Special Report—Neonatal Resuscitation:

2010 American Heart Association Guidelines for

Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care
The following guidelines are an interpretation of the evidence present- John Kattwinkel, Co-Chair*, Jeffrey M. Perlman, Co-Chair*,
ed in the 2010 International Consensus on Cardiopulmonary Resusci- Khalid Aziz, Christopher Colby, Karen Fairchild, John
Gallagher, Mary Fran Hazinski, Louis P. Halamek, Praveen
tation and Emergency Cardiovascular Care Science With Treatment Kumar, George Little, Jane E. McGowan, Barbara
Recommendations1). They apply primarily to newly born infants under- Nightengale, Mildred M. Ramirez, Steven Ringer, Wendy
going transition from intrauterine to extrauterine life, but the recom- M. Simon, Gary M. Weiner, Myra Wyckoff,
mendations are also applicable to neonates who have completed peri- Jeanette Zaichkin
natal transition and require resuscitation during the first few weeks to KEY WORDS
cardiopulmonary resuscitation
months following birth. Practitioners who resuscitate infants at birth
The American Heart Association requests that this document be
or at any time during the initial hospital admission should consider cited as follows: Kattwinkel J, Perlman JM, Aziz K, Colby C,
following these guidelines. For the purposes of these guidelines, the Fairchild K, Gallagher J, Hazinski MF, Halamek LP, Kumar P, Little
terms newborn and neonate are intended to apply to any infant during G, McGowan JE, Nightengale B, Ramirez MM, Ringer S, Simon
WM, Weiner GM, Wyckoff M, Zaichkin J. Part 15: neonatal
the initial hospitalization. The term newly born is intended to apply resuscitation: 2010 American Heart Association Guidelines for
specifically to an infant at the time of birth. Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care. Circulation. 2010;122:S909 –S919.
Approximately 10% of newborns require some assistance to begin
*Co-chairs and equal first co-authors.
breathing at birth. Less than 1% require extensive resuscitative mea-
(Circulation. 2010;122:S909 –S919.)
sures.2,3 Although the vast majority of newly born infants do not require
© 2010 American Heart Association, Inc.
intervention to make the transition from intrauterine to extrauterine
Circulation is available at http://circ.ahajournals.org.
life, because of the large total number of births, a sizable number will
doi:10.1542/peds.2010-2972E
require some degree of resuscitation.
Those newly born infants who do not require resuscitation can gener-
ally be identified by a rapid assessment of the following 3
characteristics:
● Term gestation?
● Crying or breathing?
● Good muscle tone?
If the answer to all 3 of these questions is “yes,” the baby does not need
resuscitation and should not be separated from the mother. The baby
should be dried, placed skin-to-skin with the mother, and covered with
dry linen to maintain temperature. Observation of breathing, activity,
and color should be ongoing.
If the answer to any of these assessment questions is “no,” the infant
should receive one or more of the following 4 categories of action in
sequence:
A. Initial steps in stabilization (provide warmth, clear airway if neces-
sary, dry, stimulate)
B. Ventilation

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FIGURE.
Newborn Resuscitation Algorithm.

C. Chest compressions assessment of 2 vital characteristics: estimate of the pulse and is more accu-
D. Administration of epinephrine and/ respirations (apnea, gasping, or labored rate than palpation at other sites.4,5
or volume expansion or unlabored breathing) and heart rate A pulse oximeter can provide a contin-
Approximately 60 seconds (“the Golden (whether greater than or less than 100 uous assessment of the pulse without
Minute”) are allotted for completing the beats per minute). Assessment of heart interruption of other resuscitation
initial steps, reevaluating, and beginning rate should be done by intermittently measures, but the device takes 1 to 2
ventilation if required (see Figure). The auscultating the precordial pulse. When minutes to apply, and it may not func-
decision to progress beyond the initial a pulse is detectable, palpation of the tion during states of very poor cardiac
steps is determined by simultaneous umbilical pulse can also provide a rapid output or perfusion. Once positive

