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

Ju Sun Heo1,*orcid, Young Hwa Jung2,*orcid, Ai-Rhan Ellen Kim3orcid, Gyuhong Shim4orcid, Su Jin Cho5orcid, Jung Hyun Lee6orcid, Hyun-Joo Seol7orcid, Gi-Su Lee8orcid, Ah-Young Oh9orcid, Hye Jin Myung10orcid, Sung Phil Chung11orcid, Do Kyun Kim12orcid, Tae-Youn Kim13orcid, Youdong Sohn14orcid, Yunhee Oh15orcid, Chun Song Youn16orcid, Mi Jin Lee17orcid, Jisook Lee18orcid, Chang Hee Lee19orcid, Youngbin Jang11orcid, Yong Soo Jang14orcid, Gyu Chong Cho14orcid, Kyoung-Chul Cha20orcid, Sung Oh Hwang20orcid
Clinical and Experimental Emergency Medicine 2026;13(Suppl 1):S142-S168.
Published online: May 31, 2026

1Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea

2Department of Pediatrics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea

3Department of Pediatrics, University of Ulsan College of Medicine, Seoul, Korea

4Department of Pediatrics, Inje University Sanggye Paik Hospital, Seoul, Korea

5Department of Pediatrics, Ewha Womans University College of Medicine, Seoul, Korea

6Department of Pediatrics, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea

7Department of Obstetrics and Gynecology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea

8Department of Obstetrics and Gynecology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea

9Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea

10Department of Nursing, Neonatal Intensive Care Unit, Seoul National University Hospital, Seoul, Korea

11Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea

12Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea

13Department of Emergency Medicine, Inha University College of Medicine, Incheon, Korea

14Department of Emergency Medicine, Hallym University College of Medicine, Chuncheon, Korea

15Design and Contents Team, Asan Medical Center, Seoul, Korea

16Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea

17Department of Emergency Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea

18Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea

19Department of Paramedicine, Namseoul University, Cheonan, Korea

20Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea

Correspondence to: Gyuhong Shim (peddoc@paik.ac.kr)
Co-correspondence to: Ai-Rhan Ellen Kim (arkim@amc.seoul.kr)

Ju Sun Heo and Young Hwa Jung contributed equally to this study as co-first authors.

• Received: February 21, 2026   • Accepted: February 24, 2026

Copyright © 2026 The Korean Society of Emergency Medicine

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/).

