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NRP 8th Edition “Busy Baby” Update for Busy People

This is the year for the AAP to release the long-awaited 8th Edition updates to the Neonatal Resuscitation Program. The process to transition from the 7th edition to the 8th edition started halfway through 2021, and the expectation is for the 8th Edition to be 100% instructional by January 1st, 2022.

There are some general changes as in the educational platforms that now consist of 2 options. Which option is for you, depends on the facility you are employed at, and your job responsibility. The 2 options now are referred to as NRP Essentials and NRP Advanced. The NRP Essentials is geared toward healthcare providers who routinely care for infants that are low-risk, whereas the NRP Advanced is for providers who routinely perform resuscitation beyond providing positive pressure ventilation (PPV). Those of us in EMS should be taking the NRP Advanced. There is also an RQI component if you work for an organization that has RQI. This partnership between the Neonatal Resuscitation Program and Resuscitation Quality Improvement is a quality improvement program for self-directed learning in a low-dose, high-frequency model. No more eSims in Part 1! (Most are happy about that).

Epinephrine Dose: There are some cool changes that I think will make resuscitating a newborn much easier! The dose of Epinephrine previously was in a range (0.01mg-0.03mg IV/IO) or (0.05mg-0.1mg/kg ETT) q 3-5 minutes

  • While you can still honor that range, but the suggestion now is Epinephrine 0.02mg/kg IV/IO or 0.2ml/kg IV/IO which is cool as it keeps it simple; no more debate on: “first dose, second dose?” or “go big or go home?” or “what dose should I use?” ….

  • The ETT dose (while establishing IV/IO access) now is Epinephrine 0.1mg/kg ETT or Epinephrine 1ml/kg ETT

  • The Normal Saline flush volume has been increased from 0.5 – 1.0 ml to 3ml

  • After Epinephrine administration, the Normal Saline flush volume: 3ml IV/IO regardless of gestational age/size

The 4 pre-birth questions have been simplified to the following – which I like having the discussion regarding cord management so that all providers at the delivery are on the same page, and everyone knows the expectations. Also, the prior question of “How many babies are you having?” is now considered a high-risk factor question, so that would be something you would consider when asking the question regarding any high-risk factors.

  • What is the gestational age?

  • Color of amniotic fluid?

  • Any high-risk factors?

  • Plan for umbilical cord management?

The initial steps of resuscitation for any baby have been re-ordered & simplified

  • Warm

  • Dry

  • Stimulate

  • Position airway

  • Suction if needed

Using a cardiac monitor is encouraged earlier in the resuscitation

  • When the need for an alternate airway becomes necessary, a cardiac monitor is the preferred method of assessing heart rate

  • This would be the “A” in the MR SOPA mnemonic

Extended time frame for cessation of resuscitation efforts:

  • Previously, after 10 minutes of resuscitative measures and a confirmed absence of a heart rate there would be consideration of cessation of efforts

  • 8th Edition NRP states if after all appropriate resuscitative efforts have been utilized, and there is a confirmed absence of a heart rate, to consider cessation of resuscitation efforts around 20 minutes after birth

  • This decision is individualized on each patient and any contextual factors

The Textbook of Neonatal Resuscitation, 8th Edition has 11 lessons and 3 Supplemental Lessons:

  • Foundations of Neonatal Resuscitation

  • Anticipating and Preparing for Resuscitation

  • Initial Steps of Newborn Care

  • Positive-Pressure Ventilation (includes Laryngeal Mask)

  • Endotracheal Intubation

  • Chest Compressions

  • Medications

  • Resuscitation and Stabilization of Babies Born Preterm

  • Post-resuscitation Care

  • Special Considerations

  • Ethics and Care at the End of Life

Supplemental Lessons (for enhanced learning; no exam questions for this material)

  • Improving Resuscitation Team Performance

  • Resuscitation Outside the Delivery Room

  • Bringing Quality Improvement to Your Resuscitation Team

Key Points

  • Ventilation of the lungs is always the initial priority in resuscitation of the newborn!

  • Any location where newborns may receive care should have immediate access to a bulb syringe, a self-inflating bag, and appropriately sized face masks.

  • NRP vs. PALS -> NRP specifically for immediate newborn period. Example: NRP recommends using 3:1 compression-to-ventilation ratio unless there is reason to suspect a non-respiratory etiology such as a primary cardiac arrhythmia or disturbance in electrolytes.

  • Important to establish adequate ventilation prior to initiating chest compressions. Chest compressions are indicated when the newborn’s heart rate is < 60 bpm after at least 30 seconds of adequate PPV (inflating the lungs AEB chest movement, and preferably with an alternate airway).

  • Vascular access in EMS -> placing an emergent UVC is not generally a great option in EMS settings: so, use of the intraosseous needle is great.

  • Always strive to keep baby warm! (See blog on Newborn Hypothermia)

  • Easy Epinephrine dosing

    • 0.2 ml/kg IV/IO or 1ml/kg ETT

  • Easy Epi NS flush dosing

    • 3ml NS after administration of IV/IO Epi

  • 4 Pre-Birth Questions

    • Gestational age?

    • Amniotic fluid clear?

    • Additional risk factors?

    • Umbilical cord management plan?

  • Initial Steps Re-ordered

    • Warm, dry, stimulate, position airway, suction if needed

  • Apply cardiac monitor when an alternate airway is needed

  • Timeframe expanded for cessation of resuscitative efforts

    • Considered cessation of resuscitation efforts around 20 minutes after birth, in confirmed absence of HR and individualized decision on each case

Overall, I am pleased with the changes to the program. The addition of RQI (in facilities that have RQI) will lead to improved neonatal outcomes, I am certain. For those that do not have an RQI program, emphasis on frequent simulation/debriefing on a regular, scheduled basis can also improve outcomes. And for us in EMS, the simulation does not mean in the comfort of our training rooms! Doing resuscitation scenarios in the aircraft is a great way to know your team, your equipment, and your environment! NRP re-certification is every 2 years -> we should plan for a resuscitation every month!


Aziz K, Lee HC, Escobedo MB, et al. Part 5: Neonatal Resuscitation 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2020; doi: 10.1542/peds.2020- 038505E (


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