Infant Resuscitation and DNR Orders

There are many factors that can contribute to a person requiring Cardiopulmonary Resuscitation (CPR); injuries or accidents, a heart attack, or even an uncontrolled illness, can cause the heart to stop. 

In the case of infants, premature birth, birth defects, or injuries, are all outcomes that may require CPR. Infant resuscitation must be performed by a team of specially trained healthcare professionals who understand the unique requirements of an infant. While CPR is more effective in neonates than adults on average, infant fragility means minor errors can have devastating and long lasting effects. The indicating factor for success falls largely on proper execution and a lack of common or routine mistakes.

The Outcomes of CPR in the NICU

CPR is an emergency life saving procedure that is used when a person is experiencing cardiovascular arrest. Immediate CPR is effective in adults about 10.6 percent of the time. The numbers are surprisingly different when dealing with neonates.

When it comes to neonates, CPR is much more complicated, but outcomes are generally more optimistic. In a recent study of The Children’s Hospital of Philadelphia’s, or The CHOP’s, Neonatal Intensive Care Unit (NICU), CPR results were analyzed over a four year period. The CHOP is a 96-bed, level 4 referral NICU for infants born earlier than 32 weeks gestation and weighing less than 1,500 grams. The most common reasons for admission are surgery, respiratory management, neurologic problems, and congenital anomalies which, together, make up an average of 70 percent of neonates treated in this NICU. 

Approximately half of admitted infants in the study were preterm, meaning less than 37 weeks gestation; 14 percent had a gestational age of less than 29 weeks at birth; and 9 percent were between 29 to 33 weeks gestation at birth. At the time of admission, 42 percent of infants were greater than weeks postnatal age. 

Among 113 infants who received CPR in this study, 61 percent of the infants survived to hospital discharge. In part, this success can be attributed to treatments that work alongside CPR, including delaying cord clamping, antenatal steroids, temperature stabilization, and ventilation.  

What is a DNR Order?

A Do Not Resuscitate or DNR order should be put in place before an emergency occurs. These orders allow the patient, or the patient’s family in the case of a neonate, to choose whether or not to administer CPR in an emergency. This order is specific to CPR. It does not have instructions for other treatments, such as pain management, medications, or nutrition.

A physician will write the order only after discussing it with the patient, if they are well enough to make their own medical decisions. In the case of a premature infant, the parents, or a legal guardian, are responsible for making the decision.

If an infant is born before 24 weeks gestation, parents are given the choice to resuscitate or not. Parents, at this point, often have to make this difficult decision carefully considering their belief system, their infant’s overall health, as well the suffering their infant may be subjected to in order to be stabilized. 

Gestational Age Recommendations

If this is the case, circumstances may require parents to decide if CPR is the clinically correct choice for their infant. These guidelines recommend that if an infant is born before 21 weeks six days, attempts to resuscitate an infant should only take place within a clinical research study approved by a research ethics committee and with informed parental consent. 

Resuscitation is not the clinical norm for babies born between 22 and 23 weeks, unless the parents, after being fully informed of the available evidence, request resuscitation, and reiterate that request. This is because there is not yet the technology to support a premature infant outside of the womb before 24 weeks gestation.

At 23–24 weeks, the degree of uncertainty about an infant’s prospects is such that parental views should take precedence. From 24 weeks, the emergency protocol will   include resuscitation, unless parents and clinicians have agreed that, in the light of the infant’s condition, it is not in their best interest to admit the neonate to intensive care. 

Who is Responsible for Administering CPR in the NICU?

Being prepared is the first and most important step in delivering effective neonatal resuscitation. The failure to have a team of qualified healthcare professionals prepared and present, wherever it is standard procedure to have staff and resources available for a high risk delivery, can be considered medical malpractice. However, most small hospitals and clinics do not have fully trained teams experienced in infant resuscitation on staff, therefore infants born with respiratory issues face even greater risk outside of urban centers. 

In the United States, 10 percent of all newborns need some intervention, and one percent will require extensive resuscitative measures at delivery. As a result, at every birthing location, healthcare personnel who are adequately trained in neonatal resuscitation should be readily available to perform CPR whether or not problems are anticipated.

