C H A P T E R 164 
Neonatal Resuscitation
Ryan D. Kearney  |  Mark D. Lo
PRINCIPLES
Approximately 10% of newborns require some assistance at birth,
with 1% requiring extensive resuscitative measures.1 Knowledge
of neonatal physiology, appropriate equipment, and procedural
skills are essential to successful resuscitation. Preparation for
neonatal resuscitation requires an understanding of how it differs
from pediatric and adult resuscitation, primarily as follows:
1. Newborns have rapidly changing, dynamic cardiopulmonary
physiology, with a unique range of normal vital signs.2,3
2. Neonatal resuscitation is almost entirely respiratory (not
cardiac) management.2
3. Neonates require special and dedicated equipment.
PATHOPHYSIOLOGY
Transition From Fetal to Extrauterine Life
The successful transition from fetal to extrauterine life requires
three major cardiorespiratory changes: (1) removal of fluid from
unexpanded alveoli to allow ventilation; (2) lung expansion and
establishment of functional residual capacity; and (3) redistribu-
tion of cardiac output to provide lung perfusion. Failed develop-
ment of adequate ventilation or perfusion leads to persistent
shunting, hypoxia and, ultimately, a deleterious reversion to fetal
physiology.2
In utero, fetal nutrient and gas exchange is dependent on the
placenta, a temporary organ with remarkably low vascular resis-
tance, as well as the maternal circulation. As a result of its low
resistance, the placenta receives approximately 30% of total fetal
cardiac output between 18 and 41 weeks of gestation. In contrast,
fluid-filled fetal alveoli have increased vascular resistance, leading
to poor perfusion of the developing lung. The pulmonary arterial
bed is so vasoconstricted that the fetal lung receives only 40% of
right ventricular output and approximately 10% of total cardiac
output; most of the right ventricular output is shunted from the
pulmonary artery through the ductus arteriosus to the descending
aorta.4,5 An additional right to left shunting occurs at the level of
the foramen ovale, with relatively oxygen-rich blood shunted
from the right to left atrium. Reversal of these two shunts is
essential to the successful transition into extrauterine life and is
facilitated by the significant drop in pulmonary vascular resistance
that occurs at birth. The first step in this process is alveolar fluid
clearance.
Removal of this fluid is partially accomplished by vaginal
delivery, which provides some compression of the fluid out of the
alveoli into the bronchi, trachea, and pulmonary capillary bed.
The remaining fluid is largely evacuated by the first few breaths,
with the quality of the first few breaths crucial to establishing
adequate ventilation. Alveolar expansion requires the generation
of high intrathoracic pressures and the presence of surfactant to
maintain alveolar patency. Because the lung is one of the last
organs to reach structural and functional maturity, interruptions
2032
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in this coordinated physiologic process, although rare, should be
nonetheless anticipated in all deliveries, particularly those outside
of the delivery room.6
After the first few breaths, pulmonary vascular resistance
decreases as a result of alveolar oxygen exposure. Simultaneously,
clamping of the umbilical cord removes the placenta from circula-
tion, predictably increasing systemic vascular resistance. Shunt-
ing through the ductus arteriosus reverses as systemic vascular
resistance increases; this usually ceases altogether by 15 hours
of age as the ductus arteriosus also constricts. This reversal of
flow redirects all right ventricular output to the lungs. However,
hypoxia or acidosis can cause the pulmonary vascular bed to
constrict again and, when severe or prolonged, recurrent pul-
monary vascular constriction can cause the ductus arteriosus to
reopen. The reinstitution of fetal circulation, with its attendant
shunting, leads to ongoing hypoxia and is termed persistent
fetal circulation.2,5 When indicated, resuscitation facilitates the
first few breaths, prevents and reverses ongoing hypoxia and
acidosis, and assists the newborn in the transition to extrauterine
life.
INDICATIONS FOR RESUSCITATION
At least one person, whose exclusive role is to ensure safe transi-
tion of the newborn, should be present for all deliveries, including
those that occur outside the delivery room. Any infant born
outside of a delivery room should be anticipated to need
resuscitation.1-3 Although minimal intervention may be required,
a standardized approach should still be followed. Some specific
conditions increase the likelihood that additional resuscitative
efforts will be required.
Hypoxia
Even in the uncompromised newborn, it can take 10 minutes
for blood oxygen saturation to reach normal extrauterine levels.1
Pulse oximetry may assist in determining hypoxemia, but it may
take several minutes for a reliable waveform to be achieved.7,8 In
utero or intrapartum asphyxia (pathologic lack of oxygen to the
fetus before or during delivery) can precipitate a sequence of
events that results in primary or secondary apnea. With initial
hypoxia, rapid gasps are followed by cessation of respirations
(primary apnea) and, if prolonged, decreased heart rate (HR).
Ostensibly normal respiratory effort does not ensure adequate
ventilation. However, bradycardia in the newborn (HR < 100
beats/min) almost always reflects inadequate ventilation and oxy-
genation. As such, bradycardia is a major indicator of hypoxia.1,2
Simple stimulation is required at the onset of primary apnea to
stimulate ventilation and reverse bradycardia. If asphyxia persists,
the newborn takes several final deep, gasping breaths, followed by
cessation of respirations (secondary apnea); this is accompanied
by worsening bradycardia, refractory to simple stimulation, and
eventually hypotension. For newborns with secondary apnea,