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pressure ventilation or supplementary (American Academy of Pediatrics, in prewarming the linen, drying and swad-
oxygen administration is begun, as- press).11 If a preterm delivery (⬍37 dling, placing the baby skin-to-skin with
sessment should consist of simulta- weeks of gestation) is expected, spe- the mother and covering both with a
neous evaluation of 3 vital characteris- cial preparations will be required. Pre- blanket) and are recommended, but they
tics: heart rate, respirations, and the term babies have immature lungs that have not been studied specifically (Class
state of oxygenation, the latter opti- may be more difficult to ventilate and IIb, LOE C). All resuscitation procedures,
mally determined by a pulse oximeter are also more vulnerable to injury by including endotracheal intubation, chest
as discussed under “Assessment of Ox- positive-pressure ventilation. Preterm compression, and insertion of intrave-
ygen Need and Administration of Oxy- babies also have immature blood ves- nous lines, can be performed with these
gen” below. The most sensitive indica- sels in the brain that are prone to hem- temperature-controlling interventions in
tor of a successful response to each orrhage; thin skin and a large surface place (Class IIb, LOE C).
step is an increase in heart rate. area, which contribute to rapid heat
Infants born to febrile mothers have
loss; increased susceptibility to infec-
been reported to have a higher inci-
ANTICIPATION OF tion; and increased risk of hypovole-
dence of perinatal respiratory depres-
RESUSCITATION NEED mic shock related to small blood
sion, neonatal seizures, and cerebral
Anticipation, adequate preparation, volume.
palsy and an increased risk of mortal-
accurate evaluation, and prompt initi-
ation of support are critical for suc- INITIAL STEPS ity.18,19 Animal studies indicate that hy-
cessful neonatal resuscitation. At ev- The initial steps of resuscitation are to perthermia during or after ischemia is
ery delivery there should be at least 1 provide warmth by placing the baby associated with progression of cere-
person whose primary responsibility under a radiant heat source, position- bral injury. Lowering the temperature
is the newly born. This person must be ing the head in a “sniffing” position to reduces neuronal damage.20 Hyperther-
capable of initiating resuscitation, in- open the airway, clearing the airway if mia should be avoided (Class IIb, LOE C).
cluding administration of positive- necessary with a bulb syringe or suc- The goal is to achieve normothermia and
pressure ventilation and chest com- tion catheter, drying the baby, and avoid iatrogenic hyperthermia.
pressions. Either that person or stimulating breathing. Recent studies
someone else who is promptly avail- have examined several aspects of Clearing the Airway
able should have the skills required to these initial steps. These studies are When Amniotic Fluid Is Clear
perform a complete resuscitation, in- summarized below. There is evidence that suctioning of the
cluding endotracheal intubation and nasopharynx can create bradycardia
administration of medications.6 Sev- Temperature Control
during resuscitation21,22 and that suc-
eral studies have demonstrated that a Very low-birth-weight (⬍1500 g) pre-
tioning of the trachea in intubated ba-
cesarean section performed under re- term babies are likely to become hypo-
bies receiving mechanical ventilation
thermic despite the use of traditional
gional anesthesia at 37 to 39 weeks, in the neonatal intensive care unit
techniques for decreasing heat loss.12
without antenatally identified risk fac- (NICU) can be associated with deterio-
For this reason additional warming tech-
tors, versus a similar vaginal delivery ration of pulmonary compliance and
niques are recommended (eg, prewarm-
performed at term, does not increase oxygenation and reduction in cerebral
ing the delivery room to 26°C,13 covering
the risk of the baby requiring endotra- blood flow velocity when performed
the baby in plastic wrapping (food or
cheal intubation.7–10 medical grade, heat-resistant plastic) routinely (ie, in the absence of obvious
With careful consideration of risk fac- (Class I, LOE A14,15), placing the baby on an nasal or oral secretions).23,24 However,
tors, the majority of newborns who exothermic mattress (Class IIb, LOE B16), there is also evidence that suctioning
will need resuscitation can be identi- and placing the baby under radiant heat in the presence of secretions can de-
fied before birth. If the possible need (Class IIb, LOE C17). The infant’s tempera- crease respiratory resistance.25 There-
for resuscitation is anticipated, addi- ture must be monitored closely because fore it is recommended that suctioning
tional skilled personnel should be re- of the slight, but described risk of hyper- immediately following birth (including
cruited and the necessary equipment thermia when these techniques are used suctioning with a bulb syringe) should
prepared. Identifiable risk factors and in combination (Class IIb, LOE B16). Other be reserved for babies who have obvi-
the necessary equipment for resusci- techniques for maintaining tempera- ous obstruction to spontaneous breath-
tation are listed in the Textbook of ture during stabilization of the baby in ing or who require positive-pressure
Neonatal Resuscitation, 6th Edition the delivery room have been used (eg, ventilation (PPV) (Class IIb, LOE C).

