TAGEDENS E M I N A R S I N P E R I N A T O L O G Y 46 (2022) 151626

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Seminars in Perinatology
www.seminperinat.com

Special consideration in neonatal resuscitation

Noorjahan Alia*, and Taylor Sawyerb
a
Department of Pediatrics Division of Perinatal-Neonatal Medicine UT Southwestern of Dallas Children’s Medical Center of Dallas Texas, USA
b
Department of Pediatrics Division of Neonatology, University of Washington School of Medicine Seattle Washington, USA

AB STR ACT

Delivery room resuscitation of neonates is performed according to evidence-based neona-

tal resuscitation guidelines. Neonatal resuscitation guidelines focus on the resuscitation
of newborns suffering from perinatal asphyxia. Special considerations are needed when
resuscitating newborns in locations other than the delivery room and for newborns with
congenital anomalies. In this review, we examine the resuscitation of newborns at home
and in the emergency department and highlight special considerations for resuscitating
newborns with specific congenital anomalies. In addition, we explore the resuscitation of
neonates in the neonatal intensive care unit and discuss the potential use of pediatric
advanced life support guidelines. Finally, we highlight the importance of simulation to
prepare teams for neonatal resuscitations. This review aims to prepare healthcare profes-
sionals in all disciplines caring for neonates at risk for requiring resuscitation under spe-
cial circumstances.1Evidence-based neonatal resuscitation guidelines focus on
resuscitation newborns suffering from perinatal asphyxia in the delivery room.2Modifica-
tion of neonatal resuscitation guidelines is needed for newborn resuscitations outside the
delivery room and to address certain congenital anomalies.3When resuscitating critically
ill neonates in the intensive care unit suffering from arrest etiologies not covered in neo-
natal guidelines, teams may consider using pediatric advanced life support guidelines.4-
Simulation is a central part of neonatal resuscitation training and should be used to
prepare for neonatal resuscitation in all circumstances.5With preparation and practice
for special circumstances, healthcare teams can improve the quality of resuscitation for
all neonates.
Ó 2022 Elsevier Inc. All rights reserved.

interventions for neonates transitioning from fetal to neo-

Introduction
Of the 3.5 million babies born in the United States each
year, 90% can make the fetal to neonatal transition unas-
sisted. The remaining 10% require some assistance, and
1% require extensive resuscitation. 1 Neonatal resuscita-
tion guidelines are developed to standardize resuscitation
natal life in the delivery room (DR).2 Special considera-
tions are needed for newborns delivered outside the DR,
newborns with congenital anomalies, and neonatal resus-
citation beyond the immediate postnatal period in the
neonatal intensive care unit (NICU). This review aims to
discuss these special considerations in neonatal resuscita-
tion.

*Corresponding author at: Department of Pediatrics, Division of Perinatal-Neonatal Medicine. University of Texas Southwestern Medi-
cal Center. 5323 Harry Hines Blvd. Dallas TX 75390, USA.
E-mail address: noorjahan.ali@utsouthwestern.edu (N. Ali).

https://doi.org/10.1016/j.semperi.2022.151626
0146-0005/Ó 2022 Elsevier Inc. All rights reserved.
2 S E M I N A R S I N P E R I N A T O L O G Y 46 (2022) 151626