more vigorous and prolonged resuscitation is needed to restore
ventilation and adequate circulation.2
Hypothermia
Drying and warming the newborn are vital to initial resuscita-
tion because the newborn’s inability to maintain normothermia
(>36.5° C [97.7° F]) has potentially dire consequences. Newborns
cannot generate heat by shivering, cannot retain heat due to low
fat stores, and have excess heat loss due to their large surface-
to-volume ratio. Exacerbating these challenges in the immediate
postpartum period, newborns have an acutely elevated metabolic
rate, are covered with amniotic fluid, and are suddenly exposed
to a relatively cool environment. Body temperature rapidly
decreases, with hypothermia accelerating metabolic acidosis,
oxygen consumption, hypoglycemia, and apnea.1-3 Prematurity
and very low-birth-weight status exacerbate these consequences
and require extra efforts to mitigate.1
Hypoglycemia
Poor glycogen stores, coupled with immature hepatic enzymes,
place the normal newborn at increased risk for hypoglycemia.
Hypoglycemia is particularly common in premature and small-
for-gestational-age newborns, as well as those born to diabetic
mothers. Hypoglycemia may also be a response to other factors,
including respiratory illness, hypothermia, polycythemia, asphyxia,
and sepsis. Hypoglycemia can be asymptomatic or may cause an
array of symptoms, including apnea, color changes, respiratory
distress, lethargy, jitteriness, seizures, acidosis, and poor myo-
cardial contractility.9,10 A low blood glucose level, particularly
when prolonged, recurrent, or associated with hyperinsulism, has
been associated with adverse neurologic outcomes9; correction
of hypoglycemia, if detected expeditiously, improves outcomes.11
Neonatal hypoglycemia is generally defined as a blood glucose
level less than 40 mg/dL, although this number serves as more
of a guideline than a strict cutoff. All newborns exhibiting signs
of hypoglycemia, with glucose levels less than 40 mg/dL, should
receive intravenous (IV) glucose. Of note, bedside glucometers
generally underestimate plasma glucose levels by approximately
10 mg/dL.10
Hypovolemia
Clinically significant hypovolemia is rare and usually secondary
to blood loss. Risk factors include known maternal hemorrhage
during delivery, prematurity, newborns with overt shock, and
initiation of CPR.1-3,12 Hemorrhage can lead to respiratory depres-
sion and overt shock in the newborn, whether secondary to
abruptio placentae, placenta previa, umbilical cord accident, or
trauma. In the newborn, hemorrhage is one of the few situations
in which fluid resuscitation and volume expansion improves
outcomes. The following formula should be equivalent to gesta-
tional age in weeks:
Newborn mean arterial pressure (diastolic pressure + [pulse pressure 3])
where pulse pressure = systolic pressure − diastolic pressure.
Examination findings consistent with hypovolemia or hemody-
namically significant hemorrhage include pallor, despite oxygen-
ation, weak pulses with a rapid HR, and poor response to
resuscitation.1-3,12
Prematurity
Premature infants, especially those born before 34 weeks of
gestational age, are uniquely at risk due to their pulmonary
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CHAPTER 164  Neonatal Resuscitation 2033
immaturity and susceptibility to hypothermia. Those requiring
delivery room cardiopulmonary resuscitation (CPR) have
increased risk of mortality, bronchopulmonary dysplasia, severe
brain injury, pneumothorax, and intestinal perforation.13 For
these reasons, in utero transfer of high-risk pregnant women to
tertiary centers possessing expertise and experience with prema-
ture infant resuscitation has been associated with improved neo-
natal outcomes.14 Intubation should be performed for the
premature newborn in respiratory distress, which is clinically
suggested by retractions, desaturation, or tachypnea.15 In certain
cases, surfactant may be delivered via an endotracheal tube (ETT)
shortly after birth.
Meconium-Stained Amniotic Fluid
Meconium-stained amniotic fluid (MSAF) indicates potentially
significant newborn stress prior to delivery. Aspiration of meco-
nium and its consequences can be avoided, or at least signifi-
cantly limited, by rapid intervention. Previous recommendations
stipulated suctioning meconium from the newborn’s airway after
delivery of the head but before delivery of the shoulders (intra-
partum suctioning). However, there appears to be no benefit from
intrapartum suctioning.16,17 Therefore, current recommendations
no longer advise routine intrapartum suctioning of newborns
with MSAF. To prevent aspiration of meconium, previous recom-
mendations also stipulated tracheal suctioning of all nonvigorous
newborn with MSAF immediately on delivery and before any
other resuscitative efforts (including drying and stimulation).
However, routine endotracheal intubation in nonvigorous and
vigorous term, meconium-stained newborns has shown no
benefit, including the incidence of meconium aspiration syn-
drome (MAS), pneumothorax, oxygen need, stridor, seizure, or
hypoxic ischemic encephalopathy.18 Standard measures to support
adequate ventilation and oxygenation should be initiated for all
infants born through MSAF, with a small subset eventually requir-
ing endotracheal intubation, as warranted.1
The most recent recommendations from the American Heart
Association have changed the practice of tracheal suctioning after
delivery for meconium aspiration. Indications for intubation
in newborns born through MSAF are the same as those for all
neonates; meconium aspiration should only be performed if indi-
cated for signs of airway obstruction secondary to meconium that
do not improve despite standard resuscitative measures, including
warming and drying and initiation of effective positive-pressure
ventilation (PPV). When performing tracheal suctioning, a meco-
nium aspirator (Fig. 164.1) should be attached to the appropriate-
sized ETT and connected to wall suction at 100 mm Hg or less.
On intubation by direct laryngoscopy, the ETT is then withdrawn
while suction is applied. Serial re-intubation with suctioning
should be repeated to remove obstructing meconium or until
the infant becomes vigorous, which is usually accomplished
after two rounds. If bradycardia or apnea persists beyond two
passes, ongoing resuscitation should include bag-mask ventilation
(BMV) and consideration of endotracheal intubation to secure
Fig. 164.1.  Meconium aspirator with suction and 3.0 uncuffed ETT
attached. (Courtesy Seattle Children’s Hospital, Seattle, WA.)
2034 PART V  Special Populations  |  SECTION One  The Pediatric Patient

the airway. In tertiary centers with skilled providers, lung lavage

with dilute surfactant may be beneficial, particularly if prolonged
intubation appears inevitable.19

Maternal Factors

Infection
Maternal infection (chorioamnionitis) is a particularly common
trigger for premature delivery; premature infants are themselves
more susceptible to infection. Therefore, IV antibiotics should be
administered after obtaining blood cultures and a complete blood
count should be carried out in all infants born before 37 weeks of
gestation.

