2025+AHA心肺复苏与心血管急救指南-第5部分：新生儿复苏

指南心血管内科· 心脏康复与其他 · 2025

PREAMBLE

Approximately 5% to 10% of newborn infants need help to begin breathing at birth, and approximately 1% need advanced resuscitative measures to restore cardiore-spiratory function.1-3 The neonatal mortality rate in the United States and Canada has decreased from nearly 20 per 1000 live births in the 1960s to the current rate of approximately 3.5 per 1000 live births.4.5 Yet there remain opportunities for improvement and increasing access to quality care with disparities in neonatal mortality by re-gion and disparities in access to care.6-10 The inability of newborn infants to establish and sustain adequate or spontaneous respiration contributes significantly to early deaths and the burden of adverse neurodevelopmental outcomes among survivors. Effective and timely resusci-tation at birth could therefore improve neonatal outcomes and reduce health disparities.

Successful neonatal resuscitation efforts depend on time-critical actions that must occur in rapid succession to maximize the chances of intact survival. The Interna-tional Liaison Committee on Resuscitation(ILCOR) For-mula for Survival emphasizes 3 essential components for good resuscitation outcomes: guidelines based on sound resuscitation science, effective education of health care professionals in resuscitation, and implementation of effective and timely resuscitation.11 The 2025 neonatal resuscitation guidelines contain recommendations based on the best available resuscitation science for the most impactful steps to perform during delivery and in the

neonatal period. In addition, specific recommendations regarding systems of care and training of resuscitation are provided in the respective guidelines, Parts 412 and 12.13 The 2025 guidelines also introduces the Newborn Chain of Care (Figure 1), which addresses the overall context in which neonatal resuscitation occurs and how systems of care may impact newborn infant outcomes.

# NEWBORN CHAIN OF CARE

The Newborn Chain of Care (Figure 1) provides a frame-work for considering essential elements of the health care system relating to neonatal health. A robust new-born chain of care has the potential to enhance health during the perinatal and neonatal periods and long-term outcomes. Each link in the chain is described in detail here.

Link 1: Prevention

The health of the pregnant person has a direct impact on the health of the newborn infant. Optimal care dur-ing pregnancy can help prevent or mitigate risks to the developing and growing fetus. Antenatal care includes individualized risk assessment, psychosocial support,education, and evaluation of personal and societal factors to achieve optimal health outcomes. Compre-hensive care encompasses counseling on nutrition,medication, substance use, potential environmental exposures, safety, mental health, and self-care. Com-prehensive care also includes early estimation of gesta-tional age and ongoing screening, prevention measures,and interventions for conditions that may impact the health of the pregnant person or the fetus. Screening modalities include review of symptoms, measurements of blood pressure and fundal height, laboratory tests, ul-trasonography, and monitoring of fetal heart rate, when indicated. ${}^{14}$

# Link 2: Recognition and Activation

Approximately 5% to 10% of newborn infants require assistance to breathe after birth. The need for assis-tance must be anticipated and recognized to reduce the

![Recognition\nInitial Steps\nVentilation\nAdvanced\nPostnatal Care\nRecovery\n](2/aj0YEe4oUhYkBdfpda0fYP/figured9ec27681efd40fa9d22ab36bc17a14e_0_15.png) Figure 1. Newborn Chain of Care.

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risk of poor outcomes. Risk assessments evaluate fac-tors present during pregnancy and labor that can help health care professionals identify newborn infants who are more likely to require resuscitation. When risk factors are present, an appropriate team should be mobilized to assist with resuscitation. In some cases, this may involve transferring the pregnant person to a higher level of care to a specialized hospital. When appropriate, based on an-ticipated risk, a qualified team with advanced resuscita-tion skills should be present at the time of birth. Refer to Anticipation and Preparation for Resuscitation.

Link 3: Initial Steps

Initial care at birth consists of lifesaving measures essen-tial for all newborn infants, including those who are well and those who require respiratory support or advanced resuscitation. Steps to maintain normal temperature include maintaining a warm environment, promptly dry-ing the infant, and skin-to-skin contact with the parent,keeping the infant's body and head covered while leaving the mouth and nose visible. Newborn infants receiving resuscitation may require alternative methods such as covering the body with plastic wrap or a bag and provid-ing supplemental heat from a radiant warmer or thermal mattress. Umbilical cord clamping can be deferred for at least 60 seconds while performing the initial steps of drying, evaluating breathing, providing tactile stimulation if needed to support breathing, and clearing the airway if there is evidence of obstruction. Whenever possible,skin-to-skin contact is maintained with monitoring of breathing and temperature for at least 1 hour to support early initiation of breastfeeding. Refer to Umbilical Cord Management and Initial Steps.

Link 4: Ventilation

Newborn infants who do not breathe within the first 60 seconds after birth or have a heart rate less than 100 per minute despite initial steps should receive assisted venti-lation. Delaying ventilatory support in newborn infants in-creases the risk of death. A face mask or laryngeal mask(supraglottic airway) can be used to provide initial ventila-tion. Leak and obstruction are common during face mask ventilation and are important to address because they prevent effective ventilation. A rise in heart rate is the pri-mary indicator of effective ventilation. If the newborn in-fant's heart rate remains less than 100/min and does not increase after ventilation, inserting an alternative airway,such as a laryngeal mask or an endotracheal tube often improves effectiveness of ventilation. For spontaneously breathing preterm infants who need respiratory support,continuous positive airway pressure(CPAP) is a form of noninvasive respiratory support that helps establish and maintain functional residual capacity after birth. Refer to Ventilation and Continuous Positive Airway Pressure.

Link 5: Advanced Resuscitation

Advanced neonatal resuscitation requires a comprehensive approach to address a life-threatening situation in newborn infants. If initial steps and ventilation with an alternative air-way do not improve the heart rate, then providing advanced interventions, establishing intravascular access, and admin-istering epinephrine are crucial. Chest compressions are initiated when the newborn infant's heart rate remains less than 60/min despite adequate ventilation. Chest compres-sions aim to restore cardiac output. Concurrently, epineph-rine is administered to augment perfusion to vital organs.Establishing intravascular access via umbilical venous cath-eterization or an intraosseous(IO) device is imperative for swift medication delivery and fluid resuscitation. Through the meticulous execution of these advanced interventions,health care professionals aim to optimize outcomes in new-born infants.Refer to Chest Compressions, Vascular Access During Resuscitation, Epinephrine, and Volume Expansion.

Link 6: Postnatal Care

Most healthy newborn infants can remain with their parent, prioritizing bonding, breastfeeding, and thermoregulation immediately following birth. These steps contribute to the infant's health and stability. Newborn infants who require resuscitation beyond initial steps are at risk for abnormal transition to extrauterine life and require further observa-tion and monitoring. Transitional issues can include respir-ratory compromise, hypoglycemia, or hypothermia, among others. Monitoring should include assessment of respira-tory effort and oxygenation, heart rate, temperature, and blood glucose. The duration of monitoring depends on the newborn infant's status and transition to postnatal stabil-ity. Some newborn infants may need interhospital transfer to a higher level of care during the postnatal period. Refer to Postresuscitation Care.

Link 7: Recovery

Ensuring appropriate primary care follow-up for all new-born infants after birth, as well as their parents, is crucial for promoting short- and long-term health. Appropriate follow-up, education, and support for families are even more critical for those infants who require specialized care in the neonatal period. Infants who are born very preterm, have congenital anomalies, require resuscitation,or experience neonatal complications will require special-ized services postdischarge to effectively address their unique needs. A safe and optimal transition from hospital to home may involve medical therapies such as tube feed-ing, cardiorespiratory monitoring, and portable oxygen as well as arrangements for specialized services, including developmental follow-up and early intervention services.Close communication and collaboration with the outpa-tient health care team, including social service agencies,can promote the health of infants at risk of developmental

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difficulties, particularly for those families who may have challenges navigating the health care system. ${ }^{15}$

INTRODUCTION

Scope of Guideline

This guideline is designed for North American health care professionals seeking an up-to-date summary for clinical care as well as for those looking for more in-depth in-formation on resuscitation science and gaps in current knowledge. The science of neonatal resuscitation applies to infants at birth and in the days after birth. In circum-stances of altered or impaired transition, effective neonatal resuscitation reduces the risk of mortality and morbidity.Even healthy babies who breathe well after birth benefit from the facilitation of normal transition, including appro-priate umbilical cord management and thermal protection with skin-to-skin care. The 2025 Neonatal Resuscitation Algorithm summarizes the sequence of assessments and actions contained in the guidelines(Figure 2).

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

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

Evidence Evaluation and Guidelines Development

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

Organization of the Writing Committee

The Neonatal Life Support Writing Group includes physicians, nurses, and scientists with backgrounds

in neonatology, obstetrics, education, research, and public health. A call for candidates was distributed to the American Heart Association (AHA) Emergency Cardiovascular Care (ECC) Committee and American Academy of Pediatrics (AAP) subject matter experts,and volunteers with recognized expertise in neonatal resuscitation were nominated by the writing group co-chairs. Writing group members were selected by the AHA ECC Science Subcommittee and the AAP Execu-tive Committee and then approved by the AHA Manu-script Oversight Committee. The AHA and AAP have rigorous conflict of interest policies and procedures to minimize the risk of bias or improper influence during development of the guidelines. ${ }^{21}$ Before appointment,writing group members and peer reviewers disclosed all commercial relationships and other potential (including intellectual) conflicts. Comprehensive disclosure infor-mation for writing group members is listed in Appen-dix 1. Writing group members whose research led to changes in guidelines were required to declare those conflicts during discussions and abstain from voting on those specific recommendations. This process is de-scribed more fully in "Part 2: Evidence Evaluation and Guidelines Development."

METHODOLOGY AND EVIDENCE REVIEW

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

Class of Recommendation and Level of Evidence

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

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![Antenatal counseling Team briefing Equipment check Birth\nBirth\nInitiate cord management plan\nTerm gestation?Good tone?Breathing or crying?\nNo\nWarm and maintain normal temperature\nDry\nPosition\nStimulate and clear airway if needed\nApnea or gasping?HR<100/min?\nNo\nLabored breathing or persistent cyanosis?\nYes\n$\downarrow$\nYes\n$\downarrow$\nYes\n$\downarrow$\nNo\nVentilate\nPulse oximeter Consider CPAP\nConsider cardiac monitor\n\nNo\nVentilation corrective case with family Team debriefing\n,\n\n\n\nYes\n\nTarget Oxygen Saturation Table\n2 min\n65%-70%\n3 min\n70%-75%\n4 min\n47%\n80%-85%\n5 min\n80%-85%\n5 min\n10 min\n0\nZ\n0\n$9120$\n$9250$\n$9260$\n$9260$\n$9260$\n$9260$\n$9260$\n$9260$\n$9260$\n$9260$\n$9260$\n$9260$\n$9260$\n$9260$\n$9260$\n$9260$\n$9260$\n$9260$\n$9260$\n$\n](2/aj0YEe4oUhYkBdfpda0fYP/figuread69e93aa056401bbf2c561e4eaa8b9f_0_2.png) Figure 2. Neonatal Resuscitation Algorithm.

Guideline Structure

The 2025 guidelines are organized into knowledge chunks, discrete modules of information on specific top-ics or management issues. ${}^{29}$ Each modular knowledge

chunk includes a table of recommendations using standard AHA nomenclature of COR and LOE. A short synopsis is provided to put the recommendations into context with important background information and overarching management or treatment concepts.

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Table. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care(Updated December 2024)*

CLASS(STRENGTH) OF RECOMMENDATION

Class 1(STRONG) Benefit >>> Risk

Suggested phrases for writing recommendations:

• Is recommended

● Is indicated/useful/effective/beneficial

● Should be performed/administered/other

•Comparative-Effectiveness Phrases$+

- Treatment/strategy A is recommended/indicated in preference to treatment B

- Treatment A should be chosen over treatment B

Class 2a(MODERATE)

Benefit >> Risk

Suggested phrases for writing recommendations:

• Is reasonable

• Can be useful/effective/beneficial

• Comparative-Effectiveness Phrases $\dagger$

_ Treatment/strategy A is probably recommended/indicated in preference to treatment B

It is reasonable to choose treatment A over treatment B

Class 2b (WEAK)

Benefit≥ Risk

Suggested phrases for writing recommendations:

● May/might be reasonable

● May/might be considered

• Usefulness/effectiveness is unknown/unclear/uncertain or not well-established

Class 3: No Benefit(MODERATE)Benefit= Risk(Generally, LOE A or B use only)

Suggested phrases for writing recommendations:

•Is not recommended

● Is not indicated/useful/effective/beneficial

● Should not be performed/administered/other

Class 3: HARM(STRONG)

Risk > Benefit

Suggested phrases for writing recommendations:

• Potentially harmful

· Causes harm

● Associated with excess morbidity/mortality

$\boxed{8}$ Should not be performed/administered/other

LEVEL(QUALITY) OF EVIDENCE#

Level A

•High-quality evidence$\text{from more than} 1\text{ RCT}$

Meta-analyses of high-quality RCTs

•One or more RCTs corroborated by high-quality registry studies

Level B-R

(Randomized)

• Moderate-quality evidence $\hbar $ from 1 or more RCTs

•Meta-analyses of moderate-quality RCTs

Level B-NR

(Nonrandomized)

• Moderate-quality evidence $\neq$ from 1 or more well-designed, well-executed nonrandomized studies,observational studies, or registry studies

Meta-analyses of such studies

Level C-LD

(Limited Data)

• Randomized or nonrandomized observational or registry studies with limitations of design or execution

•Meta-analyses of such studies

•Physiological or mechanistic studies in human subjects

Level C-EO

(Expert Opinion)

• Consensus of expert opinion based on clinical experience

COR and LOE are determined independently (any COR may be paired with any LOE).

A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

*The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information).

+For comparative-effectiveness recommendations(COR 1 and 2a; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.

$\ddagger$ The method of assessing quality is evolving, including the application of standardized, widely-used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee.

COR indicates Class of Recommendation; EO, expert opinion;LD,limited data; LOE, Level of Evidence; NR,nonrandomized;R,randomized; and RCT,randomized controlled trial.

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Recommendation-specific text clarifies the rationale and key study data supporting the recommendations.

Document Review and Approval

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

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MAJOR CONCEPTS

The primary goal of neonatal care at birth is to facili-tate transition of the fetus from the fluid-filled uterine environment and reliance on placental circulation to the newborn infant receiving oxygenation and air exchange through the lungs. The most important priority for new-born survival is the establishment of adequate lung in-flation and ventilation after birth. Consequently, all births should be attended to by at least 1 person skilled and equipped to provide ventilation. Other important goals include establishment and maintenance of cardiovas-cular and temperature stability as well as the promotion of parent-infant bonding and breastfeeding, recognizing that simple measures can avert disruption of transition in healthy newborn infants.

The Neonatal Resuscitation Algorithm has been updated since 2020 and is the organizing framework for major concepts that support the needs of the newborn infant, the family, and the surrounding team of perinatal caregivers (Figure 2).

Anticipation and Preparation for Resuscitation

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

Umbilical Cord Management

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

Initial Steps

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

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

Assessment of Heart Rate

Heart rate is assessed initially by auscultation. Pulse ox-imetry and electrocardiography (ECG) are important ad-juncts in babies requiring resuscitation.

Ventilation and Continuous Positive Airway Pressure

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

Oxygen Supplementation

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

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Chest Compressions

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

Intravascular Access

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

Epinephrine

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

Volume Expansion

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

Postresuscitation Care

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

Withholding and Discontinuing Resuscitation

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

Training and Human Performance

To optimize performance, teams and individuals who provide neonatal resuscitation should acquire neces-sary knowledge, technical skills, and behaviors, and also ensure ongoing maintenance of these skills. Giv-en the low frequency of advanced resuscitation and

inconsistency of resuscitation team members, institu-tions should be intentional in creating opportunities for individual and team training. Such training should include ongoing booster training and the use of simula-tion and debriefing.

Terminology

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

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

ANTICIPATION AND PREPARATION FOR RESUSCITATION

|Recommendations for Anticipation and Preparation for Resuscitation||| |---|---|---| |COR|LOE|Recommendations| |1|B-NR|1. Every birth should be attended by at least 1 person whose only responsibility is the care of the newborn infant, including performing the initial steps of resuscitation and providing ventilation when required.| |1|B-NR|2. Before every birth, a standardized risk factors assessment should be performed to determine perinatal risk and assemble a neonatal resuscitation team based on that risk.| |1|C-LD|3. Before every birth, a standardized checklist should be used to ensure the presence and function of supplies and equipment necessary for a complete resuscitation.| |1|C-LD|4. When anticipating a high-risk birth, a prebirth team briefing should be performed to identify potential interventions and assign roles and responsibilities.|

Synopsis

Approximately 5% to 10% of newborns require assis-tance to breathe after birth. ${}^{1-3}$ Newborn resuscitation requires training, preparation, and teamwork. Delays in assisting an aprecic newborn may increase risk of death.2,4,5 Therefore, it is optimal that every birth has at least 1 person in attendance whose primary re-sponsibility is the newborn infant and who can provide ventilation.6-8

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A risk assessment to evaluate factors during preg-nancy and labor can identify newborn infants likely to require resuscitation; in these cases, a team with appro-priate skills should be present at birth.4,9-15 In the absence of risk stratification, up to half of babies requiring ventila-tion may not be identified before birth.2,16

A standardized checklist is a comprehensive list of critical supplies and equipment needed in the clinical setting. A standardized checklist used before every birth can ensure that supplies and equipment for a complete resuscitation are present and functional.17,18

A prebirth team briefing can identify the leader, assign roles and responsibilities, and plan umbilical cord man-agement and potential interventions. Team briefings promote teamwork, communication, and safety but may delay communication with families.17,19-22 Facilitating communication with family during resuscitation can be considered in role assignment.21,22

Recommendation-Specific Supportive Text

1. A large observational study found that delaying ventilation increases risk of death and prolonged hospitalization.5 A systematic review and meta-analysis of pre-post training studies showed neona-tal resuscitation training improved 7-day neonatal survival in low-resource countries.8 A retrospective cohort study showed improved Aggar scores in the context of a statewide neonatal resonatal resuscitation train-ing program.23 As the need for neonatal resuscita-tion can be unexpected, having a dedicated and trained clinician is optimal.

2.Risk factors for low Apgar scores and receipt of assisted ventilation or advanced resuscitation pro-cedures include prematurity, maternal conditions,delivery mode, and meconium-stained fluid.9-15 In a prospective survey done before risk stratification,resuscitation was anticipated in less than half of births receiving ventilation.16 In a prospective cohort study, risk stratification increased attendance of an advanced neonatal resuscitation team at high-risk births.4

3.Checklist use led to reduced error rates during audits in neonatal resuscitation equipment and supplies. Quality improvement and implementation work that incorporated checklist use was associ-ated with quicker time to oxygen saturation moni-toring, reduced hypothermia for preterm infants,and increased deferred cord clamping rates.21,22,24

4. Quality improvement initiatives have demonstrated that team briefing including role assignment, in combination with checklists, improved team com-munication and was associated with quicker time to oxygen saturation monitoring and normothermia for preterm infants.21,22,24

REFERENCES

1. Bjorland PA, Oymar K, Ersdal HL, Rettedal SI. Incidence of newborn re-susclutive interventions at birth and short-term outcomes: a regional population-based study. BMJ Paediatr Open. 2019;3:e000592. doi:10.1136/bmjpo-2019-000592

2.Niles DE, Cines C, Isley E, Foglia EE, Elci OU, Skare C, Olasveengen T, Ades A, Posenchegem, Nadkarni VM, et al. Incidence and charac-teristics of positive pressure ventilation delivered to newborns in a US tertiary academic hospital. Resuscitation. 2017;115:102-109. doi:10.1016/j.resuscitation.2017.013.035

3.Skare C, Kramer-Johansen J, Steen T, Odegaard S, Niles DE, Nakstad B,Solevag AL, Nadkarni VM, Olasveengen TM. Incidence of Newborn Sta-bilization and Resuscitation Measures and Guideline Compliance during the First Minutes of Life in Norway. Neonatology.2015;108:100-107. doi:10.1159/000431075

4. Aziz K, Chadwick M, Baker M, Andrews W. Ante- and intra-partum fac-tors that predict increased need for neonatal resuscitation. Resuscitation.2008;79:444-452. doi: 10.1016/j.resuscitation.2008.08.004

5.Ersdal HL, Mduma E, Svensen E, Perlman JM. Early initiation of basic resuscitation interventions including face mask ventilation may reduce birth asphyxia related mortality in low-income countries: a prospective descriptive observational study. Resuscitation. 2012;83:869-873. doi:10.1016/j.resuscitation.2011.12.011

6. Aziz K, Lee HC, Escoded MB, Hoover AV, Kamath-Rayne BD, Kapadia VS, Magid DJ, Nermeyer S, Schmzer GM, Szyld E, et al. Part 5: Neonatal Resuscitation: 2020 American Heart Association Guidelines for Cardio-2020; American Heart Association Guidelines for Cardio-2020;142:S524-S550. doi: 10.1161/CIR.0000000000000902

7. Dempsey E, Pammi M, Ryan AC, Barrington KJ. Standardised formal re-suscitation training programmes for reducing mortality and morbidity in newborn infants. Cochrane Database Syst Rev.2015;2015:CD009106.doi:10.1002/14651858.CD009106.pub2

8. Patel A, Khatib MN, Kurhe B, Bhargava S, Bang A. Impact of neonatal resuscitation trainings on neonatal and perinatal mortality: a system-atic review and meta-analysis. BMJ Paediatr Open.2017;1:e000183. doi:10.1136/bmpo-2017-000183

9.Adnan M, Mydard J, Hageman JR, Cohen L. Fetal Heart Tracing Patterns and the Outcomes of Newborns With Meconium-Stained Amniotic Fluid.Cureus.2022;14:e24545. doi:10.7759/cureus.24545

10. Berazategui JP, Aguilar A, Escobedo M, Dannaway D, Ginsburg R,de Almeida MF, Saker F, Fernández A, Albornoz G, Valera M, et al; on behalf of the ANR study group. Risk factors for advanced resuscitation in term and near-term infants: a case-control study. Arch Dis Child Fetal Neonatal Ed.2017;102:F44-F50.doi: 10.1136/archischild-2015-309525

11.Chiruvolu A, Fine S, Miklis KK, Desai S. Perinatal risk factors as-sociated with the need for resuscitation in newborns born through meonium-stained amniotic fluid. Resuscitation. 2023;185:109728. doi:10.1016/j.resuscitation.2023.109728

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

13. Marx Delaney M, Kalita T, Hawrusik B, Neal BJ, Miller K, Ketchum R,Moina RL, Singh S, Kumar V, Semrau K. Modification of oxyto use through a coaching-based intervention based on the WHO Safe Child-birth Checklist in Uttar Pradesh, India: a secondary analysis of a clus-ter randomised controlled trial. BJOG. 2021;128:2013-2021. doi:10.1111/1471-0528.16856

14. Roto S, Nupponen I, Kalliaal I, Kaijomaa M. Risk factors for neonatal hy-poxic ischemic encephalopathy and therapeutic hypothermia: a matched case-control study. BLMC Pregnancy Childbirth. 2024:24:421. doi:10.1186/s12884-024-06596-8

15.Zarkesh MR,Moradi R,Oroji A. Cardiopulmonary resuscitation of infants at birth:predictable or unpredictable? Acute Crit Care.2022;37:438-453. doi:10.4266/acc.2021.01501

16.Mitchell A, Niday P, Boulton J, Chance G, Dulberg C. A prospective clini-cal audit of neonatal resuscitation practices in Canada. Adv Neonatal Care.2002;2:316-326. doi: 10.1053/adnc.2002.36831

17. Bennett SC,Finer N, Halamek LP,Mickas N,Bennett MV,Nisbet CC,Sharek PJ. Implementing Delivery Room Checklists and Communication Standards in a Multi-Neonatal ICU Ouality Improvement Collaborative.J Comm J 084803. doi: 10.1016/s1553-7250(16)42052-0

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18. Brown T, Tu J, Profit J, Gupta A, Lee HC. Optimal Criteria Survey for Pre-resuscitation Delivery Room Checklists. Am J Perinol. 2016;33:203-203 doi: 10.1055/s/0035-1564064

19. Katheria A, Rich W, Finner D. Development of a strategic process us ing checklists to facilitate team preparation and improve communication during neonatal resuscitation. Resuscitation. 2013;84:1552-1557. doi:10.1016/j.resuscitation.2013.06:012.