Unplanned birth outside the hospital

SPECIAL CONSIDERATIONS BASED ON BIRTH
LOCATION With the decline in hospital-based obstetric services in rural
communities, there has been an increase in unplanned child-
Hospitals and accredited birth centers are the safest places
birth outside medical settings.14 Common complications of
for birth in the United States.3 However, for various reasons,
unplanned out-of-hospital deliveries include hypothermia and
not every birth occurs in a hospital or accredited birth center.
polycythemia.15 To maintain warmth after the birth, the neo-
Regardless of the birth location, every newborn deserves the
nate can be placed in skin-to-skin contact with the mother and
highest possible standard of care and should be resuscitated
covered with blankets or dry clothes before umbilical cord
following the neonatal resuscitation guidelines. Here we
clamping.16 When clamping the umbilical cord, two strings can
examine special considerations for newborn resuscitation in
be used. One string can be tied 5-6 inches from the umbilical
locations other than a hospital or accredited birth center.
stump, and the second tied 1-2 inches from the first string.
After both strings are tied, the cord is cut using scissors or a
Planned Home Birth
knife between the two strings.17 If the newborn requires resus-
citation, the steps of neonatal resuscitation should be started,
Out-of-hospital births have grown in popularity over the last
beginning with drying and stimulating. If positive pressure ven-
few years, and the incidence of planned home births is ris-
tilation is needed and a bag-valve mask is not available, mouth-
ing.4 However, planned home birth is associated with a more
to-mouth ventilation can be given using a barrier device
than twofold increased risk of perinatal death and a threefold
designed for lay rescuer cardiopulmonary resuscitation.
increased risk of neonatal seizures or serious neurologic dys-
function.5-7 Based on these risks, neither the American Col-
Birth in the Emergency Department
lege of Obstetrics and Gynecologists (ACOG) nor the
American Academy of Pediatrics (AAP) encourages planned
Delivery in the emergency department (ED) is rare, and the
home births. At least three things must be considered to
exact number of ED deliveries is unknown. Even though the
increase the safety of planned home births.8 First, candidates
ED is equipped to manage a variety of emergencies, facing an
for home birth must be carefully selected based on known
imminent delivery can be stressful. When anticipating deliv-
maternal and fetal risk factors. The Committee on Obstetric
ery in the ED, the first steps are to notify the local pediatrician
Practice considers fetal malpresentation, multiple gestations,
or neonatologist and collect information from the mother on
or prior cesarean delivery as absolute contraindications to
the gestational age and any pregnancy complications. Next,
planned home birth.8 Second, the birth should be attended by
neonatal resuscitation equipment should be gathered,
a certified nurse-midwife, certified midwife, or midwife
including a radiant warmer, cord clamp, appropriately sized
whose education and licensure meet the International Con-
face mask for PPV, and appropriately sized intubation equip-
federation of Midwives’ Global Standards for Midwifery Edu-
ment. An emergency umbilical catheter and kit should also
cation, or a physician practicing obstetrics within an
be available. If ED providers are not confident in their ability
integrated and regulated health system with ready access to
to place an emergency umbilical catheter, an intraosseous
consultation.8 Third, the availability of safe and timely trans-
needle can be used if emergency IV access is needed. Before
port to nearby hospitals must be assured.
the delivery, a team briefing should be held to summarize
Before attending a home birth, it is essential to know the
what is known, assign roles for the resuscitation, and ensure
gestational age and any complications during the pregnancy.
all needed equipment is present.
Equipment to have when attending a home birth include
warm blankets, a self-inflating bag, bulb suction, stethoscope,
and thermometer. A pulse oximeter and oxygen tank should
SPECIAL CONSIDERATIONS BASED ON
also be available. A laryngeal mask airway (LMA) should be
CONGENITAL ANOMALIES
highly considered.9 Each state has guidelines on whether the
placement of an LMA is within a specific healthcare
Nonsyndromic congenital malformations occur in approxi-
provider’s scope of practice. Neonatal resuscitation guide-
mately 23 per 1,000 births.18 The most common isolated mal-
lines recommend using an LMA in neonates > 2000 grams
formations include anomalies of the heart, limbs, urinary
and >34 weeks of gestation when intubation is either not pos-
tract, intestinal system, and airway (including oro-facial
sible or not feasible. Data supports the feasibility of LMA in
clefts).18 For most newborns with congenital anomalies, the
this population.10 LMA use has been linked to improved
steps outlined in neonatal resuscitation guidelines are suffi-
Apgar scores and less respiratory support after delivery.11
cient. However, neonatal resuscitation guidelines need to be
LMAs have been successfully used in neonates with airway
modified to resuscitate newborns with specific congenital
malformations such as micrognathia and laryngeal cleft.12,13
anomalies. Here we examine special considerations for neo-
In situations when the neonate is not responding to positive
natal resuscitation in newborns with congenital anomalies. A
pressure ventilation (PPV) by facemask or has unexpected
summary of these considerations is provided in Table 1.
craniofacial and airway malformations, the use of LMA can
be lifesaving. After appropriate resuscitation, newborns born
Airway anomalies
at home should have their temperature, heart rate, skin color,
circulation, and activity level monitored every 30 minutes for
Airway anomalies are rare but have high morbidity and mor-
the first two hours of life.3
tality in the DR.19 For certain known airway anomalies, a
 TAGEDENS E M I N A R S I N P E R I N A T O L O G Y 46 (2022) 151626 3

Table 1 – Summary of specialized considerations and neonatal resuscitation guidelines modifications for newborns with
select congenital anomalies