Medications
Medications provided to the mother during labor or illicit drugs
taken before delivery, usually opioids, can augment newborn
respiratory depression. Maternal opioid administration or ante-
natal drug abuse should be considered in any newborn with iso-
lated respiratory depression that persists, despite a seemingly
successful initial resuscitation. As in adults, opioid-induced respi-
ratory depression could be reversed with naloxone.1,20 However,
naloxone may precipitate acute withdrawal and seizures in the
newborn of an opioid-dependent mother; thus, naloxone is not
recommended in the initial resuscitation of the newborn.3,21
Suspected opiate toxicity in the newborn should be treated with
support of oxygenation and ventilation rather than pharmaco-
logical reversal. This should include use of a bag-mask device and,
if necessary, intubation.
Withholding and Discontinuing Resuscitation
No reliable and widely adopted set of parameters has been identi-
fied for newborns who should not receive resuscitative efforts.23
Resuscitation is not currently recommended for neonates with
a confirmed gestational age less than 23 weeks, those with birth
weight less than 400 g, and those with confirmed anencephaly,
trisomy 13, or trisomy 18.23,24 Parental request has been shown
to be the most important factor determining resuscitative efforts
for newborns at 22 to 25 weeks of gestation; most neonatolo-
gists consider a gestational age more than 25 weeks of gestation
as the cutoff for obligatory resuscitation, even with parental
refusal.25 In the setting of uncertain gestational age and unclear
or conflicting parental wishes, the recommendation is to initiate
resuscitation. Similarly, if prognosis is uncertain at the time of
delivery, resuscitation should be attempted until additional data
can be obtained that can inform prognostication and align with
parental wishes. Outside the delivery room, every attempt should
be made to stabilize the neonate until further resuscitation would
clearly not improve the likelihood of survival with acceptable
morbidity. Neonates with no signs of life (asystole, apnea), after
10 minutes of resuscitation, have high mortality or severe lifelong
developmental delay, and resuscitation can be terminated.24,26
This is a rare and inherently challenging decision to make and
must account for availability of local resources and personnel
skill, transportation needs and options, and parental preference.
However, enhanced resuscitation techniques and postresuscitation
therapeutic hypothermia have recently shown promise, even for
neonates with a 10-minute APGAR score of zero,27 highlighting
the importance of dialogue with the parent(s) and acknowledg-
ment of their feelings regarding the risks of morbidity. Parents
should actively participate in the decision to continue or withdraw
resuscitative efforts in cases in which there is prognostic uncer-
tainty. For infants with a low 10-minute APGAR score but some
signs of life, especially when aligned with parental preference,
Fig. 164.2.  Chest radiograph reveals right-sided congenital diaphrag-
matic hernia. (Courtesy Seattle Children’s Hospital, Seattle, WA.)
resuscitation efforts should continue until further prognostication
can occur.
SPECIAL ANATOMIC ANOMALIES
Diaphragmatic Hernia
In addition to pulmonary hypoplasia, neonates with diaphrag-
matic hernias have exquisitely reactive pulmonary vascular beds,
predisposing them to potentially fatal pulmonary vasospasm in
the immediate and late postnatal period.28 Examination findings
concerning for congenital diaphragmatic hernia include barrel
chest, ipsilateral absence of breath sounds, tracheal or point of
maximum cardiac impulse displacement, and scaphoid abdomen.
Bag-mask ventilation will distend the stomach, which is usually
intrathoracic, further worsening respiratory distress. The neonate
should be emergently intubated if a prenatal diagnosis of dia-
phragmatic hernia is known or if a diaphragmatic hernia is
diagnosed on the chest radiograph (Fig. 164.2).
Myelomeningocele and Omphalocele
Infants with myelomeningocele should never be placed supine
but instead be placed prone or on the side to avoid pressure
on the defect. Resuscitation should proceed from this modified
position (Fig. 164.3). For unclear reasons, myelomeningocele is
associated with an elevated risk for latex allergy, necessitating
efforts to avoid latex sensitization in these neonates.29 The spinal
defect should be gently wrapped with sterile gauze pads soaked in
warm sterile saline and enclosed with plastic wrap.30 Infants with
gastroschisis or omphalocele should be resuscitated as needed,
and these defects should also be covered with an occlusive plastic
wrapping to decrease water and heat loss.31 These newborns often
require parenteral maintenance fluid infusion, orogastric tube
for gastric decompression, and antimicrobial prophylaxis with IV
antibiotics.31
Choanal Atresia
Because newborns are obligate nose breathers, bilateral choanal
atresia causes upper airway obstruction and often severe respira-
tory distress. Choanal atresia can be rapidly diagnosed by the

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Fig. 164.3.  Preoperative myelomeningocele, highlighting the obvious
anatomic challenges and sensitivities required in resuscitation of neonates
with this condition. (Courtesy Mandy Breedt, Division of Neurosurgery,
Seattle Children’s Hospital, Seattle, WA.)
inability to pass a catheter through either naris into the posterior
oropharynx. An oral airway device can bypass the obstruction.
Special attention should be paid to initial the physical examina-
tion of these children because these infants often have a multiple
congenital anomaly syndrome.
Pierre Robin Sequence
The hallmark of this abnormality is profound micrognathia,
resulting in glossoptosis (retraction or downward displacement of
the tongue) and cleft palate. Pierre Robin sequence, therefore,
confers a high risk for significant upper airway obstruction. A
nasal or oral airway should be able to bypass the obstruction; if
not, intubation may be necessary. Given the technical challenges
of performing endotracheal intubation on a patient with Pierre
Robin sequence, fiberoptic intubation is often needed, although
prone positioning and a laryngeal mask airway (LMA) or other
supraglottic airway device can be attempted to support ventila-
tion.32 Consultation with anesthesiology or otolaryngology may
be required.
Congenital Cardiac Disease
Echocardiographic evidence of congenital heart disease (CHD) is
as high as 5% for term newborns.33 However, critical CHD, defined
as requiring surgery or catheter-based intervention in the first year
of life, accounts for only up to 50% of CHD cases.33 Stereotypic
examination findings seen in critical CHD include a blood pres-
sure gradient between the upper and lower extremities, weak
femoral pulses, central cyanosis, pathologic murmur, and hepato-
megaly. These signs of cardiogenic shock in a newborn may be
fairly indistinguishable from those of severe sepsis and respiratory
failure. Resuscitation of a newborn with known or suspected
critical CHD should therefore include standard ventilatory man-
agement, as well as empiric antimicrobial therapy. Cardiomegaly
on a chest radiograph is more likely consistent with cardiogenic
shock.34 Some common laboratory findings include polycythemia
and unexplained acidosis. Many newborns with critical CHD have
a ductal-dependent lesion and are likely to experience profound
physiologic decompensation—defined by severe metabolic acido-
sis, seizure, cardiac arrest, or renal or hepatic injury—on closure
of the ductus arteriosus.35 Prostaglandin E1 (PGE1) should be used
in lesions with ductal-dependent systemic or pulmonary blood
flow (Box 164.1).36 In case of an uncertain diagnosis or in prepara-
tion for transport to a specialized facility, prostaglandin should be
started via continuous IV infusion. A second peripheral IV is
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CHAPTER 164  Neonatal Resuscitation 2035
BOX 164.1 
Ductal-Dependent Congenital Cardiac Lesions
DUCTAL-DEPENDENT PULMONARY BLOOD FLOW:
Critical pulmonary stenosis, atresia
Severe tricuspid stenosis, atresia
Severe tetralogy of Fallot
DUCTAL-DEPENDENT SYSTEMIC BLOOD FLOW:
Hypoplastic left heart syndrome
Critical aortic stenosis
Interrupted aortic arch
BOX 164.2 
Equipment Checklist for Neonatal Resuscitation
1. Gown, gloves, and eye protection (universal precautions)
2. Timing device
3. Blankets (to warm and dry infant)
4. Plastic wrap (for omphalocele, gastroschisis, possibly premature
infant)
5. Radiant warmer
6. Bulb syringe
7. Suction and suction catheters (sizes 5, 8, and 10 Fr)
8. Self-inflating (450 and 750 mL) and flow-inflating (250 and
450 mL) bags
9. Masks (premature, newborn, and infant sizes)
10. Laryngoscope with straight blades (nos. 00, 0, and 1)
11. Endotracheal tubes with stylets (2.5, 3.0, 3.5, and 4 mm),
uncuffed
12. Scissors and tape to stabilize endotracheal tube
13. Pediatric CO2 detector
14. Meconium aspirator
15. Umbilical catheters (3.5 and 5 Fr)
16. Hemostats, sterile drapes and gloves, povidone-iodine solution,
scalpel, umbilical tape, suture, and three-way stopcock for
umbilical vessel catheterization
recommended to treat the possible adverse effects of prostaglan-
din, including hypotension, tachycardia, and apnea. Continuous
PGE1 should begin soon after birth,36 with gradual dose titration
to a maximum of 0.1 µg/kg/min. For a more in depth discussion
on CHD, see Chapter 170.
PREPARATION
To maximize the effectiveness of resuscitation, all emergency
departments should have an age- and weight-appropriate pre-
stocked drug pack, standardized equipment (Box 164.2), and staff
trained on newborn resuscitation.1,3 The pediatric length-based
resuscitation tape (Broselow Luten tape) can be used to determine
equipment size and drug dosages for newborn resuscitation of
infants weighing 3 kg or more.37,38 A dedicated neonatal resuscita-
tion cart, organized according to the Neonatal Resuscitation
Program (NRP) algorithm, increases the speed of equipment
retrieval and is preferred by providers to other organizing
schemes.39 When available, additional maternal information (Box
164.3) can help anticipate resuscitation needs so that appropriate
staff, equipment and disposition plans can be expeditiously
managed.
Universal precautions, including gown, gloves, and eye protec-
tion, should be followed during neonatal resuscitations. An
2036 PART V  Special Populations  |  SECTION One  The Pediatric Patient