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When Meconium is Present bin saturation may normally remain in can be anticipated,2 when positive
Aspiration of meconium before deliv- the 70% to 80% range for several min- pressure is administered for more
ery, during birth, or during resuscita- utes following birth, thus resulting in than a few breaths, when cyanosis is
tion can cause severe meconium aspi- the appearance of cyanosis during persistent, or when supplementary ox-
ration syndrome (MAS). Historically a that time. Other studies have shown ygen is administered (Class I, LOE B).
variety of techniques have been rec- that clinical assessment of skin color To appropriately compare oxygen sat-
ommended to reduce the incidence of is a very poor indicator of oxyhemoglo- urations to similar published data, the
MAS. Suctioning of the oropharynx be- bin saturation during the immediate probe should be attached to a preduc-
fore delivery of the shoulders was con- neonatal period and that lack of cyano- tal location (ie, the right upper extrem-
sidered routine until a randomized sis appears to be a very poor indicator ity, usually the wrist or medial surface
controlled trial demonstrated it to be of the state of oxygenation of an un- of the palm).43 There is some evidence
of no value.26 Elective and routine en- compromised baby following birth. that attaching the probe to the baby
dotracheal intubation and direct suc- Optimal management of oxygen during before connecting the probe to the in-
tioning of the trachea were initially neonatal resuscitation becomes par- strument facilitates the most rapid ac-
recommended for all meconium-stained
ticularly important because of the evi- quisition of signal (Class IIb, LOE C).42
newborns until a randomized con-
dence that either insufficient or exces-
trolled trial demonstrated that there Administration of
sive oxygenation can be harmful to the
was no value in performing this pro- Supplementary Oxygen
newborn infant. Hypoxia and ischemia
cedure in babies who were vigorous Two meta-analyses of several random-
are known to result in injury to multi-
at birth.27 Although depressed infants ized controlled trials comparing neo-
ple organs. Conversely there is grow-
born to mothers with meconium-stained natal resuscitation initiated with room
ing experimental evidence, as well as
amniotic fluid (MSAF) are at increased
evidence from studies of babies receiv- air versus 100% oxygen showed in-
risk to develop MAS,28,29 tracheal suction-
ing resuscitation, that adverse out- creased survival when resuscitation
ing has not been associated with reduc-
comes may result from even brief ex- was initiated with air.44,45 There are no
tion in the incidence of MAS or mortality
posure to excessive oxygen during and studies in term infants comparing out-
in these infants.30,31 The only evidence
following resuscitation. comes when resuscitations are initi-
that direct tracheal suctioning of meco-
ated with different concentrations of
nium may be of value was based on com-
Pulse Oximetry oxygen other than 100% or room air.
parison of suctioned babies with historic
Numerous studies have defined the One study in preterm infants showed
controls, and there was apparent selec-
percentiles of oxygen saturation as a that initiation of resuscitation with a
tion bias in the group of intubated babies
function of time from birth in uncom- blend of oxygen and air resulted in less
included in those studies.32–34
promised babies born at term (see hypoxemia or hyperoxemia, as defined
In the absence of randomized, con- table in Figure). This includes satura- by the investigators, than when resus-
trolled trials, there is insufficient evi- tions measured from both preductal citation was initiated with either air
dence to recommend a change in the and postductal sites, following both or 100% oxygen followed by titration
current practice of performing endo- operative and vaginal deliveries, and with an adjustable blend of air and
tracheal suctioning of nonvigorous those occurring at sea level and at oxygen.46
babies with meconium-stained amni- altitude.35– 40
otic fluid (Class IIb, LOE C). However, if In the absence of studies comparing
attempted intubation is prolonged Newer pulse oximeters, which employ outcomes of neonatal resuscitation
and unsuccessful, bag-mask ventila- probes designed specifically for neo- initiated with other oxygen concentra-
tion should be considered, particularly nates, have been shown to provide re- tions or targeted at various oxyhemo-
if there is persistent bradycardia. liable readings within 1 to 2 minutes globin saturations, it is recommended
following birth.41– 43 These oximeters that the goal in babies being resusci-
Assessment of Oxygen Need are reliable in the large majority of tated at birth, whether born at term or
and Administration of Oxygen newborns, both term and preterm, and preterm, should be an oxygen satura-
There is a large body of evidence that requiring resuscitation or not, as long tion value in the interquartile range of
blood oxygen levels in uncompromised as there is sufficient cardiac output preductal saturations (see table in Fig-
babies generally do not reach extra- and skin blood flow for the oximeter to ure) measured in healthy term babies
uterine values until approximately 10 detect a pulse. It is recommended that following vaginal birth at sea level
minutes following birth. Oxyhemoglo- oximetry be used when resuscitation (Class IIb, LOE B). These targets may be

