NLS 5904; PLS 4050.04; EIT 6320 NODAL Interface of Newborn and Pediatric Resuscitation

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: Authors Taylor Sawyer and Georg Schmölzer have co-authored previous papers on this subject and were not involved in decisions to include/exclude, or in the extraction of data from the papers they had co-authored.

Task Force Synthesis Citation

Joe Fawke, Vix Monnelly, Taylor Sawyer, Henry C. Lee, Ryan W. Morgan, Jimena del Castillo, Jason Acworth, Mario Rüdiger, Aaron Donoghue, Kathryn Eastwood, Takahiro Sugiura, Georg M. Schmölzer, Anne Lee Solevåg-on behalf of the International Liaison Committee on Resuscitation PLS, NLS and EIT Life Support Task Forces. The use of PLS vs NLS in resuscitation of children between 24 hours and one year of age: Task Force Synthesis of a Scoping Review [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Pediatric and Neonatal Life Support, and Education, Implementation Task Force, 2026 November 1.  Available from: http://ilcor.org

Methodological Preamble

The continuous evidence evaluation process started with a scoping review of infant life support conducted by the ILCOR Pediatric Life Support (PLS), Neonatal Life Support (NLS), and Education, Implementation, and Teams (EIT) Task Force Scoping Review team. Evidence for neonatal and pediatric literature was sought and considered by the Pediatric Life Support, Neonatal Life Support, and Education, Implementation, and Teams Task Force.

Scoping Review

Currently being reviewed by all authors prior to submission for peer review.

Not published at time of reporting

PCC

The PCC (Population, Concept, Context)

Population

Neonates and infants (both real and simulated) who require cardiopulmonary resuscitation for any reason at any time after the immediate newborn period up until a year of age.

Concept

The use of NLS or PLS algorithms and strategies for cardiopulmonary resuscitation.

Exclusion criteria:

Newborn infants within 24 hours of birth

Trauma

Burns

Drowning

Advanced care plan that limits resuscitation

Lay responders

Context

Practitioners managing these infants in the neonatal intensive care unit (NICU), pediatric intensive care unit (PICU), pediatric cardiac intensive care unit, pediatric ward, emergency department, or postnatal ward want direction on which algorithm to use.

There are important training and cost implications if both algorithms need to be taught to and used by all relevant health care practitioners.

The age, pathophysiology, patient characteristics, Utstein variables,15,26 location, provider, any clinical outcomes, and the experience of the practitioners may affect the practitioners’ choice of algorithm.

Types of sources

This scoping review considered published and unpublished studies. Experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies and interrupted time-series studies, analytical observational studies including prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies were considered for inclusion. This review also considered descriptive observational study designs including case series, individual case reports and descriptive cross-sectional studies for inclusion. Simulation-, animal- and mathematical modelling studies were included. In addition, scoping, integrative and systematic reviews that met the inclusion criteria were also considered, depending on the research question.

For contextual insight, opinion papers were considered for inclusion in this scoping review.

Guidelines were excluded.

Timeframe:  All years until January 26, 2026

Literature search updated to August 10, 2026

The current review only focused on the NLS or PLS based algorithms and did not include any other guidance, eg PLS guidelines include aspects of post-ROSC management, management of non-arrest arrhythmias and these were excluded.

Data tables with the results organized according to the three research questions of the scoping review

Search Strategies

Articles for review were obtained by searching Ovid MEDLINE, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and Cinahl (EbscoHost), for all entries from database inception to January 26 2026 (last searched on August 10, 2026).

Data Tables

Task Force Insights

1. Why this topic was reviewed.

Cardiopulmonary resuscitation with chest compressions and/or epinephrine is being performed in 0.25% of neonates in tertiary NICUs and 1-2% of infants in quaternary NICUs,1,3,14,22 whereas it is used in only 0.1% in the delivery room.13 Forty to sixty percent of NICU/PICU arrests occur in infants <1 year of age. NLS focuses on management in the delivery room and must consider the specifics of perinatal transition. Therefore, it places emphasis on ventilation to recover hemodynamic stability in bradycardic or asystolic newborn infants.21,23 Effective ventilation is recommended followed by chest compressions if the heart rate remains less than 60 beats per minute despite ventilation corrective actions. On the other hand, PLS focuses on a broad variety of emergencies and emphasizes the provision of chest compressions while avoiding excessive ventilation.12,31 Other key differences between the two algorithms include early emphasis on maintaining normal temperature in preterm and term newborn infants, coordination of ventilation breaths with chest compressions when a definitive airway is in place, and the use of medications and other adjunct therapies.24,28,29 Unlike NLS, PLS includes considerations for other underlying medical conditions, e.g., shock, arrhythmias, and metabolic disturbances that may precipitate cardiac arrest. Also, rhythm assessment and defibrillation are not always part of NLS.