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  • The 2025 Korean Guidelines for Cardiopulmonary Resuscitation provide updated, evidence-based recommendations to optimize the transition from intrauterine to extrauterine life. While approximately 85% of term newborns initiate spontaneous breathing independently, timely intervention is critical for those requiring assistance. Key updates in the 2025 guidelines emphasize umbilical cord management, recommending deferred cord clamping for at least 60 seconds in vigorous term and preterm infants (<37 weeks). When deferred cord clamping cannot be performed, intact umbilical cord milking may be reasonable for nonvigorous term and late preterm infants (≥35 weeks' gestation) and for preterm infants born between 28⁰⁄₇ and 36⁶⁄₇ weeks' gestation who do not require immediate resuscitation. Respiratory support should be initiated within the "golden minute," starting with 21% oxygen for term and late preterm infants (≥35 weeks) and ≥30% for those <32 weeks’ gestation. The guidelines introduce video laryngoscopy as a preferred tool for less experienced providers and recognize supraglottic airways as a viable alternative to face masks or when intubation fails. For advanced resuscitation, a compression to ventilation ratio of 3:1 is maintained, with intravascular epinephrine (0.01–0.03 mg/kg) as the primary pharmacologic intervention. Notably, the use of sodium bicarbonate is no longer recommended. Discussions regarding the discontinuation of resuscitation are now suggested at approximately 20 minutes after birth if no response is observed. These guidelines aim to standardize clinical practice in Korea to improve neonatal survival and long-term neurodevelopmental outcomes.
  • Keywords: Heart arrest; Neonates; Resuscitation
Birth represents a rapid and profound transition from the intrauterine to the extrauterine environment. To successfully adapt from placental gas exchange to pulmonary respiration, the newborn must undergo a series of complex and interdependent physiological processes. With lung aeration, pulmonary vascular resistance decreases dramatically, leading to increased pulmonary blood flow. This, in turn, facilitates left ventricular filling and maintains cardiac output, ensuring stable coronary and cerebral perfusion [1,2]. This transitional process is critical for neonatal survival and long-term development.
Most term newborns (approximately 85%) initiate spontaneous breathing without any intervention at birth. However, approximately 10% require simple assistance, such as positioning to open the airway and tactile stimulation, and approximately 5% require positive pressure ventilation. Endotracheal intubation is performed in 0.4% to 2% of newborns, chest compressions in fewer than 0.3%, and epinephrine administration in approximately 0.05% [3–9]. Although the majority of newborns successfully adapt without significant intervention, appropriate and timely resuscitation at birth continues to play a decisive role in neonatal survival and the prevention of complications in delivery settings worldwide.
The 2025 Korean neonatal resuscitation guidelines present evidence-based medical recommendations derived from a comprehensive review of the most recent national and international literature. These guidelines are primarily based on the 2025 Consensus on Science and Treatment Recommendations issued by the International Liaison Committee on Resuscitation and have been adapted to reflect the clinical realities and health care environment in Korea.
By incorporating the latest scientific evidence and clinical validity in the application of neonatal resuscitation immediately after birth, these guidelines aim to provide standardized clinical guidance for health care professionals in Korea and ultimately to improve neonatal survival and long-term outcomes.
Key changes to the 2025 neonatal resuscitation guidelines are summarized in Table 1.
The neonatal resuscitation algorithm is shown in Fig. 1.
Umbilical cord management (immediately after birth)
(1) For vigorous term and late preterm infants who do not require additional resuscitation, deferred cord clamping (DCC) for at least 60 seconds is suggested.
(2) In nonvigorous term and late preterm infants, intact umbilical cord milking (I-UCM) may be considered as an alternative to early cord clamping (ECC).
(3) In preterm infants born at <37 weeks’ gestation who do not require immediate resuscitation at birth, DCC for at least 60 seconds is recommended.
(4) Among preterm infants born between 28⁰⁄₇ and 36⁶⁄₇ weeks’ gestation who do not receive DCC, I-UCM may be a reasonable alternative to ECC.
(5) In infants born at <28 weeks’ gestation, I-UCM is not recommended.
Three rapid assessment questions 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 newborn is term, has good muscle tone, and is breathing or crying well, the initial steps of care should be provided while maintaining skin-to-skin contact with the mother. If the answer to any of these three questions is “yes,” the infant should be transferred to a radiant warmer to initiate the resuscitation steps.
Initial steps
The initial steps include providing warmth and maintaining normothermia, positioning the infant to open the airway, clearing airway secretions if necessary, drying, and providing tactile stimulation.
Assessment of breathing and heart rate
(1) If the heart rate is ≥100/min but the infant has respiratory distress or persistent cyanosis, oxygen saturation should be monitored using pulse oximetry, and supplemental oxygen or continuous positive airway pressure (CPAP) may be considered as needed.
(2) If the heart rate is <100/min or if the infant is apneic or gasping, oxygen saturation monitoring should be initiated, electrocardiographic (ECG) monitoring should be considered, and positive pressure ventilation (PPV) should be initiated immediately. Respiratory support should begin within approximately 60 seconds after birth (“the golden minute”).
Oxygen administration during respiratory support
(1) For term and late preterm infants (≥35 weeks’ gestation), initiating respiratory support with 21% inspired oxygen is suggested.
(2) In preterm infants born at <32 weeks’ gestation, initiating resuscitation with an inspired oxygen concentration of ≥30% is reasonable. However, for infants born between 32⁰⁄₇ and 34⁶⁄₇ weeks’ gestation, the available evidence is insufficient to recommend a specific initial inspired oxygen concentration. Regardless of the initial inspired oxygen concentration used, continuous oxygen saturation monitoring and individualized titration of inspired oxygen may be needed.
Ventilation
(1) If adequate chest movement is not observed during PPV or if the heart rate remains persistently <100/min, corrective ventilation steps should be performed to ensure effective ventilation. If ventilation remains ineffective, endotracheal intubation or placement of a supraglottic airway (SGA) should be considered.
(2) If the heart rate remains <60/min after at least 30 seconds of effective PPV, endotracheal intubation should be performed, and chest compressions coordinated with PPV at a 3:1 ratio should be initiated. If the response to lower inspired oxygen concentrations is inadequate, the inspired oxygen concentration may be increased up to 100%. Emergency umbilical venous catheter (UVC) placement should be considered to allow the administration of medications and/or volume expanders.
(3) If the heart rate remains persistently <60/min despite at least 60 seconds of effective PPV and coordinated chest compressions, epinephrine (1:10,000) should be administered intravenously at a dose of 0.01 to 0.03 mg/kg and may be repeated every 3 to 5 minutes as needed. If there is no response, other potentially reversible causes, such as hypovolemia or pneumothorax, should be considered. In infants who remain unresponsive to resuscitation and in whom acute blood loss is confirmed or strongly suspected, the administration of volume expanders should be considered.
Neonatal resuscitation is primarily applied to newborn infants immediately after birth, during the transition from a fluid-filled intrauterine environment to an extrauterine environment [10,11]. The period “immediately after birth” refers to the time from delivery until the completion of resuscitation and initial stabilization in the delivery room. However, even after the transitional period, neonatal resuscitation may be applied during the neonatal period (up to 28 days after birth), when the primary cause of cardiovascular compromise is respiratory-related gas exchange failure. In infants hospitalized in the neonatal intensive care unit for such conditions, neonatal resuscitation may continue to be applied throughout hospitalization until discharge [11]. In contrast, when cardiac arrest occurs because of primary cardiac causes, such as after cardiac surgery or in infants with known cardiac arrhythmias, the application of pediatric resuscitation is considered more appropriate, even during the neonatal period [12].
To prepare for neonatal resuscitation, prenatal assessment of perinatal risk factors should be performed, and systems must be in place to ensure that appropriately trained health care personnel can be mobilized promptly according to the anticipated level of risk. In addition, the equipment and supplies required for resuscitation should be immediately available, and effective teamwork and skilled clinical performance must be ensured. Because unexpected neonatal compromise may occur in any hospital delivery, a system that allows the immediate deployment of personnel with appropriate resuscitation skills should be established for all births [10,11].
Based on the anticipated level of risk, healthcare professionals with adequate training and experience in neonatal resuscitation should attend the delivery [11]. When caring for newborns with significant perinatal risk factors, additional personnel capable of providing advanced resuscitative interventions, such as chest compressions, endotracheal intubation, and emergency UVC placement, must be available [13].
The equipment and environment required for neonatal resuscitation should be maintained in a state of constant readiness, with regular checks performed to confirm preparedness. Equipment should be organized and positioned in a standardized manner to allow easy access by all team members, and human factors should be considered during equipment layout to maximize efficiency and minimize delays [12]. Because effective resuscitation cannot be achieved if equipment or supplies are unavailable or malfunctioning, the use of standardized checklists is recommended to ensure readiness [11].
For deliveries associated with perinatal risk factors, a dedicated resuscitation team should be assembled, and a team leader should be clearly designated. Predelivery team briefings are recommended as a critical component of preparation [12]. During these briefings, relevant clinical information should be shared, potential risk factors reviewed, and roles and responsibilities clearly assigned to team members. In addition, equipment readiness and personnel allocation should be confirmed, and anticipatory guidance for families may be provided when appropriate. The systematic use of checklists and cognitive aids during this process can enhance information sharing among team members, reduce cognitive load, and improve short-term team performance [14–17].
Term and late preterm infants
For vigorous term and late preterm infants (≥34 weeks’ gestation) who do not require additional resuscitation immediately after birth, DCC for at least 60 seconds is suggested (weak recommendation, low certainty of evidence) [18–63]. However, this recommendation may be implemented at the discretion of individual institutions, considering local health care settings and staffing resources.
For nonvigorous term and late preterm infants immediately after birth, I-UCM is suggested as an alternative to ECC (weak recommendation, low certainty of evidence) [64,65]. When I-UCM is performed, one possible approach is to milk approximately 20 cm of the intact umbilical cord toward the infant over 2 seconds, repeated a total of three additional times.
At present, there is insufficient evidence to recommend for or against resuscitation with an intact umbilical cord [66–69].
Preterm infants
For preterm infants born at <37 weeks’ gestation who do not require immediate resuscitation at birth, including PPV, DCC for at least 60 seconds is recommended (strong recommendation, moderate certainty of evidence) [30,40,70–87].
In preterm infants born between 28⁰⁄₇ and 36⁶⁄₇ weeks’ gestation in whom DCC is not performed, I-UCM may be a reasonable alternative to ECC to improve hematologic outcomes, while individual maternal and neonatal circumstances should be considered (conditional recommendation, low certainty of evidence) [34,52,73,78,80,88–100].
For preterm infants born at <28 weeks’ gestation, I-UCM is not recommended, which is consistent with previous guidelines (weak recommendation, low certainty of evidence) [73,78,80,101–112]. In this gestational age group, evidence is insufficient to support or refute UCM after cord clamping [113].
For preterm infants born at <37 weeks’ gestation who require resuscitation at birth, evidence is insufficient for making a recommendation regarding umbilical cord management.
Regardless of the aforementioned recommendations, ECC should be the preferred approach, or decisions should be individualized, in the following clinical situations: multiple gestation, major congenital anomalies, placenta previa, antepartum hemorrhage, gestational diabetes, hypertensive disorders of pregnancy, umbilical cord abnormalities, intrauterine growth restriction, category III fetal heart rate patterns, and meconium-stained amniotic fluid [114].
Temperature maintenance

