Neonatal Advanced Life Support (NALS): Neonatal Resuscitation

Updated: May 10, 2018
  • Author: James J Lamberg, DO; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Neonatal Advanced Life Support (NALS): Neonatal Algorithm

Initial Evaluation

One minute (“the Golden Minute”) is allotted for the initial evaluation, for reevaluating, and for initiating ventilation, if required.

1. The initial evaluation consists of three questions, as follows: [1, 2]

  • Term gestation?
  • Breathing or crying?
  • Good muscle tone?

2. Routine care if initial evaluation findings are normal ("yes" to all three questions above), as follows:

  • Provide warmth (cover with dry linen).
  • Clear airway, if necessary.
  • Dry the newborn.
  • Skin to skin with mother
  • Ongoing evaluation

3. The following are measures if initial evaluations findings are abnormal ("no" to any of the three questions above):

  • Provide warmth (radiant warmer).
  • Clear airway, if necessary.
  • Dry, stimulate, and reposition.

Secondary Evaluation

Assess respirations, heart rate, and color.

1. If the heart rate exceeds 100 bpm and the baby is pink with nonlabored breathing, proceed with routine care

2. If the heart rate exceeds 100 bpm with labored breathing or persistent cyanosis, follow the steps below:

  • Clear airway and begin monitoring pulse oximetry oxygen saturation (SpO 2).
  • Consider supplementary oxygen.
  • Consider continuous positive airway pressure (CPAP).
  • If the baby improves, institute postresuscitation care and team briefing.

3. If the heart rate is less than 100 bpm but more than 60 bpm, follow the steps below:

  • Check chest movement.
  • Provide ventilation, if needed.
  • Intubation (ETT) or supraglottic airway (eg, LMA), if needed
  • If the baby improves, institute postresuscitation care and team briefing.

4. If the heart rate is less than 60 bpm, follow the steps below:

  • Start chest compressions.
  • Intubate if not already done.
  • Coordinate compressions with positive pressure ventilation.
  • Provide 100% oxygen and monitor electrocardiography (ECG).
  • Consider emergency umbilical vein catheterization (UVC).

5. Reassess heart rate; if the heart rate is above 60 bpm, stop compressions and continue ventilation.

6. If heart rate remains at less than 60 bpm, follow the steps below:

  • Administer IV epinephrine.
  • Consider hypovolemia (eg, consider volume expansion).
  • Consider pneumothorax.

Drug Therapy

See the list below:

  • Epinephrine 0.01-0.03 mg/kg IV/IO; repeat every 3-5 minutes if heart rate is less than 60 bpm.
  • Epinephrine 0.05-0.1 mg/kg ETT (not preferred route)
  • Crystalloid 10 mL/kg IV/IO
  • Sodium bicarbonate (4.2%) 1-2 mEq/kg IV/IO only for prolonged resuscitation and only if effective ventilation
  • Dextrose (10%) 0.2 g/kg then 5 mL/kg/hr IV/IO if blood glucose level is less than 40 mg/dL
  • Naloxone is not recommended. [3]


See the list below: [4]

  • Check pulse at brachial or femoral artery.
  • Compression landmarks: Lower third of sternum between the nipples
  • Method: Thumb-encircling
  • Depth: Approximately one-third anteroposterior chest diameter
  • Allow complete chest recoil after each compression
  • Compression rate: 100-120 per minute
  • Compression-to-ventilation ratio of 3:1
  • Coordinate compressions with ventilation
  • Minimize interruptions in compressions to less than 10 seconds


See the list below:

  • Preterm newborns (< 35 weeks) should receive low oxygen (FiO2 21%-30%).
  • Suction after birth is only for babies with obvious obstruction or who require positive pressure ventilation.
  • Suctioning during delivery has been shown to have no value.


See the list below:

  • If meconium is present and the newborn is vigorous with good respiratory effort and muscle tone, he or she may stay with the mother, and bulb suctioning can be considered.
  • If the infant is born through meconium-stained amniotic fluid and presents with poor muscle tone and inadequate breathing efforts, move him or her to a radiant warmer and follow typical initial evaluation steps.
  • If meconium is present, routine intubation for tracheal suction is not recommended.
  • If meconium is present and the infant is nonvigorous, current literature does not support routine intubation.


See the list below:

  • Rate of 40-60 breaths per minute
  • Watch for visible chest rise.
  • Administer positive end-expiratory pressure (PEEP), if available.

Consider Intubation

See the list below:

  • Ineffective or prolonged bag-mask ventilation
  • Cardiopulmonary resuscitation (CPR) is being performed
  • Special circumstances such as congenital diaphragmatic hernia

Target Preductal SpO2 At Birth

See the list below:

  • 1 minute: 60%-65%
  • 2 minutes: 65%-70%
  • 3 minutes: 70%-75%
  • 4 minutes: 75%-80%
  • 5 minutes: 80%-85%
  • 10 minutes: 85%-95%