Ideal Gap Between Adrenaline Injections in Neonatal Resuscitation
Administer epinephrine every 3 to 5 minutes during neonatal resuscitation if the heart rate remains below 60 beats per minute despite adequate ventilation and chest compressions. 1
Standard Dosing Interval
The 2020 International Consensus on Neonatal Life Support recommends repeating epinephrine doses every 3 to 5 minutes when the heart rate fails to increase to 60/min or greater, preferably via the intravascular route. 1
This interval applies to neonates of any gestational age less than 28 days old who have no detected cardiac output, asystole, or heart rate less than 60/min despite optimized ventilation and chest compressions. 1
Evidence Supporting the 3-5 Minute Interval
No direct evidence exists comparing different dosing intervals in neonates, as the systematic review identified no eligible studies evaluating this specific question. 1
The recommendation is extrapolated from pediatric data showing that dosing intervals less than 3 minutes may be harmful—pediatric patients receiving epinephrine more frequently than every 3 minutes had lower 12-month survival compared to those receiving doses every 3-5 minutes. 2
The 2020 guidelines acknowledge that confidence in optimal interval timing is too low to make specific recommendations, but the 3-5 minute interval represents the standard comparator based on consensus and extrapolation from older populations. 1, 2
Critical Timing Considerations
The timing of the first dose matters more than subsequent dosing intervals—early administration of the initial epinephrine dose is strongly associated with improved outcomes in neonatal resuscitation. 2
Prepare epinephrine doses in advance so administration can occur promptly without interrupting chest compressions, as minimizing interruptions to compressions is more important than precise timing of drug delivery. 2
Route-Specific Guidance for Repeat Dosing
If the initial endotracheal dose (0.05-0.1 mg/kg) produces an inadequate response, administer an intravascular dose (0.01-0.03 mg/kg) as soon as vascular access is obtained, regardless of the interval after the endotracheal dose. 1
This exception to the 3-5 minute rule exists because endotracheal administration results in unpredictable absorption and lower plasma concentrations compared to intravenous delivery. 1, 3, 4
Common Pitfalls to Avoid
Do not administer epinephrine more frequently than every 3 minutes in an attempt to accelerate response—very frequent dosing may worsen outcomes based on pediatric data. 2
Do not delay subsequent doses beyond 5 minutes if the heart rate remains below 60/min, as prolonged intervals may delay beneficial vasoconstrictive effects needed for return of spontaneous circulation. 1
Do not use high-dose epinephrine (≥0.03 mg/kg intravenously) for repeat doses, as doses at or above this threshold are associated with negative hemodynamic effects and do not improve long-term survival. 5
Practical Implementation
Continue chest compressions and ventilation throughout the 3-5 minute intervals between epinephrine doses, as these interventions remain the foundation of neonatal resuscitation. 1
Reassess heart rate after each dose to determine if additional epinephrine is needed—the goal is achieving a heart rate of 60/min or greater. 1
The evidence base for this recommendation is very low certainty, derived from only 2 observational studies with 97 neonates and extrapolation from pediatric populations, but represents the best available guidance. 1