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. Author manuscript; available in PMC: 2025 Dec 1.
Published in final edited form as: Semin Perinatol. 2024 Oct 9;48(8):151991. doi: 10.1016/j.semperi.2024.151991

Resuscitation Education for NICU Providers: Current practice and recommendations for NRP and PALS in the NICU

Elizabeth Schierholz 1, Elizabeth (Liz) Wetzel 2, Alyssa R Thomas 3, Beena D Kamath-Rayne 4, Danielle Reed 5
PMCID: PMC11901557  NIHMSID: NIHMS2059039  PMID: 39406611

Abstract

The Neonatal Resuscitation Program (NRP) is the most used resuscitation algorithm for infants requiring resuscitation in the neonatal intensive care unit (NICU). The population of infants cared for in the NICU is varied and complex with resuscitation needs that may extend beyond the NRP algorithm. To provide resuscitation care that addresses these needs, institutions may choose to incorporate algorithms from the Pediatric Advanced Life Support or a “hybrid” approach that includes NRP. Limited evidence exists to support one algorithm or approach over another. In this article, we identify potential gaps in the application of using NRP or PALS in the NICU population, present select patient decompensations and discuss the resuscitation management approach using the NRP or PALS algorithms. Challenges associated with NICU resuscitation education will be explored as well as approaches to overcome some of the identified resuscitation education obstacles.

There is a long-standing discussion regarding the most appropriate educational program for healthcare providers involved in the resuscitation of infants requiring care in the neonatal intensive care unit -the Neonatal Resuscitation Program (NRP) or Pediatric Advanced Life Support (PALS).1–4 There is no clear evidence favoring one program over the other for NICU-specific scenarios. The application of either program to NICU populations reveals significant gaps.5 This article will explore the nuances of the patient population in the NICU that complicate their resuscitation needs. We will discuss several NICU patient decompensation scenarios and how they would be managed using NRP, PALS or a hybrid approach. Additionally, we will address the educational challenges faced by NICU providers in managing these complex cases and propose strategies to enhance their resuscitation training.

Variation of infants in the NICU and the complexities of their resuscitation

In the US, nearly 10% of all newborn infants are admitted to neonatal intensive care unit (NICU) every year.6 The acuity and care needs of infants admitted to the NICU varies widely. According to the California Maternal Quality Care Collaborative, about 31% of NICU admissions are due to “serious” conditions such as severe birth trauma, hypoxia/asphyxia, shock, and infections/sepsis, while 23% are admitted for “moderate” conditions that typically require a hospital stay of greater than 5 days.7 Similarly, from January 2020 through December 2023, data from a 70 bed representative level 4 children’s hospital NICU reports reasons for NICU admissions are as follows: respiratory 29%, surgery 15%, hyperbilirubinemia 12%, infection 11%, neurologic 9%, growth/failure to thrive 4%, congenital anomalies/syndrome 4%, cardiac 4% and preterm birth 3%. The average length of stay was 18 days, range 1–400.8 Furthermore, the Vermont Oxford Network reported that in 2023 alone, 54,925 infants with birth weights 501– 1550 grams and 217,253 infants with birth weights over 1501 grams were admitted to NICUs across 51 centers.9

In the delivery room, approximately 10% of all newborns require some form of support during their transition from the intrauterine to extrauterine environment.10 Among infants admitted to the NICU, 93.3% of infants <1500 grams and 61.5% of those > 1501 grams required any initial resuscitation after birth.9 While only a small fraction (0.12%) of newborns overall require advanced interventions such as chest compressions or epinephrine, infants admitted to the NICU are at greater risk.11–13 Cardiopulmonary arrest with chest compressions is 10 times more common in level IV NICUs as compared to the delivery room, occurring in 1.1% of admissions.2 Likewise, the frequency of cardiopulmonary resuscitation (CPR) is 1.4% in pediatric patients admitted to the pediatric intensive care unit (PICU) and 3.1% in pediatric patients admitted to the cardiac intensive care unit (CICU).14,15

The causes of resuscitation in pediatric patients vary between the NICU, PICU and CICU. In the NICU, resuscitation is more often triggered by respiratory issues, with studies indicating that up to 91% of CPR events in the NICU stem from acute respiratory compromise.2 This is in stark contrast to the PICU, where acute respiratory compromise occurred in only 33–56% of code events while cardiovascular dysfunction was the cause of 24–42% of code events.16,17 Furthermore, code events in the NICU tend to be shorter, with fewer doses of epinephrine given.18