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achieved by initiating resuscitation some term babies without spontane- choice may be guided by local exper-
with air or a blended oxygen and titrat- ous ventilation (Class IIb, LOE C).48,50,54 If tise and preferences. There is no evi-
ing the oxygen concentration to circumstances preclude the use of dence to support or refute the use of
achieve an SpO2 in the target range as pressure monitoring, the minimal in- CPAP in the delivery room in the term
described above using pulse oximetry flation required to achieve an increase baby with respiratory distress.
(Class IIb, LOE C). If blended oxygen is in heart rate should be used. There is Although positive end– expiratory pres-
not available, resuscitation should be insufficient evidence to recommend an sure (PEEP) has been shown to be ben-
initiated with air (Class IIb, LOE B). If optimum inflation time. In summary, eficial and its use is routine during me-
the baby is bradycardic (HR ⬍60 per assisted ventilation should be deliv- chanical ventilation of neonates in
minute) after 90 seconds of resuscita- ered at a rate of 40 to 60 breaths per intensive care units, there have been
tion with a lower concentration of oxy- minute to promptly achieve or main- no studies specifically examining PEEP
gen, oxygen concentration should be tain a heart rate ⬎100 per minute versus no PEEP when PPV is used dur-
increased to 100% until recovery of a (Class IIb, LOE C). ing establishment of an FRC following
normal heart rate (Class IIb, LOE B). The use of colorimetric CO2 detectors birth. Nevertheless, PEEP is likely to be
during mask ventilation of small num- beneficial and should be used if suit-
Positive-Pressure Ventilation (PPV) bers of preterm infants in the intensive able equipment is available (Class IIb,
If the infant remains apneic or gasp- care unit and in the delivery room has LOE C). PEEP can easily be given with a
ing, or if the heart rate remains ⬍100 been reported, and such detectors may flow-inflating bag or T-piece resuscita-
per minute after administering the ini- help to identify airway obstruction.55,56 tor, but it cannot be given with a self-
tial steps, start PPV. However, it is unclear whether the use inflating bag unless an optional PEEP
of CO2 detectors during mask ventila- valve is used. There is, however, some
Initial Breaths and
tion confers additional benefit above evidence that such valves often deliver
Assisted Ventilation
clinical assessment alone (Class IIb, inconsistent end-expiratory pressures.58,59
Initial inflations following birth, either
LOE C).
spontaneous or assisted, create a func- ASSISTED-VENTILATION DEVICES
tional residual capacity (FRC).47–50 The End-Expiratory Pressure Effective ventilation can be achieved
optimal pressure, inflation time, and Many experts recommend administra- with either a flow-inflating or self-
flow rate required to establish an effec- tion of continuous positive airway inflating bag or with a T-piece mechan-
tive FRC when PPV is administered dur- pressure (CPAP) to infants who are ical device designed to regulate pres-
ing resuscitation have not been deter- breathing spontaneously, but with dif- sure.60 – 63 The pop-off valves of self-
mined. Evidence from animal studies ficulty, following birth, although its inflating bags are dependent on the
indicates that preterm lungs are easily use has been studied only in infants flow rate of incoming gas, and pres-
injured by large-volume inflations imme- born preterm. A multicenter random- sures generated may exceed the value
diately after birth.51,52 Assisted ventila- ized clinical trial of newborns at 25 to specified by the manufacturer. Target
tion rates of 40 to 60 breaths per minute 28 weeks gestation with signs of respi- inflation pressures and long inspira-
are commonly used, but the relative effi- ratory distress showed no significant tory times are more consistently
cacy of various rates has not been difference in the outcomes of death or achieved in mechanical models when
investigated. oxygen requirement at 36 weeks post- T-piece devices are used rather than
The primary measure of adequate ini- menstrual age between infants started bags,60,61 although the clinical implica-
tial ventilation is prompt improvement on CPAP versus those intubated and tions of these findings are not clear
in heart rate.53 Chest wall movement placed on mechanical ventilation in the (Class IIb, LOE C). It is likely that infla-
should be assessed if heart rate does delivery room. Starting infants on tion pressures will need to change as
not improve. The initial peak inflating CPAP reduced the rates of intubation compliance improves following birth,
pressures needed are variable and un- and mechanical ventilation, surfactant but the relationship of pressures to de-
predictable and should be individual- use, and duration of ventilation, but in- livered volume and the optimal volume
ized to achieve an increase in heart creased the rate of pneumothorax.57 to deliver with each breath as FRC is
rate or movement of the chest with Spontaneously breathing preterm in- being established have not been stud-
each breath. Inflation pressure should fants who have respiratory distress ied. Resuscitators are insensitive to
be monitored; an initial inflation pres- may be supported with CPAP or with changes in lung compliance, regard-
sure of 20 cm H2O may be effective, but intubation and mechanical ventilation less of the device being used (Class IIb,
ⱖ30 to 40 cm H2O may be required in (Class IIb, LOE B). The most appropriate LOE C).64

