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Clinical and Educational FAQs

FAQs are submitted to the NRP Education Subcommittee by NRP Instructors, the CPS or NRP Steering Committee members. They are reviewed by the Education Subcommittee, and modified or withdrawn based on new information or redundancy. The FAQ is then circulated to the NRP Steering Committee, and reviewed by the Executive for approval before being posted.

The FAQs reflect a consensus of opinion of clinicians, educators and administrators from multiple Canadian jurisdictions. Scientific answers are interpretation of the literature by the group. FAQs are normally written in response to issues requiring clarification rather than policy statements, prescriptive guidelines or evidence based scientific recommendations.

Please provide feedback or new questions if you feel either are required.


  • Are there any differences in NRP practice between the USA and Canada?

    As with the 7th edition, the NRP algorithms for the USA and Canada are the same. The USA has now endorsed a simplified dosing regimen, which we have endorsed in Canada.

    At present the CPS is retaining the existing requirements for completion of an instructor-led course and therefore is not currently adopting the RQI course format or the “test-out” options as adopted in the USA.

    Revised: September 28, 2021

  • What are the main changes in the algorithm (flow diagram) in the 8th edition?

    The main changes in the algorithm include:

    • The 4 pre-birth questions have been changed with removal of the question related to the number of babies. The 8th edition questions  are : (1) Gestational age? (2) Amniotic fluid clear? (3) Additional risk factors? (4) Umbilical cord management plan?
    • The initial steps have been reordered to reflect common clinical practice. The 8th edition order of initial steps are : Warm, dry, stimulate, position airway, suction if needed.
    • When an alternative airway becomes necessary, a cardiac monitor is recommended for the most accurate assessment of the baby’s heart rate.
    • The CARDIO mnemonic has been added to ensure effective delivery of chest compressions prior to administration of epinephrine
    • The suggested initial IV or IO dose = 0.02 mg/kg (equal to 0.2 mL/kg). Subsequent doses maybe increased to 0.03mg/kg.  The suggested endotracheal dose is 0.1 mg/kg (equal to 1 mL/kg) (a 4kg baby would receive 0.4mg or 4mls of 1:10,000 epinephrine via ETT).
    • Flush IV/IO epinephrine with 3 mL normal saline (applies to all weights and gestational ages)
    • If confirmed absence of HR after all appropriate steps performed, consider cessation of resuscitation efforts around 20 minutes after birth. This decision can be individualized based on patient and contextual factors.  

    Revised: September 28, 2021

  • Why should we use simulation-based training?

    According to the International Liaison Committee of Resuscitation [ILCOR] the "use of simulation as an adjunct to traditional education methodologies may enhance performance of healthcare professionals in actual clinical settings and simulated resuscitations." (2010, p.E1330). Simulation-based training provides an opportunity to learn both taskwork and teamwork skills within a safe learning environment.

    The creation of simulated scenarios provides a standardized learning experience and enables the Instructor to focus on key predetermined learning objectives specific to the learners’ needs. These learning objectives will integrate cognitive, technical and behavioural aspects of resuscitation and facilitate development of team skills. Well-developed scenarios enable the learner to become immersed in the scenario and behave as they would in real life. Participation in these scenarios followed by reflection and discussion enables rich learning which can be transferred to the clinical setting.

    Simulation-based training not only provides opportunities for standardized training but also enables learners to gain experience from otherwise potentially infrequent but high risk clinical scenarios.  The use of interprofessional teams (eg. RN, MD, RRT, RM) is highly recommended to best mimic the real-life environment.

    Reaffirmed: September 28, 2021

  • Do I need “high fidelity” equipment to carry out simulations?

    No. Increasing technical fidelity of a simulation does not always increase the learning experience for course participants.

    The integral component of a well-developed simulation is its realism and thereby the ability of the learner to “suspend disbelief” and act as they would in a real-life setting. The technical fidelity of the equipment may vary according to the learning objectives of a given scenario. The creation of a realistic context or learning environment is more important than the use of high technology equipment. Simple accessories such as a gown and gloves can markedly increase the “contextual fidelity” of a simulation and thereby facilitate learner engagement.