The American Academy of Pediatrics (AAP) and American Heart Association (AHA) have established the Neonatal Resuscitation Program (NRP) as the standard of care for resuscitating newborns in the delivery room.19,20. The NRP algorithm prioritizes airway management, ventilation and oxygenation, over chest compressions to reflect the physiological transition from fetus to newborn. Evidence to support the NRP algorithm is based on studies of management of the infant in the delivery room. Because those who resuscitate in deliveries are often those who also staff NICUs, NRP is the most commonly used resuscitation educational program and algorithm among NICUs.21

Outside the delivery room, newborn care unit, and NICU, the AHA/AAP Pediatric Advanced Life Support Program (PALS) is the standard for managing pediatric emergencies.22,23 The PALS curriculum is designed to prepare healthcare providers to manage respiratory and cardiovascular emergencies, as well as cardiopulmonary arrest in pediatric patients, excluding newly born infants. Despite its broader application, only 6% of level IV NICUs primarily use PALS for resuscitation.21

However, neither NRP nor PALS fully addresses the resuscitation needs of infants in the NICU. Once infants are admitted to the NICU, they are no longer considered newly born and have progressed beyond the initial period of transitional physiology. Thus, NRP may be less applicable to their physiology and resuscitation needs. On the other hand, since NICU code events are more likely to be respiratory in origin, the chest compression-focused PALS algorithm may also be inadequate. There is currently limited guidance on when to transition from an NRP-based approach to a PALS-based approach for NICU patients. The highly variable and complex resuscitation needs of the patient population in the NICU make identification of an ideal existing resuscitation algorithm challenging.

NICU teams have attempted to address the educational gaps in resuscitation in several ways. Data from the Children’s Hospital Neonatal Consortium (CHNC) reports 81% of NICUs require neonatal attendings to maintain NRP training and 46% also require PALS.21. Thirty-four percent of these NICUs require staff to have training in both NRP and PALS and some units report adoption of a “hybrid” model, combining elements of both programs to address code events in their NICU based on the patient’s age or clinical criteria.21,24 Simulation-based training, including unannounced mock codes and multidisciplinary simulations, is commonly used to prepare NICU teams for high-acuity, low-occurrence events (HALO).25–27 However, the content and implementation of such training vary significantly between institutions in terms of who participates, what HALO events are simulated, which algorithm or resuscitation steps are taught, and what content debriefed, with only 36% of units having standardized guidelines for HALO events.21 This lack of standardization in resuscitation training may impact the effectiveness of NICU code teams and, ultimately, patient outcomes.

Decompensation of the infant in the NICU and resuscitation interventions

As discussed, infants in the NICU who have decompensation events requiring resuscitation may be treated by individuals knowledgeable in the NRP or PALS algorithms. Table 1 presents four potential case scenarios of infants admitted to the NICU who required resuscitation. For each case, the resuscitation event is described and the intervention response from the NRP and PALS perspective are provided, followed by the proposed blending of each approach.

Table 1.

Resuscitation cases with hypothetical responses using NRP, PALS, or blended algorithms.

Case background & Resuscitation event NRP Resuscitation PALS Resuscitation How algorithms could be blended How was this case resolved?
8-month-old former 27 week GA infant with BPD, tracheostomy-dependent, tracheomalacia and pulmonary hypertension stable on bosentan after recently stopping inhaled nitric oxide.
During daytime, infant undergoes tracheostomy change to accommodate a longer length. Although sedated for the procedure, hours later, the infant is awake, agitated and becomes dyspneic, desaturated to SpO2 60%, and bradycardic with a heart rate of 50 BPM.

  1. As HR is <100, initiate PPV at 20/5 with 21% FiO2. Steps to improve ventilation were attempted.

  2. After effective PPV is delivered for 30 seconds, the team notes that HR now <60 BPM. FiO2 is increased to 100% and chest compressions started at 3:1 ratio with breaths.

  3. ECG leads are placed and HR and pulse is checked every 1 minute. As HR is still < 60 BPM, he receives IV epinephrine 0.02 mg/kg.

