In Neonatal Resuscitation, the ECG Monitor Informs. Ventilation Saves

I recently had the opportunity to write an editorial titled: “In neonatal resuscitation, the ECG monitor informs. Ventilation saves.”

This editorial was for the article "Impact of electrocardiogram monitoring on the frequency of tracheal intubation at birth" published in J Pediatr (Rio J), 102 (2) (2026) by Thalles de Souza Freire, Mandira Daripa Kawakami, Maria Fernanda de Almeida, Ruth Guinsburg

The promise of better monitoring

Over the past decade, electrocardiographic (ECG) monitoring has become increasingly integrated into neonatal resuscitation. It provides faster and more reliable heart rate detection compared to traditional methods such as auscultation or pulse oximetry.

From a physiological and technological perspective, this is a major advancement. Faster heart rate detection should, in theory, lead to better decision-making and improved outcomes.

And in many ways, it does—ECG enhances situational awareness, reduces uncertainty, and supports team communication.

But does better monitoring change outcomes?

That is the key question.

Emerging evidence—including the study discussed in this editorial—suggests that while ECG improves heart rate detection, it does not reduce intubation rates or the intensity of resuscitation interventions.

More importantly, there is a signal that ECG use may be associated with delays in initiating positive pressure ventilation (PPV)—the single most important intervention in neonatal resuscitation.

Even small delays matter. Establishing effective ventilation within the “Golden Minute” is critical, and every delay increases the risk of adverse outcomes.

The core principle remains unchanged

No matter how advanced our monitoring becomes, one principle remains constant:

Ventilation is the priority

Heart rate informs us.Ventilation stabilizes the newborn.

This distinction is essential. ECG provides valuable data—but it does not treat the patient.

Technology vs. workflow

The issue is not the ECG itself—it is how we integrate it into clinical practice.

Modern delivery rooms are complex environments. Adding new technology introduces:

• Additional tasks

• Increased cognitive load

• Potential shifts in team focus

Even subtle changes in workflow can influence timing of critical interventions. The risk is not the monitor—it is the unintended distraction from what matters most.

Reframing the role of ECG

ECG should be seen as a supporting tool, not a primary intervention.

Its strengths include:

• Rapid and reliable heart rate detection

• Improved team communication

• Enhanced documentation and debriefing

• Reduced ambiguity in clinical assessment

But it must never delay or compete with timely ventilation.

Where do we go from here?

The conversation is no longer about whether ECG works—it clearly does.

The next step is implementation science:

• How do we integrate ECG without delaying PPV?

• How do we optimize team workflows?

• How do we design systems that prioritize action over data collection?

These are the questions that will define the next phase of neonatal resuscitation research.

Final thought

As we continue to innovate and adopt new technologies, we must remain grounded in the fundamentals.

Precision in measurement is valuable.But precision must never come at the expense of timely intervention.

In neonatal resuscitation, the ECG monitor informs.Ventilation saves.