the ILCOR web-site.23 The review was registered on PROSPERO(CRD42024589330).

Population, Intervention, Comparator, Outcome,Study Design, and Time Frame

● Population: Newborn infants<35 weeks' estimated gestational age who receive respiratory support at delivery

● Intervention: Lower initial oxygen concentration$$(F_{02}\leqslant 0.5)$$

● Comparator: Higher initial oxygen concentration(Fio2 >0.5)

· Outcome:

-All-cause mortality in-hospital or by 28 days(critical)

-All-cause mortality before 1 to 3 years (critical)

- Neurodevelopmental impairment at 1 to 3 years of age(critical)

- Major IVH(grade III or IV)187 (critical)

- Retinopathy of prematurity (important)

- Necrotizing enterocolitis(Bell's stage II or III206)(important)

- Bronchopulmonary dysplasia (chronic neonatal lung disease) (important)

- Number with heart rate>100 bpm at 5 minutes;time from birth to peripheral oxygen saturation≥80%(important)

- Advanced resuscitation(chest compressions with or without epinephrine[adrenaline])(important)

● Study design: In addition to standard criteria, individ-ual patient data SysRevs were eligible for inclusion.

● Time frame: August 10, 2018, to August 7,2024. Articles included in the previous review were assumed to be eligible for inclusion meta-analyses.191

A priori subgroups included those based on gestational age, level of initial supplemental oxygen delivered, wheth-er there was oxygen saturation targeting, and method of umbilical cord management as well as sensitivity analysis by high versus low risk of bias.

Consensus on Science

The NetMotion individual patient data network meta-analysis193 evaluated 1055 infants from 12 of 13 eligible studies198-203,205,207-210 and was deemed suitable for ado-lopment by using the AMSTAR2 checklist211 It included only infants<32 weeks' gestation, whereas the ILCOR PICOST and the previous SysRev includes infants<35 weeks' gestation. NetMotion used individual patient data,which enabled adjustment for various important modifi-ers such as gestation at birth and birthweight,212 so it should provide greater precision of estimates than the study-level meta-analysis.

The study-level meta-analysis(new search plus stud-ies included in the previous SysRev191) identified 18 articles,127,194-202,204,205,207,208,210,213-215 reporting results from 14 RCTs. There were also 4 observational stud-ies209,216-218(all included in the previous SysRev) that included 4437 infants.

The updated study-level meta-analysis included 3 RCTs published after the previous ILCOR SysRev191(all included in NetMotion193) and 1 additional cluster-RCT214(excluded from NetMotion).The study-level meta-analysis,therefore, included 128 infants (compared with the 1007 included in the previous ILCOR meta-analysis).219 It was thought unlikely that any differences in the results

Liley et al

Neonatal Life Support: CoSTR 2025

of the NetMotion and the task force study-level meta-analyses are accounted for by study exclusions.

Results of the Individual Patient Network Meta-Analysis

The NetMotion study compared low(≤0.3), intermedi-ate(0.5-0.65) and high(≥0.9) initial Fio2, For the critical outcome of mortality, there was low certainty evidence from 8 RCTs197,199-203,206 enrolling 833 infants of lower mortality with high initial Fio2 compared with low ini-tial Fio2(aOR, 0.45; 95% CI, 0.23-0.86). The adjusted absolute risk difference was that 67 more infants per 1000 survived with high initial Fio2(95% CI), 15 more to 100 more infants survived, NNTB 16 infants(95% CI,10-66). There was very low certainty evidence from 4 RCTs206,2072,21023 enrolling 652 infants that could not ex-clude benefit or harm with intermediate initial Fio2, com-pared with low initial Fio2(aOR for mortality, 1.33; 95%CI, 0.54-3.15). There was very low certainty evidence from an indirect comparison of 519 infants of lower mor-tality with high initial Fio2 compared with intermediate ini-tial Fio2(aOR, 0.34; 95% CI, 0.11-0.99). The prediction intervals crossed the line of no effect for both the high compared with low and high compared with intermediate initial Fio2 comparisons. Prediction intervals describe the range within which the results of future studies would be expected to lie. This was interpreted by the authors as evidence of inconsistency and reduced the certainty of evidence for these comparisons.193

For the critical outcomes of severe IVH and the impor-tant outcomes of chronic neonatal lung disease and reti-nopathy of prematurity, clinical benefit or harm could not be excluded for the comparison between high (>0.90)and low (<0.30) Flio.2. In each case, the evidence was of very low certainty. For these outcomes, the comparisons between high (>0.90) and intermediate (0.50-0.65) Fio.2 are even more imprecise because fewer infants were included. Numeric results are therefore not presented.193

For subgroup analyses, the NetMotion authors reported that "there was no evidence of differential effects of treatment across gestational ages or accord-ing to infant sex (post hoc, primary outcome only) when examining treatment-covariate interactions" and that there was limited statistical power to detect such inter-actions. ${ }^{193}$ The authors also reported that there were too few participants from low-or-middle income countries to perform prespecified subgroup analysis according to country income classification, and they considered that oxygen concentration titration strategies were too heter-ogenous to explore faster versus slower titration. ${ }^{193}$

Other critical and important outcomes of the PICOST were not reported.

From the Study-Level Meta-Analysis

Clinical benefit or harm could not be excluded for the comparison of lower initial oxygen concentration(Fio2>0.5)for any of the following critical or important outcomes:

all-cause mortality(in-hospital or by 28 days),$194,196-$202,204,205,207,210,213,214\quad long-term all-cause mortality,$195,215$neurodevelopmental impairment(at 1-3 years),$195,215$major IVH(grade III or IV),195-198,200-202,204,205,213,214$reinopathy of prematurity,$195-198,200,204,205,213,214$ necrotiz-ing enterocolitis,$195-198,200,204,205,213,214$ bronchopulmonary dysplasia,195-198,200,204,205,213,214 or advanced resuscitation.$96,198,199,201,204,205,208$ All comparisons yielded evidence of very low certainty, and tests for subgroup differences were not significant for any comparison.

Observational Studies

There were no new observational studies found for inclu-sion in this updated review; hence, the evidence is the same as that from the previous ILCOR SysRev, which included 4 observational studies. For long-term mortal-ity, 2 observational cohort studies included 1225 preterm newborns who received respiratory support at birth and found a possible benefit of starting with lower compared with higher Fio,(relative risk, 0.77; 95% CI, 0.59-0.99;I2,6%; very low-certainty evidence).191 For the outcome of neurodevelopmental impairment, 2 studies including 930 infants could not exclude benefit or harm from start-ing with lower compared with higher Fio2(relative risk,0.89; 95% CI, 0.66-1.20; I2, 59%; very low-certainty evidence).191

Prior Treatment Recommendation (2018)

For preterm newborn infants (<35 weeks' gestation)who receive respiratory support at birth with subsequent titration of oxygen concentration using pulse oximetry,we suggest starting with a lower oxygen concentration(21%-30%) rather than higher oxygen concentration(60%-100%)(weak recommendation, very low-cer-tainty evidence).

Treatment Recommendations (2025)

Among newborn infants<32 weeks' gestation, it is rea-sonable to begin resuscitation with≥30% oxygen(weak recommendation, low-certainty evidence).

For infants born at 32 to 34+ 6 weeks' gestation,there is insufficient evidence to make a recommendation.

Justification and Evidence-to-Decision Framework Highlights

The complete evidence-to-decision table is provided in Appendix A. Evidence from NetMotion, which was includ-ed by adoption, suggested benefit from higher con-centrations of oxygen and that a high Fio ${ }_{2}$ (0.90-1.00)may result in the lowest mortality. ${ }^{193}$ However, the task force concluded that the overall certainty of evidence was very low, mainly because of concerns that the total sample for each comparison was substantially below the optimal information size for all outcomes. The updated study-level meta-analysis found that benefit or harm could not be excluded for any outcome for lower versus

Liley et al

Neonatal Life Support: CoSTR 2025

higher concentrations of oxygen for commencing resus-citation, with low to very low certainty of evidence for all outcomes.

There are still concerns about unmeasured adverse effects of hyperoxia and hypoxia. As a result, 2 pend-ing multicenter trials are using Fio, of 0.30 versus 0.60 for their treatment arms (clinical trial registration ACTRN12618000879268 and NCT03825835220).

Whichever initial oxygen concentration was used, oxy-gen saturation monitoring and individualized adjustments of inspired oxygen concentration were used in most of the clin-ical trials and are likely to be needed to optimize outcomes.

Knowledge Gaps

● Comparison of oxygen saturation target levels and strategies to achieve them by adjusting inspired oxygen concentrations or other aspects of respira-tory support in the first 10 to 20 minutes after birth in preterm infants

● Optimal oxygen concentration for commencing resuscitation in preterm newborn infants

● The performance of resuscitation teams (eg, in titrating oxygen concentration and other resuscita-tion interventions to the infant's response) in the setting of various initial oxygen concentrations

● Effect of initial oxygen concentrations and titra-tion targets and strategies on biomarkers of both hypoxic and hyperoxic injury to organs including the brain, lungs, and retinas

The task force concluded that the uncertainty over the optimal initial oxygen concentration means that it is rea-sonable to study a full range of oxygen concentrations(21%-100%) within a research protocol.

Oxygen Concentration for Initiating

Resuscitation in Late Preterm and Term Infants(NLS 5401: EvUp 2025)

The oxygen concentration for commencing resuscitation in late preterm and term infants was reviewed in 2010 and 2019.105,192,219 Both reviews concluded that there was improvement in survival and other outcomes from commencing resuscitation with Fio, 0.21 compared with Fio, 1.0. An EvUp was conducted for 2025. The com-plete EvUp, including the full PICOST, can be found in Appendix B.

● Time frame: July 1,2018, to August 7,2024

<BeginOfPara>A priori subgroup analyses: gestational age(≥35 weeks,≥37 weeks); grouped lower and higher oxygen concentrations; explicit oxygen saturation targeting sus-sus no oxygen saturation targeting

Summary of Evidence

<BeginOfPara>One retrospective observational study that included 68 infants with congenithent diaphragmatic hernaria,

<EndOfPara>who were resuscitated with an initial $FIO_{2}$ of 0.5 and compared with historical controls who received $FIO_{2}$ 1.0, reported similar outcomes for both groups. ${ }^{221}$ Although the limited new evidence is insufficient to justify an updated SysRev, the task force will priori-tize updating the SysRev. We have concerns that the certainty of evidence would now be judged insuffi-cient to make the previous strong recommendation against commencing resuscitation for term and late preterm infants with 100\% oxygen. ${ }^{192}$ We, therefore,withdraw this recommendation in the interim. The task force strongly encourages additional research on this important topic.

Treatment Recommendation (2019)

For newborn infants at $\geq 35$ weeks' gestation receiving respiratory support at birth, we suggest starting with 21\% oxygen (weak recommendation, low-certainty evi-dence).

CIRCULATORY SUPPORT

Chest Compressions in Newborn Infants(NLS 5500-5507: ScopRev 2023, EvUp 2025)

Chest compressions are used in only a few newborn in-fants in every thousand but can be lifesaving for infants who are asystolic or severely bradycardic and who are not responding to effective positive-pressure ventila-tion. Various aspects of chest compressions for new-born infants were addressed in 2023 using ScopRev methods because prior surveillance of the literature in-ated that there was very little available human infant evidence; hence, a broad search would be needed to evaluate indirect evidence. ${}^{222}$ Details of this review can be found in the 2023 B CoSTR summary. ${}^{6}$ An EvUp was conducted for 2025. The results are summarized here by individual PICO questions. The complete EvUp, in-cluding the full PICOST, for each of the questions can be found in Appendix B.

Heart Rate for Commencing Chest Compressions (NLS 5500: ScopRev 2023, EvUp 2025)

This question addresses neonates who are being resus-citated who have a slow heart rate and compares the ef-fect of starting chest compressions when the heart rate is $<60 bpm$ with any other heart rate on survival, neuro-prologic outcomes, and ROSC.

● Time frame: November 22,2021,to June 16,2024

Summary of Evidence

No further studies addressing this PlCOST were iden-tified in the EvUp. The task force considered that (de-spite the lack of evidence for any specific threshold),given the need to provide resuscitation teams with a

Liley et al

Neonatal Life Support: CoSTR 2025

standardized approach to clinical practice, formulation of a good practice statement was justified. This new good practice statement replaces the commentary pro-vided in lieu of a treatment recommendation after the 2023 ScopRev.

Prior Treatment Recommendation (2023)

ILCOR has not developed an evidence-based treatment recommendation on heart rate threshold to initiate chest compressions previously. However, ILCOR guidance since 1999 has been to initiate chest compressions if the heart rate is <60 bpm despite adequate assisted ventilation for 60 seconds.

Treatment Recommendation (2025)

In neonates being resuscitated who have a slow heart rate even after optimizing ventilation, initiating cardiac compressions when the heart rate is $<60$bpm is reason-able (good practice statement).

Chest Compressions With 2 Thumbs Versus Other Techniques (NLS 5501: ScopRev 2023, EvUp 2025)

This question compares the effect of using 2 thumbs with hands encircling the chest with using any other method on survival, neurologic outcomes, and ROSC.

● Time frame: November 22,2021,to June 16,2024

Summary of Evidence

Ten simulation studies, ${ }^{223-230} 1$ RCT in piglets, ${ }^{231}$ and 1 prospective observational study in children in cardiac ar-rest, of whom 16 were < 1 year of age ${ }^{232}$ overall, sup-ported the findings of the ScopRev. This ScopRev found that the 2-thumb technique resulted in greater chest compression depth, less fatigue, and higher proportion of correct hand placement compared with the 2-finger technique. ${ }^{222}$ The new studies identified in the 2025 EvUp do not provide sufficient evidence to justify a new SysRev.

Treatment Recommendation (2015)

<BeginOfPara>We suggest that chest compressions in newborn in-fants immediately after birth should be delivered by the 2-thumb, hands-encircling-the-chest method as the pre-ferred option(weak recommendation, very low-certainty evidence).

Supplemental Oxygen During Chest Compressions (NLS 5503: ScopRev 2023, EvUp 2025)

This question compares the effect of using an Fio2 of 1.0 once chest compressions have been commenced with using any lower oxygen concentration on survival, neuro-logic outcomes, and ROSC.

● Time frame: November 22,2021,to June 16,2024

Summary of Evidence

Two animal studies compared $F_{\text{fO} 2}$ 0.21 with $F_{\text{fO} 2}$ 1.0 during chest compression after asphyxial cardiac ar-rest. ${ }^{233,234}$ One was in older piglets ${ }^{233}$ rather than in neo-natal animals. The new evidence does not justify a new SysRev.

Treatment Recommendation (2015 Updated to Reflect Current Terminology)

By the time resuscitation of a newborn infant has reached the stage of chest compressions, the steps of trying to achieve ROSC using effective ventila-tion should have been completed. It is reasonable to increase the supplementary oxygen concentration(good practice statement). Once the heart rate has recovered, supplementary oxygen should be titrated to oxygen saturation targets(good practice state-ment).

Compression-to-Ventilation Ratio(NLS 5504:ScopRev 2023, EvUp 2025)

This question compares the effect of using a compression-to-ventilation ratio of 3:1 with using any other ratio,including chest compressions during sustained lung in-flation, on survival, neurologic outcomes, ROSC hemody-namic measures, and compressor fatigue.

● Time frame: November 22,2021,to June 16,2024

Summary of Evidence

The updated EvUp search identified 1 clinical and 7 ani- mal studies comparing various ratios. The new evidence does not justify a new SysRev at this time.

Treatment Recommendation (2015, Updated in 2023 CoSTR summary)

We suggest continued use of a 3:1 compression-to-ventilation ratio for CPR in newborn infants immediately after birth (weak recommendation, very low-certainty evidence).

Use of Feedback CPR Devices for Neonatal Cardiac Arrest (NLS 5505: ScopRev 2023, EvUp 2025)

This question compares the effect of using any type of feedback device, including end-tidal $CO_{2}$ monitoring,pulse oximeters, or automated compression feedback devices on survival, neurologic outcomes, ROSC and hands-off time, and measures of perfusion.

● Time frame: November 22,2021,to June 16,2024

Summary of Evidence

Three studies in animals ${ }^{236,237}$ assessed the use of chest compression feedback devices in-cluding a chest compression machine, ${ }^{235}$ real-time vi-sual feedback, ${ }^{237}$ and a new smart ring-based chest

Liley et al

Neonatal Life Support: CoSTR 2025

compression-depth feedback device.236 While each sug-gested potential benefits, no studies assessed improve-ments in resuscitation practice or outcomes in human infants. The studies do not justify a new SysRev.

Treatment Recommendation (2023)

In newborn infants with asystole or bradycardia, we sug-gest against the routine reliance on any single feedback device such as end-tidal $CO_{2}$ monitors or pulse oxime-ters for detection of ROSC until more evidence becomes available (weak recommendation, very low-certainty evi-dence).

Depth of Chest Compressions (NLS 5506:EvUp 2025)

This EvUp adds to information published in the ILCOR ScopRev222 but not reported in the 2023 CoSTR sum-mary on whether the use of any other chest compression depth than one third the anteroposterior diameter of the chest improves survival, neurologic outcomes, or time to ROSC. ${ }^{6}$ The results from all years were described in the EvUp worksheet.

● Time frame: All years to June 16,2024

Summary of Evidence

Two animal physiology studies 238,239 and 3 human infant studies that used computed tomography scans 240,241 or laser distance meters 242 to estimate chest compres-sion depths in infants were identified. The 2023 ILCOR ScopRev included some of these studies.222 No studies were found that addressed survival rates or other critical or important outcomes in newborn infants. A new SysRev was not thought to be warranted.

Treatment Recommendation (2010, Now Worded as a Good Practice Statement)

Compress the chest one third the anterior-posterior di-ameter (good practice statement).

Chest Compression Location on Sternium (NLS 5507: EvUp 2025)

This question has not been addressed since 2010105;hence, a literature search was used for the EvUp that included contemporary search terms and was conduct-ed without a start-date restriction. In infants receiving chest compressions, the PICOST compared whether any other location on the sternum than the lower one third improved survival, neurologic outcomes, or time to ROSC.

● Time frame: All years to June 16,2024

Summary of Evidence

Studies considered before 2010 included observational studies in small numbers of human infants, 243,244 cadav-ers, ${}^{245}$ or predictions from chest radiographs. ${}^{244-247}$ More

recent studies using chest radiographs ${ }^{248}$ or chest com-puted tomography ${ }^{249}$ have largely confirmed their results.The task force concluded that, because these studies had not been evaluated using Grading of Recommen-dations Assessment, Development, and Evaluation as-sessment of certainty of evidence, the 2010 treatment recommendation should be reworded as a good practice statement.

Treatment Recommendation (2025)

Neonatal chest compressions should be centered over the lower third of the sternum but above the xiphoid(good practice statement).

DRUG AND FLUID ADMINISTRATION

Epinephrine(Adrenaline) for Neonatal Resuscitation (NLS 5600: EvUp 2025)

In the 2020 ILCOR SysRev, studies of epinephrine in human infants were mostly observational cohort stud-ies or case series. ${ }^{167}$ Therefore, studies in asphyxiated newborn animals receiving effective positive-pressure ventilation and chest compressions that showed that epinephrine (especially when given intravenously)can achieve ROSC more effectively and sooner than control treatments contributed to the 2020 ILCOR treatment recommendations about epinephrine dose,route, and timing. ${ }^{5,167}$ A 2025 EvUp was performed and also included relevant animal studies. The com-plete EvUp, including the full PICOST, can be found in Appendix B.