    Video recording of simulated scenarios with subsequent review and reflective discussion may provide further opportunities for learning.

    Reaffirmed: September 28, 2021

  • What are the essential components of an effective pre-resuscitation team briefing?

    Effective teamwork and communication are essential skills during neonatal resuscitation. The application of knowledge and skills attained in simulation are optimized during an actual resuscitation when there is an emphasis on team coordination and communication. Each team member should know:

    1. How they will be contacted in the event of a resuscitation, and who will respon
    2. Who is the team leader
    3. The clinical situation (identification of perinatal risk factors) and the expected action plan
    4. Their role during the resuscitation, and what task(s) they will be assigned
    5. The supplies and equipment needed
    6. How to call for additional help

    The team leader should encourage team members to share information and communicate with one another throughout the resuscitation; to "think out loud". The use of closed-loop communication assures team members that interventions are performed in response to the correct assessment, in the correct sequence, and with the correct technique. 

    Reaffirmed: September 28, 2021

  • Why should we debrief?

    According to the International Liaison Committee of Resuscitation [ILCOR] "it is reasonable to recommend the use of debriefings during learning activities while caring for simulated patients and during clinical activities." (2010, p.E1330)

    Debriefing provides learners with an opportunity to reflect on the previous scenario and discuss important cognitive, technical and behavioural aspects of resuscitation. Debriefing should focus on predetermined learning objectives but may incorporate other discussion points which arise during the scenario.

    Facilitator-led group discussion enables learners to reflect on their performance of important task work and teamwork skills. Rather than providing direct feedback, the facilitator encourages the group reflection and learning through open questioning. This process of promoting and stimulating the learners’ own critical thinking and reflection on their performance is a powerful learning tool. The use of video recording may facilitate debriefing of simulated scenarios, allowing learning points to be identified by both the facilitator and the learners.

    Reaffirmed: September 28, 2021

  • How does delayed cord clamping affect resuscitation practice?

    “In preterm newborns, potential benefits of delayed cord clamping (DCC) include decreasing the need for medication to support blood pressure after birth, requiring fewer blood transfusions during hospitalizations and possibly improved survival. In term and late pre-term DCC may improve early hematologic measurements and although uncertain there maybe benefits for neurodevelopmental outcomes. There however may also be increased chances of needing phototherapy for hyperbilirubinemia.” (ILCOR 2020)

    DCC  for 30-60 s is reasonable for both term and preterm infants who do not require resuscitation at birth.

    While clinical trials are ongoing, for infants who require resuscitation beyond initial steps of drying and stimulation it is currently recommended to clamp the cord and place baby on the warmer for further resuscitation.

    Revised: September 28, 2021

Thermal Management

  • How should I manage temperature post resuscitation if hypoxic-ischemic encephalopathy (HIE) is suspected?

    It is very important to keep body temperature in the normal range (normothermia) during resuscitation, and to avoid both hypothermia (low temperature) and hyperthermia (high temperature). Observational data suggest that raised body temperature at birth may harm the neonatal brain in infants who have sustained hypoxic ischemic injury. There is, however, little or no evidence to suggest that compromised babies should be cooled in the first minutes after birth (i.e. during or immediately following resuscitation). There are evidence-based indications for cooling within 6 hours after birth: if a baby meets the criteria, therapeutic hypothermia should be initiated without delay. If therapeutic hypothermia is not available locally, contact your referral centre before instituting any form of passive cooling.

    Reaffirmed: September 28, 2021

Cardiovascular Support

  • Is the use of ECG required during neonatal resuscitation?

    "After birth, the newborn’s heart rate is used to assess the effectiveness of spontaneous respiratory effort, the need for interventions, and the response to interventions. In addition, accurate, fast, and continuous heart rate assessment is necessary for newborns in whom chest compressions are initiated. Therefore, identifying a rapid and reliable method to measure the newborn’s heart rate is critically important during neonatal resuscitation.

    When chest compressions are initiated, an ECG should be used to confirm heart rate. When ECG heart rate is greater than 60/min, a palpable pulse and/or audible heart rate rules out pulseless electric activity.” (ILCOR 2020)

    8th edition NRP suggests consideration of an EKG at the point at which positive pressure ventilation is required. If not applied to this point, it should be applied at the point of alternate airway insertion to ensure fast and reliable heart rate assessment with commencement of chest compressions.