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Laryngeal Mask Airways diac output confirms placement of the higher peak systolic and coronary
Laryngeal mask airways that fit over endotracheal tube within the trachea, perfusion pressure than the 2-finger
the laryngeal inlet have been shown to whereas a negative test result (ie, no CO2 technique,76 – 80 the 2 thumb– encircling
be effective for ventilating newborns detected) strongly suggests esophageal hands technique is recommended for
weighing more than 2000 g or deliv- intubation.68 –72 Exhaled CO2 detection is performing chest compressions in
ered ⱖ34 weeks gestation (Class IIb, the recommended method of confir- newly born infants (Class IIb, LOE C).
LOE B65– 67). There are limited data on mation of endotracheal tube place- The 2-finger technique may be prefer-
the use of these devices in small pre- ment (Class IIa, LOE B). However, it able when access to the umbilicus is
term infants, ie, ⬍ 2000 g or ⬍34 should be noted that poor or absent required during insertion of an umbil-
weeks (Class IIb, LOE C65– 67). A laryn- pulmonary blood flow may give false- ical catheter, although it is possible
geal mask should be considered dur- negative results (ie, no CO2 detected to administer the 2 thumb– encircling
ing resuscitation if facemask ventila- despite tube placement in the tra- hands technique in intubated infants
tion is unsuccessful and tracheal chea). A false-negative result may thus with the rescuer standing at the baby’s
intubation is unsuccessful or not feasi- lead to unnecessary extubation and re- head, thus permitting adequate access
ble (Class IIa, LOE B). The laryngeal intubation of critically ill infants with to the umbilicus (Class IIb, LOE C).
mask has not been evaluated in cases poor cardiac output. Compressions and ventilations should
of meconium-stained fluid, during be coordinated to avoid simultaneous
Other clinical indicators of correct en-
chest compressions, or for adminis- delivery.81 The chest should be per-
dotracheal tube placement are con-
tration of emergency intratracheal mitted to reexpand fully during relax-
densation in the endotracheal tube,
medications. ation, but the rescuer’s thumbs should
chest movement, and presence of
Endotracheal Tube Placement equal breath sounds bilaterally, but not leave the chest (Class IIb, LOE C).
Endotracheal intubation may be indi- these indicators have not been system- There should be a 3:1 ratio of com-
cated at several points during neona- atically evaluated in neonates (Class pressions to ventilations with 90 com-
tal resuscitation: 11b, LOE C). pressions and 30 breaths to achieve
approximately 120 events per minute
● Initial endotracheal suctioning of non-
Chest Compressions to maximize ventilation at an achiev-
vigorous meconium-stained newborns
Chest compressions are indicated for able rate. Thus each event will be allot-
● If bag-mask ventilation is ineffective
a heart rate that is ⬍60 per minute ted approximately 1/2 second, with
or prolonged exhalation occurring during the first
despite adequate ventilation with sup-
● When chest compressions are plementary oxygen for 30 seconds. Be- compression after each ventilation
performed cause ventilation is the most effective (Class IIb, LOE C).
● For special resuscitation circum- action in neonatal resuscitation and There is evidence from animals and
stances, such as congenital dia- because chest compressions are likely non-neonatal studies that sustained
phragmatic hernia or extremely low to compete with effective ventilation, compressions or a compression ratio
birth weight rescuers should ensure that assisted of 15:2 or even 30:2 may be more effec-
The timing of endotracheal intubation ventilation is being delivered optimally tive when the arrest is of primary car-
may also depend on the skill and expe- before starting chest compressions. diac etiology. One study in children
rience of the available providers. Compressions should be delivered on suggests that CPR with rescue breath-
After endotracheal intubation and ad- the lower third of the sternum to a ing is preferable to chest compres-
ministration of intermittent positive depth of approximately one third of the sions alone when the arrest is of non-
pressure, a prompt increase in heart anterior-posterior diameter of the cardiac etiology.82 It is recommended
rate is the best indicator that the tube chest (Class IIb, LOE C73–75). Two tech- that a 3:1 compression to ventilation
is in the tracheobronchial tree and niques have been described: compres- ratio be used for neonatal resuscita-
providing effective ventilation.53 Ex- sion with 2 thumbs with fingers encir- tion where compromise of ventilation
haled CO2 detection is effective for con- cling the chest and supporting the is nearly always the primary cause, but
firmation of endotracheal tube place- back (the 2 thumb– encircling hands rescuers should consider using higher
ment in infants, including very low- technique) or compression with 2 fin- ratios (eg, 15:2) if the arrest is believed
birth-weight infants (Class IIa, LOE B68 –71). gers with a second hand supporting to be of cardiac origin (Class IIb, LOE C).
A positive test result (detection of ex- the back. Because the 2 thumb– encir- Respirations, heart rate, and oxygena-
haled CO2) in patients with adequate car- cling hands technique may generate tion should be reassessed periodically,