  4. Team considers pneumothorax but breath sounds are equal.

  1. Assist breathing with PPV and oxygen.

  2. Chest compressions initiated for HR <60 at a rate of 100/min, asynchronous with 20–30 breaths/min via tracheostomy.

  3. Epinephrine 0.01 mg/kg, followed by atropine 0.02 mg/kg are administered due to concern of increased vagal tone contributing.

  4. The pulses are checked every 2 minutes while team considers “Hs/Ts” etiologies.

  1. Patient has known respiratory disease (BPD). More attention could be paid to good PPV and ventilation-corrective steps before moving to compressions.

  2. With established airway, asynchronous ventilations and compressions could be used.

  3. Pulse checks could be spaced to every 2 minutes to minimize disruption to increased diastolic pressure.

  4. Neither algorithm directly guides ICU management of advanced airway exchange, high pressure ventilation with BPD, or consideration of sedation, paralysis, inhaled nitric oxide, or vasopressors in the context of pulmonary hypertension.

  1. With known history of BPD and tracheomalacia, PPV initiated at high pressure (50/15) and due to pulmonary hypertension initiated PPV with 100% FiO2.

  2. Tracheostomy replaced and PPV appeared effective with symmetric chest rise.

  3. Despite this, HR still <60 BPM and chest compressions started.

  4. Infant received a dose of IV epinephrine and a normal saline bolus.

  5. Due to known pulmonary hypertension, the infant is sedated/paralyzed and inhaled nitric oxide is started at 20 ppm.

  6. Heart rates > 100 BPM and SpO2 recovered slowly to baseline.
10 day old former 32 week GA infant with severe intrauterine growth restriction, develops abdominal distension and lethargy after reaching full enteral feeds. Abdominal radiograph shows diffuse pneumatosis without pneumoperitoneum. After a blood culture is obtained, antibiotics are initiated and the infant is seen urgently by the general surgery team.
When assessed, her HR is elevated to 190 BPM, she has thready pulses with delayed capillary refill. She has periodic breathing and drifting SpO2 desaturation.

  1. Infant receives PPV due to inadequate respiratory effort with intermittent apnea.

  2. After corrective maneuvers and effective PPV for 30 seconds, she now has no respiratory effort.

  3. She is intubated and PPV provided invasively. FiO2 is titrated to normal SpO2.

  4. She receives a normal saline bolus due to poor perfusion and weaker pulses though her HR remains elevated.

  1. Following pediatric tachycardia with a pulse algorithm, she is placed on nasal cannula for SpO2 desaturation.

  2. A 12 lead ECG is obtained to evaluate tachycardia, showing a wide complex QRS with concern for ventricular tachycardia.

  3. Her pulses become weaker. Due to concern for cardiopulmonary compromise the team plans to perform synchronized cardioversion at 1J/kg starting dose. In preparation, she is intubated and sedated.

  1. Due to the young age and prematurity of this infant, respiratory status may need more than a passing evaluation as in PALS. Intubation may be needed sooner in more immature infants especially with abdominal competition.

  2. Hemodynamic assessment is stronger in PALS algorithm and helps the team to risk stratify the infant’s elevated heart rate.

  3. A 12 lead ECG is needed to assess the underlying rhythm. This infant could have had narrow complex sinus tachycardia due to sepsis but instead had wide complex ventricular tachycardia.

  4. In this infant without congenital heart disease, early evaluation of the underlying cause of arrhythmia might have revealed hyperkalemia and yielded additional options for medical management of the arrhythmia.

  1. Due to intermittent apnea, the infant is sedated and intubated.

  2. An arterial line is placed to monitor blood pressure

  3. Labs obtained showing severe lactic acidosis and hyperkalemia with K of 8.4

  4. Due to ongoing tachycardia with unusual appearance on 3 lead monitor, a full ECG is obtained showing a wide complex tachycardia. She received a dose of IV calcium gluconate, sodium bicarbonate, and IV furosemide for hyperkalemia.

  5. Initial management converted rhythm to sinus tachycardia, but arrhythmia recurs. She becomes hypotensive and undergoes synchronized cardioversion.
A 9 day-old, term infant presents to the emergency department with respiratory distress and poor oral feeding and is admitted to the NICU. Prenatal testing was unremarkable, and the infant had been seen at her pediatrician at 3 days old with no concerns. A preschool-age sibling has an upper respiratory infection.
In the NICU, the infant is pale, mottled, and grunting. Sepsis evaluation and antibiotics initiated. She becomes apneic and is intubated. Despite equal chest rise, heart rate remains <60 BPM. A blood gas shows metabolic acidosis: pH 6.74/ BD-30.