    Revised: September 28, 2021

  • Why am I seeing electrical activity on the ECG but cannot feel a pulse?

    Pulseless Electrical Activity (PEA) occurs when an ECG detects organized activity in the absence of a clinically detectable pulse. It can occur as a result of severe prolonged hypoxia, acidosis, extreme hypovolemia or electrolyte disturbance. Other important etiologies include cardiac tamponade and tension pneumothorax. PEA occurs in the neonatal population, and its recognition and subsequent detection of underlying etiologies can guide resuscitative interventions in the context of the clinical presentation.

    Reaffirmed: September 28, 2021

Airway Management

  • NRP no longer recommends routine intubation and tracheal suction for meconium. How do I prepare for management of the infant born through meconium stained amniotic fluid (MSAF)?

    The 8th edition does not support routine intubation with tracheal suction for the depressed infant born through MSAF. Meconium stained amniotic fluid is however a risk factor for abnormal transition and it is important that the attending team comprises a practitioner with advanced resuscitation skills, including endotracheal intubation. The presence of meconium stained amniotic fluid should be communicated to the neonatal practitioner through the 4 pre-birth questions: gestational age, UC management plan, the colour of amniotic fluid and presence of additional risk factors.

    If an infant is born through MSAF and is depressed at birth, initial resuscitation steps should be undertaken and positive pressure ventilation (PPV) initiated as required. Routine intubation and suction for meconium is no longer recommended. However, intubation may be required as part of the resuscitation if the infant fails to respond to PPV. Following corrective steps including placement of an alternative airway, if meconium is thought to cause obstruction of the airway, tracheal suction may be required. In this situation the trachea can be suctioned using a catheter placed through the endotracheal tube (ETT) or by attaching a meconium aspirator.

    Reaffirmed: September 28, 2021

  • We do not use laryngeal mask airways frequently. Should we have them available?

    Yes. NRP recommends that a laryngeal mask is readily accessible so that staff may utilize them when necessary. As with intubation, the clinical use of laryngeal mask requires additional training and supervision, as well as site-specific and professional scope of practice considerations. LM are an important part of both the essential and advanced courses in ensuring adequate ventilation if positive pressure by mask is ineffective.

    Revised: September 28, 2021

Oxygen Administration

  • When should we use pulse oximetry and how does it help guide practice?

    Pulse oximetry should be applied when resuscitation is anticipated such as the birth of an infant born prematurely or with congenital diaphragmatic hernia. It should also be applied when positive pressure ventilation (PPV) or supplemental oxygen is provided. Babies who are persistently cyanosed, or who have laboured breathing are also candidates for pulse oximetry. The goals of pulse oximetry are to avoid both high and low oxygen levels during resuscitation.

    Pulse oximetry will help to guide both the administration and titration of oxygen therapy. The table below outlines preductal saturations that are acceptable in term infants during transition.


    1 Minute 60% -65%
    2 Minutes 65% -70%
    3 Minutes 70%- 75%
    4 Minutes 75%- 80%
    5 Minutes  80%- 85%
    10 Minutes 85%- 95%

    It is essential to develop a strategy to ensure the immediate availability of pulse oximetry during neonatal resuscitation. A chart of targeted oxygen saturation in minutes should be posted in the neonatal resuscitation area. 

    Until more literature is available one should follow the manufacturer's recommendations for specific types of oxygen saturation monitors as it may vary between manufacturers.

    Reaffirmed: September 28, 2021

  • What is the optimal resuscitation gas for preterm infants?

    The optimal resuscitation gas for preterm infants is not known.  It is generally accepted that, in babies born at 35 weeks gestational age or more, resuscitation should be initiated in air (21% oxygen) and subsequent oxygen therapy be guided by pulse oximetry.  In this situation, arterial oxygen saturation targets are based on the normal rise that occurs in healthy term infants over the first few minutes of age.

