Below are clinical scenarios with considerations and questions on approaches that could happen in a children’s hospitalProtocol application and transition in neonatal resuscitation scenarios

Scenario 1: A 30-minute-old term neonate delivered at home presented to the emergency room (ER) in critical condition—pale, mottled, with poor respiratory efforts and no detectable heart rate.

In this scenario, using PALS, followed by a transition to NRP, is a reasonable approach. In an emergency scenario, immediate resuscitation is paramount to ensure survival. PALS guidelines are often necessary, especially if a neonatal provider is not immediately available. PALS emphasizes immediate CC and ventilation strategies that are applicable to pediatric resuscitation, addressing common causes of cardiac arrest. However, once a neonatal provider arrives, it is crucial to transition to NRP, since NRP is specifically designed for newborns.

NRP incorporates strategies that focus on neonates’ unique physiological characteristics, such as effective ventilation, thermoregulation, and careful oxygenation management. These aspects are critical for optimal neonatal care, particularly in the early minutes after birth, when physiological immaturity requires specialized attention.

This scenario illustrates the current gap in evidence on protocols, where initial management may lean on PALS in the absence of specialized care providers. While PALS provides a general framework for pediatric resuscitation, NRP addresses the nuances of neonatal care, ensuring the most appropriate interventions for newborns. Therefore, the initial use of PALS in this context is acceptable to provide immediate life-saving interventions, but the subsequent transition to NRP ensures that the resuscitation process is tailored to the newborn’s specific needs.

The question of whether this approach is correct hinges on the timing of provider availability and the nature of the resuscitation. The initial use of PALS may serve as a stopgap measure, but transitioning to NRP is critical to ensure the resuscitation protocol aligns with best practices for neonatal care. This approach highlights the importance of a seamless shift between protocols in settings where neonates may first present to non-specialized care providers, ensuring optimal outcomes through a multi-faceted, protocol-driven approach.

Scenario 2: A term neonate born at 38 weeks' gestation is referred to a tertiary care NICU (no in-house delivery services) shortly after birth due to respiratory distress. The baby was initially breathing but soon experienced significant oxygen desaturation, bradycardia with HR <80bpm, delayed capillary refill, and difficulty maintaining adequate respiratory efforts.

The most common etiology of respiratory distress in a term neonate shortly after birth may be due to meconium aspiration, retained fetal lung fluid, or pneumonia. NRP emphasizes gentle ventilation methods to avoid injury to the fragile neonatal lungs. In a tertiary referral center without delivery services, NRP and PALS may be used per the unit’s protocol. However, PALS providers may be more aggressive in ventilation and airway management compared to the more cautious practices of NRP for neonates.

In this situation, the use of NRP would be more suitable because it is specifically designed for neonates, considering their unique physiological needs, including more delicate respiratory management and preventing further complications, such as hypoxia or hyperoxia.

Given the absence of clear evidence favoring one protocol over another in this scenario, the initial use of PALS is understandable. However, as soon as a neonatal provider is available, transitioning to NRP would ensure that the resuscitation aligns with best practices tailored to the newborn’s specific physiological characteristics. Neonatal providers trained in NRP are well-equipped to manage neonates’ respiratory distress and bradycardia, focusing on ventilation, oxygenation, and stabilization through neonatal-specific strategies.

While there is no definitive evidence to refute one protocol over the other, available guidelines suggest that transitioning to NRP upon the arrival of a neonatal specialist is the most appropriate approach for managing respiratory distress and bradycardia in neonates, ensuring the best outcomes for the newborn.

Scenario 3: A preterm neonate in the NICU, a former 29-weeker, now corrected to 40 weeks postmenstrual age, is currently on a 2 L nasal cannula with supplemental oxygen of 25%. She has a severe apnea/bradycardia/desaturation episode about 2 hours after a feed. A travel nurse caring for this infant starts resuscitation as per the PALS algorithm.

For a preterm infant experiencing a severe apneic episode, bradycardia, and desaturation, the first-line management typically includes tactile stimulation, supplemental oxygen, and airway clearance, followed by positive pressure ventilation if necessary. This approach is effective in resolving mild to moderate apneic events. If the infant remains unresponsive to these measures, resuscitation efforts are escalated, often involving positive pressure ventilation or even intubation, depending on the severity of the situation.

However, airway management and ventilation are particularly important in neonates, especially preterm infants. As this infant is not intubated, focus should be on appropriate ventilation to restore the heart rate and improve oxygenation. NRP provides clear guidance in this area, emphasizing proper airway management and ventilation to correct bradycardia and desaturation, which are common in preterm infants experiencing apnea of prematurity or related respiratory complications.