● Time frame: March 6,2019,to August 20,2024

Summary of Evidence

The only new human infant evidence was from obser-vational studies. ${ }^{250-253}$ Eight animal studies (and an ad-ditional one published just after the search completion date ${ }^{254}$ ) examined various comparisons, including epi-nephrine versus no epinephrine as well as dose and route. ${ }^{255-262}$ The task force concluded that the PICOST question deserves an updated SysRev, mainly to assess new indirect evidence from animal studies that refines understanding of dose, route, and potential harms of epinephrine, particularly when given in high cumulative doses.

Treatment Recommendations (2020)

If the heart rate has not increased to $\geq 60$ /minute af-ter optimizing ventilation and chest compressions, we suggest the administration of intravascular epinephrine(0.01-0.03 mg/kg)(weak recommendation, very low-certainty evidence).

If intravascular access is not yet available, we sug-gest administering endotracheal epinephrine at a larger dose (0.05-0.1 mg/kg) than the dose used for intravascular administration (weak recommendation,

Liley et al

Neonatal Life Support: CoSTR 2025

very low-certainty of evidence). The administration of endotracheal epinephrine should not delay attempts to establish vascular access (weak recommendation, very low-certainty evidence).

We suggest the administration of further doses of epi-nephrine every 3 to 5 minutes, preferably intravascularly,if the heart rate remains<60 bpm (weak recommenda-tion, very low-certainty evidence).

If the response to endotracheal epinephrine is inad-equate, we suggest that an intravascular dose be given as soon as vascular access is obtained, regardless of the interval after any initial endotracheal dose (weak recom-mendation, very low-certainty evidence).

Sodium Bicarbonate During Neonatal Resuscitation (NLS 5601: EvUp 2025)

In infants (newborn or in the neonatal period) requir-ing resuscitation, the question of whether sodium bi-carbonate administration compared with no sodium bicarbonate improves survival, ROSC, or critical or im-portant neonatal morbidity outcomes was last reviewed in 2005.120 An EvUp was done in 2020.5 The complete 2025 EvUp, including the full PICOST, can be found in Appendix B.

● Time frame: January 1,2020,to June 17,2024

Summary of Evidence

No new evidence was found to support the use of so-dium bicarbonate in neonatal resuscitation. One study in 2- to 5-day-old anesthetized, nonasphyxiated piglets suggested a potential mechanism of harm, particularly when vasoconstrictors were also administered. ${ }^{263}$ One study of sodium bicarbonate treatment for acidosis in pediatric intensive care units suggested sodium bicar-bonate treatment was beneficial in the setting of hyper-chloremia but harmful if chloride values were normal(as will usually be the case in newborn infants). ${ }^{264}$ The overall evidence from the current and the previous EvUp(2019)is insufficient to justify a new SysRev.

The previous treatment recommendation(2005) was not supported by a SysRev using contemporary ILCOR methods of evidence appraisal. The conditions suggested in the previous treatment recommendation for the use of sodium bicarbonate (after adequate ventilation is estab-lished and there is no response to other therapies) are rare and unexpected in human infants needing resuscita-tion immediately after birth, meaning that human infant trials would be difficult to conduct and might take many years to complete. The animal studies assessed in previ-ous ILCOR worksheets have not addressed these cir-cumstances.

Prior Treatment Recommendation (2005,Withdrawn)

Sodium bicarbonate is discouraged during brief CPR, but it may be useful during prolonged arrests after adequate

ventilation is established and there is no response to other therapies. ${}^{265}$

Although this treatment recommendation was included in previous consensus statements(2005-2020), it can no longer be supported. Based on current methods of evaluating the certainty of evidence, the task force has concluded there is neither direct nor indirect evidence to inform a treatment recommendation. As a result, this treatment recommendation has been withdrawn and will be reconsidered if new evidence becomes available.

Glucose Management During or Immediately After Resuscitation (NLS 5602: ScopRev 2025)

Rationale for Review

Glucose management in neonatal resuscitation was last addressed for the 2010 CoSTR, which concluded that newborns who had hypoglycemia in the setting of hypoxic ischemic encephalopathy had worse outcomes than those who were normoglycemic, and that hyperglycemia might be protective, although a specific target blood glucose concen-tration range could not be identified at that time. ${}^{105}$ An EvUp in 2020 prompted the task force to conduct this ScopRev.Complete details are available on the ILCOR website. ${}^{23}$

Population, Intervention, Comparator, Outcome,Study Design, and Time Frame

● Population: Newborn infants (preterm, and term)who receive resuscitation at birth in all health care settings that provide birthing services

- Question 1. When and how should blood glu-cose be monitored in newborn infants receiving resuscitation?

● Intervention: Strategy of monitoring glucose or metabolites (lactate, ketones, insulin) or postresus-citation care bundles that include such monitoring

● Comparator: No monitoring or no defined strategy or alternative monitoring strategy

- Question 2. When and how should glucose(or other treatments to control blood glucose con-centration) be used during and after neonatal resuscitation?

● Intervention: Glucose(administered via intrave-nous, intraosseous, or buccal route) or glucagon or postresuscitation care bundles to control blood glu-cose concentration

● Comparator: No glucose(or other treatment to con-trol blood glucose concentrations) or an alternative strategy

- Question 3. What is the optimal blood glucose concentration range for newborn infants during and after resuscitation?

•Exposure: Dysglycemia or defined blood glucose target range

● Comparator: Normoglycemia or alternative target range

Liley et al

Neonatal Life Support: CoSTR 2025

• Outcome:

-All Questions

● Success of resuscitation (critical)

● Neonatal brain injury (critical)

● Long-term neurological function (critical)

● Neonatal morbidity (important)

- Questions 1 and 2

● Dysglycemia: referring to episode(s) of either hypoglycemia(blood glucose concentration≤2.5 mmol/L[≤45 mg/dL]) and hyperglycemia(blood glucose concentration≥7 mmol/L[≥126 mg/dL]), or both, for the purposes of this review(important)

- Metabolite levels: blood lactate, ketone, and insulin concentrations (important)

● Feasibility(important)

● Study design: Because this was a ScopRev,animal trials, human trials(randomized, nonrandomized,historically controlled), and human observational studies(cohort, before-and-after,case-control,case series if ≥6 participants) were eligible for inclu-sion. Studies were considered eligible for inclusion if they directly or indirectly addressed the review questions but were excluded if they had not been peer reviewed or published in full text. All years and all languages were included provided there was an English abstract.

● Time frame: All years to October 6,2024

Summary of Evidence

Question 1. When and how should blood glucose be monitored in newborn infants receiving resuscitation?

Twenty-five articles reporting 24 observational stud-ies described serial monitoring of blood glucose con-centrations, commencing at NICU admission or at≤2 hours of age to assess the frequency of neonatal dys-glycemia.266-290 Apart from 1 study in which 35% of infants were born at≤32 weeks' gestation,250 all other studies included only infants born at≥34 weeks' ges-tation.

Two studies used continuous glucose monitoring, ${}^{282,285}$ and all others used intermittent blood glucose sampling,with variation in whether the sampling site or analytic method was specified. The definitions of hypoglycemia and hyperglycemia also varied. Hypoglycemia was most often defined as blood glucose values $<2.2 mmol/ L$(<40 mg/dL) or<2.6 mmol/L (<46 mg/dL). Hyperglycemia was most often defined as $\geq 1$ blood glucose val-ues $>8.3 mmol/ L(>150 mg/ dL)$ .

Only 9 studies provided information about specific resuscitation interventions received by infants that might be associated with increased risk of dysglyce-mia.250,268,273,275,281,283,286,288,289 Three studies suggested a lower risk of hypoglycemia or higher blood glucose levels in infants who had received epinephrine compared with those who had not.250,268,289

In studies assessing the risk of hypoglycemia at dif-ferent times after resuscitation, 1 study including 60 term infants with Apgar scores ≤6 at 5 minutes (of whom 73% had subsequent hypoxic ischemic encephalopathy)reported that 92% of the 12 patients with blood glucose measurement recorded in the delivery room were hypo-glycemic.269 In studies reporting glucose measurements on NICU admission, the proportions of infants with hypo-glycemia ranged from 8% to 23%.268,273-275,279,286 The proportions with hyperglycemia ranged from 19% to 53%.274,275,279 In 6 studies reporting results in the first 6 hours after birth, the proportion of infants with hypogly-cemia ranged from 7% to 24%.270,276,277,282-284

Question 2. When and how should glucose(or other treatments to control blood glucose concentration) be used during and after neonatal resuscitation?

There were no human studies directly addressing control of blood glucose during resuscitation, and evi-dence from animal studies was inconsistent, with some studies suggesting neuroprotection when glucose was infused during asphyxia or during recovery from hypoxia-chemia280,292-312 and others suggesting harm or no ben-efit.313-318

During postresuscitation care, routine commence-ment of intravenous glucose infusions was a common practice in infants admitted to NICU, typically at infusion rates of 4 mg/kg per minute, but no studies defined an optimal strategy to achieve euglycemia(and avoid iatro-genic hyperglycemia) during the treatment of hypoglyce-mia after resuscitation at birth.

Question 3. What is the optimal blood glucose con-centration range for newborn infants during and after resuscitation?

No studies directly investigated the optimal blood glu-cose target range for infants immediately after resusci-tation at birth. Whether a lower or higher target is better remains unknown.

Task Force Insights

For infants needing advanced resuscitation at birth, it remains unknown if empiric use of glucose during re-suscitation improves the success of the resuscitation interventions.

As a whole, the studies addressed only a subgroup of the infants intended in the ScopRev questions(eg term and late preterm already defined to have-or be at high risk for-hypoxic ischemic encephalopathy), rather than including all infants who had received resuscitation,regardless of gestation. There was also considerable variation in study design and methods. Hence, for infants who have received resuscitation, the task force consid-ered that meta-analysis would not accurately determine the risk of hypo- or hyperglycemia at specific times in the first few hours or the extent to which hypo- or hypergly-cemia affects outcomes. No studies compared outcomes from any specific strategy for blood glucose monitoring

Liley et al

Neonatal Life Support: CoSTR 2025

to any other strategy in a way that allowed determination of an optimal approach. Nevertheless, in the first hours after resuscitation, the evidence that was available sug-gested that both hypo- and hyperglycemia are common and that both may be associated with harm. Research is needed to define an optimal target range for blood glu-cose in the aftermath of resuscitation, optimal strategies for monitoring, and management strategies that improve outcomes and avoid overtreatment or undertreatment.

Prior Treatment Recommendation (2010)

Intravenous glucose infusion should be considered as soon as practical after resuscitation, with the goal of avoiding hypoglycemia. ${ }^{105}$

This recommendation was not supported by a Sys-Rev of the literature using Grading of Recommendations Assessment, Development, and Evaluation methods and should be regarded as superseded. Until sufficient evi-dence is available to justify a SysRev, the task force gen-erated the following good practice statements.

Treatment Recommendations (2025)

Among newborn infants receiving resuscitation, blood glucose concentration should be measured early in the postresuscitation period and monitored with serial mea-surements until maintained within a normal range. Infants at greatest risk of hypo- and hyperglycemia during the postresuscitation period include preterm infants, infants receiving chest compressions or epinephrine, and those with hypoxic ischemic encephalopathy (good practice statement).

Treatment with intravenous glucose infusions should be guided by the infant's blood glucose concentration with the goal of avoiding both hypoglycemia and hyper-glycemia (good practice statement).

Blood Volume Expansion During Neonatal Resuscitation (NLS 5650: EvUp 2025)

The previous ILCOR assessment of the role of fluids to expand blood volume during neonatal resuscitation focused on the risk of harm if fluid boluses are given to all infants, while recognizing that a few infants have experienced critical blood loss immediately before or during resuscitation and may benefit from volume resus-citation.105 Surveillance of the literature and an EvUp in 2020 concluded that the 2010 treatment recommen-dation was still supported.5 A further EvUp addressing whether blood volume expansion with any blood prod-ucts or crystalloids(eg, sodium chloride 0.9%) compared with no blood volume expansion improved survival, neu-rodevelopmental outcomes, serious morbidity, or short-term outcomes of resuscitation was conducted for 2025.The complete EvUp, including the full PICOST, can be found in Appendix B.

● Time frame: January 1,2021,to July 2,2024

Summary of Evidence

One narrative review that included a few previously un-published animal data was identified for inclusion. ${ }^{319}$Because the sparse available evidence from previous reviews has not been evaluated using Grading of Rec-ommendations Assessment, Development, and Evalu-ation methods, the existing recommendation is now reworded as good practice statements, pending an up-dated SysRev.

Treatment Recommendations (2025)

Early volume replacement with crystalloid or red cells is indicated for newborn infants with blood loss who are not responding to resuscitation(good practice state-ment).

There is insufficient evidence to support the routine use of volume administration in newborn infants with no blood loss who are refractory to ventilation, chest com-pressions, and epinephrine. Because blood loss may be occult, a trial of volume administration may be considered in newborn infants who do not respond to resuscitation(good practice statement).

Intraosseous Versus Intravenous Cannulation for Emergency Access (NLS 5652: EvUp 2025)

A 2020 SysRev for all age groups identified that in-traosseous administration of medications and fluids could be accomplished during cardiac arrest, including during neonatal resuscitation but with some potential for serious complications in newborns. ${ }^{320}$ A 2025 EvUp was performed, focusing only on newborn infants. The complete EvUp, including the full PICOST, is provided in Appendix B.

● Time frame: December 1,2019, to July 15,2024

Summary of Evidence

Three new observational studies that reported results of intraosseous access in newborns and infants in the neonatal period were included, but none specifically compared intraosseous with intravenous access. ${}^{321-323}$Two studies identified cases from databases, ${}^{321,323}$ and 1 study322 used self-reported results of questionnaires.The proximal tibia was the most commonly used insertion site.321,322 Success rates for intraosseous insertion varied from 50% to 86% between studies,321-323 and complica-tion rates varied from 10.8%323 to 35%.321 Complications included extravasation, necrosis, compartment syndrome,superiesteal infusion, tibial fracture, broken intraosse-ous needle, osteomyelitis, and soft tissue infection.

The new studies support the current treatment rec-ommendations and appear insufficient to justify a new SysRev at this time.

Treatment Recommendations (2020)

We suggest umbilical venous catheterization as the pri-mary method of vascular access during newborn infant

Liley et al

Neonatal Life Support: CoSTR 2025

resuscitation in the delivery room. If umbilical venous access is not feasible, the intraosseous route is a rea-sonable alternative for vascular access during newborn resuscitation(weak recommendation, very low-certainty evidence). Outside the delivery room setting, we suggest that either umbilical venous access or the intraosseous route may be used to administer fluids and medications during newborn resuscitation(weak recommendation,very low-certainty evidence). The actual route used may depend on local availability of equipment, training, and experience.

POSTRESUSCITATION CARE

Rate of Rewarming Hypothermic Newborns (NLS 5700: SysRev 2024, EvUp 2025)

The effect of the rate of rewarming on outcomes of new-borns who are unintentionally hypothermic after delivery was addressed by a 2024 SysRev, and details of this review, including the complete PICOST, can be found in the 2024 CoSTR summary.7 The literature search was updated from July 1, 2023, to June 13, 2024, during the process of preparing the SysRev for submission for publication.

Treatment Recommendations (2024)

In newborn infants who are unintentionally hypother-mic after birth, rewarming should be started, but there is insufficient evidence to recommend either rapid (≥0.5 C/h) or slow (<0.5°C/h) rates of rewarming.

Regardless of the rewarming rate chosen, a protocol for rewarming should be used. Frequent or continuous monitoring of temperature should be undertaken, partic-ularly if using a supraphysiological set temperature point to accelerate the rewarming rate, because of the risk of causing hyperthermia. In any hypothermic infant, monitor blood glucose because there is a risk of hypoglycemia(good practice statement).

Therapeutic Hypothermia in Limited-Resource Settings (NLS 5701: SysRev 2024, EvUp 2025)

Therapeutic Hypothermia for the treatment of moder-ate or severe hypoxic ischemic encephalopathy in neo-nates is now the well-established standard of care in high-income countries, but its efficacy in low-resource settings had been unclear.? The task force was aware of several new studies in low- and middle-income coun-tries and considered it a sufficiently important aspect of postresuscitation care to prioritize a SysRev. Details of this review,including the complete PICOST, can be found in the 2024 CoSTR summary.? The literature search was updated from July 1,2023, to September 30,2024, dur-ing the process of preparing the SysRev for submission for publication. During this process, one study was ex-

cluded post hoc when the task force recognized some inconsistencies that raised concerns about trustworthi-ness of the findings.324 Another article325 was found to have reported additional outcomes for a subset of par-ticipants in a previous RCT326 and so is now only included as a single trial. Amended versions of the online CoSTR and evidence-to-decision table have been posted on the ILCOR website, but the task force concluded that the revised evidence still supports the 2024 treatment rec-ommendations and certainty of evidence.

Treatment Recommendations (2024)

We suggest the use of therapeutic hypothermia in com-parison with standard care alone for term(≥37+ 0 weeks' gestational age) newborn infants with evolving moderate-to-severe hypoxic-ischemic encephalopathy in low- and middle-income countries in settings where a suitable level of supportive neonatal care is available(weak recommendation, low-certainty evidence).

For late preterm infants,34+0 to 36+6 weeks' ges-tational age infants, a recommendation cannot be made due to insufficient evidence.

Therapeutic hypothermia should only be considered,initiated, and conducted under clearly defined protocols with treatment in neonatal care facilities with the capabil-ities for multidisciplinary care and availability of adequate resources to offer intravenous therapy, respiratory sup-port, pulse oxymetry, antibiotics, antiseizure medication,transfusion services, radiology(including ultrasound),and pathology testing, as required. Treatment should be consistent with the protocols used in RCTs. Most proto-cols included commencement of cooling within 6 hours after birth, strict temperature control to a specified range(typically $33°C-34°C$), and most commonly for a dura-tion of 72 hours with rewarming over at least 4 hours.Adoption of hypothermia techniques without close moni-toring, without protocols, or without availability of com-prehensive neonatal intensive care may lead to harm(good practice statement).

PROGNOSTICATION DURING CPR

Impact of Duration of Intensive Resuscitation(NLS 5800: EvUp 2025)

Deciding how long to continue resuscitative efforts in a newborn with no heart rate or a very low heart rate with absent respirations after sustained resuscitative efforts is a critical decision. If such an decision is made too early, some newborns with potential to survive without severe neurode-velomental impairments may die. If made too late, parental engagement during end-of-life care may be impeded. This topic was previously addressed in a 2020 SysRev.5,327 A 2025 EvUp was conducted, and complete details, includ-ing the full PICOST, can be found in Appendix B.

● Time frame: October 17, 2019, to July 4, 2024

Liley et al

Neonatal Life Support: CoSTR 2025

Summary of Evidence

One SysRev328 (with included studies that extensively overlapped with those in the ILCOR SysRev) was identi-fied. There was 1 additional population-based study329 and 3 cohort studies nested within RCTs of advanced resuscitation.330-332 Overall, these studies confirm that,for infants who receive resuscitation, survival without severe neurodevelopmental impairment is possible after prolonged asystole or bradycardia. However, this may vary with gestational age, the availability of therapeutic hypothermia, resuscitation practices, and access to other intensive or complex care. The new evidence is not suf-ficient to justify a new SysRev at this time.

Treatment Recommendation (2020)

Failure to achieve ROSC in newborns从前 despite 10 to 20 minutes of intensive resuscitation is associated with a high risk of mortality and a high risk of moderate-to-severe neurodevelopmental impairment among sur-vivors. However, there is no evidence that any specific duration of resuscitation consistently predicts mortality or moderate-to-severe neurodevelopmental impairment.If, despite provision of all the recommended steps of re-suscitation and excluding reversible causes, a newborn infant requires ongoing CPR after birth, we suggest dis-cussion of discontinuing resuscitative efforts with the clinical team and family. A reasonable time frame to con-sider this change in goals of care is around 20 minutes after birth (weak recommendation, very low-certainty evidence).

