What’s New in the 2025 ILCOR Neonatal Life Support Consensus on Science with Treatment Recommendations

The 2025 International Liaison Committee on Resuscitation (ILCOR) Consensus on Science with Treatment Recommendations (CoSTR) introduces several important updates to neonatal resuscitation practice — from preparation and cord management to airway, medication, and post-resuscitation care. Below is a summary of the most relevant changes and their implications for clinicians and researchers.

1. Team Preparation and Communication

Effective neonatal resuscitation begins before birth. The new CoSTR emphasizes structured team briefings before anticipated resuscitations — ideally including obstetric and midwifery staff. Early communication and clearly defined roles improve coordination, readiness, and team performance, even though direct outcome data remain limited.

2. Umbilical Cord Management

The 2025 update provides standardized terminology to improve clarity across studies and practice:

• Immediate cord clamping (ICC): ≤15 seconds

• Early cord clamping (ECC): <60 seconds

• Delayed cord clamping (DCC): ≥60 seconds

• Physiologic-based cord clamping (PBCC): clamp based on infant physiology rather than time

• Intact-cord milking (I-UCM) and cut-cord milking (C-UCM) are defined as distinct procedures.

For non-vigorous term or late preterm infants, intact cord milking is now suggested over early clamping, as it appears to reduce moderate–severe hypoxic-ischemic encephalopathy (HIE) and improve hemoglobin levels.For preterm infants (<37 weeks), delayed clamping for ≥60 seconds remains standard; if this is not feasible in infants 28–36 weeks, UCM may be a reasonable alternative, but it is not recommended below 28 weeks.

3. Temperature Management

Maintaining normothermia remains a cornerstone of resuscitation.

• For term and late preterm infants, aim for room temperature ≥23 °C and encourage skin-to-skin contact.

• For preterm infants, use plastic wrap, thermal mattresses, hats, and heated/humidified gases.Continuous monitoring is essential to prevent both hypothermia and hyperthermia.

4. Airway and Ventilation

Key updates reaffirm device and technique recommendations:

• T-Piece resuscitator remains preferred over the self-inflating bag for positive-pressure ventilation (weak, low-certainty evidence).

• Laryngeal mask airways are a reasonable alternative if mask ventilation fails or intubation is not feasible.

• Routine suctioning, even for meconium, is discouraged unless there is visible airway obstruction.

  
  

5. Medications and Vascular Access

There is no new evidence supporting sodium bicarbonate during neonatal resuscitation. In fact, recent data suggest possible harm when combined with vasoconstrictors. Its use is therefore not recommended.For vascular access, the umbilical venous catheter remains first-line; intraosseous access is a viable alternative when umbilical access cannot be achieved, though success and complication rates vary.

6. Volume Expansion

Fluid administration should be targeted. Early crystalloid or blood transfusion is indicated only if blood loss is suspectedor when infants are refractory to ventilation, compressions, and medications. Routine fluid boluses in the absence of suspected hypovolemia are not supported.

7. Glucose and Post-Resuscitation Care

Both hypoglycemia and hyperglycemia are common after resuscitation and may worsen outcomes.

• Measure blood glucose early and repeatedly in the post-resuscitation period.

• Infants at highest risk include preterm infants, those receiving chest compressions or epinephrine, and those with HIE.

• Glucose infusions should be titrated to maintain normoglycemia, avoiding both extremes.

Rewarming hypothermic infants should follow a structured protocol — there is no evidence favoring rapid or slow rewarming.Therapeutic hypothermia remains the standard of care for term infants with moderate-to-severe HIE but should only be implemented in centers with full neonatal intensive care capability.

8. Prognostication and Family Presence

After about 20 minutes of effective resuscitation without ROSC, survival with good neurodevelopmental outcome becomes unlikely. However, decisions should remain individualized, considering gestational age, underlying pathology, and availability of advanced care.Importantly, parental presence during resuscitation is supported where facilities and family preferences allow — enhancing transparency, inclusion, and compassion.

Looking Ahead

The 2025 CoSTR emphasizes individualized, physiology-guided care, thoughtful application of technology, and structured teamwork. While some recommendations remain based on low-certainty evidence, they reflect global consensus and the direction of future neonatal resuscitation research — including better integration of cord physiology, ventilation strategies, and post-resuscitation metabolic care.

Reference: Liley HG et al. Neonatal Life Support: 2025 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR). Circulation. 2025;152(Suppl 1):S00–S00.