20. Litke-Wager C, Delaney H, Mu T, Sawyer T. Impact of Task-Oriented Role Assignment on Neonatal Resuscitation Performance: a Simulation-Based Randomized Controlled Trial. Am J Perinatol. 2021;38:914-921. doi:10.1055/s-0039-3402751

21. Ortiz-Movilla R, Funes-Morux RM, Domingo-Comeche LD, Beato-Merino M, Martinez-Bernat L, Royuela-Vicente A, Román-Riechmann E,Marín-Gabriel 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

22. Talati AJ, Scott TA, Barker B, Grubb PH; Tennessee initiative for Perina-tal Quality Care Golden Hour Project Team. Improving neonatal resuscita-tion in Tennessee: a large-scale, quality improvement project. J Perinato.2019;39:1676-1683. doi: 10.1038/s41372-019-0461-3

23. Patel 3D, Piotrowski ZH, Nelson MR, Sabich R. Effect of a Statewide Neonatal Resuscitation Training Program on Apgar Scores Among High-Risk Neonates in Illinois. Pediatrics 2001;107:648-655. doi: 10.1542/peds.107.4.648

24. Sauer CW, Boutin MA, Fatayerji AN, Proufoot JA, Fatayerji NI, Golembeski DJ. Delivery Room Quality Improvement Project Improved Compliance with Best Practices for a Community NICU. Sci Rep. 2016;6:37397. doi:10.1038/srep37397

UMBILICAL CORD MANAGEMENT

|Recommendations for Term Newborn Umbilical Cord Management||| |---|---|---| |COR|LOE|Recommendations| |2a|B-R|1. For term newborn infants who do not require immediate resuscitation, deferred cord clamping for at least 60 seconds can be beneficial when compared to immediate cord clamping.| |2b|B-R|2. For nonvigorous term newborn infants and late preterm infants 35 weeks or more gestational age,intordc milking may be reasonable when compared to immediate cord clamping.| |2b|C-LD|3. For term newborn infants who do not require immediate resuscitation, the usefulness of intact umbilical cord milking compared to deferred cord clamping is uncertain.|

Synopsis

Management of the umbilical cord and placental transfu-sion at the time of birth remains an area of robust inves-tigation. Placental transfusion can be achieved either by delaying the clamping of the umbilical cord following de-livery or by milking the umbilical cord. Milking is typically done by stripping 20 cm of cord from the placenta toward the infant 3 to 4 times, allowing the cord to refill from the placenta each time. The volume of blood transferred from the placenta to the newborn infant and the impact of this transfusion vary based on gestational age at birth mode of delivery, the time from birth to cord clamping,any milking of the umbilical cord, and physiologic status of the newborn. Based on available literature, deferred cord clamping for at least 60 seconds can be beneficial compared to immediate cord clamping for term infants

who do not require resuscitation. For term infants who require resuscitation at birth, there is limited evidence to guide timing of umbilical cord clamping. Several studies currently are underway to investigate the interaction be-tween deferred cord clamping and resuscitation. Initial steps of resuscitation such as drying and tactile stimula-tion, if required, can be undertaken during deferred cord clamping.

Recommendation-Specific Supportive Text

1.For term newborns, evidence from 14 studies(n=2412)$^{1-14}$ reporting on hemoglobin and 20 studies(n=3452)$^{1,4-6,8,10,13,15-27}$ reporting on hema-tocrit showed that infants who received deferred umbilical cord clamping beyond 30 seconds had improved hematologic indices early in the newborn period. In 5 trials studying 1199 term newborn infants, those who received early cord clamping had lower ferritin levels at 3 to 6 months of age compared to those who received deferred cord clamping.1,6,18,28,29 There was no difference in mor-tality among term infants who received deferred or early cord clamping in 3 randomized controlled trials(RCTs) including 419 infants.16,18,30 More recent studies have evaluated deferred clamp-ing for at least 60 seconds3,11-13,15,18,23,25,31-34 additional studies have evaluated longer durations of deferred umbilical cord clamping.17,35-37 These studies have shown increases in hematological indices compared to shorter durations of deferred cord clamping.

2.One RCT including 1730 nonvigorous infants, lim-ited to 35 to 42 weeks' gestational age, compared intact umbilical cord milking to early cord clamp-ing(within 60 seconds of birth).38 The primary out-come, admission to neonatal intensive care unit,was not different between groups. However, com-pared to early cord clamping, intact umbilical cord milking in nonvigorous infants was associated with decreases in several secondary outcomes, includ-ing rate of cardiorespiratory support in the deliv-ery room, moderate to severe hypoxic-ischemic encephalopathy(HIE), and use of therapeutic hypothermia.

3.The currently available evidence does not sup-port intact cord milking compared to deferred cord clamping in vigorous term newborns.31,32,39 Two RCTs including 275 term infants showed no differ-ence between hematologic indices when measured between 6 and 48 hours after delivery.31,39 One study followed subjects to 4 months of age and measured hemoglobin and ferritin. No difference was noted between the cord milking and delayed cord clamping groups.31 Two RCTs including 371

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term infants did not demonstrate a difference in hyperbilirubinemia, administration of phototherapy,or need for exchange transfusions.32,39

|Recommendations for Preterm Newborn Umbilical Cord Management|||| |---|---|---|---| |COR|LOE|Recommendations|| |1|A|1. For newborn infants born at<37 weeks of gestation who do not require immediate resuscitation, deferred cord clamping for at least 60 seconds is recommended when compared to immediate cord clamping.|| |2b|B-R|2. For newborn infants born at 28+0 to 36+6 weeks of stations who do not require immediate resuscitation and in whom deferred cord clamping cannot be performed, intact cord milking may be reasonable.|| |3: Harm|B-R|3. For newborn infants born at less than 28+0 weeks of gestation, intact cord milking should not be performed.||

Synopsis

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

Recommendation-Specific Supportive Text

1. A recent pairwise individual participant data meta-analysis conducted by ILCOR included 21 studies enrolling 3292 newborns with a median gesta-tional age of 29 weeks(IQR, 27-33 weeks) and compared deferred cord clamping(30 to≥180 seconds) to immediate cord clamping(≤15 sec-onds).22,43,45-62 Twenty trials enrolling 3263 infants showed a reduction in mortality before discharge

with a number needed to treat of 40(95% CI,143-26 infants).22,45-63 For all preterm infants, there is an increase in hematological indices,43 while in those infants born at<32 weeks' gestational age,there is a reduction in need for packed red blood cell transfusion during neonatal intensive care unit admission.2,46,48-50,52,53,55,579,61-63 In comparing durations of deferred cord clamping, long duration(≥120 seconds) was associated with the greatest reduction in mortality, but the number of extreme preterm infants included in these studies was low(n=121) and adherence to this duration(67%)was significantly lower compared to adherence for short and medium durations(30 seconds to<120 seconds).43 A post hoc analysis by ILCOR demon-strated that newborn infants who received deferred cord clamping for 60 seconds or more(n=1316)had a reduction in mortality compared to those who had immediate cord clamping(<15 seconds)(odds ratio[OR], 0.63[95% CI, 0.44-0.88; P=0.01]).43,64 In 8 trials including 1995 preterm infants, hypother-mia(defined as<36.5°C) was increased on admis-sion to the neonatal intensive care unit for infants<32 weeks of gestation who received deferred cord clamping compared to immediate cord clamp-ing(mean difference,-0.13 degrees; OR,1.28).43

2. In preterm infants born at≥28 weeks' gestational age who received intact umbilical cord milking,pairwise individual participant data meta-analysis of 12 trials including 944 infants showed that hemoglobin levels in the first 24 hours after birth were higher compared with those who received immediate clamping.43 Further, data from 15 studies including 1163 infants showed a reduction in the need for red blood cell transfusion for those infants who received intact cord milking compared with immediate cord clamping.43 For infants who received intact umbilical cord milking compared with deferred cord clamping, data from 7 studies including 860 infants showed an increased risk of severe intraventricular hemorrhage in infants born at<32 weeks' gestational age. This was primar-ily related to 1 RCT including 540 infants which showed an increased incidence of intraventricular hemorrhage in infants born at<28 weeks' ges-tational age.44 One RCT including 1019 infants delivered at 28 to 32 weeks of gestation showed no increased rate of severe intraventricular hem-orrhage in the group receiving intact umbilical cord milking when compared with those receiving deferred cord clamping. ${}^{65}$

3. In a single study including 182 infants born between 23 and 27+6/7 weeks of gestation who did not require immediate resuscitation, the inci-dence of severe intraventricular hemorrhage was significantly higher in those who received umbilical

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cord milking compared with deferred cord clamp-ing of 60 seconds.44

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2. Fawzy AE-MA, Moustafa AA, El-Kassar YS, Swelem MS, El-Agwany AS,Diab DA.Early versus delay cord clamping of term births in Shatty Maternity University Hospital. Progresos de Obstetricia y Ginecologia 2015;58:389-392. doi:10.1016/j.pog.2015.05.001

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5.Yadav AK, Upadhyay A, Gothswal S, Dubey K, Mandal U, Yadav CP. Com-parison of three types of intervention to enhance placental redistribution in term newborns: randomized controlled trial. J Perinatol. 2015;35:720-724. doi:10.1038/jp.2015.65

6. Chaparo CM,Neufeld LM,Tena Alzera E,Gujia-Licz D.Rewey KG.Effect of timing of umbilical cord clamping on iron status in Mexican in infants: a randomised controlled trial. Lancet 2006;367:1997-2004. doi:10.1016/S0140-67630(66)688889-2

7. De Paco C, Florido J, Garrido MC, Prados S, Navarrete L. Umbilical cord blood acid-base and gas analysis after early versus delayed cord clamp-ing in neonates at term. Arch Gynecol Obstet. 2011;283:1011-1014. doi:10.1007/s00404-010-1516-z

8. Emhamed MO, van Rheenen B. Prabin B. Arui, The early effects of delayed cord clamping in term infants on born by Lilyman mothers. Trop Doct 2004;34:218-222. doi:10.1177/004947550403400410

9. Purisch SE,Anartb CV,Arditi B,Mauny Le Ajianem B,Heider ALeone T,Gyamfi-Bannerman C.Effect of Delayed vs Immediate by Umbilical Cord Clamp-ing on Maternal Blood Loss in Termes Carean delivery: a randomized Clini-cal trial. JAMA 2019;322:1869-1876. doi:10.1001/jama.2019.15995

10. Manzoor M, Mubashir H, Izazar, M Shahar A, Sriber A, Sher F. Effect on Neo-Netal natal hemoglobin and Hematocrit in Early Versus Delay Cord Clampinga 19. Mialar J Med Health Sci 2020;14:561-562.

11. Mukhtar S, Bashir S, Barf R, Akam S, Akhtar N, Salam R, Saeed S. Com-parison of the Frequency of Neonatal Anemia in Early Versus Delayed Cord Clamping in Bobals at Term. Pakistan J Med Health Sci 2023;17:171-173.401.10.53350/pmjhs2023176171

12.Ofjejo,El Ejeu,El Guebe,Kechbele Jl,Okpala BC,OfjeoBA,Elwq,EOlgbode EP,Onwugbuebna, Aklwuka 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. Ostebox Gynecol Reprod Biol.2021;262:99-104. doi:10.1016/j.ejogrgb.2021.04.038

13. Soliman RM, Legendy M, Said RNN, Shearawy BI Helai OM, Aly H A Randomized Control Trial of a 30-versus a 120-December Delay in Cord Clamping after Term Birth. Am J Perinatol. 2024;41:739-746. doi: 10.1056/s1177-4543

14. Targi A, Mehmood S, Zahid M, Arshad I. Frequency of anemia in delayed and early umbilical cord clamping after birth in newborn babies. Med Forum.2023;34:14-16.

15.Cavallin F, Galezzo B, Loretelli M, Vadella S, Pizzolato M, Visentin S,Trevisuto D. Delayed Cord Clamping versus Early Cord Clamping in Elescearean Section: A randomized Controlled Trial. Neonatology.2019;116:252-259. doi:10.1159/000500325

16.Cerani Cernada JM,Caroli P,Gellegini L,Olato F,Lereira M,Rico C,Sasas O, Giordano D, Lardizbal J. The effect of timing of cord clamp-ing on neonatal venous hematocrit values and clinical outcome at term:a randomized, controlled trial. Pediatrics. 2006;1177:e797e-786: doi:10.1542/peds.2005-1156

17. Chen X, Li X, Chang Y, Li W, Cui H. Effect and safety of timing of cord clamping on neonatal hematocrit values and clinical outcomes in term infants: a randomized controlled trial. J Perinatol. 2018;38:251-257. doi:10.1038/s10372-017-0001-y

18. ChopA, Thakur A, Garg P, Kler N, Fujial K. Early versus delayed cord elamping 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

19. Güner S, Saydam BK. The Impact of Umbilical Cord Clamping Time on the Infant Arenia: A randomized Controlled Trial. Iran J Public Health.2021;50:990-998. doi:10.18502/ijph.v5015.6116

20. Jahazi A, Kordi M, Mirbehbahani NB, Mazloom SR. The effect of early and late umbilical cord clamping on neonatal hematocrit. J. Perinatol.2008;28:523-525. doi:10.038/jp.2008.55

21. Philip AG. Further observations on placental transfusion. Obstet Gynecol.1973;42:334-343.

22. Sahoo T, Thukral A, Sankar MJ, Gupta SK, Agarwal R, Deorari AK, Pauli VK. Delayed cord clamping in Rh-alloimmunised infants: a ran-domised controlled trial. Eur J Pediatr. 2020;179:881-889. doi:10.1007/s00431-020-03578-8

23. Shinohara E,Kataoka,Y.Aju Y.Effects of timing of umbilical cord clamping on preventing early infantancy an in low-risk Japanese term infants with planned breastfeeding: a randomized controlled trial. Matem Health Neona-tor/ Penratiot. 2021;7:5. doi: 10.1186/s40748-021-00125-7

24. Vural I, Ozdemir H, Teker G, Yödemir T, Bilgen H, Ozek E. Delayed cord clamping in term large-for-gestational age infants: a prospective randomised study.J Paediatr Child Health.2019;55:555-560. doi:10.1111/jpc.14242

25. Korkut S, Oguz Y, Bozkaya D, Turkmen GG, Kara O, Uygur D, Oguz S. Evalu-ation of the Effects of Delayed Cord Clamping in Infants of Diabetic Moth-ers. Am J Perinatol. 2021;38:242-247. doi: 10.1055/s-0039-1695799

20. Patel S, Patil N. Effect of early versus delayed cord clamping on hematocrit and serum bilibrin levels. J Perinatal Neonatal Care.2021;22:15-19.

27.Songthanat M, Witsawapan P, Tanthawat S, Songthawat S. Effect of Delayed Cord Clamping at 30 Seconds and 1 Minute on Neonatal Hema-tocit in Term Cesarean Delivery: a Randomized Trial. Int J Womens Health.2020;12:481-486. doi: 10.2147/IJWH.S248709

28. Ceriani Cermadis JM, Carroli G, Pellegrini L, Ferreira M, Ricci C, Casas O, Lardizabal J, Morasso MC. The effect of early and delayed umbili-cal cord clamping on ferritin levels in term infants at six months of life: a randomized, controlled trial. Arch Argent Pediatr. 2010;108:201-208. doi:10.15910/0352-00572010000300005

29. Andersson O, Hellstrom-Vestas L, Andersson D, Domellof M. Effect of de-layed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. BMJ. 2011;343:d7157.

30.Backes CH,Huang H,Cua CL,Garg V,Smith CV,Yin H,Galantowicz M,Bauer JA, Hoffman TM. Early versus delayed umbilical cord clamping in infants with congenital heart disease: a pilot, randomized, controlled trial. J Perinatol.2015;35:826-831. doi: 10.1038/jp.2015.89

31.de Preud'hømder/Hailde Nieuport SMI, Krijgh EJC, Pruijssers B, Visser J,van Beek RHT.Delayed cord clamping vs cord milking in elective cesarean delivery at a term: randomized controlled trial. Am J Obstet Gynecol MFM.2024;61:101279. doi: 10.1016/j.ajogmf.2024.101279

32.Seliga-Swiceka JP, Puskarz-Gasowska J, Tolloczko J. The risk of hy-perbilirubinemia in term neonates after placental transfusion- a randomized-blinded controlled trial. Ginekol Pol. 2020;91:613-619. doi: 10.5603/GPa/2020.0096

33. Murali M, Sethraman G, Vasudevan J, Umadevi L, Devi U. Delayed cord clamping versus cord milking in vigorous neonates≥35 weeks gestation born via cosera: A randomized randomized clinical trial. J Neonatal Perinatal Med.2023;16:597-603. doi: 10.3233/NPM-230069

34. Rashiwan A, Edalyay A, EH-sharty A, Elsherbini M, Abdel-Rasheed M, Eid MM.Delayed versus early umbilical cord clamping for near-term infants born to preeclamp omothermics; a randomized controlled trial. BMC Pregnancy Child-birth 2022;22:515. doi: 10.1186/s12884-022-04831-8

35. Chaudhary P, Priyadarsih M, Singh P, Chaurasia S, Chaturvedi J, Basu S.Ef-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/s00431-023-05053-6

36. Katariya D, Swan D, Singh S, Satapathy A. The Effect of Different Tim-ings of Delayed Cord Oregling of Term Infants on Maternal and Newborn Outcomes in Normal Varginal Deliveries. Cureus. 2021;13:e17169. doi:10.7759/cureus.1179:66

37. Singh B, Kumar R, Patra S, Bansal N, Singh G, Raghava K, Lodhi SK, Panchal A, Kumar S, Verna R. Comparison of Three Methods of Umbilical Cord Management in Late Preterm and Term Newborns on Hemoglobin and Ferrit�s at Six Weeks of Age: a Randomized Controlled Trial. Cureus.2024:16e9046. doi:7859/cureus.59046

38. Katheria AC, Clark E,Yoder B, Schmolzer GM, Yan Law BH, El-Naggar W, Rittenberg D, Sheth S, Mohamed MA, Martin C, et al; on behalf of the

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Milking In Nonvigorous Infants group. Umbilical cord milking in nonvigor-ous infants: a cluster-randomized crossover trial. Am J Obstet Gynecol 2023;43:193-194. doi:10.1097/01.aaoo.000990412.16560.13

39. Panburana P. Odtthon T. Pongree P. Hansahirwadew. The Effect of Umbilical Cord Climaring Compared with Delayed Cord Clamping in Term Ne-onates: a Randomized Controlled Trial. Int J Womers Health. 2020;12:301-306. doi: 10.2017/UwH3233487

40. Mercer,JS GrathMM, Hensman,A Silver H,OH W.Immediate and delayed cord clamping in infants born between 24 and 32 weeks: a pilot randomized controlled trial. J Perinatol.2003;23:466-472. doi:10.1038/sjj:2710970

41. Rabe H, Wacker A, Hulkamp G, Hornig-Franz I, Schulze-Everding A, Harms E,Cirkel U, Louwen F, Wühter R, Schneider H HP A randomised controlled trial of delay cord damping in very low birth weight preterm infants. Eur J Pediatr:2000;159:7757-777.doi:10.1007/p100008345

42. Lu J,Yue G,Wang Q,Zhou X,Ju R,A review on development of placental transfusion in term and preterm infants. Front Pediatr: 2022;10:890988.doi:10.3389/fiped,2022.890988

43. Grefl R, Bray J, Davran Dren, IR Liley HG, Ng KC, Cheng A, Daouma MJ,Scholefield BR,Smyth M,et al.2024 International Consensus on Car-diopulmonary Resuscitation and Emergence Cardiovascular Care Science With Treatment Recommendations: summary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Edu-cation, Implementation, and Teams; and First Adi Task Forces. Circulation 2024;150e80-e687. doi:10.1161/CIR.0000000000001288

43. Kateria A, Reister F, Essers J, Mendler M, Hummler H, Subramaniam A,Carlo W,TiA,Tuong G,Wedis-Nelson S,et al.Association of Umblical Cord Milking vs Delayed Umbilord Clim Camping With Death or Severe In-traventricular Hemorrhage Among Preterm Infants. JAMA 2019;322:1877-1886. doi:10.1001/jama.2019.16004

45. Backes CH, Huang H, lams JD, Bauer JA, Giannone PJ. Timing of umbilical cord clamping among infants born at 22 through 27 week' gestation. J Perinatol.2016;36:35-40. doi: 10.1038/jp.2015.117

46. Chu K, Whittle W, Windr Rh, Shah P, Murphy K.502: The DUC trial: a pilot randomized controlled trial of immediate vs. delayed umbilical cord clamping in preterm infants born between 24 and 32 weeks gestation. Am J Obstet Gynecol.2011;204:S201. doi:10.1016/jajog.2010.521

47. Datta BVK, Kumar A., Yadav R. A Randomized Controlled Trial to Evaluate the Role of Brief Delay in Cord Clamping in Preterm Neonates(34-36 weeks)on Short-term Neurobehavioural Outcome. J Trop Pediatr. 2017;63:418-424. doi:10.1039/trope/fm/004

48. Duley L, Dorling J, Pushpa-Rajah A, Oddie J, Yoxall CW, Schoonaker B,Bradshaw L, Mitchell E, Fawie JA, on behalf of the Cord Pilot Trial Col-laborative Group. Randomised trial of cord clamping and initial stabilisation at very preterm birth. Arch Dis Child Fetal Neonatal 2018;103:F6-F14.doi:10.1136/archischid-2016-312567

49. Finn D, Ryan DH, Pavel, A O'Tole JM, Lvingstone V, Boyland GB, Kenny LC,Dempsey EM. Clamping the Umbilmpical Cord in Premature Deliveries(CU-PiD): Neuromonitoring in the Immediate Newombri Piod in a Randomized,Controlled Trial of Preterm Infants Born at<32 Weeks of Gestation. J Pedi-at.2019;208:121-126e2. doi:10.1016/jpeds:2018.12.2039

56. García P., Criert, USFertov, E-Cóth-Birmége N, Vuesada L, Lewancyk M,Pertugal M, Delgado JL, Blanco-Carnero JE, D. Peato Macatlana C.The impact of early versus delayed cord clamping on hematological and cardiovascular changes in preterm newborns between 24 and 34 weeks gestation: a randomized clinical trial. Arch Gyncol Enot.� 2024:309:2483-2490. doi:10107/s00402-03-07119-0

51. Gharebaghi MM, Yasrebinia S, Gharabaghi PM. Umbilical cord clamping in timing preterm infants delivered by cesarean section. Int J Pediatr.2020;8:11095-11101. doi:10.22038/j.2019.4313.8600

52.Gorragi A, Carbonell M, Linde A, Goya M, Maiz N, Gabriel P, Villena Y,Bérgamo S, Benefitz D, Montesbral I, et al. Timing of umbilical cord oc-clusion, delayed vs early, in first premenbries: a randomized controlled trial(CODE-P Trial). Eur J Obstet Gynecol Reprod Biol.2023;289:203-207. doi:10.1016/j.egrobr.2023.08.376

53. Kamal D, Abel-Fattah A, Saleh D. Delayed cord clamping in premature fe-tuses: randomized clinical trial. Reprod Health Popul Sci. 2019;44:66-87.