Congenital anomalies Specialized equipment & Personnel to consider Neonatal resuscitation guidelines
modifications

Airway anomalies
Intrinsic (TEF, CHAOS) Video laryngoscope, flexible fiberoptic bronchos- Rapid progression to intubation if facemask
Extrinsic (lymphatic malformations) copy, tracheostomy, otolaryngology and/or PPV is difficult. Ex-utero intrapartum treat-
anesthesia assistance ment (EXIT) in severe cases
Lung anomalies
CDH Replogle tube for gastric decompression Immediate intubation, ‘gentle ventilation’ with
lower pressures and tidal volumes
Congenital Heart Disease
TGA Cardiologist for possible early balloon septos- For intracardiac mixing lesions, targeted SpO2,
HLHS tomy in case of restricted atrial level shunt, 75%-80%
Uncontrolled arrhythmias PGE, defibrillator, equipment for thoracentesis,
and paracentesis in cases of fetal hydrops
Gastrointestinal anomalies
Gastroschisis Bowel bag, Replogle, sterile saline saturated Caution with positive pressure, intubate early
Omphalocele gauze, polythene wrap in cases of respiratory distress
Intestinal atresia, TEF
Neurological anomalies
Neural tube defects Sterile non-stick gauze, foam donut or a gauze Positioning on the side or in a prone position to
rolled into a circle for placement around the avoid putting pressure on the lesion
defect, latex-free dressing and gloves
Multiples
Conjoined twins Duplicate equipment to accommodate both Placement of EKG leads, pulse ox, and position
twins for optimal delivery of PPV and chest
compressions

TEF: tracheoesophageal fistula. CHAOS: Congenital High Airway Obstruction Syndrome. CDH: congenital diaphragmatic hernia. TGA: transpo-
sition of great arteries. HLHS: hypoplastic left heart syndrome.

