Neonatal resuscitation: An update

International guidelines on neonatal resuscitation were published in 2010 based on the best available evidence. While many of these guidelines remain unchanged, subtle refinements have evolved with recent evidence. The aim of this review is to distill these recommendations, to provide updates where appropriate, and to condense them into a framework that is useful for the clinician. Birth depression is a common event, caused by both maternal and neonatal conditions. Prompt initiation of the most appropriate support is essential for achieving best outcomes. While ventilation of the small airways is the most important intervention in the neonatal resuscitation algorithm, progression to the next step is based on the simultaneous assessment of both heart rate and respirations. Serial clinical assessment of the response to interventions is fundamental to a successful resuscitation. Pulse oximetry should be used for assessing oxygenation when resuscitation is required. And generally speaking, term and nearterm infants should be resuscitated using room air, while preterm infants should be resuscitated with the lowest concentration of oxygen needed to maintain normal oxygen saturations. Decisions regarding respiratory support should be individualized, but the lowest peak inspiratory pressure needed to achieve clinical improvement is advocated in neonatal resuscitation. The use of end-expiratory pressure reduces the need for invasive respiratory support, and support of spontaneous respirations with continuous positive airway pressure (CPAP) has been shown to result in improved long-term outcomes in preterm, but not term infants. Finally, circulatory support is rarely indicated in neonatal resuscitation scenarios, but is recommended in circumstances of presumed volume loss, persistent or prolonged bradycardia, or a persistent, suboptimal response to resuscitative efforts.