FAMILY PRESENCE

Family Presence During Neonatal Resuscitation(NLS 5900: SysRev 2021, EvUp 2025)

A SysRev conducted with the Pediatric Life Support Task Force in 2021 addressed the impact of family presence during resuscitation of infants and children on outcomes of resuscitation, on families, or on those providing resus-citation. ${}^{9,333,334}$ A 2025 EvUp assessed whether there were new studies specific to the presence of parents at the resuscitation of newborns. The complete EvUp,including the full PICOST, can be found in Appendix B.

● Time frame: September 1, 2019, to September 5,2024

Summary of Evidence

<BeginOfPara>Five studies specifically addressing parental presence during resuscitation at birth were included, all from high-income countries and all addressing caregiver percep-tions. ${ }^{335-339}$ There is a continued absence of studies from culturally diverse settings or where resources are limited,and none of the new studies interviewed parents. The new evidence does not appear sufficient to change the current treatment recommendation or to justify a new SysRev until more studies have accumulated.

Treatment Recommendation (2021)

We suggest it is reasonable for mothers/fathers/part-ners to be present during the resuscitation of neonates where circumstances, facilities, and parental inclination allow(weak recommendation, very low-certainty evi-dence).

There is insufficient evidence to indicate an interven-tional effect on patient or family outcome. Being pres-ent during the resuscitation of their infant seems to be a positive experience for some parents but concerns about an adverse effect upon performance exist among both health care professionals and family members.

Topics Not Included in the 2025 Review

The following PICOSTs are not included in this summary:

● Anticipation and Preparation

- Effect of neonatal resuscitation team composi-tion on outcomes(NLS 5000): not previously reviewed

- Checklists and cognitive aids for neonatal resus-citation (NLS 5001): addressed by Education,Implementation, and Teams Task Force as EIT 6400

- Prediction of the need for resuscitation at birth(NLS 5003): not previously reviewed

- Prediction of outcome after extremely preterm birth (NLS 5004): SysRev underway

- Prediction of outcome if mother has intrapartum hypothermia or hyperthermia (NLS 5005): not previously reviewed

● Initial Steps

- Prediction of outcomes based on infant tempera-ture during or immediately after resuscitation

● Ventilation and Oxygenation

● Upright resuscitator for administering positive-pressure potential reduction at birth (NLS 5301): not pre-viously reviewed

- High flow nasal cannula for initial respiratory sup-port (NLS 5302): not previously reviewed

- Mouth techniques for administering positive-pressure ventilation in very low resource settings(NLS 5303): not previously reviewed

- Interfaces for noninvasive positive-pressure ven-tilation(NLS 5304): not previously reviewed

- Strategies for positive-pressure ventilation (NLS 5325): ScopRev underway

- Respiratory function monitoring during simulation training (NLS 5361): SysRev underway

- Oxygen saturation targeting (NLS 5402):ScopRev underway

- Oxygen use after ROSC (NLS 5403): not previ-ously reviewed

● Drug and Fluid Administration

- Caffeine administration for preterm infants during stabilization (NLS 5311): not previously reviewed

Liley et al

Neonatal Life Support: CoSTR 2025

- Surfactant administration during or immedi-ately after neonatal resuscitation(NLS 5370):ScopRev underway

$\bullet$ Postresuscitation Care

- Therapeutic hypothermia, how to identify infants who may benefit(NLS 5702): not previously reviewed

- Therapeutic hypothermia, commencement dur-ing resuscitation(NLS 5703): not previously reviewed

- Alternatives to therapeutic hypothermia(NLS 5704): not previously reviewed

- Other and Special Considerations

- Resuscitation for infants with specific congeni-tal anomalies(NLS 5960): ScopRev planned 2025

- Face-to-face versus remote or distance learning:new question

Readers are encouraged to monitor the ILCOR web-site10 to provide feedback on planned SysRevs and to provide comments when additional draft reviews are posted.

Disclosures

Writing Group Disclosures

|Writing group Membr member|Employment|Research grant|Other research support|Speakers|Expert witness|Ownership interest|Consultant/ advisory board|Other| |---|---|---|---|---|---|---|---|---| |Helen G. Liley|The University of Queensland (Australia)|None|None|None|None|None|None|None| |Gary M. Weiner|University of Michigan|None|None|None|None|None|None|None| |Katherine M. Berg|Beth Israel Deaconess Medical Center and Harvard Medical School|None|None|None|None|None|AHA/ILCORt|None| |Marlies Bruckner|Medical University Graz (Austria)|Grant of "Initiative fur Früh- und Neugeborens"|None|None|None|None|None|None| |Daniela T. Costa-Nobre|Universidade Federal de Sao Paulo(Brazil)|None|None|None|None|None|None|None| |Peter G. Davis|The Royal Women's Hospital(Australia)|None|None|None|None|None|None|None| |Jennifer A.Dawson|The Royal Women's Hospital(Australia)|None|None|None|None|None|None|None| |Maria Fernanda de Almeida|Universidade Federal de Sao Paulo(Brazil)|None|None|None|None|None|None|None| |Walid El-Naggar|Dalhousie University (Canada)|Aerogen Pharma"; National Heart, Lung and Blood Institute (NHLBI)/National Insti-tutes of Health(NIH)t|None|None|None|None|None|None| |Jorge G. Fabres|Pontificia Universidad Catolica de Chile(Chile)|None|None|None|None|None|None|None| |Joe Fawke|University Hospitals Leicester NHS Trust (United Kingdom)|None|None|None|None|None|None|None| |Emer Finan|Mount Sinai Hospital; Uni- versity of Toronto(Canada)|None|None|None|None|None|None|(Continued)|

$\text{(Continued)}$

Liley et al

Neonatal Life Support: CoSTR 2025

Writing Group Disclosures Continued

|Writing group Employment Research research _Xearb 业u and }oraria witness Ownership 。|Consultant/ advisory|Other|||||||| |---|---|---|---|---|---|---|---|---|---| |Elizabeth E. Foglia|Children's Hospital of Philadelphia|None|None|None|None|None|Chiesi USA*|Chiesi USA*|| |Ruth Guinsburg|Federal University of Sao Paulo(Brazil)|None|None|None|None|None|None|None|| |David Honeyman|The University of Queensland(Australia)|None|None|None|None|None|None|None|| |Tetsuya Isayama|National Center for Child Health and Development (Japan)|None|None|None|None|None|None|None|| |Justin B. Josephsen|Saint Louis University|None|None|None|None|None|None|None|| |C.Omar Kamlin|Orphalan, London,Eng- land(United Kingdom)|None|None|None|None|None|None|None|| |Vishal Kapadia|UT Southwestern|National Institute of Healtht;Monivent*; Masimo*|None|None|None|None|None|None|| |Anup Katheria|Sharp Mary Birch Hospital for Women\& Newborns|None|None|None|None|None|None|None|| |Mandira Daripa Kawakami|Universidade Federal de Sao Paulo(Brazil)|None|None|None|None|None|None|None|| |Henry C. Lee|University of California San Diego|None|None|None|None|None|None|None|| |R. John Madar|University Hospitals Plymouth National Health Services Trust (United Kingdom)|None|None|None|None|None|None|European Resuscitation Council|| |Christopher J.D. McKinlay|University of Auckland (New Zealand)|None|None|None|None|None|None|None|| |Victoria J. Monnelly|The University of Edinburgh (United Kingdom)|None|None|None|None|None|None|None|| |Firdose L. Nakwa|University of the Witwa- tersrand, Johannesburg (South Africa)|None|None|None|None|None|None|None|| |Bin Huey Quek|KK Women's and Children's Hospital (Singapore)|None|None|None|None|None|None|None|| |Yacov Rabi|University of Calgary (Canada)|None|None|None|None|None|None|None|| |Shalini Ramachandran|UT Southwestern|None|None|None|None|None|None|None|| |Viraraghavan Vadakencherry Ramaswamy|Ankura Hospital for Women and Children (India)|None|None|None|None|None|None|None|| |Daniel Ibarra Rios|Instituto Nacional de Perinatologia(Mexico)|None|None|None|None|None|None|None|| |Charles Christoph Roehr|University of Bristol(Unit- ed Kingdom), Faculty of Health and Life Sciences|None|None|Speakers' Bu- reau: Chiesi Pharmaceuti- cals, Italy Relationship Myself Compensa-tion Com-pensated Level Modest ($5000 or 5%)|None|None|None|None||

$$\text{(Continued)}$$

Liley et al

Neonatal Life Support: CoSTR 2025

Writing Group Disclosures Continued

|Writing group member|Employment|Research grant|Other research support|Speakers|Expert witness|Ownership interest|Consultant/ advisory board|Other| |---|---|---|---|---|---|---|---|---| |Mario Rudiger|TU Dresden, Medical Faculty Carl Gustav Carus (Germany)|None|None|None|None|None|None|None| |Georg M. Schmolzer|University of Alberta (Canada)|Research Grant to compare 30% vs 60% oxygen in 29 wk gestation- Hilo-Trialt|None|None|None|None|None|None| |Anna Lene Seidler|German Center for Child and Adolescent Health (DZKJ)(Germany)|Australian National Health and Medical Research Council*|None|None|None|None|None|None| |Anne Lee Solevag|Oslo University Hospital (Norway)|None|None|None|None|None|None|None| |Marya L. Strand|Akron Children's Hospital|None|None|None|None|None|Mayo Clinic”; Children's Hospital of Philadelphia*|None| |Takahiro Sugiura|Nagoya City University Graduate School of Medi-cal Sciences (Japan)|None|None|None|None|None|None|None| |Daniele Trevisanuto|University of Padova (Italy)|None|None|None|None|None|None|None| |Enrique Udaeta-Mora|Asociacion Mexicana de Pediaithria (Mexico)|None|None|None|None|None|None|None| |Myra H. Wyckoff|UT Southwestern|None|None|None|None|None|None|None| |Nicole K. Yamada|Stanford University|None|None|None|None|None|None|None|

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be“significant” if(a) the person receives$5000 or more during any 12-month period, or 5% or more of the person's gross income; or(b) the person owns 5% or more of the voting stock or share of the entity, or owns$5000 or more of the fair market value of the entity. A relationship is considered to be"modest" if it is less than"significant" under the preceding definition.

*Modest.

tSignificant.

Reviewer Disclosures

|Reviewer|Employment|Research grant|Other research support|Speakers' bureau/ honoraria|Expert witness|Ownership interest|Consultant/advisory board|Other| |---|---|---|---|---|---|---|---|---| |Marilyn B. Escobedo|University of Oklahoma|None|None|None|None|None|None|None| |Noah Hillman|St. Louis Uni- versity School of Medicine|None|None|None|None|None|None|None| |Satyan Lakshminrusha|University of California, Davis|NIH(Evalua- tion of oxygen in neonatal lung injury including resuscitation)t|None|None|None|None|None|None| |Rob Moonen|Zuyderland Medical Center, Heerlen(The Netherlands)|None|None|None|None|None|None|None|

(Continued)

Liley et al

Neonatal Life Support: CoSTR 2025

Reviewer Disclosures Continued

|Reviewer|Employment|Research grant|Other research support|Speakers' bureau/ honoraria|Expert witness|Ownership interest|Consultant/ advisory board|Other| |---|---|---|---|---|---|---|---|---| |Colm P.F. O'Donnell|National Ma- ternity Hospi- tal(Ireland)|None|Karl Storz Endoskop, Tuttlingen, Germany (Loan equipment, funding for statistical support for NEU- VODE trial[NCT06757543)t]; Chiesi Farmaceutici(Providing sur-factant free-of-charge and funding for statistical support for the pro- TeCt trial[NCT06557551)t}; Karl Storz Endoskop, Tuttlingen, Ger- many(Provided two video laryn-goscopes on loan to 10 months for the purposes of the VODE trial(N Engl J Med 2024:390:1885- 1894) that were purchased by the hospital at a 40% reduction at the conclusion of the study)t|None|None|None|None|None|

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Ques-ronaire, which all reviewers are required to complete and submit. A relationship is considered to be"significant" if a) the person receives$5000 or more during any 12-month period, or 5% or more of the person's gross income; or(b) the person owns 5% or more of the voting stock or share of the entity, or owns$5000 or more of the fair market value of the entity. A relationship is considered to be"mostest" if it is less than"significant" under the preceding definition.

*Modest.

+Significant.

REFERENCES

1. Australia's mothers and babies data visualisations Australian Institute of Health and Welfare, Accessed December 15,2024.https://www.aiwh.gov.au/reports/mothers-babies/australias-mothers-babies-data-visualisa-tions/contents/summary

2. Perman Wijlie, W Jattkinkel W J, Wyckoff MH, Aziz K, Ginsburg R, Kim HS, Liley HG, Mildenhall L, Simon WM, et al; on behalf of the Neonatal Resuscitation Chapter Collaborators. Part 7: neonatal resuscitation; 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation.2015;132(suppl 1):S204-S24; doi:10.1161/CIR/00000000000000276

3.Wyckoff MH, Wyllie J, Aziz K, de Almeida MF, Fabres JW, Fawke J,Guinsburg R, Hosono S, Isayama T, Kapadia IV, Es et al; on behalf of the Neonatal Life Hospital Collaborators. Neonatal Life Support 2020 Interna-tional Consensus on Cardiopulmonary Resuscitation and Emergency Car-dovascular Care Science With Treatment Recommendations. Resuscitation at 2020;156A:156-A187. doi:10.1016/j.resuscitation.2020.09.015

4. Deleted in proof.

5.Wyckoff MH,Wiley Il,Z.Akie al-Meida MF,Fabres J.Fawke J.Guinburg R,Hosono S,Isayama T,Kapadia VS,et al; on behalf of the Neonatal Life Collaborators. Neonatal Life Support: 2020 International Consen-sus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations: Emergency J98, University 2021;186-89

6. Berg MN, Bray JE, Ng KC, Liley HE, Gr?Freig C, Carlsson JN, Morley PT, Drrennan IS, Drym S, Scholefield BR, et al; and Collaborators.2023 International Con-sensus on cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: summary from the Basic Life Support; Advanced Life Support; S342: http://www.Surphy/33.14888888888888888888888888888888888888888888888888888888888888888888888888888888888888888888888888888888888888888888888888888888888888888888

7. Gref R, Bray JE, Djarv T, Drenran IR, LG Hg, Ng KC, Cheng A Doma MJ,Solechfield BR, Smyth M, et al. 2024 International Consensus on Car-diopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendation: Nonal and Global Service and Emergency Cardiovascular Care Science With Treatment Recommendation: Nonal and Global Service and Emergency Cardovascular Care Science With Treatment Recommendation: Nonal and Global Service and Emergency Care Science With Treatment Recommendation: Nonal and Global Service and Emergency Care Science With Treatment Recommendation: Nonal and Global Service and Emergency Care Science With Treatment Recommendation: Nonal and Global Service and Emergency Care Science With Treatment recommendation:

8.Weyckhoff MH, Greif R, Morley PT, Ng KC, Olaswegen TM, Longetary EM,Soar J, Cheng A, Drenran IR, Liley HG, et al; and Collaborators. 2022 International Consensus on Cardiopulmonary Resuscitation and Emerg. Carying Science With Treatment Recommendations:

ric Life Support; Neonatal Life Support;Education,Implementation,and Teams; and First Aid Task Forces. Resuscitation. 2022;181:208-288. doi:10.1016/j.resuscitation.2022.10.005

9.Wyckoff MH,Singletary EM,Soar J, Olasveengen TM,Greif R,Liley HG,Zideman D, Bhanji F, Andersen LW, Avis SR, et al; COVID-19 Working Group.2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommen-dations: summary from the Basic Life Support; Advanced Life Support; Neo-natal Life Support; Education,Implementation, and Teams: First Aid Task Forces; and the COVID-19 Working Group. Resuscitation.2021;169:229-311.101:10.1616/j.resuscitation.2021.10.040

10.International Liaison Committee on Resuscitation. ILCOR website. Ac-cessed February 19,2025.https://www.ilcor.org/home/

11.Morley PT, Berg KM, Billi JE, Nolan JP, Montgomery WH, Atkins DL, Bray JE, Carlson JN, de Caen AR, Djarv T, et al. Methodology and conflict of interest management: 2025 International Liaison Committee on Resuscita-tion Consensus on Science With Treatment Recommendations. Circulation.2025;152(suppl) 1:S23-S33. doi: 10.1161/CIR.0000000000001366

12. Strand ML, Simon Weyl, Wyllie J, Wyckoff MH, Weiner G. Consen-sus outcome rating for international neonatal resuscitation guide-lines Arch Dis Child Fetal Anonal Med. Edd Child Fetal Anonal Ed.2020;105:328-330. doi: 10.1136/archidschild-2019-316942

13.Webbe,JWHJ,Diffuy-JMNN,Afonso E,Al-Muzaffarl,Brunton G,Greenough A,Hall NJ,Knight M,Latour JM,Lee-Davey C,et al.Core outcomes in neonatology:development of a core outcome set for neonatal research. Arch Dis Child Fetal Neonatal Ed2020;105:425-431.doi:10.1136/archischild-2019-317501

14.Fawke J, Stacey P, Yamada N. Use of briefing and debriefing in neona-tal resuscitation, a scoporing review. Resusc Plus.2020;5:100059. doi:10.1016/j.respuol.2020.100059

15.Nabeker S, Cortegiani A, Breckwoldt J, de Raad T, Lennert J, Alhaitha A, Greif R, et al. Debriefing of clinical resuscitation performance Consensus on Science with Treatment Recommendations[Internet] Brussels, Belgium International Liaison Committee on Resuscitation(ILCOR) Education,Implementation and Teams Task Force. 2024. Accessed on August 13,2025.https://costl.ironl.org/document/debriefing-of-clinical-resuscitation-performance-eit-6307-tf-rs

16.Brewer DE, Lewis S. Sebenhenger SL. Improving Communication to Neo-natal Resuscitation Team of Members During High-Risk Births. Nurs Womens Health.2023;27:110-120. doi: 10.1016/jnwh.2023.01.006

17.Jordach R, Doherty C, Kenny C, Bowie P. Preliminary Adaptation, De-velopment, and Testing of a Team Sports Model to Improve Briefing and Debriefing in Neonatal Resuscitation. Pediatr Qual Saf. 2020;5:e228. doi:10.1097/pq.00000000000000

18.Ortiz-Movilla R, Beato-Merino M, Funes Monux RM, Martínez-Bernat L. Domingero-Comeche L. Royuela-Vicente A, Román-Riechmann E,

Liley et al

Neonatal Life Support: CoSTR 2025

Marín-Gabriel M. What Is the Opinion of the Health Care Personnel Regarding the Use of Different Assistive Tools to Improve the Qual-ity of Neonatal Resuscitation? Am J Perinol. 2024;41:1645-1651. doi:10.1055/a/2240-2094

201. Horvtova-Lim R, Funes-Mofux RM, Domingo-Comeche LD, Beato-Merino M, Martinez-Bernat L, Royu-Veciva E., Román-Richemann E,Marrin-Gabri M. Combined application of various quality assessment tools in neonatal resuscitation. An Pediatr(Engl) Ed. 2022);97:405-414. doi:10.1016/j.anpede.2022.10.002

20. Bhatt S, Alon BJ, Wallace EM, Crossley KJ, GIL AW, Kluckow M, Pis pas AB, Morley CJ, Polglase GR, Hooper SB. Delaying cord clamping until ven-fitation onset improves cardiovascular function at birth in preterm lambs. J.Physiol.2015;391:2113-21126. doi:10.1113/jphysiol.20125:250084

21. Hooper SB, Polglase GR,te Pas AB. A physiological approach to the tim-ning of umbilical cord clamping at birth. Arch Dis Child Fetal Neonatal Ed.2015;100F:355-F360. doi: 10.1136/archischid-2013-305703

22. Gomersall J, Berber S, Middleton P, McDonald SJ, Nermeyer S, El-Naggar W.W.Davis PG,Schomber GM, Oleman C,Soll RF; on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Um-bilical Cord Management at Term and Late Preter Birth: Meta-analysis.Pediatrics.2021;177@e202015404.doi:101542/peds:2020-015404

23. Davis PG, El-Naggar W, Ibarra Rios S, Sorakin A, Fawke J, Nierermeyer S. Katheria A. Hooper S, Zorona S. Cordova management of non-vigorous term and onresuscitation (LCOR) Neonatal Life Support Task Force. Accessed on August 13, 2025. https://cost.irlicor.org/document/ns-5050b-cord-man-agement of-non-vigorous-term-and-late-preterm-34 weeks-gestation for infants-ns501b-500f8-rst-

24. Sarnat HB, Sarnat MS. Neonatal encephalopathy following fetal distress. A clinical and elecnocencephalographic study, Arch Neur 1976;33:696-705.12. doi:10.1003/yrheur196.075000100030012

25. Katheria AC, Clark E, Yoder B, Schmöger GM, Yan Law BH, El-Naggar W,Rttenberg D,Sheth F, Mohamed MA, Martin C, et al. Umbilical cord milling in nonvicious infants: a cluster randomized crossover trial. Am J Obstet Gynecol.2023;228:21e7-1217e1.dol.1010/ghajj.2022.08.015

25. Katheria AC, El Gorml L, Clark E, Yoder B, Schnotzer GM, Law BHY,El-Naggar W, Rittenberg D, Sheth S, Martin C, et al. Two-Year Outcomes of Umbilical Cord Milk in Univigorous in Nonviral infants: A Secondary Analysis of the MNVI Randomized Clinical Trial. JAMA New Postu. 20247:24618870. doi:101001/jamanetworkopen.2024.168707

Rana JCS,Chawda J.,Dain J.Shurana S.,Sehgal A. Rani S. Resuscitation with Intact Cord Versus Clamped Cord in Late Preterm and Term Neo-nates: A Randomized Controlled Trial. J. Pediatr. 2023;254:54-60.e4. doi:10.1016/j.jepsids.2022.08.061

28.Anderson R, Oana N, Ewald U, Malqvist M, Stripple G, Basnet O, Subedi K,Kc A. Intact cord resuscitation versus early cord clamping in the treat-ment of depressed newborn infants during the first 10 minutes of birth(Nepcord III)-a randomized clinical trial. Maternal Health Neonat Prolin.2019;5:15. doi: 10.1186/s40748-019-0110-z.