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and coordinated chest compressions venous access is established (Class monitoring and anticipatory care can
and ventilations should continue until IIb, LOE C). be provided.
the spontaneous heart rate is ⱖ60 per The recommended IV dose is 0.01 to
Naloxone
minute (Class IIb, LOE C). However, fre- 0.03 mg/kg per dose. Higher IV doses
Administration of naloxone is not rec-
quent interruptions of compressions are not recommended because ani-
ommended as part of initial resuscita-
should be avoided, as they will com- mal86,87 and pediatric88,89 studies show
tive efforts in the delivery room for
promise artificial maintenance of sys- exaggerated hypertension, decreased
newborns with respiratory depression.
temic perfusion and maintenance of myocardial function, and worse neuro-
Heart rate and oxygenation should be
coronary blood flow (Class IIb, LOE C). logical function after administration of
restored by supporting ventilation.
IV doses in the range of 0.1 mg/kg. If
MEDICATIONS the endotracheal route is used, doses Glucose
Drugs are rarely indicated in resusci- of 0.01 or 0.03 mg/kg will likely be inef- Newborns with lower blood glucose
tation of the newly born infant. Brady- fective. Therefore, IV administration of levels are at increased risk for brain
cardia in the newborn infant is usually 0.01 to 0.03 mg/kg per dose is the pre- injury and adverse outcomes after a
the result of inadequate lung inflation ferred route. While access is being ob- hypoxic-ischemic insult, although no
or profound hypoxemia, and establish- tained, administration of a higher dose specific glucose level associated with
ing adequate ventilation is the most (0.05 to 0.1 mg/kg) through the endo- worse outcome has been identified.91,92
important step toward correcting it. tracheal tube may be considered, but Increased glucose levels after hypoxia
However, if the heart rate remains the safety and efficacy of this prac- or ischemia were not associated with
⬍60 per minute despite adequate ven- tice have not been evaluated (Class IIb, adverse effects in a recent pediatric
tilation (usually with endotracheal in- LOE C). The concentration of epineph- series93 or in animal studies,94 and they
tubation) with 100% oxygen and chest rine for either route should be 1:10,000 may be protective.95 However, there
compressions, administration of epi- (0.1 mg/mL). are no randomized controlled trials
nephrine or volume expansion, or both, that examine this question. Due to the
may be indicated. Rarely, buffers, a VOLUME EXPANSION paucity of data, no specific target glu-
narcotic antagonist, or vasopressors Volume expansion should be consid- cose concentration range can be iden-
ered when blood loss is known or sus- tified at present. Intravenous glucose
may be useful after resuscitation, but
pected (pale skin, poor perfusion, weak infusion should be considered as soon
these are not recommended in the de-
pulse) and the baby’s heart rate has as practical after resuscitation, with
livery room.
not responded adequately to other re- the goal of avoiding hypoglycemia
suscitative measures (Class IIb, LOE C).90 (Class IIb, LOE C).
Rate and Dose of
An isotonic crystalloid solution or
Epinephrine Administration
blood is recommended for volume ex- Induced Therapeutic Hypothermia
Epinephrine is recommended to be ad-
pansion in the delivery room (Class IIb, Several randomized controlled multi-
ministered intravenously (Class IIb, center trials of induced hypothermia
LOE C). The recommended dose is 10
LOE C). Past guidelines recommended (33.5°C to 34.5°C) of newborns ⱖ36
mL/kg, which may need to be repeated.
that initial doses of epinephrine be weeks gestational age, with moderate
When resuscitating premature infants,
given through an endotracheal tube to severe hypoxic-ischemic encepha-
care should be taken to avoid giving
because the dose can be administered lopathy as defined by strict criteria,
volume expanders rapidly, because
more quickly than when an intra- rapid infusions of large volumes have showed that those babies who were
venous route must be established. been associated with intraventricular cooled had significantly lower mortal-
However, animal studies that showed a hemorrhage (Class IIb, LOE C). ity and less neurodevelopmental dis-
positive effect of endotracheal epi- ability at 18-month follow-up than ba-
nephrine used considerably higher POSTRESUSCITATION CARE bies who were not cooled.96 –98 The
doses than are currently recommend- Babies who require resuscitation are randomized trials produced similar
ed,83,84 and the one animal study that at risk for deterioration after their vi- results using different methods of
used currently recommended doses tal signs have returned to normal. cooling (selective head versus system-
via endotracheal tube showed no ef- Once adequate ventilation and circula- ic).96 –100 It is recommended that infants
fect.85 Given the lack of supportive tion have been established, the infant born at ⱖ36 weeks gestation with
data for endotracheal epinephrine, the should be maintained in, or trans- evolving moderate to severe hypoxic-
IV route should be used as soon as ferred to an environment where close ischemic encephalopathy should be