Maintenance of appropriate body temperature in term and late preterm infants immediately after birth

For term and late preterm infants (≥34 weeks’ gestation), the use of a delivery room temperature of approximately 23 °C is suggested to maintain normothermia (weak recommendation, very low certainty of evidence) [115]. When resuscitation is needed, late preterm and term infants should undergo resuscitation under a radiant warmer. When resuscitation is not needed, skin-to-skin contact with the mother is recommended to maintain normothermia. If skin-to-skin care is not feasible, the use of a plastic bag or wrap may be considered to assist with thermal management (weak recommendation, very low certainty of evidence) [116–121].

Maintenance of appropriate body temperature in preterm infants immediately after birth

For preterm infants born at <34 weeks’ gestation, a combination of multiple thermal protection strategies is needed to effectively maintain normothermia. Maintaining a delivery room temperature of ≥23 °C is suggested (weak recommendation, very low certainty of evidence) [122–126].
To maintain body temperature in preterm infants, the use of a plastic bag or wrap and a hat is strongly recommended (strong recommendation, moderate certainty of evidence) [127–139]. The use of a thermal mattress may be considered (conditional recommendation, low certainty of evidence). In both cases, careful monitoring and management are needed to prevent hyperthermia. When respiratory support is provided, the use of heated and humidified respiratory gases may be considered, if available (conditional recommendation, very low certainty of evidence) [140,141].
If facilities or equipment for thermal care are limited, skin-to-skin contact between the mother and infant may be considered to maintain normothermia (good practice statement).

Rate of rewarming in hypothermic newborn infants

For newborn infants who develop unintended hypothermia after birth, rewarming is needed; however, evidence is insufficient to determine whether rapid rewarming (≥0.5 °C/hr) or slow rewarming (<0.5 °C/hr) is more effective [142]. Regardless of the rewarming rate, each institution should rewarm hypothermic newborns according to its established neonatal rewarming protocol. During rewarming, the infant’s body temperature should be monitored frequently or continuously to avoid hyperthermia. In addition, because hypothermic newborns are at increased risk of hypoglycemia, blood glucose monitoring is needed (good practice statement).
Positioning to maintain airway patency
The infant should be placed in the supine position, with the head and neck in a neutral or slightly extended position. The head should be positioned so that the face is oriented upward, achieving a posture consistent with the “sniffing position.” Excessive neck extension or flexion should be avoided, as either may compromise airway patency. In preterm infants or infants with a relatively large occiput, placing a small towel or shoulder roll beneath the shoulders may help maintain optimal airway positioning.
Airway clearance

When the amniotic fluid is clear

Routine suctioning of the mouth and nose at birth in newborn infants born through clear amniotic fluid is not recommended (weak recommendation, very low certainty of evidence). Positioning and suctioning should be considered when airway obstruction is suspected (good practice statement) [143,144].