multidisciplinary team including otolaryngology and anes-
thesia may be needed at the time of birth. Airway anomalies
are not always prenatally diagnosed. Therefore, hospitals
with delivery services should have a critical/difficult airway
algorithm to use in emergencies. Airway anomalies can be
divided into two categories: intrinsic and extrinsic.20
Intrinsic airway obstruction includes mandibular hypopla-
sia, tracheal stenosis/atresia (as part of tracheoesophageal
fistula (TEF) or isolated), congenital subglottic stenosis, laryn-
geal cleft, and congenital high airway obstruction syndrome
(CHAOS). Specialized equipment for stabilizing intrinsic air-
way anomalies in the DR includes small endotracheal tubes
(2.0 and 2.5), tracheostomy kits, video laryngoscopes, and
flexible fiberoptic bronchoscopes. With severe defects, the
initial corrective ventilatory steps may need to be bypassed
or modified to facilitate the quick placement of an endotra-
cheal tube to allow ventilation of the lungs. In addition, as a
supportive measure during intubation, a high-flow nasal can-
nula can be used to provide supplemental oxygen during
endotracheal tube placement.21,22 Once the airway is estab-
lished, the remainder of the standard neonatal resuscitation
algorithm can be followed if resuscitation is still required.
Extrinsic airway obstruction can occur at the oral, cervi-
cal, and thoracic levels. Oral tumors, including teratomas,
can grow to obstruct the entire oral cavity, thus making
face mask PPV impossible and laryngoscopy difficult. Emer-
gency tracheostomies immediately after delivery might be
warranted for high-grade extrinsic obstruction in the
mouth. Large cervical and thoracic lesions, such as
lymphatic malformations, can obstruct the upper airway by
exerting external pressure or through direct invasion into
the airway tissue and narrowing of the airway lumen. In
cases where the highly vascular lymphatic malformation
has invaded the airway, care must be practiced to avoid
causing trauma and bleeding from the lesion. In addition,
some large lymphatic malformations can create a con-
sumptive coagulopathy (Kasabach Merritt syndrome), and
therefore quick access to blood and blood products in the
DR should be considered.
For both intrinsic and extrinsic compression, special atten-
tion is needed when securing the endotracheal tube to avoid
inadvertent dislodgement. In addition, syndromes associated
with mandibular hypoplasia, such as Pierre Robin sequence,
Treacher-Collins, and Goldenhar syndrome, make securing
the airway challenging. In some cases, the endotracheal tube
may need to be sutured through the tongue and/or lower jaw.
For severe intrinsic and extrinsic airway anomalies, with a
high risk of mortality in the DR, an ex-utero intrapartum
treatment (EXIT) procedure may be used. The EXIT procedure
involves synchronized coordination of multidisciplinary
teams, including obstetrics, neonatology, otolaryngology, and
anesthesia. In EXIT, the newborn's head is delivered prior to
delivery of the body. This allows time for the placement of an
advanced airway while the newborn is perfused through the
placenta and umbilical cord. After the airway is established,
the newborn is fully delivered, the cord is clamped, and the
newborn is brought to a warmer for assessment and resusci-
tation as per neonatal resuscitation guidelines. In extremely
4 S E M I N A R S I N P E R I N A T O L O G Y
rare cases of total airway obstruction, EXIT-to-extracorporeal
membrane oxygenation (EXIT to ECMO) may be needed.23
Lung anomalies
Congenital diaphragmatic hernia (CDH) occurs in one in 2,500
live births.24 In CDH, the combination of pulmonary hypopla-
sia, abnormal pulmonary vasculature, and left ventricular
(LV) dysfunction increases the risk for respiratory and cardio-
vascular instability at birth.25,26 Given these risks, the initial
resuscitation of patients with CDH involves modifications of
neonatal resuscitation guidelines to include immediate intu-
bation after birth. After intubation, a ‘gentle ventilation’ strat-
egy is used with lower airway pressures and tidal volumes
and higher FiO2.27,28 The ideal FiO2 to start reduction in new-
borns with CDH is unknown. One study comparing resuscita-
tion of newborns with CDH using 50% FiO2 or 100% FiO2
found no difference in outcomes.29 Since LV dysfunction is a
concern for newborns with CDH, being prepared to place an
emergent umbilical catheter and administer volume and/or
epinephrine is advised. Recent studies are investigating if
delaying cord clamping until after ventilation is established
improves fetal to neonatal transition for neonates with
CDH.30 Studies have shown that CDH patients who under-
went delayed cord clamping had increased in SpO2, improved
preductal SaO2, higher hemoglobin levels, and higher systemic
blood pressures in after ventilation was established.31-33 Fur-
ther studies are warranted to investigate the long-term effects
of delayed cord clamping in CDH. Other lung anomalies associ-
ated with pulmonary hypoplasia, such as large omphalocele,
prune belly syndrome, or prolonged premature rupture of
membranes, also warrant consideration of a ‘gentle ven-
tilation’ strategy and caution using higher pressures and large
tidal volumes in the delivery room.
Congenital heart defects
Prenatal detection of cardiac defects is improving, yet some
congenital heart defects are first diagnosed postnatally. For
most neonates with congenital heart defects, the fetal to neo-
natal transition does not require resuscitation. However,
some cardiac defects require special consideration in the DR.
