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Guidelines Summary

American Heart Association

Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care of neonates were published by the American Heart Association in 2020.^[35] These are some of the highlights of the guidelines without analysis or commentary.

Tactile Stimulation

If a newborn infant is breathing ineffectively or has apnea, drying the infant and/or rubbing the back and soles of the feet may help stimulate breathing.

Clearing the Airway

Routine oral, nasal, oropharyngeal, or endotracheal suctioning is not recommended for newborn infants, even those who are born with meconium-stained amniotic fluid (MSAF). However, nonvigorous infants with MSAF at birth who have evidence of airway obstruction can benefit from intubation and tracheal suction.

Ventilatory Support

Start positive-pressure ventilation (PPV) without delay in newborn infants who are gasping or apneic within 60 seconds after birth or who have persistent bradycardia (heart rate of < 100 beats/min). A rate of 40 to 60 inflations per minute is reasonable. A key indicator of successful ventilation is an increase in heart rate.

Oxygen Therapy

PPV may be started with air (21% oxygen) in term and late preterm infants; up to 30% oxygen may be used in preterm infants (less than 35 weeks’ gestation). The use of 100% oxygen should be avoided in term and late preterm newborns because it is associated with excess mortality.

Heart Rate Assessment

Electrocardiography can provide rapid and accurate measurement of the heart rate during the resuscitation of term and preterm newborn infants.

Chest Compressions

Initiate chest compressions if the heart rate is lower than 60 beats/min after at least 30 seconds of adequate PPV.

Intravascular Access

The umbilical vein is the recommended route for vascular access in infants who have failed to respond to PPV and chest compressions and who require epinephrine and/or volume expanders.

Epinephrine Administration

Administer epinephrine, preferably intravenously, if the heart rate remains lower than 60 beats/min despite 60 seconds of chest compressions and adequate PPV. The recommended intravenous dose of epinephrine is 0.01 to 0.03 mg/kg.

Volume Expansion

Failure to respond to epinephrine and known or suspected blood loss are indications for volume expansion with normal saline or blood. The recommended initial volume is 10 mL/kg over 5 to 10 minutes.

Care After Resuscitation

Newborn infants who received prolonged PPV, intubation, chest compressions, or epinephrine should be monitored closely in a neonatal intensive care unit or similar area after their condition has stabilized.

Medication

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Author

Joshua A Rocker, MD Assistant Professor of Pediatrics and Emergency Medicine, Hofstra North Shore-LIJ School of Medicine; Associate Chief, Division of Pediatric Emergency Medicine, Director of Education for Pediatrics Emergency Medicine Fellowship, Cohen's Children Medical Center of New York

Joshua A Rocker, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Santina P Bruno, DO Fellow in Pediatric Emergency Medicine, Cohen Children's Medical Center, Northwell Health; Teaching Associate in Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell

Santina P Bruno, DO is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Additional Contributors

Jeffrey Israel, MD Pediatric Emergency Medicine Fellow, Cohen Children's Medical Center of New York, North Shore-Long Island Jewish Health System

Jeffrey Israel, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Elizabeth B Jones, MD, Brent R King, MD, and Isaac Grate Jr, MD, to the development and writing of this article.

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