When the amniotic fluid is meconium stained

For nonvigorous newborn infants (defined as heart rate <100/min, poor muscle tone, and depressed respiratory effort) 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 [145–149]. However, if airway obstruction due to meconium is suspected during PPV, endotracheal intubation with tracheal suctioning may be needed.
Tactile stimulation
For newborn infants who are not breathing, have intermittent respirations, or exhibit shallow breathing immediately after birth, the addition of tactile stimulation together with measures to maintain normothermia is suggested (weak recommendation, very low certainty of evidence) [150–154]. However, tactile stimulation should not delay the initiation of PPV.
Assessment of heart rate
Assessment of heart rate immediately after birth is essential for evaluating the effectiveness of spontaneous respirations and determining the need for resuscitation. During resuscitation, an increase in heart rate is the most sensitive indicator of the effectiveness of each resuscitative step; therefore, rapid and accurate heart rate assessment in the delivery room is critical.
Among the available methods for heart rate assessment in the delivery room, ECG provides the fastest and most accurate measurement [155–170]. Accordingly, when ECG equipment is available, the use of a three-lead ECG is suggested for newborn infants requiring resuscitation (conditional recommendation, low certainty of evidence). However, ECG monitoring does not replace pulse oximetry for the assessment of oxygenation. When an ECG is not available, heart rate may be assessed using a combination of auscultation and pulse oximetry (conditional recommendation, low certainty of evidence) [171]. Although auscultation allows rapid assessment, its accuracy may be limited. Pulse oximetry generally requires more time than ECG to obtain reliable readings and may lead to an underestimation or overestimation of heart rate, potentially leading to inappropriate clinical management.
When ECG equipment is unavailable or malfunctioning or when pulseless electrical activity is suspected, auscultation (with or without concurrent pulse oximetry) should be used to assess heart rate (good practice statement) [171].
Tools for assessing respiratory function
The use of respiratory function assessment tools during resuscitation may offer advantages in monitoring excessive or inadequate ventilation; however, evidence demonstrating improvement in clinical outcomes remains insufficient. Therefore, at present, there is insufficient evidence to recommend for or against the routine use of respiratory function assessment tools during neonatal resuscitation [172–174].
In addition, evidence is insufficient to support or refute the use of exhaled carbon dioxide monitoring to assess noninvasive PPV delivered via noninvasive airway interfaces, such as face masks, SGA, or nasal cannulas, in newborn infants immediately after birth [175–187].
Cerebral regional oxygen saturation monitoring
For newborn infants receiving CPAP or PPV in the delivery room immediately after birth, there is insufficient evidence to recommend for or against the use of cerebral regional oxygen saturation monitoring guided by a dedicated treatment protocol compared with clinical assessment and pulse oximetry (ECG when indicated) alone [188–190].
Continuous positive airway pressure
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 recommendation, moderate certainty of evidence) [191–198]. However, for term and late preterm infants (≥34 wk gestation) who have spontaneous breathing but exhibit respiratory distress or are at risk of respiratory distress after birth, evidence is insufficient to suggest the routine use of CPAP in the delivery room [171,199–206].
Positive pressure ventilation
Most newborn infants initiate spontaneous breathing within 30 to 60 seconds after birth, and breathing can often be stimulated with drying and gentle tactile stimulation alone [9]. However, if apnea or gasping persists or if the heart rate remains <100/min despite these initial measures, PPV should be initiated within 60 seconds after birth (strong recommendation, moderate certainty of evidence). The effectiveness of PPV is most reliably assessed by an increase in heart rate. For newborn infants, a ventilation rate of 30–60/min is appropriate, and an initial inflation time of 0.5 to 1 second is recommended [9]. During initial lung inflation, a peak inspiratory pressure of 20 to 30 cm H2O is generally sufficient; however, if there is no improvement in heart rate or visible chest movement, the pressure may be adjusted to achieve effective ventilation [207,208]. Care should be taken to avoid excessive peak inspiratory pressures, as overdistension may increase the risk of lung injury and intraventricular hemorrhage (strong recommendation, low certainty of evidence) [209,210].
Sustained inflation
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 recommendation, low certainty of evidence) [182,191,211–221]. In late preterm and term infants who require PPV at birth because of bradycardia or ineffective breathing, there is insufficient evidence to make a recommendation regarding whether sustained inflation should be used or regarding the optimal duration of sustained inflation.
Positive end-expiratory pressure during PPV
Since the 2015 guidelines, the use of positive end-expiratory pressure (PEEP) during delivery room resuscitation has been suggested for preterm infants, and no substantial new evidence has emerged since then to warrant a change in this recommendation. Accordingly, consistent with previous guidelines, the use of PEEP of at least 5 cm H2O is suggested for preterm infants receiving PPV in the delivery room. In contrast, for term infants, evidence remains insufficient to suggest the routine use of PEEP during PPV in the delivery room [191].
Devices for PPV and advanced airway management

Comparison of the effectiveness of the T-piece resuscitator and self-inflating bag

When a T-piece resuscitator is available, its use is suggested in preference to a self-inflating bag for newborn infants who require PPV at birth (weak recommendation, very low certainty of evidence) [191,222–233]. However, a self-inflating bag should be immediately available as a backup device in case of interruption or failure of the gas supply during the use of a T-piece resuscitator. When a T-piece resuscitator is not available, a self-inflating bag may be used to provide PPV.