92. Badurdeen S, Davis PG, Hooper SB, Donath S, Santomartino GA,Heng A, Zannino D, Hoq M, Kamlin CFO, Kane SC, et al. Physiologi-cally based cord clamping for infants 32±0 weeks gestation: A ran-domised clinical trial and reference percentiles for heart rate and oxygen saturation for infants ≥35+0 weeks gestation. PLoS Med 2022;19: doi:10.1371/journal.pmed.1004029

30. Isacson M, Gurgur R, Basnet O, Andersson O, Ashise K. Neurodevelop-mental outcomes of a randomised trial of intact cord resuscitation. Acta Paediatr:2021;11:465-472. doi:10.1111/apa:15401

31. Blank DA, Badurdeen S, Omar FKC, Jacobs SE, Thio M, Dawson JA,Kane SC. Dennis A, Politin, Galerse HP, Horoper SB, et al. Babyi-directed um-bilical clamping: A feasibility study. Resuscitation. 2018;131:1-7. doi:10.1016/j.resuscitation.2018.07.020

32.Lefebre V, Raka T, Westin Nav, NS Pastur, Hofflin-Devable B, Mur S.Storme L; French CDH Study Group. Feasibility and safety of intact cord re-suscitation in newborn infants with congenital diaphragm heria(DCH).Resuscitation.2017;120:20-25 doi:10.1016/j.resuscitation.201708.233

33. Kc A, Budathoki SS, Thapa J, Niermeyer S, Gurung R, Singhal N; Nepal Neonatal Network. Impact of stimulation among non-crying neonates with intact cord versus corded cord on birth outcomes: observation study. BM/Paediat. Open 2021;5:e001207. doi: 10.1136/bmpo-2021-001207

34.Wyckoff MH,Greir Morley P.NK,Gc Oslayvenem S. Singlet al. Myar J. Springer, A. Dorrenn IR, Wiley LG, et al; Collaborators. 2022 International Consensus on Cardiplomary Resuscitation and Emer-gency Cardiovascular Care Science With Treatment Recommendations:

summary from the Basic Life Support; Advanced Life Support; Pediat-ric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation. 2022;146:e483-e557. doi:10.1161/CIR/00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000

35. Angadi C, Singh P, Shrivastava Y, Priyadarshi M, Chaurasia S, Chaturvedi J,Basu S. Effects of umbilical cord milking versus delayed cord clamp-ing on systemic blood flow in intrauterine growth-restricted neonates: A randomized controlled trial. Eur J Pediatr. 2023;182:4185-4194. doi:10.1007/s00431-023-05105-

36. Berg J.Hmiss, Icason M. Basinset O,Gurung R, Subedi K, Kc A, Andersson O. Effect of Delayed Cord Clamping on Neurodevelopment at 3 Years:A Randomized Controlled Trial. Neonatology. 2021;118:282-288. doi:10.1159/000515838

37. Cavallin F, Galeazzo B, Loretelli V, Madella S, Pizzolato M, Visentin S,Trevisuto D. Delayed Cord Clamping versus Early Cord Clamping in Eceutary Senaion Control: A Randomized Controlled Trial. Neonatology.2019;116:2529-259. doi: 10.1159/000500325

38. Chaudhary P. Phyadarshi M, Singh P, Chaurasia S, Chaturvedi J, Basu S. Eft-fects of delayed cord clamping at different time intervals in late preterm and term neonates: a randomized controlled trial. Eur J Pediatr.2023;182:3701-3711. doi:10.1007/s00413-031-023-05053-6

39. Chopra A, Thakur A, Garg P, Kler N, Gujral K. Early versus delayed cord clamping in small for gestational age infants and iron stores at 3 months of age- a randomized controlled trial. BMC Pediatr. 2018;18:234. doi: 10.1186/s12887-018-1214-8

40.De Bernardo G, Giordano M, De Santis R, Castelli P, Sordino D, Trevisanuto D, Buonocore G, Perron S. A randomized controlled study of immediate versus delayed umbilical cord clamping in infants born by elective caesare an section. Ital| Pediatr: 2020;46:71. doi: 10.1186/s13052-020-00835-2

41. de Preud'homme d'Hailly de Nieuport SMI, Krijgh EJC, Pruijssers B, Visser J,van Beek RHT.Delayed cord ampling vs cord milking in elective cesarean delivery at term: a randomized controlled trial. Am J Obstet Gynecol MFM.2024;6:101279. doi: 10.1016/j.ajogmf.2024.101279

42.George AA, Iscac M. Effect of Umbilical Cord Milking on Maternal and Neonatal Outcomes in Atertiary Care Hospital in South India: A Ran-domized Control Trial. J. Obstet Gynaecol India. 2022;72:291-298. doi:10.1007/s13224-021-01515-9

43.Guner S, Saydam BK. The impact of Umbilical Cord Clamping Time on the Infant Aemia: A Randomized Controlled Trial. Iran J Public Health.2021:50:9998. doi: 10.1018502/jiph.v5015.6116

44. H$\alpha$ gasagasi NH,Gurgun S. Effect of Delayed Cord Clamping on Breastfeed-ing Behaviors During the First Breastfeed: A Randomized Controlled Study.Breastfeed Med.2024;19:624-628. doi: 10.1089/bfm.2024.0080

45. Katiarya D, Swain D, Singh High S, Satapathy A. The Effect of Different Tim-ings of Delayed Cord Clamping of Term Infants on Maternal and Embross out of Normal Angular Deliveries. Cureus. 2021;13:e17169. doi:10.7759/cureus.17169

46. Kc A,Singhal N,G�arum J,Rana N,Andersson O.Effect of early versus de-layed cord clamping in neonate on heart rate, breathing and oxygen satura-tion during first 10 minutes of birth- randomized clinical trial. Matern Health Neonatal Perinol. 2019;5:7. doi: 10.1186/s40748-019-0103-y

47. Kilicdag Har, Karagun BS, Antmen AB, Candan E, Erbas H. Umbili-cal Cord Management in Late Preterm and Term Infants: A Randomized Controlled Trial. J. Perinatol. 2022;39:1308-1313. doi:10.1055/s0040-1722327

48.Korutis S, Ogu J, Bookays D, Turken GM, Gara K, Uyurg D, Oguz S. Evalu-ation of the Effects of Debye Related Cord Clamping in Infants of Diabetic Moth-ers.Am J Perinatol.2021;38:242-247.doi:10.1055/s-0039-1695799

49.Kumawat AK, Meena KK, Athwani V, Gothwal S, Gupta ML, Sitaraman S,Bairwa G. Effect of Umbilical Cord Milking in Term and Late Preterm Neo-nates: A Randomized Controlled Trial. Perinatology. 2022;22:258-265.

50. Mangla MK, Thukral A, Sankar MJ, Agarwal R, Deorari AK, Paul VK. Effect of Umbilical Cord Milking Delayed Cord Clamping on Venous Hematocrit at 48 Hours in Late Preterm and Term Neonates: A Randomized Controlled Trial. Indian Pediatr. 2020;57:1119-1123.

51. Manzoor M, Mubashir H, Uzair M, Shah Al, Rizwan AS, Sher SJ. Effect on Neonatal Hemoglobin and Hematocrit in Early Versus Delayed Cord Clamp-ing. Pak J Med Health Sc.2020;14:561-562.

52. Mercer J S.,Ersickon-Owans DA,Deoni SCL,Dean iIc DC,Tucker RJ,Parker AB,Joelson S. Mercer EN, Collins J, Padbury JF. The Effects of Delayed Cord Clamping on 12-Months Brain Myelin Content and Neurodevelop-ment: A Randomized Controlled Trial. Am J Perinol. 2022;39:37-44. doi:10.1055/s-0400-1741258

53.Songthamwat M, Witsavapaisan P, Tanthawat S, Songthamwat S. Ef-fect of Delayed Cord Clamping at 30 Seconds and 1 Minute on Neonatal

Liley et al

Neonatal Life Support: CoSTR 2025

Hematocrit in Term Cesarean Delivery: A Randomized Trial. Int J Womers Health.2020;12:481-486. doi:10.2021/147/JWH248709

54. Mukhtar S, Bashir S, Sabir F, Akram S, Akhtar N, Salam R, Saeed S. Com-parison of the Frequency of Neonatal Anemia in Early Versus Delayed Cord Clamping in Babies at Term. Pak Med Health Sci.2023;17:171-173. doi:10.53350/pjmsh2023176171

55. Murali S, Schuraman V. Scudene V. Jumadani E, Devul al. Devul 2022 clamping versus codling in virming in numerous neonates≥35 weeks gestation born via cesarean: A Randomized clinical trial. J. Neonatal Perinatal Med.2023;16:597-603. doi:10.10323/NF-230069

56. Ofojebe CJ, Eleje GU, Ikebechebel JU, Okpala BC, Ofojebe BA, Ugwu EO,lgibodke IP, Ovebungbae AR, Kuwka DC, Anikwe cc, et al. A randomized controlled clinical trial on peripartum effects of delayed versus immediate umbilical cord clamping on term newborns. Eur J Obstet Gynecol Reprod Biol.2021;2629-99,104. doi:10.1016/j/jeegh20210403.038

07. Orpak US,Ergin H, Crali C, Ozdermi O, Kosar Can O, Celik U. Comparison of cut and intact cord milking regarding cerebral oxygenation, hemodynamic and hematological adaptation of term infants. J Maternal Feonal Notab Med.2019;34:2359-2266. doi:10.1080/14767058.2019.1662781

58. OzbasI E, Takmaz O, Unsal G, Kazanci E, Demirece OZ, Saltin D, Sede F, Gongur M. Effects of cord clamping in sth-ative cesarese sec-tion on maternal and neonatal outcomes: a randomized trial. Arch Gynecol Obestt 2024:30081:1893-1881. doi:10.1007/s00404-023705-04705-4

59. Pan S, Lu Q, Lan Y, Peng L, Yu Hua, Y. Differential effects of delayed cord clamping on bilibrulin in normal and diabetic pregnancies. Eur J Pediatr:2022:18111:3111-1117. doi:10.1007/s0043-022-04536-2

60. Panburan P, Otdon Tghong, P. Pongsih Hansarwakea W. The Effect of Umbilical Cord Milking Compared with Delayed Cord Clamping in Term on onates: A Randomized Control Trial. Int J Wemsist Health: 2020/12:301-306. doi: 10.2147/JUWSH.S233487

61. Patel S, Patil N. Effect of early versus delayed cord clamping on hematocrit and serum bilirubin levels. Perinatology, 2021;22:15-19.

62. Purisch SE, Ananth CV, Arditi B, Mauney L, Ajemian B, Heiderich A.Leone TA, Gyaffman-Banneman C. Effect of Delayed vs Immediate Um-bilical Cord Clamping on Maternal Blood Loss in Term Cesana De-livery: A Randomized Clinical Trial. JAMA 2019;322:1869-1876. doi:10.1017/jama:2019.15995

63. Rana N, Kc A, Malvysit, M. Sbiend K, Andersson O. Effect of Delayed Cord Clamping of Term Babies on Neurodevelopment at 12 months: A randomized Controlled Trial. Neonatology. 2019;115:36-42. doi:10.1159/000491994

64. Rana N, Ranneberg LJ, MAlqvist M, Ashke SC, Anderson O. Delayed cord clamping was not associated with an increased risk of hypertibril-naemia on the day of birth or jaudein in the first 4 weeks. Acta Paediatr.2020;109:71-77. doi:10.1111/apa.14913

65. Rashwan A Eilday A, El-Harty A, Elsherbin M, Alexd-Rishao E,Mid E.M.Delayed versus early umbilical cord clamping for near-term infants born to preeclompic mothers; a randomized controlled trial. BMC Pregnancy Child-birth 2022:225:515. doi:10.1186/s12884-0204-0381-8.

66. Sahoo T, Thukral A, Sankar MJ, Gupta SK, Agarwal R, Deorari AK,Paul VK. Delayed cord clamping in R'hoolimmouled infants: a ran-domised controlled trial. Eur J Pediatr. 2020;179:881-899. doi:10.1007/s00431-020-03578-8

67. Schwaber B, Rbitsch M, Pichler G, Krainer A, Avan Baik-Schedntz N,Ziehberger E, Mieder LP, Martensen J, Mattersberger C, et al. Does physiological-based cord clamping more cerebral tissue oxygenation and perfusion in healthy term neonates? A randomized controlled trial. Front Pediatr: 2023;10:1005947. doi: 10.3389/pfed2022.1005497

68. Seliga-Siwecka JP, Puskar-Gasowska H, Tolloczock J. The risk of hy-perbilubinemia in term neonates after placental transfusion- a a randomized-blinded controlled trial. Ginekeol Pol.2020;91:613-619. doi:10.50603/Pa20200096

69. Shao H, Lan Y, Qian Y, Chen R, Peng L, Hua Y, Wang X. Effect of later cord clamping on umbilical cord blood gas in term neonates of diabetic mothers: a randomized clinical trial. BMC Pediatr: 2022:11:11. doi:10.1186/s12887-0221-0370-1

70. Shinohara E, Kataoka Y, Yaju Y. Effects of timing of umbilical cord clamping on preventing early infancy anemia in low-risk Japanese term infants with planned breast-freeding: a randomized controlled trial. Matem Health Neona-tol Perinol.2021;7:5. doi:10.1186/s40748-021-00125-7

6117. Singh B, Ramar P, Barra S, Bansal N, Singh G, Raghava K, Lodhi SK,Panchal A, Kumar S, Verma R. Comparison of Three Methods of Umbilical Cord Management in Late Preterm and Term Newborns on Hemoglobin and Ferritin levels at Six Weeks of Age: A Randomized Controlled Trial. Cureus 2024;16:e59046. doi:10.7759/cureus.59046

72. Soliman RM, Elgendy M, Said RN, Shaarawy BI, Helal OM, Aly H. A Randomized Controlled Trial of a 30- versus a 120-Second Delay in Cord Clamping after Term birth. Am J Perinolat 2024;41:739-746. doi:10.1054/a-1772-4543

73. Deleted in proof.

7. Tariq A, Mehmood S, Zahid MM, Arshad I. Frequency of Anemia in Delayed and Early Umbilical Cord Clamping after Birth in Newborn Babies. Med Fo-rum Mon.2023;34:14-16. doi:10.60110/medforum.340704

75. Tekin M, Gokdemir M, Toprak E, Silahli M, Energin H, Gokmen Z. The haemodynamic effects of umbilical cord milking in term infants: a ran-domised controlled trial. Singapore Med J. 2023;64:439-443. doi:10.1162/smedi=2022041

76. Vural I, Ozdemir H, Bilger N H, Ozek E, Teker G, Yoldemir T. Delayed cord clamping in term large-for-gestational age infants: A prospective randomised study.J Paediatd Child Health.2019;55:555-560. doi:10.1111/jpc.14242

77. Zanardo V, Guerrini P, Severino L, Simbi A, Parotto M, Straface G. A Ran-domized Controlled Trial of Intact Cord Milking versus Immediate Cord Clamping in Term Infarons Born by Elective Cesarean Section. Am J Perinatol 2021;38:392-397.10.1055/s-0039-1697673

78. Seidler AL, Gyte GML, Rabe H, Diaz-Rossello JL, Duley L, Aziz K,Testoni Costa-Nobre D, Davis PG, Schmzer GM, Ovelman C, et al; on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Umbilical Cord Management for Newborns<34 Weeks' Gestation: A Meta-analysis. Pediatrics. 2021;147:e20200576. doi:10.1542/peds.2020-0576

79. Seidler AL, Anderoumand, M; Hunter KE, Barba A, Libesman S, Williams JG,Shrestha A,Nideragur J,Sotropoulos JX,Montgomery AA,et al; on behalf of the iCOMP Collaborators. Deferred cord clamping, cord milking, and immediate cord clamping at preterm birth: a systematic review and indi-vidual participant data meta-analysis. Lancet 2023;402:2209-2222. doi:10.1016/S0140:6783(2023)02468-6

80. Seidler AL, Libesman S, Hunter KE, Barba A, Aberoumand M, Williams JG,Shrestha N, Aagerup J, Sotropoulos JX, Montgomery AA, et al; iCOMP Col-laborators. Short medium, and long deferral of umbilical cord clamping com-pared with umbilical cord emulating and immediate clamping at preterm birth: a systematic review and network meta-analysis with individual participant data network meta-analysis with individual participant data.Lancet 2023;402:2223-2334. doi:10.1016/S0140-6736(23)02469-8

81.Seider AL, Duley L, Katheria AC, De Paco Matallana C, Dempsey E, Rabe H,Kattwinkel J, Mercer J, Josephsen J, Fairchild K, et al; on behalf of the iCOMP Collaboration. Systematic review and network meta-analysis with individual participant data to perform data on cord management at preterm birth (iCOMP): study proto-col. BI; Open 2020;10x0a304595. doi: 10.1136/bmjopen-2019-034595

82.Bora RL,Bandyopadhyay S, Saha B, Mukherjee S, Hazra A. Cut um-bilical cord milling(CU-ICM) as a mode of placental transfusion in non-vigorous preterm neonates: a randomized controlled trial. Eur J Pediatr.2023;182:3883-3891. doi:10.1007/s00431-023-05063-4

83. Fairchild KD, Petroni GR, Varhegyi NE, Strand ML, Josephsen JB, Niermeyer S,Barnu JS,Warne R, Bencon M, Fang JL,et al; VentFirst Consortium.Ven-tilatory Assistance Before Umbilical Cord Clamping in Extremely Preterm Infants: A Randomized Clinical Trial. JAMA Netw Open.2024;7:e2411140 doi:10.1001/jametworkopen.2024.11140

84. Garcia Criot, Monte E, Escudero F, Bosh-Giménez V, Quesada L, Lewanczyk M, Perlegal M, Delgado J, Blanco-Carnero JE, De Paco Mattala C,N The impact of early versus delayed cord clamping on hematological and cardiovascular changes in preterm newborns between 24 and 34 weeks's gestation: a randomized clinical trial. Arch Gynecol Obstet. 2024;309:2483-2490. doi:10.1007/s1004-023-07119-0

85. Kuehe B, Grüttner B, Hellmich M, Hero B, Kribs A, Oberthuer A. Extra uterine Placental Perfusion and Oxygenation in Infants With Very Low Birth Weight: A Randomized Clinical Trial. JAMA Netw Open.2023;6:e2340597.doi:10.1001/janamerworkopen.2023.40597

86.Raja AVN, Balakrishnan U, Amboriamo R, Abiramathala T. Effect of Novel Placental Transfusion Technique-Gravity-Aided Cord Blood Transfusion at Birth on Hemoglobin Levels in Preterm Infants Born Less than 30 Weeks: A Randomized Controlled Trial. J. Neonatol. 2023;37:257-263. doi:10.1177/09732179231178120

87.Rao NN, Prakash NSF. Yamagoudar A. A randomised controlled trial com-paring umbilical cord milling to delayed cord clamping to delayed cord clamping at birth in preterm infants 28:36 weeks gestational age.Eur.J Pediatr.2024;183:2791-2796.