  1. Infant is receiving effective PPV through an advanced airway but HR remains <60 BPM. Chest compressions are initiated.

  2. Chest compressions are coordinated with manual breaths with a 3:1 ratio.

  3. IV epinephrine at 0.02 mg/kg is given until HR is sustained >100 BPM.

  1. Following the pediatric bradycardia with a pulse and poor perfusion algorithm, infant’s breathing is assisted using PPV followed by intubation.

  2. Infant is placed on a monitor and lower extremity blood pressure is attempted but unable to obtain.

  3. Due to signs of shock and apparent hypotension, with HR <60, epinephrine is given and chest compressions initiated.

  4. Underlying causes “H’s and T’s” are systematically evaluated.

  1. PALS initially risk stratifies management of bradycardia based on impact on perfusion (hypotension or signs of shock). May consider initial focus on ventilation/oxygenation as per NRP as in a young infant with respiratory distress, cardiac decompensation is more likely secondary to respiratory cause.

  2. After establishing oxygenation/ventilation, both pathways advocate for chest compressions and epinephrine to support hemodynamics.

  3. Systematic evaluation of the underlying cause of bradycardia with compromise can help the team with a more comprehensive approach to resuscitation.

  1. Infant was intubated and received adequate PPV with chest rise.

  2. As HR remained <60, infant received chest compressions and IV epinephrine bolus.

  3. Team is unable to obtain a blood pressure despite 20 ml/kg of normal saline and 4 doses of IV epinephrine with sustained HR >100.

  4. Due to clinical suspicion based on age and poorer lower extremity perfusion, echocardiogram is obtained, and the infant was found to have coarctation of the aorta with severe obstruction.
A 2 day-old term infant presents as a transfer to the NICU for poor oral feeding and irritability. Because of intermittent tachycardia, she undergoes a sepsis evaluation and is started on antibiotics.
The infant is initially stable in the NICU, but suddenly the monitor alarms with a HR of 240. She appears to be fussy and irritable. She begins to have mild desaturation to SpO2 90% and periods of apnea.

  1. Due to apnea, PPV is initiated.

  2. Despite effective PPV with good chest rise for 30 seconds, the infant remains apneic and so she is sedated and intubated.

  3. She continues to have a HR of 240 but blood pressure is now low. She receives a NS bolus.

  1. Due to apnea, breathing is assisted with PPV.

  2. 12-lead ECG shows narrow complex tachycardia, concerning for SVT.

  3. Rapid bolus adenosine is given, first 0.1 mg/kg with no change in HR, then 0.2 mg/kg.

  4. Team performs synchronized cardioversion with 0.5 J/kg.

  1. In patients with high suspicion for decompensation due to reversible cardiac cause (i.e. SVT), if able to adequately ventilate with PPV consider an approach which prioritizes quick re-establishment of sinus rhythm versus potentially delaying these interventions due to sedation and ETT placement.

  2. Consider LMA placement if the team anticipates only a brief need for a secure airway.

  3. Consider intubation for airway protection if sedation/analgesia is going to be given prior to cardioversion.

  4. Follow PALS SVT algorithm

  1. Infant was intubated due to continued apnea.

  2. Team administered 2 doses of IV adenosine without return to sustained sinus rhythm.

  3. Cardiology consulted and the infant underwent synchronized cardioversion at 0.5 J/kg with return to normal sinus rhythm.

  4. With a return to sinus rhythm, the infant regained spontaneous respirations. She was able to be extubated to room air.
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Abbreviations in order of appearance: GA: gestational age; BPD: bronchopulmonary dysplasia; SpO2: pulse oxygen saturation; HR: heart rate; BPM: beats per minute; PPV: positive pressure ventilation; FiO2: fraction of inspired oxygen; ECG: electrocardiogram; IV: intravenous; ppm: parts per million; SVT: supraventricular tachycardia; LMA: laryngeal mask airway; ETT: endotracheal tube.