54. Wang T. Wang S, Zhou M. Uuan Chen, W. Chen P. Li, Z. Zhou J. Liu J.Omp, and limited errowal clinical trial. EcllinicMedicine. 2025;81:103126. doi:10.1016/j.eclin.2025.103126

55. Oh W, Fanoffar AA, Carlo WA, Donovan EF, McDonald SA, Poole WK; on behalf of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Eunice 密京军 Shriver National Institute of Child Health and Human Development

$\text{search Network. Effects of delayed cord clamping in very-low-birth-weight}$

56. Okulu E, Haskologlu S, Goluloglu D, Kostekci E, Erdeve O, Atasay B, Koc A,Soymezler F, Dogu F, kinocgiullari A, et al. Effects of Umbilical Cord Man-agement Strategies on Stem Cell Transfusion, Delivery Room Adaptation,and Cerebral Oxygenation in Term and Late Preterm infants. Front Pediatr.2022:108.83444 doi:10.3389/fped.2022.838444

57. Rana A, Agarwal K, Ramj S, Gandhi G, Sahu L. Safety of delayed umbilical cord clamping in pretermen neonates of less than 34 weeks of gestation:a randomized controlled trial. Obstet Gynecol Sci.2018;61:655-661. doi:10.5468/ogs.2018.61.6.655

56. Ranjt, N. Nessager, Rao PN, Sao JP, Ashok C, Chandrakala BS, Bhat S. Effect of early versus delayed cord clamping on hematological status of preterm infants at 66k of age. Indian J Pediatr. 2015;82:29-34. doi:10.1007/32098-013-1329-8

59. Ruangkit, C. Burnupghun S, Panburana P, Khositseth A, Nunnarumit P. A Randomized Controlled Trial of Immediate versus Delayed Umbilli- cal Cord Clamping in Multiple-Birth Infants Born Preterm. Neonatology.2019;11:159/163-10. doi:10.1159/000494132

60.Salae R, Tanprasertkul C, Somprasit C, Bhamarapravatana K, Suwannaruk K. Efficacy of Delayed versus Immediate Cord Clamping in Late Preterm Newborns Following Normal Labor: a Randomized Control Trial. J Med Assoc Thai.2016:S99:59-S165.

61. Tarnow-Mordri W, Morris J, Kirby I, Robledo K, Askie L, Brown R, Evans N,Finlayson S, Fogarty M, Gebski V, et al; on behalf of the Australian Placen-tal Transusion Study Collaborative Group. Delayed versus Immediate Cord Clamping in Preterm Infants. N Engl J Med.2017;377:2445-2455. doi:10.1056/NEmOa1711281

62. Yunis M, Nour J, Gibrebel A, Darwish M, Sarhan M, Shouman B, Nasef N. Effect of delayed cord clamping on stem cell transfusion and hematological param-eters in preterm infants with placental insufficiency: a pilot randomized trial.Eur J Pediatr:2021;180:157-166. doi:10.1007/s00431-020-03730-4

63. Kugelman A, Borenstein-Levin L, Riskin A, Chistyakov I, Ohel G, Gonen R,Bader D. Immediate versus delayed umbilical cord clamping in premature neonates born<35 weeks: a prospective, randomized, controlled study. Am J Perinol.2007;24:307-315. doi:10.1055/s-2007-981434

64. Siderel A, Alanderoumand M, Hunter KE, Barba A, Libesman S, Williams JG,Shrestha N, Aagerup J, Sotiropoulos 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/S0140-6178(2023)02468-6

65. Katheria A, Szychowski J, Carlo WA, Subramaniam A, Reister F, Essers J, Vora F, Martin C, Schnolmer GM, Law B, et al; on behalf of Lumbilica Cord Miling Versus Delayed Cord Clamping in Infants 28 to 32 Weeks: a Randomized Trial. Pediatrics. 2023;152:e2023063113. doi:10.1542/peds.2023-063113

INITIAL STEPS

Maintaining Normothermia at Birth

|Recommendations for Maintaining Normothermia|||| |---|---|---|---| |COR|LOE|Recommendations|| |COR|LOE|Recommendations|| |1|B-NR|1. The temperature of newborn infants should be monitored and maintained between 36.5℃ and 37.5℃ after birth through admission and stabilization.|| |2|B-NR|1. The temperature of newborn infants should be monitored and maintained between 36.5℃ and 37.5℃ after birth through admission and stabilization.|| |1|B-NR|2. Hypothermia(temperature less than 36℃) should be prevented due to its association with adverse outcomes in newborn infants.|| |1|B-NR|3. Hyperthermia(temperature greater than 38℃) should be prevented due to its association with adverse outcomes in newborn infants.||

Synopsis

Temperature after birth is an important measure of re-suscitation quality. ${}^{12}$ The ideal temperature of newborn

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infants is between 36.5°C and 37.5°C.3 Hypothermia is associated with increased neonatal mortality and morbid-ity, especially in very preterm(less than 33 weeks' ges-tational age) and very low-birth-weight infants(less than 1500 g), who are at increased risk for hypothermia.4-7 Hyperthermia is associated with increased mortality and cerebral injury in both term and preterm infants.5,8-10 Ad-verse outcomes are more frequent as temperature devia-tion on either side of the normal range increases.4,5

Recommendation-Specific Supportive Text

1. There are long-standing worldwide recommenda-tions for routine temperature management for the newborn infant.3 Monitoring of temperature after birth shows that hypothermia is common worldwide,with a higher incidence in newborn infants of lower gestational age and birth weight.4-7,11 Hyperthermia may occur when warming interventions are provided in the delivery room without careful monitoring.12

2. In observational studies, the presence and degree of hypothermia after birth is strongly associated with increased neonatal mortality and morbidity, particu-larly in preterm(less than 37 weeks' gestational ace)and low-birth-weight infants(less than 2500 g).4-7

3. Two observational studies found an association between hyperthermia and increased morbidity and mortality in very preterm and very low-birth-weight newborn infants.5,10 Two observational stud-ies showed an association between hyperthermia in preterm infants and major abnormalities on cra-nial ultrasound, neurodevelopmental impairment,and necrotizing enterocolitis.8,13 Meta-analysis of 31 observational studies of epidural analge-sia showed an association between intrapartum hyperthermia and adverse neonatal neurological outcome in both term and preterm infants.9

Interventions to Maintain Normothermia at Birth

|Recommendations for Interventions to Maintain Normothermia||| |---|---|---| |COR|LOE|Recommendations| |2a|B-R|1. For preterm infants in the delivery room, the use of radiant warmers,plastic bags or wraps(with a cap),increased room temperature, and warmed humidified inspired gases, separately or in combination, can be effective in preventing hypothermia.| |2a|C-LD|2. Placing newborn infants skin-to-skin after birth can be effective to maintain normothermia.| |2a|C-LD|3. For newborn infants who require resuscitation,temperature-controlling interventions can be beneficial.| |2b|B-R|4. For preterm infants,exothermic matters may be considered for the prevention of hyperthermia.| |2b|B-NR|5. For preterm infants, various combinations of warming strategies(or“bundles”) may be reasonable to prevent hypothermia but may also increase the risk of hyperthermia.|

Synopsis

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

Recommendation-Specific Supportive Text

1. RCTs and observational studies of warming adjuncts, alone and in combination, demonstrate reduced rates of hypothermia in very preterm and very low-birth-weight infants.15,16,19 However, meta-analysis of RCTs of interventions that reduce hypo-thermia in very preterm or very low-birth-weight infants show no impact on neonatal morbidity or mortality.16 Two RCTs and expert opinion support ambient temperatures of 23°C and above.3,17,20

2. Two meta-analyses of RCTs showed that early skin-to-skin contact promotes normothermia in healthy newborn infants.2,14 A single-center RCT compar-ing immediate skin-to-skin contact during and after elective cesarean delivery with conventional management showed elimination of hypothermia and hypoglycemia in the intervention group as well as improved breastfeeding outcomes.21 Two meta-analyses reviewed RCTs and observational studies of extended skin-to-skin care after initial resus-citation or stabilization, some in resource-limited settings, showing reduced mortality, improved breastfeeding and blood glucose stability, short-ened length of stay, and improved weight gain in preterm and low-birth-weight infants.22,23

3. Most RCTs in well-resourced settings routinely manage at-risk babies and those requiring resus-citation under a radiant warmer.15,16 Other warming adjuncts are utilized when resuscitation is initiated with the cord intact.12

4. Several RCTs suggest that exothermic mattresses(combined with other measures) prevent hypother-mia in preterm infants.19 One RCT found higher rates of hyperthermia with exothermic mattresses. ${}^{18}$

5. Numerous nonrandomized quality improvement studies support the combined use of multiple warming adjuncts("bundles").24 The use of radi-ant varmers in manual mode or exothermic mat-tresses in combination with other interventions to conserve heat effectively maintains temperature but increases the risk of hyperthermia.19

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Tactile Stimulation in Newborn Infants

|Recommendation for Tactile Stimulation in Newborn Infants|||| |---|---|---|---| |COR|LOE|Recommendation|| |2a|C-LD|1. Tactile stimulation can be useful in newborn infants who appear to have ineffective respiratory effort after birth.||

Synopsis

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

Recommendation-Specific Supportive Text

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

Clearing the Airway in Newborn Infants

|Recommendations for Clearing the Airway in Newborn Infants|||| |---|---|---|---| |COR|LOE|Recommendations|| |2a|C-EO|1. Suctioning of the mouth and nose can be considered in newborn infants if ventilation is required and the airway appears obstructed.|| |2a|C-EO|2. Intubation and tracheal suction can be beneficial for newborn infants who have evidence of tracheal obstruction during ventilation.|| |3:No Benefit|B-R|3. Routine oral, nasal, oropharyngeal, or endotracheal suctioning of newborn infants is not recommended, regardless of whether the fluid is clear or meconium stained.||

Synopsis

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

Recommendation-Specific Supportive Text

1. Suctioning for suspected airway obstruction dur-ing ventilation is based on expert opinion. When ventilation is indicated and the airway appears obstructed, use of a bulb syringe or other suction device can clear the airway. There is no evidence or consensus to support the use of deep suctioning of the stomach.

2. Endotracheal suctioning for apparent airway obstruction is based on expert opinion. Regardless of the presence of meconium, when ventilation corrective steps do not lead to an increase in heart rate or to chest rise, endotracheal suctioning may help to relieve an obstruction. Obstruction may be caused by meconium, mucus plug, blood, or amni-otic fluid.

3. A meta-analysis of 7 RCTs found no benefit from routine upper airway suctioning after birth in infants born through clear amniotic fluid.29 Two RCTs and 2 prospective observational studies found lower oxy-gen saturations in infants who received suctioning within the first 10 minutes, while 2 RCTs did not find significant differences.29 A meta-analysis of 4 RCTs found no benefit of endotracheal suction for infants born through meconium-stained amniotic fluid.30 A large quality improvement trial found that avoiding suction prior to spontaneous breathing,but only wiping the mouth of nonvigorous infants with a towel, was associated with decreased expo-sure to oxygen in the delivery room(12.4% versus 4.4%) but no differences in Apgar scores, use of ventilation or CPAP, or neonatal intensive care unit admission.31

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19. Ramaswamy V, Dawson JA, de Almeida MF, Trevisanuto D, Nakwa FL,Kamlin C, Frang T, Wyckoff MH, Weiner GM, Lilley HG; on behalf of the In-ternational Liaison Committee on Hydration Neonatal Life Support Task Force. Maintaining normothermia immediately after birth in preterm infants<34 weeks' gestation: a systematic review and meta-analysis. Resuscitation.2023;191:109934. doi: 10.1016/j.resuscitation.2023.109934

20.Jia Y.SL Zn,Lv H.Li YU M,Green R,Lin J.Effect of delivery room tem-perature on the admission temperature of premature infants: a randomized controlled trial. J Perinatol 2013;33:264-267. doi: 10.1038/jp.2012.100

21. Xu J.,Zhang M,Li Y,Gu S.Implementation of early essential neonatal care for newborns delivered by cesarean section in Jiaxing: a single-center prospective randomized controlled trial. Int Breastfeed J. 2024;19:31. doi: 10.1186/s13006-024-06035-y

22. Boundy EO, Dastierder R, Sipgelman D, Fawzi WW, Missmer SA, Lieberman E, Kajepeta S, Wall S, Chan GJ. Kangaroo mother care and neona-tal outcomes: a meta-analysis. Pediatrics. 2016;137:e20152238. doi:10.1542/peds.2015-2238

23. Conde-Aguelo A, Diaz-Rossello JL. Kangaroo mother care to reduce mor-bidity and mortality in low birthweight infants. Cochrane Database Syst Rev.2016;2016;CD002771.doi:10.1002/14651858.CD002771.pub4

24.Donnellan D, Moore Z. Patton D, O'Connor T, Nugent L. The effect of thermoregulation quality improvement initiatives on the admission tem-perature of premature/very low birth-weight infants in neonatal intensive care units: a systematic review. J Spec Pediatr Nurs.2020;25:e12286.doi:10.1111/jspn.12286

25. Ginsburg R, de Almeida MFB, Finan E, Perlman JM, Wyllie J, Liley HG, Wyckoff MHS, Jayale T. Tactile Stimulation in Newborn Infants With Inadequate Respiration at Birth: a Systematic Review. Pediatrics.2022;149:021050678. doi: 10.1542/peds.2021-055067

26. Dekker J, Hooper SB, Martherus T, Cramer SJE, van Geloven N, Te Pas AB. Repetitive versus standard tactile stimulation of preterm infants at birth: a randomized controlled trial. Resuscitation. 2018;127:37-43. doi:10.1016/j.resuscitation.2018.03.030

27. Dekker J, Martherus T, Cramer SJE, van Zanten HA, Hooper SB, Te Pas AB. Tactile Stimulation to Stimulate Spontaneous Breathing during Stabi-ization of Preterm Infants as Birth: a Retrospective Analysis. Front Pediatr.2017:51.68.doc:10.3388/pfed.2017:00061

28. Kc A, Budhathoki SS, Thapa J, Niermeyer S, Gurung R, Singhal N,Nepal Neonatal N. Impact of stimulation among non-crying neonates with intact cord versus clamped cord on birth outcomes: observation study. BMJ Paediatr Open.2021;5:0001207. doi:10.1136/bmjpo-2021-001207

29.Fawke J, Wille J, Ustaeda E, Rudiger M, Ersdal H, Wright MD, Wyckoff MH,Liley HG, Rabi Y, Weiner GM; International Liaison Committee On Resuscitation Neonatal Life Support Task Force. Suctioning of clear anni-otic fluid at birth: a systematic review. Resusc plus.2022;12:100298. doi:10.1016/j.respudd2022.100298

30. Trevisano D, Strand M L, Kawakami MD, Fabres J, Szyld E, Nation K,Wyckoff MH,Rabi Y,Lee HC; International Liaison Committee on Resuscita-tion Neonatal Life Support Task Forceternational Liaison Committee on Re-suscitation Neonatal Life Support Task F.Tracheal suctioning of meconium at birth for non-vious infants: a systematic review and meta-analysis.Re-suscitation.2020;149:117-126.doi:10.1016/j.resuscitation.2020.01.038

19. Nestesterenko TH, Pocevic 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

ASSESSMENT OF HEART RATE

|Recommendations for Assessment of Heart Rate in Newborn Infants||| |---|---|---| |COR|LOE|Recommendations of Heart Rate in Newborn Infants| |2a|B-NR|1.ECG can be useful for fast and accurate heart rate assessment in newborn infants.| |2a|2.CU-AL|2. Auscultation and pulse oximetry are reasonable alternatives to ECG for heart rate assessment in newborn infants.|

Synopsis

After birth, the newborn infant's heart rate is used to as-sess the effectiveness of spontaneous respiratory effort,

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the need for interventions, and the response to inter-ventions. Auscultation of the precordium remains the preferred physical examination method for the initial as-sessment of the heart rate, although assessment by aus-cultation(or palpation) may be unreliable and inaccurate. ECG provides the most rapid and accurate measurement of the newborn infant's heart rate at birth and during re-suscitation.1 Compared to ECG, pulse oximetry is both slower in detecting the heart rate and tends to be inac-curate during the first few minutes after birth. Several emerging technologies show potential for fast and accu-rate heart rate assessment, but insufficient clinical data exists for inclusion in these recommendations. Underes-timation of heart rate can lead to potentially unnecessary interventions. Alternatively, overestimation of heart rate when a newborn infant is bradycardic may delay neces-sary interventions. Limited data are available comparing the different approaches to heart rate assessment dur-ing neonatal resuscitation on other neonatal outcomes.Use of ECG for heart rate detection does not replace the need for pulse oximetry to evaluate oxygen satura-tion to assess the need for supplemental oxygen. Pulse oximetry can be placed in anticipation of resuscitation or when assisted ventilation is initiated. ECG can be consid-ered when assisted ventilation is initiated and placed by the time that an alternative airway is being considered for bradycardia(Figure 2).

Recommendation-Specific Supportive Text

1. In 1 RCT and 1 observational study including 70 infants, there were no reports of technical dif-ficulties with ECG monitoring during neonatal resuscitation, supporting its feasibility as a tool for monitoring heart rate during neonatal resus-citation.23 One observational study including 630 infants compared neonatal outcomes before (his-torical cohort) and after implementation of ECG monitoring in the delivery room.4 Compared with the newborn infants in the historical cohort, new-born infants with ECG monitoring had lower rates of endotracheal intubation and higher 5-minute Apgar scores. Newborn infants in that study with ECG monitoring had higher odds of receiving chest compressions in the delivery room with appropri-ateness of compressions not assessed. Evidence from 11 nonrandomized studies.25-14 enrolling 452 newborn infants and 3 RCTs ${}^{15-17}$ enrolling 187 newborn infants suggest that at birth, ECG is faster and more accurate for newborn heart assessment compared with pulse oximetry. Data from 4 non-randomized studies enrolling 156 newborns and 1 RCT enrolling 45 newborn infants show that aus-cultation is not as accurate as ECG for heart rate assessment during stabilization immediately after birth. ${}^{6,18-21}$

2. In the absence of ECG, studies demonstrate auscul-tation and pulse oximetry are faster or more accu-rate than palpation for heart rate assessment.1,18 When ECG is unavailable or not functional, auscul-tation or pulse oximetry are reasonable alternatives and adjuncts for heart rate assessment.

|Recommendation for Assessment of Heart Rate in Newborn Infants Receiving Chest Compressions||| |---|---|---| |COR|LOE|Recommendation| |1|C-EO|1. ECG should be used for the rapid and accurate assessment of heart rate during chest compressions in term and preterm infants.|

Synopsis

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

Recommendation-Specific Supportive Text

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

REFERENCES

1. Kapadia VS,Kawakami MD,Strand ML,Hurst CP,Spencer A,Schmölzer 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 monitoring at birth: a systematic review.Resuscity Plus.2024;19:100668. doi:10.1016/j.resplu.2024.100668

2. Katheria A, Rich W, Finer N. Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation. Pediatrics.2012;130:e1177-e1181.doi:10.1542/peds.2012-0784

3. Katheria A, Arnell K, Brown M, Hassen K, Maldonado M, Rich W, Finer N.A pilot randomized controlled trial of EKG for neonatal resuscitation. PLoS One.2017;12:e0187730. doi: 10.1371/journal.pone.0187730

4. Shah BA, Wlodaver AG, Escobedbo MB, Ahmed ST, Blunt MH, Anderson MP,Szyld EG. Impact of electronic cardiac(ECG) monitoring on delivery room resuscitation and neonatal outcomes. Resuscitation.2019;143:10-16. doi:10.1016/j.resuscitation.2019.07.031

5. Bjorland PA, Ersdal HL, Oymar K, Rettedal SI. Compliance with Guide-lines and Efficacy of Heart Rate Monitoring during Newborn Resuscita-tion: a Prospective Video Study. Neonatology. 2020;117:175-181. doi: 10.1159/000506772

6. Bobillo-Perez S, Balaguero S, Jordan I, Batista-Munoz A, Ramon M, Otero O,Sorribes C, Rodriguez-Fanujl J. Delivery room ultrasound study to assess heart rate in newborns: DELIROUS study. Eur J Pediatr. 2021;180:783-790. doi: 10.1007/s00431-020-03776-4

7. Bush JB, Cooley V, Perlman J, Chang C. NeoEtab offers rapid newborn heart rate assessment. Arch Dis Child Fetal Neonatal Ed. 2021;106:550-552. doi:10.1136/archild-2020-320901

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8. Dawson JA, Saraswat A, Simionato L, Thio M, Kamlin CO, Owen LS,Schmolzer GM, Davis PG. Comparison of heart rate and oxygen satu-ration measurements from Masimo and Nellcorp pulse oximeters in newly born term infants. Acta Paediatr. 2013:102:955-960. doi: 10.1111/apa.123299

9. Henry C, Shipley L, Ward C, Mirrahami S, Liu C, Morgan S, Crowe J,Carpenter J, Hayes-Gill, Shayker D, Acute neonatal heart rate monitor-ing using a new wireless, cap mounted device. Acta Paediatr. 2021;110:72-78. doi:10.1111/apa.15303

10.1163s. Rodriguez MJ.A, Leo E, Criado E, Horzang M. More M, Martínez Orgado J, Arruza L. Pulse oxymity versus electrocardiogram for heart rate assessment during resuscitation of the preterm infant). An Pediatr(Barc).2016;84:2771-277. doi: 10.1016/j.panedi.2015.08.012

11. Iglesias B, Rodri Guez MAJ, Aleo E, Criado E, Martí Nez-Orgado J,Aruzra L. 3-lead electrocardiogram is more reliable than pulse oxim-etry to detect bradycardia during stabilisation at birth of very preterm infants. Arch Dis Child Fetal Neonatal Ed 2018;F323-F237. doi:10.1136/archisch-child-2016-31492

12. Kamlin CO, Dawson O, O'Donnell CP, Morley CJ, Donth SM, Sekhon J, Davis PG. Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room. J Pediatr. 2008;152:756-760. doi:10.1016/j.jpeds.2008.01.002

13. Mizumoto H,Tomotaki S, Shibata H Ueda K, Ashari R, Uho H, Hata D.Electrocardiogram shows reliable heart rates much earlier than pulse ox-imetry during neonatal resuscitation. Pediatr Int. 2012;54:205-207. doi:10.1111/j.1442-200X.2011.03506.x

14. van Vonderen JJ, Hooper SB, Kroese JK, Roese JL, Anaray IC, van Zwet EW, te Pas AB. Pulse oximetry measures a lower heart rate at birth compared with electrocardiography. J Pediatr: 2015;166:49-53. doi:10.1016/j.jpps.2014.09.015

15.Abbey NV, MashuwaV, Weydig HM, Steven Brown L, Ramon EL, Irhambi J, Mir IN, Wyckoff MH, Kapadia V. Electrocardiogram for heart rate evalu-ation during preterm resuscitation at birth: a randomized trial. Pediatr Res.2022;91:1445-151. doi:10.1038/s41390-021-01731-z

16. Murphy MC,De Angelis L,McCarthy LK,O'Donnell CPF,Randomised study comparing heart rate measurement in newly born infants using a monitor incorporating electrocardiogram and pulse oximeter versus pulse oxim-eter alone. Arch Dis Child Fetal Neonatal Ed. 2019;104:F547-F550. doi: 10.1136/archidschild-2017-314366

17. Murphy MC, Jenkinson A, Coveney J, McCarthy L, Kordon |\$PF.\nRandomised study of heart rate measurement in preterm new borns with ECG plus pulse oximetry versus oximetry alone.Ach Dis Child Fetal Neonatal Ed. 2021;106:438-441. doi:10.1136/archischid-2020-320892

