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2025 Korean Guidelines for Cardiopulmonary Resuscitation: Part 9. Neonatal resuscitation.

Published by Korean Association of Cardiopulmonary Resuscitation · Class of Recommendation and Level of Evidence / GRADE

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Summary

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This clinical guideline presents the 2025 Korean Guidelines for Cardiopulmonary Resuscitation: Part 9, focusing on Neonatal Resuscitation. It covers evidence-based recommendations adapted from ILCOR consensus science to fit the Korean healthcare context. Detailed protocols include umbilical cord management (deferred clamping or milking), initial thermal and airway management steps, respiratory support (CPAP, PPV, and avoidance of routine sustained inflations), endotracheal intubation incorporating video laryngoscopy, chest compressions, epinephrine and volume expansion dosing, post-resuscitation glucose and therapeutic hypothermia management, and ethical guidelines on withholding or discontinuing resuscitation.

Heart arrestNeonatesResuscitation

Key Takeaways

  • 1
    Deferred cord clamping (DCC) for at least 60 seconds is strongly recommended for preterm infants <37 weeks who are vigorous at birth.
  • 2
    Intact umbilical cord milking (I-UCM) serves as a suggested alternative to early clamping for nonvigorous term/late preterm infants and preterm infants born between 28 and 36 weeks.
  • 3
    CPAP is preferred over intubation and PPV for preterm infants with spontaneous breathing who require respiratory support at birth.
  • 4
    Video laryngoscopy is recommended over direct laryngoscopy for neonatal endotracheal intubation, particularly when performed by less experienced providers.
  • 5
    Sodium bicarbonate administration is not recommended during brief or prolonged cardiopulmonary resuscitation.
  • 6
    Discontinuation of resuscitation may be considered and discussed with the family at approximately 20 minutes after birth if there is no response.

What's New in This Version

Key updates from the 2020 guidelines include: (1) extending the applicable period of neonatal resuscitation throughout the first 28 days of life and NICU hospitalization until discharge; (2) introducing specific DCC and I-UCM cord management pathways based on vigor and gestational age; (3) introducing video laryngoscopy as a preferred intubation tool; (4) withdrawing the routine recommendation against initiating resuscitation with 100% oxygen in term/late preterm infants; (5) recommending against the routine use of sustained inflations lasting >=5 seconds; (6) formally advising against the use of sodium bicarbonate; and (7) extending the time threshold to consider the discontinuation of resuscitation from 10-20 minutes to approximately 20 minutes after birth.

Key Recommendations

Umbilical Cord Management

  • REC-001

    For newborn infants who are vigorous immediately after birth and do not require additional resuscitation, deferred umbilical cord clamping for at least 60 sec is suggested.

    weak recommendationEvidence: low certainty of evidenceIntervention
  • REC-002

    For term infants and late preterm infants who are not vigorous immediately after birth, intact umbilical cord milking is suggested.

    weak recommendationEvidence: low certainty of evidenceIntervention
  • REC-003

    For preterm infants born at <37 weeks' gestation who do not require immediate resuscitation at birth, deferred umbilical cord clamping for at least 60 sec is recommended.

    strong recommendationEvidence: moderate certainty of evidenceIntervention
  • REC-004

    In preterm infants born between 28 0/7 and 36 6/7 weeks' gestation in whom DCC is not performed, intact umbilical cord milking (I-UCM) may be a reasonable alternative to early cord clamping (ECC) to improve hematologic outcomes.

    conditional recommendationEvidence: low certainty of evidenceIntervention
  • REC-005

    For preterm infants born at <28 weeks' gestation, intact umbilical cord milking (I-UCM) is not recommended.

    weak recommendationEvidence: low certainty of evidenceContraindication

Thermal Care

  • REC-006

    To maintain body temperature in preterm infants born at <34 weeks' gestation, the use of a plastic bag or wrap and a hat is strongly recommended.