Respiratory compromise is a common primary cause of decompensation in the NICU. When the cause of the event is known, the appropriate intervention is clear. But even when the cause of the event is unknown the need to establish airway and breathing is likely still the necessary and most appropriate starting point for NICU infants. Oxygenation and ventilation are paramount in both NRP and PALS. When effective respiratory support is not sufficient for recovery, utilizing the algorithms for cardiac arrest from PALS and a systematic approach to identify the underlying and reversible cause of cardiac arrest may be the next most effective steps to initiate appropriate interventions.

Challenges to education implementation of NRP and/or PALS for resuscitation needs in the NICU

Implementing resuscitation protocols like the NRP and PALS within NICU settings presents significant challenges, both in terms of clinical application and educational logistics. Training staff in these protocols is costly, both financially and in terms of time commitment. The current 8th edition of NRP offers two courses: Essentials, which covers initial stabilization and resuscitation, and Advanced, which includes complex interventions and invasive procedures. The Essentials course can be completed either through an in-person instructor-led session every 2 years or via Resuscitation Quality Improvement (RQI) for NRP every 3 months. RQI for NRP is a self-directed, low-dose, high-frequency program that allows learners to practice on a simulation station within their hospital. In contrast, Advanced learners must renew their NRP certification through an instructor-led event every two years. Both NRP courses employ a blended learning approach, with an online adaptive learning component followed by a skills component. The online adaptive learning module varies in length depending on the learner’s experience with NRP content, and the instructor-led event usually lasts 3–5 hours.

The PALS course also has time and cost burdens. It can be completed with a blended learning approach through HeartCode PALS, an online module that uses adaptive learning is completed before attending an in-person instructor led session that takes approximately 5 hours to complete. Alternatively, PALS can be completed in a traditional classroom format, with the full course taking up to 17.25 hours and an update course taking 8.75 hours. The cost of PALS training is approximately three to four times that of NRP, and additional fees may be incurred depending on where the learner chooses to do their in-person portion of the training. The monetary and time cost of requiring staff to take both trainings may be prohibitive for some hospitals, especially when factoring in the wages the hospitals often pay their hourly employees while they take these courses. Given the lack of definitive evidence favoring one resuscitation algorithm over the other, convincing hospital administrators to invest in dual training for all staff may prove challenging.

While the type of resuscitation algorithm may impact patient care, team performance has also been shown to impact the quality of resuscitation. When team members are trained in different programs and do not share a common mental model, confusion can arise during resuscitation efforts, leading to delays in critical interventions. Effective team dynamics, including situational awareness, leadership, communication, diagnosis of the primary problem, and task prioritization, may differ depending on the chosen algorithm.28 Resuscitation team training has been shown to improve these competencies.29

Given that NRP is the predominant resuscitation program in most NICUs, introducing PALS requires careful consideration. PALS includes multiple algorithms, which necessitates clear communication among team members regarding which algorithm is being used during a resuscitation event. A unified approach, with all team members adhering to a clearly stated algorithm, is crucial for optimizing outcomes.30

Variation in hospital resources and policies further complicates resuscitation education and planning. For example, the same infant may be cared for in the NICU, the PICU, and or CICU depending on the hospital, with resuscitation education varying across units. In the NICU, nurses may primarily be trained in NRP, while other providers, such as respiratory therapists or surgeons who work throughout the hospital, may have PALS training. Staff in the PICU and CICU are most likely to have training in PALS. This disparity underscores the need for code leaders to clearly announce which resuscitation algorithm is being followed, ensuring that all team members share the same expectations of what to do next and can perform their duties in a coordinated fashion. Even with clear communication, challenges persist if all team members do not share the same foundational resuscitation education.

Considerations for implementing resuscitation education

To determine the most appropriate resuscitation education and training for NICU teams, it is essential to assess the specific needs of an individual NICU patient population, as well as the capacity and support for training within the unit. A key step to identifying the best resuscitation algorithm to routinely review infant code events, assessing the algorithm used, teamwork, communication, and resources. This process can help identify successes and gaps in the current approach.