18. Cavallin F, CoriMS, Negash S, Azontini G, Vento G, Patotris A0. The heart Rate Determination in newborns at Risk for Resuscitation in a Low-Resource Setting: A randomized Controlled Trial. J. Pediatr. 2020;221:88-92.e.d.10.1016/j.jpeds.200202026

19. Kamlin CO,O'Donnell CP,Erest NJ,Davis PG,Romley CJ.Accuracy of clinical assessment of infant heart rate in the delivery room. Resuscitation 2006;71:319-321. doi:10.1016/j.resuscitation.2006.04.015

20.Treston BP, Semberova J, Kerman R, Crothers E, Branagan A, O'Cathain N,Milein J. Assessment of neonatal heart rate immediately after birth using digital dithestoscope, handheld ultrasound and electrocardiography: an ob-servational cohort study. Arch Dis Child Fetal Neonatal 2019;104:F227.10.1136/archischchild-2018-315619

21. Murphy MC, De Angelis L, McCarthy LK, O'Donnell CPF. Comparison of infant heart rate assessment by auscultation, ECG and oximetry in the de-livery room. Arch Dis Child Fetal Neonatal 2018;103:F490-F492. doi:10.1136/archischd-2017-314367

22. Luong DH,Cheung PY,OR Orelly M, Lee TF, Schmolzer GM. Electrocardiography as Vuscultation to Assess Heart Rate During Cardiac Arrest With Pulseless Electrical Activity in Newborn Infants. Front Pediatr. 2018;6:366.doi:10.33897/ped2018.003866

25. Luong D, Cheung PY, Barrington KJ, Davis Pruira, Unau Jakshimaturi S, Schmolzer GM. Cardiac arrest with pulseless electrical activity rhythm in newborn infants: a case series. Arch Di Child Fetal Neonatal Ed 2019;104:F527-F527-F547. doi: 10.1136/archidschild-2018-316087

204. Patel, Cheung PY, Solevá AL, Barrington KJ, Kamin, CF Davis PG,Schmolzer GM. Pulsse electrical activity: a misdiagnosed entity dur-ing asphyxia in newborn infants? Arch Dis Child Fetal Neonatal Ed.2019;104F215-F217: doi:10.1136/archidisch-2018-314907

25. Sillers, L00ack, CS James JR, Fologia E. Flesse Electrical Activity Complicating Neonatal Resuscitation. Neonatology. 2019;1155:98.98. doi:10.1159/00049357

26. Solevág AL, Luong D, Lee TF, O'Reilly M, Cheung PY, Schmözer GM.Non-perfusing cardiac rhythms in asphyxiated newborn piglets. PLoS One.2019;14:e0214506.doi:10.1371/journal.pone.0214506

VENTILATION AND CONTINUOUS POSITIVE AIRWAY PRESSURE

Ventilatory Support

|Recommendations for Ventilatory Support|||| |---|---|---|---| |COR|LOE|Recommendations|| |1|1. Ventilation should be provided within 60 seconds after birth in newborn infants who are gasping or apneic or who are persistently bradycardic(heart rate less than 100/min) despite appropriate initial steps.||| |2a|C-LD|2. For newborn infants, initial peak inflation pressures of 20 to 30 cm H2O are reasonable, with adjustment of peak inflation pressures to provide effective ventilation.|| |2b|C-LD|3. In newborn infants receiving ventilation, it may be reasonable to provide positive end-expiratory pressure(PEEP).|| |3: Harm|C-LD|4. Excessive peak inflation pressure can result in high tidal volume, which is potentially harmful and should be avoided.||

Synopsis

Most newborn infants start breathing spontaneously within 30 to 60 seconds after birth, sometimes with the help of drying and gentle stimulation.1 If a newborn infant does not breathe spontaneously or has a persistent heart rate below 100/min despite initial efforts including tactile stimulation, ventilation is required at a rate of 30 to 60 inflations per minute. Delay in providing ventilation can increase the risk of death.1 The effectiveness of ventila-tion is assessed by increase in heart rate and, to a lesser extent, with chest movement. For newborn infants, initial peak inflation pressures of 20 to 30 cm H2O are gener-ally sufficient to inflate the lungs. In some cases, higher peak inflation pressures may be necessary.23 However,excessive tidal volumes have been associated with lung and brain injury in preterm newborns.45 As tidal volumes can be both insufficient for effective ventilation if too low,or injurious if too high, titration of peak inflation pressure can be considered during neonatal resuscitation.

Lungs of sick or preterm infants are prone to collapse due to immaturity or inflammation. PEEP improves lung function and oxygenation and maintains lung inflation during expiration. While PEEP may be advantageous,human studies in neonates are limited and the optimal level of PEEP remains undetermined.67

Recommendation-Specific Supportive Text

1. Most nonrigorous newborn infants respond to stimulation and ventilation. The risk of death or pro-longed hospitalization increases by 16% for every 30-second delay in initiating ventilation.

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2.An observational study in 129 term newborn infants using a T-piece resuscatori(refer to the Devices for Ventilation section) reported that dur-ing ventilation, median (IQR) peak inflation pres-sures of 30.6(28.6-31.6) cm H2O resulted in a tidal volume of 4.5(1.6-7.8) mL/kg.2 Similarly, an observational study in 821 term newborn infants using a self-inflating bag reported that during ventilation, median peak inflation pressure of 37.7(32.6-40.8) cm H2O resulted in a tidal volume of 5.2(2.3-8.6) mL/kg.3 Furthermore, a multicenter cluster-crossover trial randomized preterm infants greater than 26 weeks' gestational age and term infants to ventilation with either a self-inflating bag with or without a PEEP valve or a T-piece with PEEP and reported a mean (standard deviation)maximum peak inflation pressure of 26(2) cm H2O with the T-piece versus 28(5) cm H2O with the self-inflating bag.8 Observational studies in pre-term newborn infants reported that a peak inflation pressure of 20 to 25 cm H2O delivered a median (IQR) tidal volume of 9(3-15.7) mL/kg during ventilation, but higher initial pressures may some-times be required.9-14 After initiation of assisted ventilation, titrating peak inflation pressures both up and down during resuscitation may be needed to achieve effective, but not excessive, ventilation.

3. A cohort study of 1962 infants born between 23 and 33 weeks' gestational age reported lower rates of mortality and chronic lung disease dur-ing ventilation with PEEP versus ventilation with no PEEP.6 Furthermore, using logistic regression with adjustment for maternal and neonatal charac-teristics, use of the T-piece resuscatorit with PEEP compared with self-inflating bag without PEEP increased the chance of survival to hospital dis-charge without major morbidities(OR, 1.38; 95%CI, 1.06-1.80).6

In preterm animal models, PEEP facilitates lung acceleration and development of functional residual capacity, prevents distal airway collapse, increases lung surface area and compliance, decreases expi-ratory resistance, conserves surfactant, and reduces hyaline membrane formation, alveolar collapse, and the expression of proinflammatory mediators. ${}^{15-17}$

4.Animal studies reported that ventilation with high volumes initiates inflammatory cascades, which result in lung and brain injury in immature ani-mals.18,19 The 2 pathways (cerebral blood flow instability and cerebral inflammatory cascade)increase the risk of brain injury and potential life-long adverse neurodevelopmental outcomes.18 Observational studies in preterm newborn infants have associated high tidal volume delivery dur-ing ventilation with higher rates of intraventricu-lar hemorrhage.4.5 When preterm newborn infants

Observational studies in preterm newborn infants have associated high tidal volume delivery dur-ing ventilation with higher rates of intraventricu-lar hemorrhage.4.5 When preterm newborn infants

received tidal volumes $>6~mL/ kg$ , grade III and IV intraventricular hemorrhage was found in 33/124(27%) infants compared to tidal volumes $<6~mL/$ kg in 2/41(6%).4 Similarly, infants who had a greater number of inflations with a tidal volume $>6~mL/ kg$ were more likely to develop intraventricular hemorrhage.5

Rate and Inflation Time During Ventilation

|Recommendations for Rate and Inflation Time During Ventilation||| |---|---|---| |COR|LOE|Recommendations| |2a|C-LD|1. It is reasonable to provide ventilation at a rate of 30 to 60 inflations per minute in newborn infants.| |2a|C-LD|2. It is reasonable to initiate ventilation with an inflation time of 0.5 to 1 seconds in newborn infants.| |3: Harm|B-R|3. In preterm newborn infants less than 28 weeks of gestation, the routine use of sustained inflation (>5 seconds) to initiate ventilation is potentially harmful and should not be performed.|

Synopsis

During ventilation, an inflation time of 0.5 to 1 second dur-ing ventilation aligns with the natural breathing patterns of both term and preterm newborn infants.2,2021 It is appropri-ate to provide ventilation at a rate of 30 to 60 inflations per minute for newborn infants who are not breathing ef-fectively.1,2 Studies that explored the effects of sustained inflations>5 seconds reported higher risks for preterm newborns.22 The potential benefits or risks of sustained in-flations lasting between 1 and 5 seconds remain unclear.

Recommendation-Specific Supportive Text

1. An observational study of 129 term newborn infants reported that ventilation using inflation time of approximately 0.5 seconds with a rate of 30 to 60/min resulted in delivered tidal volumes between 5 and 10 mL/kg.2 An observational study of 434 late preterm and term newborns reported that an inflation rate of 30/min was associated with the highest carbon dioxide clearance and the shortest time to reach exhaled carbon dioxide $>20\%^{23}$

2. Observational studies including 950 term newborn infants reported that median inflation time of 0.46 seconds(IQR,0.35-0.59 seconds) was associated with adequate tidal volume delivery. ${}^{1,2}$ Furthermore,increased inflation times were associated with a rise in tidal volume. ${}^{2}$

3.An ILCOR task force review reported no benefit in using 1 or more sustained inflations of $>5$ seconds for preterm infants at birth.22 Sustained inflations may increase mortality among the subgroup of preterm newborns<28 weeks of gestation.22 The Sustained Aeration for Infant Lungs trial included 426 newborn infants 23 to 26 weeks' gestational

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age and compared ventilation with up to 2 initial sustained inflations using a peak inflation pressure of 25 cm$H_{2} O$ for 15 seconds(intervention) to standard ventilation(control) and reported signifi-cantly higher early mortality with sustained inflation compared to standard ventilation.24

Ventilation Corrective Maneuvers

|Recommendations for Ventilation Corrective Maneuvers|||| |---|---|---|---| |COR|LOE|Recommendations|| |2a|C-LD|1. Ventilation corrective maneuvers can be useful when initial positive pressure inflations are not effective for newborn infants who require ventilation.|| |2a|B-R|2. Video laryngoscopy can be useful for newborn infants who require endotracheal intubation.|2. Video laryngoscopy can be useful for newborn infants who require endotracheal intubation.|

Synopsis

Effective ventilation is difficult to perform in newborn infants due to problems such as leak around the face mask,airway obstruction, and insufficient inflating pres-sures.25-28 Neonatal manikin studies have shown that large leaks around the face mask can occur during venti-lation,29-32 and these findings have been replicated in clin-ical studies of term and preterm infants receiving mask ventilation.13,28,33-35 Ventilation corrective maneuvers to overcome common challenges to effective ventilation in-clude airway repositioning, mask adjustment or use of the 2-handed mask hold, suctioning,increasing peak inflation pressure, and placement of an alternative airway.36,37

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

Recommendation-Specific Supportive Text

1. In an infant manikin study of 48 subjects and a pilot RCT of 30 preterm infants, mask leak was signifi-cantly reduced when using a 2-handed mask hold technique compared to a single operator holding the mask and providing the ventilation.44,45 In an obser-vational study of ventilation corrective maneuvers on the impact of tidal volume delivery during ventilation in 30 preterm infants, performing ventilation correc-tive steps led to improved tidal volume delivery in about one third of patients but resulted in ineffective or excessive tidal volumes in others. The number sequence, and combination of maneuvers varied across resuscitations.46 In an observational study

<EndOfPara>of physiological response to ventilation corrective maneuvers in 28 preterm infants, mask adjustment,airway repositioning, and increasing peak inflation pressure led to improved oxygen saturation. Mask adjustment and increasing peak inflation pressure were also observed to increase expired tidal volume,although excessive tidal volumes were seen in this study.47 An observational study of 58 term and 76 preterm infants reported a total of 427 maneuvers to improve noninvasive respiratory support. Cerebral regional tissue oxygen saturation measured by near infrared spectroscopy increased after the first ven-tilation corrective maneuver. There were nonsignifi-cant improvements in heart rate, oxygen saturation,and face mask leak.48

2. In a meta-analysis of 6 RCTs involving 862 intu-bations, video laryngoscopy compared to tradi-tional laryngoscopy led to increased endotracheal intubation success.38-43,49 In a meta-analysis of 4 RCTs involving 610 intubations, video laryngoscopy led to increased likelihood of endotracheal intubation on first attempt.39,41-43 In a meta-analysis of 4 RCTs involving 555 intubations, video laryngoscopy com-pared to traditional laryngoscopy led to decreased number of intubation attempts.38-40,43 Adverse outcomes such as airway trauma, bradycardia,oxygen saturation, esophageal intubation, and pneumothorax were not increased in 5 compara-tive RCTs.39-43 In a observational studies involving 3342 intubations, video laryngoscopy compared to traditional laryngoscopy was associated with increased likelihood of endotracheal intubation on first attempt.50-53 While traditional laryngoscopy remains a reasonable method to achieve an alter-native airway, video laryngoscopy may be prefer-able when resources and training allow.

Interfaces to Deliver Ventilation to Newborn Infants

|Recommendations for Interfaces to Deliver Ventilation to Newborn Infants|||| |---|---|---|---| |COR|LOE|Recommendations|| |2a|C-LD|1. It is reasonable to use a laryngeal mask as an alternative to endotracheal intubation for newborn infants 34+0/7 weeks' or more gestational age for whom ventilation via face mask is unsuccessful.|| |2b|C-LD|2. It may be reasonable to use a laryngeal mask as the primary interface to administer ventilation instead of a face mask for newborn infants 34+0/7 weeks' or more gestational age.||

Synopsis

Available interfaces for delivery of ventilation during new-born resuscitation include face masks, nasal prongs, and

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

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

Recommendation-Specific Supportive Text

1.In 2 separate meta-analyses of the same 3 RCTs(158 infants born at≥34+0/7 weeks' gestational age), there was no significant difference in inser-tion time, failure to correctly place the device, or first attempt success when a laryngeal mask was used as a secondary device instead of endotracheal intu-bation after face mask ventilation was unsuccessful-ful.54,55 In RCT(68 infants born at≥34+0/7 weeks' gestational age) that was not included in these meta-analyses, there was no significant difference in insertion time, first attempt success, or duration of ventilation. ${}^{56}$ In 1 observational study(86 infants born at 34+0/7 to 36+6/7 weeks' gestational age) that was not included in these meta-analyses, use of a laryngeal mask instead of an endotracheal tube was associated with decreased likelihood of admis-sion to the neonatal intensive care unit. ${}^{57}$ There were insufficient subjects to determine statistical difference in important outcomes such as incidence of pneumothorax or mortality.

2.A meta-analysis of 6 RCTs(1823 infants born at≥34+0/7 weeks' gestational age) found that use of a laryngeal mask decreased the probability of failure to improve with the assigned device and the rate of endotracheal intubation in the delivery room when compared to use of a face mask.58 These studies had heterogeneity in regard to subjects in their resuscitation experience for face mask ven-tilation and tended to be conducted in low- and middle-income countries. The duration of ventila-tion and time until heart rate reached >100/min were also shorter with the laryngeal mask. Similarly,a quasi-randomized study of 67 infants born at>36 weeks' gestational age that was not cap-tured in the above meta-analysis found that infants who received ventilation using a laryngeal mask required shorter duration of ventilation and were less likely to require intubation when compared to infants who were ventilated using a face mask.59

Devices for Ventilation

|Recommendation for Devices to Deliver Ventilation to Newborn Infants|||| |---|---|---|---| |COR|LOE|Recommendation|| |2a|B-R|1. It can be beneficial to use a T-piece resuscator instead of a self-inflating bag, with or without a PEP valve, for administering ventilation to new- born infants, particularly preterm infants.||

Synopsis

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

Recommendation-Specific Supportive Text

1. A meta-analysis of 4 RCTs (1247 infants) found that resuscitation with a T-piece resuscitor com-pared with a self-inflating bag reduced the dura-tion of assisted ventilation and decreased risk of bronchopulmonary dysplasia.7 A more recent meta-analysis of 5 RCTs (1271 infants) comparing "fixed-pressure devices" (ie, T-piece resuscitators and mechanical ventilators) to "hand-pressure devices" (ie, self-inflating bags and flow-inflating bags) simi-larly found that fixed-pressure devices were associ-ated with decreased bronchopulmonary dysplasia, intubation in the delivery room, requirement and duration of mechanical ventilation, and surfactant administration.60 Neither meta-analysis showed a difference in mortality between groups. Although subgroup analyses by gestational age were not feasible' or not significant, ${ }^{60}$ bronchopulmonary dysplasia is an outcome that affects preterm infants and the use of a T-piece resuscitator may pro-vide the greatest benefit to preterm infants. Since these meta-analyses, 2 additional RCTs (92 pre-term infants) comparing the use of a self-inflating bag and T-piece resuscitator have been published.Ventilation provided by a T-piece resuscitator deliv-ered tidal volumes within goal range more consis-tently when compared to a self-inflating bag, ${ }^{61}$ but there was no significant difference in duration of assisted ventilation or other outcomes. ${ }^{61,62}$ There were no new studies identified that evaluated the use of flow-inflating bags.

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Neonatal Resuscitation: 2025 AHA/AAP Guidelines for CPR and ECC

Continuous Positive Airway Pressure

|Recommendations for Providing Continuous Positive Airway Pressure|||| |---|---|---|---| |Newborn Infants|Newborn Infants|Newborn Infants|Newborn Infants| |COR|LOE|Recommendations|| |2a|A|1. For spontaneously breathing preterm infants who require respiratory support immediately after birth, it is reasonable to use CPAP rather than intubation and mechanical ventilation.|| |2b|C-LD|2. For spontaneously breathing preterm infants who require respiratory support immediately after birth, the effectiveness of high-flow nasal cannula compared to CPAP is not well-established.|| |2b|C-LD|3. The usefulness of CPAP for spontaneously breathing term and late preterm infants34 weeks' or more gestational age who have or are at risk of having respiratory distress immediately after birth is not well-established.||

Synopsis

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

Recommendation-Specific Supportive Text

1. Four RCTs and 1 meta-analysis64-68 showed reduc-tion in the combined outcome of death and bron-chopulmonary dysplasia when starting treatment with CPAP compared with intubation and ventila-tion in preterm infants less than 30 weeks of ges-tation with respiratory distress. The meta-analysis reported no differences in the individual outcomes of mortality, bronchopulmonary dysplasia, pneu-motherax, intraventricular hemorrhage, necrotizing enterocolitis, or retinopathy of prematurity.68

2.One randomized trial enrolling 124 preterm infants(28-36 weeks of gestation) compared CPAP to high-flow nasal cannula as primary respiratory support in the delivery room.69 There was no dif-ference in“treatment failure” within 24 hours between groups. Treatment failure was defined as oxygen concentration>40%, failure of immediate extubation following surfactant administration by the Intubation-Surfactant-Extubation technique,predefined levels of acidosis or hypercarbia, apnea with predefined criteria of severity, or subsequent mechanical ventilation.

3. Two RCTs, ${}^{70,71}$ 2 observational studies, ${}^{72,73}$ and 1 meta-analysis ${}^{74}$ inform the use of CPAP in the delivery room. The studies included both prophyl-lactic use of CPAP for prevention of and treatment of respiratory distress. The use of CPAP for spon-taneously breathing term and late preterm infants is≥34 weeks' gestational age in the delivery room may decrease neonatal intensive care unit admis-sion or respiratory support in the neonatal intensive care unit, though the incidence of pneumothorax may be increased.

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OXYGEN

|Recommendations for Oxygen Administration During Neonatal Resuscitation|||| |---|---|---|---| |COR|LOE|Recommendations|| |1|C-EO|1. Oxygen supplementation should be titrated to target oxygen saturation goals in newborn infants receiving respiratory support.|| |2|C-LD|2. A pulse oximeter should be placed as soon as possible for newborn infants receiving respiratory support or supplemental oxygen.|| |3|2b|3. In term and late preterm newborn infants born at 35 weeks' or more gestational age receiving respiratory and pretermary support at birth, it may be reasonable to begin with within 21% oxygen.|| |2|C-LD|4. In preterm newborn infants born at 32 to preterm newborn infants born at 32 to preterm at birth, it may be reasonable to begin with 21% oxygen.|| |2|2b|4. In preterm newborn infants born at 32 to preterm at birth, it may be reasonable to begin with 21% oxygen.|| |3|2b|5. In preterm newborn infants born at 53 weeks' gestational age receiving respiratory support at birth, it may be reasonable to begin with 21% oxygen.|| |2|C-LD|4. In preterm newborn infants born at 32 weeks' gestational age receiving respiratory support at birth, it may be reasonable to begin with 30% to 100% oxygen.||

Synopsis

At birth, the newborn infant's blood oxygen levels rise over several minutes. For newborn infants who require resuscitation, supplemental oxygen may prevent harm from hypoxia1. However, hyperoxia may also be asso-ciated with harm.2 The balance of benefit and harm of oxygen supplementation varies by gestational age and according to the individual newborn infant's physiology.

Pulse oximetry allows oxygen titration to prevent either hypoxia or hyperxia: Placement of a pulse oximeter sen-sor and acquisition of a reliable signal takes time. Appro-priate sensor placement is preductal, on the infant's right hand or wrist, as this reflects the blood oxygen saturation of the myocardium and brain.

In the very preterm population, failing to reach an oxy-gen saturation of 80% by 5 minutes has been associated with death regardless of initial oxygen concentration.3,4 For infants less than 32 weeks' gestational age, initial oxygen concentrations of 21% to 30% may be insuf-ficient to achieve target oxygen saturations.

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Recommendation-Specific Supportive Text

1. Multiple studies have measured oxygen saturation in newborn infants at birth, but there are limited data on different oxygen saturation targets or titration strategies during newborn resuscitation. Optimal oxygen saturation targets for newborn infants receiv-ing resuscitation at birth remain unknown. In the absence of such evidence, currently recommended preductal oxygen saturation goals remain based on ranges measured in healthy term infants after vagi-nal birth at sea level with the goal of avoiding the risks associated with hypoxia and hyperoxia.6-8

2. Placement of a pulse oximeter early in resuscitation results in earlier reading of oxygen saturation for guidance of oxygen therapy during resuscitation.In an observational study of videos of 230 resusci-tated infants, median time to obtain pulse oximetry was 238 seconds.9 In an observational study com-paring asphyxiated infants to controls, the median time for oxygen saturation detection was longer(260 seconds) than in controls(100 seconds).1° In an observational study of 428 infants, time taken to achieve an oxygen saturation reading in preterm infants was longer than in term infants.1

3. For term and late preterm infants 35 or more weeks of gestation requiring respiratory support at birth,initiating resuscitation with 21% oxygen(air) com-pared with 100% oxygen is reasonable because evidence from meta-analysis suggests that it may reduce short-term mortality.12 The ILCOR system-atic review of initial oxygen concentration for term and late preterm infants included 5 randomized and 5 quasi-randomized trials.12 Most of the evidence came from studies with a high risk of bias and all summary estimates had serious imprecision. Meta-analysis of 7 randomized and quasi-randomized tri-als showed decreased short-term mortality when using 21% oxygen compared with 100% oxygen.12 No difference was found in the risk of HIE or mod-erate to severe neurodevelopmental impairment among survivors at 1 to 3 years of age.12 Although this systematic review included randomized and quasi-randomized controlled trials, the LOE has been downgraded to C-LD because of the high risk of bias in the studies included and the serious imprecision for all reported outcomes. No studies have compared initiating resuscitation with interme-diate oxygen concentrations(22%-99% oxygen).

