R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6
Available online at ScienceDirect
Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation
Practice Guideline
European Resuscitation Council Guidelines 2025
Newborn Resuscitation and Support of Transition
of Infants at Birth
Marije Hogeveen a,1,*,
1
Joint first author.
Vix Monnelly b,1
, Mathijs Binkhorst a
, Jonathan Cusack c
,
Joe Fawke c
, Darjan Kardum d,e
, Charles C. Roehr f,g,h
, Mario Ru¨diger i
, Eva Schwindt j
,
Anne Lee Soleva˚g k,l
, Tomasz Szczapa m,n
, Arjan te Pas o
, Daniele Trevisanuto p
,
Michael Wagner q
, Dominic Wilkinson r,s,t
, John Madar u,v
Abstract
These European Resuscitation Council (ERC) Guidelines 2025 on Newborn Life Support are based on the International Liaison Committee on
Resuscitation (ILCOR) Consensus on Science wtih Treatment Recommendations (CoSTRs) for Neonatal Life Support. These Guidelines present
a logical approach to resuscitation and support of transition to extra-uterine life, for both preterm and term newborn infants. These Guidelines include
factors before birth, training and education, thermal control, management of the umbilical cord after birth, initial assessment, airway, breathing and
circulation assessment and interventions, emergency vascular access, low resource and out of hospital settings, communication with parents, and
considerations on withholding and discontinuing life sustaining treatments. Life support guidelines for older infants and children are covered in the
ERC Guidelines 2025 Paediatric Life Support.
The ERC Guidelines 2025 on Newborn Life Support (NLS) include
both resuscitation at birth and support of transition from fetus to newborn
infant across all gestational ages (GA). Newborn resuscitation
differs fundamentally from resuscitation in every other age group
due to the unique physiological transition from intrauterine to
extrauterine life. The adaptation at birth requires a complex interplay
of respiratory, cardiovascular, and metabolic changes, making timely
and appropriate intervention crucial. It primarily focuses on supporting
postnatal transition, with establishment of lung aeration, effective
breathing or ventilation, and optimising pulmonary blood flow.
*
Abbreviations: CPR, Cardiopulmonary resuscitation, C:V, Compression to ventilation (ratio), CI, Confidence intervals, CoSTR, Consensus on
Science and Treatment Recommendations, CPAP, Continuous positive airway pressure, DCC, Delayed cord clamping, ECG, Electrocardiography,
FRC, Functional residual capacity, GA, Gestational age, HCP, Health care professional, HR, Heart rate, HIE, Hypoxic ischemic encephalopathy,
ICC, Immediate cord clamping, IO, Intraosseous, IV, Intravenous or intravascular, NICU, Neonatal Intensive Care Unit, NLS, Newborn Life Support,
FiO2, Fractional inspired oxygen concentration, OR, Odds ratio, PLS, Paediatric Life Support, SpO2, Peripheral oxygen saturation, PEEP, Positive
end-expiratory pressure, PPV, Positive pressure ventilation, RCT, Randomized controlled trial, ROSC, Return of spontaneous circulation, s, Second
(s), SGA, Supraglottic airway device, UVC, Umbilical venous catheter
Corresponding author.
E-mail address: marije.hogeveen@radboudumc.nl (M. Hogeveen).
https://doi.org/10.1016/j.resuscitation.2025.110766
0300-9572/© 2025 European Resuscitation Council. Published by Elsevier B.V.
The evidence to support newborn resuscitation remains limited,
with many recommendations extrapolated from animal studies,
observational data, or expert consensus. The ERC NLS Writing
Group recognises these challenges but has aimed to develop clear,
evidence-informed guideline recommendations that balance scientific
rigor with practical applicability. By emphasising consistency,
simplicity, and effective education, they serve as a foundation for
improving newborn resuscitation practices across diverse healthcare
environments.
Introduction and scope
2 R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6
The ERC Guidelines 2025 NLS are based on the International
Liaison Committee on Resuscitation (ILCOR) Consensus on Science
and Treatment Recommendations (CoSTRs) for Newborn Life Sup-
port.2–6
For the purposes of these Guidelines, the ILCOR recommendations
were supplemented by focused literature reviews undertaken
by the ERC NLS Writing Group for topics not reviewed by ILCOR
CoSTRs. When required, the Guideline was informed by expert consensus
of the ERC NLS Writing Group. The ERC Guidelines 2025
NLS were drafted and agreed by the ERC NLS Writing Group members
and the ERC Guidelines 2025 Steering Committee. These
Guidelines were posted for public comment between 15 May and
30 May 2025. A total of 69 individuals submitted comments, this
feedback was reviewed by the NLS writing group. The Guidelines
were thereafter updated where relevant, resulting in 40 changes in
the final version. The ERC Guidelines 2025 NLS were presented
to and approved by the ERC Board and the ERC General Assembly
in June 2025. The methodology used for guideline development is
presented in the Executive summary.7
For consistency, the ERC Guidelines 2025 NLS describe a baby at
birth as a ‘newborn infant’ and a baby or a neonate as an ‘infant’
throughout this guideline. The term ‘mother’ is used to describe the person
giving birth, the term ‘parents’ is used to describe the caregivers.
Newborn life support or paediatric life support?
In agreement with the ERC Guidelines 2025 Paediatric Life Support
(PLS) Writing Group, the ERC recommends the following:
Fig. 1 – Neonatal life support – key messages.
Use the ERC Guidelines 2025 NLS immediately after birth irrespective
of birth location (i.e. hospital or home birth)
The ERC Guidelines 2025 NLS can also be used during Neonatal
Intensive Care Unit (NICU) stay, especially in preterm infants or
term infants with primary respiratory problems.
Use the ERC Guidelines 2025 PLS1
after first hospital discharge.
Using the ERC Guidelines 2025 PLS1
during first hospital stay
after birth is also reasonable in the following circumstances:
o after cardiac surgery,
o in known cardiac arrhythmia, and
o In other non-respiratory cardiac arrests
Develop local policies defining which guideline to use for which
infants, applicable to the healthcare setting. Factors to take into
consideration include:>
o individual NICU case-mix,
o algorithm familiarity and training, and
o human and organisational factors
Teams may initiate resuscitation using the guideline they are most
familiar with (NLS or PLS) and summon appropriate help and
switch guideline if needed, in a timely and coordinated manner.
Preterm infants at the threshold of viability
The ERC Guidelines 2025 NLS apply predominantly to management
of infants with gestational age (GA) 25 weeks. Until more evidence
from trials including the most preterm infants is available, the ERC
R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6 3
Fig. 2 – Neonatal Life Support algorithm. CPAP: continuous positive airway pressure; ECG: electrocardiography; IO: intra-osseous
needle; PEEP: positive end-expired pressure; PPV: positive pressure ventilation; SGA: supraglottic airway; SpO2: peripheral oxygen
saturation; UVC: umbilical venous catheter.
4 R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6
Table 1 – Key changes in NLS 2025 Guidelines.
Topic ERC 2021 NLS Guidelines ERC 2025 NLS Guidelines
When to use Newborn Life
Support (NLS) or Paediatric
Life Support (PLS) algorithms
Not included The NLS and PLS Writing Groups have included
aligned statements relating to when it might be
appropriate to use either resuscitation algorithm.
Both writing groups consider it reasonable for
teams to initiate resuscitation of an infant outside
the delivery area using the guideline most familiar
to them (either NLS or PLS) whilst summoning
appropriate help and switching algorithm in a timely
fashion if necessary.
Applicability of Guidelines to
the most preterm infants at the
limits of viability
Not included The Guidelines acknowledges the paucity of
resuscitation data available from extremely preterm
infants especially <25 weeks and cautions that this
guideline is based upon evidence from
predominantly older gestational ages, which limits
applicability to extremely low gestational ages
Telemedicine Not included Telemedicine can provide remote advice and health
systems should consider how this can be used.
Environment and equipment All equipment must be regularly checked and ready
for use. Where possible, the environment and
equipment should be prepared in advance of the
birth of the infant.
Equipment should be easily accessible and
organised in a standardised way.
Consider human factor elements when organising
equipment and training to maximise efficiency and
to minimise time delays.
Delayed cord clamping (DCC) Where immediate resuscitation or stabilisation is
not required, aim for delayed cord clamping of at
least 60 s. A longer period may be more beneficial.
Although recommendations about delayed cord
clamping have not changed significantly, there is
even more emphasis on the importance of delayed
cord clamping for all newborn infants, especially
preterm infants. In newborn infants needing
resuscitation, clamp the cord <30 s to minimise
delay to necessary interventions.
Where delayed cord clamping is not possible
consider cord milking in infants >28 weeks
gestation
Cord milking The guideline reinforces not milking the cord in
preterm infants <28 weeks and focusses on trying
to perform delayed cord clamping if possible. Cut
cord milking is acknowledged as a reasonable
alternative if >28 weeks and delayed cord clamping
not possible.
Initial assessment colour There is a reduced emphasis on skin colour during
initial assessment. This reflects the subjective
nature of detecting cyanosis or pallor especially in
different skin tones.
As part of initial assessment, observe tone (&
colour).
Determine the heart rate with a stethoscope and a
saturation monitor +/- electrocardiogram (ECG) for
later continuous assessment.
The guideline recognises the increasing role for
ECG as a continuous method of HR evaluation
which is more precise than other methods.
However, auscultation with a stethoscope remains
a reasonable first option.
Initial assessment heart rate
(HR)
Airway management If there is no heart rate response and the chest is
not moving with inflations consider a 2-person
facemask support if single handed initially
Securing the airway via tracheal intubation or
insertion of a laryngeal facemask.
Use the two-person method of airway support (jaw
thrust) if sufficient providers are available as this
approach is more effective than single person
technique.
A supraglottic airway should be considered if
facemask ventilation is ineffective.
Airway – no chest wall
movement – increasing
pressures
If there is no heart rate response and the chest is
not moving with inflations, consider a gradual
increase in inflation pressure
If there is no HR response, the chest is not moving
with inflations and airway opening techniques are
ineffective, increase inflation pressure.
Reduce inflation pressure when chest movement
seen and clinical improvement.
R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6 5
Table 1 (continued)
SpO2 target ranges incorporating newer data from
preterm infants in addition to the established data from
mostly term infants before DCC was standard practice
now result in a target range of acceptable SpO2
Time after birth: target SpO2
. 3 min: 70–75 %
5 min: 80–85 %
Topic ERC 2021 NLS Guidelines ERC 2025 NLS Guidelines
Airway video laryngoscopy Use video laryngoscopy if available. This reflects
evidence of increased first attempt success in
tracheal intubation when video laryngoscopy is
used. A conventional direct laryngoscope should be
available as an alternative.
The use of video laryngoscopy may aid
endotracheal tube placement.
Breathing – CPAP/PEEP In spontaneously breathing preterm infants
consider CPAP using either facemask or nasal
interface. Use PEEP at minimum of 5–6 cm H2O
when providing positive pressure ventilation (PPV)
to these infants.
Apply appropriately fitting nasal interface or a
facemask connected to a device for providing
positive pressure ventilation.
CPAP and PEEP is now recommended at a level of
6 cm H2O.This guideline acknowledges that CPAP
may be considered in infants >32 weeks GA with
respiratory distress if they require supplemental O2.
Infants 32 weeks needing respiratory support:
start with 21 % O2.
Infants >28 weeks but <32 weeks start with 21–
30 % O2. Infants <28 weeks gestation start with
30 % O2
Initial oxygen concentration according to gestation
has been simplified:
Infants 32 weeks needing respiratory support:
start with 21 % O2
Infants <32 weeks: start with 30 % O2
Breathing – Initial oxygen
concentration
Aim to achieve target SpO2 >25th percentile for
healthy term infants.
Time after birth: target SpO2
2 min: 65 %
5 min: 85 %
10 min: 90 %
Breathing – Oxygen target
saturations
10 min: 85–95 %Reduce O2 if saturations
exceed 95 %
When chest compressions are performed, a
supraglottic airway or tracheal tube should be
considered, depending on training and experience.
The time intervals of intravenous or intraosseous
adrenaline have been simplified:
Circulation If chest compressions are required consider
securing the airway, ideally with a tracheal tube.
Drugs Adrenaline An intravenous dose of adrenaline of 10–
30 mg kg 1
(0.1–0.3 mL kg 1
of 1:10,000
adrenaline [0.1 mg/mL]) every 3–5 min. 10–30 mg kg 1
(0.1–0.32 mL kg 1
of 1:10,000
adrenaline [0.1 mg/mL]) every 4 min.
Sodium bicarbonate may be considered in a
prolonged unresponsive resuscitation with
adequate ventilation to reverse intracardiac
acidosis.
Drugs – Sodium Bicarbonate Removed from 2025 guideline
Drugs Naloxone A dose of naloxone may help in the few infants who,
despite resuscitation, remain apnoeic with good
cardiac output when the mother is known to have
received opioids in labour.
Removed from 2025 guideline
An intravenous dose of 2 mg kg 1
(2 mL kg-1
of
10 % glucose) is suggested in a prolonged
resuscitation to reduce the likelihood of
hypoglycaemia
Glucose There is greater emphasis on checking blood
glucose during resuscitation and treating only if it is
low, rather than empirical treatment of presumed
hypoglycaemia during resuscitation.
The guideline acknowledges the potential for harm
from both hypoglycaemia and hyperglycaemia. The
bolus glucose has been aligned with ERC 2025
guideline PLS.
Not included The guideline considers out of hospital births as low
resource settings, especially when unexpected
and/or preterm birth. Includes a section on
identifying and managing the common problem of
hypothermia and safe transfer to hospital.
Low resource and remote
settings
Not includedParent input into Guideline
2025
Guideline has been developed with input by a
parent organisation in relevant sub-sections
NLS Writing Group recommends caution when applying the recommendations
in these Guidelines to them.8
6 R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6
Local approaches should be defined.
Standardised gestational age cut-off across the Guideline
To ensure consistency and practical applicability, the ERC NLS Writing
Group standardised the gestational age (GA) cut-off across all subtopics.
Although many ILCOR reviews on preterm infants focus on
infants <34 weeks, most studies include predominantly infants
<32 weeks, therefore 32 weeks was adopted as a pragmatic cut-off.
This aligns with the ERC Guideline 2021 NLS9
and common clinical
thresholds for determining the appropriate level of perinatal care.
Key messages and key changes
Key messages are presented in Fig. 1. Summary of key changes is presented
in Table 1 and the Neonatal Life Support Algorithm is shown in
Fig. 2.
Concise guidelines for clinical practice
Factors before birth
Staff attending births in hospitals
Any infant may develop problems during birth. Local guidelines
should indicate who should attend births taking into consideration
identified risk factors (Fig. 3).
Fig. 3 – Common factors associated with the need for stabilisation, or resuscitation at birth BMI: body mass index.
As a guide:
An interprofessional team with appropriate experience and training
in NLS proportionate to the expected risk should attend the birth.
Neonatal staffing levels should acknowledge the potential need to
deliver unexpected support in the delivery area.
A process should be in place for rapidly mobilising extra team
members with adequate resuscitation skills for any birth.
Telemedicine
Consider the use of collaboration through telemedicine, as it facilitates
providing remote advice.
