Neonatal Resuscitation Question: Persistent Heart Rate Around 80 bpm Despite Effective Ventilation

In neonatal resuscitation, it seems possible to get stuck in a decision loop, and I am wondering whether NRP offers any explicit guidance for this scenario.Consider a freshly delivered neonate who is breathing but has a persistent heart rate of approximately 80 bpm. The infant is receiving oxygenated positive-pressure ventilation, which appears effective, yet there is no improvement in heart rate after repeated 30-second reassessments. The infant continues to appear clinically unwell.Following the algorithm strictly, progression to chest compressions does not occur because the heart rate remains above 60 bpm. However, 80 bpm is clearly abnormal for a term newborn, and after several ventilation cycles it can feel uncomfortable to continue without escalation. My instinct in this situation would be to consider starting compressions, particularly if the overall clinical picture is deteriorating.Does NRP provide any guidance for exiting this loop, or is management primarily based on the global clinical picture and provider judgment?

Current Neonatal Resuscitation Program guidance does not recommend initiating chest compressions in this scenario. The threshold for compressions remains a heart rate persistently below 60 bpm despite effective ventilation, and this cutoff is deliberate and physiologically based (Lee et al., 2025; Hammer et al., 2021).

In neonates with a heart rate between 60 and 100 bpm, bradycardia is most commonly the result of inadequate oxygenation or ventilation rather than primary cardiac dysfunction. For this reason, NRP emphasizes ventilation as the single most important intervention during neonatal resuscitation, with compressions reserved only for severe bradycardia refractory to effective ventilation (Lee et al., 2025).

External chest compressions in newborns generate substantially less cardiac output than native myocardial contraction when an organized rhythm is present. When intrinsic heart rate remains above 60 bpm, compressions may interfere with native cardiac output without providing meaningful hemodynamic benefit, which is why this threshold is treated as a hard cutoff rather than a flexible range (Binkhorst et al., 2025).

When heart rate fails to improve despite apparently adequate ventilation, recommended management focuses on reassessing ventilation quality and identifying contributing factors rather than escalating to compressions. This includes ensuring adequate tidal volume delivery, correcting mask leak or airway obstruction, considering advanced airway placement, and addressing physiological confounders such as hypothermia, hypoglycemia, acidosis, or delayed pulmonary transition. Guidance documents acknowledge that hospitalized and newly born neonates may not always follow a linear algorithm, but escalation beyond established thresholds should remain grounded in neonatal physiology rather than discomfort with prolonged ventilation alone (Sawyer et al., 2023).

In short, NRP does not provide an “exit” from this loop via chest compressions. Continued optimization of ventilation and correction of reversible causes is the recommended path until the heart rate either improves or falls below 60 bpm, at which point compressions clearly confer benefit and are indicated (Lee et al., 2025; Hammer et al., 2021).

References

Binkhorst, M., van Elsäcker, E., Matthijsse, R. P., et al. (2025). Threshold to initiate chest compressions for bradycardia at birth: A narrative review. Journal of Perinatology: Official Journal of the California Perinatal Association.

Hammer, N. C., Koch, J. J., & Hopkins, H. C. (2021). Neonatal resuscitation: Updated guidelines from the American Heart Association. American Family Physician.

Lee, H. C., Strand, M. L., Finan, E., et al. (2025). Part 5: Neonatal resuscitation: 2025 American Heart Association and American Academy of Pediatrics guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation.

Sawyer, T., McBride, M. E., Ades, A., et al. (2023). Considerations on the use of neonatal and pediatric resuscitation guidelines for hospitalized neonates and infants: On behalf of the American Heart Association Emergency Cardiovascular Care Committee and the American Academy of Pediatrics. Pediatrics.