    strong recommendationEvidence: moderate certainty of evidenceIntervention

Airway Clearance

  • REC-007

    Routine suctioning of the mouth and nose at birth in newborn infants born through clear amniotic fluid is not recommended.

    weak recommendationEvidence: very low certainty of evidenceContraindication
  • REC-008

    For nonvigorous newborn infants born through meconium-stained amniotic fluid, routine laryngoscopy with tracheal suctioning at the initiation of resuscitation is not recommended. Instead, resuscitation should be initiated with immediate PPV to rapidly establish effective ventilation.

    weak recommendationEvidence: very low certainty of evidenceIntervention

Physiological Monitoring

  • REC-009

    When ECG equipment is available, the use of a three-lead ECG is suggested for newborn infants requiring resuscitation.

    conditional recommendationEvidence: low certainty of evidenceDiagnostic

Respiratory Support

  • REC-010

    For preterm infants with spontaneous breathing at birth who require respiratory support, the use of CPAP as initial respiratory support is preferable to endotracheal intubation and PPV.

    weak recommendationEvidence: moderate certainty of evidenceIntervention
  • REC-011

    For preterm infants receiving PPV at birth due to bradycardia or ineffective breathing, the routine use of sustained inflations lasting >=5 seconds is not recommended.

    weak recommendationEvidence: low certainty of evidenceContraindication

Advanced Airway

  • REC-012

    When resources and educational conditions permit, the use of video laryngoscopy is recommended over direct laryngoscopy for endotracheal intubation, particularly when intubation is performed by less experienced providers.

    conditional recommendationEvidence: high certainty of evidenceIntervention

Pharmacologic Therapy

  • REC-013

    The use of sodium bicarbonate is not recommended, both during brief cardiopulmonary resuscitation (CPR) and in prolonged resuscitation scenarios, even when adequate ventilation has been established and there is no response to other therapies.

    strong recommendationEvidence: low certainty of evidenceContraindication

Post-Resuscitation Care

  • REC-014

    For newborn infants born at >=36 weeks' gestation with moderate to severe hypoxic-ischemic encephalopathy (HIE), therapeutic hypothermia should be initiated according to clearly defined protocols and provided in centers capable of multidisciplinary care and long-term follow-up.

    strong recommendationEvidence: high certainty of evidenceIntervention

Discontinuation of Resuscitation

  • REC-015

    In newborn infants who require CPR after birth, if the return of spontaneous circulation is not achieved despite the completion of all appropriate resuscitative steps and the exclusion of reversible causes, it is appropriate to consider discussions regarding discontinuation of resuscitation with the team and the family at approximately 20 minutes after birth.

    weak recommendationEvidence: very low certainty of evidenceIntervention

Scope & Objectives

Clinical Topic

Neonatal resuscitation

Objectives

To provide updated, evidence-based medical recommendations for neonatal resuscitation immediately after birth and during the neonatal period, standardizing clinical practice in Korea to improve neonatal survival and long-term neurodevelopmental outcomes.

Target Patient Population

Newborn infants immediately after birth, during the transitional period, and throughout the neonatal period (up to 28 days after birth) when gas exchange failure causes cardiovascular compromise (extending until discharge for NICU-hospitalized infants).

Diagnostic Criteria

At birth, three rapid assessment questions are utilized to determine the need for resuscitation: (1) Is the infant preterm? (2) Does the infant have poor muscle tone? (3) Is the infant not breathing or not crying effectively? If the answer to any of these questions is 'yes,' the infant is transferred to a radiant warmer to initiate resuscitation steps.

