Neonatal Resuscitation Clinical Practice Guidelines (AHA, 2020)

American Heart Association

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

November 02, 2020

In October 2020, the American Heart Association published their updated recommendations for neonatal resuscitation.[1]

Cord Management

Clamping of the umbilical cord may be delayed for more than 30 seconds in term and preterm infants after an uncomplicated birth. Note that umbilical cord milking is not recommended for preterm infants.

Prevention of Hypothermia

Skin-to-skin contact with the mother is recommended for healthy newborn infants because it can promote breastfeeding, improve blood glucose stability, and help prevent hypothermia. The infant’s temperature should be maintained between 97.7°F (36.5°C) and 99.5°F (37.5°C).

Tactile Stimulation

If a newborn infant is breathing ineffectively or has apnea, drying the infant and/or rubbing the back and soles of the feet may help stimulate breathing.

Clearing the Airway

Routine oral, nasal, oropharyngeal, or endotracheal suctioning is not recommended for newborn infants, even those who are born with meconium-stained amniotic fluid (MSAF). However, nonvigorous infants with MSAF at birth who have evidence of airway obstruction can benefit from intubation and tracheal suction.

Ventilatory Support

Start positive-pressure ventilation (PPV) without delay in newborn infants who are gasping or apneic within 60 seconds after birth or who have persistent bradycardia (heart rate of <100 beats/min). A rate of 40 to 60 inflations per minute is reasonable. A key indicator of successful ventilation is an increase in heart rate.

Oxygen Therapy

PPV may be started with air (21% oxygen) in term and late preterm infants; up to 30% oxygen may be used in preterm infants (less than 35 weeks’ gestation). The use of 100% oxygen should be avoided in term and late preterm newborns because it is associated with excess mortality.

Heart Rate Assessment

Electrocardiography can provide rapid and accurate measurement of the heart rate during the resuscitation of term and preterm newborn infants.

Chest Compressions

Initiate chest compressions if the heart rate is lower than 60 beats/min after at least 30 seconds of adequate PPV.

Intravascular Access

The umbilical vein is the recommended route for vascular access in infants who have failed to respond to PPV and chest compressions and who require epinephrine and/or volume expanders.

Epinephrine Administration

Administer epinephrine, preferably intravenously, if the heart rate remains lower than 60 beats/min despite 60 seconds of chest compressions and adequate PPV. The recommended intravenous dose of epinephrine is 0.01 to 0.03 mg/kg.

Volume Expansion  

Failure to respond to epinephrine and known or suspected blood loss are indications for volume expansion with normal saline or blood. The recommended initial volume is 10 mL/kg over 5 to 10 minutes.

Care After Resuscitation  

Newborn infants who received prolonged PPV, intubation, chest compressions, or epinephrine should be monitored closely in a neonatal intensive care unit or similar area after their condition has stabilized.

For more information, please go to Neonatal Resuscitation.

For more Clinical Practice Guidelines, please go to Guidelines.


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