Neonatal Resuscitation

Neonatal Resuscitation Algorithm

Algorithm adapted from the 2025 AHA/AAP Neonatal Resuscitation Guideline.

Escalation Pathway

Neonatal resuscitation follows a stepwise escalation chain. Move to the next step only when the current intervention fails to raise the heart rate above 100 bpm AHA/AAP 2025.

Warm, dry, stimulate, position airway — initial steps for all newborns who do not cry or breathe after birth PMID 41122887.
Positive-pressure ventilation (PPV) — if HR < 100 bpm or ineffective breathing after initial steps. Use room air (21% O₂) initially in term infants; titrate oxygen to achieve preductal SpO₂ within target ranges PMID 41122887.
Intubation or laryngeal mask — if PPV ineffective, chest not moving, or prolonged ventilation needed PMID 41122887.
Chest compressions — if HR < 60 bpm despite adequate ventilation with 100% O₂ and endotracheal intubation. Use 3:1 compression:ventilation ratio (90 compressions and 30 ventilations per minute) PMID 41122887.
Epinephrine — indicated only after adequate ventilation and at least 30 seconds of coordinated chest compressions fail to raise HR above 60 bpm PMID 41122887.
Volume expansion — consider for suspected hypovolemia (pallor, weak pulses, poor perfusion, history of blood loss). Give 10 mL/kg normal saline IV/IO over 5 to 10 minutes; may repeat once PMID 41122887.

If resuscitation is not progressing despite the above steps, consider AHA/AAP 2025:

Pneumothorax (transilluminate, needle decompression)
Congenital airway anomaly (difficult intubation, failed ventilation) AHA/AAP 2025
Congenital heart disease (cyanosis disproportionate to respiratory effort, poor perfusion despite volume)
Severe anemia or hydrops (consider O-negative blood instead of saline for volume)

Code Medications

Drug	Dose	Notes
Epinephrine IV or IO	0.01 to 0.03 mg/kg (initial 0.02 mg/kg) PMID 33712718	Repeat every 3 to 5 min until HR > 60; give only after adequate ventilation and chest compressions
Epinephrine ETT	0.05 to 0.1 mg/kg (initial 0.1 mg/kg) PMID 33712718	IV or IO route preferred when available; use ETT route only if no vascular access
Normal Saline	10 mL/kg PMID 41122887	For suspected hypovolemia; give over 5 to 10 min; may repeat once

Endotracheal Equipment

Gestation	ETT Size	ETT Insertion (cm)
23 to 24w	2.5	5.5
25 to 26w	2.5	6.0
27 to 29w	2.5 to 3.0	6.5
30 to 32w	3.0	7.0
33 to 34w	3.0	7.5
35 to 37w	3.5	8.0
38 to 40w	3.5	8.5
41 to 43w	3.5 to 4.0	9.0

NRP 8th Edition sizing. Weight-based estimate: insertion depth (cm) ≈ 6 + weight (kg). PMID 41122887

Emergency Medications

Drug	Dose	Notes
D10W	1 to 2 mL/kg IV for glucose < 20 mg/dL or symptomatic hypoglycemia PMID 21357346	Recheck glucose q15 min; can use D10 ¼NS if > 1500 g
PGE₁ / Alprostadil	Initial 0.01 to 0.05 mcg/kg/min IV; titrate to effect PMID 40931686	For ductal-dependent congenital heart disease; monitor for apnea, hypotension, and fever (dose-dependent adverse effects)