What’s New:

Making the Transition to NRP 8th edition

Click here to read about the NRP 8th edition timeline, the revised textbook, significant practice changes and how NRP is different. Then make a plan to transition from NRP 7th edition to NRP 8th edition.

Making the Transition to NRP 8th Edition

What’s Different about NRP 8th Edition?

The American Academy of Pediatrics/American Heart Association Neonatal Resuscitation Program® (NRP®) 8th edition materials were released in June 2021 and must be in use by January 1, 2022. Ongoing international review and consensus of resuscitation science since 2015 has yielded no major changes in practice.  However, the NRP Steering Committee revised several practices in the interest of patient safety and educational efficiency. The NRP 8th edition offers NRP Essentials and NRP Advanced levels of learning and two recommended Provider Course formats. In most hospitals, NRP Essentials and NRP Advanced will be taught using instructor-led Provider Courses. RQI® for NRP® , a self-directed learning program that uses low dose, high frequency quarterly learning and skills sessions, may be used in hospitals that already use RQI for life support education.

The Textbook of Neonatal Resuscitation, 8th Edition

In addition to updated familiar content in lessons 1 through 11, the 8th edition textbook features three supplemental lessons that include information about improving resuscitation team performance by considering human factors and ergonomics, resuscitation outside of the delivery room, and quality improvement practices related to resuscitation (Table 2). The content of these supplemental lessons will not be included in test questions but allows every NRP learner the opportunity to enhance their resuscitation knowledge and performance.

The Textbook of Neonatal Resuscitation, 8th edition, has been improved in the following ways5:

  • Key Points are at the beginning of each lesson rather than at the end
  • Many lessons include Quick Response (QR) codes that enable the reader to view short videos about the topic on their mobile device
  • Lesson Review Questions are grouped together at the end of each lesson instead of being placed intermittently within the lesson
  • Each lesson ends with Quality Improvement Opportunities and Frequently Asked Questions
  • Lesson 10 (Special Considerations) has new sections about resuscitation of the newborn with a myelomeningocele and resuscitation of the newborn with an abdominal wall defect

Significant NRP 8th Edition Practice Changes

Several practices have been revised in the interest of patient safety and educational efficacy. See the table below.

  • The four pre-birth questions have been revised to include a new question about the umbilical cord management plan. This question replaces “How many babies are expected?”
  • The initial steps of newborn care have been reordered to better reflect common practice. The initial steps are warm, dry, stimulate, position airway, and suction if needed.
  • An electronic cardiac monitor is recommended earlier in the algorithm when an alternative airway is required.
  • The new suggested dose for epinephrine is based on a desire to simplify the dosing for educational efficiency. This single dose may be easier for NRP providers to remember in an emergency, may improve teamwork by allowing the team member preparing epinephrine to anticipate the requested dose, and may allow easier preparation across a wide range of newborn weights. The current suggested dose is not based on evidence of superior efficacy and does not represent an endorsement of any particular dose within the recommended dosing range. The ideal epinephrine dose for persistent, severe neonatal bradycardia and asystole remains an important knowledge gap and additional research is needed.
  • Evidence from an animal study has suggested that a 1-mL flush volume may leave a significant amount of epinephrine in the umbilical vein or liver instead of carrying it to the heart. Pending additional studies to identify the ideal flush volume in newly born humans, this program recommends a 3-mL flush volume for babies of all gestational ages after intravascular epinephrine administration.1
  • A recent systematic review completed by ILCOR found that stopping resuscitative effort at 10 minutes may preclude survival of some newborns who would have survived without significant disabilities. If confirmed absence of HR after all appropriate steps are performed, consider cessation of resuscitation efforts around 20 minutes after birth. The decision is individualized and based on patient and contextual factors.2