Equipment and environment
Regularly check all equipment to ensure it is ready for use.
Ensure that equipment is easily accessible and organised in a
standardised way.
Consider human factor elements when organising equipment to
maximise efficiency and minimise time delays.
Resuscitation should take place in a warm, well-illuminated, draughtfree
area with a flat resuscitation surface and an external heat source,
e.g. a radiant heater (see thermal control).
Briefing
Team briefing is important and should be performed before birth.
The purpose of briefing is to:
R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6 7
Review available clinical informationo
o Assign roles and tasks
o Check equipment and presence of personnel
o Prepare the family
Use a checklist and/or cognitive aid to facilitate all of the above,
reduce mental load, and enhance safety.
Education
Institutions or clinical areas where births may occur should provide
sufficient opportunities and resources for healthcare professionals
involved in neonatal resuscitation to receive regular training, maintaining
up-to-date knowledge as well as technical and non-technical skills.
The content and organisation of such educational programmes
may vary according to the needs of the providers and the local
organisation.
Undertake training at least once per year to prevent skill decay,
preferably supplemented with more frequent short-duration booster
sessions (e.g. every 3–6 months). For more information on
education see ERC Guidelines 2025 Education for Resuscitation.
Thermal control
Standards
Maintain the temperature of newborn infants between 36.5 °C
and 37.5 °C.
Monitor the infant’s temperature regularly or continuously after birth.
Record the admission temperature as a prognostic and quality
indicator.
Rewarm infants who are hypothermic after birth; avoid hyperthermia.
In appropriate circumstances, therapeutic hypothermia may be
considered after resuscitation (see post-resuscitation care).
Environment
Protect the infant from draughts. Ensure windows are closed and
air-conditioning appropriately programmed.
In infants >28 weeks, keep the delivery area at 23–25 °C.
In infants 28 weeks, keep the delivery area at >25 °C.
Newborn infants 32 weeks
Dry the infant immediately after birth and remove wet towels.
Cover the infant’s head with a hat, and the body with >dry towels.
Table 2 – Assessment of breathing and heart rate.
Assessment Intervention
Breathing assessment
Regular Satisfactory None required
Slow, gasping or grunting Inadequate Assess – may require intervention
Not breathing Absent Intervention required
HR assessment
>100 min 1
(fast) Satisfactory None required
60–100 min 1
Inadequate Assess – may require intervention
<60 min 1
(very slow or absent) Emergency Intervention required
If no intervention is required, place the infant skin-to-skin with
mother or let her do so herself- and cover both with towels.
Ongoing careful observation of mother and infant is required,
especially in more preterm and growth restricted infants to ensure
they both remain normothermic.
Consider the use of a plastic bag/wrap if skin-to-skin care is not
possible.
Place the infant on a warm surface using a preheated radiant
warmer, if support of transition or resuscitation is required.
Newborn infants <32 weeks
Dry the infant’s head and cover with a hat.
Put the infant’s body in a plastic (polyethylene) bag or wrap without
drying.
Use a preheated radiant warmer.
Consider the use of additional measures during delayed cord
clamping to ensure thermal stability (e.g. increasing room temperature,
warm blankets, and thermal mattress).
Be careful to prevent hypothermia during skin-to-skin care during
assisted transition, especially in the more preterm and/or growth
restricted infants.
Consider the use of heated humidified respiratory gases for
infants receiving respiratory support.
Be aware of the risk of hyperthermia when multiple heatpreservation
interventions are used simultaneously.
Management of the umbilical cord
Ideally, delayed cord clamping is performed in all births, after
inflation of the lungs and before uterotonics are given.
Cord clamping
Discuss the options for managing cord clamping and the rationale
with parents and team before birth.
Perform thermal management, tactile stimulation and initial
assessment during delayed cord clamping.
Newborn infants without need for support: facilitate at least 60 s
of delayed cord clamping.
Newborn infants in need of resuscitation: clamp the cord < 30 s to
minimise any delay to necessary interventions.
If stabilisation with intact cord can be safely undertaken, longer
delayed cord clamping is preferred, especially in infants
<34 weeks.
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Cord milking
Do not milk the cord in preterm infants <28 weeks.
Consider intact cord milking as an alternative in infants
28 weeks, but only if delayed cord clamping cannot be
performed.
Initial assessment
Perform initial assessment as soon as possible after birth, ideally
during delayed cord clamping, drying and wrapping to:
o Identify the need for support and/or resuscitation
o Aid decisions relating to the appropriateness and duration of
delayed cord clamping.
Assess: (Table 2).
o Breathing
o Heart rate (HR)
o Muscle tone
Provide thermal management and tactile simulation during
delayed cord clamping and assessment.
Reassess breathing and HR frequently to assess any response
and determine if further interventions are required.
Fig. 4 – Initial assessment and interventions. DCC: delayed cord clamping; HR: heart rate; SpO2: peripheral oxygen saturation; ECG:
electrocardiography. a
Slow HR may indicate hypoxia, so airway and breathing require support. Ventilatory support will likely be adequate for a
higher HR and adequate transition. b
HR suggestive of significant hypoxia, so airway and breathing support required urgently. c
SpO2 +/- ECG.
Breathing
Note presence or absence of breathing.
If breathing: note the rate, depth, symmetry and work of
breathing.
Heart rate
Initial HR assessment can be performed with a stethoscope.
Continuous HR assessment methods (pulse oximetry,
electrocardiography (ECG)) are preferred when interventions
are indicated or during stabilisation of preterm newborn
infants.
Do not interrupt resuscitation to place pulse oximetry or
ECG.
Response to tactile stimulation
Gently stimulate the newborn infant by drying them, and rubbing
the soles of the feet or the back.
Avoid more vigorous methods of stimulation, especially in preterm
infants.
Muscle tone & skin colour
A very floppy infant is likely to need breathing support.
Hypotonia is common in preterm infants.
Do not use colour to assess oxygenation.
R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6 9
Interpret pallor within clinical context, as it may have several
causes such as acidosis, asphyxia, blood loss, or chronic
anaemia.
Fig. 5 – Head positions. Head needs to be in a neutral position. Face is horizontal.
Classification according to initial assessment
Based on the initial assessment, further actions can be implemented
guided by the NLS algorithm (Fig. 2). These are summarised
in Fig. 4.
Newborn life support
Ensure the airway is open and the lungs are inflated.
Do not undertake subsequent interventions before the airway is
open and the lungs have been inflated.
Following initial assessment, start respiratory support if the infant
is not breathing regularly or the HR is <100 min 1
.
Airway
Assess the effect of each airway technique by observing for chest
movement and assessing HR.
Fig. 6 – Jaw thrust. Jaw thrust = pushing the lower jaw forwards
with pressure from behind, enlarges the pharyngeal space.
Position
Place the newborn infant on their back with the head supported in
a neutral position (Fig. 5).
Gently push the lower jaw forwards with pressure from behind
(jaw thrust) to open the airway (Fig. 6).
Two-person method
Use the two-person method of airway support (jaw thrust) as this
approach is more effective than single person jaw thrust.
Suction
Do not routinely suction meconium or amniotic fluid from infant’s’
airways because it delays initiating ventilation.
Consider physical airway obstruction if lung inflation is unsuccessful
despite alternative airway opening techniques.
Perform suction under direct vision.
Rarely, with no response to inflations and no chest wall movement,
an infant may require tracheal suctioning to relieve an airway
obstruction below the vocal cords.
Airway devices
Use airway devices only if competent personnel are available and
trained in the appropriate equipment; if not continue with facemask
ventilation and call for help.
Supraglottic airway devices. Consider using an appropriate size
supraglottic airway device (SGA) (see manufacturer’s instructions for
use):
When facemask ventilation is ineffective;
As an alternative for facemask ventilation if SGA size permits;
When a more definitive airway is required as an alternative to tracheal
intubation;
Where tracheal intubation is not possible or deemed unsafe
because of congenital abnormality, a lack of equipment, or a lack
of skill;
2
2
2
O 21 %
When chest compressions are performed.
10 R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6
Nasopharyngeal and oropharyngeal airway devices.
Consider nasopharyngeal or oropharyngeal airway devices,
especially when facemask ventilation may be difficult (e.g.
micrognathia).
Use oropharyngeal airway devices with caution in infants < 34 weeks.
They might contribute to airway obstruction.
Tracheal tube. Consider tracheal tube placement:
When equipment and skills permit;
When facemask or SGA ventilation are ineffective;
With prolonged ventilation;
When suctioning the lower airways (removal of presumed tracheal
blockage);
When performing tracheal intubation:
When chest compressions are performed.
Have a range of different sized tubes available
Use video laryngoscopy or, if unable, direct laryngoscopy
Use exhaled CO2 detection and clinical assessment to confirm
tracheal intubation
o Be aware that exhaled CO2 detection may be false negative in
low or no cardiac output states at birth
Use appropriate imaging to confirm correct tube position
If available, respiratory function monitoring may be used to help
confirm tube position within the airway and assist adequate ventilation
(expired tidal volume 4 to 8 mL kg 1
with minimal leak).
Breathing
Inflate the lungs when the newborn infant is not breathing using a
facemask or nasal interface.
Nasal interfaces used to provide positive pressure ventilation
(PPV) may vary: single or binasal prongs, short or long prongs,
or nasal mask.
Assisted ventilation
Lung inflation.
If apnoeic, gasping or not breathing effectively, start PPV as soon
as possible to inflate the lungs – ideally within 60 s.
Apply appropriately fitting nasal interface or a facemask connected
to a device for providing positive pressure ventilation.
Give 5 inflations with an inflation time up to 2–3 s.
Infants <32 weeks: starting inflation pressure 25 cm H O.
Infants 32 weeks: starting inflation pressure 30 cm H O.
Consider pulse oximetry ± ECG (Table 3).
Assessment.
During lung inflations: look for chest movement.
o Visible chest movement during inflations indicates a patent airway
and delivered volume.
o Failure of the chest to move may indicate that the airway is not
open, or that insufficient inflation pressure/volume is delivered.
Table 3 – Inflations, inflation pressure, positive end-expiratory pressure and initial oxygen.
GA Inflations PIP PEEP O2
32 weeks 5 x up to 2–3 s 30 cm H2O 6 cm H2
<32 weeks 5 x up to 2–3 s 25 cm H2O 6 cm H2O 30 %
After lung inflations: check HR
o An increase in HR within 30 s of positive pressure ventilation,
or a stable HR >100 min 1
, usually confirms adequate ventila-
tion/oxygenation
o HR <100 min 1
or decreasing usually suggests continued
hypoxia and almost always indicates inadequate ventilation
If there is a HR response.
Continue uninterrupted positive pressure ventilation until the
infant begins to breathe adequately and the HR >100 min 1
.
Aim for a positive pressure ventilation rate of 30 ventilations
min 1
with an inflation time of approximately 1 s.
Adapt inflation pressure based on clinical observation (chest
movement and HR).
Reassess breathing and HR every 30 s, until the newborn infant
is deemed stabilised.
Consider inserting SGA or tracheal tube if apnoea continues.
If there is no HR response. If there is no HR response and the
chest is not moving with inflations:
Call for help.
Recheck equipment.
Perform airway opening technique of choice.
If the airway opening techniques are ineffective in inflating the
lungs, increase inflation pressure.
Repeat inflations after every airway opening technique or after
increasing inflation pressure.
Re-assess chest movement and HR after inflations until visible
chest movement or HR response.
Reduce inflation pressure when chest movement is seen and clinical
improvement.
I
Without adequate lung inflation, chest compressions will be
ineffective:
f being used, check with a respiratory function monitor that
expired tidal volume is within target range (4–8 mL kg 1
, depending
on gestational age).
Confirm effective ventilation through observed chest movement
or other measures of respiratory function.
Then progress to chest compressions, if the HR remains
<60 min 1
.
Continuous positive airway pressure (CPAP) and positive endexpiratory
pressure (PEEP)
Use either nasal interface or a facemask as device-patient interface
to deliver CPAP or PEEP.
Start with CPAP at 6 cm H O as initial breathing support in:
o Spontaneously breathing infants <32 weeks with respiratory
distress
o Spontaneously breathing infants 32 weeks with respiratory
distress requiring supplemental O2
In infants needing positive pressure ventilation, start with PEEP
at 6 cm H2O.
2
2
[0.1 mg/mL])
R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6 11
Ventilation devices
Use appropriately sized nasal interface or facemask.
Ensure effective seal with minimal force on the facemask.
Where possible, use a T-piece resuscitator capable of providing
either CPAP or positive pressure ventilation + PEEP when giving
ventilatory support, especially in the preterm infant.
Self-inflating bags should be available as backup:
o Take care not to deliver excessive volumes and pressures.
o Be aware that CPAP might not be effectively delivered even
when a PEEP valve is used.
Oxygen
Use pulse oximetry and O2-blenders during resuscitation or stabilisation
in the delivery area.
Check O2 and saturations every 30 s.
Titrate inspired O2 to achieve target SpO2 between the 25th
–75th
percentile (Fig. 7).
Infants 32 weeks needing respiratory support:
o Start at 21 % O2
Infants <32 weeks:
o Start at 30 % O
o Avoid SpO <80 % and/or bradycardia at 5 min of age
Circulation
Chest compressions
Start chest compressions if the HR remains <60 min 1
after at
least 30 s of effective ventilation.
When starting chest compressions:
o Increase O2 to 100 %
o Call for experienced help if not already summoned
o Anticipate the need to secure the airway and establish vascular
access for medication
Use a 3:1 compression-to-ventilation ratio (C:V), aiming for 90
compressions and 30 ventilations (120 events) per minute.
Use the two-thumb-hands-encircling-technique with overlapping
or adjacent thumbs to deliver chest compressions.
Compress to a depth of one-third of the anterior-posterior chest
diameter.
Allow full chest recoil between compressions.
Re-assess HR every 30 s.
If HR <60 min 1
, secure the airway with an SGA or tracheal tube
(if competent and not already done) with minimal interruptions to
ongoing chest compressions.
After SGA placement or tracheal intubation continue with the
3:1C:V ratio.
Titrate O2 against the oxygen saturation once a reliable value is
achieved (Table 4)
Table 4 – Target oxygen saturation ranges. Derived
from Dawson et al. 2010 and Wolfsberger et al. 2024, and
consensus within the NLS WG.10–12
Time after birth SpO2 [%]
3 min 70–75
5 min 80–85
10 min 85–95
Discontinue chest compressions if the HR is >60 min 1
; check for
output (e.g. auscultation, pulse check, pulse oximetry, signs of life).
Vascular access
Umbilical venous access.
Use the umbilical vein for rapid emergency vascular access during
resuscitation at birth.
Perform emergency umbilical venous catheter (UVC) placement
under clean rather than sterile conditions to ensure timely vascular
access is secured.
Consider the use of emergency umbilical venous catheter until
some days after birth as it may still be achievable.
Intraosseous access.
Use intraosseous (IO) access as an alternative method of emergency
vascular access for medication and fluids.
Consider device-specific weight limitations for IO related
equipment.
Ensure there is no extravasation when administering medication
and fluids.