MANAGEMENT
As part of their shared NRP curriculum, the American Heart
Association and American Academy of Pediatrics, with the Inter-
national Liaison Committee On Resuscitation, have developed a
newborn resuscitation algorithm (Fig. 164.5). This stepwise
approach is detailed below.1-3 However, if a term neonate is crying
and appears to have good tone, she or he can be warmed, dried,
and returned to the mother for ongoing care and evaluation,
without any additional resuscitation efforts.1

Newborn Resuscitation Algorithm

Fig. 164.4.  Appropriate self-inflating resuscitator with appropriate
neonatal-sized mask attached. This device has additional functionality
with manometer and single-use positive end-expiratory pressure (PEEP)
valve attachments. (Courtesy Seattle Children’s Hospital, Seattle, WA.)
TABLE 164.1  futile. To prevent these and more subtle sequelae of hypothermia,
Endotracheal Tube Size by Birth Weight and
Gestational Age
ETT TUBE SIZE DEPTH OF
BIRTH GESTATIONAL (mm, INSERTION
WEIGHT (kg) AGE (wk) uncuffed) (cm)
<1 <28 2.5
1–2 28–34 3 8
2–3 34–38 3.5
3+ 38+ 3.5–4
ETT, Endotracheal tube.
Adapted from American Academy of Pediatrics; American Heart Association: neonatal
resuscitation textbook, ed 6, Elk Grove Village, IL, 2011, American Academy of
Pediatrics.
BOX 164.3 
Maternal History Questions
1. What is the estimated gestational age?
2. Is this a multiple gestation?
3. Is meconium present?
4. Is there a history of vaginal bleeding?
5. Were medications given or drugs taken?
6. Was there documented maternal fever?
7. Did mother have routine prenatal care? If so, were any
abnormalities seen on prenatal ultrasonography?
external heat source should be turned on early and the table
warmed prior to the start of resuscitation. Hypothermia is an
independent risk factor for neonatal mortality worldwide.40,41
Similarly, hyperthermia is an effect modifier of neonatal encepha-
lopathy and correlates with respiratory depression, cerebral palsy,
and mortality.42 Correct equipment size is essential; in particular,
respiratory supplies are most likely to be used and are key to most
resuscitative efforts. Appropriately sized self-inflating devices (Fig.
164.4) decrease complications from overventilation, prevent
injury, and limit the inability to ventilate due to improper mask
fit. When available, and in the hands of experienced providers,
flow-inflating devices have the added ability to deliver continuous
positive airway pressure (CPAP), control ventilation pressure with
greater precision, and ensure a proper fit. Table 164.1 lists the
recommended ETT sizes by birth weight and gestational age.
Dry, Warm, Position, Suction, Stimulate, and Assess Need for
Further Intervention
Hypothermia increases metabolic demand and oxygen consump-
tion, which can render seemingly effective resuscitation efforts
all newborns should be dried immediately on delivery and placed
under a radiant heat source. In the case of crying term infants
with normal tone, this may be accomplished by simple drying and
skin to skin contact with the mother.1 Wet blankets should be
replaced with dry blankets and preferably warm linens, but the
baby should be left uncovered to facilitate radiant warming and
team access, when required. All resuscitation techniques are
7 designed to be performed with these temperature-controlling
efforts in place.1 The supine neonate should be further positioned
to maximize air entry and avoid obstruction of airflow. Due to a
9 relatively large occiput and anterior glottic opening, airway
10 patency is best achieved with the neck in slight extension. A
slightly extended position that aligns the posterior pharynx,
larynx, and trachea is best accomplished by placing a rolled diaper
or small towel under the infant’s shoulders. Placement under the
neck is not useful. However, a towel that is too large and under
the shoulders can also lead to airway occlusion due to hyperexten-
sion of the neck.
Only if meconium is present and the newborn has poor tone,
poor respiratory effort, or bradycardia (HR < 100 beats/min) after
1 minute of appropriate PPV should the trachea be suctioned with
an ETT and meconium aspirator attachment. Poor respiratory
effort and obvious obstruction from secretions should otherwise
be treated with bulb or mechanical suction (≈100 mm Hg wall
suction). Upper airway suctioning, including that performed with
a bulb syringe, should be reserved only for newborns with these
signs because suctioning has been associated with decreased lung
compliance, bradycardia, and lowered cerebral blood flow veloc-
ity.1 In one randomized study comparing NRP-recommended
bulb suctioning versus mouth wiping, there were no differences
in mean respiratory rate, use of advanced resuscitation efforts,
APGAR scores, neonatal intensive care unit (NICU) admission,
and discharge oxygen saturation levels.42 When suction is indi-
cated, the NRP protocol should be followed, with the mouth
suctioned first, followed by the nose. This sequence helps avoid
aspiration of oral secretions if the neonate inspires after nasal
suctioning. Overly vigorous or deep suctioning should be avoided
because it can cause significant vagal stimulation and subsequent
bradycardia or apnea.2,43 Because NRP recommendations stipulate
suctioning with less than 100 mm Hg, emergency clinicians
should be judicious with syringe use because even standard
delivery bulb syringes produce a modest negative pressure, which
easily exceed this threshold.43
For most term neonates, these measures stimulate breathing
sufficiently and may be all that is required to resuscitate a newborn.
If adequate respirations are still not present, additional stimula-
tion should be given. This is best done by flicking the soles of the
feet and rubbing the back; more aggressive efforts could prove

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 CHAPTER 164  Neonatal Resuscitation 2037

Antenatal counseling,
team briefing, and equipment check

Birth

Infant stays with mother for routine

Term gestation? Yes care: warm and maintain normal
Good tone? temperature, position airway, clear
Breathing or crying? secretions if needed, dry.
Ongoing evaluation
No

Warm and maintain normal temperature,

1 minute

position airway, clear secretions if

needed, dry, stimulate.