4. Evidence from meta-analysis of 10 randomized tri-als enrolling newborn infants less than 35 weeks'gestational age found no difference in short-term mortality when respiratory support was started with low compared with high oxygen.13 In the included studies, low oxygen was generally 21% to 30%and high oxygen was 60% to 100%. In addition,no differences were found in multiple secondary

outcomes. Most evidence came from studies with unclear risk of bias and all summary estimates had serious imprecision. In the subgroup of trials that used oxygen saturation targeting as a co-intervention, all preterm infants in whom respiratory support was initiated with 21% oxygen(air) required supplemental oxygen to achieve the predetermined oxygen saturation target. The recommendation to initiate respiratory support with a lower oxygen con-centration reflects a preference to avoid exposing preterm newborn infants to excess oxygen beyond that necessary to achieve the predetermined oxy-gen saturation target without evidence demonstrat-ing a benefit for important outcomes.14

5. Analyses of the currently available data compar-ing initial oxygen concentration for very preterm infants have yielded conflicting conclusions,including for the critical outcome of mortality. A study-level meta-analysis of 10 RCTs enrolling preterm infants, including subanalysis of 7 trials reporting outcomes for newborn infants 28 weeks'gestational age or less, showed no difference in short-term mortality when respiratory support was started with low compared with high oxygen.13 In these studies, low oxygen was generally 21% to 30% and high oxygen was 60% to 100%. No dif-ferences were found in long-term mortality, neuro developmental outcome, retinopathy of prematurity,bronchulmonary dysplasia, necrotizing enteroco-litis, or major cerebral hemorrhage.13 In a system-atic review of 8 trials that used oxygen saturation targeting as a cointervention, all preterm newborns in whom respiratory support was initiated with 21%oxygen required supplemental oxygen to achieve the predetermined oxygen saturation target.13 A recent individual patient data meta-analysis found that in preterm infants less than 32 weeks of ges-tation, high initial(90%-100%) oxygen was asso-ciated with lower mortality when compared with low initial(21%-30%) oxygen concentrations.5

REFERENCES

1. Saugstad OD. Resuscitation of newborn infants: from oxygen to room air.Lancet 2010;376:1970-1971. doi: 10.1016/S0140-6736(10)60543-0

2.Weinberger B, Laskin DL, Heck DE, Laskin JD. Oxygen toxic-ity in premature infants. Toxicol Appl Pharmacol 2002;181:60-67. doi:10.1006/taap.2002.9387

3. Oei JL,Finner NN, Saugstad OD, Wright IM, Rabi Y, Tarnow-Mordi W, Rich W,Kapadia V,Rook D,Smyth JP,et al.Outcomes of oxygen saturation targeting during delivery room stabilisation of preterm infants. Arch Dis Child Fetal Neo-natal Ed.2018;103:F446-F454.doi:10.1136/archischid-2016-312366

4. Jiang S, Cui X, Katheria A, Finer NN, Bennett MV, Profit J, Lee HC. As-sociation between 5-minute oxygen saturation and neonatal death and intraventricular hemorrhage among extremely preterm infants. J Perinatol 2025;45:1145-1151.doi: 10.1038/s41372-024-02194-w

5. Sotropoulos JX, Oei JL, Schmolzer GM, Libesman S, Hunter KE, Williams JG, Webster AC, 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;1787:774-783. doi: 10.1001/jamapediatrics.2024.1848

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6. Dawson JA, Kamlin COF, Vento M, Wong C, Cole TJ, Donath SM, Davis PG,PMrey CJ. Defining the reference range for oxygen saturation for infants after birth. Pediatrics.2010;125:e1340-e1347. doi:10.1542/peds.2009-1510

7. Mariani G, Dik PB, Exquer A. Aguire A. Estban ML, Perez C, Fernandez Sus, Fastinica F. Pre-ductal and post-ductal O2 satura-tion in healthy term neonates after birth. J Pediatr. 2007;150:418-421. doi:10.1016/j.jpeds.2006.12.015

8. Padilla-Sánchez C.,Baixauli-Alacreu S,Canada-Martinez AJ,Solaz-Garcia A,Alemany-Anchel MJ,Vento M. Delayed vs Immediate Cord Clamping Chang-Es oxygen Saturation and Heart Rate Patterns in the First Minutes after Birth. J.Pediatr.2020;227:149-156.e1.doi:10.1016/j.jpeds.2020.07045

9. Kolostad V. Pike E1vestjonn J., Buskov J,F erald H.Rettald S. Use of Pulse Oximetry during Resuscitation of 230 Newborns-A Video Analysis. Children(Base).2023;10:1124. doi:10.3390/children 10071124

10. Amin A, Showkat HI, Chowdhary J, Wani S, Sarmast AH, Bhat RA, Jan B.The role of pulse in resuscitation by asphyxated neonates. Eur J Gen Med.2014;11:85-89.

11. Reddy KS, Venkataravanappa ST, Gururaja G. Fessiblity of Oxygen Satu-ration Monitoring During Neonatal Resuscitation in Indian Scenario. Indian Pediatr:2018;55:999.

12.Welford M,Nishiyama C,Shortt C, isayama T, Dawson JA, 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 infiltration term newborn resuscitation: a systematic review with meta-analysis. Pediatr.2019;143:e20181825.doi:10.1542/peds.2018-1825

13. Welsford M,Nishiyama C,Shortt C,Weiner G,Roehr C,Isayama T,Dawson JA, Wyckoff MH, Rabi Y; on behalf of the International Liaison Commit-tee on Resuscitation Neonatal Life Support Task Force. Initial oxygen use for preterm newborn resuscitation: a systematic review with meta-analysis.Pediatrics.2019;143:e20181828. doi:10.1542/peds.2018-1828

14. Escobedo MB, Aziz K, Kapadia VS, Lee HC, Niermeyer S, Schmüller GM,Szyl E, Weiner GM, Wyckoff MH, Yamada NK, et al. 2019 American Heart Association focused update on neonatal resuscitation: an update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics.2020;145:e20191362. doi: 10.1542/peds.2019-1362

CHEST COMPRESSIONS

Chest Compression Timing, Ventilation, and Oxygen Use

|Recommendations for Initiating Chest Compressions in Newborn Infants||| |---|---|---| |COR|LOE|Recommendations| |1|C-EO|1. In newborn infants, chest compressions are recommended if the heart rate remains less than 60/min despite 30 seconds of ventilation that inflates the lungs, as evidenced by chest movement.| |1|C-EO|2. During chest compressions in newborn infants, ventilation with an endotracheal tube is recommended.| |2b|C-EO|3. During chest compressions for newborn infants born at 34 weeks' or more gestational age when placement of an endotracheal tube is not possible or is unsuccessful, laryngeal mask may be a reasonable alternative.| |2b|C-EO|4. It may be reasonable to use 100% oxygen during chest compressions in newborn infants. Once compressions are no longer needed, titrate the oxygen to meet saturation targets.|

Synopsis

Most newborn infants who require resuscitation at birth respond to initial steps of resuscitation or to ventilation that inflates the lungs. Effective ventilation is indicated

by a rise in heart rate. Ventilation must be optimized be-fore starting chest compressions, including placement of an alternative airway, if possible(intubation or laryngeal mask), as chest compressions compete with delivery of effective ventilation.

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

Recommendation-Specific Supportive Text

1.Initiation of chest compressions in newborn infants with a heart rate less than 60/min is based on expert opinion because there are no clinical or physiological human studies addressing this ques-tion. A review article regarding strategies to pre-vent progression of bradycardia and the role of chest compressions for persistent neonatal brady-cardia in the delivery room included some poten-tially useful animal data.5 Fetal lambs(n=14) were asphyxiated until cardiac arrest. Heart rates were continuously monitored and coronary, carotid, and pulmonary flows recorded and compared during asphyxia at different levels of bradycardia. Peak systolic carotid flows were significantly lower for heart rates<60/min compared to baseline.5

2.In a neonatal simulation study, once chest com-pressions were initiated, health care professionals(n=30) were unable to recognize changing lung compliance and thus made little effort to optimize ventilation.1 Based on expert opinion, intubation is suggested during chest compressions in order to assure efficacy of ventilation, which is a priority for neonatal resuscitation.

3. A recent ILCORp scoping review examined the evidence for using a laryngeal mask during chest compressions in newborn infants.6 Two animal studies suggest that ventilation via a laryngeal mask during chest compressions provides similar rates and time to ROSC compared to ventilation through an endotracheal tube.7.8 Animal and mani-kin data suggest that laryngeal masks can deliver comparable ventilation to that provided through an endotracheal tube during chest compressions.7-9

4. A recent scoping review4 identified that to date there are no human studies comparing air, 100%oxygen, or any other oxygen concentration dur-ing newborn infant chest compressions. Animal studies have not found any difference in rates of ROSC, mortality, markers of injury or oxidative

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stress, hemodynamics, or oxygen delivery.4,10-12 None of the animal studies examined any longer-term outcomes. Based on expert opinion,100% oxygen during chest compressions is sug-gested. Once ROSC is achieved, oxygen should be weaned to meet goal saturations, as hyper-oxia following resuscitation is associated with morbidity.13-15

Compression-to-Ventilation Ratio and Techniques(Newborn)

|COR|LOE|Recommendations| |---|---|---| |2b|C-LD|1. It may be reasonable to repeatedly deliver 3 compressions followed by a ventilation breath (3:1 ratio) when providing chest compressions to newborn infants.| |2b|C-LD|2. It may be reasonable to use the 2 thumb- encircling hands technique compared to the 2-finger or other techniques when providing chest compressions to newborn infants.| |2b|C-LD|3. It may be reasonable to compress to one third the anterior-posterior diameter of the chest when providing chest compressions to newborn infants.| |2b|C-LD|4. It may be reasonable to compress over the lower one third of the stermum, taking care to be above the xiphoid process when providing chest compressions to newborn infants.| |2b|C-EO|5. It may be reasonable to change the compressor role every 2 to 5 minutes when providing chest compressions to newborn infants and to switch the compressor during the heart rate assessment period.|

Synopsis

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

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

Recommendation-Specific Supportive Text

1.In animal studies, the use of compression-to-ventilation ratios different from 3:1(eg,2:1,4:1,5:1,9:3,15:2) is associated with similar times to ROSC and mortality rates.20-25 The use of chest compressions with asynchronous ventilations com-pared to a ratio of 3:1 has varied results with incon-sistencies between studies with some reporting improvements in ROSC and survival, others show-ing no difference and some showing deteriorations in depth of compression and compressor fatigue.4 A new technique of providing continuous compres-sions during a sustained inflation has been studied in animals $4,11,26,27$ as well as in a small pilot trial in newborn infants.28 The majority of studies sug-gest potential benefit with faster time to ROSC but inconsistent survival results. A larger clini-cal trial found no differences but was underpow-ered.29 Providing continuous compressions during a sustained inflation remains an interesting area of research but is not ready for clinical application.

2. Animal and manikin studies frequently demon-strate greater chest compression depth, improved carotid blood flow, lower fatigue, and higher pro-portion of correct hand placement with the 2 thumb-encircling hands technique compared with the 2-finger and other techniques.4,30 In 2 newborn infants with indwelling catheters, the 2 thumb-encircling hands technique generated higher sys-tolic and mean blood pressures compared with the 2-finger technique. ${}^{31}$

3. In a randomized animal trial, time to ROSC was simi-lar with chest compression depths of 25%, 33%,and 40% of the anteroposterior chest diameter.A chest compression depth of only 12.5% did not achieve ROSC.32 The same group also reported on hemodynamic parameters, with the highest carotid blood flow and systemic mean blood pressure being achieved with 40% chest compression depth.32 A retrospective clinical study examined chest com-puted tomography scans of 54 neonates and concluded that the recommended one third antero-posterior diameter would be more effective than one fourth anteroposterior diameter compression and safer than one half anteroposterior diameter com-pressions.33 No neonatal survival outcomes or long-term outcomes of newborn infants who received varying depths of compression are available.

4.One of the earliest reports of newborn infant chest compressions compared abdominal versus xiphoid versus middle ternum versus simultaneous chest/abdominal compression. Fresh cadavers of infants and young children(n=15) were used with subse-quent autopsy examination. No rupture of the liver was produced when pressure was applied to the

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chest alone at midsternum. Superficial tears of the liver capsule were produced when pressure was applied to the xiphoid process, and all patients with simultaneous chest/abdominal or abdominal com-pressions alone had liver rupture. Compression of the middle part of the sternum(above the xiphoid)produced effective circulatory pressures.34 Chest radiograph studies with markers at the sternal notch and xiphoid process prior to taking the film subsequently identified that for the majority of infants, the heart lies under the lower one third of the sternum.35-37 Additional studies found that the nipple line is not a good landmark for deter-mining compression position.38,39 Review of infant chest computed tomography scans to evaluate the optimal chest compression site found that the left ventricle was located beneath the lower quarter of the sternum the majority of the time.40 Due to the safety concerns from the older cadaveric studies, it is important to make sure the compression is above the xiphoid on the lower one third of the sternum.33

5. High-quality chest compressions encompass multiple factors, including optimal compression-to-ventilation ratio, adequate rate, depth of com-pression, and full recoil between compressions. If the compressor experiences fatigue, the quality of the compressions declines.41,42 Neonatal manikin studies demonstrate that compression quality can diminish by 2 to 5 minutes when a single clinician performs compressions.43-46

REFERENCES

1. Hyunth Y, Hemnay RJ, Perman JM. Assessment of effective face mask ventilation is compromised during synchronised chest com-pressions. Arch Dis Child Fetal Neonatal Ed. 2015;100:F39-F42. doi:10.1136/archischid-2014-306309

2. Saugstad OD. Oxygenation of the newborn. The impact of one molecule on newborns. J. Perntal Med. 2025;31:20-26. doi:10.1515/jpm-2022-059

3.Aziz K, Lee CHC, Escobedo MB, Hoover AV, Kamath-Rayne BD, Kapadia VS, Magid DJ,Nemeyer S, Schmolizer GM, Syldey et al. Part 5: Neonatal Resuscitation 2020 American Heart Association Guidelines for Cardio-pulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics 2021;147:e2020038505E. doi:10.1542/peds.2020-038505E

4. Ramachandran S, Bruckner M, Wockyck MH, Scholmer G. Chest com-pressions in newborn infants: a scoping review. Arch Dis Child Fetal Neonatal Ed 2023;108:44-450. doi:10.1136/archschideli-2022-342592

5.Agrawal V, Lakshminrusinha S, Chandrasekharan P. Chest Compressions for Brady Cardia during Neonatal Resuscitation-Do We Have Evidence? Chil-dren(Bas).2019;6:119. doi:10.3390/children6110119

6. Liley HG, Weiner GM, Wyckoff MH, Rabi Y, Schmolzer GM, de Almeida MF,Costa-Nobre DT, Kawakami MD, Davis PG, Dawson JA, et al. Neonatal life support:2025 International Liaison Committee on Resuscitation Consensus on Science With Treatment Recommendations. Circulation. 2025;152(suppl 1)1:S165-Sd.2040. doi:10.1161/CIR/000000000001365

7. Mani S, Gugino S, Helman J, Bawa M, Nair J, Chandrasekharan P, Rawat M.Laryngeal mask ventilation with chest compression during neonatal resuscri-tation: randomized, non-inferiorial tri in lambs. Pediatr Res. 2022;92:671-677. doi: 10.1038/s41390-021-01820-z

8.Mehre AA, Graham R, Srinivasan G, Heese D, Rudakharini S.63: La-nygeval mask Air Wayvers Endusotrical Infusion for Positive Pressure Ventilation with Chest Compressions in Neonatal Porcine Model. Paediat Child Health.2014;19:e57-e67.d.10:1093/prh/196:53-61

9.Isobe A,Asui R,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.respuil.2022.100276

10. Garcia-Hidalgo C, Cheung PY, Solev AG, Vento M, O'Reilly M, Saugstad O, Schmolzer GM. A Review of Oxygen Use During Chest Compressions in Newborns-A Meta-Analysis of Animal Data. Front Pediatr. 2018;6:400. doi:10.3389/fped.2018.00400

11. Nyame S, Cheung PY, Lee TF, O'Reilly M, Schmolzer GM. A Randomized,Controlled Animal Study: 21% or 100% Oxygen during Cardiuophmonary Resuscitation in Asphyxialated Infant Piglets. Children(Basel). 2022;9:1601.doi: 10.3390/children9111601

12. Sankaran D, Giusto EM, Lesneski AL, Hardie ME, Joudi HM, Lane ECA,Hammitt VL, Tully KC, Vali P, Lakshminurisma S. Randomized Trial of 21%versus 100% Oxygen during Chest Compressions followed by Gradual versus Abrupt Oxygen Titration after Return of Spontaneous Circulation in Neonatal Lambs. Children(Basel). 2023;10:575. doi: 10.3390/children10030575

13. Badurdeen S, Galinsky R, Roberts CT, Crossley KJ, Zahra VA, Thiel A, Pham Y,Davis PG,Hooper SB, Polglase GR,et al. Rapid oxygen titration following cardiopulmonary resuscitation mitigates cerebral overperfusion and stria-tal mitochondrial dysfunction in asphyxiated newborn lambs. J Cereb Blood Flow Metab.2024;45:630-642. doi:10.1177/0271678x241302738

14. Kapadia,VS Chalak LF,DuPont TL, Rollins NK, Brion LP, Wyckoff MH.Perinatal asphyxia with hyperoxemia within the first hour of life is associ-ated with moderate to severe hypoxic-ischemic encephalopathy. J Pediatr.2013;1639:949-954.doi:10.1016/j.jpps.2013.04.034

15. Klinger G, Beyene J, Shah P, Perlman M. Do hyperoxaemia and hypocapnia add to the risk of brain injury after intrapartum asphyxia? Arch Dis Child Fetal Neonatal Ed.2005;90:F49-F52. doi: 10.1136/adc.2003.048785

16. Handley SC, Sun Y,Wyckoff MH, Lee HC. Outcomes of extremely preterm infants after delivery room cardiopulmonary resuscitation in a population-based cohort.J Perinatol.2015;35:379-383. doi:10.1038/jp.2014.222

17. Perlman JM, Risser R. Cardiopulmonary resuscitation in the delivery room.Associated clinical events. Arch Pediatr Adolesc Med. 1995;149:20-25. doi: 10.101/1037/archpedi.1995;02170130022005

18. Berg KM, Bray JE, Ng KC, Lily HG, Greif R, Carlson JN, Morley PT,Drennan IR, Smyth M, Scholefield BR, et al; on behalf of the Collabora-tors.2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommenda-tions: summary from the Basic Life Support; Advanced Life Support; Pe-diatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces. Circulation. 2023;148:e187-e280. doi:10.1016/C.IR/0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000

19.Aranda-Garcia,San Roman-Mata S,Otero-Agra M, Rodriguez-Nunez A,Fernandez-Mendez M, Navarro-Paton R, Barcaala-Fureros L. Is the Over-the-Head Thean technique for Infant CPR Performed by a Single Resuer? A Randomized Simulation Study with Lifeguards. Pediatr Rep.2024;16:100-109.doi:10.3390/pediatic1601010

20.Dannevig I, Solevag AL, Saugstad OD, Nakstad B. Lung Injury in Asphyxi-aled Newborn Pigs Resuscitated from Cardiac Arrest- The Impact of Supplementary Oxygen, Longer Ventilation Intervals and Chest Compres-sions at Different Compression-to-Ventilation Ratios. Open Respir Med J.2012:689-96. doi:10.2174/1874306401206010089

21.Danvireg I, Slevag AL, Sonnerud T, Saugstad OD, Nakstad B. Brain inflam-mation induced by severe asphyxia in newborn pigs and the impact of al-ternative resuscitation strategies on the newborn central nervous system.Pediat Res.2013;73:1639-170. doi:10.1038/pr.2012.167

22.Pasquin MP,Cheung PY,PZel,Su M,Lee TF,Wagner M,O'Reilly M,Schmolzer GM. Comparison of Different Compression to Ventilation Ratios(2:1,3:1, and 4):1 during Coplulmonary Resuscitation in a Porcine Model of Neonatal Asphyna. Neonatal Aspyria. 2018;11:34:37-45. doi:10.1159/000487988

23.Solevag AL, Dannevig AL, Wyckoff M, Saugstad OD, Nakstad B. Ex-tended series of cardiac compressions during CPR in a swine mod-el of perinatal asphyxia. Resuscitation. 2010;81:1571-1576. doi: 10.1016/j.resuscitation.2010.06.007

24. Solevag AL, Dannevig I, Wyckoff M, Saugstad OD, Nakstad B. Return of spontaneous circulation with a compression:ventilation ratio of 15:2 versus 3:1 in newborn pigs with cardiac arrest due to asphyxia. Arch Dis Child Fetal Neonatal Ed.2011;96:F417-F421.doi:10.1136/adc.2010.200386

25.Srikant SK, Berg RA, Cox T, Tice L, Nadkarni VM. Effect of one-rescue-compression/ventilation ratios on cardiopulmonary resuscitation in infant,pediatric, and adult markings in Pediatr Crit Care Med. 2005;6:293-297. doi:10.1097/01.PCC.0000161621.74554.15

26.Schmolzer GM, Roberts P, Blank DA, Badurdeen S, Miller SL, Crossley Kl, Stojanovski V, Galinsky R, Kluckow M, Gill AW, et al. Single versus

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28. Schmolzer GM, OR Fray, C van Os S, Cheung PY. Chest compres-sion during sustained inflation versus 3:1 chest compression:ventilation ratio during neonatal cardiopulmonary resuscitation: a randomised fea-sibility trial. Arch Dis Child Fetal Neonatal Ed. 2018;103:F455-F460. doi: 10.1136/archidschild-2017-313037

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33. Meyer A, Nadkari V, Pollock A, Babbs C, Nishisaki A, Braga M, Berg RA,Ades A Evaluation of Neonatal Resuscitation Program's recommended chest compression depth using computerized tomography. Resus-citation.2010;81:544-548. doi:10.1016/j.resuscitation.2010.01.032

34. Thaler MM, Stobieh GN. Improved Technic of External Cardiac Compres-sion in Infants and Young Children. Engl N. Engl J Med. 1963;269:606-610. doi:10.1056/NEJM196309192691204

35 FinhortDA,KettrickRG,WagnerHR,SwedDB.The heart is under the lower third of the sternum.Implications for external cardiac massage. Am J Dis Child.1986;140:646-649. doi:10.1001/archpedi.1986.0821400244022

36.Orlowski JP. Optimum position for external cardiac compression in in-fants and young children. Ann Emerg Med. 1986;15:667-673. doi:10.1016/s0196-0644(86)8042-1

37. Phillips GW, Zideman DA. Relation of infant heart to stermum: its signifi-cance in cardiopulmonary resuscitation. Lancet. 1986;1:1024-1025. doi:10.1016/s0140-6736(86)91284-5

38. Clements F, McGowan J. Finger position for chest compressions in cardiac arrest in infants. Resuscitation. 2000;44:43-46. doi:10.1016/s3000-9572(99)00165-3

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

40. You Y. Optimum location for chest compressions during two-rescuer infant cardiopulmonary resuscitation. Resuscitation. 2009;80:1378-1381. doi:10.1016/j.resuscitation.2009;08:013

41. Boldhing AM, Solevag AL, Aasen E, Nakstad B. Resuscitators who com-pared four simulated infant cardiopulmonary resuscitation methods fa-voured the three-to-one compression-ent-rotation ratio. Acta Paediatr.2016;105:910-916. doi: 10.1111/apa.13339