As mentioned earlier, the decision to adopt NRP or PALS is often influenced by location, patient population, or provider training. Sawyer et al. suggest four strategies for adopting NRP or PALS in clinical units: location-based, age-based, patient-based, and provider-based.5 Each of these approaches has its own set of benefits and challenges. In a location-based strategy, the resuscitation algorithm used is chosen based on the location of the patient, i.e. in the NICU, the NRP algorithm is used and in the PICU and CICU, PALS is used. In an age-based strategy, an infant with a postmenstrual age greater than 44 weeks will receive PALS and NRP is used for all younger infants. In a patient-based strategy, the etiology of the arrest is used to determine the appropriate algorithm. PALS is utilized for cardiac etiologies and in all other causes NRP is utilized. Such a strategy could be particularly effective in NICUs where a diverse patient population presents varied resuscitation needs. Finally, a provider-based approach would promote using the resuscitation algorithm most aligned with the training of the clinical team.

A review of patient population, infant characteristics and etiology of codes/resuscitation events aligns with the patient-based approach described by Sawyer et al. and could result in the decision to adopt either PALS or NRP. Such a review might also identify resuscitation needs not met exclusively by a single algorithm. In some cases, adopting elements of both NRP and PALs may provide a more comprehensive approach to resuscitation. One example with this approach may be to identify branching points where the team would shift from one algorithm to another: for example, after adequate oxygenation and ventilation are established, the team might shift focus to cardiac dysfunction and reversible causes of cardiac arrest (Table 2).

Table 2.

Hs and Ts: Reversible causes of cardiac arrest in pediatric patients23

Hypoxia
Hypovolemia
Hydrogen ion (acidosis)
Hypo/Hyperkalemia
Hypothermia
Hypoglycemia		 Toxins
Tamponade (cardiac)
Tension Pneumothorax
Thromboembolic event
Trauma
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A patient-based approach has been successfully implemented in some institutions. Harer et al. evaluated their Level IV NICU population and identified patients who would benefit from PALS-based resuscitation, such as those with postmenstrual ages greater than 44 weeks, a history of non-PDA cardiac surgery, or those with cardiac arrhythmias.24 They trained staff, including neonatology attendings, fellows, nurse practitioners, respiratory therapists and nursing care leaders in both NRP and PALS. A bedside notification card was displayed to indicate the appropriate algorithm for each patient. At the time of publication, after 13,450 patient days, it was reported that 28.9% of patient days qualified for PALS versus 71.1% for NRP.24. Of the 6 documented codes reported, 5 qualified for NRP and 1 qualified for PALS. This approach allowed for more tailored resuscitation efforts, though it did highlight the challenge of convincing hospital administration to invest in dual training for all staff without stronger indications supporting its necessity.

Regardless of the chosen algorithm or the training background of team members, there is strong evidence supporting the value of team-based training and simulation for events that occur outside the delivery room. Best practices for team training emphasize closed-loop communication, situational awareness and clear identification of a team leader. Interdisciplinary (neonatology, surgery, cardiology, radiology) and interprofessional (MD/DO, NP/PA, RNs and RTs) scenarios that incorporate elements of both NRP and PALS can help teams practice resuscitation skills, review multiple algorithms, and improve their overall performance. Regular debriefing sessions following these scenarios are essential to identify opportunities for improvement.

The variability in resuscitation practices and education among NICU teams presents an opportunity to enhance the quality of resuscitative care for NICU patients. The unique resuscitation needs of infants in the NICU differ significantly from those of newborns in the delivery room, necessitating a thoughtful approach to education and training. While elements of both the NRP and PALS algorithms may be required to fully address these needs, further research is needed to establish clear guidelines for resuscitation education and implementation in the NICU. Ultimately, efforts to improve resuscitation care should prioritize evidence-based practices, including team training and simulation, to ensure the best possible outcomes for this vulnerable patient population.

Disclosures

The following authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.

Elizabeth Schierholz, PhD, NNP-BC

Elizabeth (Liz) Wetzel, MD MS

Danielle Reed, MD

Alyssa R. Thomas, MD

Dr. Thomas is supported by T32 HD 098061

Beena Kamath-Rayne is an employee of the American Academy of Pediatrics and oversees clinical skills training programs, including the Neonatal Resuscitation Program, in her role. She is the AAP Liaison to the American Heart Association Emergency Cardiovascular Care Committee.

Contributor Information

Elizabeth Schierholz, Neonatal Nurse Practitioner, Nurse Scientist, Children’s Hospital Colorado, Aurora, CO.

Elizabeth (Liz) Wetzel, Associate Professor of Clinical Pediatrics, Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.