Do not aspirate bone marrow; even when correctly positioned, it
is often not possible.
Support of transition/post-resuscitation care.
If venous access is required following resuscitation, peripheral
access may be adequate unless multiple infusions and/or vasopressors
are required in which case central access may be preferred.
Medication during resuscitation at birth
Resuscitation medication may be considered where, despite adequate
control of the airway, effective ventilation, and chest compression for at
least 30 s, HR remains <60 min 1
and is not increasing.
Adrenaline
Umbilical venous catheter or IO is the preferred route.
o Give 10–30 mg kg 1
(0.1–0.3 mLkg 1
of 1:10,000 adrenaline
o Give subsequent doses every 4 min if HR remains <60 min 1
If no umbilical venous catheter/IO access but intubated:
o Give intra-tracheal adrenaline at dose of 100 mg kg 1
(1 mL kg 1
of 1:10,000 adrenaline [0.1 mg/mL])
o If HR remains <60 min 1
: as soon as umbilical venous catheter/
IO access is obtained, immediately give a dose via this route,
irrespective of when the intra-tracheal dose was given
Glucose
If possible, check the blood glucose value during resuscitation.
If blood glucose is low: give glucose 200 mg kg 1
(2 mL/kg of
10 % glucose).
Intravascular volume replacement
Give 10 mL/kg of group O Rh-negative blood or isotonic crystalloid
solution if suspected blood loss or in a newborn infant unresponsive
to other resuscitative measures.
Absence of an adequate response despite appropriate
resuscitation measures
Consider other factors which may be impacting the response to
resuscitation, and which require addressing such as the presence
of pneumothorax, hypovolaemia, congenital abnormalities, equipment
failure.
12 R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6
Low resource or remote settings
Births outside the hospital may be considered birth in a remote or
lower resource setting, and not all hospitals have the same resources.
HCPs have to adapt according to available resources. Focus
needs to be on prevention or treatment of hypothermia and
hypoxia within the existing possibilities.
Planned home births
Ideally, two trained HCPs should be present at all home births.
Have at least one HCP competent in providing inflations, PPV
and CC to the newborn infant.
Have a minimum set of equipment of an appropriate size for the
newborn infant available.
Have a clear plan of who will attend, what equipment will be available,
and how transfer will be arranged if newborn support is
required and agreed this with parents when formulating the home
birth plan.
HCPs attending home births should have pre-defined plans for
unexpected or difficult situations, including knowing how to communicate
with receiving healthcare facilities for the mother and
newborn infant.
Unexpected births outside the hospital
Emergency services should be prepared and trained for such
events and carry appropriate equipment, especially related to
thermal care and support of airway and breathing.
Equipment to support thermal care and oxygenation should be
available.
Temperature control out of hospital
Involved HCPs should have a heightened awareness of the
increased risk of hypothermia in infants born (unexpectedly) out
of hospital.
They should perform regular temperature checks and intervene if
the temperature is too low.
Most interventions for infants born in hospital (see temperature
management) can also be applied outside the hospital.
If possible, place compromised, preterm (<37 weeks), and/or
growth restricted infants in a preheated incubator for thermal control
and transport.
Post-resuscitation care
Once effective ventilation and circulation are established, the
infant should be cared for in or transferred to an environment in
which close monitoring and anticipatory care can be provided.
Glucose management
Measure blood glucose values early and regularly until they have
stabilised in the normal range; especially in newborns resuscitated
at birth, those at risk of hypoxic-ischaemic encephalopathy
(HIE), and/or receiving intravenous glucose.
Avoid hypoglycaemia, hyperglycaemia, and large swings in blood
glucose value.
Thermal care
Monitor the infant’s temperature frequently or continuously after
resuscitation.
Maintain temperature between 36.5 °C and 37.5 °C and rewarm if
the temperature is below this.
Therapeutic hypothermia
Consider inducing therapeutic hypothermia (33–34 °C) after completion
of resuscitation and detailed assessment of potentially eligible
infants with clinical, biochemical, and (if available)
neurophysiological evidence of HIE.
Use appropriate eligibility criteria and strictly defined protocols to
guide the cooling process; inappropriate application of therapeutic
hypothermia may be harmful.
Arrange safe transfer to an appropriately equipped facility where
monitoring and treatment can be continued.
Monitor (rectal) temperature during transport and, if available,
apply active cooling with a servo-controlled device while transferring
the infant.
Oxygenation & ventilation
Consider additional monitoring of post-ductal oxygen saturation
to identify pulmonary hypertension.
Avoid hypoxia and hyperoxia.
Avoid inadvertent hypocapnia during mechanical ventilation.
Documentation & Prognostication
Keep an accurate time-based record of the infant’s clinical state,
interventions and responses during resuscitation to facilitate retrospective
review.
Record APGAR scores.
Clinical team debriefing
Use performance-focused, interdisciplinary/interprofessional
team debriefings following resuscitation or other non-routine situations
to optimise individual and team performance as well as
systems issues (e.g., emergency supplies, equipment).
Communication with parents
Where intervention is anticipated
The decision to attempt resuscitation of an extremely preterm or
clinically complex infant should be taken in close consultation with
the parents and senior paediatricians, midwifes, and obstetricians.
Discuss the options, including the potential need and magnitude
of resuscitation and the likely prognosis before birth, so that an
individualised management plan can be agreed.
Ensure concise and factual documentation of discussions is
recorded in mother’s notes before birth and in the infant’s notes
after birth.
For every birth
If parents want and resources allow, enable parents to be present
during the stabilisation or resuscitation.
Consider the views of the resuscitation team, parents and
circumstances.
Ensure that parents are fully informed about the progress of the
care provided to their infant.
Identify a member of healthcare staff to support parents and be
aware that witnessing the resuscitation of their infant will be distressing
for them.
Encourage parents to hold or touch their infant as soon as possible
after resuscitation; this should be facilitated especially when
the resuscitation was unsuccessful.
R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6 13
Ensure an accurate record is kept of the resuscitation and of any
subsequent parental communication.
Provide an explanation of any procedures and why they were
required.
Facilitate further discussions later to enable parents to reflect and
to aid their understanding of events.
Provide additional support for parents following resuscitation at
birth.
Discontinuing or withholding resuscitation
Use national or regional outcomes and guidelines to interpret
these recommendations
When discontinuing, withdrawing or withholding resuscitation, care
should be focused on the comfort and dignity of the infant and family
and should ideally involve senior paediatric/neonatal staff.
Discontinuing resuscitation
If the HR remains absent despite ongoing resuscitation,
review clinical factors (for example potential reversible factors,
gestation of the infant), effectiveness of resuscitation, and the
views of other members of the clinical team about continuing
resuscitation.
If the HR of a newborn infant remains absent for more than 20 min
after birth despite the provision of all recommended steps and
exclusion of reversible causes, consider stopping resuscitation.
For preterm infants (particularly extremely preterm), it may be
appropriate to discontinue resuscitation earlier than 20 min. The
decision should be individualised.
Where there is partial or incomplete HR improvement despite
apparently adequate resuscitative efforts, the choice is much less
clear. It may be appropriate to take the infant to the intensive care
unit and later consider withdrawing life sustaining treatment.
Where life-sustaining treatment is withheld or withdrawn, infants
should be provided with appropriate palliative (comfort focused) care.
Withholding resuscitation
Decisions to withhold life sustaining treatment should be made in
advance of birth together with parents in the light of regional/national
evidence on outcome if resuscitation and active (survival
focused) treatment is attempted.
In situations where there is extremely high (e.g. >90 %) predicted
neonatal mortality and unacceptably high morbidity in surviving
infants, attempted resuscitation and active (survival focused)
management is usually not appropriate.
Resuscitation is nearly always indicated in conditions associated
with lower (e.g. <50 %) neonatal mortality and what is deemed to
be acceptable morbidity. This will include most infants with congenital
malformations and most infants >24 weeks or above in
high resource settings with access to neonatal intensive care.
Resuscitation should usually be commenced in situations where
there is uncertainty about the outcome and there has been no
chance to have prior discussions with parents.
In situations where there is high mortality (e.g. >50 %) and/or a
high rate of morbidity, and where the anticipated burden of medical
treatment for the child is high, parental wishes regarding
resuscitation are usually supported. It may be appropriate to provide
full resuscitation, to provide some measures (but withhold
other interventions) or to provide comfort focused care. Provision
of antenatal palliative care support can be beneficial to parents in
the face of certain or uncertain poor outcomes.
Evidence informing the guidelines
Newborn life support or paediatric life support?
These ERC Guidelines 2025 NLS apply mainly to newborn infants at
birth and in the immediate postnatal phase, i.e. during perinatal transition.
There is no clear definition of when transition ends. Thus,
evidence-based recommendations on when to convert from NLS to
Paediatric life support (PLS) guideline are challenging to produce.
Epidemiology
Neonatal intensive care units (NICU) often set distinct age thresholds
for admitting and keeping infants. Some transfer infants to paediatric
units at 44 weeks’ postmenstrual age,13
whereas other NICUs transfer
infants as late as 24 months.14
Moreover, some NICUs operate
separately from birthing hospitals, affecting the patient case-mix.
Thus, the incidence of NICU resuscitation with chest compressions
and/or adrenaline varies between 0.25 % and 1–2 % of infants,15–18
and a significant proportion of CPR events in paediatric intensive care
units (PICUs) is in infants <1 year of age.19
Most NICU arrests are
respiratory in origin,17,18
with more respiratory-related instances
including tracheal tube and airway complications in NICU resuscitation
events compared with PICU/cardiac intensive care unit resuscitation
events.20
Pulseless electrical activity or asystole occurs in 13 %
of NICU resuscitation events, while ventricular tachycardia or fibrillation
incidents are rare in NICUs.21
Differences between NLS and PLS guidelines
Neonatal resuscitation guidelines prioritise ventilation to stabilise
bradycardic or asystolic newborns.9
Paediatric resuscitation guidelines
emphasise chest compressions while managing ventilation carefully
to prevent overventilation by the HCP.22
The two Guidelines
also diverge in areas such as thermal care for different maturity of
newborns, synchronisation of breaths with compressions after tracheal
intubation, and use of medications and adjunctive methods.23
Unlike paediatric guidelines, neonatal guidelines omit management
strategies for (septic) shock and arrhythmias other than bradycardia/asystole,
leaving out rhythm evaluation and defibrillation.
Evidence informing the transition from NLS to PLS
Several approaches on the use of NLS or PLS have been suggested
or are used, such as location-based, age-based,
patient-based or provider-based approaches.23
A locationbased
approach would be to take education and training implications
into consideration by choosing guidelines based on location
(e.g., NICU or PICU). Observational studies that found differences
in outcomes after PICU versus NICU CPR events did
not account for prematurity and low birth weight in infants in
the NICU.24
The presence of fluid-filled lungs only during immediate
perinatal transition may provide a rationale for changing
from the neonatal to paediatric resuscitation guideline using a
time-based approach. For example, after the first 24 h of life,23,25
or at 44 weeks postmenstrual age as a cut-off point. A patientoriented
approach may be to focus on the pathophysiology of
the bradycardia or arrest, as in cases of congenital and acquired
heart disease.26
A provider-based approach may have many
similarities with a location-based approach, but if HCP are
trained in both NLS and PLS they can apply both.
In the absence of evidence, an approach to education and
training tailored towards the decision to use one or both guideli-
nes based on individual unit case-mix and epidemiology of cardiac
arrests may be reasonable. The ERC recommends creation
of local policies applicable to the healthcare setting (good practice
statement).
14 R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6
The most preterm infants at the limits of viability
Survival and outcomes of preterm infants continue to improve, especially
for those born at extremely low gestational age (GA).27
Following
recently changed guidance concerning the initial stabilisation of
the most preterm infants, i.e. those born below 25 weeks,28,29
these
infants are now increasingly being offered survival-oriented
care.30–32
However historically, trials in neonatal medicine have,
almost without exception, excluded the most preterm infants.33
Consequently, the ERC NLS Writing Group cautions that recommendations
given in the ERC Guidelines 2025 NLS are based on evidence
from studies of higher GA infants and any extrapolation of
such evidence to the most preterm infants will not fully take into
account their distinct physiology and response to treatment.34
Implementation
The Utstein formula for survival identifies resuscitation science, efficient
education and local implementation as key factors influencing
outcomes.35
To aid health care professionals, hospitals and policymakers
in improving local implementation, a ten steps consensus
based framework has been published recently.36
Factors before birth
Perinatal transition
Survival at birth involves major physiological changes during perinatal
transition from fetal to newborn life. First, lung liquid-clearance
and aeration need to occur after which pulmonary gas exchange
can be established.37
Most newborn infants transition smoothly,
but some have problems with transition and without timely and adequate
support might need resuscitation.38–41
Approximately 11 % of
all newborns receive interventions with large variation between hospitals
(1.4–38.1 %).42
Newborn infants born via caesarean section
receive an intervention (19.6 %) more often than vaginally born
infants (5.9 %), with most common interventions being CPAP
(7 %), O2 supplementation (8 %), suctioning (6 %) and noninvasive
ventilation (4 %).42
Less common interventions include tracheal
intubation (1 %), cardiac compressions (0.1 %) adrenaline
administration (0.1 %), intraosseous access (0.01 %) and SGA insertion
(0.01 %).42
Intervention frequencies varied considerably
between hospitals and countries.42
In preterm infants, the need for
respiratory support is higher, with almost all infants born with a
GA < 30 weeks receiving CPAP and/or positive pressure ventilation
(PPV).42
Risk factors
Several maternal and fetal prenatal and intrapartum factors increase
the risk for compromised transition and the need for resuscitation. A
recent multicentre survey and an ILCOR evidence update confirm
previously identified risk factors for needing assistance after
birth.42,43
There is no universally applicable model to predict risk
for resuscitation or need of support during transition, and the list of
risk factors in the guidelines is not exhaustive. Elective caesarean
delivery at term, in the absence of other risk factors, does not
increase the risk of needing newborn resuscitation.44,45
In accordance with the unchanged ILCOR recommendation, the
ERC recommends that when an infant is delivered at term by caesarean
section under regional anaesthesia an HCP capable of performing
an initial assessment and assisted ventilation should be
present at the birth. It is not necessary for a provider skilled in neonatal
intubation to be present at that delivery.43
Staff attending births in hospitals
It is not always possible to predict the need for stabilisation or resuscitation
before an infant is born. Therefore, the ERC recommends that those in
attendance at birth need to be able to undertake initial resuscitation steps
effectively. The experience of the team and their ability to respond in a
timely manner can improve outcomes of term46
and preterm infants.47–
49
It is essential that resuscitation teams can respond rapidly if not present
from the beginning. In a simulation-based study on term neonatal resuscitation
a significant increase in workload was demonstrated in 2-person
teams compared to 3-person teams.50
The ERC advises a process should
be in place for rapidly mobilising extra HCPs with appropriate resuscitation
skills.
