What are the latest guidelines for Neonatal Resuscitation Program (NRP) for newborns, including term and preterm infants?

Latest NRP Guidelines for Neonatal Resuscitation

The 2023 American Heart Association/American Academy of Pediatrics focused update represents the most current NRP guidelines, with key changes including preferential use of T-piece resuscitators over self-inflating bags, supraglottic airways as a primary interface option for infants ≥34 weeks, and refined umbilical cord management strategies based on gestational age. 1

Umbilical Cord Management (2023 Update)

For term and late preterm infants ≥34 weeks who do not require resuscitation:

• Delay cord clamping for ≥30 seconds (beneficial for hemodynamic stability and reduced transfusion needs) 1
• Intact cord milking is NOT recommended over delayed cord clamping in this population 1

For nonvigorous term/late preterm infants (35-42 weeks):

• Intact cord milking may be reasonable compared with early cord clamping (<30 seconds) 1

For preterm infants <34 weeks not requiring resuscitation:

• Delayed cord clamping ≥30 seconds is beneficial 1
• For infants 28-34 weeks when delayed clamping cannot be performed, intact cord milking may be reasonable 1
• For extremely preterm infants <28 weeks, intact cord milking is NOT recommended 1

Positive Pressure Ventilation Device Selection (2023 Update)

T-piece resuscitators are now preferred over self-inflating bags for delivering PPV. 1 This represents a significant shift from the 2015 guidelines that considered all three devices (flow-inflating bag, self-inflating bag, T-piece) equally effective. 1

Critical backup requirement: Because T-piece resuscitators and flow-inflating bags require compressed gas, a self-inflating bag must be available as backup in case of gas source failure. 1

Airway Interface Options (2023 Update)

Supraglottic airways (laryngeal masks) may now be considered as the PRIMARY interface for PPV instead of face masks for infants ≥34 weeks gestation. 1 This is a major advancement from 2015 guidelines that positioned laryngeal masks only as alternatives when face-mask ventilation failed or intubation was unsuccessful. 1

The 2015 guidelines restricted laryngeal mask use to term and preterm infants ≥34 weeks when intubation was unsuccessful or not feasible, with limited data for infants <34 weeks or <2000g. 1

Initial Oxygen Concentration

For term and late preterm infants ≥35 weeks:

• Initiate resuscitation with 21% oxygen (room air) 1, 2
• 100% oxygen should NOT be used to initiate resuscitation due to associated excess mortality (Class 3: Harm recommendation) 2
• Titrate oxygen based on pulse oximetry targeting preductal saturations (60-65% at 1 minute, gradually reaching 85-95% by 10 minutes) 1

For preterm infants <35 weeks:

• Initiate with low oxygen (21-30%) 1
• Titrate to achieve preductal oxygen saturation approximating healthy term infants 1
• Starting with high oxygen (≥65%) is NOT recommended 1

Ventilation Parameters

When PPV is administered to preterm newborns:

• Apply approximately 5 cm H₂O PEEP 1
• Use ventilation rate of 40-60 breaths per minute 3
• Initial pressure of 20 cm H₂O (though 30-40 cm H₂O may be necessary in some term infants) 3

Sustained inflations >5 seconds duration: There is insufficient data to support routine application in transitioning newborns. 1

Chest Compressions

Technique and ratio:

• Use 2-thumb encircling hands technique (preferred method generating higher blood pressures and coronary perfusion pressure with less rescuer fatigue) 1
• Compress lower third of sternum to depth of approximately one-third anterior-posterior diameter 1
• Maintain 3:1 compression-to-ventilation ratio (90 compressions and 30 breaths achieving ~120 events/minute) 1
• Consider higher ratios (e.g., 15:2) if arrest is believed to be of cardiac origin 1

Oxygen during compressions:

• Increase oxygen concentration to 100% whenever chest compressions are provided 1
• Wean supplementary oxygen as soon as heart rate recovers to reduce hyperoxia complications 1

Heart Rate Assessment

3-lead ECG may be reasonable for rapid and accurate heart rate measurement during resuscitation (Class IIb recommendation), as it provides faster detection than auscultation or pulse oximetry. 1 This was introduced as a late-breaking recommendation in 2015 after being identified as a major knowledge gap. 1

Meconium-Stained Amniotic Fluid

Routine intubation for tracheal suction is NOT recommended for nonvigorous infants born through meconium-stained amniotic fluid. 1 Instead, complete initial resuscitation steps under the radiant warmer and initiate PPV if the infant is not breathing or heart rate is <100/min. 1

Temperature Management

For preterm infants:

• Maintain temperature between 36.5-37.5°C 3
• Use plastic wrapping up to neck level (without drying first) for infants <28 weeks 1
• Preheat delivery room 3
• Avoid hyperthermia (>38.0°C) due to potential associated risks 3

For term infants in resource-limited settings:

• May use clean food-grade plastic bag up to neck level after drying 1
• Skin-to-skin contact or kangaroo mother care is another reasonable option 1

Critical Timing Algorithm

The "Golden Minute" approach:

• Complete initial steps within approximately 60 seconds from birth 1, 4
• If apnea persists, initiate PPV within 60 seconds 1
• Reassess heart rate after 30 seconds of adequate ventilation 3, 4
• Do NOT start chest compressions until after 30 seconds of adequate ventilation with visible chest rise 3

Common pitfall: The 30-second time point for initial assessment was removed from the 2015 algorithm to avoid unreasonable pressure, but the 60-second initiation of PPV remains critical to prevent delays. 1