Key learning point: The first step in neonatal resuscitation is to provide the neonate with warmth.

Very-low-birth-weight (VLBW) infants are at increased risk for hypothermia because of an increased surface-to-body-mass ratio and minimal subcutaneous adipose tissue. Hypothermia has been linked to increased mortality in VLBW infants and in infants born at less than 26 weeks’ estimated gestational age. Suggested means of minimizing heat loss at birth include warming the delivery room, removing wet blankets, and using warmed air, a polyethylene wrap, and a warming mattress.

![bpm: beats per minute; PPV: positive pressure ventilation; CPAP: continuous positive airway pressure; HR: heart rate; ETT: endotracheal tube; GA: gestational age.

• If there is no labored breathing or persistent cyanosis, the neonate stays with the mother for ongoing evaluation. Refer to UpToDate's topics on initial management of newborn infants for additional details.](https://prod-files-secure.s3.us-west-2.amazonaws.com/00d604f5-5c4e-4bfa-b48e-30413b075be1/e9926e57-0550-46b7-847e-d3d61b226c3b/image.png)

bpm: beats per minute; PPV: positive pressure ventilation; CPAP: continuous positive airway pressure; HR: heart rate; ETT: endotracheal tube; GA: gestational age.

• If there is no labored breathing or persistent cyanosis, the neonate stays with the mother for ongoing evaluation. Refer to UpToDate's topics on initial management of newborn infants for additional details.

NICU NRP

• Term, note, breathing or crying
  • None = keep with mama
  • Any issue = go to NICU team
    • For KFSH, only go to NICU station
  • Steps (Nurse and RT)
    • Warm
    • Dry
    • Stimulate
    • Suction
  • Steps (Physician)
    • Physician listen to HR; need stethoscope, stay prepared
    • If HR>100, no breathing issue = continue warming, drying, stimulating and suctioning
    • If HR <100, gasping, apneic = start PPV (done by RT)
      • Observe if HR is rising
      • If not rising, assess quality of PPV (done by RT)
    • Monitor pre-ductal O2 saturation [table]
      • If not meeting stats, showing signs of respiratory distress [retractions, grunting, nasal flaring] = CPAP + call fellow
        • If >20 mins CPAP, will require NICU admission
      • At birth examination:
        • Patent airway
        • Nose, mouth
          • Cleft lip or palate
          • Choanal atresia
        • Head – skull trauma
        • Delivery trauma
        • Anal patency
        • Limbs
        • Back

Neonatal Resuscitation Program (NRP) – Concise and Comprehensive Guide for On-Call Pediatric Residents in the NICU

1. Initial Rapid Assessment (Within 30 Seconds of Birth)

   • Evaluate:
   • Gestational age
   • Tone (limp vs. active)
   • Breathing/crying
   • Decision:
   • If term, good tone, and breathing/crying → Routine care (dry, warm, clear airway, ongoing evaluation)
   • If ANY abnormality → Move to resuscitation steps.

2. First Steps of Resuscitation (Golden Minute)

   • Warmth: Place under radiant warmer.
   • Position & Airway: Sniffing position, clear secretions if needed (mouth first, then nose).
   • Dry and Stimulate: Towel dry, rub back, flick feet if needed.

   If no response → Proceed to positive pressure ventilation (PPV).

3. Positive Pressure Ventilation (PPV) – Most Crucial Step

   • Indication: Apnea, gasping, or HR < 100 bpm.
   • Technique:
   • Use a T-piece resuscitator, self-inflating, or flow-inflating bag.
   • Rate: 40–60 breaths/min.
   • Pressure: PIP 20–25 cmH₂O (higher in severe cases), PEEP 5 cmH₂O.
   • Check effectiveness: Chest rise + HR improvement.
   • If no improvement after 30 seconds → Check mask seal, reposition, suction, increase pressure.
   • If still ineffective → Consider intubation.

4. Chest Compressions (If HR < 60 bpm Despite Effective PPV)

   • Depth: 1/3 of AP chest diameter.
   • Ratio: 3:1 (compressions to ventilation).
   • Rate: 120 events per minute (90 compressions + 30 ventilations).
   • Technique: Two-thumb encircling method preferred.

   If HR remains < 60 bpm after 60 seconds → Administer epinephrine.

5. Medications & Advanced Management

   • Epinephrine (if HR < 60 bpm despite effective ventilation & compressions)
   • Dose: 0.01–0.03 mg/kg IV (preferred) or 0.05–0.1 mg/kg via ETT.
   • Repeat every 3–5 min if needed.
   • Volume Expansion (if blood loss suspected)
   • 10 mL/kg NS or LR IV over 5–10 min.
   • Correct Hypoglycemia: If glucose < 40 mg/dL → D10W 2 mL/kg IV.

Common Clinical Scenarios

Scenario 1: Term Newborn, Poor Tone, Apneic

• Action: Warm, dry, position, clear airway, stimulate.
• No improvement → PPV.

Scenario 2: Preterm (28 Weeks), Gasping, HR 80