NRP 9th Edition Practice Changes Explained

The Neonatal Resuscitation Program (NRP) 9th Edition introduces important updates to improve newborn resuscitation and early neonatal care. Endorsed by the American Academy of Paediatrics, these changes focus on clearer birth management, improved ventilation practices, revised cord clamping guidance and updated resuscitation techniques. 

 Key updates include the Birth and Initiate Code Management Plan, use of “ventilation” instead of PPV, no routine suctioning and revised oxygen saturation targets. This highlights the major differences between the NRP 8th and 9th editions, helping healthcare professionals understand the latest practice changes for safer and more effective neonatal resuscitation. 

Key Changes Between NRP 8th Edition and 9th Edition

The NRP 9th Edition introduces important updates compared with the 8th Edition, covering birth management, ventilation terminology, suctioning practice, cord clamping, oxygen saturation targets, ETT sizing and ventilation parameters. These changes aim to make neonatal resuscitation clearer, safer and more consistent. Check the key changes between both editions below. 

1. Birth and Initiate Code Management Plan

The NRP 9th Edition introduces a "Birth and Initiate Code Management Plan". Immediately after birth, even before assessing term gestation, tone, or crying, this plan must be initiated for the first minute. This is a major change from the 8th Edition, which focused on immediate assessment.

2. Suctioning Practices

The NRP 9th Edition has removed routine suctioning. Previously, the 8th Edition allowed suctioning "if needed." Now, for term infants with good tone and breathing/crying, direct skin-to-skin contact with parents, routine care, temperature maintenance, and ongoing evaluation are prioritised.

3. Terminology Update: Positive Pressure Ventilation (PPV)

A key terminology change in the NRP 9th Edition is the update from "Positive Pressure Ventilation (PPV)" to simply "Ventilation". This reflects a simplified and modernised approach.

4. Deferred Cord Clamping (DCC)

For newborns not requiring immediate resuscitation, the NRP 9th Edition mandates deferred umbilical cord clamping for at least 60 seconds. The 8th Edition recommended 30-60 seconds. This extension aims to ensure optimal blood transfer to the infant.

5. Umbilical Cord Milking

Umbilical cord milking involves squeezing the umbilical cord to deliver blood from the placenta to the baby.

• Non-vigorous term and late preterm newborns (35-42 weeks gestation): Milking the intact umbilical cord may be a reasonable alternative to early cord clamping if the infant remains non-vigorous after stimulation.

• Non-vigorous preterm newborns (28-34 weeks gestation): Currently, there is not enough evidence to routinely recommend umbilical cord milking.

• Preterm infants less than 28 weeks of gestation: Intact umbilical cord milking is NOT recommended in the 9th Edition. This is a critical change from the 8th Edition's caution due to a potential risk, as it now explicitly states a significant increase in the risk of severe intraventricular haemorrhage.

6. Target Oxygen Saturation Table

The NRP 9th Edition has updated the target oxygen saturation table. Assessment at 1 minute post-birth has been removed, and the table now starts at 2 minutes. 

For example, the target is 65-70% at 2 minutes, gradually increasing to 85-95% by 10 minutes. This is an important update for monitoring.

7. Initial Oxygen Concentration (FiO2) for Preterm Infants

The NRP 9th Edition refines initial oxygen concentration (FiO2) settings for preterm infants based on gestational age:

• Gestational Age ≥ 35 weeks: Initial FiO2 setting is 21% (for non-invasive or invasive ventilation).

• Gestational Age 32-34 weeks: Initial FiO2 setting is 21-30% (new category).

• Gestational Age < 32 weeks: Initial FiO2 setting is > 30% (new category).

8. Ventilation Rate Target

The NRP 9th Edition has expanded the ventilation rate target to 30 to 60 breaths per minute. The 8th Edition typically targeted 40 to 60 breaths per minute.

9. Peak Inspiratory Pressure (PIP) Inflation

Recommended Peak Inspiratory Pressure (PIP) inflation settings are now categorized in the NRP 9th Edition:

• Gestational Age ≥ 32 weeks: PIP can be set between 25 to 30 cm H2O.

• Gestational Age < 32 weeks: PIP should be maintained between 20 to 25 cm H2O.

10. Extended Time Before Ventilatory Corrective Steps

The NRP 9th Edition extends the acceptable time before initiating ventilatory corrective steps to 15 to 30 seconds. Previously, the 8th Edition initiated steps if heart rate and chest movement weren't observed within 15 seconds of positive pressure ventilation.

11. Ventilatory Corrective Steps Order

Unlike the 8th Edition's fixed sequential approach, the NRP 9th Edition allows ventilatory corrective steps to be performed in an order most likely to be helpful. Practitioners are encouraged to prioritize steps based on clinical judgment rather than a rigid sequence.

12. Laryngeal Mask Airway (LMA) as a Primary Device

In the NRP 9th Edition, the Laryngeal Mask Airway (LMA) is now considered a primary device for ventilation initiation, used alongside the face mask. The 8th Edition regarded it primarily as a rescue device.

13. Endotracheal Tube (ETT) Size

The recommended Endotracheal Tube (ETT) sizes have been revised in the NRP 9th Edition. This is a very important point and may be asked in exams.

Additionally, a 2.0 mm ETT may be considered in cases of difficult breathing.

14. Endotracheal Tube (ETT) Depth Measurement

The NRP 9th Edition introduces a new, critical reference point for ETT depth measurement. Instead of the lip-tip method, ETT depth is now measured by aligning the tube marking with the anterior edge of the baby’s upper maxillary gum in the midline.