NALS - Neonatal Resuscitation 

Updated: Mar 21, 2014
  • Author: James J Lamberg, DO; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Neonatal Advanced Life Support (NALS): Neonatal Algorithm

Time: 0-30 seconds

1. Initial evaluation [1, 2, 3]

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

2. Routine care if initial evaluation findings are normal

  • Provide warmth
  • Clear airway if necessary
  • Dry newborn
  • Ongoing evaluation

3. Measures if initial evaluations findings are abnormal

  • Provide warmth
  • Clear airway if necessary
  • Dry, stimulate, and reposition

Time: 30-60 seconds

4. Secondary evaluation

  • Respirations
  • Heart rate
  • Color

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

6. If the heart rate is >100 bpm and the baby is cyanotic or has labored breathing, 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

7. If the heart rate is < 100 bpm and the baby is gasping or apneic, follow the steps below

  • Clear airway and begin SpO 2 monitoring
  • Provide positive-pressure ventilation
  • Consider supplementary oxygen
  • If the baby improves, institute postresuscitation care

Time: 60-90 seconds

8. If the heart rate is < 60 bpm, follow the steps below

  • Start chest compressions
  • Consider intubation; intubate if no chest rise

9. Reassess heart rate

  • If the heart rate is >60 bpm, stop compressions and continue ventilation
  • If the heart rate is < 60 bpm, administer epinephrine and/or volume expansion

Drug therapy

See the list below:

  • Epinephrine 0.01-0.03 mg/kg IV
  • Crystalloid 10 mL/kg IV
  • Naloxone is not recommended

Target preductal SpO

See the list below:

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


See the list below:

  • Check pulse at brachial or femoral artery
  • Compression landmarks: Lower half of sternum between the nipples
  • Method: Thumb-encircling
  • Depth: At least one-third anteroposterior chest diameter
  • Allow complete chest recoil after each compression
  • Compression rate: At least 100 compressions per minute
  • Compression-to-ventilation ratio of 3:1
  • Continuous compressions if advanced airway present
  • Minimize interruptions in compressions to < 10 seconds


See the list below:

  • 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
  • Despite lack of evidence, continue current practice of endotracheal suctioning of nonvigorous babies with meconium-stained amniotic fluid


See the list below:

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

Factors that should prompt consideration of intubation

See the list below:

  • Nonvigorous meconium-stained newborn
  • Ineffective bag-mask ventilation
  • Cardiopulmonary resuscitation (CPR) is being performed
  • Special circumstances such as extremely low birth weight or congenital diaphragmatic hernia