Target Providers

Healthcare professionalsResuscitation teamsPediatriciansNeonatologistsObstetriciansGynecologistsAnesthesiologistsNursesParamedics

Patient Criteria & Setting

Therapeutic Area

Neonatology

Guideline Scope

National Clinical Guideline

Inclusion Criteria

  • Newborn infants immediately after birth during transition in the delivery room
  • Infants during the neonatal period (up to 28 days after birth) with cardiovascular compromise primarily due to respiratory-related gas exchange failure
  • Hospitalized infants in the neonatal intensive care unit (NICU) with respiratory-related compromise up to discharge

Exclusion Criteria

  • Infants experiencing cardiac arrest due to primary cardiac causes, such as after cardiac surgery or with known cardiac arrhythmias

Care Settings

Delivery roomNeonatal Intensive Care Unit (NICU)Hospital delivery settings

Special Populations

Preterm infantsLate preterm infantsNonvigorous term infantsNewborns with hypoxic-ischemic encephalopathy (HIE)Hypothermic newborn infants

Evidence Grading

System: Class of Recommendation and Level of Evidence / GRADE

Evidence Distribution

6low_certainty
2high_certainty
3moderate_certainty
7very_low_certainty
5expert_consensus_or_good_practice

Evidence Levels

lowLow certainty of evidence; limited confidence in the effect estimate, and the true effect could be substantially different.
highHigh certainty of evidence; very confident that the true effect lies close to the estimate of the effect.
moderateModerate certainty of evidence; moderately confident in the effect estimate, though the true effect may differ.
very_lowVery low certainty of evidence; very little confidence in the effect estimate, where the true effect is likely to be substantially different.

Recommendation Strength

strongStrong recommendation; the desirable effects of the action clearly outweigh its undesirable effects (or vice versa).
expert_consensusExpert consensus recommendation; based on the consensus of the professional panel when formal systematic review evidence is limited but a clinical direction is necessary.
weak_or_conditionalWeak or conditional recommendation; the desirable effects probably outweigh the undesirable effects, but there is appreciable uncertainty, or the action is appropriate only in specific settings.
good_practice_statementGood practice statement; a clinical message agreed upon by the development panel as being highly beneficial, where formal testing or grading is not practical or necessary due to obvious benefit or harm.

Safety & Contraindications

Contraindications

  • Routine suctioning of the mouth and nose at birth in infants born through clear amniotic fluid is not recommended.
  • Routine laryngoscopy with tracheal suctioning at the initiation of resuscitation is not recommended for nonvigorous infants born through meconium-stained amniotic fluid.
  • Initial sustained inflations should not be used, and routine use of sustained inflations lasting >=5 seconds is not recommended for preterm infants.
  • Intact umbilical cord milking (I-UCM) is not recommended for preterm infants born at <28 weeks' gestation.
  • Initiating resuscitation with 100% oxygen is not recommended for term and late preterm infants (>=35 weeks).
  • The use of sodium bicarbonate is not recommended during both brief and prolonged neonatal resuscitation.

Monitoring Guidance

Rapid and accurate heart rate assessment is critical; a three-lead ECG is suggested as the fastest and most accurate method for infants requiring resuscitation. Preductal oxygen saturation (SpO2) must be continuously monitored via pulse oximetry. For infants with unintended hypothermia, temperature and blood glucose must be monitored frequently to prevent hyperthermia and hypoglycemia. Serial blood glucose monitoring is also required post-resuscitation.

Authors & Contributors

Ju Sun HeoYoung Hwa JungAi-Rhan Ellen KimGyuhong ShimSu Jin ChoJung Hyun LeeHyun-Joo SeolGi-Su LeeAh-Young OhHye Jin MyungSung Phil ChungDo Kyun KimTae-Youn KimYoudong SohnYunhee OhChun Song YounMi Jin LeeJisook LeeChang Hee LeeYoungbin JangYong Soo JangGyu Chong ChoKyoung-Chul ChaSung Oh Hwang

Guideline Features

Dosing informationFlowcharts includedBased on systematic reviewMultidisciplinary

Learning Context

Difficulty

advanced

Estimated Read Time

60 minutes

Learning Paths

Neonatal ResuscitationCritical CarePediatricsPerinatologyEmergency Medicine