Alyssa R. Thomas, Department of Pediatrics, Division of Newborn Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA.

Beena D. Kamath-Rayne, Senior Vice President, Global Health and Clinical Skills, American Academy of Pediatrics, Itasca, IL, USA.

Danielle Reed, Associate Professor of Pediatrics, Department of Pediatrics, Division of Neonatology, Children’s Mercy-Kansas City, Kansas City, MO, USA.

References:

  • 1.Ali N, Sawyer T, Barry J, Grover T, Ades A. Resuscitation practices for infants in the NICU, PICU and CICU: results of a national survey. Journal of Perinatology. 2017;37(2):172–176. doi: 10.1038/jp.2016.193 [DOI] [PubMed] [Google Scholar]
  • 2.Ali N, Lam T, Gray MM, et al. Cardiopulmonary resuscitation in quaternary neonatal intensive care units: a multicenter study. Resuscitation. 2021;159:77–84. doi: 10.1016/j.resuscitation.2020.12.010 [DOI] [PubMed] [Google Scholar]
  • 3.Foglia EE, Langeveld R, Heimall L, et al. Incidence, characteristics, and survival following cardiopulmonary resuscitation in the quaternary neonatal intensive care unit. Resuscitation. 2017;110:32–36. doi: 10.1016/j.resuscitation.2016.10.012 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Shah PS. Extensive cardiopulmonary resuscitation for VLBW and ELBW infants: a systematic review and meta-analyses. Journal of Perinatology. 2009;29(10):655–661. doi: 10.1038/jp.2009.71 [DOI] [PubMed] [Google Scholar]
  • 5.Sawyer T, McBride ME, Ades A, et al. Considerations on the Use of Neonatal and Pediatric Resuscitation Guidelines for Hospitalized Neonates and Infants: On Behalf of the American Heart Association Emergency Cardiovascular Care Committee and the American Academy of Pediatrics. Pediatrics. 2024;153(1). doi: 10.1542/peds.2023-064681 [DOI] [PubMed] [Google Scholar]
  • 6.Gamber RA, Blonsky H, McDowell M, Lakshminrusimha S. Declining birth rates, increasing maternal age and neonatal intensive care unit admissions. Journal of Perinatology. 2024;44(2):203–208. doi: 10.1038/s41372-023-01834-x [DOI] [PubMed] [Google Scholar]
  • 7.Haidari ES, Lee HC, Illuzzi JL, Phibbs CS, Lin H, Xu X. Hospital variation in admissions to neonatal intensive care units by diagnosis severity and category. Journal of Perinatology. 2021;41(3):468–477. doi: 10.1038/s41372-020-00775-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Children’s Hospitals Neonatal Database.
  • 9.Vermont Oxford Network Database Summary for Infants 501 to 1500 Grams Born in 2023. Published online 2024.
  • 10.Aziz K, Lee CHC, Escobedo MB, et al. Part 5: Neonatal Resuscitation 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2021;147(Supplement 1). doi: 10.1542/peds.2020-038505E [DOI] [PubMed] [Google Scholar]
  • 11.Barber CA, Wyckoff MH. Use and Efficacy of Endotracheal Versus Intravenous Epinephrine During Neonatal Cardiopulmonary Resuscitation in the Delivery Room. Pediatrics. 2006;118(3):1028–1034. doi: 10.1542/peds.2006-0416 [DOI] [PubMed] [Google Scholar]
  • 12.Perlman JM, Risser R. Cardiopulmonary Resuscitation in the Delivery Room: Associated Clinical Events. Arch Pediatr Adolesc Med. 1995;149(1):20. doi: 10.1001/archpedi.1995.02170130022005 [DOI] [PubMed] [Google Scholar]
  • 13.Soraisham AS, Lodha AK, Singhal N, et al. Neonatal outcomes following extensive cardiopulmonary resuscitation in the delivery room for infants born at less than 33 weeks gestational age. Resuscitation. 2014;85(2):238–243. doi: 10.1016/j.resuscitation.2013.10.016 [DOI] [PubMed] [Google Scholar]