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offered therapeutic hypothermia. The functional survival is highly unlikely.103 birth-weight babies born in a network
treatment should be implemented ac- The following guidelines must be inter- of regional perinatal centers may be
cording to the studied protocols, which preted according to current regional found at that site. However, unless con-
currently include commencement within outcomes: ception occurred via in vitro fertiliza-
6 hours following birth, continuation for ● When gestation, birth weight, or tion, techniques used for obstetric dat-
72 hours, and slow rewarming over at congenital anomalies are associ- ing are accurate to only ⫾3 to 4 days if
least 4 hours. Therapeutic hypothermia ated with almost certain early death applied in the first trimester and to
should be administered under clearly and when unacceptably high mor- only ⫾1 to 2 weeks subsequently. Esti-
defined protocols similar to those used bidity is likely among the rare survi- mates of fetal weight are accurate to
in published clinical trials and in facili- vors, resuscitation is not indicated. only ⫾15% to 20%. Even small discrep-
ties with the capabilities for multidisci- ancies of 1 or 2 weeks between esti-
Examples include extreme prematu-
plinary care and longitudinal follow-up mated and actual gestational age or a
rity (gestational age ⬍23 weeks or
(Class IIa, LOE A). Studies suggest that 100- to 200-g difference in birth weight
birth weight ⬍400 g), anencephaly,
there may be some associated adverse may have implications for survival and
and some major chromosomal ab-
effects, such as thrombocytopenia and long-term morbidity. Also, fetal weight
normalities, such as trisomy 13
increased need for inotropic support. can be misleading if there has been
(Class IIb, LOE C).
intrauterine growth restriction, and
GUIDELINES FOR WITHHOLDING ● In conditions associated with a high outcomes may be less predictable.
AND DISCONTINUING rate of survival and acceptable mor- These uncertainties underscore the
RESUSCITATION bidity, resuscitation is nearly al- importance of not making firm com-
For neonates at the margins of viability ways indicated. This will generally mitments about withholding or provid-
or those with conditions which predict include babies with gestational age ing resuscitation until you have the op-
a high risk of mortality or morbidity, ⱖ25 weeks and those with most portunity to examine the baby after
attitudes and practice vary according congenital malformations (Class IIb, birth.
to region and availability of resources. LOE C).
Studies indicate that parents desire a ● In conditions associated with uncer- Discontinuing Resuscitative Efforts
larger role in decisions to initiate re- tain prognosis in which survival is In a newly born baby with no detect-
suscitation and continue life support borderline, the morbidity rate is rel- able heart rate, it is appropriate to
of severely compromised newborns. atively high, and the anticipated consider stopping resuscitation if the
Opinions among neonatal providers burden to the child is high, parental heart rate remains undetectable for 10
vary widely regarding the benefits and desires concerning initiation of re- minutes (Class IIb, LOE C104 –106). The de-
disadvantages of aggressive therapies suscitation should be supported cision to continue resuscitation efforts
in such newborns. (Class IIb, LOE C). beyond 10 minutes with no heart rate
should take into consideration factors
Withholding Resuscitation Assessment of morbidity and mortality
such as the presumed etiology of the
It is possible to identify conditions as- risks should take into consideration
arrest, the gestation of the baby, the
sociated with high mortality and poor available data, and may be augmented
presence or absence of complications,
outcome in which withholding resusci- by use of published tools based on
the potential role of therapeutic hypo-
tative efforts may be considered rea- data from specific populations. Deci-
thermia, and the parents’ previously
sonable, particularly when there has sions should also take into account
expressed feelings about acceptable
been the opportunity for parental changes in medical practice that may
risk of morbidity.
agreement (Class IIb, LOE C101,102). occur over time.
A consistent and coordinated ap- Mortality and morbidity data by gesta- STRUCTURE OF EDUCATIONAL
proach to individual cases by the ob- tional age compiled from data col- PROGRAMS TO TEACH
stetric and neonatal teams and the lected by perinatal centers in the US NEONATAL RESUSCITATION
parents is an important goal. Nonini- and several other countries may be Studies have demonstrated that use of
tiation of resuscitation and discontinu- found on the Neonatal Resuscitation simulation-based learning methodolo-
ation of life-sustaining treatment dur- Program (NRP) website (www.aap. gies enhances performance in both
ing or after resuscitation are ethically org/nrp). A link to a computerized tool real-life clinical situations and simu-
equivalent, and clinicians should not to estimate mortality and morbidity lated resuscitations,107–110 although a
hesitate to withdraw support when from a population of extremely low- few studies have found no differences

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when compared to standard or other data is complicated by the hetero- gram adopt simulation, briefing, and
nonsimulated training.111,112 Also, stud- geneity and limitations of the studies, debriefing techniques in designing an
ies examining briefings or debriefings including a paucity of data about education program for the acquisition
of resuscitation team performance clinical outcomes. Based on available and maintenance of the skills neces-
have generally shown improved knowl- evidence, it is recommended that the sary for effective neonatal resuscita-
edge or skills.113–118 Interpretation of AAP/AHA Neonatal Resuscitation Pro- tion (Class IIb, LOE C).
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DISCLOSURES
GUIDELINES PART 15: Neonatal Resuscitation Writing Group Disclosures
Writing Group Employment Research Grant Other Research Support Speakers’ Bureau/ Honoraria Ownership Consultant/ Advisory Board Other
Member Interest
John University of Virginia–Professor None None None None None None
Kattwinkel of Pediatrics
Jeffrey M. Weill Cornell-Professor of †NIH-NIH- Improving antimicrobial None None None None None
Perlman Pediatrics prescribing practices in the NICU
Khalid Aziz University of Alberta– Associate None None None None None None
Professor of Pediatrics
Christopher Mayo Clinic–physician None None None None None None
Colby
Karen University of Virginia Health None None None None None None
Fairchild System–Associate Professor of
Pediatrics
John Univ. Hosp of Cleveland-Crit None None None None None None
Gallagher Care Coordinator of Ped.Resp
Care
Mary Fran Vanderbilt University School of None None None None None None
Hazinski Nursing—Professor; AHA ECC
Product Development-Senior
Science Editor
†Significant AHA compensation
to write, edit and review
documents such as the 2010
AHA Guidelines for CPR and ECC.
Louis P. Stanford University–Associate †Laerdal Foundation: The Laerdal None *I have received ⬍ 10 honoraria None *Laerdal Medical Advanced *I provide medical
Halamek Professor Foundation (not company) in amounts of $500 or less from Medical Simulation Both of consultation to the legal
provided a grant to the Center for speaking at various academic these companies profession for which I am
Advanced Pediatric and Perinatal meetings in the past 24 months; reimburse me directly. reimbursed directly.
Education at Packard Children’s none of these meetings were
Hospital at Stanford during the conducted by for-profit entities.
academic years 2006–07, 2007–08,
2008–09; I develop simulation-
based training programs and
conduct research at CAPE. This
support was provided directly to
my institution.
Praveen PEDIATRIC FACULTY FOUNDATION- None None None None None None
Kumar ATTENDING NEONATOLOGIST
George Little Dartmouth College- Ped. None None None None None None
Professor; Dartmouth Hitchcock
Medfont. Center Neonatologist
Jane E. St Christopher’s Pediatric None None None None None * reviewed records of cases
McGowan Associate/ involving neonatal
Tenet Healthcare–Attending resuscitation on one or two
neonatologist; medical director, occasions over the past 5
NICU years.
*As co-editor for Textbook of
Neonatal Resuscitation 6th
edition, to be published by
the AAP, being paid a total
of $4000 over 3 years by the
AAP.
Barbara Univ.Health Assoc,Nurse None None None None None None
Nightengale Practitioner
Mildred M. Univ of Texas Med School None None *Signed as consultant for Cyto- None None *Expert for Current expert
Ramirez Houston-Physician kine Pharmasciences, Inc., for a case of triplets and preterm
lecture in Mexico City. Product delivery. Money to the
Propress for cervical rippening. university ’09
$2,000 Money to Univ.
Steven Ringer Brigham and Women’s None None *Vermont Oxford Neonatal None *Alere $2000, consultation †Several Attorneys, serving
Hospital–Chief, Newborn Network, $1000, comes to me Dey Pharamaceutical $1000 as expert witness in
Medicine Consultation Forrest Medical malpractice cases
Pharmaceuticals $1500
Grant Review Committee
Wendy M. American Academy of None None None None None None
Simon Pediatrics–Director, Life
Support Programs
Gary M. St. Joseph Mercy Hospital-Ann None †Received equipment on-loan None None None None
Weiner Arbor Michigan–Attending (3 resuscitation mannequins,
Neonatologist 2 sets of video recording
equipment) from Laerdal
Medical Corporation to be
used to complete a research
project evaluating
educational methods for
teaching neonatal
resuscitation. The value of the
on-loan equipment is
approximately $35,000.
(Continued)