88. Zhang Y, Tao M, Wang S, Chen J, Hu Q, Luo S, Tang S, Zu M, Luo N, Wang Q,et al.Effectiveness and safety of umbilical cord milking in premature infants:A randomized controlled Trial. Medicine(Baltimore).2023;102:e36121.doi:10.1097/MD.0000000000036121

Liley et al

Neonatal Life Support: CoSTR 2025

89. Watson ED, Roberts LF, Harding JE, Crowther CA, Lin L. Umbilical cord milking and delayed cord clamping for the prevention of neonatal hypogly-caemia: a systematic review and meta-analysis. BMC Pregnancy Childbirth.2024:2448:0.10:11868/12884-024-06427-w

90. Lunze K, Bloom DE, Jamison DT, Hammer D.H. The global burden of neonatal hyperthermia: systematic review of a major challenge for newborn survival.BMC Med 2011;13:24:10.1186/1741:7015-11-24

91. Ramaswamy VV, de Almeida MF, Dawson JA, Trevisanuto D, Nakwa FL, Kamlin CO, Hosono S, Wyckoff MH, LIEG; H on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force.Maintaining normal temperature immediately after birth in late preterm and term infants: A systematic review and meta-analysis. Resuscitation 2022;180:81-98. doi:10.1016/j.resuscitation.2022.09.014

92. Tourneux P, Thiriez G, Renesme L, Zores C, Sizun J, Kuhn P; The Group of Reflection and Evaluation of the Environment of Newborns(GREEN)study group of the French Neonatology Society. Optimising homeo-thermy in neonates: a systematic review and clinical guidelines from the French Neonatal Society. Acta Padatex: 2022;111:1490-1499. doi: 10.1111/apa.16407

93.Ambia AM, Duryea EL, Wyckoff MH, Tao W, Mclntir, DEsealy AR, Moussa M, Lavenko J. A randomized trial of the effects of anbi-ent operating room temperature on neonatal morbidity. Am J Perinatol.202441±1553=1559=1559. doi:10.1055/a2053=7242

94. Brophy H., Tan GM, Yoxall CW. Very low birth weight outcomes and admis-sion temperature: does hyperthermia matter? Children. 2022;9:1706. doi: 10.3390/children11:0706.

95. Chiu M, Mir I, Adhikari E, Heyne R, Onelras N, Tolentino-Ptaka K, Thomas A, Burchfield P, Simcik V, Ramon E, et al. Risk factors for admission hydro-therperia and associated outcomes in infants born preterm. J. Pediat:2024;265:113842. doi:10.1016/j.jpeds.2023.113842

96. de Almeida MF, Ginsburg, San Cho RA, Rosa IR, Lamy ZC, Martinez,fe, da Silva RP, Ferrari, LS de Souza Rugolma, Abdul Mahadi VO, et al.Hypothermia and early neonatal mortality in preinfants. J Pediatr.2014:1642-27175e+2771.52; doi:10.1016/j.jpeds.2013.069.049

97. Wilson E, Maier RF, Norman M, Misselwitz B, Howell E, Theritil, J Bonamy AK; Effective Perinatal Intensive Care in Europe (EPICE) Research Group.Admission hypothesis in very preterm infants and neonatal mortality and morbidity.J Pediatr.2016;175:61-67e4.do.10.1016/j.jpeds.2016.04.016

98. Ramaswamy VV, Dawson JA, de Almeida MF, Trevison DAK, Nako FL, Kamino CF, Trang J, Wyckoff MH, Weiner GM, Liley HG; on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Maintaining normotherm imse-diately after birth in preterm infants <34's gesturation: A system-atic review and meta-analysis. Resuscitation. 2023;191:109934. doi: 10.1016/j.resuscitation:2023.109934

99.Dunne EA,Ni Chathaischa GM,Cheragky LE O'Donnell CP, McCarthy L.Kolyethylene polyheads bags core clamping in very preterm infants: a ran-domised controlled trial. Arch Disci Fetal Neonatal Ed.2024:109:317-321. doi: 10.1136/archidschild-2023-325808

100.Possidene ALC, Bazan IGM, Machado HC, BAmbra STM, Caldas JPS.Evaluation of two polyethylene bags in preventing admission hypo-thermia in preterm infants: a quasi-randomized clinical trial. J Pediatr.2023;99.51-120. doi: 10.1016/jjpedest 2023.004.004

101. Carreiro L, Al Sarout J, Jeanneaud C, Clenet N, Favrais G. Skin-to-skin contact for transferring preterm infants from the delivery room to the neonatal intensive care unit is promising despite moderate heat loss during the procedure. Am J Pernatol. 2024;41:e1037-e1044. doi: 10.1055/a-1979-8433

102.Kristoffersen, L Bergseng H, Engesland H, Bagstovald A, Aker K, Stoen R. Skin-to-skin contact in the delivery room for very preterm infants: a randomised clinical trial. B/MAPI datad Open. 2023;7:001831. doi: 10.1163/bpmj-2020-0018231.

103. Lode-Kolz K, Hermansson C, Linnér A, Klemming S, Hetland HB, Bergman N,Lillesoid S, Pike H, Westup B, Jonas W, et al. Immediate skin-to-skin contact after birth ensures stable thermoregulation in very preterm infants in high-resource settings. Acta Paediatr.2023;112:934-941. doi:10.1111/apa.11590.6590

104.MRini M, De Doncker L, Huet E, Rochez C, Kelen D. Skin-to-skin trans-fer for the delivery room to the neonatal unit for neonates of 1500g or above: a feasibility and safety. Front Pediatr. 2024;12:1379763. doi:10.3389/fped.2024.1379763.

105. Perman J, Willye J, Katwinkel J, Atkins D, Chlamides L, Goldsmith JP,Guinsburg R, Hazinski MF, Morley C, Richmond S, et al; on be JP, half of the Neonatal Resuscitation Chapter Collaborators. Part 11:

neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendation. Circulation. 2010;122:S516-S538. doi:10.10116/CIRCULATIONAHA.110.971127

10. Fawke J, Wyllie J, Udeeta E, Rudiger M, Ersdal H, Wright MD, Wyckoff MH, Liley HG, Rabi Y, Weiner GM; on behalf of the International Liaison Committee On Resuscitation Neonatal Life Support Task Force.Suctioning of clear amiotic fluid at birth: A systematic review. Resusc Plus.2022;12:100298. doi:10.1016/j.resplu.2022.100298

10. Nesterenko TH, Povicov S, Elgendy M, Mohamed MA, Aly H. Is it feasible to avoid suction before spontaneous breathing is established? J Neonatal Perinatal Med. 2023;16:387-391. doi: 10.3233/NPM-230080

108. Kattwinkel J, Niermeyer S, Nadkarni V, Tibballs J, Phillips B, Zideman D, Van Reempts P, Osmond M. Resuscitation of the newly born infant: an advisory statement from the Pediatric Working Group of the International Liaison Committee on Resuscitation. Eur J Pediatr. 1999;158:345-358.doi: 10.1007/s04310051090

10.1097:Srivaton D, Strand ML, Kawakami MD, Fabres J, Szyld E, Nation K, Wyckoff MH, Rabi Y, Lee HC; on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Tracheal suctioning of meconium at birth for non-vigorous infants: a system-atic review and meta-analysis. Resuscitation. 2020;149:117-126. doi:10.1016/j.resuscitation.2020.01.038

10.1130PPrastatinous N,Nartangmsunsan W,Ungtrakul T.Outcomes of endotra-cheal suctioning in non-vigorous neonates born through meconium-stained amniotic fluid: A systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed.2021;106:381-38. doi:10.1136/archischild-2020-318941

111. Ramamsavy V, Bandyopadhyay T, Nangia S, Kumar G, Pullatally AK,Trevisanuto D, Roehr CC, Lakshminirusha S. Assessment of change in practice of routine trachle suctioning approach of non-vigorous infants through neonatal swidinated amniotic fluid: a pragmatic systematic re-view and meta-analysis of evidence outside randomized trials. Neonatology.2023;120:161-175. doi: 10.1159/000528715

112. Allalehman Ei, Makhafri A, Bhamzhi M, A-Wassiah A. Have the 2015 Neonatal Resuscitation Program Guidelines changed the management and outcome of infants born through meconium-stained amniotic fluid?Ann Saud Med 2019;39:87-91. doi:10.5144/0256-4947.2019.87

113. Kalra,V. Leegwater AJ, Valadaputi P, Garlapati P, G. Larapati P, Chawla S, Lakshminrusimha S. Neonatal outcomes of non-vigorous neonates with meconium-stained amniotic fluid before and after change in tracheal suctioning recommenda-tion.J Perinatol.2022;42:769-774. doi:10.1038/s41372-021-01287-0

114. Kumar G, Goel S, Nangia S, Ramaswamy V. Outcomes of nonvigorous neonates born through meconium-stained amniotic fluid after a practice change to no routine ennototracheal suctioning from a developing country.Am J Peninatol.2004:41:1163-1170. doi:10.1055/a1-1797-7005

115. Li KL, Tang CH. A. Retrospective cohort study of tracheal intub-tion for merconium suction in nonvigorous neonates. Zhongguo Dang Dai Er Ke Za Zhi= Chin J Contemp Pediatr. 2022;24:65-70. doi: 10.7499/j.issn.1008-8830.2109178

116. Myers for Gupta AG. Impact of the revised NRP meconium aspiration guidelines on term outcomes. Hosp Pediatr. 2020;10:295-299. doi: 10.1542/hpeds.2019-0155

117. Oommen VI, Ramaswamy VV, Szyld E, Roehr CC. Resuscitation of non-vigorous neonates born through meconium-stained amniotic fluid:post policy change impact analysis. Arch Dis Child Fetal Neonatal Ed.2021;106:324-306. doi: 10.1136/archischild-2020-319771

118.Saint-Fleur Al, Alcaú HE, Sridhar S. Outcomes of neonates born through meonium-stained amniotic fluid pre and post 2015 NRP guideline implementation. PLoS One 2023;18:e0289945. doi:10.1371/journal.pone.0289945

19. Sheikh M, Nanda V, Kumar R, Khilfeh M. Neonatal Outcomes since the Implementation of No Routine Dotroneed Tracheal Suctioning of Meconium-Stained Nonvigorous Neonates. Am J Perinatol. 2024;41:1366-1372. doi:10.1055/a-1950-2672

120.International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Part 7: neonatal resuscitation. Resuscitation. 2005;67:293-303. doi:10.1016/j.resuscitation.2005.09.014

121. Kattwinkel J, Nierermey S, Nadkarni V, Tibballs J, Phillips B, Zideman D Van Reempts P, Osmon M. ILCOR advisory statement: resuscitation of the newly born infant. An advisory statement from the pediatric working group of the International Liaison Committee on Resuscitation. Circulation.1999;99:1927-1938. doi: 10.1161/01.cir.99.14.1927

Liley et al

Neonatal Life Support: CoSTR 2025

122. Deleted in proof.

123. Deleted in proof.

124. Quinsburg R, de Almeida MFB, Finan E, Perlman JM, Wyllie J, Liley HG, Wyckoff MH, Isamaer T, Tactile stimulation in newborns with inadequate respiration at birth: a systematic review. Pediatrics.2022;149:e2021055067. doi:10.1542/peds.2021-055067

150.Kaufmann M, Mense L, Springer L, Dekker J. Tactile stimulation in the delivery room: past, present, future. A systematic review. Pediatr Res.2024;96:616-624. doi:10.1038/s41390-022-01945-9

126. Gaertner Rd, Rüegger CM, Bassier D, CurOran, E.Klinu C: Hopfer SB, Davis PG, Springer L. Effects of tactile stimulation on spontaneous breathing during face mask ventilation. Arch Dis Child Fetal Neonatal Ed.2022;107:508-512. doi:10.1136/archids-2021-322989

127. Kaufmann M, Seipolt B, Rudiger M, Nense L, Tactile stimulation in very preterm infants and their needs of non-invasive respiratory support. Front Pediatr. 2022;10:1041898. doi:10.11389/fped2022.1041898.

128. Mayer, M Xhinti N, Dyavuza V, Bobotiana Y, Perlman J, Velaphi S.Assessing implementation of helping babies breathe program through observing immediate care of neonates at time of delivery. Front Pediatr.2022;10:864431. doi:10.3389/fped2.2022.864431.

120. Kapadia VS, Kawakami MD, Strand ML, Hurst CP. Spencer A.Schmolzer GM, Rabi Y, Wyllie J, Weiner G, Liley HG, et al; on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Fast and accurate newborn heart rate monitor-ing at birth: A systematic review. Resusc Plus. 2024;19:100668. doi:10.1016/j.respuplu:2024.100668

130. Kapadia VS,Kawakami MD, Strand ML, Gately S, Spencer A, Schmzer GM, Rabi Y, Wylie J, Weiner G, Liley HG, et al; on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Newborn heart rate monitoring methods at birth and clini-cal outcomes: A systematic review. Resusc Plus: 2024;19:100665. doi:10.1016/j.respupl.2024.100665

131. Mende S, Ahmed S, DeShea L, Szyl E, Shah BA. Electronic Heart (ECG)Monitoring at Birth and Newborn Resuscation. Children: 2024;11685.doi:10.3390/children11060685

132. Roehr CC, Davis PG, Weiner GM, Jonathan Wyllie, Wyckoff MH,Trevisuto D. T-piece resuscator or self-inflating bag during neona-tal resuscitation: a scoping review. Pediatr Res. 2021;89:760-766. doi:10.1038/s41390-020-1005-4

13. Trevisante A, Roode CC, Davis PG, Esner GM, Schnotzer GM, Wyckoff MH,Liley HG, Rabi Y, Weiner GM; on behalf of the International Liaison Committee On Resuscitation Neonatal Life Support for administering ventilation at birth: a systematic review. Pediatrics.2021;148:e2021050174. doi:10.1542/peds.2021-050174

13.Bellos I, Pillai A, Pandata A. Providing Positive End-Expratory Pressure during Neonatal Resuscitation: A Meta-analysis. Am J Perinatol 2024;41:690-699. doi:10.1055/a-1933-7235

135. Tribelov S, Hennyn R, Voire V. Ventilation devices for neonatal resus-citation at birth: A systematic review and meta-analysis. Resuscitation.2023:183:109681.d:10.1016/j.resuscitation:2022.109681

136. Khan M, Bateman D, Sahn R, Leone TA. Assisted ventilation: imdiately after birth with self-inflating bag versus T-piece resuscitation in preterm infants. J Neonatal Perinatal Med 2023;16:265-270. doi:10.3233/ NPM-210728

137. Pallapoth B, Priyadarishi M, Singh P, Kumar S, Chaurasia, S. Basu S,T-Piece resuscator versus self-inflating bag for delivery room resusculi-tation in preterm neonates: a randomized controlled trial. Eur J Pediatr.2023;182:5565-5576.doi:10.1007/s00431-023-05230-7

138.Subramanian P. Ho J, Davis PG. Prophylactic or very early ini-tiation of continuous airway pressure(CAPP) for preterm infants. Cochrane Database Syst Rev. 2021;10:CD001243. doi:10.1002/14651885.CD001234.pub4

139. Shah BA, Fabres JG, Leone TA, Schmolger GM, Sylzd EG; on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Continuous positive airway pressure for term and≥34+0 weeks' gestation newborns at birth: A systematic review. Resusc Plus 2022;12:100320. doi:10.1016/j.1895.2023.10320

140.Stocks EF,Jaleel M,Smithhart W,Burchfield PJ,Thomas A,Mangona KLM,Kapadia V,Wyckoff M,Kakkilaya V,Branen S,et al. Decreasing delivery room CPAP-associated pneumothorax at≥35-week gestational age.J Perinatal.2022;42:761-768. doi:10.1038/s41372-022-01334-4

141. Kapadia VS, Iruzberger B, Soraishan A. Liley HG, Schmolzer GM, Rabi Wyllie W, Jyckhoff MH; on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Center. Sustained lung

inflations during neonatal resuscitation at birth: a meta-analysis. Pediatrics.2021;147:e2020021204.doi:10.1542/peds.2020-021204

142. Abuel Ham WA, Elsheriny DE, El Houchi SZ, Iskandar IF,Akmal DM. Sustained Lung Inflation in Pre-term Infants at Birth:A Randomized Controlled Trial. J. Trop Pediatr. 2021;67:1. doi: 10.1093/tropej/fmao97

143. Yamada NK, McKinay CJ, Quek BH, Schmolzer GM, Wyckoff MH, Liley HG, Rabi Y, Weiner GM. Supraglottic Airways Compared With Face Masks for Neonatal Resuscitation: A Systematic Review. Pediatrics.2022:150x220256568. doi:10.1542/peds.2022-056568

144. Mathai SS,Adhikari KM,Joy A. Laryngeal Mask Airway as Primary Mode in Neonatal Resuscitation-Does it reduce Need of Positive Pressure Ventilation: Pediatr Res Int.J.2014;1-5. doi:10.5171/2014.216089

145. Antoine J, Dunn B, McLanders M, Jardine L, Liley H. Approaches to neo-natal intubation training: A scoping review. Resuscus Plus:2024;20:100776.