Before attending the birth of a newborn with a known cardiac
lesion, it is vital to know the following: the type of defect,
patency of atrial level shunt (e.g., foramen ovale or atrial sep-
tal defect), targeted saturation goals for mixing lesions, the
presence of arrhythmias, and the presence of any associated
anomalies.34,35 The targeted oxygen SpO2 goals in neonatal
resuscitation guidelines need to be adjusted for mixing
lesions such as truncus arteriosus, single ventricles, and
transposition of the great arteries (TGA). Most experts recom-
mend titration of FiO2 in the DR to target a pre-ductal satura-
tion in the 75-85% range for these lesions.
Several models to predict the outcomes of fetal congenital
heart disease have been proposed.36 Heart lesions associated
with the highest risk of hemodynamic instability in the DR
include d-TGA, hypoplastic left heart syndrome (HLHS) with
small or restrictive atrial shunt, obstructed total anomalous
pulmonary venous return (TAPVR), Ebstein anomaly, uncon-
trolled arrhythmias (such as congenital heart block with heart
46 (2022) 151626
failure), and heart lesions with associated hydrops.34 In cases
of HLHS and TAPVR with restrictive atrial shunt, delivery plan-
ning should include the ready availability of an interventional
cardiologist for emergent balloon septostomy.34-38 For cardiac
lesions with a high risk of hemodynamic instability and need
for early surgical intervention, delivery at a hospital with a
dedicated cardiac intensive care unit and neonatal cardiotho-
racic surgical capabilities should be considered.34-38
Gastrointestinal anomalies
Gastroschisis and omphalocele are two gastrointestinal
anomalies that require special consideration in the DR. Gas-
troschisis can be associated with oligohydramnios and pre-
mature delivery.39,40 The exposed bowel is at risk for injuries,
including volvulus and inflammation. To minimize these
injuries, specific steps are needed in the DR.41,42 After birth,
neonates with gastroschisis should be brought to a warmer
and the lower body placed in a plastic bag to protect the
exposed bowel. A Replogle should be placed to decompress
the stomach. Face mask PPV can lead to air trapping in the
intestine. Therefore, if assistance with ventilation is required,
most experts recommend rapid placement of an endotra-
cheal tube. After stabilization, neonates with gastroschisis
should be placed on their right side to prevent compression
of the mesenteric circulation.43 Omphaloceles are often asso-
ciated with pulmonary hypoplasia, cardiac anomalies, cloacal
exstrophy, and trisomies.44,45 Given the associated pulmo-
nary hypoplasia, high ventilatory pressures should be
avoided during PPV.46 After delivery, the omphalocele defect
should be wrapped in saline-soaked sterile gauze, and a
Replogle should be placed to decompress the stomach. Car-
diac defects should be considered in newborns with ompha-
locele that do not respond to neonatal resuscitation efforts.47
Intestinal obstructive lesions, including intestinal atresia,
esophageal atresia with tracheoesophageal fistula (TEF), and
imperforated anus, require caution when delivering PPV via
facemask. In such cases, ventilation can result in air trapping
in the intestine, abdominal distention, and compression of
the lungs resulting in respiratory failure. In these cases, rapid
placement of a gastric tube to decompress the stomach,
avoidance of prolonged mask ventilation, and early consider-
ation of endotracheal intubation are advised. Esophageal
atresia with TEF can be combined with intestinal atresia in
rare cases. In such cases, air can pass into the stomach and
small bowel through the TEF and become trapped in the
upper gastrointestinal tract proximal to the intestinal atresia.
This trapped air phenomenon is especially concerning in neo-
nates receiving PPV since intestinal dilation can result in sig-
nificant respiratory compromise and possible intestinal
rupture. In such cases, an emergent gastrostomy may be
needed to decompress the stomach and upper gastrointesti-
nal tract.48
Neurological anomalies
Neural tube defects (NTD) require special care in the DR to
prevent injury to the spinal cord. For newborns with NTD, the
initial steps of neonatal resuscitation must include position-
ing on the side or in a prone position to avoid putting pressure
 TAGEDENS E M I N A R S I N
on the lesion. After proper positioning, the defect should be
inspected for rupture and then covered with sterile non-stick
gauze. A foam donut or a gauze rolled into a circle can then
be placed around the defect as a protective measure. Some
centers also apply a dressing extending from below the site of
the NTD over the buttocks to avoid inadvertent contamina-
tion of the lesion with meconium or stool (a.k.a., ‘mud flap’).
Latex-free dressing and gloves should be used in the DR to
prevent the later development of latex allergy.49
Arnold Chiari malformation, with herniation of the cerebral
tonsil and brainstem through the foramen magnum, is com-
mon with NTD. This herniation can result in compression of
the part of the brain stem that controls the vocal cords. This
can result in vocal cord dysfunction or paresis, resulting in
stridor or respiratory distress in the DR. Early endotracheal
intubation may be needed in such cases.
Conjoined twins
Conjoined twins are rare, occurring in 1 in 500,000 live births,
and have different presentations depending on the orientations
of the neonates and fusion site.50 The conjoined bodies of the
twins and the presence of additional congenital anomalies cre-