Apnea or gasping? No Labored breathing or

HR below 100/min? persistent cyanosis?

Yes Yes

PPV Position and clear airway

SpO2 monitor SpO2 monitor
Consider ECG monitor Supplementary O2 as needed
Consider CPAP

No
HR below 100/min? Postresuscitation care
team debriefing
Yes

Check chest movement,

ventilation; corrective steps if needed
ETT or laryngeal mask if needed Targeted preductal SpO2
after birth
1 min 60%-65%
No
HR below 60/min? 2 min 65%-70%
Yes 3 min 70%-75%
Intubate if not already done 4 min 75%-80%
Chest compressions
Coordinate with PPV 5 min 80%-85%
100% O2 10 min 85%-95%
ECG monitor
Consider emergency UVC

HR below 60/min?

Yes

IV epinephrine
if HR persistently below 60/min
Consider hypovolemia
Consider pneumothorax © 2015 American Heart Association

Fig. 164.5.  Algorithm for neonatal resuscitation. ECG, Electrocardiogram; ETT, endotracheal tube; HR,
heart rate; PPV, positive-pressure ventilation; UVC, umbilical vein cannula. (Adapted from Wyckoff MH,
et al: Part 13: neonatal resuscitation: 2015 American Heart Association Guidelines Update for Cardiopul-
monary Resuscitation and Emergency Cardiovascular Care. Circulation 132:S543–S560, 2015.)

harmful. If stimulation and warming efforts prove inadequate,
PPV is required, followed by intubation, if necessary.
Time is an important component of NRP guidelines. Within
the first 60 seconds of life, the newborn should be assessed with
simultaneous warming, drying, and stimulation; if necessary,
upper airway clearance should be performed (see Fig. 164.5). If
the HR is below 100 beats/min, or if the newborn has primary
apnea or respiratory distress, PPV and pulse oximetry should be
initiated within the first minute of life. If bradycardia (HR < 60
beats/min) persists, despite adequate ventilation, chest compres-
sions should be initiated. HR calculation can be manual—by
palpation of the pulse at the base of the umbilical or auscultation

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2038 PART V  Special Populations  |  SECTION One  The Pediatric Patient
TABLE 164.2  BOX 164.4
a
APGAR Score
POINTS
SIGN 0 1 2
Heart rate Absent Slow (<100) ≥100
(beats/min)
Respirations Absent Slow, irregular Good, crying
Muscle tone Limp Some flexion Active, good
flexion
Reflex irritability No response Grimace Cough, sneeze
Color Blue, pale Pink body, Pink
blue hands
and feet
a
Calculate at 1, 5, and 10 minutes of life.
of cardiac sounds—with pulse oximetry, or with a standard
electrocardiographic lead.44 Persistent bradycardia is usually sec-
ondary to inadequate ventilation. Thus, intubation is recom-
mended in the event that chest compressions are indicated.
Routinely counted at 1, 5, and 10 minutes of life, the APGAR
score (Table 164.2) is a composite that reflects HR, respiratory
effort, muscle tone, reflex irritability, and color. The score is pri-
marily for assessing the need for (1 minute) and efficacy of (5
minute) ongoing resuscitative measures. In the setting of modern
algorithm-based resuscitation, low 5- and 10-minute APGAR
scores are associated with increased mortality because they iden-
tify infants who are failing medical management.44 Muscle tone
and reflex irritability do not significantly aid in the assessment of
the newborn during resuscitation.44,45 Instead, HR and respiratory
effort are the important indicators and should be continuously
monitored. Skin color is a poor indicator of oxyhemoglobin satu-
ration during the first several minutes of life while the transition
from fetal to infant circulation ensues.46-48 In this brief period,
pulse oximetry may be a useful tool to assess the oxygenation
status of the newborn.7,8,48 NRP guidelines specify pulse oximeter
use in only a few select situations—anticipated resuscitation,
prolonged PPV use, persistent cyanosis, and use of supplemental
oxygen.1
Ventilation, Oxygen, Intubation
Any neonate with persistent cyanosis or signs of respiratory
distress (eg, grunting, nasal flaring, tachypnea) should be assisted
by CPAP or PPV. For apnea, severe respiratory distress, or an HR
less than 100 beats/min, BMV (with a manometer, if available)
should be initiated. The first breaths often require higher pres-
sures (30–40 mm Hg) to remove lung fluid, with the adequacy
of ventilation assessed by chest rise. An initial sustained breath of
2 to 5 seconds may further increase functional residual capacity
(FRC) and promote clearance of lung fluid, but several clinical
trials have yet to prove the efficacy and safety of this technique.49-52
Subsequent breaths generally require 20 mm Hg of peak inspira-
tory pressure.1,2 To minimize barotrauma and the incidence of
pneumothorax, excessive pressures (defined as more than needed
to achieve adequate chest rise) should be avoided. An appropri-
ately sized mask with a tight seal (covering the mouth and nose,
but not the eyes), proper positioning of the newborn, and use
of pressure to attain correct chest wall movement are essential
for effective ventilation. Unless otherwise dictated by blood gas
levels, recommended ventilation rates are 40 to 60 breaths/min,
aimed at achieving a heart rate above 100 beat/min. Current NRP
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Intubation Corrective Action and Deterioration
Mnemonics
MR SOPA
M: Mask adjustment
R: Reposition airway
S: Suction mouth and nose
O: Open mouth
P: Pressure increase
A: Airway alternative
DOPE
D: Displacement of ETT
O: Obstruction of ETT
P: Pneumothorax
E: Equipment failure
guidelines recommend PPV, but do not delineate between CPAP
and PEEP (positive end-expiratory pressure). However, preterm
neonates (<33 weeks’ gestation) receiving single-inflation CPAP
(pressure-controlled inflation at 20 cm H2O for 10 seconds)
appear less likely to be intubated at 72 hours of age, receive
more than one dose of surfactant, or develop bronchopulmonary
dysplasia (BPD). When BMV is required for more than 2 minutes,
an orogastric tube should be placed to prevent respiratory com-
promise from gastric distention.2
Resuscitation with 100% oxygen is no longer recommended.53-56
There appears to be reduced mortality in infants resuscitated with
room air, with no obvious evidence of harm.56 Resuscitation-
induced hyperoxia results in increased oxidative stress, including
direct cardiac and renal injury.57 Neurologic outcomes appear
improved by resuscitation with room air versus 100% oxygen,
likely due to a reduction in cerebral free radical generation.1,3,5,56,58
Current NRP guidelines recommend initiating resuscitation with
room air and then blending to increasing oxygen concentrations,
as needed. Use of 100% oxygen for resuscitation should occur
only if the newborn has persistent bradycardia below 60 beats/
min bradycardia after 90 seconds. Attempts to restore adequate
ventilation are more beneficial than increasing the oxygen con-
centration. There has been a growing body of literature suggesting
that lower initial preductal oxygen saturation in healthy uncom-
plicated newborns may contribute to the appearance of cyanosis;
oxygen saturation after birth may not reach 90% or more until 10
minutes of life.46-48
Endotracheal intubation is indicated at several points during
neonatal resuscitation—tracheal suctioning for meconium in
infants with failure to improve, despite effective PPV; if BMV is
ineffective or prolonged; when chest compressions are performed;
and for extremely low-birth-weight infants or infants with ana-
tomic anomalies (eg, diaphragmatic hernia). Traditional direct
laryngoscopy and videolaryngoscopy are both reasonable options,
with video-assisted techniques consistently having improved
views but slightly longer total intubation times.59-61 Confirmation
of proper ETT placement should include detection of expired
carbon dioxide. Although ultrasonography can show appropriate
ETT positioning in term and preterm infants, the gold standard
remains plain radiography.62-66
If acute deterioration occurs shortly after intubation, equip-
ment must be immediately checked. Consider the DOPE and
MR SOPA mnemonics when trying to determine the cause of the
deterioration (Box 164.4). In the absence of an obvious explana-
tion, it is safest to extubate the newborn and promptly ventilate
with a BMV device by an experienced provider. Needle aspiration