Telemedicine
In hospitals with low birth rates, it can be difficult for staff to maintain
neonatal resuscitation skills.51–53
Video telemedicine may help
address these challenges by providing immediate access to neonatal
specialists, allowing a neonatologist to virtually assist with neonatal
resuscitation at remote locations, which ultimately might improve
patient outcomes.54–57
Limited observational data suggests that
video telemedicine may improve the quality of neonatal resuscitation
and reduce the need for neonatal transfers and can be introduced
without significant adverse effects.54,58–62
The ERC recommends that where the technology is available
and/or access to a neonatologist is not immediately available, telemedicine
use is considered.
Equipment and environment
Suggestions have been made on standardising an optimal layout of a
resuscitation area,63
but no published evidence has demonstrated
improvement in patient outcome due to specific arrangements. However,
some studies suggest a reduced retrieval time for emergency materials
when organized according to specific frameworks such as the ABC protocol
(airway, breathing, circulation),64
task-based package approach,65
or with a focus on emergency supplies or airway management.49
Briefing, debriefing & checklists
Briefing with role allocation and the use of checklists improve team
functioning and communication and are suggested.66,67
Evidence
on the isolated impact of briefing on patient outcomes is challenging,
as it is typically implemented within quality improvement bundles.
However, an ILCOR scoping review (2021) on the effect of briefing
and debriefing on the outcome of neonatal resuscitation concluded
that ‘improvements in the process of care ( ), short term clinical
outcomes and a reduction in communication problems’ were associated
with briefing and debriefing.68,69
The use of checklists during
briefings and debriefings may help improve team communication
and process, but there is little evidence of effect on clinical out-
comes.70,71
The ERC recommends (de)briefing the team present
at birth and suggests the use of cognitive aids.
Education
For an in-depth discussion on resuscitation education principles, see
ERC Guidelines 2025 Education for Resuscitation. Research on educa-
tional methods in neonatal resuscitation is evolving, but due to study
heterogeneity with non-standardised outcome measures, there is still little
evidence on the effect of different educational modalities on clinical out-
come.72–74
Nevertheless, available studies on the clinical impact of
neonatal resuscitation education are summarised in Table 5.
R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6 15
Frequency of training
Infrequent neonatal resuscitation training and rare clinical exposure lead
to skills decay. Two observational studies using video analysis found
that annual training may be insufficient,85
as skills deteriorate within
3–6 months, highlighting the benefits of high-frequency, short-duration
sessions.40,86
After NLS courses significant knowledge and skill decay
was found within three months, with technical skills declining faster than
knowledge.87
Another study focusing on neonatal ventilation skills,
found that airway patency requires training every 4.5 months, and facemask
seal every 1.5 months.85
The ERC recommends training at a minimum
interval of 12 months, preferably supplemented with more
frequent short booster sessions every 3–6 months.
Technical skills, behavioural skills and self-efficacy
Optimal newborn life support requires neonatal providers to possess
not only technical expertise but also behavioural skills, including
team collaboration competences, crisis resource management, and
personal resilience.88,89
A 2021 ILCOR systematic review about
training of team competences in resuscitation found improved skills
performance during clinical resuscitation and suggests its inclusion
in basic and advanced life support courses.5,90
Providers need
strong confidence to perform NLS optimally, initiate and persist in
resuscitation, and stay resilient under pressure.91–93
Confidence
can be achieved, among others, through practice and reflection,
and observational learning, where participants are motivated to
attain a similar level of performance as they observed in their
peers.91,94,95
The ERC recommends incorporating team collaboration
competencies in newborn life support training.
System training
In situ neonatal simulation training is highly effective not only for
training in human factors and teamwork, it also enables adaptation
of team composition, the environment and equipment to create ideal
circumstances for newborn resuscitation performance.96–99
Simulation
training may also be used to rigorously test new neonatal environments
or procedures. The ERC recommends that simulation
training forms part of resuscitation training.
Thermal control
The World Health Organization recommends keeping newborn temperatures
between 36.5 °C and 37.5 °C.100
Exposed, wet newborn
infants cannot maintain their body temperature in a room that feels
comfortably warm for adults. The mechanisms (convection, conduction,
radiation, evaporation) and effects of hypothermia and how to
avoid these have been reviewed elsewhere.101,102
Hypothermia may impair respiratory function, lower the arterial
oxygen tension, cause elevated pulmonary vascular resistance,
and increase the risk of metabolic acidosis, hypoglycaemia, and
bradycardia.101
Two recent systematic reviews showed associations
between admission hypothermia and various morbidities (intraventricular
haemorrhage, bronchopulmonary dysplasia, sepsis, retinopathy
of prematurity) and mortality in very low birthweight infants
(<1500 g) and very preterm infants, respectively.103,104
As the admission temperature of non-asphyxiated infants is associated
with morbidity and mortality at all gestations and in all set-
tings,5,105,106
the ERC recommends recording temperature as both
a predictor of outcome and a quality indicator.9
A recent systematic
review and network meta-analysis showed that (the combination of)
plastic bags/wraps, plastic caps, thermal mattress, and heated
humidified gases in the delivery room reduced major brain injury
and mortality in preterm infants.107
The ERC recommends that as
a minimum, plastic bags/wraps and hats are used in preterm infants
at birth, and where available heated humidified gases are also used
at the earliest opportunity in preterm infants.
To align recommendations across the ERC Guideline 2025 NLS,
we use 32 weeks as a pragmatic cut-off in our recommendations.
Temperature monitoring
Temperature monitoring is key to avoiding hypothermia. However,
there is very little evidence to guide the optimal placement of temperature
monitoring probes on the infant. In a study of 122 preterm
infants (28–36 weeks) randomised to different sites for temperature
monitoring, dorsal, thoracic, and axillary sited probes all had comparable
temperature measurements.108
There are no published studies
comparing the use of rectal temperature probes. The ILCOR NLS
Task Force does not specify the site where the temperature should
be determined.43,109,110
In infants <1500 g immediately after birth, servo-controlled
thermoregulation did not improve admission normothermia compared
with using a radiant warmer in manual mode.111
ILCOR
stated that there is insufficient published human evidence to suggest
for or against the use of a radiant warmer in servo-controlled
mode compared with manual mode in infants <34 weeks directly
after birth.112
In newborns who are unintentionally hypothermic
after birth, ILCOR concluded that there is insufficient evidence
to recommend either a rapid ( 0.5 °C/hour) or slow (<0.5 °C/
hour) rewarming rate.113
The ERC recommends that all newborn infants undergoing
resuscitation and all preterm infants undergoing support of transition
have their temperature monitored frequently or continuously during
resuscitation until stabilisation.
Hyperthermia
Hyperthermia ( 38.0 °C) should be avoided, because it is associated
with adverse effects.9
Infants born to febrile mothers have a
higher incidence of perinatal respiratory compromise, neonatal seizures,
early mortality, and cerebral palsy.114–116
Animal studies indicate
that hyperthermia during or following ischaemia is associated
with a progression of cerebral injury.116
Term and near-term infants 34 weeks
ILCOR treatment recommendation110,117
suggests a room temperature
of 23–25 °C in infants 34 weeks.110,117
If support of transition
or resuscitation is not required, immediate skin-to-skin care is good
practice to maintain normothermia. A Cochrane review involving 46
trials and 3850 dyads of mothers with their (predominantly healthy
term and some late preterm) newborns concluded that skin-to-skin
contact may be effective in maintaining thermal stability and improve
maternal bonding and breast-feeding rates.118
Aligning with ILCOR,
the ERC recommends skin to skin care, and in the situation where
skin to skin care is not possible, and resuscitation is not required,
to consider the use of plastic bags/wraps among other measures.
16 R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6
Table 5 – Summary of studies on effect of NLS training.
Reference Study design Setting Intervention Sample size Results
Review
11 studies with NWKM level IV,
all HBB studies;
8 pre-post intervention, 2
prospective cohort studies, 1
clinical trial;
LMIC n = 412,741 newborns ; overall neonatal
mortality
; intrapartum
stillbirth
; 1d-mortality
Agudelo-Pe´rez
(2022)80
One-day trainings (HBB) in
various intervals
success rate LISA
; duration of
intubation
Bayoumi (2022)75
HIC 5 in-situ simulation trainings and
27 workshops in post-era
(2016–2021)
n = 799 in courses,
n = 1,199 newborns,
n = 326 intubations
Pre-post intervention;
1 level III unit (18000/a births)
10–12 in-situ simulation
workshops per year (2012–
2018)
Pre-Post intervention;
tertiary unit with 3 sites (9000/a
births), multidisciplinary
HIC n = 445 HCW, n >40,000
newborns,
n = 11,284 resuscitations
; perinatal mortality
; chest
compressions,
; medication
Bhatia
(2021)76
Retrospective observation;
5 hospitals (2 district, 2 regional,
1 tertiary)
MIC ; neonatal mortalityMayer
(2022)77
Annual one-day training (HBB,
2016–2020)
n = 4795 HCW, n = 123.898
newborns
Pre-Post intervention;
1 level IV unit (3500/a births),
multidisciplinary
HICMileder
(2024)72
41 in-situ simulation trainings in
4 months
n = 48 HCW,
n = 28 resuscitations
5-minute Apgar
score
Pre-post intervention; 5
hospitals (secondary healthcare
regions)
MIC n = 431 HCWLima
(2023)83
n = 700 training sessions in 106
NRP courses
; neonatal mortality
in DR
Lindhard (2021)82
Review
2 Studies with NWKM level IV
Lebanon: pre-post intervention
Mexico: pair-matched study
LMIC Lebanon: QI with 10 ex-situ
simulation workshops (22
hospitals, 3 years);
Mexico: 2 simulation trainings
(12 hospitals)
Lebanon: n = 256 HCW,
n = 84,398 births;
Mexico: n = 450 HCW;
; neonatal
mortality,
team performance
n = 1,653,805 newborns;
variability in participants of the
interventions
LMIC Variability in neonatal
resuscitation training curricula,
from basic to advanced life
support
; neonatal mortality
; stillbirth mortality
; perinatal mortality
Patel
(2017)79
Review
20 studies with NWKM level IV
Pre-Post intervention;
1 level II unit (2000/a births),
multidisciplinary
HIC n = 35 core and 200 additional
HCW,
n = 13,950 newborns,
n = 826 resuscitations
Schwindt
(2022)73
11 in-situ simulation trainings in
post-era (2015–2019)
; chest
compressions
LIC High-frequency, self-guided
skills training (simulator with
automatic feedback)
n = 10,481 ; time to first
ventilation
; pauses in
ventilation
= neonatal mortality
Vadla
(2022)78
3-year prospective clinical
observation study
Prospective observational
study; 1 hospital site (3000/a
births)
LIC Annual one-day training (HBB
2nd, 2017–2021) + Low dose
high frequency trainings
; neonatal mortalityVadla
(2024)74
n = 12,983 newborns,
n = 1,320 resuscitations
Collected evidence from studies in neonatal settings72–83
on the impact of simulation-based training, focusing on Kirkpatrick Level IV outcomes (clinical
resuscitation outcomes) as defined by the New World Kirkpatrick Model.84
Abbreviations: HBB: Helping babies breathe; HCW: healthcare workers; HIC: high income country; LISA: less invasive surfactant administration; LIC: low income country;
MIC: middle income country; NRP; Neonatal Resuscitation Program NWKM: new world Kirkpatrick model; PPV: positive pressure ventilation; QI: Quality improvement.
Preterm infants <34 weeks
For infants <34 weeks a room temperature of 23–25 °C is sug-
gested.109,112
For infants <28 weeks, room temperature should ideally
be >25 °C.101,102,119
The use of plastic bags or wraps (without drying)
is advocated in infants <34 weeks. Further thermal control while using
radiant warmers in the delivery area can be achieved with a combination
of warmed blankets, cap, thermal mattress, heated humidified respiratory
gases, and skin-to-skin care. With these interventions, both
hypothermia and hyperthermia are possible and require attention.112
Quality improvement programs, including the use of checklists, continuous
feedback, and debriefing have shown to significantly reduce the
incidence of hypothermia at admission in very preterm infants.119,120
Delivery or operating room cuddles
Following stabilisation after birth it may be possible to offer physical
contact between the parents and their baby in the form of
supervised skin-to-skin contact or a cuddle. Studies have considered
the feasibility of a delivery room cuddle in relation to
physiological variables (HR, temperature).121,122
The effect of
delivery room cuddles on thermoregulation was conflicting; with
some studies reported no difference121–124
and others reported
more hypothermia in infants who received skin to skin care after
birth.123–127
There is emerging evidence of positive effect on
maternal bonding121,128,129
and that delivery room cuddles may
promote breast feeding in near term and term infants.129
However,
there is also evidence of potential risks including accidental
extubation, disconnections, or apnoea.116,119
R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6 17
Current evidence is insufficient to provide a specific recommendation
and there is no ILCOR evidence review on this topic. Discussing
the possibility of a delivery room cuddle on an individual basis is reasonable,
if the clinical team feels confident to support this. However,
the practicality of offering this will not be clear until after their baby
has been born. If a delivery room cuddle is impractical, encourage brief
physical contact, e.g. touching their baby’s hand as an alternative.
Where resuscitation measures are required, this takes priority.
Umbilical cord clamping
There is no universally accepted definition of ‘delayed’ or ‘deferred’
cord clamping (DCC), only that it does not occur immediately after
birth. Early or immediate cord clamping (ICC) has been defined as
less then 30 s after birth, later or delayed cord clamping as >30 s
after birth or when cord pulsation has ceased.130,131
Physiological
based cord clamping (PBCC) is not based on time, but on physiological
parameters (i.e. when breathing has been initiated).132,133
When
possible, interventions for stabilising the infant may take place close
to the mother with intact cord.134
The ERC recommends facilitating at least 60 s of DCC for newborn
infants without need for support; and to clamp the cord <30 s
to minimise delay in interventions in those in need for resuscitation.
If intact cord stabilisation can be safely performed, longer DCC is
preferred, especially in newborn infants <34 weeks.
Rationale: Experimental and observational studies
Although ICC was introduced as part of a package to reduce postpartum
haemorrhage,135
its impact was minimal and primarily associated
with reduced birth weight.136,137
Clamping the cord before lung inflation
and the increase in pulmonary circulation has occurred results in
reduced ventricular preload and increased left ventricular afterload,138
impairing the circulation and causing hypoxia.132,138
A second rationale
for DCC is placental transfusion – blood redistribution from placenta to
newborn which can account for up to 25 % of placental volume.139,140
Gravity and uterine contractions do not drive this transfusion,141,142
but
spontaneous breathing of the infant might. Therefore, clamping should
ideally be delayed until breathing has been established.143
Infants 34 weeks
A 2019 Cochrane review found that DCC compared to ICC increased
birth weight, neonatal haemoglobin, and reduced iron deficiency at
3–6 months, without increasing polycythaemia.144
A 2021 ILCOR
meta-analysis of 33 trials in newborns 34 weeks confirmed these
findings, showing no effect on mortality or need for resuscitation.131
DCC improved early ( 24 h) and later (7 days) haematological and
circulatory parameters, but had no impact on longer term anaemia,
neurodevelopment, or phototherapy.131
Evidence on DCC in (near) term newborns needing resuscitation is
limited. One study found no HR difference between cord intact resuscitation
and ICC,145
while two RCTs reported better vital parameters,
higher Apgarscores,andreducedneedfor ventilationand/orchestcom-
pression.146,147
Only one trial reported mortality with no difference.147
Admission temperatures were similar across all three trials.145–147
Infants <34 weeks
Multiple trials have compared DCC with ICC in preterm infants. Most
used DCC for 30–60 s, excluding infants needing immediate resuscitation.