42. Schmzerol GM. Remember fatigue during neonatal cardiopulmonary resuscitation and don't forget to change resuscitations. Acta Paediatr.2016;105:866-867. doi:10.1111/apa.13449

43. Enrique D, Meritano J, Shah SA, Song C, Szyld E. Fatigue during Chest Compression Using a Neonatal Patient Simulator. Am J Perinatol 2018;35:796-800. doi:10.1055/s-0037-1620231

44. Li ES, Cheung PY, OREly M. Aziz, K. Schmolzer GM. Resuer fatigue during simulated neonatal cardiopulmonary resuscitation. J. Perinatol 2015;35:142-145. doi:10.1038/jp.2014.165

45. Reynolds C, Cox J, Livingstone V. Dempsey EM. Resuer Exertion and Fatigue Using Two-Thumb vs. Two-Finger Method During Simulated Neo-natal cardiopulmonary Resuscitation. Front: Pediatr. 2020;8:133. doi:10.3389/fpedz.2020010.003

46.Sandhu T,Szyld EG, Anderson MP, Shah BA. Effect of rotating pro-viders on chest compression performance during simulated neona-tal cardiopulmonary resuscitation. PLoS One. 2022;17:e0265072. doi:10.1371/journal.pone.0265072

VASCULAR ACCESS DURING RESUSCITATION

|Recommendations for Vascular Access During Resuscitation||| |---|---|---| |COR|LOE|Recommendations| |1|C-LD|1. Insertion of an umbilical vein catheter is recommended for newborn infants requiring emergency vascular access.| |2a|C-LD|2. Insertion of an intraosseous(IO) vascular access device can be useful for newborn infants requiring emergency vascular access if intravenous access is not successful or not feasible.|

Synopsis

Newborn infants who do not respond to ventilation and chest compressions require emergency vascular access to administer epinephrine or volume expanders. Although few newborn infants receive emergency medications,1,2 health care professionals must be prepared to obtain rapid vascular access because delayed administration of epinephrine is associated with a decreased likelihood of survival.3 In the newborn infant, the umbilical vein is read-ily accessible and provides direct access to the heart and ascending aorta,4 but many health care professionals without neonatology specialty training perceive umbilical vein catheterization to be difficult.5 The insertion of an IO vascular access device into the medullary cavity of a long bone is an alternative route and is commonly used in prehospital and emergency department settings.6 IO vas-cular access devices have been associated with serious complications, including fractures, extravasation leading to compartment syndrome, and tissue necrosis.7

Recommendation-Specific Supportive Text

1. Historically, umbilical vein catheterization has been the standard approach to emergency vascular the standard approach to emergency vascular mended since in delivery room and has been recom-mended since the first international consensus guidelines for neonatal resuscitation.8 In a registry study of 93 656 neonates in the delivery room, of the 47 neonates who received epinephrine, 32%achieved ROSC with endotracheal epinephrine while 779% achieved ROSC with intravascular epi-nephrine(by umbilical venous catheter) after fail-ing endotracheal epinephrine.1 In a single-center retrospective case series, 15/20(75%) newborn infants who received the first dose of epineph-rine through an umbilical vein catheter achieved ROSC.9 In an animal model of neonatal asphyxia,epinephrine influenced through a low-lying umbilical vein catheter achieved comparable peak plasma epinephrine concentrations and ROSC when com-pared with direct injection into the right atrium.10 There are no human studies directly comparing

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the safety and effectiveness of umbilical vein cath-eters or IO vascular access devices or describing the first attempt success and complication rate for umbilical vein catheterization during neonatal resuscitation.

2.A systematic review, including 1 case series and 12 individual case reports, described success-ful IO vascular access device insertion among 41 neonates during resuscitation in the delivery room or neonatal intensive care unit. In total, 5 infants had serious complications, including 2 cases of limb ischemia leading to subsequent amputation and 1 tibial fracture. Subsequently, 3 case series have described IO vascular access device insertion among 12 neonates(10 newborn infants) identi-fied by a survey from a single center,11 161 neo-nates(113 in the first day of life) identified from a multicenter pediatric emergency registry,12 and 102 neonates(13 in the delivery room) identified from records of a pediatric emergency transfer service.13 Successful IO vascular device insertion on the first attempt in neonates ranged from 50% to 86%,with any complication reported in 10% to 35%. In an asphyxiated lamb model of neonatal resuscita-tion, the peak serum epinephrine concentration and ROSC rates were similar between the umbilical vein catheter and IO vascular access device groups.14 In simulation studies, participants inserted an IO vas-cular access device more quickly than an umbilical vein catheter.15-17 However, in an anatomic cadaver study(n=16; median gestational age, 29 weeks[IOR, 27-38 weeks]) using 2 different IO vascu-lar access devices, computed tomography imaging showed the tip of the device within the medullary cavity after only 39.7% to 61.1% of insertions.18

REFERENCES

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

2. Kapadia P,Hurst,C Harley D,Phenston J,Tretz B,Piley HG.Trends in neonatal resuscitation patterns in Queensland, Australia: a 10-year retrospective cohort study. Resuscitation. 2020;157:126-123. doi:10.1016/j.resuscitation.2020.10.031

3. Halling C, Raymond T, Brown LS, Aedes A, Foglia EE, Allen E, Wyckoff MH;American Heart Association's Get With The Guidelines-Resuscitation In-vestigators. Neonatal delivery room: CPR; an analysis of the Get With the Guidelines(R)-Resuscitation Registry. Resuscitation: 2021;158:236-242.dol. 10:1016/j.resuscitation:2020.10.007

4 Spuray 1, Logan P, Pak S. The development, structure and blood flow within the umbilical cord with particular reference to the ve-nous system. Australas J Ultrasound Med 2012;15:97-102. doi:10.1016/j.2205-0140.2012.tb00013.x

5.Haase B, Springer L, Poets CF. Evaluating practitioners' prefernce-es regarding vascular emergency access in newborn infants in the delivery room: a national survey. BMC Pediatr. 2020;20:405. doi:10.1186/s12887-020-02294-4

6. Rosetti VA, Thompson BM, Miller J, Mater JR, Aprahamian C. Intrasseous infusion: an alternative route of pediatric intravascular access. Ann Emerg Med 1985;14:885-888. doi:10.1016/5016-0644(85)80639-9

7. Scrivens A, Reynolds PR, Emery FE, Roberts CT, Polglase GR, Hooper SB,Roeh CR. Use of Intraosseous Needles in Neonates: a Systematic Review.Neonatology.2019;116:305-314. doi:10.1159/000502212

8. Nierermeyer S, Kattwinkel J, Van Reempts P, Nadkarni V, Phillips B, Zideman D, Azzopardi D, Berg R, Boyle D, er al. on behalf of the Contribu tors and Reviewers for the Neonatal Resuscitation Guidelines. International Guidelines for Neonatal Resuscitation: an excerpt from the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science. Pediatrics.2000;106:E29.doi:10.1542/pedits.1063.e29

9. Halling C, Sparks JE, Christie L, Wyckoff MH. Efficacy of Intravenous and Endotracheal Epinephrine during Neonatal Cardiopulmonary Re-suscitation in the Delivery Room. J Pediatr. 2017;185:232-236. doi:10.1016/j.jpeds.2017.02.024

10. Vali P. Chandrasekharan P, Rawat M, Gugino S, Koenigsknecht C, Helman J,Jusko JW, Mathew B, Berkelhamer S, Nair J, et al. Evaluation of Timing and Route of Epinephrine in a Neonatal Model of Asphyxial Arrest. J Am Heart Assoc.2018;76:e004402, doi: 10.1161/JAHA.116.004402

11. Milder LP, Urlesberger B, Schwaberger B. Use of Intraosseous Vascular Access During Neonatal Resuscitation at a Tertiary Center. Front Pediatr.2020:8:571285. doi: 10.3389/fped.2020.571285

12. Schwindt E, Pfeiffer D, Gomes D, Brenner S, Schwindt JC, Hoffmann F,Olivieri M. Intraosseous access in neonates is feasible and safe: an analysis of a prospective nationwide surveillance study in Germany. Front Pediatr.2022;10:952632. doi: 10.3389/fped.2022.952632

13.Joerck C, Wilkinson R, Angitii R, Lutz T, Scerri R, Carmo KB. Use of In-traosessac Access in Neonatal and Pediatric Retrieval-Neonatal and Pe-diatric Emergency Transformer Service, New South Wales. Pediatr Emerg Care.2023;39:853-857. doi:10.1097/PEC.00000000003005

14. Roberts CT, Klink S, Schmolzer GM, Blank DA, Badurdeen S, Crossley KJ, Rodgers K,Zahra V, Moxham A, Roehr CC,et al Comparison of in-traosseous and intravenous epinephrine administration during resusci-tation of asphyxiated newborn lambs. Arch Dild Fetal Neonatal Ed.2022;107:311-316. doi:10.1136/archildisch-2021-322638

15. Schwindt EM, Hoffmann F, Deindl P, Waldhoer TJ, Schwindt JC. Dura-tion to Establish an Emergency Vascular Access and How to Accel-erate it: 1: Simulation-Based Study Performed in Real-Life Neonatal Resuscitation Rooms. Pediatr Crit; Care Med. 2018;19:468-476. doi:10.1097/PCC.000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000

16.Abe KK, Blum GT, Yamamoto LG. Intraosseous is faster and easier than umbilical venous catheterization in newborn emergency vas-ular access models. Am J Emerg Med. 2000;18:126-129. doi: 10.1016/s0735-6757(00)90001-9

17. Rajani AK, Chitkara R, Oehlert J, Halamek LP. Comparison of umbilical venous and intraosseous access during simulated neonatal resuscitation. Pediatrics.2011;128:e954-e958.doi:10.1542/peds.2011-0657

18.Fuchs Z, Saalma M, Haverkamp H, Koerber F, Persigeh T, Eifinger F. Ana-tomical investigations on intraosseous access in stillborns- Comparison of different devices and techniques. Resuscitation. 2018;127:79-82. doi:10.1016/j.resuscitation.2018.04.003

EPINEPHRINE

|Recommendations for Epinephrine Administration in Neonatal Resuscitation||| |---|---|---| |COR|LOE|Recommendations| |1|B-NR|In. Newborn infants whose heart rate has not increased to 60/min or more after optimizing ventilation and chest compressions, it is recommended to administer intravascular epinephrine(0.01-0.03 mg/kg).|

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Recommendations for Epinephrine Administration in Neonatal Resuscitation(Continued)

|COR|LOE|Recommendations| |---|---|---| |2b|C-LD|4. In newborn infants receiving epinephrine, it may be reasonable to administer additional doses of epinephrine every 3 to 5 minutes, preferably in intravascularly, if the heart rate remains less than 60/min.|

Synopsis

Medications are rarely needed in resuscitation of the newborn infant because low heart rate usually results from poor gas exchange or inadequate lung inflation af-ter birth. Establishing ventilation is the most important step in the resuscitation of a bradycardic newborn infant.However, if heart rate remains less than 60/min after ventilating with 100% oxygen(preferably through an al-ternative airway,eg,endotracheal tube or laryngeal mask)and chest compressions, administration of epinephrine is indicated. Epinephrine is a cardiac and vascular stimulant that improves blood flow to the coronaries and causes vasoconstriction to the peripheral vessels. Providing epi-nephrine in a newborn infant who remains bradycardic despite adequate ventilation may improve the heart rate and strength of contractions.

Administration of intravascular epinephrine(through either a low-lying umbilical venous catheter or IO vascu-lar access device) provides the most rapid and reliable medication delivery. The bioavailability of epinephrine using either method should be similar, and the choice of route may depend on the location of birth, training of health care professionals, team experience in vascular access, and available supplies. The intravascular dose of epinephrine is 0.01 to 0.03 mg/kg. This can be followed by a 3 mL normal saline flush regardless of birth weight.1 While intravascular access is in progress, epinephrine may be given by the endotracheal route in a dose of 0.05 to 0.1 mg/kg, as a higher dose is likely needed to achieve a similar level to intravascular administration.2-7

Recommendation-Specific Supportive Text

1. A term piglet model of asphyxia-induced cardiac arrest demonstrated that intravenous epinephrine improved rates of ROSC compared to compres-sions alone.8 Observational evidence in human infants does not demonstrate greater efficacy of endotracheal or intravenous epinephrine; how-ever, most babies received at least 1 intravenous dose before ROSC.29,10 Three studies using a term perinatal lamb model of asphyxia-induced cardiac arrest found that central venous epinephrine was associated with shorter time to ROSC and higher rates of ROSC than endotracheal epinephrine.11-13 In a similar model, IO epinephrine was as effective

<EndOfPara>as intravenous ${}^{14}$ Intravenous epinephrine followed by a normal saline flush improves medication delivery. ${}^{1,15}$

2.In both a single-center observational study and a multicenter registry study, most infants who received an endotracheal dose achieved ROSC after subsequent intravenous doses.9,10 Although the more rapid response to intravenous epineph-rine warrants its immediate administration once umbilical access is obtained, repetitive endotra-cheal doses or higher intravenous doses may result in potentially harmful plasma levels that lead to associated hypertension and tachycardia.16-19

3.One small observational human study demon-strated 0.01 to 0.03 mg/kg to be an inadequate endotracheal dose.2 Both a single-center observa-tional study and a multicenter registry study showed that although some newborn infants can achieve ROSC in response to endotracheal epinephrine while vascular response is being obtained, the major-ity need subsequent intravascular doses to achieve ROSC.9,10 In a perinatal model of cardiac arrest,peak plasma epinephrine concentrations in ani-mals were higher and were achieved sooner after central or low-lying umbilical venous administration compared with the endotracheal route, despite a lower intravascular dose(0.03 mg/kg intravascu-lar versus 0.1 mg/kg endotracheal route).13 Given these data, up to 0.1 mg/kg may be needed for an endotracheal dose to achieve adequate plasma concentrations.

4.In a single-center observational study and a mul-ticenter observational registry study, many infants received multiple doses of epinephrine before ROSC.9,10 One perinatal model of cardiac arrest documented peak plasma epinephrine concen-trations at 1 minute after intravenous administra-tion but not until 5 minutes after endotracheal administration. ${}^{13}$

REFERENCES

1. 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 Flush Volume on Bioavailability and Efficacy of Umbilical Venous Epinephrine during Neonatal Resuscitation in Ovine Asphyxial Arrest. Children (Basel).2021;8:464. doi:10.3390/children8060464

2.Barber CA,Wyckoff MH.Unse and efficacy of endotracheal versus intravenous epinephrine during neonatal cardiopulmonary resuscitation in the delivery room.Pediatrics.2006;118:1028-1034. doi:10.1542/peds.2006-0416

3.Crespo SG,Schoffstall JJM,Fuhs LR,Spivey WH.Comparison of two doses of endotracheal epinephrine in a cardiac arrest model. Ann Emerg Med.1991;20:230-234. doi:10.1016/s0196-0644(05)80928-x

4.Hornchen U,Schuttler J,Sosteckel H,Eichkelraut W,Hahn N.Endobronchial instillation of epinephrine during cardiopulmonary resuscitation. Crit Care Med.1987;15:1037-1039. doi:10.1097/00003246-198711000-00009

5.Jasani MS,Nadkari VM,Finkelstein MS,Mandell GA,Salzman SK,Norman ME.Effects of different techniques of endotracheal epinehrine administra-tion in pediatric porcine hypoxic-hypercarbic cardiopulmonary arrest. Crit Care Med.1994;22:1174-1180. doi:10.1097/00003246-199407000-00021

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6. Mielke LL, Frank C, Lanzinger MJ, Wilhelm MG, Entholzner EK, Hargasser SR, HipF R. Plasma catecholamine levels following tracheal and intrave-nous epinehrine administration in swine. Resuscitation. 1998;36:187-192.doi:10.1016/s3030-9572(98)200007-0

7. Roberts JR,Greenberg M,Knauba,Kendrick V,Basin St.Bl. Blood levels following intravenous and endotrachee epinephrine administration. JACEP.1979;85:53-66. doi:10.1016/s0361-1124(79)80036-2

8.Andersen HB, Andersen M, Andelius TCK, Pedersen MV, Lofgren B,Pedersen M, Ringgaard S, Kyng KJ, Henristen B.Epinephrine vs placebo in neonatal resuscitation: ROSC and brain MRS/MR in term piglets. Pediatr Res.2023;93:511-519. doi: 10.1038/s41390-022-0212-64

9. Halling C, Conroy S, Raymond T, Foglia E, Haggery M, Brown LL,Wyckoff MH; on behalf of the American Heart Association's Get With The Guidelines-Resuscitation Investigators. Use of Initial Endotracheal Ver-sus intravenous Epinephrine During Neonatal Cardiopulmonary Resus-citation in the Delivery Room: Review of a National Database. J Pediatr.2024;2711:114058. doi:10.1016/jjpeds.2024.114058

10. Halling, C, Sparks JE, Christle L, Wyckoff M. Ethicacy of Intravenous and Endotracheal Epinephrine during Neonatal Cardiopulmonary Re-suscitation in the Delivery Room. J Pediatr. 2017;185:2323-236. doi:10.1016/j.jpds.201702.024

11. Polglase GR, Brian Y, Tanantis 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 lambs. Re-suscitation.2024;198:110191.doi:10.1016/j.resuscitation.2024.110191

12.Songstad NT, Kingenberg C, McGilick EV, Pjagliase GR, Zaha V,Schmolzer GM, Davis PG, Hooper SB, Crossley J.Efficacy of Intrave-nous, Endotracheal, or nasal Adrenaline Administration During Resusculi-tation of Near-Term Asphyxated Lambs. Front Pediatr: 2020/8:262. doi:10.3389/fped.2020.00262

13. Vali P. Chandrasekharan P, Rawat M, Gugino S, Koenigsknecht C, Helman J,Skuo J, Mathew B, Berkelhamer S, Nair et J, al Evaluation: Timing and Route of Epinephrine in a Neonatal Model of Asphyxial Arrest. J Am Heart Assoc:2017;6:e004402; doi:10.1161/JAHA,116004402

14. Roberts CT, Klink S, Schmözer GM, Blank DA, Badurdeen S, Crossley KJ, Rodgers K, Zahra V, Moxham A, Roehr CC, et al. Comparison of in-trascrosses and intravenous epinephrine administration during resuscri-tation of asphyxial newborn lambs. Arch Dis Child Fetal onation of phasythial newborn lambs. Arch Dis Child Fetal onation of phasythial西南年年2022;107:311-316. doi:10.1136/archidschild-2021-322638

15.Sankaran D, Chandrasekharan PK, Gugino SF, Koenigsknecht C, Helman J,Nair J,Mathew B,Rawat M, Vali P, Nielsen L,et al. Randomised trial of epi-nephose dose and flush volume in term newborn lambs. Arch Dis Child Fetal Neonatal Ed.2021;106:578-583. doi:10.1136/archischchild-2020-321034

16. Berg RA, Otto CW, Kern KB, Hilwig RW, Sanders AB, Henry CP, Ewy GA.A randomized, blinded trial of high-ose epinephrine versus standard-dose epinephrine in a sinome study of pediatric asphyxial cardiac arrest. Crit Care Med. 1996;24:1695-1700. doi: 10.1097/00003246-199610000-00016

17. Burchfield DJ, Prezis MP, Lucas PJ, Wan F.J. Effects of graded doses of epinephrine during asphxia-induced bradycardia in newborn lambs. Resus-citation.1993;25:235-244. doi:10.1016/0300-9572(93)90120-f

18. Perdioni MB, Reis AG, Paiva EF, Nadkarni VM, Berg RA. A comparison of high-dose and standard-dose epinephrine in children with cardiac arrest. N Engl J Med.2004;350:1722-1730. doi:10.1056/NEJMO32440

19. Vandycke C, Martens P. High dose versus standard dose inparine cardiac arrest- a meta-analysis. Resuscitation. 2000;45:161-166. doi:10.1016/s0300-9572(00)00188-

VOLUME EXPANSION

|Recommendations for Volume Expansion||| |---|---|---| |COR|LOE|Recommendations| |2b|C-EO|1. It may be reasonable to administer a volume expander to newborn infants with evidence of hypovolemia, based on history and physical examination, who remain bradycardic(heart rate less than 60/min) despite ventilation, chest compressions, and epinephrine.| |2b|C-EO|2. It may be reasonable to use normal saline(0.9% sodium chloride) or blood at 10 to 20 mL/kg for volume expansion.|

Synopsis

Newborn infants who continue to have respiratory and circulatory compromise after assisted ventilation, chest compressions, and epinephrine require further assess-ment and interventions. Tension pneumothorax requir-ing thoracentesis or acute blood loss that necessitates volume infusion can be considered. Newborn infants in shock from blood loss may respond poorly to the initial resuscitative efforts of ventilation, chest compressions,or epinephrine. History and physical exam findings sug-gestive of blood loss include a pale appearance, weak pulses, and persistent bradycardia(heart rate less than 60/min). Blood may be lost from the placenta into the mother's circulation, from the cord, or from the infant.

When blood loss is suspected in a newborn infant who responds poorly to resuscitation, administering a volume expander without delay may improve circulation and perfusion. Normal saline(0.9% sodium chloride) is the crystalloid fluid of choice. Uncrossmatched type O,Rh negative blood(or crossmatched, if immediately avail-able) is preferred when blood loss is substantial.1,2 The recommended route is intravascular via an umbilical line,with the IO route being an alternative(refer to the Vascu-lar Access During Resuscitation section).

Recommendation-Specific Supportive Text

1.The recommendation for volume resuscitation at delivery is based on the recognition that extensive blood loss can occur at the time of birth leading to cardiorespiratory compromise in the newborn infant. Conditions such as uterine rupture may be noted by the obstetric team, while conditions such as fetal-maternal hemorrhage may be unrecog-nized. A newborn infant with decreased intravas-cular volume due to blood loss may not respond to resuscusistative measures fully until there is increased oxygen-carrying capacity and adequate cardiac preload provided by volume resuscitation. There is no evidence from randomized trials to support the use of routine volume resuscitation at delivery.One large retrospective review found that 0.04%of newborns received volume resuscitation in the delivery room, confirming that it is an uncommon event.3

2.There is insufficient clinical evidence to determine what type of volume expander(crystalloid or blood)is more beneficial during neonatal resuscitation.Extrapolation from studies in hypotensive new-borns shortly after birth4-6 and studies in animals(piglets) support the use of crystalloid over albu-min solutions2 and blood over crystalloid solutions.The amount of volume expansion is based on usual practice in neonatal intensive care, 10 to 20 mL/kg initially, and repeating if inadequate

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response. In an animal study of asphyxia in the context of blood loss, providing 1 to 3 aliquots of 10 mL/kg was associated with ROSC in 33/44 animals. ${}^{1}$ While no clinical trials have established an optimal infusion rate, a steady infusion over 5 to 10 minutes may be reasonable.

