Guideline sources The following summarized guidelines for the evaluation and management of neonatal resuscitation are prepared by our editorial team based on guidelines from the International Liaison Committee on Resuscitation (ILCOR 2022) and the American Heart Association (AHA 2020). 1 2 Calculator Apgar score Guidelines 1. Diagnostic investigations Heart rate assessment: As per ILCOR 2022 guidelines, consider obtaining an ECG, when resources permit, for HR assessment in infants requiring resuscitation in the delivery room. C https://web.pathway.md/diseases/recm1AF36WoTETUub 1/4 6/30/23, 1:15 AM Neonatal resuscitation Pathway Show 3 more As per AHA 2020 guidelines: Consider obtaining an ECG for the rapid and accurate measurement of the HR during resuscitation of term and preterm infants. C Consider obtaining an ECG for the rapid and accurate assessment of the HR during chest compressions. B 2. Respiratory support Airway clearing: As per ILCOR 2022 guidelines: Avoid performing suctioning of clear amniotic fluid from the nose and mouth at birth as a routine step. D Consider performing airway positioning and suctioning if airway obstruction is suspected. E As per AHA 2020 guidelines, do not perform routine oral, nasal, oropharyngeal, or endotracheal suctioning in newly born infants. D Show 3 more Noninvasive positive pressure ventilation: As per ILCOR 2022 guidelines, insufficient evidence to recommend for or against the routine use of CPAP in spontaneously breathing late preterm and term infants with respiratory distress in the delivery room. Show 2 more As per AHA 2020 guidelines, initiate positive pressure ventilation without delay in newly born infants gasping or apneic within 60 seconds after birth or persistently bradycardic (HR < 100/minute) despite appropriate initial actions (including tactile stimulation). B Show 7 more Supplemental oxygen: consider initiating oxygen supplementation at 21% concentration in term and late preterm infants ( 35 weeks of gestation) receiving respiratory support at birth. C Show 2 more 3. Medical management Vascular access: Prefer the umbilical vein in infants requiring vascular access at the time of delivery. B Consider using the intraosseous route if intravenous access is not feasible. C Volume resuscitation: Consider administering a volume expander in newly born infants with suspected hypovolemia, based on history and physical examination, remaining bradycardic (HR < 60/minute) despite ventilation, chest compressions, and epinephrine administration. C https://web.pathway.md/diseases/recm1AF36WoTETUub 2/4 6/30/23, 1:15 AM Neonatal resuscitation Pathway Consider administering normal saline (0.9% sodium chloride) or blood at 10-20 mL/kg for volume expansion. C Epinephrine: consider administering intravascular epinephrine (0.01-0.03 mg/kg) if the HR has not increased to 60/minute after optimizing ventilation and chest compressions. C Show 3 more 4. Nonpharmacologic interventions Temperature management: As per ILCOR 2022 guidelines, consider maintaining the room temperature of 23 C at birth in order to maintain a normal temperature in late preterm and term infants ( 34 weeks gestation). C Show 3 more As per AHA 2020 guidelines, record admission temperature routinely. B Maintain the temperature of newly born infants between 36.5-37.5 C after birth through admission and stabilization. B Show 7 more Tactile stimulation: As per ILCOR 2022 guidelines: Consider performing tactile stimulation, in addition to routine handling with measures to maintain the temperature, in infants with absent, intermittent, or shallow respirations during resuscitation immediately after birth. C Do not delay the initiation of positive pressure ventilation because of tactile stimulation in infants with continued absent, intermittent, or shallow respirations after birth. D As per AHA 2020 guidelines, consider performing tactile stimulation in infants with ineffective respiratory effort after birth. C 5. Therapeutic procedures Cardiopulmonary resuscitation: consider initiating chest compressions if the HR after birth remains at < 60/minute despite adequate ventilation for at least 30 seconds. C Show 3 more Umbilical cord clamping: insufficient evidence to recommend early versus delayed cord clamping in term and preterm infants requiring resuscitation at birth. I 6. Follow-up and surveillance Discontinuation of resuscitation: view non-initiation of resuscitation and discontinuation of life- sustaining treatment during or after resuscitation as ethically equivalent. B Show 2 more https://web.pathway.md/diseases/recm1AF36WoTETUub 3/4 6/30/23, 1:15 AM Neonatal resuscitation Pathway Post-resuscitation care: provide therapeutic hypothermia under clearly defined protocols in newly born infants born at 36 weeks of estimated gestational age with evolving moderate-to-severe hypoxic-ischemic encephalopathy. A Show 3 more 7. Quality improvement Pre-resuscitation preparation: ensure that every birth is attended by at least 1 specialist able to perform the initial steps of neonatal resuscitation and initiate positive pressure ventilation, and whose only responsibility is the care of the newborn. B Show 3 more Health professional training: As per ILCOR 2022 guidelines, provide accredited courses in neonatal resuscitation training (neonatal resuscitation training, neonatal resuscitation program) and Helping Babies Breathe for healthcare specialists providing advanced life support care for newborns and babies. B As per AHA 2020 guidelines: Provide individual or team booster training more frequently than every 2 years at a frequency supporting the retention of knowledge, skills, and behaviors in participants trained in neonatal resuscitation. B Provide briefing before delivery and debriefing after neonatal resuscitation for neonatal resuscitation providers. B References 1. Khalid Aziz, Henry C Lee, Marilyn B Escobedo et al. Part 5 Neonatal Resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142 16_suppl_2 S524 S550. Open 2. Myra H Wyckoff, Robert Greif, Peter T Morley et al. 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Resuscitation. 2022 Oct 29;S0300 9572 22 00684 0. Open 3. No authors listed. WHO recommendations for care of the preterm or low-birth-weight infant. Geneva: World Health Organization; 2022. Open https://web.pathway.md/diseases/recm1AF36WoTETUub 4/4