Category: Pediatrics
Keywords: Neonate, Newborn, resuscitation, NRP (PubMed Search)
Posted: 11/3/2023 by Kelsey Johnson, DO
(Updated: 4/27/2024)
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Term? Tone? Tantrum?
Immediately after delivery, your initial neonatal assessment should evaluate for:
- Appearance of full or late pre-term gestation (>34 weeks)
- Appropriate tone (flexed extremities, not floppy)
- Good cry and respiratory effort
Newborns meeting this criteria should not require resuscitation. They can be placed skin to skin on mother and allowed to breastfeed. Delayed cord clamping for 60 seconds is recommended, as data shows improved neurodevelopmental outcomes and iron stores in first year of life.
Neonates not meeting these criteria should be brought to the warmer for resuscitation, with the focus being on:
- Warm - via radiant warmer. Maintain temps 36.5 C – 37.5 C
- Dry - Neonates have thin skin and lose heat readily from evaporative loses
- Stim - tactile stimulation on the head, midline of the back and extremities to provoke a cry and encourage respiratory effort
Avoid routinely bulb-suctioning unless there is significant obstructing mucous, as this can increase vagal tone and result in bradycardia. If bulb suctioning is used, first suction the mouth before the nose.
Majority of resuscitations do not require additional support, however if heart rate is <100 or there is poor respiratory effort, the physician should initiate PPV.
PPV settings: PIP 20 PEEP 5 FiO2 21% Rate of 60 breaths per minute
Improvement in the neonate’s HR is the primary indicator of effective PPV!
If HR poorly responding (remains <100), ensure appropriate mask size, reposition, suction, and increase PIP (max 35) and FiO2.
If HR drops below 60, intubate with uncuffed ETT
- Prioritize adequate ventilation as this is the highest priority in neonatal resuscitation
- Initiate compressions at rate of 120/min.
- Epi dosing is 0.01-0.03 mg/kg q3-5 min
- ETT size estimation by gestational age:
25 weeks = 2.5, 30 weeks = 3.0, 35 weeks = 3.5, 40 weeks = 4.0