TABLE 164.3 
Resuscitation Medications
MEDICATION CONCENTRATION DOSE
Epinephrine 1:10,000 0.01–0.03 mg/kg (0.1–
0.3 mL/kg)
Dopamine Varies Continuous infusion at 5 µg/
kg/min; increase to 20 µg/
kg/min as needed.
Glucose D10W 2–4 mL/kg
Volume expanders O-negative packed RBCs 10 mL/kg
Normal saline 10 mL/kg
Ringer’s lactate 10 mL/kg
Ampicillin Varies 100 mg/kg
Gentamicin Varies 4 mg/kg
Cefotaxime Varies 50 mg/kg
D10W, 10% dextrose in water; ETT, endotracheal tube; IM, intramuscular; IO, intraosseous; IV, intravenous; RBCs, red blood cells; SC, subcutaneous.
of the chest may be considered for treatment of a possible pneu-
mothorax, particularly if unequal breath sounds are appreciated
upon extubation, ventillatory pressures are inexplicably high, or
a neonate’s condition fails to improve with effective ventilation.
If ETT intubation is indicated but is technically challenging,
the LMA has been shown to be effective for ventilating full-term
newborns.67-69 However, there are limited data on LMA use in
preterm infants (<2000 g or <34 weeks’ gestation), in the setting
of MAS or during cardiopulmonary resuscitation (CPR).
Chest Compressions
Bradycardia (HR < 100 beats/min) is a reliable indicator of clini-
cally significant hypoxia. Fortunately, most neonates with brady-
cardia respond promptly to effective ventilation. If a neonate has
an HR less than 60 beats/min, despite oxygen and adequate ven-
tilation (good air movement and chest rise) for at least 30 seconds,
chest compression should be started.1,2,70 Compressions should be
performed at a rate of 90/min, coordinated with 30 breaths/min
for a total of 120 events/min. The preferred neonatal resuscitation
compression-to-ventilation ratio is 3:1. If the provider is certain
that the cardiac arrest has a primary cardiac cause, a compression-
to-ventilation ratio of 15 : 2 may be considered.1,3 The preferred
method for performing chest compressions, the two thumb-
encircling hands technique, is as follows: the fingers of both hands
encircle the chest and support the back, with the thumbs of both
hands placed side by side or one over the other on the sternum,
just below the nipple line. The depth of compression is one-third
the anteroposterior diameter of the chest.2,71,72 Spontaneous res-
pirations and HR should be assessed every 30 seconds, attempting
to minimize interruptions, when possible, with coordinated chest
compressions and ventilation continuing until the HR is at least
60 beats/min.1,2 A yellow color change on a colorimetric CO2
monitor during PPV administration often precedes a significant
rise in HR and should be used, when available.73
Medications
Few neonates require pharmacotherapy during resuscitation.12
Medications (Table 164.3) are primarily indicated for bradycardia
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CHAPTER 164  Neonatal Resuscitation 2039
ROUTE COMMENTS
IV (preferred) or ETT
IV
IV Avoid higher concentrations
IV Give over 5–10 min for acute
bleeding; repeat as needed
IV Give over 5–10 min; repeat as
needed
IV Give over 5–10 min; repeat as
needed
IV, IM
IV, IM
IV, IM
or asystole unresponsive to effective ventilation and chest com-
pressions, as well as hemorrhage (maternal, fetal, or placental)
that necessitates fluid resuscitation.1-3
Vascular Access
The umbilical vein is the preferred route of immediate vascular
access because it can be easily identified and cannulated. Umbili-
cal vein access can have serious complications (eg, infection,
portal vein thrombosis), so the umbilical vein cannula (UVC)
should be removed by the accepting neonatologist after the infant
has been stabilized and additional venous access has been obtained.
Other vascular access routes include peripheral veins, peripherally
inserted central catheters, and the femoral vein. Intraosseous (IO)
access can be problematic in neonates (especially premature
infants) because of bone fragility and the small size of the intraos-
seous space. However, in simulated resuscitation, placement of an
IO line has been shown to be almost 1 minute faster than a UVC,
even for skilled providers.74 Preferred IO access sites in newborns
include the proximal tibia (≈2 cm below the tuberosity and 1 cm
medially on the tibial plateau) and distal femur (midline; ≈1 cm
above the superior border of the patella, with the leg in extension).
If vascular access cannot be achieved, certain drugs including
epinephrine, can be given through the ETT, although this is not
the optimal route.
Types
Epinephrine.  Epinephrine is indicated for asystole and
persistent bradycardia less than 60 beats/min despite effective
ventilation with 100% oxygen and ongoing coordinated chest
compressions. Although it may be given by ETT, the preferred
epinephrine administration route is the IV route. The recom-
mended IV dose is 0.01 to 0.03 mg/kg, or 0.1 to 0.3 mL/kg, of a
1:10,000 solution. Unlike epinephrine use in adult patients,
weight-based dosing with no known minimum is required for
neonates. Repeat doses may be given every 3 to 5 minutes.1,2,75 If
administered via an ETT, higher doses (0.05–0.1 mg/kg) with a
1:10,000 solution are indicated, but the safety and efficacy of this
practice have not been rigorously evaluated.1,2,75,76 Unlike many
2040 PART V  Special Populations  |  SECTION One  The Pediatric Patient
adult resuscitations, sodium bicarbonate is not routinely used,77,78
although it may be beneficial in the NICU setting when ventila-
tion is known to be adequate.1,79
Volume Expanders.  When indicated, volume expansion is
accomplished with packed red blood cells (Rh-negative type O
blood), normal saline or Ringer’s Lactate solution given in IV
boluses of 10 mL/kg over 5 to 10 minutes. During resuscitation
of premature infants, rapid administration of volume expanders
should be avoided because this practice has been associated with
increased incidence of intraventricular hemorrhage.2 Higher
volume (eg, 20 mL/kg) fluid boluses are recommended for full-
term infants. Boluses may be repeated several times, as indicated
by the ongoing response to resuscitative efforts.
Antibiotics.  Antibiotics are not indicated in the initial resus-
citation phase, but may be required once the neonate has been
stabilized. When suspected, sepsis should be treated aggressively
with broad-spectrum antimicrobial therapy directed against the
most likely pathogens. The most common bacterial pathogens
implicated in early-onset neonatal sepsis are a heterogeneous
group that includes group B Streptococcus (GBS), Escherichia coli,
Klebsiella spp., Enterobacter spp., and Listeria. In the United States,
where GBS and E. coli represent the most common newborn
pathogens, a recommended empirical antibiotic regimen is ampi-
cillin (100 mg/kg IV) plus an aminoglycoside (usually gentamicin,
4 mg/kg).80 Reasonable alternative regimens include ampicillin
with a third-generation cephalosporin, but there is evidence that
several members of the latter group predispose a neonate to
invasive candidiasis. Because ceftriaxone can increase the risk of
kernicterus, cefotaxime (50 mg/kg IV) is preferred.80
Glucose.  Concomitant hypoglycemia should be considered
and promptly treated in a neonate requiring ongoing resuscita-
tion. Hypoglycemia is most easily diagnosed by rapid bedside
glucose testing or serum glucose level measurement. Neonates
with a glucose level less than 40 mg/dL and with symptoms of
hypoglycemia—irritability, tremors, jitteriness, apnea, tachypnea,
seizures, cyanosis, lethargy, poor feeding—require treatment with
IV glucose. Standard therapy is 2 mL of 10% dextrose in water
(D10W)/kg as well as starting a continuous infusion of D10W at 80
to 100 mL/kg/day.10 Higher concentrations of glucose (eg, 25%
dextrose in water, D25W) are hyperosmolar and should be avoided.
If the newborn can safely tolerate feeds, oral glucose solution,
maternal breast milk, or formula should be given by mouth (PO)
on demand. Repeat glucose measurement should be obtained 10
to 20 minutes after glucose administration. Asymptomatic neo-
nates with hypoglycemia should be encouraged to feed more often
and are treated with IV glucose only if glucose levels fall precipi-
tously (<25 mg/dL at birth to 4 hours of age or <35 mg/dL at 4–24
hours of age).10
Dopamine.  Dopamine is indicated only when signs of shock
(eg, poor peripheral perfusion, weak pulses) are still present,
despite adequate volume replacement. Given as a continuous
infusion beginning at 5 µg/kg/min, dopamine may be increased
to 20 µg/kg/min as necessary, before additional inotrope support
is indicated.
Therapeutic Hypothermia
When moderate to severe hypoxic-ischemic encephalopathy is
suspected, selective cerebral hypothermia in asphyxiated infants
may protect against brain injury.1,81-89 Therapeutic hypothermia of
33.5° to 34.5° C (92.3°–94.1° F) in this population can lower mor-
tality and improve the likelihood of normal neurologic outcome
at 18 months. Current NRP guidelines recommend therapeutic
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hypothermia for patients with suspected early neonatal asphyxia.
Symptoms of possible evolving brain injury include abnormal
levels of consciousness, seizures, hypotonia, and hyporeflexia.90
Established protocols generally recommended the initiation of
cooling within 6 hours of birth, for a total of 72 hours, followed
by gradual rewarming over at least 4 hours. Neonates meeting
eligibility criteria should be transferred to facilities capable of
providing this specialized care. Emergency clinicians and families
should be aware that the risks associated with therapeutic hypo-
thermia include thrombocytopenia and hypotension.81-88
DISPOSITION
Early consultation with a neonatologist can assist in the resuscita-
tion and postresuscitation phases of care. Once a neonate is sta-
bilized, the monitoring of oxygenation, ventilation, perfusion,
temperature, and glucose level continues. Neonates who require
extensive resuscitation (ie, obtaining venous access, medication
requirement, and/or endotracheal intubation) should be trans-
ported to an NICU by personnel skilled in neonatal resuscitation.
If feasible and safe, parents should be allowed to see, touch, and
hold the newborn before transport.
OUTCOMES
Safety
Advanced life support skills are critical for successful neonatal
resuscitation, yet are far from routine for most emergency clini-
cians. For example, in a cohort of almost 5000 births at a tertiary
level hospital, only 30 infants required intubation, 15 were given
chest compressions, and only 10 received epinephrine or volume
expanders.90 An important step toward improving outcomes is
team adherence to NRP guidelines. Highlighting the importance
of safety, an essential component of the new NRP curriculum is
the inclusion of simulation.91 Simulation in neonatal resuscitation
allows for a multidisciplinary team to practice behavioral and
teamwork skills, not only individual technical skills, in a safe
environment. Implementation of an integrated TeamSTEPPS
(Team Strategies and Tools to Enhance Performance and Patient
Safety) and NRP curriculum has been shown to result improved
outcomes in regard not only to communication, but also to incor-
rect medication dosing and inadequate chest compression depth.92
Furthermore, routine (and unannounced) simulation-based
neonatal resuscitation training has been shown to improve pro-
vider self-confidence in addition to knowledge and technical and
nontechnical skills.93
Effectiveness
In the hands of trained emergency clinicians, neonates requiring
advanced resuscitative efforts receive improved PPV, decreased
time to vascular access, and shortened time to first IV medica-
tion.94 Deliberate training of emergency medicine residents
has been shown to result in double their self-rated confidence
scores and improved ability to perform the key first steps of
resuscitation—dry, warm, position, stimulate.95 These dramatic
provider level improvements are seen worldwide with the imple-
mentation of guideline-based care. For patients, the results are
just as profound. For example, implementing neonatal resuscita-
tion practice protocols at county-level hospitals in China has
been shown to decrease birth asphyxia from 8.8% to 6.0% and
asphyxia-related deaths from 27.6 to 5.0/100,000.96 Early analyses
of the NRP program, which has now trained more than 5 million
providers in the United States alone, have suggested that fewer
high-risk infants experience a drop in APGAR score from 1 to
5 minutes, with many actually showing an improvement since