e1412 FROM THE AMERICAN ACADEMY OF PEDIATRICS

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 FROM THE AMERICAN ACADEMY OF PEDIATRICS

GUIDELINES PART 15: Neonatal Resuscitation Writing Group Disclosures, Continued

Writing Employment Research Grant Other Research Support Speakers’ Bureau/ Honoraria Ownership Consultant/ Advisory Board Other
Group Interest
Member
Myra UT Southwestern Medical †American Academy of Pediatrics †Received a SimNewB *Speaker at Symposia on None None None
Wyckoff Center–Associate Professor of Neonatal Research Grant- neonatal simulator for help in Neonatal Care from University of
Pediatrics Ergonomics of Neonatal CPR Beta testing prior to final Miami-honoraria paid to me
2008–2009 production Speaker at Symposia on
Neonatal Care from Columbia/
Cornell-honoraria paid directly
to me Speaker for Grand Rounds
from University of Oklahoma-
honoraria paid directly to me
Jeanette Seattle Children’s None None *I receive honoraria directly to None None None
Zaichkin Hospital–Neonatal Outreach me from the AAP as
Coordinator compensation for editorial
activities for NRP instructor ms.

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire,
which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month
period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the
entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.

PEDIATRICS Volume 126, Number 5, November 2010 e1413

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ERRATUM Kattwinkel, et al. Special Report: Neonatal Resuscitation: 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Pediatrics. 2010;126(5):e1400 – e1413
An error occurred in this article by Kattwinkel et al (doi:10.1542/peds.2010-
2972E). On page e1401, in the figure, “Newborn Resuscitation Algorithm” it reads:
“NO” between “Heart rate below 60” and “Consider intubation, Chest compres-
sions, Coordinate with PPV.” This should have read: as a double pointed arrow
between “Heart rate below 60” and “Take ventilation corrective steps” and dele-
tion of the word, “no.” The corrected figure is below.

FIGURE

doi:10.1542/peds.2011-1260

176 ERRATUM
 Neonatal Resuscitation: 2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
John Kattwinkel, Jeffrey M. Perlman, Khalid Aziz, Christopher Colby, Karen
Fairchild, John Gallagher, Mary Fran Hazinski, Louis P. Halamek, Praveen Kumar,
George Little, Jane E. McGowan, Barbara Nightengale, Mildred M. Ramirez, Steven
Ringer, Wendy M. Simon, Gary M. Weiner, Myra Wyckoff and Jeanette Zaichkin
Pediatrics 2010;126;e1400; originally published online October 18, 2010;
DOI: 10.1542/peds.2010-2972E

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/126/5/e1400.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2010 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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 Neonatal Resuscitation: 2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
John Kattwinkel, Jeffrey M. Perlman, Khalid Aziz, Christopher Colby, Karen
Fairchild, John Gallagher, Mary Fran Hazinski, Louis P. Halamek, Praveen Kumar,
George Little, Jane E. McGowan, Barbara Nightengale, Mildred M. Ramirez, Steven
Ringer, Wendy M. Simon, Gary M. Weiner, Myra Wyckoff and Jeanette Zaichkin
Pediatrics 2010;126;e1400; originally published online October 18, 2010;
DOI: 10.1542/peds.2010-2972E
Updated Information & including high resolution figures, can be found at:
Services /content/126/5/e1400.full.html

References This article cites 113 articles, 25 of which can be accessed

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2010 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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