    The evidence is less clear for preterm infants and the current recommendation for initial oxygen concentration for infants born < 35 weeks is 21-30%.   As many preterm infants may require supplemental oxygen to meet the target saturations many experts recommend initiating resuscitation with 30% oxygen below a certain gestational age cut-off (somewhere between 28 and 32 weeks).

    As most of these babies are born in tertiary and advanced secondary level perinatal centres, it is recommended that one follows the well-established protocols in your local high-risk centre.

    Revised: September 28, 2021

  • When should we administer supplemental oxygen?

    There are 2 times when supplemental oxygen should be added: 

    1. When the baby appears cyanotic or the oximeter readings are lower than expected during resuscitation. Oxygen should be adjusted to maintain the oxygen saturation within the minute specific ranges based on the chart below. This is accomplished through the use of an oxygen blender that provides for adjustments in the amount of oxygen delivered to the infant.


    1 Minute 60% -65%
    2 Minutes 65% -70%
    3 Minutes 70%- 75%
    4 Minutes 75%- 80%
    5 Minutes  80%- 85%
    10 Minutes 85%- 95%

    There is limited evidence to indicate how fast to titrate inspired oxygen, and at what increments. Observational data would support increasing or decreasing inspired oxygen concentration by 10-15% every 30 seconds to achieve target saturations. Further research is required to clarify best practice.

    2. When chest compressions are initiated the concentration of oxygen should be increased to 100% regardless of the infant's oxygen saturation (p.171 of the NRP textbook)

    Reaffirmed: September 28, 2021

  • Does the self inflating bag replace the need for a blender in our delivery room?

    No, a self-inflating bag does not replace the need for a blender.  The use of a blender is the most reliable way to titrate oxygen delivery between 21-100%.

    The NRP textbook states that it is possible to provide approximately 40% oxygen by removing the reservoir from the self-inflating bag when attached to an oxygen source. However, recent literature suggests that this may not be the case and different self-inflating resuscitation bags may, in fact, deliver a higher concentration of oxygen than described above. Therefore, it is important that users are familiar with the function and capability of their particular resuscitation bag.

    Reaffirmed: September 28, 2021

Respiratory Support

  • What peak inspiratory pressure should be used during positive pressure ventilation?

    There is limited evidence to make a strong recommendation on initial peak inspiratory pressure (PIP). The lowest pressure which results in effective ventilation and an increase in heart rate should be provided.

    Initial PIP of 20-25 cm H2O is suggested.

    PIP may be increased if effective ventilation cannot be achieved with MRSOPA corrective steps. There is limited evidence to make a recommendation on how to increase peak inspiratory pressure. Increasing gradually in increments of 5 cm H2O every 30 seconds while assessing heart rate and chest rise would seem reasonable when providing pressures in the range of 20 -30 cm H2O. If sustained PIP greater than 30 cm H2O is required, an alternative airway should be considered. Initial pressures of up to 30 -40 cm H2O may be required in term infants.

    As discussed above, the aim should be to provide the least pressure necessary to achieve adequate ventilation. When PIP greater than 30 cm H2O is required, an alternative airway should be considered. Thereafter if still not achieving adequate ventilation, slower increase in increments of 2-3 cm H2O may seem reasonable. If there is no clinical improvement, alternative causes for lack of response to ventilation measures should be sought, e.g. pneumothorax.

    Reaffirmed: September 28, 2021

  • Which is the more accurate way to confirm adequate positive pressure ventilation: chest movement, auscultation of air entry or increasing heart rate?

    Studies suggest that during neonatal resuscitation, a rising heart rate is the most important indicator of successful positive pressire ventilation (PPV). Although, a rising heart rate is the primary indicator of adequate PPV, one should observe for bilateral chest movement, and auscultate for bilateral air entry.
    If heart rate is increasing after the initial 15 seconds of PPV, the assistant should announce that the "heart rate is increasing" and reassess the heart rate after another 15 seconds of PPV.
    If the heart rate is not increasing after the initial 15 seconds of PPV, the assistant should announce that the "heart rate is not increasing" and check for chest rise and air entry.