implementation.97 However, resuscitation is not without potential
pitfalls.
Complications
Relatively common complications post–neonatal resuscitation
include hypoglycemia, transient tachypnea of the newborn, MAS,
pneumothorax, hypermagnesemia, significant hyperbilirubine-
mia, and sepsis.97 These conditions are associated with increased
NICU admission rates, as well as morbidity and mortality.98
Additional risk factors in infants requiring prolonged PPV at
delivery that predict NICU stay for longer than 1 day include
placental abruption, assisted delivery, small for dates, gestational
age less than 37 weeks, low 5-minute APGAR score, and need for
intubation at birth.99
KEY CONCEPTS
• Resuscitation should be anticipated for all neonates born outside the
delivery room; 10% of newborns will require some resuscitation, and
1% will require advanced life support interventions after birth.
• Predictable indications for resuscitation include hypoxia, hypothermia,
hypoglycemia, hypovolemia, prematurity, maternal infection, and
adverse effects of maternal medication.
• Drying, warming, positioning, and stimulating the infant are sufficient
resuscitative measures for most deliveries.
• Adequate ventilation will reverse most bradycardia whereas, in
general, 100% oxygen is not indicated for most neonatal
resuscitations.
• The NRP resuscitation algorithm provides a proven guide for
management and its implementation has shown to improve
short- and long-term outcomes, including neurodevelopment.
• Routine tracheal suctioning of vigorous and nonvigorous infants born
through meconium-stained amniotic fluid is no longer recommended.
• Weight-based epinephrine and volume expanders are rarely required.
• Significant hypovolemia is rare in neonates. Hemorrhage is one of
the few predictable situations in which volume expansion improves
newborn outcome.
• Preterm infants and those born to mothers with suspected infection,
including chorioamnionitis, should receive empirical antibiotic
therapy. An acceptable regimen includes dual therapy with ampicillin
and gentamicin.
• Any neonate with persistent cyanosis or signs of respiratory distress
(eg, grunting, nasal flaring, tachypnea) should be assisted by CPAP
The references for this chapter can be found online by accessing the accompanying Expert Consult website.
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CHAPTER 164  Neonatal Resuscitation 2041
Further Considerations
The need for chest compressions and CPR is a known prognostic
marker for increased rates of morbidity and mortality in neonates.
Undergoing CPR at delivery increases the likelihood of pneumo-
thorax, grades 3 and 4 intraventricular hemorrhage, bronchopul-
monary dysplasia, and death by 12 hours and 120 days after
birth.100 Unfortunately, these complications have also been associ-
ated with long-term neurodevelopment impairment (NDI), with
less than 15% of infants with 5-minute APGAR scores lower than
2 surviving without NDI.100 The implementation of a local neo-
natal resuscitation protocol appears to improve neurodevelop-
ment outcome; follow-up data have suggested that the incidence
of electroencephalographic abnormalities, cerebral palsy, and
seizure disorders are all greatly reduced.101
or PPV. Endotracheal intubation should be performed in several
situations, such as when bag-mask ventilation is ineffective or
prolonged, chest compressions are performed, an extremely
low-birth-weight infant is born, and tracheal suctioning for
meconium in infants results in failure to improve, despite effective
PPV.
• Chest compressions are rarely required because bradycardia generally
responds to effective ventilation. However, compressions should be
started for an HR less than 60 beats/min, despite oxygen and
adequate ventilation for 30 seconds.
• The umbilical vein is the preferred route of immediate vascular
access, followed by peripheral veins, peripherally inserted central
catheter lines, and the femoral vein. IO line placement can be
problematic in neonates.
• No reliable and widely adopted set of parameters has been identified
for newborns who should not receive resuscitative efforts. Unless
there is clear family, parent, and/or health care provider agreement,
all resuscitation efforts should continue until further prognostication
can occur.
• Infants receiving appropriate resuscitation efforts nonetheless
showing no signs of life after 10 minutes may have further efforts
withheld, particularly when this decision is in accord with parental
preference.
• All newborns requiring IV placement, medication administration,
chest compressions or endotracheal intubation should be transferred
to an appropriate neonatal intensive care unit.