NICUs have different age limits for admitting and keeping infants in their unit. In a recent level IV NICU survey from the Unites States, three units transferred infants out of the NICU at 6-9 months of age, whereas five units transferred first at 9-24 months age.4 Furthermore, some NICUs are not located in birth hospitals and do not provide care immediately after birth, so they may have a different case-mix from birth hospital NICUs. Also, practices regarding when to use NLS and when to use the PLS differ.2 The varied use of NLS and/or PLS in neonates and infants might influence clinical outcomes, including survival from bradycardia or cardiac arrest, and practitioners managing these infants want direction on which algorithm to use. There are important training and cost implications if both algorithms need to be taught to and used by all relevant health care practitioners. The age, pathophysiology, patient characteristics, location, and experience of the practitioners may affect the practitioners’ choice of algorithm. The question of when to use NLS or PLS was prioritized by the International Liaison Committee in Resuscitation (ILCOR) NLS Task Force, and the PLS and Education, Implementation and Teams (EIT) Task Forces were invited to contribute to a nodal review. Acknowledging that a scoping review cannot answer the question of which algorithm is better under different circumstances, the task forces intended to perform systematic reviews provided that sufficient evidence was identified after having scoped the literature.

2. Narrative summary of evidence identified

To address the research questions, data were extracted on the application of NLS and PLS in neonates and infants across diverse clinical settings. This included identifying the types of algorithms used, the contexts in which they are applied (e.g., NICU, PICU, pediatric cardiac intensive care unit, pediatric ward, emergency department, postnatal ward), and the characteristics of the providers implementing them. Patient-centered outcomes (e.g., survival rates, neurological outcomes, complication rates) and provider-centered outcomes (e.g., protocol adherence, decision-making accuracy) were collected if included. Educational factors influencing algorithm selection and performance—such as training modalities, assessment tools, and provider attitudes were examined. Implementation factors including cost, infrastructure, technology requirements, and certification standards were planned to be analyzed. All data were planned to be stratified by gestational age, postconceptional age, and postnatal age.

• The literature identified by this scoping review fell into seven main subgroups

Studies describing education and implementation of hybrid approaches (n=2)

Surveys (n=3)

Animal studies (n=8)

Manikin studies (n=5)

Modelling/benchtop studies (n=2)

Observational studies (n=3)

Reviews (n=2)

The results were categorized to answer the three pre-specified research questions of the scoping review:

1. How are PLS and/or NLS algorithms currently applied to neonates and infants who require

cardiopulmonary resuscitation for any reason at any time after the immediate newborn period up

until a year of age? (Table 1)

• The identified clinical studies were mainly from US level IV NICUs, and there were large differences in the use of NLS and PLS in infants less than one year of age.

• Most of the studies identified focused on the chronological age,2,4 weight (size) and location of infants receiving CPR. In some studies, location was a main determinant for algorithm choice.2,9 Other studies described more differentiated approaches.4,5,19,34

• Surveys,2,4 observational9,17,18 and educational studies5,19 described characteristics including the pathophysiology of cardiac arrest in different ICUs.

2. What are the training and cost implications if both algorithms need to be taught to and used by all

relevant health care practitioners? (Table 2)

• No study presented data on training and cost implications of a requirement to train staff in both algorithms.

• Harer et al19 stated that due to expected costs, PLS training was only offered to nursing team leaders rather than all nursing staff in the NICU.

• Anderson et al5 found a substantial proportion of the standard PLS curriculum to be irrelevant to NICU practice, and full PLS training for all staff was considered not cost-effective.