ate many challenges for resuscitation.51 Planning for resuscita-
tion involves preparation for the simultaneous resuscitation of
two newborns. Preparation should include having two dupli-
cate sets of resuscitation equipment: one for each twin.
Depending on the orientation of the twins, positioning may
include the use of blankets, pillows, or foam padding to ensure
proper positioning of each newborn’s airway. In addition, the
placement of pulse oximetry and ECG leads may need to be
modified to accommodate the unique anatomy of the twins.
The resuscitation of conjoined twins requires modification
to neonatal resuscitation guidelines, including ventilation
and airway management, administration of chest compres-
sions, obtaining vascular access, and medication dosing.51
The majority of the ventral conjunction twins have limited
distance between the faces making face mask PPV and intu-
bation challenging. This may require rotating the twin receiv-
ing PPV or intubation to a side-lying position. Fusion at the
thorax level or limited distance between the thoraces, as in
the case of thoracopagus, omphalopagus, and janiceps twins,
requires performing chest compressions from the opposite
side of the twin receiving the compressions. This positioning
may also be considered for the placement of vascular access.
If the umbilical cord is shared or not easily accessible, alter-
native methods of vascular access such as a peripheral IV or
IO needle may be considered. Shared organs can impact the
pharmacokinetics of medications, including epinephrine.
Therefore, using a higher than recommended dose of epi-
nephrine should be considered.52 If there is no response,
administering epinephrine to the other twin may be benefi-
cial since the circulatory pathways can be complex.52
RESUSCITATION IN THE NEONATAL INTENSIVE
CARE UNIT
About 0.25% of neonates in tertiary NICUs and 1-2% of infants
in quaternary NICUs require cardiopulmonary resuscitation
P E R I N A T O L O G Y 46 (2022) 151626 5
with chest compressions and/or epinephrine.53-56 This means
that complex resuscitations are up to ten-fold more common
in the NICU than in the DR.1 Most neonates resuscitated in
the NICU have a history of prematurity and deteriorate to car-
diac arrest due to acute respiratory compromise on a
mechanical ventilator.56 Other common causes of neonatal
cardiac arrest in the NICU include multiorgan failure, septic
shock, and arrhythmias.56
The neonatal resuscitation guidelines developed by the
American Heart Association and the American Academy of
Pediatrics apply to newborns transitioning from intrauterine
to extrauterine life. However, they can also be used for neo-
nates who have completed the newborn transition and
require resuscitation anytime during the initial hospitaliza-
tion in the NICU.2 Therefore, most practitioners who resusci-
tate babies in the NICU follow the neonatal resuscitation
guidelines. However, given the complex nature of some NICU
resuscitations, the pediatric advanced life support (PALS)
guidelines for infant resuscitation may also be applicable.57
The PALS guidelines on infant resuscitation differ in several
respects from the neonatal resuscitation guidelines (Table 2).
Neonatal resuscitation guidelines focus on inflation and ven-
tilation of the lungs as the cornerstones of newborn resusci-
tation. This is why the recommended sequence of events is
Airway, Breathing, and then Chest compressions (A-B-C).58
PALS guidelines follow a chest compression, Airway, and
then Breathing (C-A-B) sequence, which was adopted to
match adult resuscitation guidelines. Neonatal resuscitation
guidelines recommend a synchronized 3:1 compression to
ventilation ratio. PALS uses various compression to ventila-
tion ratios depending on the number of rescuers and the
presence of an advanced airway (Table 2). Neonatal resuscita-
tion guidelines use a single algorithm focused on treating
perinatal asphyxia. PALS guidelines address a broad range of
pathologies and use a variety of resuscitation algorithms.
Additionally, the PALS guidelines include instructions on
using numerous emergency medications not included in the
neonatal resuscitation guidelines (Table 2).
There are no formal recommendations for when - or how -
to transition between neonatal resuscitation and PALS guide-
lines for older neonates in the NICU.2,57 This is due to the lack
of scientific evidence to determine a specific age after birth
when resuscitation should switch from a focus on the airway
(A-B-C) to a focus on chest compressions (C-A-B) and a lack of
data to suggest when PALS chest compression to ventilation
ratios are superior to those recommended in the neonatal
guidelines. We speculate that there is no specific post-con-
ceptual age, a number of days after birth, or weight when
resuscitation outcomes are improved by following the PALS
guidelines rather than the neonatal resuscitation guidelines.
We suggest that the resuscitation guidelines should align
with the presumed etiology of the arrest. For NICU patients
with an arrest etiology not addressed in the neonatal resusci-
tation guidelines, such as shock, cardiac arrhythmias, or elec-
trolyte disturbances, PALS guidelines are more appropriate
than neonatal resuscitation guidelines.
The practical implications for training NICU teams in both
neonatal and pediatric resuscitation guidelines must be consid-
ered. The leadership in each NICU must decide what resuscita-
tion training is most appropriate for its staff based on the needs
6 S E M I N A R S I N P E R I N A T O L O G Y 46 (2022) 151626