Supraglottic airway

For term and late preterm infants (≥34 weeks’ gestation), in institutions where SGA devices are available and health care providers are adequately trained through simulation (e.g., manikin-based training), the use of an SGA may be considered as an alternative to a face mask when PPV is needed during resuscitation immediately after birth (weak recommendation, low certainty of evidence) [234–243]. In term and late preterm infants (≥34 weeks’ gestation) in whom face mask ventilation is unsuccessful, an SGA may be used as an alternative to endotracheal intubation (weak recommendation, low certainty of evidence). If endotracheal intubation is not feasible, the use of an SGA is recommended (expert consensus recommendation) [194,234,243–249]. When chest compressions are required despite optimized PPV and endotracheal intubation is not feasible or is unsuccessful, ventilation via an SGA during chest compressions may be a reasonable option (good practice statement) [3,10,191,238,247,250–273].
These recommendations may be implemented at the discretion of individual institutions, considering local health care settings, resources, and staffing conditions.

Endotracheal intubation (use of video laryngoscopy)

When resources and educational conditions permit, the use of video laryngoscopy is recommended over direct laryngoscopy for endotracheal intubation, particularly in situations where intubation is performed by less experienced providers (conditional recommendation, high certainty of evidence) [6,8,9,191,257,267,274–309].
Conventional direct laryngoscopy is not associated with an increased risk compared with video laryngoscopy and therefore remains a reasonable option (weak recommendation, very low certainty of evidence). In addition, a direct laryngoscope should be readily available as a backup device (good practice statement).
Use of pulse oximetry
The use of pulse oximetry is recommended when resuscitation is anticipated, PPV is needed, central cyanosis persists, or supplemental oxygen is needed.
Oxygen administration

Term and late preterm infants (≥35 weeks’ gestation)

For term and late preterm infants who require respiratory support at birth, initiating respiratory support with an inspired oxygen concentration of 21% is suggested (weak recommendation, low certainty of evidence) [310]. Although previous guidelines recommended against initiating resuscitation with 100% oxygen, this recommendation has been withdrawn because of insufficient supporting evidence.

Preterm infants (<35 weeks’ gestation)