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CHAPTER 164  Neonatal Resuscitation 2041.e1
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2041.e2 PART V  Special Populations  |  SECTION One  The Pediatric Patient
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CHAPTER 164: QUESTIONS & ANSWERS
164.1. With most neonatal deliveries, which resuscitative
measures are usually sufficient?
A. Administer fluids.
B. Administer glucose.
C. Bag-mask ventilate.
D. Intubate.
E. Warm, dry, stimulate, and position.
Answer: E. Drying, warming, positioning, and stimulating the
infant are usually sufficient resuscitative measures in most
deliveries.
164.2. For a newborn with cyanosis, respiratory distress and a
heart rate more than 100 beats/min, which of the
following is not initially indicated?
A. Apply 100% oxygen.
B. Position airway.
C. Suction.
D. Ventilate with bag-mask with room air.
E. Warm, dry, and stimulate.
Answer: A. 100% oxygen is no longer indicated for initial resus-
citation; avoiding unnecessary supplemental oxygen is thought to
minimize free radical creation in the brain and decreases the
incidence of retinopathy of prematurity. Initial resuscitation with
room air is recommended.
164.3. In a typical neonatal resuscitation, what is the preferred
compression-to-ventilation ratio?
A. 3 : 1
B. 5 : 1
C. 10 : 2
D. 15 : 2
E. 30 : 2
Answer: A. Unlike pediatric or adult cardiopulmonary resuscita-
tion (CPR), neonatal CPR is performed at a ratio of three com-
pressions to one breath, with a goal of approximately 90
compressions with 30 synchronized breaths (120 “events”) per
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minute. If the cause of the bradycardia is known to be cardiac, a
ratio of 15 : 2 is acceptable.
164.4. A nonvigorous and crying newborn is delivered with
copious meconium-stained fluid. What is the correct
recommended resuscitative measure?
A. Bag-mask ventilate.
B. Intubate.
C. Intubate and suction.
D. Suction at maternal perineum before cutting
umbilical cord.
E. Gentle mouth suctioning if needed, followed by
warming, drying, and stimulation.
Answer: E. For infants born with meconium-stained amniotic
fluid, routine intubation and endotracheal tube suctioning are no
longer recommended because they have shown no consistent
benefit. Vigorous and nonvigorous infants born through even
thick meconium should instead have gentle mouth suctioning, if
needed, followed by warming, drying, and stimulation.
164.5. After drying, stimulating, and bag-mask ventilation, what
is the next step in resuscitation of a newborn that
appears floppy and apneic and with a heart rate of
50 beats/min?
A. Give a normal saline bolus of 20 mL/kg.
B. Give epinephrine (1:10,000) intravenous (IV) at a
dose of 0.1 mg/kg.
C. Intubate.
D. Start with a chest compression-to-ventilation ratio of
3:1.
E. Suction.
Answer: D. With a heart rate less than 60 beats/min in a neonate,
intubation may be considered, but compressions should be
started. If the low heart rate persists, IV epinephrine (1:10,000)
may be considered at a dose of 0.01 mg/kg.