REFERENCES

1. Mendler MR, Schwarz S, Hechenrieder L, Kurth S, Weber B, Hofler S,Kalbitz M, Mayer B, Hummler HD. Successful Resuscitation in a Model of Asphyxia and Hemorrhage to Test Different Volume Resuscitation Strategies. A Study in Newborn Piglets After Transition. Front Pediat.2018;6:192. doi:10.3389/fped.2018.00192

2.Wyckoff M,Garcia D,Margraf L,Perman J,Laptook A Randomized trial of volume infusion during resuscitation of asyphiaated neonatal piglets. Pediatr Res.2007;61:415-420. doi: 10.1203/pdb:0183e3180332c45

3.Wyckoff MH, Perllman JM, Laptook AR. Use of volume expansion dur-ing delivery room resuscitation in near-term and term infants. Pediatrics.2005;115:950-955. doi: 10.1542/peds.2004-0913

4. Nierermeyer S. Volume resuscitation: crystalloid versus colloid. Clin Perinatol.2006;33:133-140, viii: 10.1016/j.clp.2005.12.002

5. Shalish W, Olivier F, Aly H, SantAnna G. Uses and misuses of albumin during resuscitation and in the neonatal intensive care unit. Semin Fetal Neonatal Med. 2017;22:328-335. doi: 10.1016/j.siny.2017.07.009

6. Keir AK, Karam O, Hodyl N, Stark MJ, Liley HG, Shah PS, Stanworth SJ;on behalf of the NeoBulus Study Group. International, multicentre, obser-vational study of fluid bolus therapy in neonates. J Paediatr Child Health.2019;55:632-639. doi:10.1111/jpc.14260

POSTRESUSCITATION CARE

|Recommendations for Postresuscitation Care|||| |---|---|---|---| |COR|LOE|Recommendations|| |1|A|1. Newborn infants born at≥36 weeks' gestational age with moderate to severe HIE should be offered therapeutic hypothermia under clearly defined protocols.|| |2|B-NR|2. Newborn infants who receive prolonged ventilation or advanced resuscitation(intubation, chest compressions, or epinephrine) should be closely monitored, including checking glucose levels early in the postresuscitation period and continuing until the glucose levels are maintained in the normal range.|| |1|C-LD|3. For newborn infants who are unintentionally hypothermic(temperature<36°C) after resuscitation, rewarming is indicated. The optimal rate of rewarming is unknown.||

Synopsis

Therapeutic hypothermia, lowering the newborn infant's core temperature to a target temperature of 33.5℃ to 34.5℃ within 6 hours of birth for a duration of 72 hours,has the potential to improve outcomes for selected infants with neurologic injury, but careful implementation and monitoring are necessary.1 Newborn infants who receive prolonged ventilation or advanced resuscitation(eg, in-tubation, chest compressions, or epinephrine) should be closely monitored after stabilization in a neonatal intensive care unit or a monitored triage area because these infants are at risk for further deterioration. Monitoring may identify

and prevent subsequent complications, including neuro-logic, metabolic, or respiratory issues that can impact both short- and long-term outcomes for newborn infants.

Recommendation-Specific Supportive Text

1. Infants 36 weeks' or greater gestational age who receive advanced resuscitation should be exam-ined for evidence of HIE to determine if they meet criteria for therapeutic hypothermia. Therapeutic hypothermia should be provided under defined protocols similar to those used in published clinical trials and in facilities capable of multidisciplinary care and longitudinal follow-up.1 Therapeutic hypo-thermia for infants<36 weeks' gestational age with HIE has not shown benefit and may be asso-ciated with harm.2

In a meta-analysis of 8 RCTs involving 1344 term and late preterm infants with moderate to severe encephalopathy and evidence of intrapartum asphyxia, therapeutic hypothermia resulted in a significant reduction in the combined outcome of mortality or major neurodevelopmental disability at 18 months of age(OR,0.75;95% CI,0.68-0.83).3

2.Newborn infants who required advanced resusci-tation, such as prolonged ventilation, chest com-pressions, or epinephrine, are at significant risk of developing moderate to severe HIE4-6 and other morbidities. ${}^{7-9}$ Close monitoring to assess the need for interventions is warranted. This may involve care in a nursery with additional staffing, monitors,and equipment or in a neonatal intensive care unit.Hypoglycemia is common in infants who have received advanced resuscitation and is associated with poor outcomes. ${}^{10,11}$ These infants should be monitored for hypoglycemia and treated appropri-ately. Newborn infants with abnormal glucose lev-els(both low and high) are at increased risk for brain injury and adverse outcomes after a hypoxic-ischemic insult. ${}^{12-14}$ Retrospective chart review has shown risk of hypoglycemia after advanced resus-citation, especially in preterm infants born<32 weeks' gestational age. ${}^{11}$

3.Infants with unintentional hypothermia(tempera-ture<36°C) immediately after stabilization should be rewarmed to avoid complications associated with low body temperature(including increased mortality, brain injury, hypoglycemia, sepsis, and respiratory distress). Evidence suggests that warming can be done rapidly(0.5°C/h) or slowly(<0.5°C/h) with no significant difference in out-comes. ${}^{15-19}$ Three small RCTs ${}^{15,16,20}$ and 6 observa-tional studies ${}^{17-19,21-23}$ of infants with hypothermia after delivery room stabilization found no differ-ence between rapid or slow rewarming for out-comes of mortality, ${}^{17-23}$ convulsions/seizures, ${}^{16}$

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intraventricular or pulmonary hemorrhage,16-18,20,21 hypoglycemia,15,16,18,20 or apnea.15,16,18,20 One obser-vational study found less respiratory distress in infants who were slowly rewarded,19 while a sepa-rate study found less respiratory distress syndrome in infants who were rapidly rewarded.18 An RCT found no difference in respiratory distress or need for intubation.20

REFERENCES

1. Papile LA, Bailey JE, Benitz W, Cummings J, Carlo WA, Ehewald Eenwald, Kumar P, Polin RA, Tan RC, Wang KS; on behalf of the Committee on Fe-tus and Newton. Hypotheremia and neonatal encephalopathy. Pediatrics.2014;133:1146-1150. doi: 10.1542/peds.2014-0899

2.Faix RG, Laptook AR, Shankaran S, Eggleston B, Chowdhury H, Heynei RJ, Das A, Pedroza C, Tyson JE, Wushoff C, et al: on behalf of the Eu-Nice Kennedy Shriver National Institute of Child Health and Human De-velopment Neonatal Research Network. Whole-Body Hypothermia for Neonatal Encephalopathy in Pretrm Infants 33 to 35 Weeks' Gesta-tion: a Randomized Clinical Trial. JAMA Pediatr. 2025;179:396-406. doi:10.1001/jamagedietrics.2024.6613

3.Jacobs SE, Berg M, Hunt T, Rarnowi-MordO, WRO, Inter D, Davis PG. Cooling for newborns with hypoxic ischaemic encephalopha-ty. Chathero Database Syst Rok 2013;2013:CD00311.31 doi: 10.10214651858.CD003111.pub3

4. Ayrapetyan M, Talekar K, Schwabenbaev K, Carola D, Solarin K, McElwee D, Adideni-Yjos, Greensan J, Aghai ZH. Aghar Scores at 10 Minutes and Outcomes in Term and Late Preterm Neonates with Hypoxic-Ischemic Encephalopathy in the Cooling Era. Arm J perinatol. 2019;36:554-554. doi:10.1055/s-0038-1670637

5. Kasdorf E, Laptook A, Azzopardi D, Jacobs S, Perlman JM. Improving in-fant outcome with a 10 min Aparp of O. Arch Dis Child Fetal Neonatal Edel. 2015;100±F102-105. doi:10.1136/archidschild-2014-306687

6. Laptook AR, Shankaran S, Ambalavan N, Carlo WA, McDonald SA,Higros RD, As D; on behalf of the Hypotherm Institute of the NICHD Neonatal Research Network. Outcome of term infants using apgar scores at 10 minutes following hypoxic-chemic ancephalopathy. Pediat-ics 2009;124:1619-1626.10:1542/peds.2009-0934

7. Barber CA, Wyckoff MH. Use and efficacy of endotracheal versus intravenous epinephrine during neonatal cardiopulmonary resuscitation in the delivery room. Pediatrics.2006;118:1028-1034. doi: 10.1542/peds.2006-0416

8. Harrington DJ, Redman CW, Moulden M, Greenwood CE. The long-term outcome in surviving infants with Apgar zero at 10 minutes: a systematic review of the literature and hospital-based cohort. Am J Obstet Gynecol 2007;196:463,e1.5 doi:10.1016/jajog.2006.10.877

9.Wyckoff MH,Salwah WA, Heyne RJ, Kendrick DE, Stoll BI, Laptok AR, on behalf of the National Institute of Child Health and Human Develop-ment Neonatal Research Network. Outcome of extremely low birth weight infants who received delivery room cardiopulmonary resuscitation. J Pediatr.2012;160:239-244.e2.doi:10.1016/j.jpeds.2011.07.041

10. Salhab WA, Wyckoff MH, Laptook AR, Perman JM. Initial hypothermia and neonatal brain injury in term infants with severe fetal acidemia. Pediatrics 2004;114:361-366. doi: 10.1542/peds.114.2361

11. Alsaleme M, Zenai Li, Mathew B, Kumar VHS. Glucose levels during the First 24 Hours following Perinatal Hypoxia. Am J Perinatol. 2021;38:490-496. doi:10.1055/s0039-1698834

12. Basu SK, Ottolini K, Govanad V, Mashat N, Vezina G, Wang Y, Rodire M, Chang T, Kaiser JR, Massaro AN Early Glycemic Profile Is Asoci-ated with Brain Injury Patterns on Magnetic Resonance Imaging in Hy-poxic Ischemic Encephalopathy. J Pediatr. 2018;203:137-143. doi:10.1016/j.jpeds.2018.0701.04

13.Guellec I, Encali PY, Beck J, Lonor G, Chevaller M, Pierat V,Kayem G,Viliotch A, Baud O, Ego A, et al. Glycemia and Neonatal Encephalopathy:Outcomes in the LyTONEPAL(Long-Term Outcome of Neonatal Hypoxic En-cePhALopathy in the Era of Neuroprotective Treatment With Hypothermia(Cohort.J Pediatr.2023;257:113350. doi:10.1016/j.jpeds.2023.02003

14. Ali MAM,Farghaly MAA,El-Dib I, Kamati S al, Ay H. Acunc Glucose in-stability and outcomes of neonates with hypoxic ischemic and hypothermally undergoing therapeutic hypothermia. Brain Dev.2024;46:262-267. doi:10.1016/jbraindev.2024.05.003

15. Motil KJ, Blackburn MG, Pleasure JR. The effects of four different radi-ant warmer temperature set-points used for rewarming neonates. J Pediatr.1974;85:546-550. doi: 10.1016/s0022-3476(74)80467-1

19. Farani N, Gentz J. Aspects of rewarming newborn infants with severe accidental hypothermia. Acta Paediatr Scand. 1974;63:595-600. doi:10.1111/j.1651-2227.1974.tb04853.x

17. Feldman A, De Benedictis B, Alpan G, La Gamma EF, Kase J. Mor-bidity and mortality associated with rewarming hypothermic very low birth weight infants. J Neonatal Perinatal Med. 2016;9:295-302. doi:10.3233/ NPM-16915143

18.Rech Morassutti F,Cavallin F,Zaramella P,Bortolus R,Parotto M,Trevisanuto D.Association of Rewarming Rate on Neonatal Outcomes in Extremely Low Birth Weight Infants with Hypothermia. J Pediatr. 2015;167:557-561.e2.doi:10.1016/j.jpds.2015.06.008

19.Soler S,Yagupsky P,Herskowskits J,Bearman JE. Improved outcome of hypothermic infants. Pediatr Emerg Care. 1986;2:211-214. doi:10.1097/00006565-198612000-00001

20.Jain P. Dalai JS, Gatwala G. Rapid vs. Slow Rewarming for Manage-ment of Moderate to Severe Hypothermia in Low-Birth-Weight Pre-term Neonates-An Open Label Randomized Controlled Trial. J. Trop Pediatr.2001;67:fmau098. doi: 10.1093/tropej/fmaua098

21. Racine J, Jaroui E. Severe hypothermia in infants. Helv Paediatr Acta.1982:37:317-322.

22. Rossi E, Maziku DM, Leluko DE, Guadagno C, Brasili L, Azzimonti G, Putoto G, Pietravalle A, Cavallin F, Trevisanuto D. Rewarming rate of hypothermic neonates in a low-resource setting: a retrospective single-center study.Front Pediatr: 2023;11:1113897. doi: 10.3389/fped.2023.1113897

23. Wilson, Eaier RF, Norman M, Misselwitz B, Howell EA, Zeitlin J, Bonamy AK; on behalf of the Effective Perinatal Intensive Care in Europe(EPICE)Research Group. Admission Hypothermia in Very Preterm Infants and Neonatal Mortality and Morbidity. J Pediatr. 2016;175:61-67.e4. doi:10.1016/j.jpgs.2010.06.016

WITHHOLDING AND DISCONTINUING RESUSCITATION

|Recommendations for Withholding and Discontinuing Resuscitation|||| |---|---|---|---| |COR|LOE|Recommendations|| |1|C-LD|In. newborn infants receiving resuscitation, if there is no heart rate and all the steps of resuscitation have been performed, cessation of resuscitation efforts should be discussed with the team and the family. A reasonable time frame to consider this change in goals of care is around 20 minutes after birth.|| |2|C-EO|2. In newborn infants, noninitiation of resuscitation and discontinuation of life-sustaining treatment during or after resuscitation should be considered ethically equivalent.|| |2a|C-EO|3. If a birth involves a condition likely to result in early death or severe morbidity of a newborn, noninitiation or limitation of resuscitation is reasonable after appropriate consultation and shared decision-making with the family.||

Synopsis

Experts agree that in certain clinical conditions, it is rea-sonable to not initiate or to discontinue life-sustaining efforts while continuing to provide supportive care for newborn infants and their families.1-7 If the heart rate re-mains undetectable and all steps of resuscitation have been completed by around 20 minutes after birth, it may be reasonable to redirect goals of care. Case series show few intact survives after 20 minutes of no detect-able heart rate.4 Variables to consider include whether

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resuscitation was considered optimal, availability of ad-vanced neonatal care, circumstances before delivery, and the family's wishes. ${ }^{4,7}$

Some newborn infants are so sick or immature at birth that survival is unlikely, even if resuscitation and inten-sive care are provided. In addition, some conditions are so severe that the burden of the illness and treatment greatly outweighs the likelihood of survival or a health outcome that aligns with the family's wishes. These situ-ations benefit from appropriate consultation and shared decision-making with families. Some of these scenarios may result in noninitiation or limitation of resuscitation efforts at birth, focusing on humane, compassionate, and culturally sensitive palliative care to ensure the newborn infant’s comfort.1,3-7

Recommendation-Specific Supportive Text

1. An ILCOR review of RCTs and observational stud-ies in settings where therapeutic hypothermia is available describes variable rates of survival without moderate to severe disability in newborn infants who achieve ROSC after 10 minutes or more despite continued resuscitation. None of these studies eval-uate outcomes of resuscitations that extend beyond 20 minutes of age, by which time the likelihood of intact survival was very low. The studies were too heterogeneous to be amenable to meta-analysis.4 More recent data from the Optimizing Cooling trial also demonstrated that an Agram score of 0 at 10 minutes, in isolation, did not accurately predict death or significant neurodevelopmental impairment.8

2.National medical societies agree that conditions exist for which it is reasonable to not initiate resus-citation, to limit resuscitation, or to discontinue resuscitation once these conditions are identi-fied.1-6.9 Further aspects of medical ethics are addressed in "Part 3: Ethics."10

3.Conditions in which noninitiation,limitation,or discon-tinuation of resuscitation may be considered include extremely preterm birth and certain severe congeni-tal anomalies. National guidelines recommend indi-vidualization of parent-informed decisions based on social, maternal, and fetal/neonatal factors.1-3,5,6 A systematic review showed that international guide-lines variably described perivability between 22 weeks' and 24 weeks' gestational age. ${}^{11}$

REFERENCES

1.Bell EF; on behalf of the American Academy of Pediatrics Committee on Fe-tus and Newborn. Noninitiation or withdrawal of intensive care for high-risk newborns. Pediatrics.2007;119:401-403. doi:10.1542/peds.2006-3180

2.American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Obstetric Care consensus No. 6: Perivable Birth. Obstet Gynecol.2017;130:e187-e199. doi:10.1097/AOG.0000000000002352

3.Cummings J, Watterberg K, Eichenwald E, Poindexter B, Stewart DL, Aucott SW, Puopolo KM, Goldsmith JP; on behalf of the Committee on Fetus and

Newborn. Antenatal Counseling Regarding Resuscitation and Intensive Care Before 25 Weeks of Gestation. Pediatrics.2015;136:588-595. doi:10.1542/peds.2015-2336

4. Foglia EE, Weiner G, de Almeida MFB, Wyllie J, Wyckoff MH, Rabi Y,Guinsburg R; on behalf of the International Liaison Committee On Re-suscitation Neonatal Life Support Task F. Duration of Resuscitation at Birth, Mortality, and Neurodevelopment: a Systematic Review. Pediatrics.2020;146:e20201449.doi:10.1542/peds.2020-1449

5. Lemyre B, Moore G. Counselling and management for anticipated ex-tremely preterm birth. Paediatr Child Health. 2017;22:334-341. doi: 10.1093/pched/px058

6.Weise KL,Okun AL,Carter BS,Christian CW;on behalf of the Committee on Bioethics; Section on Hospice and Palliative Medicine; Committee on Child Abuse and Neglect. Guidance on Forgoing Life-Sustaining Medical Treat-ment. Pediatrics. 2017;140e.20171905. doi: 10.1542/peds.2017-1905

7.Wyckoff MH, Wyllie J, Aziz K, de Almeida MF, Fabres JW, Fawke J,Guinsburg R, Hosono S, Isayama T, Kapadia VS, et al; on behalf of the Neonatal Life Support Collaborators. Neonatal Life Support 2020 Interna-tional Consensus on Cardiopulmonary Resuscitation and Emergency Car-diovascular Care Science With Treatment Recommendations. Resuscitation.2020;156A156-A187; doi:10.1016/j.resuscitation.2020.09.015

8.Shukla VV, Bann CM, Ramani M, Ambalavanan N, Peralta-Carcelen M, Hintz SR, Higgins RD, Natarajan G, Laptook AR, Shankaran S, et al.Predictive Ability of 10-Minute Apgar scores for Mortality and Neu-rodevelopmental Disability. Pediatrics. 2022;149:e2021054992. doi:10.1542/peds.2021-054992

9.Wyckoff MH, Singletary EM, Soar J, Olasveengen TM, Greif R, Liley HG,Zideman D, Bhanji F, Andersen LW, Avis SR, et al; on behalf of the Collabo rators.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. Circulation. 2022;145:e645-e721. doi: 10.1161/CIR.000000000001010

10. Elmer J, Atkins DL, Daya MR, Del Rios M, Fry JT, Henderson CM,Lewis-Newby M, Madrigan VN, Marco CA, Ornato JP, et al. Part 3: ethics:2025 American Heart Association Guidelines for Cardiopulmonary Resus-citation and Emergency Cardiopulvascular Care. Circulation. 2025;152(suppl)2):S323-S352. doi: 10.1161/CIR.0000000000001371

11. Guillen U, Weiss EM, Munson D, Maton P, Jefferies A, Norman M, Naulaers G,Mendes J,Justo da Silva L,Zoban P,et al. Guidelines for the Manage-ment of Extremely Premature Deliveries: a Systematic Review. Pediatrics.2015;136:343-350. doi: 10.1542/peds.2015-0542

TRAINING AND HUMAN PERFORMANCE

There are 7 topics regarding education and training methods for resuscitation that are discussed in "Part 12:Resuscitation Education Science" and are relevant to neonatal resuscitation. The recommendations for these topics are summarized as follows:

● Spaced training (training or retraining distributed over time) may be considered rather than massed training (training provided at a single time point).

● Blended training (a combination of face-to-face and online instruction) is recommended compared to a nonblended training approach (either face-to-face or online instruction only).

● Rapid-cycle deliberate practice may be considered in instructional design.

● Gamified learning(use of game-like elements in the context of training, such as point systems, group competition, leaderboards, or increasing levels of challenge) may be considered as a component of resuscitation training.

● The teaching of teamwork competencies may be considered during resuscitation training.

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● High-fidelity manikin use may be considered during resuscitation training when local resources allow. In the absence of such resources, low-fidelity mani-kins may be used.

● Augmented reality (hands-on experience with addi-tion of virtual content) or traditional training may be considered for resuscitation training. The use of vir-tual reality alone is not recommended.

Please refer to "Part 12: Resuscitation Education Sci-ence" for the full recommendations and additional infor-mation on these topics. ${ }^{1}$

REFERENCES

1. Donoghue A,Auerbach M,Banerjee A,Blewer A,Cheng A,Kadlec K,Lin Y,Diederich E,Sawyer T,Stallings D,et al.Part 12:resuscitation educa-tion science: 2025 American Heart Association Guidelines for Cardio-pulmonary Resuscitation and Emergency Cardiovascular Care. Circulation.2025;152(suppl 2):S719-S750.doi:10.1161/C1R0000000000001374

KNOWLEDGE GAPS

Neonatal resuscitation science continues to advance,with contributions by many researchers in laboratories,in the delivery room, and in other clinical settings. This research has led to refinement and improvements in the Neonatal Resuscitation Algorithm. It has also led to the recognition of gaps in knowledge to further optimize neonatal resuscitation. Innovative study designs, such as cluster randomization and stepped wedge designs, along with changes in consent processes informed by families may further advance neonatal resuscitation research. Re-view of the knowledge chunks during this update identi-fied questions and practices for which evidence level was low, uncertain, or absent. The following knowledge gaps would benefit from further research:

Resuscitation Preparedness

● Specific maternal and fetal factors that may warrant the need for an advanced resuscitation team

● Current rates of various interventions during neona-tal resuscitation in different birth settings

During and Just After Birth

● Optimal cord management strategies for specific populations, including multiple gestations, mod-erately preterm infants, and those with congenital heart or lung disease

● Optimal duration of deferred cord clamping for pre-term gestational age groups

● Specific clinical indications for immediate or early cord clamping

Early Resuscitation

● Adjunctive interventions that may optimize out-comes during deferred cord clamping

● Optimal interface for initial ventilation for term and preterm newborn infants

● Effectiveness of laryngeal mask for newborn infants<34 weeks' gestational age or $<2$ kg birth weight

● Optimal ventilation rate and whether it may depend on gestational age

● Effectiveness of new technologies for rapid heart rate measurement in regard to accuracy and clinical outcomes

• Optimal oxygen management during and after resuscitation, including titration strategies

Advanced Resuscitation

● Optimal techniques for chest compressions in newborn infants, including ratio of compressions to ventilations, asynchronous versus synchronous technique, and method of compression

● Optimal airway management during chest compres-sions, such as the use of a laryngeal mask and its effectiveness compared to ventilation delivered by endotracheal tube

● Whether certain populations outside of the imme-diate birth period may have better outcomes when resuscitated by using the neonatal or the pediatric resuscitation algorithm

● Optimal mode of intravascular access outside of the delivery room setting to administer setting medications or fluids

● Optimal timing, dosing, dose interval, and deliv-ery routes for epinephrine, including earlier use in newborn infants requiring extensive advanced resuscitation

● Indications for volume expansion, as well as optimal dosing, timing, and type of volume

● The recognition and management of pulseless elec-trical activity

● Passive cooling during resuscitation in infants with moderate to severe HIE

Postresuscitation Care

● Optimal dose, route, and timing of surfactant in at-risk newborn infants, including less-invasive admin-istration techniques

● Indications for and effectiveness of CPAP for vari-ous populations

● Strategies to prevent subsequent hypothermia after the immediate birth period

● Optimal rewarming strategy for newborn infants with unintentional hypothermia

● Strategy for blood glucose monitoring after neo-natal resuscitation, including appropriate patient selection, method, and frequency of measurement

● Effectiveness of therapeutic hypothermia for mild IHE

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Education and Maintenance of Skills

$\bullet$ Optimal training strategies for individual and team performance, including methods of learning, fre-quency, and adjunctive tools such as virtual reality

For these gaps, when relevant and feasible, it is important to select outcomes considered critical or important by both health care professionals and families of newborn infants. The research community should seek to design studies that will lead to evidence with a high level of certainty. Internal validity is ideally addressed by clearly defined primary outcomes, appropriate sample sizes,relevant and timed interventions and controls, and time series analyses in implementation studies. ILCOR has published a guideline that should be followed for uniform reporting of neonatal resuscitation research.' External validity can be optimized by studying relevant health care professional populations and systems of care and by measuring the impact on critical patient outcomes.