In all instances, at least one health care provider is assigned primary responsibility for the newborn infant. The physician in this role should have the necessary skills to evaluate the infant, and, if required, to initiate resuscitation procedures, such as positive pressure ventilation and chest compressions. In addition, either the primary physician or a physician who is immediately available, should have the requisite knowledge and skills to carry out a complete neonatal resuscitation, including endotracheal intubation and administration of medications.

How is CPR Used in the NICU?

Resuscitation and stabilization of a preterm neonate consists of complex decisions and tasks undertaken by the team. In recent years, there is growing evidence for providing the most gentle, and least invasive support in the delivery room to reduce immediate and long term morbidities. This means CPR is only part of a process used to treat complications of premature newborns. 

The initial steps of neonatal resuscitation are to provide warmth by placing the infant under a radiant heat source; positioning the head in a ‘sniffing’ position, which means extending the neck to open the airway; clearing the airway with a bulb syringe or suction catheter; drying the infant; and stimulating breathing. Evaluation of the neonate for respiration, heart rate, and color at every 30-second interval must be performed.

In high-risk births, the majority of newborns requiring resuscitation can be identified before birth. If the need for resuscitation is anticipated, additional skilled personnel should be recruited and the necessary equipment prepared. This team of skilled personnel are required at the delivery of the infant and is made up of many members—one member of the team is responsible for positioning, suctioning and drying the infant, and other team members are responsible for airway and endotracheal intubation, and a fourth for administering medication. If a preterm delivery less than 37 weeks of gestation is expected, special preparations will be required.

When is CPR Needed?

In general, all infants should be initially evaluated on their muscle tone and ability to breathe and cry. In the assessment of a term newborn, if it is found that the infant has good muscle tone and is able to both breathe and cry, they likely will not need resuscitative assistance. However, if the infant is preterm, has poor muscle tone, and/or has difficulty breathing or crying, neonatal resuscitation may be necessary. 

The steps to neonatal resuscitation are fully outlined and are as follows:  

  1. Initial stabilization: Medical professionals should warm, dry, and properly position the infant. They should also provide tactile stimulation and clear the infant’s airway, if necessary.
  2. Breathing assistance: At this point, the infant should either be ventilated or oxygenated, depending on the circumstances. 
  3. Chest compressions: Chest compressions are often used if the newborn’s heart rate stays under 60 bpm despite adequate ventilation for 30 seconds.
  4. Epinephrine administration: Epinephrine, a hormone and intervention for resuscitation, can be administered intravenously if the above steps failed to provide assistance.
  5. Volume expansion: Though rarely used, volume expansion can be administered in order to prevent neonatal hypovolemia (decreased amount of blood flowing through the body) if the infant’s heart rate stays < 60 bpm after the above steps.


If, after a particular step, the infant responds with spontaneous respiration and a heart rate greater than 100 bpm, no further steps should be taken. However, if at any point, an infant is still gasping, has apnea or labored breathing, has cyanosis, or has a heart rate less than 100 bpm, medical professionals should continue to the next step.

Which Errors are Expected During Infant Resuscitation?

Errors do happen during infant resuscitation. In a recent study looking into errors in the NICU, 194 tasks were completed incorrectly, for an average error rate of 23 percent. 42 were errors of omission, 28 percent of all errors, and 107 were errors of commission, making up 72 percent of all errors. 

Many errors were repetitive and potentially clinically significant: failure to assess heart rate and/or breath sounds, improper rate of positive pressure ventilation, inadequate peak inspiratory and end expiratory pressures during ventilation, and improper chest compression technique.

Having a team of trained professionals is the building block of successful neonatal resuscitation. Because premature infants are so fragile, small errors can lead to severe and lasting injury or illness. If a infant is deprived of oxygen too long, permanent damage can happen within a matter of minutes, including:

Unfortunately, there are many reasons for delayed infant resuscitation, but most occur due to lack of medical experience and negligent errors. Some of most common reasons for failed resuscitation include the delay in resuscitation, failure to have a qualified team of experienced medical professionals prepared for what has been determined a high risk birth, and the improper use of infant resuscitation techniques.

Is it Medical Malpractice? 

If the process of infant resuscitation is followed promptly and by a trained team of professionals, neonates have a high chance of recovery. On the other hand, the fragility of a neonate can mean that even small mistakes can have severe and lasting consequences. And while there is typically an encouraging rate of success when performing CPR on infants, if CPR is delayed, if steps are missed, or the procedures are done improperly, the healthcare worker acting negligently may be liable for malpractice.

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