  • 14.Berg RA, Nadkarni VM, Clark AE, et al. Incidence and Outcomes of Cardiopulmonary Resuscitation in PICUs. Crit Care Med. 2016;44(4):798–808. doi: 10.1097/CCM.0000000000001484 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Alten JA, Klugman D, Raymond TT, et al. Epidemiology and Outcomes of Cardiac Arrest in Pediatric Cardiac Intensive Care Units. Pediatric Critical Care Medicine. 2017;18(10):935–943. doi: 10.1097/PCC.0000000000001273 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Pollack MM, Holubkov R, Berg RA, et al. Predicting cardiac arrests in pediatric intensive care units. Resuscitation. 2018;133:25–32. doi: 10.1016/j.resuscitation.2018.09.019 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Ray CM, Pizzuto M, Reyes-Alvarado E, Jackson K, Turner DA, Kamath S. Cardiac arrest in the paediatric intensive care unit: defining the problem and developing solutions. BMJ Open Qual. 2020;9(4):e000930. doi: 10.1136/bmjoq-2020-000930 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Groden CM, Cabacungan ET, Gupta R. Code Blue Events in the Neonatal and Pediatric Intensive Care Units at a Tertiary Care Children’s Hospital. Am J Perinatol. 2022;39(08):878–882. doi: 10.1055/s-0040-1719116 [DOI] [PubMed] [Google Scholar]
  • 19.Weiner G, Zaichkin J. Textbook of Neonatal Resuscitation. (Weiner GM, Zaichkin J, eds.). American Academy of PediatricsItasca, IL; 2021. doi: 10.1542/9781610025256 [DOI] [Google Scholar]
  • 20.Weiner GM, Zaichkin J. Updates for the Neonatal Resuscitation Program and Resuscitation Guidelines. Neoreviews. 2022;23(4):e238–e249. doi: 10.1542/neo.23-4-e238 [DOI] [PubMed] [Google Scholar]
  • 21.Ali N, Schierholz E, Reed D, et al. Identifying Gaps in Resuscitation Practices Across Level-IV Neonatal Intensive Care Units. Am J Perinatol. Published online May 26, 2022. doi: 10.1055/a-1863-2312 [DOI] [PubMed] [Google Scholar]
  • 22.Disque K. Pediatric Advanced Life Support (PALS) Provider Handbook. Satori Continuum; 2020. [Google Scholar]
  • 23.Topjian AA, Raymond TT, Atkins D, et al. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16_suppl_2). doi: 10.1161/CIR.0000000000000901 [DOI] [PubMed] [Google Scholar]
  • 24.Harer MW, Konkol LJ, Limjoco JJ. Transitioning from NRP to a combined PALS-NRP resuscitation model at a level IV NICU. Journal of Perinatology. 2022;42(11):1533–1534. doi: 10.1038/s41372-022-01416-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Lindhard MS, Thim S, Laursen HS, Schram AW, Paltved C, Henriksen TB. Simulation-Based Neonatal Resuscitation Team Training: A Systematic Review. Pediatrics. 2021;147(4). doi: 10.1542/peds.2020-042010 [DOI] [PubMed] [Google Scholar]
  • 26.Yousef N, Moreau R, Soghier L. Simulation in neonatal care: towards a change in traditional training? Eur J Pediatr. 2022;181(4):1429–1436. doi: 10.1007/s00431-022-04373-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Reed DJW, Hermelin RL, Kennedy CS, Sharma J. Interdisciplinary onsite team-based simulation training in the neonatal intensive care unit: a pilot report. Journal of Perinatology. 2017;37(4):461–464. doi: 10.1038/jp.2016.238 [DOI] [PubMed] [Google Scholar]
  • 28.Coolen E, Draaisma J, Loeffen J. Measuring situation awareness and team effectiveness in pediatric acute care by using the situation global assessment technique. Eur J Pediatr. 2019;178(6):837–850. doi: 10.1007/s00431-019-03358-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Farquharson B, Cortegiani A, Lauridsen KG, et al. Teaching team competencies within resuscitation training: A systematic review. Resusc Plus. 2024;19:100687. doi: 10.1016/j.resplu.2024.100687 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Jogie JA. A Case Report on Successful Resuscitation of a Two-Month-Old Infant in the Emergency Room: Neonatal Resuscitation Program (NRP) Guidelines in Practice. Cureus. Published online April 29, 2023. doi: 10.7759/cureus.38291 [DOI] [PMC free article] [PubMed] [Google Scholar]

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