In the delicate and high-stakes environment of the neonatal intensive care unit (NICU), the approach to cardiac arrest in infants remains a subject of ongoing debate and research. Recent discussions have centered on whether the guidelines established by Neonatal Resuscitation Program (NRP) or Pediatric Advanced Life Support (PALS) more effectively address the unique physiological needs of infants experiencing in-hospital cardiac arrest (IHCA). This question is critical, as hypoxia-induced bradycardia is the predominant precipitating event in infant IHCA, largely stemming from respiratory failure—a factor that both NRP and PALS guidelines agree upon in principle. However, the methods they recommend, particularly in terms of ventilation rates during resuscitation, differ considerably and have significant implications for clinical outcomes.
Both NRP and PALS guidelines emphasize the paramount importance of optimizing oxygenation and ventilation during the initial resuscitative steps. This focus stems from the understanding that hypoxia triggers bradycardia and cardiac arrest in infants more frequently than primary cardiac pathology. The NRP, which primarily caters to newborns within the immediate postnatal period, advocates a ventilation strategy involving rescue breathing at a rate of 40 to 60 breaths per minute before initiating chest compressions. Moreover, once chest compressions begin in coordination with ventilation, the NRP maintains a similar high respiratory rate of approximately 30 breaths per minute. This recommendation is drawn from observational data reflecting natural respiratory rates in neonates, suggesting a physiological basis for sustaining such elevated ventilation frequencies during resuscitation.
Contrastingly, PALS guidelines, which address a wider pediatric population extending beyond the neonatal period, recommend rescue breathing at a slower rate of 20 to 30 breaths per minute both before and during chest compressions. This difference in ventilation frequency is not merely a stylistic preference but stems from an evolving understanding of pediatric resuscitation complexity and training considerations. Notably, the revision to lower ventilation rates in PALS was recently introduced with the aim of simplifying training curricula rather than on the basis of strong empirical evidence. This adjustment acknowledges the practical challenges in teaching pediatric life support but highlights an important knowledge gap in the critical area of optimal ventilation strategies during infant CPR.
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This gap is underscored by the insufficiency of pediatric data concerning ventilation rates during cardiopulmonary resuscitation (CPR), especially the interplay between ventilation frequency, airway management status, and the patient’s age. Current PALS guidelines explicitly acknowledge this dearth of information, noting that fundamental questions remain unresolved on whether ventilation rates should be adjusted based on whether an advanced airway is present and how age-related changes in respiratory physiology impact optimal resuscitation protocols. These unanswered questions have fostered a dialogue around whether a uniform approach, possibly one aligned more closely with NRP recommendations, should be extended to neonatal populations experiencing IHCA, particularly within NICU settings.
Adding layers of complexity, a systematic review examining respiratory rates in infants and young children reveals a clear age-dependent decline in baseline respiratory frequency. Median respiratory rates were reported to decrease from approximately 44 breaths per minute in newborns immediately following birth to around 26 breaths per minute by the age of two years. This downward trend persisted into early adolescence, reflecting maturation in pulmonary and neurological control of respiration. Such physiological data provide a rationale supporting the concept that ventilation strategies during resuscitation must be tailored to developmental stage rather than applying a one-size-fits-all methodology.
Given these physiological differences, clinical algorithms must be scrutinized carefully with regards to age-specific effectiveness, especially in the high-acuity context of neonatal ICUs. The NICU population typically involves infants whose respiratory and cardiovascular resilience is already compromised by prematurity or underlying illness, necessitating a nuanced approach to resuscitation. Therein lies a crucial clinical dilemma: should all infants experiencing IHCA in the NICU be resuscitated strictly according to NRP guidelines, which recommend higher respiratory rates, or should PALS recommendations, which propose slower rates, be adopted to align with pediatric practice at large?
The inherent tension arises from the potentially contrasting physiological demands and clinical environments. NRP guidelines are meticulously crafted based on immediate postnatal respiratory patterns and the perinatal transition period. They emphasize rapid ventilation to overcome hypoxia swiftly—a primary driver of neonatal bradycardia and cardiac arrest. On the other hand, PALS guidelines, by endorsing lower ventilation frequencies, reflect a broader pediatric context where the pathophysiology of cardiac arrest may diverge, and where training harmonization across age groups is also a priority. This discrepancy invites further interrogation of whether current guideline silos inadvertently hinder unified clinical practice and whether NICU protocols should be distinctively calibrated.
From a mechanistic perspective, infants in NICUs are frequently exposed to conditions such as respiratory distress syndrome, persistent pulmonary hypertension, and congenital anomalies that affect normal ventilatory mechanics and gas exchange. The urgency to reverse hypoxia quickly makes the higher ventilation rates of NRP seemingly advantageous in this milieu, yet the lack of randomized controlled trials comparing the efficacy of these divergent protocols limits evidence-based consensus. Furthermore, concerns remain regarding the potential detrimental effects of overventilation, such as volutrauma, hypocarbia, or disruptions to cardiac output through increased intrathoracic pressure, which must be balanced against the risk of inadequate oxygen delivery.
Technological advances such as real-time capnography, improved pulse oximetry, and refined airway adjuncts might help bridge this knowledge gap by enabling personalized ventilation strategies during resuscitation. Future research leveraging these tools could clarify how best to modulate ventilation parameters in real time, optimizing outcomes according to an infant’s immediate physiological responses and underlying condition. Until then, the debate between adhering strictly to NRP, embracing PALS adaptations, or developing hybrid protocols remains unresolved but critical.
Moreover, educational ramifications underscore the need for refined training programs that reflect evolving insights into pediatric resuscitation. Conflicting recommendations can complicate skill acquisition and retention among healthcare providers, especially those working across neonatal and pediatric settings. Simplification in training must be weighed carefully against the nuances demanded by patient physiology and clinical context to avoid inadvertently compromising care quality.
Ultimately, resolving this question requires robust, age-specific clinical trials designed to evaluate outcomes associated with varying ventilation rates during infant resuscitation in the NICU. Such research must account for diverse clinical scenarios, spanning from immediate postnatal resuscitation to IHCA occurring days or weeks later, adjusting for gestational age, comorbidities, and airway management strategies. Until such data are available, clinicians are tasked with making judicious decisions grounded in current guidelines, physiological principles, and individual patient assessment while advocating for ongoing research.
The conversation surrounding NRP versus PALS application within NICU resuscitation protocols remains a microcosm of broader challenges in pediatric critical care—balancing evidence-based standards with dynamic clinical realities, physiological variability, and training considerations. Bridging this divide promises not only improved outcomes for the most vulnerable patients but also advancements in the science and art of pediatric resuscitation itself.
As neonatal care continues to evolve, so too must the frameworks guiding life-saving interventions during cardiac arrest. Collaborative efforts combining clinical expertise, physiological research, and training innovation hold the greatest promise for formulating optimized, flexible resuscitation guidelines that adapt to infant needs in real time. Until such milestones are reached, the debate over ventilation rates and guideline preference will remain a compelling and essential dialogue in neonatal intensive care.
Subject of Research: Ventilation strategies and resuscitation guidelines in infants experiencing in-hospital cardiac arrest within the neonatal intensive care setting.
Article Title: Resuscitation after birth and beyond in the neonatal intensive care unit: NRP or PALS?
Article References:
Mani, S., Bawa, M., Srinivasan, N. et al. Resuscitation after birth and beyond in the neonatal intensive care unit: NRP or PALS?.
J Perinatol (2025). https://doi.org/10.1038/s41372-025-02348-4
Image Credits: AI Generated
DOI: https://doi.org/10.1038/s41372-025-02348-4
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