Heart Rate for Starting Neonatal Chest Compressions: NLS 5500 TF ScR

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Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors declared an intellectual conflict of interest, and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: Bruckner M, Wyckoff MH, and Smölzer GM have all published studies regarding neonatal cardiac compressions. 2 reviewers were used to select or exclude each paper for this scoping review and no reviewer was allowed to determine inclusion or exclusion of their own publications.

Task Force Scoping Review Citation

Ramachandran S, Bruckner M, Wyckoff MH, Smölzer GM on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Neonatal Cardiac Compressions Scoping Review and Task Force Insights [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 2022, Dec 19. Available from:

Methodological Preamble

The continuous evidence evaluation process started with a scoping review of neonatal cardiac compressions literature conducted by the ILCOR NLS Task Force and Content Expert Scoping Review Team comprised of Shalini Ramachandran, MD, Marlies Bruckner, MD, Myra Wyckoff MD, Georg M. Schmölzer MD, PhD. Neonatal cardiac compression literature was sought via a structured search strategy with the help of an information specialist, Ms. Helen Mayo from University of Texas Southwestern Medical Center. Studies identified were evaluated using Covidence. This allowed independent title and abstract review by two authors (SR and MB) to see if full text review was warranted. When MB was an author on a study under consideration, she was recused from the decision and MW gave the second opinion. Abstracts put forward by both reviewers were included for full text review. Conflicting opinions were reviewed, discussed and resolved with the help of MW and GS as long as they were not authors on the paper under consideration. The Neonatal Life Support Task Force considered the findings for each included PICOST and developed Task Force insights regarding the compiled literature for each PICOST.

Studies screened by title / abstract, those undergoing full text review and those extracted for data analysis for the scoping review are shown in the PRISMA diagram below.

Attachment: NLS 5500 PRISMA

Link to Published Scoping Review

Ramachandran S, Bruckner M, Wyckoff MH, Schmölzer GM. Chest compressions in newborn infants: a scoping review. Arch Dis Child Fetal Neonatal Ed. 2022 Dec 1:fetalneonatal-2022-324529. doi: 10.1136/archdischild-2022-324529.


The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: In neonates being resuscitated with ventilation who have a slow heart rate

Intervention: does starting cardiac compressions at other heart rates

Comparators: versus starting cardiac compressions when the heart rate is < 60 bpm

Outcomes: impact any short or long term outcomes (increase survival rates, improve neurologic outcomes, decrease time to return of spontaneous circulation)

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies), and case series were eligible for inclusion. Manikin, computer model and animal studies were eligible for inclusion. Conference abstracts and unpublished studies (e.g. trial protocols) were excluded.

Timeframe: All years and all languages were included as long as there was an English abstract; Literature search updated to Nov 22, 2021.

Search Strategies

NLS 5500 Search Strategy

Inclusion and Exclusion criteria

We included animal, manikin, and human studies if there was an abstract in English. Reviews, unpublished studies, or studies published in abstract only, and studies that did not specifically address the PICOST questions were excluded.

Data tables

No studies identified for this PICOST question.

Task Force Insights

1. Why this topic was reviewed

  • This topic was chosen for scoping review by the NLS Task Force because it is a new PICOST regarding cardiac compressions and it was not known what evidence existed regarding this important question.
  • Initiation of cardiac compressions when the heart rate remains less than 60 bpm after successful inflation of the lungs has long been suggested in neonatal resuscitation algorithms. However, the evidence for using this cut-off has never been examined by the NLS Task Force or put through a GRADE evaluation.

2. Narrative summary of evidence identified

  • No studies were found that examined different heart rate thresholds to initiate chest compressions in newborn infants in the delivery room.

One review article regarding strategies to prevent progression of bradycardia and the role of chest compressions for persistent neonatal bradycardia in the delivery room included some animal data which might be useful.{Agarwal 2019 119} Fetal lambs (n=14) were instrumented and asphyxiated until cardiac arrest. Heart rates were continuously monitored using an invasive aortic line. Coronary, carotid and pulmonary flows were recorded and compared during asphyxia at different levels of bradycardia. Peak systolic carotid flows were significantly lower for heart rates <60/min compared to baseline.

3. Narrative Reporting of the task force discussions

We identified a significant gap in the published literature regarding the optimal threshold for which to initiate cardiac compressions as there were no studies that directly addressed this question.

  • We acknowledge that this heart rate cut-off was originally selected based on expert opinion and a desire to simplify the resuscitation algorithm. (The earliest neonatal resuscitation recommendations included starting compressions when the heart rate was 60-80/min and not rising).
  • The information from the scoping review is thus insufficient to alter the current existing recommendations of starting compressions when the heart rate is < 60/min after successful inflation of the lung..

Knowledge Gaps

As noted above there is no data regarding the optimal threshold for which to support an infant with cardiac compressions either in appropriate animal models or in the clinical setting. Thus, the gaps in knowledge remain immense


  1. Agrawal V, Lakshminrusimha S, Chandrasekharan P. Chest Compressions for Bradycardia during Neonatal Resuscitation-Do We Have Evidence? Children (Basel). 2019;6:119.



Racire Silva
We still use below 60.
Norma suely Oliveira
We use below 60
Giselda Silva
Always below 60 we start cardiac massage
Colin Morley
Most neonates have a healthy heart and the bradycardia mainly occurs because the myocardium is hypoxic. The best way to improve bradycardia just after birth is good lung fluid clearance, formation and maintenance of an FRC and thereby aeration to oxygenate the blood. This review assumes the cardiac compression is being started, "after successful inflation of the lungs." Unfortunately, there is no way resuscitators can determine successful aeration of the lungs. If there is bradycardia the first thing to do is improve ventilation by increasing the peak inflation pressure, or tidal volume if measured, maintaining the inflation for at least 1 second, and ensuring adequate PEEP to maintain lung volume. This review is about chest compression but before that is done either this, or another PICOST should does mention techniques of ensuring adequate lung aeration before chest compression.
Jamie Tegart
I think that a HR of under 60 is still an acceptable rate to use, for now, as that is what is currently practiced at most sites. While there is enough evidence to agree that a rising chest & audible air entry are acceptable indicators of effective ventilation, along with a rising HR as the primary indicator. I would be curious to review length of time providing effective ventilation before starting chest compressions. Our current practice is 30 seconds. Since we know that most infants are in a respiratory arrest and not a cardiac maybe more emphasis on the length of time effective ventilation is being done for would be beneficial

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