Studies using intact cord resuscitation applied longer clamping
times. A 2021 ILCOR meta-analysis (infants <34 weeks) DCC
( 30 s) may slightly improve survival,130
with better cardiovascular
stability, less inotropic support, improved haematological indices,
and fewer transfusions – without effects on prematurity complications
(or adverse maternal outcomes). Subgroup analysis showed
a possible positive link between survival and DCC duration.130,148,149
A separate systematic review and individual participant data metaanalysis
confirmed reduced mortality with DCC vs ICC, but no difference
in morbidity or transfusion rates.148
A network meta-analysis comparing short (15–45 s), medium
(45–120 s), and long (>120 s) cord clamping times with ICC and cord
milking found the strongest survival benefit with longer delays (mortality
OR 0.31, 95 % CI 0.11–0.80).149
They concluded that for newborns
requiring resuscitation/stabilisation, longer DCC is only
feasible with intact umbilical cord.149
Three multi-centre RCTs on intact cord resuscitation have been
completed. Two used fixed clamping times and one used physiological
criteria. The VentFirst trial (<29 weeks) found no difference in intraventricular
haemorrhage or mortality between 120 s DCC with intact cord
ventilation vs DCC 30–60 s and ventilation afterwards.150
No difference
was reported in the composite outcome of death, severe intraventricular
haemorrhage, and bronchopulmonary dysplasia between 3-minute
intact cord resuscitation and cord milking.151
In the ABC3 trial physiologically
based cord clamping vs 30–60 s DCC showed no overall difference
in intact survival, but improved outcomes in male infants and
with increased intact cord resuscitation experience.152
Umbilical cord milking
Umbilical cord milking has been considered an alternative to DCC when
DCC is not feasible.153
In ‘intact cord milking’, the cord is milked 3–5
times before clamping, promoting faster blood transfer. In ‘cut cord milking’,
a 25 cm cord segment is milked after clamping, usually during
resuscitation.153
Experimental studies show intact cord milking causes
significant fluctuations in cerebral blood flow.154,155
A large clinical trial
in preterm infants was stopped early due to increased risk of severe
intraventricular haemorrhage in the <28 weeks GA subgroup who were
randomised to umbilical cord milking.156
Meta-analyses in preterm
infants showed no differences in mortality or morbidity.148,149
Umbilical
cord milking reduced transfusion need compared to ICC, but to DCC. A
recent cluster RCT in 1730 non-vigorous infants 35 weeks found no
difference in mortality or NICU admission between intact cord milking
and ICC.157
The reported reduction in moderate-to-severe hypoxic
ischemic encephalopathy (HIE) (RR 0.49, 95 % CI: 0.25–0.97) was
based on unadjusted data and may reflect later clamping. The ERC recommends
that for all infants the focus should be on DCC instead of
umbilical cord milking. The ERC recommends avoiding cord milking in
infants <28 weeks, acknowledging that intact cord milking is an alternative
to DCC in infants 28 weeks, only if DCC cannot be performed.
Initial assessment
Breathing
Not crying may be due to apnoea and can function as a marker of inadequate
breathing needing support.158
In an observational study of
almost 20,000 infants (>22 weeks GA) just after birth in a rural hospital
setting, 11 % were not crying, around half of whom were assessed as
apnoeic. About 10 % of those assessed as breathing at birth became
apnoeic. Breathing without crying compared to breathing and crying
was associated with a 12-fold increase in morbidity.158
The presence
or adequacy of breathing effort in preterm infants can be difficult to
assess as breathing can be very subtle and is often missed.159,160
When breathing was perceived as inadequate infants were more likely
to receive interventions.161,162
The ERC recommends assessing rate,
depth, symmetry and work of breathing.
18 R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6
Heart rate
HR is the most sensitive indicator of a successful response to resuscitation
interventions.145,163,164
There is no published evidence
clearly defining the thresholds for intervention during newborn resuscitation.
Historically, heart rates of >100 min 1
were pragmatically
selected as reassuring and <60 min 1
as prompting interventions.165
A 2023 ILCOR review found no new evidence on alternative HR
thresholds.166
In uncompromised breathing term infants undergoing
DCC, the HR is usually above 100 min 1
.164
In an observational
study in resuscitated term/near-term infants, initial HRs at birth were
distributed showing bimodal peaks around 60 and 165 min 1
.167
In
preterm infants <30 weeks the HR did not stabilise until it reaches
approximately 120 min 1
and, in some, stability was only achieved
once the HR was >150 min 1
.168
A recent study in extremely or very
preterm neonates with favourable outcome established that the 10th
percentile of HR at 2, 5, 10, and 15 min after birth were 70, 109, 126,
and 134 min 1
respectively, indicating varying expected HR values
during the immediate postnatal transition period.11
Heart rate assessment. The main methods of HR assessment
are auscultation, pulse oximeter, and ECG. The advantages and disadvantages
of these are summarised in Table 6. Most studies
excluded newborns who were bradycardic at birth, required resuscitation
or were very preterm infants, which limits applicability of study
results.5,169,170
Auscultation by stethoscope is simple and enables
rapid assessment of HR in any setting, including low resource settings
(ERC practice statement). The 2024 ILCOR review suggests
that if resources allow, ECG to continuously assess HR is reasonable,
with pulse oximeter and auscultation as alternatives.169,170
It
is currently unclear if speed/precision of HR assessment at birth is
associated with clinically important differences in interventions, performance
or outcomes.169,170
There is insufficient evidence to recommend
the use of digital stethoscopes, Doppler ultrasound, dry
electrode technology or other techniques to assess HR at
birth.169,170
The ERC recommendations align with ILCOR. Initial
HR assessment can be done by auscultation; continuous HR
assessment through ECG or pulse oximetry are recommended with
ongoing resuscitation.
Tactile stimulation
ILCOR systematic reviews on both cord management and tactile
stimulation suggest tactile stimulation immediately after birth in
infants with inadequate breathing efforts, regardless of method of
umbilical cord management.161,183,184
Tactile stimulation should not
delay the initiation of breathing support if required. The optimal type
and length of tactile stimulation as well as differences in different
gestational ages is unknown.184
An RCT in a preterm population
reported that repetitive stimulation improved oxygen saturations
and reduced need for supplemental inspired oxygen.185
Data from
an observational study shows that tactile stimulation at birth is associated
with more spontaneous breathing, especially if the cord was
still intact.158
The ERC recommends performing tactile stimulation
on all newborn infants at birth, especially if breathing is inadequate,
but it must not delay initiation of breathing support if required.
Colour
Healthy infants are cyanosed at birth, reflecting lower in utero saturations,
but this improves within approximately 30 s of the onset of
effective breathing.160
Peripheral cyanosis is common and does
not, by itself, indicate hypoxia. Persistent pallor despite ventilation
may indicate significant acidosis, or, more rarely, hypovolaemia with
intense cutaneous vascular vasoconstriction. Colour is an unreliable
marker of oxygenation, and it should not be used to judge oxygena-
tion.186
The ERC recommends using pulse oximetry to measure oxygen
saturations in preference to using colour as a proxy for
oxygenation.
Airway
Airway obstruction is most commonly caused by suboptimal airway
positioning, lack of pharyngeal tone, and adducted vocal cords,
especially in preterm newborns.187,188
There is no evidence that normal
lung fluid and secretions cause obstruction.189
In line with
ILCOR, the ERC recommendation is not to routinely suction clear
fluid from the oropharynx.
Position
With flexion and extension of the neck, the newborn airway can easily
become occluded.190
Evidence on the mechanisms of airway occlusion
in the newborn is limited. A retrospective analysis of images of
the airway of 53 sedated infants between 0–4 months undergoing
cranial MRI indicates how, in extension, obstruction might occur
through anterior displacement of the posterior airway at the level of
the tongue.191
Video review of airway position and airway obstruction
also found hyperextension of the neck is associated with airway
obstruction.192
Therefore, the ERC recommends a neutral head position
to ensure optimal airway patency in newborn infants.
Jaw thrust and two-person method
Studies in children demonstrate that anterior displacement of the
mandible enlarges the pharyngeal space through lifting the epiglottis
away from the posterior pharyngeal wall, reversing the narrowing of
the laryngeal inlet.193
Two-person manual ventilation techniques are
superior to single handed airway support: it reduces facemask leak
and is more effective,190,194–196
which is recommended by the ERC.
Preterm newborns
Vocal cord adduction is a cause of airway obstruction at birth in preterm
infants <30 weeks.188
In an observational study of 56 preterm
infants <32 weeks significant facemask leak (>75 %) and/or obstruction
to inspiratory flow (75 %) were identified using respiratory function
monitoring in 73 % of interventions during the first 2 min of
PPV.197
In an animal model of premature birth, phase contrast Xrays
demonstrated that the larynx and epiglottis were predominantly
closed (adducted) in those with un-aerated lungs and unstable
breathing patterns, making intermittent PPV ineffective unless there
was an inspiratory breath, and only opening once the lungs were
inflated.187
This may be an explanation for the challenges in inflating
preterm infant lungs, but a solution for overcoming these phenomena
is not yet known.
R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6 19
Table 6 – Heart rate assessment.
Advantages Disadvantages RecommendationsMethod of HR
assessment
Continuous HR
monitoring?
Rapid assessment
Cheap
Simple
Readily available in all
settings
No Intermittent HR monitoring
Less reliable compared to
other HR methods
Auscultation might be used for
quick first assessment
Auscultation reasonable
alternative for HR assessment
Auscultation (+/- pulse oximetry)
should be used if ECG is
unavailable, malfunctioning or
PEA is suspected
Auscultation with
stethoscope
Continuous HR
monitoring
Provides a measure of
oxygenation and
perfusion
Unclear whether connecting
sensor to infant first or to the
pulse oximetry first confers
advantage
Pulse Oximetry
Ideally placed on the
right hand or wrist.
Yes May underestimate HR as
ECG in first 2–5 mins
Interference in values
caused by:
o Signal dropout
o Movement
o Hypoperfusion
o Lighting
Potential cost implication
Use of ECG is reasonable to
assess HR after birth
ERC recommends ECG should
not replace pulse oximetry for
further treatment, but used in
addition
Yes Continuous HR
monitoring
Faster and more accurate
than pulse oximetry
May indicate a HR in
absence of cardiac output
May adhere poorly to
infants with vernix
Potential cost implication
Electrocardiogram
(ECG)
Sources for Table 6: 16,169–181,182
Abbreviations: HR: heart rate; ECG: electrocardiogram; PEA: pulseless electrical activity.
Suctioning
Routine oropharyngeal and nasopharyngeal suctioning in newborn
infants has not been shown to improve respiratory function, may
delay other necessary manoeuvres and the onset of spontaneous
breathing and is associated with adverse events.198–202
The ERC, following ILCOR, does not recommend routine intrapartum
oropharyngeal and nasopharyngeal suctioning for newborn
infants with clear or meconium-stained amniotic fluid.189
If suctioning
is attempted, in order to clear a presumed blocked airway, it
should be undertaken under direct vision, ideally using a laryngoscope
and a wide-bore catheter or Yankauer sucker. Bulb suctioning
can be useful if no vacuum source is available. A meconium
aspirator, attached to a tracheal tube, can clear thick material from
the trachea, applied suctioning should not exceed 150 mmHg
(20 kPa).203,204
Meconium
Lightly meconium-stained liquor is common and usually does not
cause difficulty with transition. Non-vigorous newborns delivered
through meconium-stained amniotic fluid are at significant risk for
requiring advanced resuscitation and a neonatal team competent
in advanced resuscitation may be required. Routine suctioning of
non-vigorous infants can delay initiating ventilation and there is no
evidence to support intrapartum suctioning nor routine tracheal intubation
and suctioning of vigorous infants born through meconiumstained
liquor.205–207
Evidence from retrospective registry-based
studies,208,209
meta-analyses,210–212
a post policy change impact
analysis,213
and ILCOR 20256
all support omitting suctioning in
favour of immediate ventilation.
The ERC recommends against routine suctioning of either pharynx
or trachea in newborn infants born through meconium stained liquor
and recommend providing standard NLS. If there is evidence of airway
obstruction, the ERC recommends suctioning under direct vision in the
first instance. Rarely, airway obstruction may occur below the level of
the larynx, and this may require tracheal suctioning.
Airway devices
Supraglottic airway devices (SGA). SGAs are effective in newborns,
particularly if facemask ventilation or tracheal intubation is
unsuccessful or not feasible.5
A systematic review showed that
PPV with SGAs was more effective than bag-facemask ventilation
in terms of shorter resuscitation and shorter duration of ventilation
with less need for tracheal intubation.214
Bag-facemask ventilation
was effective in more than 80 % of enrolled infants. Efficacy of
an SGA was comparable to tracheal intubation.
Aligned with ILCOR, ERC recommends using an SGA as a valid
alternate airway device, particularly if tracheal intubation is unsuccessful
or intubation skills are unavailable.5,6
Studies generally included infants with birth weight >1500 g or
GA 34 weeks, so evidence supporting SGAs in more premature
infants is limited.214,215
A 2024 Cochrane update found no or little difference
in neonatal morbidities and mortality when giving surfactant
via an SGA compared with a tracheal tube.216
The SGA has not been
evaluated in the setting of meconium-stained fluid, during chest compressions,
or for the administration of emergency intra-tracheal medications.
ILCOR considers it reasonable to use an SGA during chest
compressions if tracheal intubation is not possible/unsuccessful
(good practice statement)6
and the ERC aligns with this.
20 R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6
Oropharyngeal airway. Although the oropharyngeal airway is
effective in children,217
there is no published evidence demonstrating
effectiveness in maintaining airway patency at birth. In an RCT of
137 preterm newborns where gas flow through a facemask was measured,
obstructed inflations were more common in the oropharyngeal
compared to control group.218
However, by helping lift the tongue
and preventing it occluding the laryngeal opening, an oropharyngeal
airway may facilitate airway support where difficulty is experienced
and where other airway opening techniques, like jaw thrust, fail to
improve ventilation.
Nasopharyngeal airway. A nasopharyngeal airway may help
establish an airway where there is congenital upper airway abnor-
mality219
and has been used successfully in preterm infants at
birth.159,217–219
Tracheal tube. Safe tracheal intubation is facilitated by welltrained
clinicians with appropriate equipment, and the use of an intubation
checklist.220
Tracheal tube insertion depth and internal diameter
can be estimated from birth weight or gestational age.221–225
Neither provide a perfect estimate but weight might be slightly more
accurate than GA.224
Rules of thumb are less accurate in the youngest
and smallest newborns.224,225
Therefore, once insertion, confirmation
of tracheal tube position by clinical assessment, appropriate
imaging and the use of exhaled CO2 detection is required.226
Contingency
plans should be made for an unexpectedly difficult airway.
