Written by Vivian Lei
Spoon Feed
The updated AHA and AAP guidelines on neonatal life support provide the most current, evidence-based recommendations for recognizing and managing newborns who require resuscitation, a time-critical responsibility that has a major impact on survival and neurodevelopmental outcomes.
Key updates of neonatal care
Here is a summary of the updated, evidence-based recommendations for neonatal resuscitation that optimize the transition from fetal to neonatal life and improve short- and long-term outcomes. These clinical updates are integrated within a systems-based framework emphasizing preparation, team performance, and continuity of care from birth through post-resuscitation recovery.
1. Cord Management
- Deferred cord clamping for at least 60 sec is recommended for term and preterm infants who do not require immediate resuscitation.
- Intact cord milking may be reasonable for infants ≥28 to 36+6 weeks when delayed clamping is not possible, but should not be performed in infants <28 weeks due to increased risk of severe IVH.
2. Initial Steps & Thermoregulation
- Stronger emphasis on skin-to-skin placement for vigorous term infants and rigorous temperature monitoring to avoid both hypo- and hyperthermia.
- Airway suctioning is no longer routine and should be reserved only for visible obstruction.
3. Ventilation & Airway Management
- Effective ventilation remains the single most important intervention for a newborn infant that does not breathe spontaneously or has a persistent heart rate below 100/min despite initial efforts. Heart rate increase is a primary feedback marker.
- Ventilate at a rate of 30-60 inflations per minute. Troubleshoot mask leak/obstruction early with airway repositioning, mask adjustment, 2-handed mask hold, suctioning, increasing peak inflation pressure, or placement of an alternative airway.
- Laryngeal mask airway may be used earlier as a primary alternative to endotracheal intubation in infants ≥34 weeks.
- CPAP is recommended for spontaneously breathing preterm infants with respiratory distress.
4. Oxygen Therapy
- Initiate with 21% O₂ for term and late preterm infants (>35 weeks); 21–30% for preterm infants (32 to 34+6 weeks); 30–100% may be needed for very preterm infants (<32 weeks) to reach updated target oxygen saturations.
5. Advanced Resuscitation
- Chest compressions begin if HR <60/min after adequate ventilation with an advanced airway. Use a compression to ventilation ratio of 3:1 and 2-thumb encircling hands technique.
- IO access is acceptable if umbilical venous catheterization is not feasible.
- Epinephrine is indicated if HR <60/min after compressions with effective ventilation, preferably via IV/UV access. Endotracheal dosing only while securing access.
- Consider volume expansion with normal saline or blood in infants with hypovolemia and HR<60/min despite ventilation, chest compressions, and epinephrine.
6. Discontinuation of Efforts
- If no detectable heart rate persists after 20 minutes of high-quality resuscitation, redirection of care may be considered.
7. Training & Human Performance
- Structured simulation, spaced training, and team-based performance are emphasized as methods to maintain readiness and reduce errors.
How will this change my practice?
Although neonatal resuscitation is rare in the emergency department, it carries significant clinical risk. Recent updates to the neonatal resuscitation algorithm emphasize effective ventilation and delayed cord clamping, and also expand guidance on intraosseous access and early supraglottic airway use. These recommendations will influence how I approach neonatal airway strategies, oxygen titration, IO access, and team readiness during emergent deliveries.
Source
Part 5: Neonatal Resuscitation: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025 Oct 21;152(16_suppl_2):S385-S423. doi: 10.1161/CIR.0000000000001367. Epub 2025 Oct 22. PMID: 41122887.