3. Practitioners managing these infants in the neonatal intensive care unit, pediatric intensive care

unit, pediatric cardiac intensive care unit, pediatric ward, emergency department, postnatal ward or

locations outside the hospital (e.g., emergency medical system response) want direction on which

algorithm to use (Table 3)

• No clinical studies directly compared the two algorithms in matched patient populations.

• No studies addressed premature and ex-premature infants as a separate group.

• There was only indirect evidence about outcomes of PLS and NLS as algorithms choice is mainly driven by the type of ICU. In one study, survival to discharge was higher after PICU events (53%) compared with after NICU events (35%).18 One conference abstract reported worse outcomes after changing from NLS to PLS for all NICU arrests.17

• Manikin/simulation studies focused on chest compression and ventilation mechanics with a 3:1 versus a 15:2 chest compression to ventilation ratio,7,8,20,27 as well as provider fatigue6 and preferences.6,7,20,27 The results were conflicting.

• Animal studies evaluated hemodynamics, return of spontaneous circulation and survival16,25,30,32,33 with a 3:1 versus higher chest compression to ventilation ratios, as well as markers of organ inflammation.10,11 No differences were found that warrant a change toward higher chest compression to ventilation ratios in newborns.

The age, pathophysiology and other characteristics of the patient, location and practitioners may affect the practitioners’ choice of algorithm and are summarized in Table 1-3.

3. Narrative Reporting of the task force discussions

1. How are PLS and/or NLS algorithms currently applied to neonates and infants who require

cardiopulmonary resuscitation

• The studies that reported differences in the use of NLS and PLS in NICUs did not specify whether algorithm choice differed between hospitals with or without in-hospital delivery services.

2. What are the training and cost implications if both algorithms need to be taught to and used by all

relevant health care practitioners?

• No empiric data, only considerations and opinions, were identified in the included studies

3. Practitioners managing these infants in the neonatal intensive care unit, pediatric intensive care

unit, pediatric cardiac intensive care unit, pediatric ward, emergency department, postnatal ward or

locations outside the hospital (e.g., emergency medical system response) want direction on which

algorithm to use.

• No randomized controlled trials and no large non-randomized studies were identified that met our inclusion criteria. Overall, our findings do not warrant a systematic review.

• In the included clinical studies with patient-level data, the location of arrest and provider characteristics appeared to determine the choice of algorithm more than age or other patient characteristics.

• NICU patients tend be younger at the time of arrest, and it has been shown that lower gestational and postnatal age is associated with a higher mortality after CPR. Thus, data comparing survival across units (NICU, PICU, CICU) are difficult to interpret.

• The presence of confounding interactions such as gestational age prompt caution when interpreting the results of retrospective (registry) data.

• The information from the studies identified was considered insufficient to make recommendations on a certain age threshold for changing from NLS to PLS. Algorithm selection should consider the infant’s pathophysiology, presumed arrest etiology, age and size, care setting, and team expertise.

• NLS might be appropriate if failed transition, low functional residual capacity, or inadequate ventilation are the primary concerns. PLS if cardiac disease, shock, arrhythmia, or need for broader medication and defibrillation pathways are suspected. However, the overlap in underlying conditions, causes of arrest, and initial rhythms between patients presently treated with PLS or NLS is substantial and no single characteristic is likely to discriminate which approach is superior or ideal.

• Especially NICUs caring for older, complex infants, might consider neither pure PLS nor pure NLS, but an integrated neonatal-pediatric resuscitation model with clear local triggers for transition.

Knowledge Gaps

Future research should move beyond location alone and consider the relevant pathophysiology of infant arrest. We suggest that studies compare individual algorithm components, including C:V ratio, asynchronous ventilation, timing of chest compressions, rhythm assessment, medication dosing, and readiness of defibrillation. Preterm infants represent a broad spectrum of patients, with differing physiology through their NICU stay. Future research may include large, population-based registry studies or possibly large before-and-after or cluster randomized trials. It is vital that such studies include information about gestational age, postmenstrual age and weight, in addition to location, airway status, initial rhythm, presumed etiology, algorithm used, deviations from algorithm, time to key interventions, ROSC, survival, and neurologic outcomes. Simulation studies should evaluate team decision-making at the NLS-PLS interface, not only chest compression and ventilation mechanics. Hybrid-approaches have been described and need further study, including reporting of associated cost. No study examined out-of-hospital setting.

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