    • If the chest is moving, the assistant should announce that the "chest is moving" and the heart rate should be re-assessed after another 15 seconds of PPV
    • If the chest is not moving, the assistant should announce that the "chest is not moving" and the ventilation corrective actions (MRSOPA) should be performed.

    Used with permission from the AAP, 7th edition NRP textbook p. 84.

    Reaffirmed: September 28, 2021

  • What is the difference between PEEP and CPAP?

    Positive end expiratory pressure (PEEP) is generally the term used when a patient is receiving positive pressure ventilation, either by manual ventilation (‘bagging’) or by mechanical ventilator. Animal studies have suggested that the use of PEEP is beneficial in preserving surfactant function and maintaining lung volumes. Continuous positive airway pressure (CPAP) is the term used when the patient is receiving positive pressure to open the lungs while breathing spontaneously with inspiratory support.

    Technically, PEEP and CPAP describe the same phenomenon; positive pressure being maintained in the patient's airways and alveoli during expiration. The purpose of both PEEP and CPAP is to prevent airway and alveolar collapse on expiration and maintain functional lung volume.

    CPAP is used for the infant who is breathing spontaneously and displays respiratory distress and/or remains persistently cyanotic. If the patient is breathing spontaneously and does not require manual breaths, CPAP can be provided using a flow-inflating bag or a T-piece resuscitator. CPAP CANNOT be provided with a self-inflating bag, even if a PEEP valve is used.

    A pressure manometer should be used to monitor either PEEP or CPAP. PEEP or CPAP is usually started at 5 cm H2O. The level of PEEP or CPAP may be titrated up to 8 cm H2O if the patient is working hard to breathe and/or needing high levels of oxygen. Caution must be employed as high levels of CPAP may be harmful. High levels of CPAP/PEEP may increase the work of breathing, causing overdistention of the lung, impair cardiac output, and increase the risk of pneumothorax. Preterm babies who require respiratory support with CPAP may be candidates for surfactant therapy, particularly if their oxygen requirements are rising.

    Reaffirmed: September 28, 2021

  • How can PEEP or CPAP be provided using the various positive pressure devices?

    During your pre-resuscitation equipment check you may use these practical tips for providing PEEP or CPAP during and after resuscitation.

    a) Flow-inflating bag: Using approximately 8 L/min of gas flow (starting with 21% oxygen), occlude the patient outlet (or mask) and adjust the flow control valve to provide a baseline PEEP/CPAP to 5 to 6 cm water. 

    b) Self-inflating bag: This device cannot provide CPAP, but can provide PEEP during manual ventilation if an external PEEP valve is attached. With the PEEP valve attached to the self-inflating device, turn the PEEP valve screw to the 5 cm water mark. One may test the effectiveness of this setting using a manometer and bagging with the patient outlet (mask) occluded.

    c)T-piece resuscitator: During the set-up of the T-piece resuscitator, occlude the patient outlet (or mask) and adjust the PEEP valve so that the manometer reads 5 cm water. The manufacturer may recommend the use of an artificial lung bag during setup.

    It is becoming increasingly common practice to utilize nasal CPAP (by prongs or mask) after the resuscitation of preterm babies, while evaluating the need for surfactant therapy, and considering endotracheal intubation. If you do not provide CPAP routinely you should consider how you might provide this type of support before the occasion arises – your regional outreach education program may assist you in this respect.

    Reaffirmed: September 28, 2021

  • What Positive End Expiratory Pressure (PEEP) level should be used when initiating positive pressure ventilation?

    Administration of PEEP prevents alveolar collapse during exhalation. When PEEP is used, 7th edition NRP recommends an initial starting pressure of 5 cm H2O. Most recent ILCOR consensus guidelines recommend the use of PEEP when positive pressure is provided to the preterm infant. Data were inadequate to guide practice in the term infant.

    Reaffirmed: September 28, 2021

  • We do not admit babies to NICU who have received brief periods of positive pressure ventilation. Should we?

    Post-resuscitation care is subject to clinical judgment and stabilization protocols. These are clinical decisions influenced by institutional practice.

    Reaffirmed: September 28, 2021

Medication Administration

  • What is the best practice when administering epinephrine to newborns?

    There is no longer a separate Canadian addendum for the medications table.