In this scenario, the travel nurse initiated PALS guidelines. While the PALS algorithm is often used for resuscitation in older infants and children, its application in this scenario could still be justified, particularly in an environment where a provider not trained in NRP was at the bedside. However, NRP would be more appropriate for this infant to address the underlying causes of apnea and bradycardia.

Since the infant is on supplemental oxygen and experiencing an apnea/bradycardia/desaturation event, the initial steps, such as ensuring airway patency and applying positive pressure ventilation, would fall within the scope of NRP guidelines. While the PALS algorithm may still provide a framework for resuscitation, a provider trained in PALS may start compressions before optimizing ventilation.

If this infant was being managed in a pediatric floor for bronchopulmonary dysplasia (BPD) and experienced a similar episode, the application of PALS could be considered appropriate, as PALS is designed for managing such events in older infants and children. However, no clear evidence exists to refute either approach, and NRP and PALS could be utilized depending on the circumstances. Transitioning to NRP when a neonatal specialist is available would be ideal to ensure the most appropriate resuscitation strategy is employed. This scenario underscores the importance of tailored resuscitation protocols in the NICU, particularly for preterm infants who may have specific respiratory needs.

To summarize, these scenarios demonstrate the complexities and challenges of neonatal resuscitation, particularly in settings where neonatal providers may not be immediately available. While both NRP and PALS have their merits, the protocols are designed for different patient populations, and the transition from PALS to NRP is crucial when caring for neonates. In each scenario, the initial use of PALS may be justifiable, but as soon as a neonatal provider is available, transitioning to NRP is essential for ensuring that resuscitation is aligned with the best practices for neonates, particularly for their unique physiological needs and challenges. On pediatric floors and in pediatric intensive care units, some infants may be resuscitated using PALS; however, currently a dilemma exists in choosing one over the other.

Guidelines for infant (age <12 months) resuscitation

NRP and PALS are the two guidelines recommended by the American Heart Association (AHA) that are widely used in the resuscitation of infants [12, 13]. A national survey analyzed the resuscitation practices of the US healthcare providers (n = 152) in three different settings, including 118 NICUs, 19 pediatric intensive care units (PICUs), and 15 cardiac intensive care units (CICUs) [14]. The survey results showed that neonatal providers preferred neonatal guidelines in infants <28 days and pediatric guidelines in infants beyond 28 days with a primary cardiac etiology for the arrest. In contrast, the providers in the PICU and CICU preferred pediatric guidelines for any infant after birth, irrespective of the age or etiology of the cardiac arrest. The provider’s preference determined the application of either NRP or PALS based on similar foundational principles of resuscitation.

The fundamental differences between NRP vs. PALS were discussed in a recent report published collaboratively on behalf of the AHA Emergency Cardiovascular Care Committee and the American Academy of Pediatrics (AAP) [11]. The emphasis is on adequate ventilation in the NRP guidelines and CC in the PALS guidelines (Table 1). The NRP recommends 3 CC to 1 breath with a pause for the breaths, including in the presence of an advanced airway [15]. There are 120 events in a minute (90 CC and 30 breaths). The PALS guidelines recommends for one rescuer include 30 CC to 2 breaths, or 15 CC to 2 breaths for two-rescuer resuscitations with no advanced airway [13]. Two rescuers with an advanced airway include continuous CC with one breath every 2-3 seconds, which adds up to 100-120 CC to 20 -30 breaths in a minute [16]. Epinephrine is the only medication recommended in NRP with blood transfusion and a normal saline bolus during special circumstances [17]. PALS recommends multiple medications, cardioversion, and defibrillation based on the various rhythm abnormalities through algorithms relatively more complex than NRP [18].

Table 1 Summarizing the perspective.Identification of pulse – Salient points of divergence

NRP does not distinguish the resuscitation of infants with severe bradycardia (HR < 60 bpm), asystole, and pulseless electrical activity (PEA). NRP has a common approach toward different etiologies of cardiac arrest. PALS recommendations for severe bradycardia with a pulse are distinct from asystole/PEA. The choice of these approaches depends on identifying the brachial pulse in the infants. The identification of pulses in severe bradycardia determines whether the initial resuscitative efforts are being targeted toward optimizing oxygenation and ventilation versus analyzing the rhythm with an automated external defibrillator (AED) and starting high-quality CPR. NRP recommends epinephrine, preferably intravascular if the HR is <60 bpm despite 1 min of coordinated effective PPV + CC. In a similar situation, pediatric guidelines recommend epinephrine and atropine.