Overview of Significant NRP® 8th Edition Practice Changes

Change NRP 7th Edition NRP 8th Edition
Umbilical cord management plan added to 4 pre-birth questions, replacing “How many babies?” The 4 pre-birth questions:
  1. Gestational age?
  2. Amniotic fluid clear?
  3. How many babies?
  4. Additional risk factors?
 The 4 pre-birth questions:
  1. Gestational age?
  2. Amniotic fluid clear?
  3. Additional risk factors?
  4. Umbilical cord management plan?
Initial steps reordered to better reflect common practice. Initial steps: Warm and maintain normal temperature, position airway, clear secretions if needed, dry, stimulate. Initial steps: Warm, dry, stimulate, position airway, suction if needed.
An electronic cardiac monitor is recommended earlier in the algorithm. An electronic cardiac monitor is the preferred method for assessing heart rate during cardiac compressions. When an alternative airway becomes necessary, a cardiac monitor is recommended for the most accurate assessment of the baby’s heart rate.
Epinephrine intravenous/intraosseous (IV/IO) flush volume increased. Flush IV/IO epinephrine with 0.5 to 1 mL normal saline Flush IV/IO epinephrine with 3 mL normal saline (applies to all weights and gestational ages)1
Epinephrine IV/IO and endotracheal doses have been simplified for educational efficiency. The dosage range is unchanged. The simplified doses (IV/IO and ET) do not represent an endorsement of any particular dose within the recommended dosing range. Additional research is needed. Range for IV/IO dose = 0.01 - 0.03 mg/kg (equal to 0.1 - 0.3 mL/kg)
Range for ET dose = 0.05 - 0.1 mg/kg (equal to 0.5 – 1 mL/kg) 		The suggested initial IV/IO dose = 0.02 mg/kg (equal to 0.2 mL/kg)
The suggested ET dose (while establishing vascular access) = 0.1 mg/kg (equal to 1 mL/kg)
Expanded timeframe for cessation of resuscitative efforts. If there is a confirmed absence of heart rate after 10 minutes of resuscitation, it is reasonable to stop resuscitative efforts; however, the decision to continue or discontinue should be individualized. If confirmed absence of HR after all appropriate steps performed, consider cessation of resuscitation efforts around 20 minutes after birth (decision individualized on patient and contextual factors).2

References for the table

  1. Vali P, Lakshminrusimha S. Epinephrine in Neonatal Resuscitation in a Term Lamb Model of Perinatal Asphyxial Arrest. Baltimore, MD: Pediatric Academic Society (2015).
  2. Aziz K, Lee HC, Escobedo MB, Hoover AV, Kamath-Rayne BD, Kapadia VS, Magid DJ, Niermeyer S, Schmölzer GM, Szyld E, Weiner GM, Wyckoff MH, Yamada NK, Zaichkin J. Part 5: neonatal resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(suppl 2):S524–S550. doi: 10.1161/CIR.0000000000000902

Making the Transition to NRP 8th Edition

Many NRP providers and instructors are familiar with making the transition to a new edition of NRP every five years. The 8th edition of NRP recommends only a few practice changes, making the transition to implementing those changes in the delivery room easier than previous transitions. However, this new edition brings numerous changes to the way instructors teach NRP and how learners will experience NRP instruction.

Transitions for Instructors

Current NRP instructors do not need to take an NRP 8th edition Provider Course before teaching NRP 8th edition courses. Current NRP instructors are strongly encouraged to review the 8th edition instructor course content and updated Instructor Toolkit materials before teaching 8th edition Provider Courses.

Prepare NRP Learners for the Transition

The NRP 8th Edition materials must be implemented by January 1, 2022. To make a smooth transition to 8th edition NRP, everyone must know:

  • What the revised practice changes entail
  • Which NRP provider category they are expected to achieve: NRP Essentials or NRP Advanced
  • When everyone is expected to use the NRP 8th edition recommendations in the delivery room
  • How NRP Provider Courses may change and how learners will be oriented to those changes

All NRP providers do not need to attend an NRP 8th edition Provider Course by January 1, 2022. Providers may maintain their current renewal date unless your hospital administration chooses to require an 8th edition course before the implementation deadline of January 1, 2022.

NRP instructors can use a variety of methods to educate and update NRP providers about 8th edition practice revisions and education requirements. Here are some ideas:

  • Post materials from the Instructor Update Newsletters and Busy People Updates (https://aap.org/NRP) in common areas
  • Provide access to the February 18, 2021 webinar: Innov8te NRP: An Introduction to the NRP 8th Edition (https://aap.org/nrp)
  • Email NRP information and updates to your providers
  • Provide brief in-service sessions to discuss NRP 8th edition changes and how they impact resuscitation practice and education
  • Film your own short video of informational material and post it for your providers

If instructors continue to teach NRP 7th edition Provider Courses (Lessons 1-11) and implement NRP 8th edition practice revisions at the same time, they will need to teach a hybrid version of the course. Learners who use the 7th edition textbook and take the 7th edition exam will also need a summary of 8th edition practice revisions. If the NRP 8th edition recommendations are already in use in the delivery room, use the 8th edition practice revisions during skills review and during simulation and debriefing.

Set an Implementation Date

By January 1, 2022, all NRP Provider Courses must use NRP 8th edition materials and practices. You may implement the practice changes when staff are ready at any time after NRP 8th edition materials are available.

To make the transition, announce a date when changes will “go live” in your institution. Make sure systems are in place to support the changes, including a policy about the number of providers and necessary qualifications when deciding who will attend births based on perinatal risk factors. After resuscitation, debriefing is important. A debriefing provides all team members the opportunity to identify what went well and what needs improvement, as well as providing an opportunity to discuss 8th edition practice revisions that require additional infrastructure, education, or practice.