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Article explores when to use neonatal vs. pediatric resuscitation guidelines

Many neonates and infants in the intensive care unit experience cardiopulmonary instability or cardiopulmonary arrest.

Cardiopulmonary resuscitation (CPR) with chest compressions occurs in approximately 1% of neonatal intensive care unit (NICU) admissions, 1.4% of pediatric intensive care unit (PICU) admissions and 3.1% of pediatric cardiac intensive care unit (PCICU) admissions. Most CPR events in these units occur in neonates and infants less than 1 year old. The incidence of CPR with chest compressions in the NICU is 10 times higher than the 0.1% incidence of CPR at birth.

Therefore, it’s important to optimize the resuscitation approach. The lack of robust scientific data, however, makes it impossible to provide definitive recommendations on when to transition from neonatal to pediatric resuscitation guidelines.

A new article provides an overview and summary of the existing guidelines and describes some potential approaches to consider when addressing this issue.

The article 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 is available at and will be published in the January issue of Pediatrics.

The authors summarize neonatal resuscitation and pediatric advanced life support guidelines; consider how to apply the guidelines to hospitalized neonates and infants; and identify knowledge gaps and future priorities. A key consideration is when, and under what circumstances, to use neonatal or pediatric resuscitation guidelines for hospitalized neonates and infants.

The article, intended for general consideration, is based primarily on expert opinion and clinical experience, and may not apply to all circumstances.

Various approaches

The article describes four potential approaches to transitioning from neonatal to pediatric resuscitation guidelines for hospitalized neonates and infants: location-based, age-based, patient-based and provider-based.

The location-based approach calls for using neonatal resuscitation guidelines in the NICU and pediatric guidelines in the PICU and PCICU.

For the age-based approach, patients over 44 weeks’ postmenstrual age (outside the ”neonatal” period) could be resuscitated using pediatric guidelines, while younger patients could be resuscitated using neonatal guidelines.

The patient-based approach uses the etiology of arrest to determine which resuscitation guidelines to use. Patients with arrhythmias would be resuscitated using pediatric guidelines, since neonatal guidelines do not cover arrhythmia.

In the provider-based approach, the resuscitation guidelines are based on the health care team's training and experience. NICU teams trained in the Neonatal Resuscitation Program (NRP) would use neonatal guidelines, and PICU and PCICU teams trained in Pediatric Advanced Life Support (PALS) would use pediatric guidelines.

A model that combines two or more approaches (e.g., both age- and patient-based) also could be used.

The article reviews the benefits and limitations of each approach, as well as the challenges in training teams in both NRP and PALS.

Ultimately, it is up to health care teams and institutions to decide if neonatal or pediatric guidelines are the best choice based on local circumstances, health care team preferences and resources. 

Dr. Sawyer and Dr. McBride are among co-authors of the article.


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