For preterm infants born at <32 weeks’ gestation, initiating resuscitation with an inspired oxygen concentration of ≥30% is reasonable (weak recommendation, low certainty of evidence). However, for preterm infants born between 32⁰⁄₇ and 34⁶⁄₇ weeks’ gestation, evidence is insufficient to determine the optimal initial inspired oxygen concentration [311–313]. Given these limitations in the evidence, it is clinically acceptable in this gestational age group to initiate resuscitation with an inspired oxygen concentration of 21% to 30% and to titrate oxygen delivery according to target oxygen saturation ranges. Regardless of the initial inspired oxygen concentration used, continuous oxygen saturation monitoring and individualized adjustment of inspired oxygen may be needed.
For newborn infants with persistent bradycardia despite optimized ventilation, initiating chest compressions when the heart rate is <60/min is reasonable (good practice statement) [314]. Chest compressions should be performed on the lower one-third of the sternum, just above the xiphoid process (expert consensus recommendation) [315–321]. Compressions should be delivered to a depth of approximately one-third of the anteroposterior diameter of the chest, allowing complete chest recoil between compressions to ensure full chest wall rebound (expert consensus recommendation) [322–326]. During neonatal chest compressions, the two-thumb encircling hand technique is suggested over the two-finger technique because it is associated with greater compression depth, lower provider fatigue, and more accurate hand positioning (weak recommendation, very low certainty of evidence) [272,327–330].
A compression to ventilation ratio of 3:1 is suggested, targeting 90 chest compressions and 30 ventilations per minute (weak recommendation, very low certainty of evidence) [330].
During chest compressions, increasing the inspired oxygen concentration to 100% is reasonable (expert consensus recommendation). After recovery of heart rate, the inspired oxygen concentration should be titrated according to target oxygen saturation ranges (expert consensus recommendation) [272,330].
In newborn infants with asystole or severe bradycardia, routine reliance on a single monitoring modality, such as end-tidal carbon dioxide monitoring or pulse oximetry, to confirm the return of spontaneous circulation is not recommended (weak recommendation, very low certainty of evidence) [330].
Epinephrine
When the heart rate remains <60/min despite optimized ventilation and chest compressions, intravascular epinephrine at a dose of 0.01 to 0.03 mg/kg should be administered (weak recommendation, very low certainty of evidence) [331]. If intravascular access is not yet available, endotracheal epinephrine at a higher dose of 0.05 to 0.1 mg/kg may be administered (weak recommendation, very low certainty of evidence) [332]. However, endotracheal administration of epinephrine should not delay attempts to establish vascular access. If the response to endotracheal epinephrine is inadequate, intravascular epinephrine should be administered as soon as vascular access is obtained, regardless of the dosing interval (weak recommendation, very low certainty of evidence) [206,333]. If the heart rate remains <60/min, additional doses of epinephrine should be administered every 3 to 5 minutes intravascularly whenever possible (weak recommendation, very low certainty of evidence) [191]. Regardless of gestational age or birth weight, each intravenous or intraosseous dose of epinephrine should be followed by a 3-mL normal saline flush.
Sodium bicarbonate
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 when there is no response to other therapies [334,335].
Volume expansion therapy
For newborn infants with suspected or confirmed blood loss who do not respond to resuscitation, early volume replacement with a crystalloid solution or packed red blood cells at a dose of 10 to 20 mL/kg is recommended (expert consensus recommendation) [336]. In newborn infants without apparent blood loss who fail to respond to ventilation, chest compressions, and epinephrine, evidence is insufficient to support the routine use of volume expansion. However, because occult blood loss may be present, a trial of volume expansion may be considered in newborns who are unresponsive to resuscitation (good practice statement).
Comparison of intravenous and intraosseous drug administration
For neonatal resuscitation in the delivery room, umbilical venous catheterization is suggested as the first-line method for vascular access. When umbilical venous access is difficult or cannot be established, intraosseous access is recommended as an alternative route for vascular access (weak recommendation, very low certainty of evidence) [191]. In settings outside the delivery room, either umbilical venous access or intraosseous access may be used for the administration of fluids and medications (weak recommendation, very low certainty of evidence) [337–344]. The choice of vascular access route in practice may depend on the local availability of equipment, the level of training, and the experience of the provider.
Blood glucose
In newborn infants, both hypoglycemia and hyperglycemia increase the risk of brain injury and adverse neurologic outcomes [345–358]. Therefore, blood glucose should be measured as early as possible after resuscitation (and during resuscitation when indicated) and monitored serially until normoglycemia is achieved and maintained. During resuscitation, infants at increased risk of hypoglycemia or hyperglycemia include preterm infants, those who require chest compressions, those who receive epinephrine, and those with hypoxic-ischemic encephalopathy (HIE) (good practice statement) [206,312,313]. Glucose therapy in newborn infants should be guided by measured blood glucose levels, with the goal of preventing both hypoglycemia and hyperglycemia (good practice statement) [206,312,313]. In infants with HIE, intensive blood glucose monitoring and maintenance of appropriate glucose levels are necessary (good practice statement) [359,360].
Therapeutic hypothermia
For newborn infants born at ≥36 weeks’ gestation with moderate to severe 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 recommendation, high certainty of evidence) [10,361,362].
Withholding resuscitation
In newborn infants for whom mortality and morbidity are expected to be extremely high, withholding resuscitation may be reasonable, particularly when there has been an opportunity to obtain informed parental agreement in advance (weak recommendation, low certainty of evidence) [12,363]. In such situations, it is essential that the obstetric and neonatal teams actively involve parents and adopt a consistent and coordinated approach tailored to the individual case. Withholding resuscitation and withdrawing life-sustaining treatment during or after resuscitation are ethically equivalent, and clinicians should not hesitate to discontinue treatment when the likelihood of survival is extremely low [363,364].
The following guidance should be interpreted and applied with consideration of local health care resources and outcomes: when early death is almost certain and an unacceptably high morbidity is likely among rare survivors, withholding resuscitation may be considered (weak recommendation, low certainty of evidence) [12,363]. Thorough prenatal counseling and informed parental consent are essential in these circumstances.
Examples include extreme prematurity (e.g., gestational age <23 weeks or birth weight <400 g; note that thresholds may vary by institution and require prior discussion between parents and clinicians), anencephaly, certain major chromosomal abnormalities (e.g., trisomy 13), and bilateral renal agenesis.
Discontinuation of resuscitation
Decisions to discontinue resuscitation should be individualized for each patient, considering the underlying cause, gestational age, and the availability and application of neonatal intensive care and neuroprotective strategies, such as therapeutic hypothermia after resuscitation. 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 initiate discussions regarding the discontinuation of resuscitation with the resuscitation team and the infant’s family. A reasonable time point to consider such discussions is approximately 20 minutes after birth, and clear, compassionate communication with the family is essential throughout the decision-making process (weak recommendation, very low certainty of evidence) [365,366].
Healthcare provider education

Training frequency

Healthcare provider training should be conducted at least every 12 months, and shorter, more frequent refresher sessions may be needed (weak recommendation, low certainty of evidence) [7,367,368].

Technical skills, behavioral skills, and self-efficacy

Optimal neonatal resuscitation requires not only technical skills but also behavioral competencies, including team collaboration, crisis management, and resilience. Because team-based skills and teamwork training can improve both resuscitation performance and provider confidence, enhancing team collaboration competencies should be an essential component of neonatal resuscitation education programs [369].

Simulation-based training

In situ simulation training allows teams to practice resuscitation under conditions that closely resemble real clinical settings by addressing not only human factors and teamwork but also team composition, the environment, and equipment. Such simulations can also be used to evaluate the effectiveness of new equipment or procedures. Therefore, simulation-based education should be an essential component of neonatal resuscitation training programs.
Instructor education
No clear association has been demonstrated between providing formal education to resuscitation instructors and improvements in instructor performance [370,371]. Until further evidence identifies optimal methods for instructor training, educating instructors using timely, objective, structured, and individualized verbal and/or written feedback is reasonable (expert consensus recommendation) [11].
Video-assisted debriefing has been shown to improve clinical processes and adherence to resuscitation guidelines [372], and the use of checklists as cognitive aids has been associated with improvements in team communication and process performance [373,374]. In addition, compared with standard debriefing, rapid cycle deliberate practice has demonstrated potential for improving short-term performance [375]. Accordingly, the regular use of briefing and debriefing during neonatal resuscitation is suggested (weak recommendation, low certainty of evidence) [11]. However, the effects of briefing and debriefing on long-term clinical outcomes and sustained performance remain uncertain, and further research is needed.

Author contributions

Conceptualization: SOH; Funding acquisition: SPC; Investigation: all authors; Project administration: SPC; Writing–original draft: JSH, YHJ; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

Sung Phil Chung, Chun Song Youn, Mi Jin Lee, Jisook Lee, and Sung Oh Hwang are editorial board members of this journal, but were not involved in the peer reviewer selection, evaluation, or decision process of this article. The authors have no other conflicts of interest to declare.