146. Granfeldt A, Avis SR, Nicholson TC, Holmberg MJ, Moskowitz A, Coker A, Bergal KM, Parr MJ, Donnino MW, Soar J, et al; on behalf of the International Liaison Committee on Resuscitation and Committee on Resuscitation Advanced Life Support Task Force Collaborators. Advanced airway management during adult car-diac arrest: A systematic review. Resuscitation. 2019;139:133-143. doi:10.1016/j.resuscitation.2019.04.003

147. Lavoras EJ. Onishino S, Nation K, Van de Voorde P, Nuthall G,Monacochle, I Torabi N, Morrison LJ, on behalf of the International Liaison Committee on Resuscitation(ILCOR) Pediatric Life Support Task Force. Advanced airway interventions for paediatric cardiac arrest: A system-otic review and meta-analysis. Resuscitation. 2019;138:114-128. doi:10.1016/j.resuscitation.2019.02.040

14. Diggikar S, Krishnegodwa R, Nagesh KN, Lakshminrusima S, Trevisanuto D. Laryngeal mask airway versus face mask ventilation or intubation for neonatal resuscitation in low-and-middle-income countries: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed.2023;108:156-163. doi: 10.1136/archild-2022-324472

149. Uuresh MJ, Kumar M. Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscita-tion. Cochrane Database Syst Rev.2018;3:CD003314. doi:10.1002/1465185.CD003314.pub3

150.EI-Ahmbadi M,El-Shimi MS,AbuSaif IS, Khafagy SM, Mohamed RM.Efficacy of largalousm dark airway in neonatal resuscitation. Egypt J Hosp Med.2018;70:1767-1772.

151.Feroze F, Masood N, Khuywaja A, Llyas Malik F, Neonatal resuscitation: The use of laryngeal mask airway. Professional Med J. 2008;15:148-152.

152. Yang C,Zhu X, Lin W, Zhang Q, Su J, Lin B, Ye H, Yu R. Randomized,controlled trial comparing laryngeal mask versus endotracheal intubation during neonatal resuscitation--a secondary publication. BMC Pediatr.2016;16:17:00.1186/s12887-016-0553-6

153. Zanardo V, Weiner G, Micaglio M, Doglioni N, Buzzacchero R,Trevanitano D, Delivery room resuscitation of near-term infants: role of the laryngeal mask airway. Resuscitation. 2010;81:327-330. doi:10.1016/j.resuscitation.2009.11.005

154. Deleted in proof.

155. Song ES, Jeon GW. Updates in neonatal resuscitation: routine use of laryngeal masks an alternative to face masks. Clin Exp Pediatr.2024;67:240-246.doi:10.3345/cep.2023.00619

156. Mani S, Gugino S, Helman J, Bawa M, Nair J, Chandrasekharan P, Rawat M. Laryngeal mask ventilation with chest compression during neona-tal resuscitation: randomized, non-inferiority trial in lambs. Pediatr Res.2022;92:671-677. doi:10.1038/s41390-021-01820-z

157.Mehream A,Graham R,Srinivasan G,Heese R,Dakshinaturm S.Laryngeal Mask Airway Versus Endotracheal Intubation for Positive Pressure Ventilation with Chest Compressions in Neonatal Porcine Model. Paediatr Child Health.2014;19:e57-e58.doi:10.1093/pch/19.6.e35-61

158.Chen KT,Lin HJ,Guo H.R,Lin MT,Lin CC.Feasibility study of epinephrine ad-ministration via laryngeal mask airway using a porcine model. Resuscitation.2006:69:503-507. doi:10.1016/j.resuscitation.2005.10.014

159. Liao C-K, Lin H-J, Foo N-P, Lin C-C, Guo H-H-R, Chen K-T. Epinephrine administration via a laryngeal mask airway: what is the optimal dose? Signa Vitae:2010;5:25-28. doi:10.22514/swv52.112010.4

160. Isobe A, SuiR, Katayama T, Mizumoto H. One-rescuer newborn CPR using a face mask or an i-gel supraglottic airway and two-finger compressions-A manikin study with cross-over design. Resuscus Plus: 2022;11:100276.doi: 10.1016/j.esplu.2022.100276

161. Weiner G, Zaichkin J. Textbook of Neonatal Resuscitation. 8th ed. American Academy of Pediatrics; 2021.

Liley et al

Neonatal Life Support: CoSTR 2025

162. Le Bastard Q, Rouziou J, Montassier E, Baert V, Recher M, Hubert H, Leuttere S, Javudin F; GR-RAC. Endotracheal intubation ver-susagtricologic procedure in paediatric out-of-hospital cardiac ar-reast: a registry-based study. Resuscitation: 2021:168:191-198. doi:10.1016/j.resuscitation.2021.08.015

163. Hansen ML, Lin A, Eriksson C, Dayma M, McNally, Bu R, Yanez D, Zive D, Newward C; CARES surveillance group. A comparison of pediat-ric airway management techniques during out-of-hospital cardiac ar-rest using the CARES database. Resuscitation. 2017;120:51-56. doi: 10.1016/j.resuscitation.2017;020:015.

164. Andersen LW, Raymond TT, Berg RA, Nadkarni VM, Grosestreuer EV, Kurth T, Donnino MW, American Heart Association's Get With The Guidelines-Resuscitation Investigators. Association between tracheal intubation during pediatric in-hospital cardiac arrest and survival. JAMA 2016,136:186-1797: doi:10.1001/jama.2016.14486

165. Wang CH, Lee AF, Chang WT, Huang ChT, Tsai MS, Chou E, Lee CC, Chen SC,Chen WJ. Comparing effectiveness of initial airway interventions for out-of-hospital cardiac: an systematic review and network meta-analysis of clinical controlled trials. Ann Emerg Med. 2020;75:627-636. doi:10.1016/j.ennermmed.2019.12.003

16. Forestell B, Ramsden S, Sharif S, Centoflani J, Lawati K A, Fernando SM,Welsford M, Nichol G, Nolan JP, Rochberg B, Supraglatic airway versus tracheal intubation for airway management in out-of-hospital cardiac ar: rest: a systematic review, meta-analysis, and trial sequential analysis of randomized controlled trials. Crit Care Med. 2024;52:e89-e99. doi: 10.1097/ccm000000000000000112

167. Isama T, Mildernall L, Scholmer GM, Kim H, Rabi Y, Ziegler C, Liley HG; on behalf of the International Liaison Committee On Resuscitation Newborn Life Support Task Force. The Route, Does, and Interval of Epinephrine for Neonatal Resuscitation: A Systematic Review. Pediatrics.2020;146:e20200586. doi:10.1542/peds:2020-0586

168. Kibsaard A, Ersald H, Kvaly E, Tlevjstjenn J, Rettedal S. Newborn requiring resuscitation: Two third have heart rate≥100 beats/minute in the first minute after birth. Acta Padiat: 2023:112697-705. doi: 10.1111/apa.166599

16. Monnelly V, Josephsen JB, Isayama T, de Almeida MFB, Guinsburg R,Schmolger GM, Rabi Y, Wyckoff MH, Weiner G. Liley H, EGI, H, et al. Exhaled CO2, monitoring to guide non-invasive ventilation that birth: a system-atic review. Arch Dis Child Fetal Neonatal Ed. 2023;109:74-80. doi: 10.1136/archidschild-2023-325698

170.Foglia EE, Ades A, Sawyer T, Glass KM, Singh N, Jung P, Quek BH,Johnston LC, Jiang Z17, Zenge J, et al. NEARNESO Investigators. Neonatal intubation practice and outcomes: an international registry study. Pediatrics.2019;143:e20180902. doi: 10.1542/peds.2018-0902

171.Esmal N, Saleh M, Al A. Laryngeal mask airway versus endotracheal in-tubation for Apgar score improvement in neonatal resuscitation. Egypt J Anesthesiol.2002;18:115-121.

172. Fawke J, Costa-Bnoe DT, Antoine J, Ginsburg R, de Ameida MF, Schmolzer GM, Wyckoff MH, Weiner GM, Liley HG; on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Video vs. traditional laryngoscopy for tracheal intubation at birth or in the neonatal unit: A systematic review and meta-analysis. Resusc Plus 2025/23:10096. doi:10.1016/j.respu2025.100965

173. Bartle DG, Powell R, Pearson K, Adeboye. TVS video for direct laryngoscopy.

174. Geraphyley L, Dunne EA, CM N, Vellinga A, Adams-AC Ocuram EM,McCarthy LK, O'Donnell CPF, Vector Seeous Direct Laryngoscopy for Urgent Intubation of Newborn Infants. ENJ Gell.2024;390:1885-1894. doi:10.1056/NEoJMA20240785

175. Moussa A, Luangxay Y, Tremblay S, Lavo Jie, A Ube G, Savoie E, Lachance C. Videolaryngoscope for teaching neonatal endotralache intubation:a randomized controlled trial. Pediatrics.2016;137:e2015156. doi:10.1542/peds.2015-2156

176. Osha JE, Tioe H, Mino KM, CO: Lloydner W, Longson C, John J. Roberts C, Kuschel C, Davis PG. Volearyngoscopy to teach neonatal in-tubation: a randomized trial. Pediatrics 2015;136:912-919. doi: 10.15142/peds.2015-1028

177. Tippmann S, Schafer J, Winter J, Mühler AK, Schmitk K, Schonfeld M,Eichinger M, Mildenberger E, Kidsuzan A. Video versus direct laryngoscopy to improve the success rate of nasotracheal in the neonatal intensive care setting: a randomised controlled trial. BMJ Paediatar Open.2023/57:00e1958. doi:10.1136/bmpo:2023-001958

178. Volz S, Stevens TP, Dadiz R. A randomized controlled trial: does coaching using video during direct laryospinology improve residents'

<EndOfPara>success in neonatal cubations? J Perinatol. 2018;38:1074-1080. doi:10.1038/s.1372018-0134-7

179. Lacquiere D, Smith J, Bhanderi N, Lockie F, Pickles J, Steere M, Craven J,Mazur S. Early experience in use of videolaryngosopy by a neonatal pre-hospital and seriral service. Emerg Med Australas.2024;36:476-478. doi:10.1111/1742-6723.14374

180. Bouwmeester RN, Binkhorst M, Yamada NK, Geurtzen R,van Heijst AFJ, Halamek LP, Draisma JMT, Hogeveen M. Appraisal of a scoring instrument for training and testing neonatal intubation skills. Arch Dis Child Fetal Neonatal Ed. 2019;104:F521-F527. doi:10.1136/archidschild-2018-315221

18.Falak Al,Escobedo MB,Baillargeon JG,Villard LG,Gunkel JH. Proficiency of pediatric residents in performing neonatal endotracheal intubation.Pediatrics.2003;112:1242-1247. doi:10.1542/peds.112.6.1242

18. Oonnell CP, Kamlin CO, Davis PG, Morley CJ. Ondetracheal intu-bation attempts during neonatal resuscitation: success rates, du-ration, and adverse effects. Pediatrics. 2006;117:e16-e21. doi:10.1542/peds.2005-0901

183. Rumpel J,ONéel K, Kaukis N, Rogers S, Stack J, Hollenberg J, Hall RW.Manikin to patient intubation: does it translate? J Perinatol. 2023;43:233-235. doi:10.1038/s41372-022-01553-9

184.Fuerch JH,Thio M,Halanek LP,Liley HG,Wyckoff MH,Rabi Y.Respiratory function monitoring during neonatal resuscitation: A systematic review.Resusc Plus:2022;12:100327. doi:10.1016/j.resplu.2022.100327

18. Baik N, Urlesberger B, Schwaberger B, Schmolzer GM, Avian A, Pichler G. Cerebral haemorrhage in preterm neonates: does cere-bral regional oxygen saturation during the immediate transition mat-ter? Arch Dis Child Fetal Neonatal Ed. 2015;100:F422-F427. doi:10.1136/archidschild-2014-307590

18. Monnelly V, Nakwa F, Josephsen JB, Schmolzer GM, Solvagv AL, Rabi Y,Wyckoff MH, Weiner GM, Liley HG; on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Near-infrared spectroscopy during respiratory support at birth: a systematic re-view. Arch Dis Child Felano Neonatal Ed.2025;fetalneonatal-etalneon2025.

187.Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subperdyminal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J Pediatr. 1978;92:529-534. doi: 10.1016/s0022-3476(78)80282-0

1887. Plicker U, Lruesberger B, Baik N, Schwaberger B, Binder-Heschl C, Avian A, Pansy J, Cheung Y, Schmolzer GM. Cerebral oxygen saturation to guide oxygen delivery in preterm neonates for the immediate transition after birth: a 2-center randomized controlled pilot feasibility trial. J Pediatr.2016;170:73-78. doi:10.1016/j.jpeds.2015.11.053

198. Pichler G, Goeral K, Hammerl M, Perme T, Dempsey EM, Springer L,Lista G, Szczapa T, Fuchs H, Karpinski L, et al; COSGOD III study group.Cerebral regional tissue oxygen saturation to guide oxygen delivery in preterm neonates during immediate transition after birth(COSGOD III):multicentre randomised phase 3 clinical trial. BMJ. 2023;380:e072313 doi:10.1136/bmj-2022-072313

10.Woflshberger CH, Schwaberger B, Urlesberger B, Scheucheneger A,Avian A, Hammer M, Kiehl-Kohlendorfer U, Griesmaer E, Pichler G.Cerebral oxygenation during immediate fetal-to-neonatal transition and fidegymetoseconds between six to 20 weeks of corrected age: An ancillary study to the COSGOD I trial. Eur J Pediatr. 2024;183:4425-4433. doi:10.1007/s00431-024-05711-3

191. Welford M, Nishiyama C, Short C, Weiner W, Coerne R, Regich, Osilyama T,Dawson JA, Wyckoff MH, Rabi Y; on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Initial oxy-gen use for preterm new born resuscitation: a systematic review with meta-analysis. Pediatrics 2019;143:1-17. doi:10.1542/peds.2018-1828

192. Soar J, Maconochie I, Wypockfich M, Olusaveengen TM, Singletary EM, Greif R,Aickin R, Bhanji F, Donnino MW, Mancini ME, et al. 2019 International Consensus on Cardopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: sum-mary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation. 2019;140:e826-e880. doi:10.1161/CIR/00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000

39. Soltropoulos J, OJei L, Schmolzer GM, Libesman S, Hunter KE, Williams JG, Webster A, Vento M, Kapadia V, Rabi Y,et al. Initial oxygen concentra-tion for the resuscitation of infants born at less than 32 weeks' gestation:a systematic review and individual participant data network meta-analysis.JAMA Pediatr.2024:1787:400.101/jamapediatrics.2024.1848

Liley et al

Neonatal Life Support: CoSTR 2025

194. Armanian AM,Badiee Z. Resuscitation of preterm newors with low con-centration oxygen versus high concentration oxygen. J Res Pharm Pract 2012;1:25-29. doi: 10.4103/2279-042X.99674

195. Boronat N. Aguar, M. Oarq R, Dorki i. M. Burgada M. Cemada M, Nunez A. Izquierdo M. Cubells E, Martinez M. et al. Survival and neurodevelop-mental outcomes of preterminates with different oxygen fractions.Pediatrics:2016;138:20161405. doi:10.1542/peds.2016-1405

19. Kapadia VS,Chalak LF, Sparks JE, Allen JR, Savani RC, Wyckoff MH.Resuscitation of preterm neonates with limited versus high oxygen strat-eg. Pediatrics.2013;132:e1488-1496: doi:10.1542/peds.2013-0978

197. Lundstrom KE, PyDs O., Greisen G. Oxygen at birth and prolonged core-ral basil reconstriction in preterm infants. Arch Ds Child Fetal Neonatal Ed.1995;73F-F81-F86. doi: 10.1136/n73.f281.

198. OeI JL, Saugstad OD, Lü K, Wright IM, Smy PT, Craven P, Wang YA,McWulan R, Cores E, Ward et al. Targeted oxygen in the resuscitation of preterm infants, a randomized clinical trial. Pediatrics 2017;139:26-26. doi: 10.1542/peds.2016-1452

199 Rabi, S Ninel: Schnal-Netl-Agure-A. Room-air versus oxygen adminis-tration for resuscitation of preterm infants: the ROAR study. Pediatrics.2011;128:e374-e381.doi:10.1542/peds.2010-3130

2000. Vento M, Moro E, Scrigr A, Luza Vll, Lörig G, Izquier, O 杍BERT, J. 2nd, Arduini A, Escobar JJ, Sastre J, et al. Preterm resuscitation with low oxy-gen causes less oxidative stress, inflammation, and chronic lung disease.Pediatrics.2009;124:e439-e449.d.100:1542/peds.2009-0344

201. Wang CL, Anderson C, Leone TA, Rich W., Govindaswini B, Finner NN.Resuscitation of preterm neonates by using room air or 100% oxygen.Pediatrics.2008;121:1083-1089. doi: 10.1542/peds.2007-1460

2022. Dekker J, Martherus T, Lopriore E, Giera M, McGillick EV, Hutten J,van Leuteren RW, van Kaam AH, Hopser TE, Pas IB. The effect of initial high vs. low FiO2 on breathing effort in preterm infants at birth: a randomized controlled trial. Front Pediat: 2019;7:504. doi: 10.3389/2019.00504

3043. Niner V.,Mero Saugdot. Study of room air versus 60%00y-gen for resuscitation of premature infants(PRESOX). NCT01773467.PACCest 17774678;tabhistory

204. Kaban RK, Aminullah A, Rohiswato R, Hegar B, Sukadari A, Davis PG. Resuscitation of very preterm infants with 30% vs. 50% oxygen: a randomized controlled trial. Paediatr Indonesia. 2022;62:104-114. doi:10.14238/p622.2022.104-14

2085. Linnyak A. Kumar, S. Daram V. Room air versus 100% oxygen for de-livery reosuit formation of preterm neonates in low resource settings: A randomised, blinded controlled trial. J Paedradel Child Health, 2023;59:794-801. doi: 10.1117/j.1163.1693.

206. Bell MJ, Ternberg MJ, Feigin RD, Keating JP, Marshall R, Barton L, Brotherton T. Neonatal necrotoring enterolocitis. Therapeutic deci-sions based upon clinical staging. Ann Surg. 1978;187:1-7. doi:10.1097/00000658-197801000-00001

207. Agruar, Blugada M, Escobar J. Resuscitation of ELBW infants with initial FIO, of 30% vs.60%, a randomized, controlled, blinded study; the REOX trial. In: Pediatric Academic Societes Annual Meeting (conference ab-tract). Washington DC; 2013.

208. Escrig R,Arruza L, Izquierdo I, Villar G, Saenz P, Gimeno A, Moro M, Vento M. Achievement of targeted saturation values in extremely low gesta-tional age neonates resuscitated with low or high oxygen concentra-tions: a prospective, randomized trial. Pediatrics 2008;121:875-881. doi:10.1542/peds.2007-1984

209. Kapadia VS, Lal CV,Kakkilaya V, Heyner R, Savani RC, Wyckoff MH. Impact of the neonatal resuscitation program-recommended low oxygen strategy on outcomes of infants born preterm. J. Pediatr: 2017;19:351-41. doi: 10.1016/j.jpeds.2017.08.074

10. Rook, D. Schierbeek H, Vento M, V ~Aiaorungbroeck H, van der Eijk AC.Longini M, Buonocore G, Escobar J, van Goudoever JB, Vermeulen MJ.Resuscitation of preterm infants with different inspired oxygen fractions.J Pediatr:2014;164:1322-1326.130. doi:1016/j.1008j/p.20140.2019

211. Shea BJ, Reeves BC, Wills H, Mamel C, Moran J, Moher D,Tugwell P, Welch V, Kristjansson E, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017;35874008. doi:10.1136/bmj.j4008

212. Sotropois JLO, SJchmer GM. Oei JL, JLibansman S, Hunter KE,Williams JG, Webster A, Tarnow-Mordi W, VOment, M aszaltes E, et al.RPROspective Meta-analysis of Trials of Initial Oxygen in preterm Newborns(PROMOTION): Protocol for a systematic review and prospective meta-analysis with individual participant data on initial oxygen concentration for

resuscitation of preterm infants. Acta Paediatr. 2023;112:372-382. doi:10.1111/apa.16622.