    It is recommended that epinephrine be routinely drawn up using 2 different sized syringes (5 mL for ETT administration and 1 mL for IV/UV administration). Labeling ETT and IV/UV epinephrine optimizes patient safety.

    It is also recommended that the volume of epinephrine drawn up is the amount required to administer a single dose of epinephrine. This will ensure that the appropriate volume is given and reduce the risk of administering an excessive dose in the event that the entire contents of the syringe is administered.

    While intravenous administration of epinephrine is the preferred route, an initial endotracheal dose may be administered while obtaining IV access. Intravenous epinephrine should be administered as soon as access has been obtained however if the heart rate remains less than 60 bpm.

    Simplified epinephrine dosing of 0.1mg/kg via endotracheal tube and 0.02mg/kg via intravenous/intraosseous route are recommended here in Canada. We no longer recommend a maximum dose of ETT Epinephrine of 0.3mg (0.3ml). IV/IO administration should be followed with a flush of 3 mL of normal saline, given through the same port as the medication. The 8th edition textbook suggests that if the initial dose was 0.02mg/kg or lower, follow up doses at the higher range of 0.03 mg/kg should be considered. Doses can be repeated as necessary at 3-5 minute intervals as required.

    Revised:  September 28, 2021

  • What are the NRP recommendations on the use of Naloxone as a resuscitation drug?

    Naloxone has been used in past editions of NRP for infants born to mothers with a history of narcotic administration in which there is diminished respiratory drive. There is insufficient evidence to evaluate either the safety or efficacy of using naloxone to manage respiratory depression in these infants. In addition, there is little known about the pharmacology of naloxone along with concerns regarding possible complications from its use. NRP recommends that these infants be managed with appropriate respiratory support using PPV as would any infant in which there is apnea or inadequate respiratory drive.

    Revised:  September 28, 2021

  • When might we consider the use of Intraosseous?

    The UVC is the preferred method of obtaining emergency vascular access in the delivery room. An intraosseous (IO) needle is a reasonable alternative and is frequently used for emergency access in pre-hospital and emergency departments. An IO may be placed during neonatal resuscitation when staff are unable or unfamiliar with UVC insertion in a baby who requires medications and/or volume expansion. Additionally, an IO needle may be inserted in an older newborn requiring resuscitation who no longer has the umbilical vessel as an insertion route. An IO needle is inserted in neonates into the bone marrow of the tibia. The preferred site is the flat surface of the tibia approximately 2cm below and 1-2cm medial to the tibia tuberosity (the bony bulge below the knee cap). Any medication that can be safely given through an IV or UVC can be given safely through an IO. IO and IV doses are the same. An IO can remain in place for up to 24 hours; however, it should be removed when suitable intravenous access is obtained. There are a number of different IO needles and devices available; sizing and insertion technique should follow manufacturer's recommendations.

    Reaffirmed: September 28, 2021

Ethics and End of Life

  • When it is reasonable to discontinue resuscitation?

    If fetal compromise is suspected prior to delivery, a practitioner with the skills and scope of practice to make a decision to discontinue resuscitation should be present and should make this decision. A resuscitation plan should be in place for babies with extreme prematurity or serious antenatally diagnosed anomalies.

    A systematic, team approach to history taking, physical exam, monitoring and problem-solving during resuscitation will allow consideration of reversible causes of cardiorespiratory arrest such as tube dis/misplacement, electrolyte abnormalities, air leak, tamponade and equipment failure. There should be involvement of the family and/or consultation with a specialist or referral centre while resuscitation is ongoing.

    ILCOR states that “if the heart rate remains undetectable and all steps of resuscitation have been completed, it may be reasonable to redirect goals of care. Case series show small numbers of intact survivors after 20 minutes of no detectable heart rate. The decision to continue or discontinue resuscitative efforts should be individualized and should be considered at about 20 minutes after birth. Variables to be considered may include whether the resuscitation was considered optimal, availability of advanced neonatal care (such as therapeutic hypothermia), specific circumstances before delivery, and wishes expressed by the family.” (ILCOR 2020)

    Revised:  September 28, 2021

Last updated: Mar 16, 2023