Table 2 – Comparison of neonatal resuscitation and pediatric advanced life support guidelines

Neonatal resuscitation Pediatric advanced life support

Focus Resuscitation Life support

Patient populations Newly born Infants and children

Arrest etiologies Perinatal asphyxia Respiratory failure
Shock
Arrythmias
CPR sequence A-B-C C-A-B
Chest compression 3:1 CC:V ratio One rescuer: 30 CC : 2 V (coordinated CC and V, with pause of CC for V)
(CC) to ventilation (coordinated CC and V, Two rescuers: 15 CC : 2 V (coordinated CC and V, with pause of CC for V)
(V) ratios with pause of CC for V) Advanced airway in place: 100-120 CC/min + 20-30 V/min
(no coordinated CC and V, with no pause of CC for ventilations)
Algorithms 1 6+
Medications epinephrine, normal saline adenosine, albuterol, amiodarone, atropine, calcium chloride, calcium gluco-
nate, dexamethasone, dobutamine, dopamine, epinephrine, epinephrine,
etomidate hydrocortisone, ipratropium bromide, lidocaine, magnesium sul-
fate, methylprednisolone, milrinone, naloxone, nitroglycerin, nitroprusside,
norepinephrine, procainamide, prostaglandin E, sodium bicarbonate, terbu-
taline, vasopressin

of their specific patient population. If the staff within a NICU are Because the incidence of resuscitation is higher in the NICU
trained in both neonatal and pediatric resuscitation guidelines, than in the DR, hospitals and healthcare organizations should
it is essential to develop guidelines and protocols to determine use simulation to improve the quality of NICU resuscitation.
which resuscitation guidelines are used for each specific patient Unlike the DR, where there is often time to conduct a pre-
and communicate this plan to all staff to avoid confusion. brief and assign roles before a resuscitation, such a pre-arrest
huddle is impossible for NICU resuscitation. This makes it
challenging to have a shared mental model and effective
communication during NICU resuscitations. In addition, neo-
PREPARING FOR SPECIAL RESUSCITATIONS nates resuscitated in the NICU have a variety of causes and
are often already on a ventilator with IV access. Therefore,
Simulation is widely used to teach healthcare providers the NICU simulations should include respiratory and non-respi-
cognitive, technical, and behavioral skills needed for effective ratory arrest cases of intubated neonates. Also, the simula-
neonatal resuscitation, and simulation is a critical part of the tions should encourage interprofessional teamwork during
Neonatal Resuscitation Program (NRP) course.59,60 Prepara- an unexpected arrest, including assignment of team member
tion for neonatal resuscitation in special circumstances roles and clear communication within the team.
should include simulations of resuscitations outside the DR,
newborns with congenital anomalies, and resuscitation of
neonates in the NICU.
Simulation-based educational curricula on the manage-
ment of mothers and newborns during a precipitous delivery
Conclusion
in ED have improved knowledge and comfort level in neona-
tal resuscitation.61-63 Such simulation training is essential for
Evidence-based neonatal resuscitation guidelines are devel-
emergency department providers, nurses, and staff, to ensure
oped to focus on the resuscitation of newborns in the DR suf-
that all members of the care team are prepared in the rare
fering from perinatal asphyxia. Modification in neonatal
event that a newborn is delivered in the ED.
resuscitation guidelines is needed for newborn resuscitations
Simulation models for congenital anomalies can be
outside the DR, to address certain congenital anomalies, and
developed and used to practice the initial steps of
to manage neonatal resuscitation in the NICU. Simulation is a
resuscitation.64,65 For certain anomalies such as conjoined
central part of neonatal resuscitation training and should be
twins, having a simulation model based on prenatal imaging
used to prepare for neonatal resuscitation in these different
may aid in resuscitation preparedness. Such a model allows
circumstances. With preparation and practice for special cir-
the providers to become familiar with the unique aspects of
cumstances, healthcare teams can improve the quality of
the anatomy that will impact procedures such as facemask
resuscitation for all neonates.
PPV, intubation, chest compressions, and obtaining vascular
access. In situ simulation for delivery of conjoined twins can
detect systems issues, such as equipment, crowd control, and
team communication, which could impact the resuscita-
tion.52 Simulation exercises should focus on teamwork,
including role assignments, closed-loop communication, and Funding source
shared knowledge on modifications to resuscitation proce-
dures that might be needed. No funding was secured for this study.
 TAGEDENS E M I N A R S I N
Financial disclosure
Authors have no financial relationships relevant to this arti-
cle to disclose.
Declaration of Competing Interest
Authors have no conflicts of interest to disclose.
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