Neonatal Resuscitation: Updated Guidelines from the American Heart Association
Am Fam Physician. 2021 Oct ;104(4):425-428.
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Key Points for Practice
• In newborns who do not require resuscitation, delaying cord clamping for more than 30 seconds reduces anemia, especially in preterm infants.
• No type of routine suctioning is helpful, even for nonvigorous newborns delivered through meconium-stained amniotic fluid.
• If resuscitation is required, heart rate should be monitored by electrocardiography as early as possible.
• Positive-pressure ventilation should be started in newborns who are gasping, apneic, or with a heart rate below 100 beats per minute by 60 seconds of life.
From the AFP Editors
Approximately 10% of infants require help to begin breathing at birth, and 1% need intensive resuscitation. The American Heart Association released minor updates to neonatal resuscitation recommendations with only minor changes to the previous algorithm (Figure 1).
Anticipation of Resuscitation
Every birth should be attended by one person who is assigned, trained, and equipped to initiate resuscitation and deliver positive pressure ventilation. Additional personnel are necessary if risk factors for complicated resuscitation are present. Equipment checklists, role assignments, and team briefings improve resuscitation performance and outcomes.
Care of the Well Newborn
Early skin-to-skin contact benefits healthy newborns who do not require resuscitation by promoting breastfeeding and temperature stability. Term newborns with good muscle tone who are breathing or crying should be brought to their mother's chest routinely. Routine suctioning, whether oral, nasal, oropharyngeal, or endotracheal, is not recommended because of a lack of benefit and risk of bradycardia.
Delaying cord clamping for more than 30 seconds is reasonable for term and preterm infants who do not require resuscitation. In term infants, delaying clamping increases hematocrit and iron levels without increasing rates of phototherapy for hyperbilirubinemia, neonatal intensive care, or mortality. In preterm infants, delaying clamping reduces the need for vasopressors or transfusions. Cord milking in preterm infants should be avoided because of increased risk of intraventricular hemorrhage.
Initial Resuscitative Actions
Preterm and term newborns without good muscle tone or without breathing and crying should be brought to the radiant warmer for resuscitation. Newborn temperature should be maintained between 97.7°F and 99.5°F (36.5°C and 37.5°C), because mortality and morbidity increase with hypothermia, especially in preterm and low birth weight infants.
According to the recommendations, suctioning is only necessary if the airway appears obstructed by fluid. For nonvigorous newborns with meconium-stained fluid, endotracheal suctioning is indicated only if obstruction limits positive pressure ventilation, because suctioning does not improve outcomes.
Tactile stimulation is reasonable in newborns with ineffective respiratory effort, but should be limited to drying the infant and rubbing the back and the soles of the feet.
Heart rate assessment is best performed by auscultation. If resuscitation is required, electrocardiography should be used, especially with chest compressions. Electrocardiography detects the heart rate faster and more accurately than a pulse oximeter.
Ventilation and Oxygen Support
Positive pressure ventilation should be delivered without delay to infants who are apneic, gasping, or have a heart rate below 100 beats per minute within the first 60 seconds of life despite initial resuscitation. For every 30 seconds that ventilation is delayed, the risk of prolonged admission or death increases by 16%. Positive pressure ventilation should be provided at 40 to 60 inflations per minute with peak inflation pressures up to 30 cm of water in term newborns and 20 to 25 cm of water in preterm infants. Positive end-expiratory pressure of up to 5 cm of water may be used to maintain lung volumes based on low-quality evidence of reduced mortality in preterm infants.
For newborns who are breathing, continuous positive airway pressure can help with labored breathing or persistent cyanosis. In preterm infants younger
Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.
This series is coordinated by Michael J. Arnold, MD, contributing editor.
A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide.
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