Neonatal Resuscitation Guidelines

Initial Assessment and Resuscitation

The American Academy of Pediatrics recommends immediately assessing three critical characteristics: term gestation, good muscle tone, and breathing or crying—if all three are present, the infant stays with mother for routine care; if any are absent, begin resuscitation under a radiant warmer 1
Provide warmth by placing infant under radiant heat source, with preterm infants <32 weeks requiring plastic wrapping up to neck level and room temperature >25°C to maintain 36.5-37.5°C 2, 3
Position the head in "sniffing" position to open airway 2, 3
Clear secretions only if copious and obstructing airway—avoid routine nasopharyngeal suctioning as it causes bradycardia 4, 3
Dry thoroughly and remove wet linen 2
Stimulate breathing through drying and gentle tactile stimulation 2

Begin PPV immediately with room air (21% oxygen) for term infants using 40-60 breaths/minute at initial pressure of 20 cm H₂O—the primary indicator of effective ventilation is rising heart rate, not chest rise 4, 1
Use face mask with flow-inflating bag, self-inflating bag, or T-piece resuscitator 1
Apply 5 cm H₂O PEEP 1
Initial pressure 20 cm H₂O (may need 30-40 cm H₂O in some term infants) 4
Attach pulse oximetry to right hand/wrist (preductal) with targets: 60-65% at 1 minute, 85-95% by 10 minutes 1
Use the two-thumb encircling hands technique with compressions on lower third of sternum to depth of one-third anterior-posterior diameter, coordinated with ventilation at 3:1 ratio (90 compressions:30 breaths = 120 events/minute) 6

Administer epinephrine 0.01-0.03 mg/kg IV (preferred route) if heart rate remains <60 bpm despite adequate ventilation with 100% oxygen and chest compressions—endotracheal route is less effective and requires higher doses (0.05-0.1 mg/kg) 6
It is appropriate to consider discontinuing resuscitation if there has been no detectable heart rate for 10 minutes, though many factors contribute to decisions beyond 10 minutes 5

Never delay ventilation to establish IV access or prepare for intubation 1
Never start with 100% oxygen in term infants—begin with room air and titrate based on pulse oximetry 4, 1
Never perform routine endotracheal suctioning for meconium-stained fluid 4, 1
Never start chest compressions before achieving 30 seconds of effective ventilation with chest rise 1
Avoid hypothermia (maintain 36.5-37.5°C) and hyperthermia (>38°C) 1, 3
Never use bicarbonate in the delivery room—it is not recommended during acute resuscitation 6