Updates in the NRP 9th edition
Key updates from 8th to 9th edition
Dr. M. Tauseef Omer
Umbilical Cord Management: The algorithm now explicitly includes a cord management plan in the first minute. Delayed cord clamping (DCC) is advised for at least 60 seconds (up from 30–60s) for infants not requiring immediate resuscitation. Focus on delayed cord clamping and natural transition before oxygen titration.
Cord Milking: NOW recommended for non-vigorous infants 35-42 weeks when DCC isn't possible, but not recommended for those <34 weeks due to IVH risk.
Oxygen Targets & Management: The 1-minute SpO2 target (previously 60%-65%) has been removed to prioritize initial assessments/ventilation, with the target table now starting at 2 minutes. Stronger emphasis on spO2 monitoring. Early SpO₂ values (before 2 minutes) are highly variable and not reliable for titration.
Initial FiO2 Adjustments:
>35 weeks 21% (already in 8th Ed)
32 - 34 weeks 21 - 30 % FiO2 (9th Ed)
<32 FiO2 ≥30 (Increased)
For preterm infants, the 9th edition suggests higher initial oxygen: 21–30% for 32–34 weeks, and 30% for less than 32 weeks.
Ventilation Rates & Pressures: The recommended ventilation rate has shifted to 30–60 breaths per minute (previously 40–60). Initial Positive Inflation Pressure (PIP) is set to 25 cmH20 for babies >32 weeks. For babies <32 weeks it is 20-25 cmH20. If PEEP is required it is 5cmH20.
Evaluation Timing: The timeframe to begin ventilation corrective steps if the heart rate does not increase or the chest does not rise has been extended to 15 to 30 seconds (formerly 15 seconds) to allow for a more accurate clinical assessment.
Laryngeal Mask (LMA): The LMA is now considered a primary option alongside the face mask for initial ventilation, rather than just a rescue device for failed intubation.
Corrective Steps (MR. SOPA): Providers are no longer required to follow the MR. SOPA steps in a fixed order. Instead, they should choose the most clinically appropriate step first.
Suctioning and Airway: Routine suctioning is no longer included in the standard resuscitation steps, emphasizing "suction if needed" rather than automatic suctioning.
Endotracheal Tube insertion depth: ETT Insertion Depth (Tip-to-Gum)The 8th Edition's "Initial Depth" table (based on weight and gestation) has been updated to the "Tip-to-Gum" measurement for more accuracy:
The Change: You now measure from the upper gum line to the centimeter mark on the ETT, rather than the lip. This reduces the risk of the tube shifting when the baby moves their mouth.
(ETT placement still recommended to be confirmed using colorimetric change paper blue/purple to yellow) ( Also pass OG tube 8 Fr)
The table for ETT size has been revised. Nasal-Tragus length + 1 cm is discussed as getting estimate of depth of insertion.
New Curriculum Components: The 9th edition introduces new, optional lessons for neonatal intensive care unit (NICU) resuscitation, congenital heart disease, and a specialized NRP Cardiac course.
(Review) Oral Fenofibrate for hyperbilirubinemia
Oral fenofibrate (10 mg/kg) acts as an effective adjunct to phototherapy in term neonates with hyperbilirubinemia, significantly reducing total serum bilirubin (TSB) levels. It works by inducing glucuronyl transferase activity, boosting bilirubin conjugation and excretion. Studies show it is safe, reduces hospital stay duration, and significantly lowers bilirubin levels within 24 to 48 hours.
No major side effects were reported with a single dose.
Facets of Neonatal Care
Facets of Neonatal Care
by Dr. M. Tauseef Omer
Apart from all that you are doing for the management of the baby, do not forget the following.
Thermoregulation:
..Maintain body temperature 98 to 99.5 degF
..Maintain a neutral thermal environment with environmental temperature between 25 to 28 degC and humidity around 60%
Maintain normoglycemia
Glucose infusion rate (GIR) 4 to 6 mg/Kg/min if feeds are not yet started. May need to increase GIR as required.
Monitoring of vital signs
.. Pulse rate, respiratory rate, capillary refill time, oxygen saturation, temperature, blood pressure
nCPAP Care Bundle
Mechanical Ventilation Care bundle
Apnea of prematurity Care Bundle
Maintenance fluids and electrolytes:
Calcium supplements on Day 0
Na and K on Day 3
Infection prevention
Maintain hand hygiene
Advise hygiene of hands and chest to mother
Disinfection of equipment and devices used in case of baby as per protocols of the unit.
Minimal Handling and Clustering of care provided to the baby.
Partial or complete kangaroo mother care.
Prevent oxygen toxicity
Oxygen Saturation Targets:
91 to 95 % with alarms set at 89% to 96% to avoid both hypoxia and hyperoxia.
Calculate oxygenation index in mechanically ventilated babies.
Neurodevelopmental care: Make nest around baby, dim lights in the night for 8 to 12 hours for circadian rhythm to develop, and to promote physiologic stability.
Pain management before procedures.
Nutrition:
..Apply buccal colostrum in oropharynx of babies who are on OG feeding or nill per oral (unless contraindicated).
..Orogastric tube feeding with expressed breast milk
..Peripheral parenteral nutrition
..Total Parenteral nutrition
..Oral breast feeding
.. Human milk fortification
..Micronutrient and multivitamin supplementation
-Screening for DDH
-Screening for ICH
Point of care ultrasound scan (POCUS)
Multidisciplinary care.
Written counselling of parents relating the ongoing management, prognosis, complications associated with the disease and treatment, and risks such as neurocognitive delays, etc, if any.
Discharge and follow-up
-Disease specific instructions at discharge
-General instructions (breast feeding advice, vaccinations advice, vitamin D3 drops (400 IU/drop) one drop daily)
-Retinopathy of prematurity screening at follow-up or during admission
-Screening cranial ultrasound scan at follow-up or during admission
-Hearing assessment, visual assessment and complete developmental assessement
--Advocacy of breast feeding, and counselling against formula feeding.
--Advise mother to take her own care, balance her diet, have adequate sleep, and maintain hand hygiene. So parents may need family planning advice also.
Critical baby Care bundle
It should be formulated as per case basis.
Preterm baby care bundle , review and include surfactant
Family centered care
Baby friendly hospital initiative
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