Researchers studying these gaps will need to con-sider innovations in clinical trial design; examples include pragmatic study designs and novel consent processes. As mortality and severe morbidities decline with advancements and improvements in health care delivery, having adequate power for some clinical ques-tions using traditional individual patient randomized tri-als declines. Another barrier is the difficulty in obtaining antenatal consent for clinical trials in the delivery room.

Disclosures

Appendix 1. Writing Group Disclosures

Adaptive trials and those using cluster randomization may be suitable for some questions.When feasible, well-designed multicenter randomized clinical trials should be used to generate the highest-quality evidence.

Research should address the values and preferences of our key stakeholders, the families and teams who are involved in the process of resuscitation. Research in neonatal resuscitation has been noted to have under-representation of various populations. In the context of disparities in care and outcomes, researchers can make efforts to elicit input from representative families and work to ensure appropriate recruitment in trials.

REFERENCES

1. Foglia EE, Davis PG, Guinsburg R, Kapadia V, Lilley HG, Rudiger M,Schmolzer GM, Strand ML, Wyckoff MH, Wyllie J,et al; on behalf of the In-ternational Liaison Committee on Resuscitation Neonatal Life Support Task Force. Recommended Guideline for Uniform Reporting of Neonatal Resus-citation: The Neonatal Utstein Style. Pediatrics.2023;151:e2022059631.doi:10.1542/peds.2022-059631

ARTICLE INFORMATION

The American Heart Association requests that this document be cited as fol-lows: Lee HC, Strand ML, Finan E, Illuzzi J, Kamath-Rayne BD, Kapadia V,Mah-goub M,Niermeyer S,Schexnayder SM,Schmolzer GM,Weglarz J,Williams AL,Weiner GM, Wyckoff M, Yamada NK,Szyld E. Part 5: neonatal resuscitation:2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation.2025;152(suppl 2):S385-S423. doi: 10.1161/CIR.0000000000001367

This article has been copopished in Pediatrics.

Appendix 1. Writing Group Disclosures

|Writing Group Member|Employment|Research Grant|Other Research Support|Speakers Bureau/ Honoraria|Expert Witness|Ownership Interest|Consultant/ Advisory Board|Other| |---|---|---|---|---|---|---|---|---| |Henry C. Lee|University of California San Diego|Genentech*|None|None|None|None|American Heart Associationt; American Academy of Pediatric of|Chiesi USA*| |Edgardo Szyld|Indiana University|None|None|None|None|None|Fisher and Paykel*|None| |Emer Finan|Mount Sinai Hospital; University of Toronto (Canada)|None|None|None|None|None|None|None| |Jessica Illuzzi|Yale School of Medicine|None|None|None|None|None|None|None| |Beena D. Kamath-Rayne|American Academy of Pediatrics|None|None|None|None|None|Cerebral Palsy Alliance Research Foundation*|Lurie Children's Hospital; Children's Healthcare of Atlantat| |Vishal Kapadia|UT Southwestern|NIHt|Masimo*|None|None|Anishet|None|None| |Melissa Mahgoub|American Heart Association|None|None|None|None|None|None|None| |Susan Niermeyer|University of Colorado|NIH*|None|None|None|None|World Health Organizationt|None|

$\text{(Continued)}$

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Appendix 1. Continued

|Writing Group Member|Employment|Research Grant|Other Research Support|Speakers Bureau/ Honoraria|Expert Witness|Ownership Interest|Consultant/ Advisory Board|Other| |---|---|---|---|---|---|---|---|---| |Stephen Schexneray|University of Arkansas/ Arkansas'|None|None|None|Love& Kirschenbaum LLLCt; Best and Sharp*|None|American Heart Associationt|None| |Georg M. Schměelzer|University of Alberta (Canada)|Canadian Institute of Health Researcht|None|None|None|RETAIN Labs Medical*|None|None| |Marya L. Strand|Akron Children's Hospital|Mayo Clinic*|None|None|None|None|None|None| |Jessica Weglarz|American Academy of Pediatrics|None|None|None|None|None|None|None| |Gary M. Weiner|University of Michigan|None|None|None|None|None|American Academy of Pediatricist|None| |Amanda L. Williams|Cedars Sinai|None|None|None|None|None|None|Stryker Corporation*| |Myra 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.

Disclosures are reviewed and mitigated through a conflict-of-interest process that consists of reviewing pertinent information which is then used to decide what action is required to maintain content integrity. Disclosures may include salary, wages or other remuneration of any kind(including but not limited to consulting or advising fees,speaking fees, research funding, ownership interests, honoraria, participation in pension or benefit plans or programs or other perquisites, and reimbursement for travel,lodging, and meals) given for services rendered or other activities for which remuneration is received or expected, whether that compensation or other remuneration is paid directly to the individual or to the individual's employer or another third party.

*Modest.

tSignificant.

Appendix 2. Reviewer Disclosures

|Reviewer|Employment|Research Grant|Other Research Support|Speakers’ Bureau/Honoria|Expert Witness|Ownership Interest|Consultant/ Advisory Board|Other| |---|---|---|---|---|---|---|---|---| |Namasivayam Ambalavanar|University of Alabama at Birmingham|None|None|None|None|None|None|None| |Holly Engelstad|Monroe Carel Jr. Children's Hospital at Vanderbilt|None|None|None|None|None|None|None| |Jesse Hackell|Committee on Practice & Ambulatory Medicine|None|None|None|None|None|None|None| |David Kaufman|University of Virginia School of Medicine|None|None|None|None|None|None|None| |Tomitra Latimer|Lurie Children's Hospital|None|None|None|None|None|None|None| |John Loyd|Dell Children's Hospital|None|None|None|None|None|None|None| |Arun Pramanik|LSU Health|None|None|None|None|None|None|None| |Alaina Pyles|Connecticut Children's Medical Center|None|None|None|None|None|None|None| |Clara Song|Kaiser Permanente|None|None|None|None|None|None|None| |Preethi Srinivasakumar|Pedriatrix Medical Group|None|None|None|None|None|None|None| |Muhammad Waseem|Lincoln Medical Center|None|None|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-tionnaire, 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“modest” if it is less than“significant” under the preceding definition.

*Modest.

tSignificant.

表 1
Recommendations for Anticipation and Preparation for Resuscitation
COR	LOE	Recommendations
1	B-NR	1. Every birth should be attended by at least 1 person whose only responsibility is the care of the newborn infant, including performing the initial steps of resuscitation and providing ventilation when required.
1	B-NR	2. Before every birth, a standardized risk factors assessment should be performed to determine perinatal risk and assemble a neonatal resuscitation team based on that risk.
1	C-LD	3. Before every birth, a standardized checklist should be used to ensure the presence and function of supplies and equipment necessary for a complete resuscitation.
1	C-LD	4. When anticipating a high-risk birth, a prebirth team briefing should be performed to identify potential interventions and assign roles and responsibilities.

表 2
Recommendations for Term Newborn Umbilical Cord Management
COR	LOE	Recommendations
2a	B-R	1. For term newborn infants who do not require immediate resuscitation, deferred cord clamping for at least 60 seconds can be beneficial when compared to immediate cord clamping.
2b	B-R	2. For nonvigorous term newborn infants and late preterm infants 35 weeks or more gestational age,intordc milking may be reasonable when compared to immediate cord clamping.
2b	C-LD	3. For term newborn infants who do not require immediate resuscitation, the usefulness of intact umbilical cord milking compared to deferred cord clamping is uncertain.

表 3
Recommendations for Preterm Newborn Umbilical Cord Management
COR	LOE	Recommendations
1	A	1. For newborn infants born at<37 weeks of gestation who do not require immediate resuscitation, deferred cord clamping for at least 60 seconds is recommended when compared to immediate cord clamping.
2b	B-R	2. For newborn infants born at 28+0 to 36+6 weeks of stations who do not require immediate resuscitation and in whom deferred cord clamping cannot be performed, intact cord milking may be reasonable.
3: Harm	B-R	3. For newborn infants born at less than 28+0 weeks of gestation, intact cord milking should not be performed.

表 4
Recommendations for Maintaining Normothermia
COR	LOE	Recommendations
COR	LOE	Recommendations
1	B-NR	1. The temperature of newborn infants should be monitored and maintained between 36.5℃ and 37.5℃ after birth through admission and stabilization.
2	B-NR	1. The temperature of newborn infants should be monitored and maintained between 36.5℃ and 37.5℃ after birth through admission and stabilization.
1	B-NR	2. Hypothermia(temperature less than 36℃) should be prevented due to its association with adverse outcomes in newborn infants.
1	B-NR	3. Hyperthermia(temperature greater than 38℃) should be prevented due to its association with adverse outcomes in newborn infants.

表 5
Recommendations for Interventions to Maintain Normothermia
COR	LOE	Recommendations
2a	B-R	1. For preterm infants in the delivery room, the use of radiant warmers,plastic bags or wraps(with a cap),increased room temperature, and warmed humidified inspired gases, separately or in combination, can be effective in preventing hypothermia.
2a	C-LD	2. Placing newborn infants skin-to-skin after birth can be effective to maintain normothermia.
2a	C-LD	3. For newborn infants who require resuscitation,temperature-controlling interventions can be beneficial.
2b	B-R	4. For preterm infants,exothermic matters may be considered for the prevention of hyperthermia.
2b	B-NR	5. For preterm infants, various combinations of warming strategies(or“bundles”) may be reasonable to prevent hypothermia but may also increase the risk of hyperthermia.

表 6
Recommendation for Tactile Stimulation in Newborn Infants
COR	LOE	Recommendation
2a	C-LD	1. Tactile stimulation can be useful in newborn infants who appear to have ineffective respiratory effort after birth.

表 7
Recommendations for Clearing the Airway in Newborn Infants
COR	LOE	Recommendations
2a	C-EO	1. Suctioning of the mouth and nose can be considered in newborn infants if ventilation is required and the airway appears obstructed.
2a	C-EO	2. Intubation and tracheal suction can be beneficial for newborn infants who have evidence of tracheal obstruction during ventilation.
3:No Benefit	B-R	3. Routine oral, nasal, oropharyngeal, or endotracheal suctioning of newborn infants is not recommended, regardless of whether the fluid is clear or meconium stained.

表 8
Recommendations for Assessment of Heart Rate in Newborn Infants
COR	LOE	Recommendations of Heart Rate in Newborn Infants
2a	B-NR	1.ECG can be useful for fast and accurate heart rate assessment in newborn infants.
2a	2.CU-AL	2. Auscultation and pulse oximetry are reasonable alternatives to ECG for heart rate assessment in newborn infants.

表 9
Recommendation for Assessment of Heart Rate in Newborn Infants Receiving Chest Compressions
COR	LOE	Recommendation
1	C-EO	1. ECG should be used for the rapid and accurate assessment of heart rate during chest compressions in term and preterm infants.

表 10
Recommendations for Ventilatory Support
COR	LOE	Recommendations
1	1. Ventilation should be provided within 60 seconds after birth in newborn infants who are gasping or apneic or who are persistently bradycardic(heart rate less than 100/min) despite appropriate initial steps.
2a	C-LD	2. For newborn infants, initial peak inflation pressures of 20 to 30 cm H2O are reasonable, with adjustment of peak inflation pressures to provide effective ventilation.
2b	C-LD	3. In newborn infants receiving ventilation, it may be reasonable to provide positive end-expiratory pressure(PEEP).
3: Harm	C-LD	4. Excessive peak inflation pressure can result in high tidal volume, which is potentially harmful and should be avoided.

表 11
Recommendations for Rate and Inflation Time During Ventilation
COR	LOE	Recommendations
2a	C-LD	1. It is reasonable to provide ventilation at a rate of 30 to 60 inflations per minute in newborn infants.
2a	C-LD	2. It is reasonable to initiate ventilation with an inflation time of 0.5 to 1 seconds in newborn infants.
3: Harm	B-R	3. In preterm newborn infants less than 28 weeks of gestation, the routine use of sustained inflation (>5 seconds) to initiate ventilation is potentially harmful and should not be performed.

表 12
Recommendations for Ventilation Corrective Maneuvers
COR	LOE	Recommendations
2a	C-LD	1. Ventilation corrective maneuvers can be useful when initial positive pressure inflations are not effective for newborn infants who require ventilation.
2a	B-R	2. Video laryngoscopy can be useful for newborn infants who require endotracheal intubation.	2. Video laryngoscopy can be useful for newborn infants who require endotracheal intubation.

表 13
Recommendations for Interfaces to Deliver Ventilation to Newborn Infants
COR	LOE	Recommendations
2a	C-LD	1. It is reasonable to use a laryngeal mask as an alternative to endotracheal intubation for newborn infants 34+0/7 weeks' or more gestational age for whom ventilation via face mask is unsuccessful.
2b	C-LD	2. It may be reasonable to use a laryngeal mask as the primary interface to administer ventilation instead of a face mask for newborn infants 34+0/7 weeks' or more gestational age.

表 14
Recommendation for Devices to Deliver Ventilation to Newborn Infants
COR	LOE	Recommendation
2a	B-R	1. It can be beneficial to use a T-piece resuscator instead of a self-inflating bag, with or without a PEP valve, for administering ventilation to new- born infants, particularly preterm infants.

表 15
Recommendations for Providing Continuous Positive Airway Pressure
Newborn Infants	Newborn Infants	Newborn Infants	Newborn Infants
COR	LOE	Recommendations
2a	A	1. For spontaneously breathing preterm infants who require respiratory support immediately after birth, it is reasonable to use CPAP rather than intubation and mechanical ventilation.
2b	C-LD	2. For spontaneously breathing preterm infants who require respiratory support immediately after birth, the effectiveness of high-flow nasal cannula compared to CPAP is not well-established.
2b	C-LD	3. The usefulness of CPAP for spontaneously breathing term and late preterm infants34 weeks' or more gestational age who have or are at risk of having respiratory distress immediately after birth is not well-established.

表 16
Recommendations for Oxygen Administration During Neonatal Resuscitation
COR	LOE	Recommendations
1	C-EO	1. Oxygen supplementation should be titrated to target oxygen saturation goals in newborn infants receiving respiratory support.
2	C-LD	2. A pulse oximeter should be placed as soon as possible for newborn infants receiving respiratory support or supplemental oxygen.
3	2b	3. In term and late preterm newborn infants born at 35 weeks' or more gestational age receiving respiratory and pretermary support at birth, it may be reasonable to begin with within 21% oxygen.
2	C-LD	4. In preterm newborn infants born at 32 to preterm newborn infants born at 32 to preterm at birth, it may be reasonable to begin with 21% oxygen.
2	2b	4. In preterm newborn infants born at 32 to preterm at birth, it may be reasonable to begin with 21% oxygen.
3	2b	5. In preterm newborn infants born at 53 weeks' gestational age receiving respiratory support at birth, it may be reasonable to begin with 21% oxygen.
2	C-LD	4. In preterm newborn infants born at 32 weeks' gestational age receiving respiratory support at birth, it may be reasonable to begin with 30% to 100% oxygen.

表 17
Recommendations for Initiating Chest Compressions in Newborn Infants
COR	LOE	Recommendations
1	C-EO	1. In newborn infants, chest compressions are recommended if the heart rate remains less than 60/min despite 30 seconds of ventilation that inflates the lungs, as evidenced by chest movement.
1	C-EO	2. During chest compressions in newborn infants, ventilation with an endotracheal tube is recommended.
2b	C-EO	3. During chest compressions for newborn infants born at 34 weeks' or more gestational age when placement of an endotracheal tube is not possible or is unsuccessful, laryngeal mask may be a reasonable alternative.
2b	C-EO	4. It may be reasonable to use 100% oxygen during chest compressions in newborn infants. Once compressions are no longer needed, titrate the oxygen to meet saturation targets.

表 18
COR	LOE	Recommendations
2b	C-LD	1. It may be reasonable to repeatedly deliver 3 compressions followed by a ventilation breath (3:1 ratio) when providing chest compressions to newborn infants.
2b	C-LD	2. It may be reasonable to use the 2 thumb- encircling hands technique compared to the 2-finger or other techniques when providing chest compressions to newborn infants.
2b	C-LD	3. It may be reasonable to compress to one third the anterior-posterior diameter of the chest when providing chest compressions to newborn infants.
2b	C-LD	4. It may be reasonable to compress over the lower one third of the stermum, taking care to be above the xiphoid process when providing chest compressions to newborn infants.
2b	C-EO	5. It may be reasonable to change the compressor role every 2 to 5 minutes when providing chest compressions to newborn infants and to switch the compressor during the heart rate assessment period.

表 19
Recommendations for Vascular Access During Resuscitation
COR	LOE	Recommendations
1	C-LD	1. Insertion of an umbilical vein catheter is recommended for newborn infants requiring emergency vascular access.
2a	C-LD	2. Insertion of an intraosseous(IO) vascular access device can be useful for newborn infants requiring emergency vascular access if intravenous access is not successful or not feasible.

表 20
Recommendations for Epinephrine Administration in Neonatal Resuscitation
COR	LOE	Recommendations
1	B-NR	In. Newborn infants whose heart rate has not increased to 60/min or more after optimizing ventilation and chest compressions, it is recommended to administer intravascular epinephrine(0.01-0.03 mg/kg).

表 21
COR	LOE	Recommendations
2b	C-LD	4. In newborn infants receiving epinephrine, it may be reasonable to administer additional doses of epinephrine every 3 to 5 minutes, preferably in intravascularly, if the heart rate remains less than 60/min.

表 22
Recommendations for Volume Expansion
COR	LOE	Recommendations
2b	C-EO	1. It may be reasonable to administer a volume expander to newborn infants with evidence of hypovolemia, based on history and physical examination, who remain bradycardic(heart rate less than 60/min) despite ventilation, chest compressions, and epinephrine.
2b	C-EO	2. It may be reasonable to use normal saline(0.9% sodium chloride) or blood at 10 to 20 mL/kg for volume expansion.

表 23
Recommendations for Postresuscitation Care
COR	LOE	Recommendations
1	A	1. Newborn infants born at≥36 weeks' gestational age with moderate to severe HIE should be offered therapeutic hypothermia under clearly defined protocols.
2	B-NR	2. Newborn infants who receive prolonged ventilation or advanced resuscitation(intubation, chest compressions, or epinephrine) should be closely monitored, including checking glucose levels early in the postresuscitation period and continuing until the glucose levels are maintained in the normal range.
1	C-LD	3. For newborn infants who are unintentionally hypothermic(temperature<36°C) after resuscitation, rewarming is indicated. The optimal rate of rewarming is unknown.

表 24
Recommendations for Withholding and Discontinuing Resuscitation
COR	LOE	Recommendations
1	C-LD	In. newborn infants receiving resuscitation, if there is no heart rate and all the steps of resuscitation have been performed, cessation of resuscitation efforts should be discussed with the team and the family. A reasonable time frame to consider this change in goals of care is around 20 minutes after birth.
2	C-EO	2. In newborn infants, noninitiation of resuscitation and discontinuation of life-sustaining treatment during or after resuscitation should be considered ethically equivalent.
2a	C-EO	3. If a birth involves a condition likely to result in early death or severe morbidity of a newborn, noninitiation or limitation of resuscitation is reasonable after appropriate consultation and shared decision-making with the family.

表 25
Writing Group Member	Employment	Research Grant	Other Research Support	Speakers Bureau/ Honoraria	Expert Witness	Ownership Interest	Consultant/ Advisory Board	Other
Henry C. Lee	University of California San Diego	Genentech*	None	None	None	None	American Heart Associationt; American Academy of Pediatric of	Chiesi USA*
Edgardo Szyld	Indiana University	None	None	None	None	None	Fisher and Paykel*	None
Emer Finan	Mount Sinai Hospital; University of Toronto (Canada)	None	None	None	None	None	None	None
Jessica Illuzzi	Yale School of Medicine	None	None	None	None	None	None	None
Beena D. Kamath-Rayne	American Academy of Pediatrics	None	None	None	None	None	Cerebral Palsy Alliance Research Foundation*	Lurie Children's Hospital; Children's Healthcare of Atlantat
Vishal Kapadia	UT Southwestern	NIHt	Masimo*	None	None	Anishet	None	None
Melissa Mahgoub	American Heart Association	None	None	None	None	None	None	None
Susan Niermeyer	University of Colorado	NIH*	None	None	None	None	World Health Organizationt	None
Stephen Schexneray	University of Arkansas/ Arkansas'	None	None	None	Love& Kirschenbaum LLLCt; Best and Sharp*	None	American Heart Associationt	None
Georg M. Schměelzer	University of Alberta (Canada)	Canadian Institute of Health Researcht	None	None	None	RETAIN Labs Medical*	None	None
Marya L. Strand	Akron Children's Hospital	Mayo Clinic*	None	None	None	None	None	None
Jessica Weglarz	American Academy of Pediatrics	None	None	None	None	None	None	None
Gary M. Weiner	University of Michigan	None	None	None	None	None	American Academy of Pediatricist	None
Amanda L. Williams	Cedars Sinai	None	None	None	None	None	None	Stryker Corporation*
Myra Wyckoff	UT Southwestern	None	None	None	None	None	None	None
Nicole K. Yamada	Stanford University	None	None	None	None	None	None	None

表 27
Reviewer	Employment	Research Grant	Other Research Support	Speakers’ Bureau/Honoria	Expert Witness	Ownership Interest	Consultant/ Advisory Board	Other
Namasivayam Ambalavanar	University of Alabama at Birmingham	None	None	None	None	None	None	None
Holly Engelstad	Monroe Carel Jr. Children's Hospital at Vanderbilt	None	None	None	None	None	None	None
Jesse Hackell	Committee on Practice & Ambulatory Medicine	None	None	None	None	None	None	None
David Kaufman	University of Virginia School of Medicine	None	None	None	None	None	None	None
Tomitra Latimer	Lurie Children's Hospital	None	None	None	None	None	None	None
John Loyd	Dell Children's Hospital	None	None	None	None	None	None	None
Arun Pramanik	LSU Health	None	None	None	None	None	None	None
Alaina Pyles	Connecticut Children's Medical Center	None	None	None	None	None	None	None
Clara Song	Kaiser Permanente	None	None	None	None	None	None	None
Preethi Srinivasakumar	Pedriatrix Medical Group	None	None	None	None	None	None	None
Muhammad Waseem	Lincoln Medical Center	None	None	None	None	None	None	None

图示：Recognition Initial Steps Ventilation Advanced Postnatal Care Recovery

图示：Antenatal counseling Team briefing Equipment check Birth Birth Initiate cord management plan Term gestation?Good tone?Breathing or crying? No Warm and maintain normal temperature Dry Position Stimulate and clear airway if needed Apnea or gasping?HR<100/min? No Labored breathing or persistent cyanosis? Yes $\downarrow$ Yes $\downarrow$ Yes $\downarrow$ No Ventilate Pulse oximeter Consider CPAP Consider cardiac monitor No Ventilation corrective case with family Team debriefing , Yes Target Oxygen Saturation Table 2 min 65%-70% 3 min 70%-75% 4 min 47% 80%-85% 5 min 80%-85% 5 min 10 min 0 Z 0 $9120$ $9250$ $9260$ $9260$ $9260$ $9260$ $9260$ $9260$ $9260$ $9260$ $9260$ $9260$ $9260$ $9260$ $9260$ $9260$ $9260$ $9260$ $9260$ $

引用 / 出处

2025+AHA心肺复苏与心血管急救指南-第5部分：新生儿复苏. 2025.