213. Harling AE,Beresford MW, Vince GS,Bates M, Yoxall CW. Does the use of 50% oxygen at birth in preterm infants reduce lung injury? Arch Dis Child Fetal Neonatal Ed.2005;90:F401-F405. doi:10.1136/adc.2004.059287

214. Law BHY, Asztalos E, Finer NN, Yaskina M, Vento M, Tarnow-Mordi W,Shah PS, Schmiber GM. Higher versus lower oxygen concentration during respiratory support in the delivery room in extremely preterm infants: a pilot feasibility study. Children.2021;8:942. doi: 10.3390/children8110942

215. Thamin V, Suagstad OD, Tarnow-Mordi W, Wang YA, Lui K, Wright IM,De Waal K, Travadi J, Smyth JP, Craven P, et al. Preterm infant outcomes after randomization to initial resuscitation with FiO2, 0.21 or 1.0. J Pediatr.2018;2015;55:61.e1.doi:10.1016/j.jpeds.2018.05.053

216. Dawson A, Kamin C, Wong D, Wong C, te Pas AB, O'Donnell CP, Donath SM, Davis PG, Morley CJ. Oxygen saturation and heart rate during de-livery room recombination of infants<30 weeks' gestation with air or 100% oxygen. Arch Dis Child Fetal Neonatal Ed. 2009;94:F87-F91. doi:10.1136/adc,2008;141341

217. Rabi Y, Lodha A, Soraisham A, Singhal N, Barrington K, Shah PS. Outcomes of preterm infants following the introduction of room air resuscitation. Resuscitation. 2015;96:252-259. doi:10.1016/j.resuscitation.2015.08.012

218. Soraisham AS, Rabi Y, Shah PS, Singhal N, Synnes A, Yang J, Lee SK,Lodha AK. Neurodevelopmental outcomes of preterm infants resuscitated with different oxygen concentration at birth. J Perinatol. 2017;37:1141-1147. doi: 10.1038/jp.20178.

219. Welsford M, Nishiyama S, Shortt C, Isayama T, Dawson J, Weiner G, Roehr CC, Wyckoff MH, Rabi Y; on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Room air for initat-ing term newborn resuscitation: a systematic review with meta-analysis.Pediatrics.2019;143:1-13. doi: 10.1542/peds.2018.1825

230. Schmolzer GM, Aszalton EV,Beltempo M,Boix H,Dempsey E,EI-Naggar W,Finer NN,Hudson JA, Mukerji A, Law BHY,et al; on behalf of the HiLo trial collaborators. Does the use of higher versus lower oxygen concentration improve neurodevelopmental outcomes at 18-24 months in very low birth-weight infants? Trials.2024;25:237. doi:10.1186/s13063-024-08080-2

21.Riley JS,Antiel RM,Rintoul NE,Ades AM,Wagar LN,Lin N,Herkert LM,DAgostino JA, Hoffman, Corp. Peranteau WH, et al. Reduced oxygen concen-tration for the resuscitation of infants with congenital diaphragmatic hernia.J Perinol.2018;38:834-843. doi:10.1038/s41372-017-0031-5

222. Ramachandran S, Bruckner M, Wyckoff MH, Schmolzer GM. Chest com-pressions in newborn infants: a scoping review. Arch Dis Child Fetal Neonatal Ed.2023;108:442-450. doi:10.1136/archidschild-2022-324529

223. Aranda-Garcia,San Roman-Mata S,Otero-Agra M,Rodriguez-Nunez A,Femndem-Zndem M, Navarro-Patón R, Barcala-Furelros. Is the over-the-head technique an alternative for crop pcr performed by a single rescuer? a randomized simulation study with lifeguards. Pediatr Rep.2024;16:100-109. doi:10.3390/pediatric16010010

224. Barcala-Furelos R, Barcala-Furelos M, Cano-Noguera F, Otero-Agra M,Alonso-Calvee A, Martinez-Isasi S, Aranda-Garcia S, López-Garcia S,Rodriguez-Nunez A. A comparison between three different techniques considering quality skills, fatigue and hand pain during a prolonged infant resuscitation: a cross-over study with lifeguards. Children. 2022;9:910. doi: 10.2399/children 9060910

225. Ciocari G, Sica a RDera T, Piva JP. Two-thumb technique is superior to two-finger technique in cardiopulmonary resuscitation of simulated out-of-fospital industrial arrest in infants. J Am Heart Assoc.2021;10:e018050 doi:10.1016/1JA.120.018050

226.Gugelmin-Almeida D, Clark R, Rolfe U, Jones M, Williams J. Dominant versus non-dominant hand during simulated infant CPR using the two-finger technique: a randomised study. Resusc Plus. 2021;7:100141. doi: 10.1016/j.repsu.2021.100141

227.Hirayama,Y Ito Y,Ogawa M,Fukushima Y,Ikeyama T.Quantitative assess-ment of chest compression techniques on an infant manikin. Pediatr Int.2022;64:e115118. doi:10.1111/ped.15118

228. Jahnsen J, Gonzalez A, Fabres J, Bahamondes A, Estay A. Effect of two different chest compression techniques on ventilation dur-ing neonatal resuscitation. J Perinatol. 2021;41:1571-1574. doi:10.1038/s41372-021-01061-2

229.Jonew,W.,Ko J,Yong,Lee J.New chest compression method in infant resuscitation: Cross thunk technique. PLoS One 2022;17:e0271636. doi:10.1371/joupano.0271636

320.Ko CL,Tsou JY,Hong MY,Chang CJ,Tu YF,Huang SP,Su FC,Chi CH.A novel CPR-assist device vs. established chest compression techniques

Liley et al

Neonatal Life Support: CoSTR 2025

in infant CPR: A manikin study. Am J Emerg Med. 2024;77:81-86. doi: 10.1016/j.ajem.2023.12002

231. Bruckner M, Neset M, O'Reilly M, Lee TF, Cheung P, Sychmolzer GM. Four different finger positions and their effects on hemodynamic changes during chest compression in asphyxiated neonatal piglets. Children (Basel,Switzerland).2023;10:283. doi:10.3390/children/10020283

232.OnConnell, KJ and Sandler A, Dutta A. Ahmed R, Neubrand T. Myers, S Kereto B, Donoghue A. The effect of hand position on chest compression quality during CPR in young children: findings from the Videography in Pediatric Resuscitation(VIPER) collaborative. Resuscitation.2023;185:109741.d 10.1016/j.resuscitation.2023.109741

233. Namey,S-Cheung PY, Lee TF, O'Reilly M, Schmolzer GM. A Randomized,Controled Animal Study: 21% 100% Oxygen during cardiopulmonary resuscitation in asphyxiated infant piglets. Children (Basel, Switzerland).2022:1601:1. doi:10.3390/children@11601160

234. Sankaran D, Giustos EM, Lesneski AL, Hardie ME, Joudi HM, Lane ECA,Hammitt VL, Tully KC, Vali P, Lakshmirusha S. Randomized trial of 21%versus 100% oxygen during chest compressions followed by gradual ver-sus abrupt oxygen titration after return of spontaneous circulation in neona-tal lambs. Children (Basel). 2023;10:575. doi: 10.3390/children10030575

23.ORell M, Lee TF, Cheung Py, Schmözer GM. Comparison of her-modynamic effects of chest compression delivered via machine or human in asphyssitated leptons. Pediatr Res. 2024:95:156-159. doi:10.1038/s41390-023-28274.

236. Lee S, Song Y, Lee J, Oh J, Lim TH, Ahn C, Kim IY. Development of smart-ring-based chest compression depth feedback device for high quality chest compressions: a proof-of-concept study. Biosensors. 2021;11:35. doi: 10.3390/bios 11020035

1927.Wagner M,Groplel P,Ebelstein F,Kessler L,BibK,Gliz B,Herger A.Cardona FS. Visual attention during pediatric resuscitation with feedback devices: a randomized simulation study. Pediatr Res. 2022:91:1762-1768.10. doi:10.3081/s41390-01-021-1653-w

238. Bruckner M, Kim SY, Shim GH, Neset M, Garcia-Halgocl, C Lee TF, O'Reilly M, Cheung P, Schmlzer GM. Assessment of optimal chest compression depth during neonatal cardiopulmonary resuscitation: a randomised con-trolled animal. Arch Dis Child Fetal Neonatal E, 2022:107;262:268. doi:10.1136/archidschid-2021-321860

239. Bruckner M, O'Reilly M, Lee TF, Neset M, Cheung PY, Schmolzer GM. Effects of varying chest compression depths on carotid blood flow and blood pressure in asphylated piglets. Arch Di Child Fetal Neonatal Ed.2021;106:553-556. doi: 10.1136/archidschild-2020-319473

240 Lee J. Lee DK, OJ H, Park SM, Kang K H. Lim H, Jo J. Ho K, Soch PO. Evaluation of the proper chest compression depth for neonatal resus-citation using computed tomography: A retrospective study. Medicine(Balimore) 2021;100:e26122; doi: 10.1097/MD.0000000000026122

241.Meyer A,Nadkami V,Pollock A,Babbs C,Nishisiaki,A Braga,M.Berg RA,Ades A. Evaluation of the neonatal resuscitation program's recommended chest compression depth using computerized tomography imaging. Resuscitation 2010:81:544-548. doi:10.1016/j.resuscitation.2010.01.032

242. Kayama T, Hizumi T, Kikuyama K, Niles D, Nadkami V, Ito K. Chest compression depth targets in critically ill infants and children me-sured with a laser distance meter: single-center retrospective study from Japan, 2019-2022. Pediatr Care Med 2024;27520-727-727. doi:10.1097/PCC.0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000

243. Moya F, James LS, Burnard ED, Hanks EC. Cardiac massage in the new-born infant through the intact chest. Am J Obstet Gynecol 1962;84:798-803. doi: 10.1016/0002-9378(62)90035-2

244. Orlowski JP. Optimum position for external cardiac compression in in-fants and young children. Ann Emerg Med. 1986;156:677-637. doi:10.1016/s0196-0644(86)80423-1

245 FILinho D. Kettrik RG, Wagner H. Redswole D. The heart is under the lower third of the sternum. Implications for exter-nal cardiac massage. Am J Dis Child. 1986;140:646-649. doi:10.1001/chapsperi.1886.02140214004022

246.Phillows GW,Zideman DA. Relation of heart treatment to sternum: its signifi-cance in cardiopulmonary resuscitation. Lancet. 1986;1:1024-1025. doi:10.1016/s0140-07636(86)91294-53.

247. Shah NM,Gaur HK. Position of heart in relation to sternum and nipple line at various ages. Indian Pediatr. 1992;29:49-53.

<BeginOfPara>248. Clements F, McGrawan J. Finger position for chest compressions in cardiac arrest in infants. Resuscitation.2000;44:43-46. doi:10.1016/s0300-977(2022)1000-165.3

249.You O. Optimum location for chest compressions during two-Resuscert precrun cardiac pulmonary resuscitation. Resuscitation. 2009;80:1378-1381. doi:10.1016/j.resuscitation.2009.08.013

250.Alsaleme M, Zeinali Li, Mathew B, Kumar VHS. Glucose levels during the first 24 hours following perinatal hypoxia. Am J Perinatol. 2021;38:490-496.496. doi:10.1055/s-0039-1698834

251. Halling C, Conroy S, Raymond T, Foglia EE, Haggerty M, Brown LL,Wyckoff MH; American Heart Association's Get With The Guidelines Resuscitation Epinephrine during neonatal cardiopulmonary resuscitation in the delivery room: review of a national database. J Pediatr. 2024;271:114058. doi:10.1016/j.jpeds.2024.114058

252. Halling C, Raymond T, Brown LS, Ades A, Foglia EE, Allen E, Wyckoff MH;American Heart Association's Get With The Guidelines-Resuscitation Investigators. Neonatal delivery room CPR: An analysis of the Get with the Guidelines-Resuscitation Guidelines-Resuscitation Registry. Resuscitation. 2021;158:236-242.doi:10.1016/j.resuscitation.2020.10.007

253.Holmberg MJ, Ross CE, Yankama T, Roberts JS, Andersen LW; American Heart Association's Get With The Guidelines®-Resuscitation Investigators.

254. de Jager J, Pohof R, Crossley KJ, Schmolzer GM, Te pas AB, Galinsky R,Tran, NT, Songstad NT, Klingenberg C, Hooper SB, et al. Evaluating the efficacy of endotracheal cheal and intranasal epinephrine administration in severely asphytic bradycal newborn lambs: a randomised pre-clinical study. Arch Dis Child Fetal Neonatal Ed. 2024;110:207-212. doi:10.1136/archild-2024-327348

255.Roberts CT, Klink S, Schmolzer GM, Blank DA, Badurdeen S, Crossley KJ, Rodgers K, Zhara V, Moxham A, Roehr CC, et al. Comparison of in-trosseous and intravenous epinephrine administration during resuscita-tion of asphyssivated newborn lambs. Arch Dis Childhood Fetal Neonatal Ed.2022;107:311-316. doi:10.1136/archidschild-2021-322638

256. Polglase GR, Schmolzer GM, Roberts CT, Blank DA, Badurdeen S,Crossley KJ, Miller SL, Stojanovska V, Galinsky R, Kluckow M, et al. Cardiopulmonary resuscitation of asystolic newborn lambs prior to um-bilical cord clamping; the timing of cord clamping matters! Front Physiol.2020;11:902. doi:10.3389/fphys.2020.00902

257. Polglase GR, Brian Y, Tantanis D, Blank DA, Badurdeen S, Crossley KJ, Kluckow M, Gill AW, Camm E, Galinsky R, et al. Endotracheal epinephrine at standard versus high dose for resuscitation of asystolic newborn almb. Resuscitation. 2024;198:110191. doi:10.1016/j.resuscitation.2024.110191

258. Sankaran D, Vali P, Chandrasekharan P, Chen P, Gugino SF,Koenigsknecht C, Helman J, Nair J, Mathew B, Rawat M, et al. Effect of a larger flash volume on bioavailability and efficacy of umbilical venous epinephrine during neonatal resuscitation in ovine asphyxial arrest. Children 2021:8464. doi: 10.3390/children8060464

259. Songstad, NT, Klingberg C, Gilclick EV, Polglase GR, Zahra V,Schmolzer GM, Davis PG, Hooper SB, Crossley KJ. Efficacy of intrave-nous, endotracheal, or nasal adrenaline administration during resusci-tation of near-term asphyxiated lambs. Front Pediatr. 2020;8:262. doi:10.3389/fped.2020.00262

260.Andersen HB, Anderson M, Andelius TCK, Pedersen MV, Lofgren B, Pedersen M, Ringberg S, Kyng KJ, Henriksen TB. Epinephrine vs placebo in neonatal resuscitation: ROSC and brain MRS/RMI in term pigs. Pediatr Res. 2023;93:511-519. doi: 10.1038/s41390-022-02126-4

261. Berkehamer SK, Vallai P, Nair J, Gugino S, Helman J, Koenigsknecht C,Nielsen L, Lakshminusimha S. Inadequate bioavailability of intramuscular epinephrine in a neonatal asphyxia model. Front Pediatr. 2022;10:828130 doi: 10.3389/fped.202282130

262. Vali P,Chen P, Giusto E M, Lesneski AL, Hardie ME, Knych HK, Sankaran D, Ahnassen Z, Joudi HM, Lakshminusrius M. Direct umbilical vein in-jection of epinephrine with cut-cord milking in an ovine model of neo-natal resuscitation. Children(Basel, Switzerland). 2024:11:527. doi:10.3390/children:11050527

263. Chalikala Sk, Farpenova H, Pourcyrous M. The effects of sodium bicar-bonate infusion on cerebrovascular function in newborn pigs. Pediatr Res.2022:929:729-736. doi:10.1038/s41390-021-01876-x

264. Liu H, Cao Y, Xue X, Bai Z, Wu S. Clinical efficacy of sodium bicarbon-ate in treating pediatric metabolic acidosis with varying level of acid-base balance parameters: a real-world study. BMC Med. 2023;21:473. doi:10.1186/s12910-023-03189-8

265. ILCOR. The International Liaison Committee on Resuscitation (ILCOR)consensus on science with treatment recommendations for pediatric and neonatal patients: pediatric basic and advanced life support. Pediatrics.2006;1175±997.677. doi:10.1542/peds.2006-0206

Liley et al

Neonatal Life Support: CoSTR 2025

266. Ali M. Farghaly MAA, El-Dib I, Karnati S, Aly H, Acun C. Glucose in-stability and outcomes of neonates with hypoxic ischemic encephalopathy undergoing therapeutic hypothermic. Brain Dev.2024;46:262-267. doi:10.1016/j.braindev.2024.05.003.

267. Deleted proof.

268. Barber CA, Wyckoff MH. Use and efficacy of endotraleas versus in-travenous epinephrine during neonatal cardiopulmonary resusca-tion in the delivery room. Pediatrics. 2006;118:1028-1034. doi:10.1542/peds.2006-0416

269. Basu P. S. Choudhuri N. Das H. Contribution of the blood glu-cose level in perinatal asphyxia. Eur J Pediatr. 2009;168:833-838. doi: 10.1007/s00431-008-0844-5

270. Basu SK, Kaiser, JR, Duffine K, MinD CG, Guillet R, Gunn AJ; CoolCap Study Group. Hypoglycaemia and hyperglycaemia are associated with un-favourable outcome in infants with hypoxic ischaemic encephalopathy; a post hoc analysis of the CoolCap Study. Arch Dis Child Fetal Neonatal Ed 2016;101:149-F155. doi: 10.1136/archidschild-2015-308733

271. Basu SK, Ottolini K, Govei D, Vashat M, Savat S, Vina G, Wang R, Ridore M, Chang T, Kaiser JR, Massaro AN. Early glycemic profile is associ-ated with brain injury patterns on magnetic resonance imaging in hy-poxic ischemic encephalopathy. J Pediatr. 2018;2037:143-139. doi:10.1016/j.jpeds.2018.07.041

272. Basu SK, Salemi JL, Gunn AJ, Kaiser, JR. CoolCap Study Group.Hyperglycaemia in infants with hypoxic isemicence cephalotry is as-sociated with improved outcomes after therapeutic hypothemia: a post hoc analysis of the CoolCap Study. Arch Dis Child Fetal Neonatal Edt 2017;102:599-F306. doi:10.1136/archischd-2016-311385

273. Davis DJ,Creery WD, Radziuk J.Inappropriately high plasma insulin lev-els in suspected perinatal asphysis. Acta Mediat: 1999:88:76-81. doi:10.1080/08035259950170655

278. Debliton T,Sentithes L,Kayem G,Chevaller M,Zitellin J,Baud O,Vilotit P,Aerrat V, Guellicr I, Encel P, Acte R, Risk factors for unfavorable out-come at discharge of newborns with hypoxic-ischemic encephaloma:thfy in the era of hypotherma. Pediat Res.2023:953:1975-1982; doi:10.1038/s41390-022-02352-w

275. Fitzgerald MP, Reynolds A, Garvey CM, Norman G, King MD, Hayes BC.Hearing impairment and hypoxis achaemic encephalopathy. Incidence and associated factors. Eur J Paediatr Neurol. 2019;23:81-86. doi:10.1016/j.ejpn.2018.10.002

276. Frazder M. Werthammer J. Post-resuscitation complications in term neo-nates.J.Perninol.2007;27:82-84.doi:10.1038/sjjp.7211644

277. Galderis A, Rontin M, Supplin A, Caineil E, Barreidi E, Travensuto D. Glucose-to-lactate ratio and neurodevelopment in infants with hypoxic-chemic anencephalopathy: an observational study. Eur J Pediatr. 2023;182:837-844.dol.10:1007/0431-022-04694-3

278. Guellic l, Ancel PY, Beck J, Loron G, Chevallier M, Pierat RT, Kayama G, Vilitiot A, Baud O, Ego A, et al. Glycemia and neonatal cephalopathy: outcomes in the LYOTONEAL Long-Term Outcome of Neonatal Hypoemic EncePhALopathy in the era of neuroprotective treatment with hypothermia)cohort. J Pediatr.2023;257:113530. doi:10.1016/j.1ppeds.2023.02.003

297. Lee IC, Yang JJ, Liou YM. Early blood glucose level post-admission cor-relates with the outcomes and oxidative stress in neonatal hypoxic ischemic encephalopathy. Antoxidants(Basel, Switzerland) 2021:11:39.doi:10.3390/antiox11010398.