Declining intubation skills mean unsuccessful intubation is more
common and safe airway management around intubation attempts
is vital (Table 7).227,228
Video laryngoscopy. A 2024 ILCOR systematic review of video
laryngoscopy versus direct laryngoscopy229,230
found higher overall
intubation success rates and higher first attempt success rates using
a video laryngoscopy compared to a direct laryngoscope. These findings
are confirmed by a 2025 systematic review.231
Table 7 – Approximate tracheal tube size and lengths for oral and nasal intubation.221–223
Internal diameter (mm) Oral intubation length (cm) Nasal intubation length (cm)Birthweight
(grams)
Gestation
(weeks)
500 23–24 2.5 6.0 7.0
750 25–26 2.5 6.5 7.5
1000 27–29 2.5 7.0 8.0
1250 30–32 2.5 7.5 8.5
1500 30–32 2.5/3.0 7.5 8.5
1750 33–34 2.5/3.0 8.0 9.0
2000 35–36 3.0 8.5 9.5
2500 36–37 3.0 9.0 10.0
3000 37–39 3.0/3.5 9.5 10.5
3500 39–41 3.5 10.0 11.0
4000 41–43 3.5 10.5 11.5
Where resources and training allow, the ERC recommends using
a VL to intubate newborn infants, especially in settings where less
experienced staff are intubating. Direct laryngoscopy remains a reasonable
option, and such a laryngoscope should be available as a
backup device.
Exhaled CO2
Detection of exhaled CO2 alongside clinical assessment is used to
confirm tube placement in the trachea in newborn infants, even from
>400 g.9,232–235
Failure to detect exhaled CO2 strongly suggests
tube misplacement – no trace, wrong place.233,236
However, studies
relating to exhaled CO2 have mostly excluded infants in need of
extensive resuscitation. False negative CO2 detection can occur in
cases of poor or absent pulmonary blood flow, tracheal obstruction,
low or absent cardiac output in resuscitation at birth and in birthweight
<1500 g.234,236
Where there is no CO2 detection after tracheal
intubation, tracheal tube position should be rechecked by VL or direct
laryngoscopy by the most skilled person present as soon as possible
to avoid unnecessary tracheal tube removal.
Like ILCOR,235
the ERC recommends using exhaled CO2 detection
combined with clinical assessment, to confirm tracheal tube
placement.
Both qualitative (colorimetric) and quantitative (waveform) CO2
detection methods have been successfully used in intubated newborn
infants.237
Colorimetric detection offers a simple, easy to use,
cheap device where a colour change indicates exhaled CO2. Waveform
detection provides a continuous graphical and numerical representation
of exhaled CO2 throughout the respiratory cycle, allowing
for continuous monitoring, but requires specialised equipment and
power sources may not be readily available in all delivery area settings.
Colorimetric detection failed to detect correct tube placement
in one-third of delivery area intubation in very preterm infants in
one study.238
Although waveform capnography is more sensitive in
adults, limited newborn data advise caution, especially if being used
during resuscitation.239–241
R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6 21
The ERC cannot recommend one method over the other.
Exhaled CO2 can be used in non-intubated patients.242–245
Exhaled CO2 detector use with interfaces such as SGAs are standard
in adult patients, but as newborn physiology differs markedly
from that of older children and adults, practices of proven benefit
for older patients may not apply to neonatal patients, especially during
perinatal transition.
The ERC currrently cannot recommend the routine use of
exhaled CO2 detection in non-intubated newborn infants in the delivery
area.
Respiratory flow monitoring
Flow monitoring via a respiratory function monitor was reported in an
RCT to confirm tracheal tube position faster and more reliably that
end-tidal CO2 detection, suggesting it may be used as an additional
measure to assess correct tube or SGA placement.246,247
One study
reported higher quality of PPV at birth with less excessive tidal volumes
and less leak when respiratory function monitoring was
used.248
However, an ILCOR systematic review249
and a 2025 evidence
update6
found insufficient evidence to recommend for or
against the routine use of respiratory function monitoring to guide
PPV at birth, and ERC recommendations align with ILCOR.
Breathing
Initial inflations and assisted ventilation
Lung inflation must begin without delay in apnoeic or inadequately
breathing newborn infants. An observational study in low-resource
settings found a 16 % increase in morbidity/mortality for every 30 s
delay in starting ventilation.250
Optimal inflation pressure, inspiratory
and expiratory times, and duration of PPV remain uncertain.
Facemask
Facemask ventilation is limited by leaks, often caused by poor facemask
fit or suboptimal technique, both of which contribute to facemask
leak which can be improved after training.195,251
A clinical
study demonstrated obstruction and/or leak >75 %) during initial ventilations
in preterm infants.197
An observational study in preterm
infants <32 weeks suggested that the application of a facemask to
support breathing might induce apnoea by triggering the
trigeminocardiac reflex in spontaneously breathing infants. However,
the significance of this is currently unclear.252
Nasal interfaces
While facemasks are most commonly used, nasal interfaces (single
or binasal short or long prongs or nasal masks) have been found to
be as effective as facemasks.253,254
Emerging studies suggest nasal
interfaces also reduce delivery room intubation and PPV use in
infants <28 weeks).255,256,257
The ERC recommends performing
PPV using either a facemask or nasal interfaces.
Inflation duration
Initial inflations or spontaneous breathing establish functional residual
capacity (FRC).258,259
There is ongoing debate about the optimal
inflation duration.260–268
This should not be confused with sustained
inflations (i.e. inflations 5 s), which are not recommended by
ILCOR or the ERC.9,43
Previous ERC guidance recommended (up
to) 2–3 s inflations,9
while other NLS guidelines around the world
support shorter durations of inflations ( 1 s).12,269
Available evidence
shows no clear advantage nor disadvantage of longer (2–
3 s) over shorter ( 1 s) inflations.12,268,270,271
As a HR response may not be seen until at least 20 s of PPV in
bradycardic infants,272,273
the number of inflations should vary
depending on the length of inflation. Although there is no evidence
to suggest superiority nor inferiority of 2–3 s over 1 s inflations, since
the ERC has recommended inflation times of or up to 2–3 s since
inception, this approach is used in NLS courses throughout Europe.
Therefore, the ERC continues to recommend 5 inflations of up to 2–
3 s based on pragmatic consensus.
Inflation pressure
Inflation pressures of 30 cm H2O are usually sufficient to inflate
the fluid-filled lungs of apnoeic term infants, based on historical
cohort studies.259,274,275
However, a prospective cohort study of
821 term and near-term infants resuscitated using bag-facemask
ventilation found median peak pressures of 36 cmH2O required
for successful stabilisation.276
For preterm infants, an initial inflation
pressure of 25 cmH2O is considered reasonable,263,277–279
though higher pressures may be needed due to greater airway
resistance. If no chest movement is observed, the ERC recommends
increasing inflation pressures, regardless of GA, to achieve
lung inflation.
Ventilation rate
Evidence on the optimal ventilation rate for newborn resuscitation is
limited. In an observational study of 434 late preterm and term
infants, ventilation at 30 breaths min 1
achieved adequate tidal volumes
without hypocarbia, with the best CO2 clearance at 10–14 mL/
kg.280
An observational study suggest that PPV rates >60 min 1
compared to rates <60 min 1
fail to achieve adequate tidal vol-
umes.281
Other studies suggest optimum rates for PPV are 30–
40 min 1
.259,274
The ERC recommends PPV rate of 30–40 min 1
once lungs have been inflated.
Effectiveness of inflations
The primary sign of adequate lung inflation is a rapid HR increase, usually
within 20–30 s of onset of effective ventilations.163,282,283
Chest
wall movement usually indicates lung inflation, although this may be
less obvious in preterm infants.284
Excessive chest movements may
indicate excessive tidal volumes, which should be avoided. If HR
improves but breathing remains inadequate, PPV must continue.
Failure of the HR to increase is most often due to suboptimal airway
control or inadequate ventilation.195,251,285
Adjustments to head/
airway position,190
choosing alternative airway opening techniques,
or increased inflation pressures may be needed.276
In preterm
infants, facemask pressure, glottal closure, or triggering the trigeminocardic
reflex may impair PPV.187,197,286,287
Although exhaled CO2
monitoring can sometimes detect such obstructions and facemask
leaks, current evidence is insufficient to recommend its routine use
to assess quality of PPV.245
Sustained inflations >5 s
Animal studies suggested longer inflations may have physiological
benefits,288,289
but clinical benefits in human infants have not been
demonstrated. In preterm infants, there is evidence of possible harm
from sustained inflation >5 s.290
A Cochrane systematic review found
that sustained inflations (15–20 s) were not better than intermittent
ventilation ( 1 s) for reducing mortality, intubation, need for respiratory
support or bronchopulmonary dysplasia.291
An ILCOR review
advises against routine use of sustained inflations >5 s in preterm
infants receiving PPV at birth, due to a possible increase in mortality
in infants <28 weeks. (266,268
ILCOR did not recommend a specific
inflation duration for late preterm and term infants due to lowconfidence
in the estimates of the effect. The ERC guidance aligns
with ILCOR and recommends against sustained inflations >5 s in
preterm infants.
22 R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6
CPAP and PEEP
Successful respiratory transition at birth relies on alveolar aeration,
lung inflation, and formation of FRC.292
Most premature infants can
breathe at birth but often struggle to obtain and maintain
FRC.293,294
(251) The need for respiratory support at birth is inversely
correlated to GA.295,296
Animal studies show that a few early
inflations at high tidal volumes can cause lung injury and inactivate
surfactant.297,298
Preclinical studies demonstrated that applying
CPAP or PEEP immediately after birth assists lung inflation.299
Unlike CPAP, PEEP is only present during exhalation and is applied
during manual or mechanical ventilation.300
While other non-invasive
respiratory supports are under investigation, CPAP remains the goldstandard
for newborn infants <32 weeks.301
CPAP for infants <32 weeks. Large RCTs show that starting
CPAP at birth, compared with intubation and ventilation, significantly
reduces death and bronchopulmonary dysplasia.302–306
An ILCOR
systematic review recommends starting CPAP promptly in spontaneously
breathing preterm infants with respiratory distress instead
of TI and PPV.6,43,307
. The ERC Guideline 2025 NLS align with this
recommendation. Whilst some RCTs used CPAP levels up to
8 cmH2O,302,303
an observational study shows that levels of 5–
6 cmH2O are most commonly used in practice.308
Comparative studies
on optimal CPAP levels remain limited.309,310
A 2021 Cochrane
Review concluded that it was not possible to recommend a specific
starting level.310
Animal data suggest that CPAP at 15 cmH2O (with
O2 60 %) improves lung inflation compared to 4–8 cmH2O.311
An
ongoing trial is studying dynamic CPAP (8–12 cm H2O) vs static
CPAP (6 cm H2O) at birth. (clinicaltrials.gov NCT04372953).
Until higher-quality evidence is available, and based on indirect
measures showing better lung inflation at 6 cm H2O,301
aligning with
the European Consensus Guidelines on the Management of Respiratory
Distress Syndrome,312
the ERC recommends starting CPAP
at 6 cm H2O in spontaneously breathing preterm infants <32 weeks.
CPAP for infants 32 weeks. The 2022 ILCOR CoSTR, states
that there is insufficient evidence for or against routine CPAP in late
preterm and term infants.313
However, late preterm infants and term
infants with conditions such as transient tachypnoea of the newborn,
or those requiring supplemental O2, may benefit from CPAP (good
practice statement).314
The ERC considers it reasonable to start
CPAP at 6 cm H2O in newborn infants 32 weeks with respiratory
distress needing supplemental O2.
PEEP during PPV. Self-inflating bags can be equipped with
PEEP valves to deliver defined PEEP during PPV, but cannot provide
CPAP, even with attached bias gas flow.315
ILCOR recommends
using PEEP during initial PPV of preterm newborn infants
at birth.43
Accordingly, the ERC recommends starting with a PEEP
of 6 cmH2O in preterm newborn infants receiving PPV.
Assisted ventilation devices
Recent reviews summarize the principles of interfaces, devices and
settings for delivering CPAP, PEEP and PPV during fetal-to-neonatal
transition.315,316
T-piece resuscitators deliver more consistent
CPAP/PEEP compared to self-inflating bags.315
ILCOR (2021) concluded
T-piece resuscitators may slightly improve outcomes like survival,
intraventricular haemorrhage and bronchopulmonary dysplasia
over self-inflating bags.317,318
Thus, the ERC recommends using Tpiece
resuscitators for PPV at birth, but self-inflating bags should be
available as a backup if gas supply fails.
Oxygen
Term infants and late preterm infants 32 weeks
Lower inspired O2 concentrations may result in suboptimal oxygenation
where there is significant lung disease,319
while higher O2 may
delay spontaneous breathing in term infants.320
ILCOR recommended
starting with 21 % O2 in infants 35 weeks receiving respiratory
support at birth, and advises against 100 % O2.43
An updated
systematic review (2164 patients) demonstrated 27 % lower shortterm
mortality with 21 % O2 vs 100 % O2, without differences in neurodevelopment
or hypoxic ischaemic encephalopathy (HIE).321
For
neonates born at 32–34+6
weeks, ILCOR found insufficient evidence
for specific O2 recommendations.6
The ERC recommends starting
with 21 % O2 in infants 32 weeks and titrating O2 to achieve target
saturations.
Preterm infants <32 weeks
In preterm infants, higher supplemental O2 improves breathing effort
and oxygenation and results in shorter facemask ventilation and
higher minute volumes.286,322
The NetMotion individual patient data network meta-analysis
(1055 infants from 12 studies) suggested high O2 >90 % may reduce
all-cause mortality compared to lower O2 (<30 % and 50–65 %).323
An updated ILCOR study level meta-analysis found insufficient evidence
to definitively recommend high (>50 %) vs low ( 50 %) O2
(1804 infants from 16 studies + NetMotion, infants
<35 weeks).6,323,324
For infants <32 weeks, the ERC recommends
starting resuscitation with 30 % O2 and adjusting O2 to achieve
and maintain target saturations.
Target oxygen saturations
In 2010 target oxygen saturation curves were published, however,
these data predated DCC and the majority of included infants were
37 weeks (Fig. 7).10
In 2024, different saturation and HR references
were published for infants <32 weeks stabilised according to
more current guidelines. All included infants had favourable outcomes,
defined as survival without cerebral injury (Fig. 8).11
Most (92 %) of the cohort received O2 and CPAP (91 %).11
Table 8 provides an overview of target saturation ranges that are
also used in the Newborn Resuscitation Programme (NRP).10–12
A systematic review showed that failing to reach SpO2 80 % at
5 min doubled the risk of death and severe intraventricular haemorrhage
in very preterm infants.325
Nearly all infants <32 weeks require supplemental O2 after
birth,10,11,325
but achieving target saturations in the minutes after
birth can be challenging; only 12 % reached 80 % SpO2 at 5 min of
life.325
SpO2 readings <60 % are considered inaccurate.182
Dark skin
tones may be associated with oxygen saturation discrepancies, with
a higher incidence of occult hypoxaemia,326
although limited data
suggests that the discrepancy may be less pronounced in
neonates.327,328
There is no direct evidence for the optimal oxygen saturations to
strive for after birth. The ERC provides a consensus-based recom-
mendation on uniform oxygen saturation targets across all GAs, balancing
out the perceived detrimental effects of hypoxia that may be
worse than those for hyperoxia (Table 4).