Funding

This work was supported by the Korea Disease Control and Prevention Agency (No. 2024100BE7B-00) and the Korean Association of Cardiopulmonary Resuscitation.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.
Neonatal resuscitation algorithm. HR, heart rate; PPV, positive pressure ventilation; CPAP, continuous positive airway pressure; ET, endotracheal; UVC, umbilical venous catheter; IV, intravascular; SpO2, oxygen saturation as measured by pulse oximetry.
ceem-26-083f1.jpg
Table 1.
Key changes in the 2025 neonatal resuscitation guidelines
Table 1.
Item 2020 Guidelines 2025 Guidelines
Indications for neonatal resuscitation Applicable within a few weeks after birth when the primary cause of cardiovascular compromise is gas exchange failure. Applicable during the neonatal period (up to 28 days after birth) when cardiovascular compromise is primarily due to gas exchange failure; in NICU-admitted infants, application may extend until discharge.
Umbilical cord management
 Term and late preterm infants For term and late preterm infants who do not require resuscitation, deferred umbilical cord clamping while assessing breathing and activity during maternal contact may be considered (class IIb, level of evidence C-LD). 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 recommendation, low certainty of evidence).
For term or preterm infants who require resuscitation at birth, evidence is insufficient to recommend either early or deferred umbilical cord clamping. For term infants and late preterm infants who are not vigorous immediately after birth, intact umbilical cord milking is suggested (weak recommendation, low certainty of evidence).
 Preterm infants For preterm infants who do not require resuscitation, deferred umbilical cord clamping may be beneficial, as it can reduce the need for blood pressure support and transfusions and may improve survival (class IIa, level of evidence B-R). For preterm infants born at <37 wk gestation who do not require immediate resuscitation at birth, deferred umbilical cord clamping for at least 60 sec is recommended (strong recommendation, moderate certainty of evidence).
Cerebral regional oxygen saturation monitoring Not mentioned. For newborn infants receiving CPAP or PPV in the delivery room immediately after birth, there is insufficient evidence to recommend for or against the use of cerebral regional oxygen saturation monitoring guided by a dedicated treatment protocol, compared with clinical assessment and pulse oximetry alone (with electrocardiography when indicated) (very low certainty of evidence).
Sustained inflation For preterm infants receiving PPV at birth due to bradycardia or inadequate breathing, initial sustained inflations should not be used (class III: harm, level of evidence C-LD). For preterm infants receiving PPV at birth due to bradycardia or ineffective breathing, the routine use of sustained inflations lasting ≥5 sec is not recommended (low certainty of evidence).
CPAP No separate mention of infants ≥34 wk gestation. For term and late preterm infants (≥34 wk gestation) who have spontaneous breathing at birth but exhibit respiratory distress or are at risk of respiratory distress, evidence is insufficient to suggest the routine use of CPAP in the delivery room (weak recommendation, low certainty of evidence).
Supraglottic airway Not addressed as an alternative to a face mask. For term and late preterm infants (≥34 wk gestation) who require PPV during resuscitation immediately after birth, the use of a supraglottic airway as an alternative to a face mask may be considered (weak recommendation, low certainty of evidence).
Not evaluated for use during chest compressions or medication administration. When chest compressions are required despite optimized PPV, and endotracheal intubation is not feasible or unsuccessful, ventilation via a supraglottic airway during chest compressions may be a reasonable option (good practice statement).
Endotracheal intubation (use of video laryngoscopy) Not mentioned. 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 recommendation, high certainty of evidence).
Oxygen administration
 Term and late preterm infants (≥35 wk gestation) Initiation of resuscitation with 100% oxygen is not recommended (class III: harm, level of evidence C-LD). Previous guidelines recommended against initiating resuscitation with 100% oxygen; however, this recommendation has been withdrawn due to insufficient supporting evidence.
 Preterm infants (<35 wk gestation) For preterm infants born at <35 wk gestation receiving initial respiratory support, including CPAP or PPV, initiating support with a lower inspired oxygen concentration (21%–30%) rather than a higher concentration (60%–100%) may be considered (class IIb, level of evidence C-LD). For preterm infants born at <32 wk gestation, initiating resuscitation with an inspired oxygen concentration of ≥30% is reasonable (weak recommendation, low certainty of evidence).
However, for preterm infants born between 32⁰⁄₇ and 34⁶⁄₇ wk gestation, evidence is insufficient to make a recommendation regarding the optimal initial inspired oxygen concentration.
Sodium bicarbonate Not mentioned. The use of sodium bicarbonate is not recommended, both during brief CPR and in prolonged resuscitation scenarios, even when adequate ventilation has been established and there is no response to other therapies.
Therapeutic hypothermia Resource-limited settings are mentioned. Mention of resource-limited settings removed.
Discontinuation of resuscitation Discussion regarding discontinuation of CPR may be considered approximately 10–20 min after birth (class IIb, level of evidence C-LD). Discussion regarding discontinuation of CPR may be considered at approximately 20 min after birth (weak recommendation, very low certainty of evidence).

NICU, neonatal intensive care unit; CPAP, continuous positive airway pressure; PPV, positive pressure ventilation; CPR, cardiopulmonary resuscitation.