280. Liu CH, Liu HY, Peng SP, Pan S, Wan ZT, Wu SY, Fang CC, Jiao R, Wang WX, Gan B, et al. Effect of birth asphyria on neonatal blood glucose during the early postnatal life: A multi-center study in Hubei Province, China Pediatr Neonat.2023:64:562-569. doi:10.1016/j.pedena.2021.11.016

281. Mietzsch U. Wood RW, T. Wu, Naratajan N. Giass HC, Gonzalez FF,Mayock DE, Comstock BA, Heagery PJ, Juul SE, et al; HEAL Study Group. Early glycemic state and outcomes of neonates with hypoxic-emic ischaemic encephalopathy. Pediatrics.2023;152:e202060965. doi:10.1542/peds.2022-060965

282. Montallo P. Caredella E, Pugliese L. Zanthardino A. Debyeellay E, Cisnera A,Depozzi L,Chello G,Capristo C, Miraglia Del Giudice E,et al. Continuous glucose monitoring profile during therapeutic hyphenemia in encephalo-pathic infants with unfavorable outcome. Pediatr Res 2020:888:218-224 doi:10.1038/s41390-020-0827-4

2839. Nadeem M, Murray DM, Boylan GB, Dempsey EM, Ryan CA. Early blood glucose profile and neurodevelopmental outcome at two years in neonatal hypoxic-ischaemic encephalopathy. BMC Pediatr. 2011:11:10. doi:10.1186/1471-2431-11-10

24ERAM. Deierē CS, V der Jies, LS van der Aa NE, Eijsermans MJC, Harteman JC, Lequin MH, Swanenburg de Veyh FHI, Koopan-Sseboom C,

Groenendaal F. Hypoglycemia in Infants with hypoxic-ischemic en-cephalopathy is associated with additional brain injury and worse neurodevelopmental outcome. J Pediatr. 2022;245:30-38.e1. doi:10.1016/j.jpeds.2022.01.051

28. Pinchefsky EF, Hahn CD, Kamino D, Chau V, Brant R, Moore AM,Tam EW. Hyperglycemia and glucose variability are associated with worse brain function and seizures in neonatal encephalopa-hy: a prospective short study. J Pediatr. 2019;209:23-32. doi:10.1016/j.jpeds.2019.02.027

28. Sahlab WA, Wyckoff MH, Laptook AR, Perlman JM. Initial hypoglyce-mia and neonatal brain injury in term infants with severe fetal acidemia.Pediatrics.2004;114:361-366. doi: 10.1542/peds.114.2.361

287. Spies EE, Lababidi S.L., McBride MC. Early hyperglycemia is associated with poor gross motor outcome in asphyxiated term newborns. Pediatr Neurol.2015:50:586-590. doi: 10.1016/j.pediatriu.2018.10.014.01.043

282.Tam EW, Haeusslein L. Bonifacio SL, Glass HC, Rogers EE, Jeremy RJ, Barkovich AJ, Ferniero DM. Hypoglycemia is associated with in-creased risk for brain injury and adverse neurodevelopmental outcome in neonates at risk for preencephalopathy. J Pediatr. 2012;161:88-93. doi:10.1016/j.jpeds.2011.11.2.047

209.Tan JKG, Minitullo C, McMichael J, Rao S. Impact of hypoglycaemia on neurodevelopmental outcomes in hypoxic ischaemic encephalopathy: a retrospective cohort study. BMJ Paediatr Open.2017;1:e000175. doi:10.1136/bmjp:2017-000175

290.Wang J, Liu N, Zheng S, Wang X, Zhang P, Lu C, Wang L, Zhou W,Cheng G, Hu L, Association between continuous glucose profile dur-ing therapeutic hypothesis and unfavorable outcome in neonates with hypoxic-iscemic encephalopathy. Early Hum Dev.2023;187:105878. doi:10.1016/j.hearumdbunder.2023.105878

291. Deleted in proof.

292. Chao CR, Hohimer AR, Bissonette JM. The effect of elevated blood glucose on the electroncephalogram and cerebral metabolism dur-ing short-term brain ischemia in fetal sheep. Am J Obstet Gynecol.1989;161:221-228.doi:10.1016/0002-9378(89)90270-6

293. Dawes G, Hibbard EE, Windle WF. The effect of alkali and glu-cose infusion on permanent brain damage in rhesus mon-keys asphylaxated at birth. J Pediatr. 1964;65:801-806. doi:10.1016/s0022-3476(64)80001-9

294. Hattori H, Wasterlain CG. Posthypoxic glucose supplement reduces hypoxic: brain damage in the neonatal rat. Ann Neurol.1990;28:122-128. doi:10.1002/ana.410280203

295.McGowan JE, Marro PJ, Mishra OP, Delivoria-Papadopoulos M. Brain cell membrane function during hypoxia in hypergly-cemic newborn piglets. Pediatr Res. 1995;37:133-139. doi:10.1013/00006450-199502000-00001

296. Anju TR, Abraham PM, Altony S, Paulose CS. Alterations in cortical GABAB receptors in neonatal rats exposed to hypoxic stress: role of glucose, oxy-gen, and epinephrine resuscitation. Mol Cell Biochem.2010;343:1-11. doi:10.1007/s11010-010-0491-9

297. Anju TR, Ajayan MS, Paulose CS. Disruption of cerebellar cholinergic system in hypoxic neonatal rats and its regulation with glucose, oxygen and epinephrine resuscitation. Neuroscience. 2013;236:253-261. doi:10.1016/j.neuroscience.2012.12.056

298. Anju TR, Anitha M, Chinthu R, Paulose CS. Cerebellar GABA(A) recep-tor alterations in hypoxic neonatal rats: Role of glucose, oxygen and epinephrine supplementation. Neurochem Int. 2012;61:302-309. doi:10.1016/j.neunint.2012.05.023

299.Anju JR, Babu A, Paulo CS. Superoxide dismutase functional regulation in neonatal hypoxiae effect of glucose, oxygen and epinehrage. Indian J Biochem Biophys.2009;46:166-171.

300.Anju TR, Boiny J, Anitha M, Paulose CS. Striatal GABA receptor al-terations in hypoxic neonatal rats: role of glucose, oxygen and epi-terations in hypoxic neonatal rats: role of glucose, oxygen and epi-terations in hypoxic neonatal rats: role of glucose, oxygen and epi-terations in hypoxic neonatal rats: role of glucose, oxygen and epi-terations in hypoxic neonatal rats: role of glucose, oxygen and epi-terations in hypoxic neonatal rats: role of glucose, oxygen and epi-terations in hypoxic neonatal rats: role of glucose, oxygen and epi-terations in hypoxic neonatal rats: role of glucose, oxygen and epi-terations in hypoxic neonatal rats: role of glucose, oxygen and epi-terations in hypoxic neonatal rats: role of glucose, oxygen and epi-terations in hypoxic neonatal rats: role of glucose, oxygen and epi-terations in hypoxic neonatal rats: role of glucose, oxygen and epi-terations in hypoxic neonatal rats: role of glucose, oxygen and epi-terations in hypoxic neonatal rats: role of glucose, oxygen and epi-terations in hypoxic neonatal rats: role of glucose, oxygen and epi-terations

301. Anju TR, Jayanarayanan S, Paulose CS. Decreased GABAB receptor func-tion in the cerebellum and brain stem of hypoxic neonatal rats: role of glucose, oxygen and epinephrine resuscitation. J Biomed Sci 2011;18:31.

302. Anju TR, Korah PK, Jayananarayan S, Paulose CS. Enhanced brain stem 5HT2A receptor function under neonatal hypoxic insult: role of glucose, oxygen, and epinephrine resuscitation. Mol Cell Biochem. 2011;354:151-160. doi:10.1107510110-0814-5

303. Anju TR, Matthew J, Jayanaranayan S, Paulose CS. Cerebellar 5HT2A re-ceptor function under hypoxia in neonatal rats: role of glucose, oxygen, and

Liley et al

Neonatal Life Support: CoSTR 2025

epinephrine resuscitation. Respir Physiol Neurobiol. 2010;172:147-153.

304. Anju TR, Naiji G, Shilpa J, Roshni T, Paulose CS. Neonatal hypoxic insult-mediated cholinergic disturbances in the brain stem: effect of glucose, oxygen and epinephrine resuscitation. Neurol Sci. 2013;34:287-296. doi:10.1007/s10072-012-0988-x

305. Anju TR, Paulose CS. Amelioration of hypoxia-induced striatal 5-HT(2A)receptor, 5-HT transporter and HHT1 alterations by glucose, oxygen and epinephrine in neonatal rats. Neurosci. Lett. 2011;502:129-132. doi:10.1016/j.neulet2011.05.2366

306. Anju TR, Paulose CS. Striatal cholinergic functional alterations in hypox-ic neonatal rats: role of glucose, oxygen, and epinephrine resuscitation. Biochem Cell Biol.2013;91:350-356. doi:10.1139/bcb-2012-0102

307. Anju TR, Peeyush Kumar, T. Paulose CS. Decreased GABAA receptors functional regulation in the cerebral cortex and brainstem of hypoxic neonatal rats: effect of glucose and oxygen supplementation. Cell Mol Neurobiol.2010;30:599-606. doi:10.1007/s10571-009-9485-0

308. Anju TR, Smijin S, Chinuth R, Paulose CS. Decreased cholinergic function in the cerebral cortex of hypoxic neonatal rats: role of glucose, oxygen and epinephrine resuscitation. Respir Physiol Neurobiol. 2012;180;8-13. doi: 10.1016/j.resp.2011.08.013

309. Anju TR, Smijin S, Korah PK, Paulose CS. Cortical 5HT 2A recep-tor function under hypoxia in neonatal rats: role of glucose, oxygen,and epinephrine resuscitation. J Mol Neurosci. 2011;43:350-357. doi:10.1007/s12031-010-9449-3

310. Chathu F, Krishnakumar A. Paulose CS. Acetylcholine erase activity and behavioral response in hypoxia induced neonatal rats: effect of glucose,oxxygen and epinephrine supplementation. Brain Cogn. 2008;68:59-66. doi:10.1016/j.bandc.2008.02.124.

311. Joseph B, Nandhu MS, Paulose CS. Dopamine D1 and D2 receptor functional down regulation in the cerebellum of hypoxic neonatal rats:neuroprotective role of glucose and oxygen, epinephrine resuscitation.Pharmacol Res.2010;61:136-141.doi:10.1016/j.phrs.2009.08.007

312 have Rendran et Al, Skarcia $\quad $ Learning and cognitive deficits in hypoxic neonatal rats is intensified by BAX mediated apoptosis: protective role of glucose, oxygen, and epinephrine. Int J Neurosci. 2013;123:80-88. doi:10.3109/00207454.2012731457

313. Cataltepe O, Vannucci RC, Heitjan DF, Towfighi J. Effect of status epilep-ticus on hypoxic-chemisbrain damage in the immature rat. Pediatr Res.1995,385:251-257. doi:10.1203/00006450-19580000-00019

314. Hope PL,Cady EBD, DelpY, LV Ises NK, Gardiner RM, Reynolds EO. Brain metabolism and intracellular PH during ischaemia: effects of systemic glucose and bicarbonate administration studied by 31P and 1H nucle-nucle-ant magnetic resonance spectroscopy in vivo in the lamb. J. Neurochem.1988;50:194-1402:111.1011/1171/415-191988;90:0322x2022

315. Park WS, Chang YS, Lee M. Effects of hyperglycemia or hypoglycemia on brain cell membrane function and energy metabolism during the im-mediate reyaution-reperfusion period after acute transient global hypoxia-ischemia in the newborn piglet. Brain Res.2001;901:102-108.doi:10.1016/s0006-8993(01)02295-8

16.Sheldon RA, Partridge JC, Ferrier MD. Stomiscery hyperglycemia is not protective to the neonatal brain. Pediatr Res. 1992;32:489-493. doi:10.1203/00006450-19921000-00022

317. Young RS, Petroff OA, Aquila WJ, Cheung A, Gore JC. Hyperglycemia and the rate of lactic acid accumulation during cerebral ischemia in developing animals in two proM Teron S. Lawri, Bioon Natea. 1992/8125-242. doi:10.1159/000243749

318. Yuan SZ, Blennow M, Runold M, Lagerrantz H. Effects of hyperglyceria-mia on gapsing and autosuscusion in newborn rats. Biol Neonate 1997;72:255-264. doi:10.1159/000244491

319. Sankariran D, Lane ECA, Valde R, Lesneski AL, Lakshminusha S. Role of Volume Replacement during Neonatal Resuscitation in the Delivery Room. Children(Basel). 2022;9:148.40. 10:3390/children9101484

320. Granfeld A, Davis SR, LP,ich Holm, MLEkin M, Maconchio. L, Hsu CH, Fernanda de Almeida M, Wang TL, Neurwar R, et al.Intravenous vs. intraosseous administration of drugs during cardiac ar-reast: A systematic review. Resuscitation. 2020:149:150-157. doi:10.1016/j.resuscitation.2020.02.025

321. Schwindt E, Pfeifer L, Domes G. Brenner, S. Schwindert JC, Hoffman F, Olivier M. Introusse access in neonates is feasible and safe- An analysis of a prospective nationwide surveillance study in Germany. Front Pediatr. 2022:1056532. doi: 10.33889/20229502632

322.Mieder LP, Irlesberger B, Schwaberger B. Use of intrasuscusov eac-lar access during neonatal resuscitation at a tertiary center. Front Pediatr.202081:57285. doi:10.3388/fped20205071285

323. Joerck C, Wilkinson R, Angiti RR, Lutz T, Scerri L, Carmo KB. Use of in-trausosce access in neonatal and pediatric retrieval-neonatal and pedi-atic emergency transfer service, New South Wales. Pediatr Emerg Care.2023;39:835-837; doi:10.1097/PEC.0000000000003005

324. Jose S IK. Effect of hypothermia for peratal asphyxia on child-hood outcomes. Int J Contemp Pediatrics. 2017;5:89-91. doi: 10.18203/2349-3291.jcp20175489

325.Zou L, Yuan H, Liu Q, Lu C, Wang L. Potential protective effects of bilirubin following the treatment of neonatal hypoxic-ischemic en-cephalopathy with hypothermia therapy. Biosci Rep. 2019;39: doi: 10.1042/bsr20182332

326.Zhou WH,Cheng GQ,Shao XM,Liu XZ,Shan RB,Zhuang DY,Zhou CL,Du LZ,Cao Y,Yang Q,et al; China Study Group. Selective head cool-ing with mild systemic hypothermia after neonatal hypoxic-ischemic en-cephalopathy: a multicenter randomized controlled trial in China. J Pediatr.2010;157:367-372,127:1 doi:10.1016/j.jpeds.2010.03.030

327. Foglia EE, Weiner G, de Almeida MFB, Wyllie J, Wyckoff MH, Rabi Y, Guangsuri R, on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Duration of Resuscitation at Birth, Mortality and Neurodevelopment: A Systematic Review. Pediatrics.2020;146:e201449. doi:10.1542/peds.2020-1449

328. Khoramre B, Kilmakin KC, Dahan M, Zhong YJ, Abdelmageed W, Wintermark P. Shah PS. Outcomes of Neonates with a 10-min Apgar Score of Zero: A Systematic Review and Meta-Analysis. Neonatology. 2022;119:669-685. doi:10.1159/000525926

329. Clattingus, J. Johansson S, Razaz N. Apgar Score and Risk of Neonatal Death on Preterm Infants. N Engl J Med. 2020;383:49-57. doi:10.1056/NEJmoA1915075

330. Schmolzer G, Pichler G, Solevag AL, Law BHY, Mitra S, Wagner M,Pfurtscheller D, Yaskina M, Cheung PY; SURV1VE- Trial Investigators. Sustained inflation and chest compression versus 3:1 chest compression to ventilation during cardiopulmonary resuscitation of asphyxiated new-borns(SURV1VE): A cluster randomised controlled trial. Arch Dis Child Fetal Neonatal Ed2024:109:428-435. doi:10.1136/archdischild-2023-326383

331. Shukla Ev, Bann CM, Ramani M, Ambalaman N, Peralta-Carcelen M, Hintz SR,Higgins RD,Natarajan G,Laptook AR,Shankaran S,et al.Predictive abil-ity of 10-mute agar scores for mortality and neurodevelopmental disabil-ity. Pediatrics 2022;20149:20e21054992.doi:10.1542/peds.2021-054992

332. Tylleskar T, Cavallin F, Hóok SM, Pejovic NJ, Lubulwa C, Byamugisha J,Nankunda J, Trevisunato D; NeoSupra Trial Team. Outcome of infants with 10 min Apgar scores of 1-1 in a low-resource setting. Arch Dis Child Fetal Neonatal Ed2027:1047:221-424. doi:10.1136/archischid-2021-322545

33. Dainty KN, Atkins DL, Breckwaldt J, Maconochie l, Schexnayder SM.Skrifvans MB, Tijssen J, Wyllie J, Furuta R, Aickin R, et al; on behalf of the International Liaison Committee on Resuscitation's(ILCOR) Pediatric. Family presence during resuscitation in paediatric and neonatal car-diac arrest: A systematic review. Resuscitation. 2021;162:20-34. doi:10.1016/j.resuscitation 2021.01.017

334.Wyckoff MH,Singleletary EM,Soar J, Olasveengen TM, Greif R,Liley HG,Dzieman D, Bhanji F, Anderson LW, Avis SR, et al; and Collaborators.2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: sum-mary from the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID/19 Working Group. Circulation. 2022;145:e645-e721. doi:10.1161/CR/00000000000000000000000000000000000000000000000000000000000000000000000

335. den Boer MC, Houtlosser M, Witlox R, van der Stap R, de Vries MC,Lopriore E, Te Pas AB. Reviewing recordings of neonatal resuscitation with parents. Arch Dis Child Fetal Neonatal Edal. Phys. Discriol Child Fetal Neonatal Edal. 2021;106:346-351. doi:10.1163/archild-2020-320059

336. Karlsson L, Gustafsson U, Thernstrom Blomqvist Y, Wallstrom L, Brostrom A. Neonatal resuscitation on: a critical incident technique study exploring pediatric registered nurses' experiences and actions. Adv Neonatal Care.2023/2320-228. doi:10.1097/ANC.0000000000001063

337. Patriksson K, Andersson O, Stierra F, Haglund K, Thies-Lagergren L.Midwives' experiences of intact cord resuscitation in nonvigorous neo-nates after vaginal birth in Sweden. J Obstet Gynecol Neonatal Nurs.2024;53:255-263. doi:10.1016/j.jogn.2023.12.003

338. Patriksson K, Andersson O, Thies-Lagergren L, Ronnerhag M. Neonatal healthcare professionals' experiences of intact cord resuscitation in the mother's bed: an interview study. BMC Pregnancy Childbirth.2024;24:362.doi:10.1186/s12884-026-04558-0

339.Zehnder Law,BHY,Schmolzer GM. Does parental presence affect workload during neonatal resuscitation? Arch Dis Child Fetal Neonatal Ed.2020/105:569-561 doi:10.1136/archidschild-2020-318840