R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6 23
Fig. 7 – Oxygen saturations in healthy infants at birth without medical intervention (3rd, 10th, 25th, 50th, 75th, 90th,
97th centiles. Reproduced with permission.299
Table 8 – Overview of oxygen saturation target ranges.10–12
Dawson10
Wolfsberger11
Dawson10
NRP12
<32 weeks, n = 29 <32 weeks, n = 207 >=37 weeks, n = 308
P25 P75 P25 P75 P25 P75
3 min 67 83 51 77 71 90 70–75
5 min 82 91 73 92 83 96 80–85
10 min 89 95 89 95 94 98 85–95
NRP: Newborn Resuscitation Program.
Titration of oxygen
Timely adjustment in delivery of O2 is critical to avoid hypoxia, hyperoxia
and bradycardia. The ERC recommends reviewing O2 every
30 s329
and adjusting O2 to achieve target SpO2. There can be a
delay between titration of intended O2 and delivery of O2 to the baby.
One study suggests a T-piece resuscitator takes 19 s (IQR 0–57) to
achieve the desired O2 at the distal end,330
and another that nasal
interfaces may reduce this delay (Fig. 8).331
Cerebral tissue oxygenation monitoring
Using the same population of preterm infants, the application of different
statistical methodology has resulted in differing conclu-
sions.332–334
The ERC, following the 2024 ILCOR
recommendation, recommends that near infrared spectroscopy monitoring
of cerebral oxygenation in the delivery room should only be
considered where resources permit, preferably within structured
research trials to help close knowledge gaps.6,333
Circulatory support
Circulatory support with chest compression is effective only after
successful lung inflation and subsequent oxygen delivery to the
heart. Ventilation may be compromised during chest compressions,
so ensuring effective ventilation before starting chest compression
is critical.335
Threshold for initiating and discontinuing chest compressions
The HR threshold to initiate chest compression at birth (<60 min 1
)
was based on expert opinion and limited animal data.166,336
No
human studies have compared different HR thresholds for initiating
chest compression in human newborns,166
and current practice
remains to start chest compression if HR is <60 min 1
after successful
lung inflation.
In asystolic piglets, starting chest compression after 30 or 60 s of
PPV resulted in comparable outcomes, however, delaying chest
compression beyond 90 s worsened outcomes.165
Two narrative
reviews reconsidered the HR threshold for starting chest compression
at birth,336,337
suggesting chest compression could potentially
be delayed an additional 30 s of PPV, if HR is rising after 30 s of ventilation,
but still <60 min 1
, though more research is needed.
24 R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6
Fig. 8 – Oxygen saturations during the first 15 min after birth of infants <32 weeks with favorable outcome of SpO2
(%); (10th, 50th, and 90th centile (bold lines); 5th, 15th, 20th, 25th, 30th, 35th, 40th, 45th, 55th, 60th, 65th, 70th, 75th, 80th, 85th, 95th centile
(gray lines)). Reproduced with permission.9
The ERC recommends considering an additional 30 s of PPV
when HR is still <60 min 1
but increasing. The ERC also recommends
checking the HR every 30 s unless using continuous monitoring
(pulse oximetry, ECG). Whilst chest compression may be
discontinued when HR is >60 min 1
, a continued increase in rate
and confirmation of cardiac output, e.g. auscultation, pulse check,
pulse oximetry, signs of life, are necessary to truly demonstrate
improvement. Stability often occurs only when HR exceeds
120 min 1
.167,168
Compression technique
ERC recommendations align with ILCOR, whose 2023 systematic
review reaffirmed that for infants at birth, the two-thumb-hands-e
ncircling-the-chest method should be used to deliver CC, because
it results in improved compression depth, less fatigue, and better
digit placement than the two-finger technique.6,166
Two overlapping
or adjacent thumbs should be placed on the lower third of the
sternum from either the lateral or over-the-head position.338,339
The over-the-head position may facilitate umbilical catheterisation.
Alternative techniques were also considered but were not superior
(Fig. 9).166
Fig. 9 – Two thumbs encircling technique for chest compressions.
Compression depth
In a post-transitional piglet model, compressions of 25–40 % depth
achieved ROSC, while 12.5 % compression depth did not.340
Evidence
in human newborn infants is lacking,166
although deeper com-
pressions improved blood pressures in post-surgical infants.341
Full
recoil between compressions is important.342–346
The ERC recommends
compressing the sternum one-third of the anterior-posterior
chest diameter (good practice statement), allowing full recoil
between compressions.
R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6 25
Compression-to-ventilation ratio
ILCOR (2023) found insufficient evidence to change the recommended
3:1C:V ratio, aiming for 90 compressions and 30 ventilations
per minute.43,166
However, the quality of compressions and ventilations
is probably more important than the rate.347
Animal studies
suggested chest compression with sustained inflations improved outcomes
over 3:1C:V, but human trials remain inconclusive.347–350
The
ERC continues to recommend a 3:1C:V ratio for resuscitation at
birth, even after securing the airway.
Supplemental oxygen during chest compressions
Available evidence remains insufficient to alter the recommendation
of increasing O2 to 100 % when starting chest compression (good
practice statement).9,166
No human studies have compared 21 %
with 100 % O2 (or any other O2 concentration) during chest compres-
sion,351
and animal studies reported no major differences in time to
ROSC, mortality, inflammation, or oxidative stress between concen-
trations.166,351
Both hypoxia and hyperoxia can be detrimental.166,351
In a transitional term ovine model of asphyxia-induced cardiac arrest,
21 % O2 was associated with lower cerebral oxygen levels and
higher brain lactic acid after ROSC compared to be reported with
the 100 % O2.352
Rapid weaning of inspired O2 after ROSC may prevent
hyperoxia and thereby possibly mitigate oxidate stress and
organ damage. Thus, ERC recommends that, once HR recovers,
O2 should be actively reduced, guided by pulse oximetry (good practice
statement).
Prompts and feedback devices
Earlier studies suggested exhaled CO2 monitoring and pulse oximetry
may be useful in detecting ROSC.353–356
ILCOR reviewed 16
studies examining chest compression in relation to (audio)visual
feedback devices, auditory feed forward devices, audiovisual
prompts provided by a decision support tool, capnography, and
blood pressure monitoring, but findings were difficult to compare
due to heterogeneity.166
Currently, ERC cannot recommend the clinical
use of prompts or feedback devices to assess CC during neonatal
resuscitation
Automated chest compression devices
Mechanical chest compression devices are used in adults but not yet
in newborns.357
In a neonatal asphyxiated piglet model, machinedelivered
chest compression improved stroke volume and left ventricular
contractility compared to manual chest compression.358
More
research is needed before clinical use in human newborn infants can
be recommended.
Vascular access
Umbilical venous catheter (UVC) and intraosseous (IO) access
No new evidence was identified comparing umbilical venous catheter
(UVC) route or use of intravenous (IV) cannulas against the intraosseous
(IO) route in the newborn for drug administration in any setting
in an ILCOR systematic review.43
A systematic review on the use of
IO in neonates in any situation identified one case series and 12 case
reports of IO device insertion into 41 neonates delivering several
drugs including adrenaline and fluid/blood.359
First attempt success
rates for IO varied from 50–86 %. Both UVC and IO access have
complications associated and adverse events have been
described.43,360–363
The actual route and method used may depend on local availability
of equipment, training and experience.43
There is limited evidence
on the effectiveness of IO devices immediately after birth, or the optimal
site or type of device,364,365
although simulation studies undertaken
in a delivery room setting suggest that the IO route can be
faster to insert and use than UVC.366,367
Proximal tibia is the anatomical
site usually used in newborn infants, but proximal and distal
femur may be feasible as well.368,369
IO access might be possible
in preterm infants. However, device-specific weight limitations must
be considered. ERC recommends, in alignment with ILCOR, to use
UVC as the primary method of vascular access at birth, and if
UVC is not feasible, or birth occurs in another setting, the IO route
is a reasonable alternative.
Peripheral access
No studies were identified reviewing the use of peripheral IV cannulation
in infants requiring resuscitation at birth. A retrospective analysis
of 61/70 stable newborn preterm infants in a single centre
showed that peripheral IV cannulation is feasible and successful in
most cases at first attempt.370
Medication
Medications are rarely indicated in resuscitation of the newborn
infant.42,371,372
Bradycardia is usually caused by profound hypoxia
and the key to resuscitation is inflating the fluid filled lungs and establishing
adequate ventilation. However, if the HR remains less than
60 min 1
despite effective ventilation and chest compressions, it is
reasonable to consider the use of medication. Knowledge of the efficacy
of medication in newborn resuscitation is largely limited to retrospective
studies, as well as extrapolation from animals and adult
humans.373
Adrenaline
A systematic review identified two observational studies involving
97 newborns comparing doses and routes of administration of
adrenaline.374
There were no differences between IV and endotracheal
adrenaline for the primary outcome of death at hospital discharge,
for failure to achieve return of spontaneous circulation,
time to return of spontaneous circulation or proportion receiving
additional epinephrine. There were no differences in outcomes
between 2 endotracheal doses. No human newborn studies were
found addressing IV dose or dosing interval (very low certainty evidence).
Recent animal data show no differences in response to
doses between 0.2, 0.4, or 0.8 IU/kg vasopressin, or 0.02 mg/kg
adrenaline and support intravenous administration as the most
effective route for adrenaline.375
Despite the lack of newborn
human data, it is reasonable to use adrenaline when effective ventilation
and chest compressions have failed to increase HR above
60 beats min 1
.
ILCOR suggests that if adrenaline is used, an initial dose of 10–
30 mg kg 1
(0.1–0.3 mL kg 1
of 1:10,000 adrenaline [1 mg in 10 mL))
should be administered intravenously.6
If intravascular access is not
yet available, endotracheal adrenaline at a larger dose of 50–
100 mg kg 1
(0.5–1.0 mL kg 1
of 1:10,000 adrenaline [1 mg in
10 mL]) is suggested but should not delay attempts at establishing
vascular access.376
If HR remains <60 min 1
further doses preferably
intravascularly every 3–5 min are suggested. If the response
to tracheal adrenaline is inadequate ILCOR suggests an IV dose is
given as soon as vascular access is established regardless of the
interval between doses.5,6,43,377
In previous editions, an interval of
3–5 min was advised. For pragmatic reasons, ERC recommends
using iv/io route preferably at a dose of 10–30 mcg kg 1
or an endotracheal
dose of 100 mg kg 1
; and to repeat further doses of adrenaline
every 4 min if required.
26 R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6
Glucose
Dysglycaemia (hyper or hypoglycaemia) is common during neonatal
resuscitation and may be associated with poorer resuscitation outcomes.
Hypoglycaemia is an important additional risk factor for perinatal
brain injury.378
The definition of hypoglycaemia in the context of
resuscitation is unknown. Hyperglycaemia is a stress response and
does not need to be corrected during resuscitation but may need to
be addressed during post resuscitation care. Different amounts of
bolus glucose have been published varying between 1 and 2 ml Kg 1
,
with the majority advising 2 ml Kg 1
intravenously.379–381
To align
with these publications and the ERC 2025 Guideline PLS, the ERC
recommendation is to check blood glucose during a prolonged resuscitation
and if low, IV or IO glucose should be given as a 200 mg kg 1
bolus (2.0 mL kg 1
of 10 % glucose). After successful resuscitation
formal steps to prevent both hypoglycaemia and hyperglycaemia
should be instituted.
Intravascular volume replacement
Early intravascular volume replacement is indicated for newborns
with blood loss who are not responding to resuscitation.43
Therefore,
if there has been suspected blood loss or the newborn appears to be
hypovolaemic and has not responded adequately to other resuscitative
measures then consider giving volume replacement with crystalloid
or red cells. Blood loss causing acute hypovolaemia in the
newborn is a rare event. There is little to support the use of volume
replacement in the absence of blood loss when the newborn is unresponsive
to ventilation, chest compressions and adrenaline. However,
because blood loss may be occult and distinguishing
normovolaemic newborns with shock due to asphyxia from those
who are hypovolaemic can be problematic, a trial of fluid administration
may be considered.9,43
The ERC recommends in the absence of suitable blood (i.e.
group O Rh-negative blood), isotonic crystalloid rather than albumin
is the solution of choice for restoring intravascular volume and to give
a bolus of 10 mL kg 1
initially. If successful it may need to be
repeated to maintain an improvement. When resuscitating preterm
newborns, fluid is rarely needed and has been associated with intraventricular
and pulmonary haemorrhages when large volumes are
infused rapidly.382
Sodium bicarbonate
ILCOR concluded that a 2005 treatment recommendation on the use
of sodium bicarbonate during prolonged resuscitation was not supported
by a systematic review using contemporary ILCOR methods
of evidence appraisal; consequently, the recommendation for the
routine use of sodium bicarbonate has been withdrawn from the
2025 CoSTR.6
Indeed, there may be harm associated with its use,
as it is hyperosmolar and generates CO2 which may impair myocardial
and cerebral function.383
Given insufficient data to recommend
routine use of bicarbonate in resuscitation of the newborn the ERC
has followed ILCOR’s recommendation and removed it from the
Guideline.
Naloxone
Naloxone is very seldomly used during newborn resuscitation (writing
group experience). There is no high-certainty evidence for the
use of naloxone during resuscitation.384
Consequently, the ERC cannot
recommend the use of Naloxone in that setting.
Low resource or remote settings
Infants born unplanned out of hospital are often in a remote area with
lower resources and at higher risk of needing resuscitation. Resuscitation
then needs to be provided by out of hospital practitioners, possibly
with less experience of neonatal resuscitation. Stabilisation is
followed by additional challenges of safe transfer to an appropriate
healthcare facility. Hypoxia and hypothermia are common and
should be anticipated and proactively managed.105,385–387
Not all
hospital settings have the same resources, and remote locations
may benefit from use of telemedicine.
Planned home births
A systematic review of eight studies involving 14,637 low risk planned
home births compared with 30,177 low risk planned hospital births concluded
that the risks of neonatal morbidity and mortality were similar.63
However, unplanned births are more at risk of needing resuscitation
and despite risk stratification, infants born at home may still require
resuscitation.388
Those attending home births must have appropriate
skills to manage this. Thermal care with a focus on prevention of
hypothermia is essential irrespective of birth location.387
This can be
supported, by increasing room temperature in the birth location (e.g.,
turn heating up, close windows), use of warming mattresses or skinto-skin
contact. Plastic bags can be used for preterm babies as a useful
thermal care adjunct alongside a heat source.
Post-resuscitation care
Glucose management
Hypoglycaemia may occur after perinatal asphyxia because of rapid
glucose consumption during anaerobic metabolism, stress-induced
hyperinsulinism, impaired gluconeogenesis, and concomitant risk
factors.389,390
Conversely, hyperglycaemia may result from endogenous
stress hormone release, adrenaline administration, and
reduced insulin sensitivity. Both hypoglycaemia and hyperglycaemia
occur frequently after resuscitation: approximately 1 in 7 and 1 in 4
newborns in the first 6 h, increasing to 1 in 5 and 1 in 2 newborns
at 24 h after birth, respectively.389
Infants with hypoxic-ischaemic
encephalopathy and severe acidosis are particularly at risk.
