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Updated 2025 Neonatal Resuscitation Guidelines: What’s New for Babies at Risk of HIE

November 10th, 2025  | Advocacy  | Care  | News  | Research

 

The American Heart Association (AHA) and American Academy of Pediatrics (AAP) have released updated 2025 Guidelines for Neonatal Resuscitation, shaping how birth and neonatal teams respond in the crucial first minutes of life.

These updates strengthen evidence around cord management, refine resuscitation practices, and emphasize team readiness—all with the goal of improving outcomes for newborns, especially those at risk of hypoxic-ischemic encephalopathy (HIE).

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What’s Changed — and Why It Matters

🩸 Cord Management: Keeping the Connection a Little Longer

Delayed Cord Clamping (DCC)

• Recommended for at least 30–60 seconds for most term and preterm infants who do not need immediate resuscitation.
• Shown to improve blood volume, oxygen delivery, and iron stores—important for stable brain perfusion during transition.
• For babies who require resuscitation, the optimal timing remains under study, but teams are encouraged to plan ahead and evaluate feasibility.

Why it matters for HIE:
A smoother transition and improved oxygenation may help protect the brain in those fragile first minutes when HIE risk is highest.

Intact Cord Milking (ICM)

• For term or late-preterm infants (≥ 35 weeks) who are non-vigorous, ICM may be reasonable compared to immediate clamping.
• For preterm infants (28–34 weeks) when DCC isn’t possible, ICM may be considered.
• Not recommended for babies < 28 weeks, due to higher risk of brain bleeding.

Why it matters for HIE:
In situations where quick resuscitation is needed and full DCC isn’t possible, cord milking could help provide that vital placental transfusion—delivering oxygen-rich blood faster.

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💨 Breathing Is the Priority

The updated guidelines reinforce that effective ventilation is the most critical step in newborn resuscitation.

• Ventilate early, effectively, and monitor response—restoring heart rate and oxygen flow to the brain as fast as possible.
• T-piece resuscitators are preferred over self-inflating bags.
• For infants ≥ 34 weeks, a supraglottic airway may be used as an initial interface when appropriate.

Why it matters for HIE:
Every second counts. Rapid, controlled ventilation can make the difference between transient oxygen deprivation and lasting brain injury.

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Page 2: Translating Evidence Into Action

🌡️ Keep the Baby Warm, Not Hot

The first 10 minutes after birth are crucial. Both hypothermia and hyperthermia can worsen outcomes in at-risk babies. Normothermia, or a controlled normal temperature, is important for management of all infants, and especially those at risk of HIE before learning if cooling should be initiated or not.

• Use thermal mattresses, warm towels, and environmental control.
• For babies who later meet criteria for therapeutic hypothermia, cooling should begin under controlled NICU conditions—not during resuscitation.
• Some HIE studies in preemies have shown that normothermia has better outcomes than therapeutic hypothermia in preemies with HIE <36 weeks.

Why it matters for HIE: Temperature is incredibly important, especially for those who may need therapeutic hypothermia, or those who do not qualify due to gestational age, or severity like mild HIE babies.

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🤝 Preparation and Teamwork Save Time

The guidelines emphasize anticipation and preparation—especially when an HIE-risk delivery is expected.

Before delivery:

• Assign team roles and review cord-management plan.
• Confirm resuscitation equipment and temperature control setup.
• Alert neuro and transport teams if cooling may be needed.

During delivery:

• Communicate clearly: “vigorous” vs “non-vigorous” dictates cord strategy.
• Document cord-clamping time, Apgars, and time to ventilation.
• Maintain normothermia and monitor heart rate continuously.

After delivery:

• Ensure timely transition to NICU if HIE is suspected.
• Begin documentation for eligibility for therapeutic hypothermia within the first six hours.
• Support and inform families throughout—communication is part of care.

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🧠 What This Means for Families

These updates highlight what many families and clinicians already know:
The way babies transition at birth matters profoundly for their brains.

For babies at risk of HIE:

• Delayed cord clamping is now standard when feasible.
• Cord milking may help when immediate resuscitation is needed.
• Preparation and teamwork are essential for timely, coordinated care.
• Data collection and follow-up are vital—tracking how these practices impact long-term outcomes.

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Hope for HIE’s Perspective

At Hope for HIE, we advocate for evidence-based, family-centered care from delivery through long-term follow-up. These new guidelines move the field forward—affirming practices that can make real differences for babies at risk of HIE.

We advocate globally for every birth team having the tools, protocols, and partnerships to give these babies the best possible start.

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References:
American Heart Association and American Academy of Pediatrics. 2025 Guidelines for Neonatal Resuscitation. Circulation. 2025;152(Suppl 1):S399–S445.
AAP News: Neonatal Resuscitation Guideline Updates Endorsed by AAP. August 2023.
Heart.org: 2025 AHA/AAP CPR and ECC Guidelines Highlights.