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2025 Korean Guidelines for Cardiopulmonary Resuscitation: Part 9. Neonatal resuscitation
Clin Exp Emerg Med. 2026;13(Suppl 1):S142-S168.   Published online May 31, 2026
DOI: https://doi.org/10.15441/ceem.26.083
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2025 Korean Guidelines for Cardiopulmonary Resuscitation: Part 9. Neonatal resuscitation
Clin Exp Emerg Med. 2026;13(Suppl 1):S142-S168.   Published online May 31, 2026
DOI: https://doi.org/10.15441/ceem.26.083
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2025 Korean Guidelines for Cardiopulmonary Resuscitation: Part 9. Neonatal resuscitation
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Fig. 1. Neonatal resuscitation algorithm. HR, heart rate; PPV, positive pressure ventilation; CPAP, continuous positive airway pressure; ET, endotracheal; UVC, umbilical venous catheter; IV, intravascular; SpO2, oxygen saturation as measured by pulse oximetry.

Fig. 1.

2025 Korean Guidelines for Cardiopulmonary Resuscitation: Part 9. Neonatal resuscitation
Item 2020 Guidelines 2025 Guidelines
Indications for neonatal resuscitation Applicable within a few weeks after birth when the primary cause of cardiovascular compromise is gas exchange failure. Applicable during the neonatal period (up to 28 days after birth) when cardiovascular compromise is primarily due to gas exchange failure; in NICU-admitted infants, application may extend until discharge.
Umbilical cord management
 Term and late preterm infants For term and late preterm infants who do not require resuscitation, deferred umbilical cord clamping while assessing breathing and activity during maternal contact may be considered (class IIb, level of evidence C-LD). 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 recommendation, low certainty of evidence).
For term or preterm infants who require resuscitation at birth, evidence is insufficient to recommend either early or deferred umbilical cord clamping. For term infants and late preterm infants who are not vigorous immediately after birth, intact umbilical cord milking is suggested (weak recommendation, low certainty of evidence).
 Preterm infants For preterm infants who do not require resuscitation, deferred umbilical cord clamping may be beneficial, as it can reduce the need for blood pressure support and transfusions and may improve survival (class IIa, level of evidence B-R). For preterm infants born at <37 wk gestation who do not require immediate resuscitation at birth, deferred umbilical cord clamping for at least 60 sec is recommended (strong recommendation, moderate certainty of evidence).
Cerebral regional oxygen saturation monitoring Not mentioned. For newborn infants receiving CPAP or PPV in the delivery room immediately after birth, there is insufficient evidence to recommend for or against the use of cerebral regional oxygen saturation monitoring guided by a dedicated treatment protocol, compared with clinical assessment and pulse oximetry alone (with electrocardiography when indicated) (very low certainty of evidence).
Sustained inflation For preterm infants receiving PPV at birth due to bradycardia or inadequate breathing, initial sustained inflations should not be used (class III: harm, level of evidence C-LD). For preterm infants receiving PPV at birth due to bradycardia or ineffective breathing, the routine use of sustained inflations lasting ≥5 sec is not recommended (low certainty of evidence).
CPAP No separate mention of infants ≥34 wk gestation. For term and late preterm infants (≥34 wk gestation) who have spontaneous breathing at birth but exhibit respiratory distress or are at risk of respiratory distress, evidence is insufficient to suggest the routine use of CPAP in the delivery room (weak recommendation, low certainty of evidence).
Supraglottic airway Not addressed as an alternative to a face mask. For term and late preterm infants (≥34 wk gestation) who require PPV during resuscitation immediately after birth, the use of a supraglottic airway as an alternative to a face mask may be considered (weak recommendation, low certainty of evidence).
Not evaluated for use during chest compressions or medication administration. When chest compressions are required despite optimized PPV, and endotracheal intubation is not feasible or unsuccessful, ventilation via a supraglottic airway during chest compressions may be a reasonable option (good practice statement).
Endotracheal intubation (use of video laryngoscopy) Not mentioned. 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 recommendation, high certainty of evidence).
Oxygen administration
 Term and late preterm infants (≥35 wk gestation) Initiation of resuscitation with 100% oxygen is not recommended (class III: harm, level of evidence C-LD). Previous guidelines recommended against initiating resuscitation with 100% oxygen; however, this recommendation has been withdrawn due to insufficient supporting evidence.
 Preterm infants (<35 wk gestation) For preterm infants born at <35 wk gestation receiving initial respiratory support, including CPAP or PPV, initiating support with a lower inspired oxygen concentration (21%–30%) rather than a higher concentration (60%–100%) may be considered (class IIb, level of evidence C-LD). For preterm infants born at <32 wk gestation, initiating resuscitation with an inspired oxygen concentration of ≥30% is reasonable (weak recommendation, low certainty of evidence).
However, for preterm infants born between 32⁰⁄₇ and 34⁶⁄₇ wk gestation, evidence is insufficient to make a recommendation regarding the optimal initial inspired oxygen concentration.
Sodium bicarbonate Not mentioned. The use of sodium bicarbonate is not recommended, both during brief CPR and in prolonged resuscitation scenarios, even when adequate ventilation has been established and there is no response to other therapies.
Therapeutic hypothermia Resource-limited settings are mentioned. Mention of resource-limited settings removed.
Discontinuation of resuscitation Discussion regarding discontinuation of CPR may be considered approximately 10–20 min after birth (class IIb, level of evidence C-LD). Discussion regarding discontinuation of CPR may be considered at approximately 20 min after birth (weak recommendation, very low certainty of evidence).
Table 1. Key changes in the 2025 neonatal resuscitation guidelines

NICU, neonatal intensive care unit; CPAP, continuous positive airway pressure; PPV, positive pressure ventilation; CPR, cardiopulmonary resuscitation.

Table 1.

CEEM : Clinical and Experimental Emergency Medicine

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