Animal studies suggest hypoxic cerebral injury is worsened by
both hypoglycaemia and hyperglycaemia.391,392,393
Research in
human infants with hypoxic-ischaemic encephalopathy has revealed
that initial hypoglycaemia and glycaemic lability are associated with
more brain injury on MRI, lower cognitive scores, and poorer neurological
outcome.394–397
Hyperglycaemia and glycaemic lability were
also associated with amplitude-integrated electroencephalographic
evidence of worse global brain function and seizures.398
Hypoglycaemia and hyperglycaemia are associated with higher
mortality rates, and (early) hypoglycaemia ( 12 h after birth) also
causes more neurodevelopmental impairment in newborns treated
with therapeutic hypothermia for moderate-to-severe hypoxicischaemic
encephalopathy.399,400
A systematic review and metaanalysis
confirmed the association of hypoglycaemia and hypergly-
caemia with death and worse neurodevelopmental outcome in babies
with neonatal encephalopathy.401
Early hypoglycaemia and hyperglycaemia
were independently associated with death and/or severe neurodevelopmental
impairment at 18 months in infants with moderate-tosevere
hypoxic-ischaemic encephalopathy, irrespective of cooling.402
Fluctuating glucose levels in neonates with hypoxic-ischaemic
encephalopathy also correlate with unfavourable outcomes.403,404
R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6 27
ILCOR concluded that evidence on glucose management is
scarce.389
Only two good practice statements could be issued and
these are the ERC recommendations: 1) measure blood glucose
concentration early and regularly after resuscitation until normoglycaemia
is achieved; 2) titrate infusion of intravenous glucose against
the infant’s blood glucose values to avoid hypoglycaemia and iatrogenic
hyperglycaemia. Although the optimal blood glucose target
range for newborns with HIE is uncertain,4,405
it seems appropriate
to maintain blood glucose 2.6 mmol/l (47 mg/dL) (good practice
statement).390,400
Thermal care
If therapeutic hypothermia is not indicated, hypothermia after birth
should be corrected because of its association with poor out-
comes.117
Infants should be maintained within the normal temperature
range (36.5–37.5 °C).100,117
Hyperthermia ( 38 °C) after cardiopulmonary resuscitation is
also associated with unfavourable outcomes (death, moderate or
severe disability) in neonates, children, and adults.406–410
A secondary
analysis of an RCT comparing whole-body cooling with standard
care in term infants with hypoxic-ischaemic encephalopathy
demonstrated that the risk of death or moderate-to-severe disability
was increased 3.6–5.9-fold for every 1 °C increase in tempera-
ture.411
Hyperthermia should thus be avoided.412
The ERC recommends
monitoring temperature and aiming for normothermia.
Therapeutic hypothermia
A Cochrane review including 11 RCTs comprising 1505 term and late preterm
infants calculated that therapeutic hypothermia resulted in a statistically
significant and clinically important reduction in the combined
outcome of mortality or major neurodevelopmental disability to 18 months
of age and concluded that newborn infants at term or near-term with
evolving moderate-to-severe hypoxic-ischaemic encephalopathy (HIE)
should be offered therapeutic hypothermia.411
A more recent systematic
review and meta-analysis including 29 RCTs with 2926 infants
35 weeks of gestation with HIE showed that therapeutic hypothermia
diminishes the risk of neurological disability and cerebral palsy.412
The
overall effect of therapeutic hypothermia on mortality was uncertain.
Cooling should be performed in NICUs with the capabilities for
multidisciplinary care, using clearly defined protocols. During transfer
to a NICU, servo-controlled active cooling is the preferred method to
maintain hypothermia in the desired range.413
Treatment should
commence within 6 h of birth, target a temperature between 33 °C
and 34 °C, and continue for 72 h, with rewarming over at least four
hours.414
A clinical trial of 364 infants randomised to receive longer
(120 h) or deeper (32 °C) cooling found no evidence of benefit of
longer cooling or lower temperatures.415
Animal data strongly suggest
that the effectiveness of cooling is related to early intervention.
Hypothermia initiated at 6–24 h after birth may have benefit, but
there is uncertainty in its effectiveness.416
Such therapy can be considered
on an individual basis. Current evidence is insufficient to recommend
routine therapeutic hypothermia for infants with mild HIE.417
The ERC recommends applying therapeutic hypothermia in term
newborns ( 37 weeks) with evolving moderate-to-severe HIE in
low- and middle-income countries as long as appropriate supportive
neonatal care can be provided. There is insufficient evidence to offer
a recommendation on therapeutic hypothermia in low- and middleincome
countries for late preterm infants (34 to 37 weeks).
Oxygenation & ventilation
Evidence on oxygen targets in infants with perinatal asphyxia is lacking.
It seems prudent to continuously monitor oxygen saturations and
regularly draw arterial blood gases.418
Considering the increased risk
of pulmonary hypertension in infants with hypoxic-ischaemic
encephalopathy, sometimes aggravated by therapeutic hypothermia,
measurement of pre and post-ductal saturations is sensible.419–423
Both hypoxaemia and hyperoxaemia can be detrimental.424
The
ERC recommends titrating O2 to avoid hypoxaemia and hyperoxaemia,
and to aim for normocapnia.
A review of nine retrospective studies reported that hypocapnia in
newborns with HIE is associated with adverse short- and long-term
outcomes.425
A retrospective cohort study including 188 infants managed
with therapeutic hypothermia for HIE showed that hypocapnia
was associated with more severe brain injury on MRI in a dosedependent
fashion.426
Targeting normocapnia appears sensible after
neonatal resuscitation.424
Prognostication
The Apgar score was designed to focus attention on the newborn and
to identify infants needing interventions.427
Individual components of
the score (e.g. breathing, HR) reflect the physiological relationships
during postnatal transition. Lower scores at one minute are associated
with more interventions at 5 and 10 min.42
Although the overall Apgar
score is widely recorded in clinical practice and for research purposes,
its applicability has been questioned because of large inter- and intraobserver
variations and racial bias.428160,429,430
A retrospective study
involving 42 infants (23–40 weeks) found a significant discrepancy (average
2.4 points) between retrospective video-based Apgar scores and
scores applied by those attending the birth.428
Individual components
of the Apgar score are used to guide resuscitation, but the overall
Apgar scores are not. Apgar scores are calculated after resuscitation
and are often required by institutions and national registries.
Several studies have looked at the prognostic ability of clinical parameters,
biochemical results, medication use, neuroimaging, and neurophysiological
studies to predict neurodevelopmental outcomes of
newborn infants (treated) with (hypothermia for) hypoxic-ischaemic
encephalopathy.431–438
However, a recent systematic review concluded
that all clinical prediction models proposed so far have methodological
limitations hampering their routine use in clinical practice.439
The ERC cannot recommend a specific clinical prediction model.
Clinical team debriefing
Debriefing after a resuscitation may help improve team performance
in subsequent resuscitation events.440
A meta-analysis revealed that
team debriefings after simulated events outperformed non-debriefing
teams by approximately 25 %.441
Another meta-analysis of 61 studies
evaluated the effectiveness of After-Action Reviews following
training and clinical events, indicating an average improvement
effect size of 0.79 (Cohen’s d) in task performance, cognitive skills,
attitudes toward training/learning.442
An ILCOR review on the effect of debriefing on clinical outcome
(resuscitation skills and knowledge) and patient outcome (good neu-
rological outcome, survival at discharge, survival to hospital) found
studies with no effect, but also improved favourable neurological outcome,
survival to discharge, ROSC, chest compression depth, rate
and fraction and adherence to guidelines. No undesirable effects
from debriefing could be demonstrated. The ERC recommends
post-event debriefing after neonatal cardiac arrest in settings that
have adequate resources.67
28 R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6
Communication with the parents
The principles governing the need for good communication with parents
are derived from clinical consensus and enshrined in published
European guidance.443,444
Mortality and morbidity for newborns
varies according to region, ethnicity and to availability of
resources.445–447
Social science studies indicate that parents wish
to be involved in decisions to resuscitate or to discontinue life support
in severely compromised infants.448,449
Local survival and outcome
data are important in appropriate counselling of parents. The
institutional approach to management (for example at the border of
viability) affects the subsequent results in surviving infants.450
The ERC is supportive of family presence during cardiopulmonary
resuscitation.451
Healthcare professionals are increasingly
offering family members the opportunity to remain present during
resuscitation, and this is more likely if the resuscitation takes place
within the delivery room. Parents’ wishes to be present during resuscitation
should be supported where possible.43,452,453
There is insufficient evidence to indicate an interventional effect
from parental presence on patient or family outcome. Being present
during the resuscitation of their baby seems to be a positive experience
for some parents but there are concerns among professionals
and family members that it may impair performance.43,453
In a single centre review of management of birth and resuscitation
at the bedside, parents who were interviewed were supportive,
but some found witnessing resuscitation difficult.454
Clinicians
involved felt the close proximity improved communication, but interviews
suggested support and training in dealing with such situations
might be required for staff.455
In a retrospective survey of clinicians’
workload during resuscitation the presence of parents appeared to
be beneficial in reducing perceived workload.456
Qualitative evidence emphases the need for support during and
after any resuscitation, without which the birth may be a negative experience
with post traumatic consequences.457,458
There should be an
opportunity for the parents to reflect, ask questions about details of
the resuscitation and be informed about the support services avail-
able.452
It may be helpful to offer any parental witness of a resuscitation
the opportunity to discuss what they have seen at a later date.457,458
Decisions to discontinue or withhold resuscitation should ideally
involve senior paediatric staff.
The ERC recommends that where practically possible and parental
inclination allows, parents should be supported and empowered to
be present during the resuscitation of their newborn infant with
appropriate support from staff. Decisions to discontinue or withhold
resuscitation should involve senior paediatric staff.
Discontinuing or withholding treatment
Discontinuing resuscitation
Failure to achieve return of spontaneous circulation in newborn
infants after 10–20 min of intensive resuscitation is associated with
a high risk of mortality and a high risk of severe neurodevelopmental
impairment among survivors. There is no evidence that any specific
duration of resuscitation universally predicts mortality or severe neurodevelopmental
impairment.
The outcomes of infants whose heart rate has been absent for
longer than 10 min are not universally poor.459–461
An ILCOR systematic
review identified 13 studies involving 271 infants with at
least 10 min of asystole, bradycardia or pulseless electrical activity.
Of these infants, 70 % died, 18 % survived with moderate/severe
neurodevelopmental impairment, and 11 % survived without moderate/severe
impairment.462
Another review identified 820 infants with
absent heart rate >10 min after birth: 40 % survived; 21 % survived
with moderate to severe neurodevelopmental impairment and 19 %
without moderate or severe neurodevelopmental impairment.463
A
secondary analysis of the Optimising Cooling Trial, found that a
10-minute Apgar score of 0 alone did not predict well death or moderate
or severe disability.464
It can be helpful to consider clinical factors,
effectiveness of resuscitation and the views of other members
of the clinical team about continuing resuscitation.465
The ERC recommends discontinuing resuscitation after prolonged
cardiopulmonary resuscitation if all recommended interventions have
been applied and potentially reversible causes excluded. A reasonable
time to consider this is around 20 min after birth.
In extremely preterm infants, prolonged resuscitation is associated
with lower survival rates and higher morbidity; it may be appropriate
to discontinue resuscitation sooner.462,466
The decision should
be individualized. The decision to cease resuscitation is a medical
decision, but it is important, where possible, to give the family
updates during the resuscitation and advance warning that there is
a high chance the baby will not survive.
Withholding resuscitation
In situations where there is extremely high predicted mortality and
severe morbidity in surviving infants, withholding resuscitation may
be reasonable, particularly when there has been the opportunity
for prior discussion with parents.27–29,467,468
Examples from the
published literature include extreme prematurity (GA <22 weeks
and/or birth weight less than 350 g),468
and anomalies such as
anencephaly and bilateral renal agenesis. Withholding resuscitation
and discontinuation of life-sustaining treatment during or following
resuscitation are considered by many to be ethically
equivalent and clinicians should not be hesitant to withdraw treatment
when it would not be in the best interests of the infant.469
The ERC recommends a consistent and coordinated approach to
individual cases by the obstetric and neonatal teams which
actively involves the parents. In conditions where there is low survival
and a relatively high rate of morbidity, and where the anticipated
burden to the child is high, parental wishes regarding
resuscitation should be sought and supported.444
Declaration of competing interest
Declarations of competing interests for all ERC Guidelines
authors are displayed in a COI table which can be found online at
https://doi.org/10.1016/j.resuscitation.2025.110766.
Acknowledgements
We thank Sylvia Obermann, parent representative for the Dutch
organisation Care4Neo for her contribution to thses Guidelines.
R E S U S C I T A T I O N 2 1 5 ( 2 0 2 5 ) 1 1 0 7 6 6 29
Author details
a
Department of Neonatology, Amalia Children’s Hospital, Radboudumc,
Nijmegen, the Netherlands b
Simpson Centre for Reproductive
Health, Edinburgh Royal Infirmary, Edinburgh, UK c
Neonatal Service,
University Hospitals Leicester NHS Trust, Leicester, UK d
Department
of Neonatology, General Hospital Zadar, Croatia e
Faculty of Medicine,
University of J. J. Strossmayer Osijek, Croatia f
Faculty of Health
and Life Sciences, University of Bristol, UK g
Newborn Services,
Southmead Hospital, North Bristol NHS Trust, Bristol, UK h
National
Perinatal Epidemiology Unit, Oxford Population Health, Medical
Sciences Division, University of Oxford, Oxford, UK i
Saxonian Center
for Feto/Neonatal Health, Faculty of Medicine, University Hospital Carl
Gustav Carus, Technische Universita¨t Dresden, Dresden, Germany
j
St. Josef Hospital GmbH, Department of Pediatrics and Neonatology,
Vienna, Austria k
Department of Neonatal Intensive Care, Division of
Paediatric and Adolescent Medicine, Oslo University Hospital
Rikshospitalet, Norway l
Institute of Clinical Medicine, Faculty of
Medicine, University of Oslo, Oslo, Norway m
II Department of
Neonatology, Poznan University of Medical Sciences, Poznan,
Poland n
Neonatal Biophysical Monitoring and Cardiopulmonary
Therapies Research Unit, Poznan University of Medical Sciences,
Poznan, Poland o
Division of Neonatology, Willem-Alexander Children’s
Hospital, Leiden University Medical Center, Leiden, the
Netherlands p
Department of Woman’s and Child’s Health,
University Hospital of Padova, University of Padova, Padova, Italy
q
Division of Neonatology, Pediatric Intensive Care and Neuropediatrics,
Department of Pediatrics, Comprehensive Center for Pediatrics,
Medical University of Vienna, Vienna, Austria r
Uehiro Oxford
Institute, University of Oxford, UK s
John Radcliffe Hospital, Oxford,
UK t
Murdoch Children’s Research Institute, Melbourne, Australia
u
Department of Neonatology, University Hospitals Plymouth
v
Faculty of Medicine, University of Plymouth, Plymouth, UK
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