#373 - NRP 9th Edition Updates ft Dr. Henry Lee

Hello friends 👋

The Incubator Podcast welcomes Dr. Henry Lee, Associate Editor of the Textbook of Neonatal Resuscitation, to discuss the ninth edition of the Neonatal Resuscitation Program (NRP). They review major updates released October 22, 2025, including the extended 60 second delayed cord clamping, new guidance on cord milking, refined oxygen targets, ventilation parameters, and updates to airway management and corrective steps. They also highlight three new educational modules, NRP Cardiac, Resuscitation in the NICU, and Neonatal Education for Prehospital Professionals, emphasizing how these changes support evidence based and effective neonatal care worldwide.

Link to episode on youtube: https://youtu.be/aoCguoVvUZw

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Short Bio: Dr. Henry Lee is Clinical Director of UCSD Neonatology and Medical Director of the UCSD Jacobs Medical Center NICU. Prior to joining the division of neonatology at UCSD / Rady, he was faculty in neonatology at UCSF from 2008 to 2012 and Stanford from 2013 to 2022. Since 2008, he has been a volunteer member of several committees of the California Perinatal Quality Care Collaborative, which seeks to advance quality improvement across California NICUs. One of his clinical and research interests is in neonatal resuscitation, and he currently serves as co-chair of the American Heart Association neonatal guidelines group.

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The transcript of today's episode can be found below 👇

Ben Courchia (00:00.77) Hello, everybody. Welcome back to The Incubator Podcast. We’re back today for a special edition of Journal Club with Dr. Henry Lee. Welcome back to the podcast.

Henry Lee (00:13.969) Thank you so much for having me, Ben. It’s great to be here.

Ben Courchia (00:16.332) It’s a pleasure to chat with you. You’re joining us as Associate Editor of the Textbook of Neonatal Resuscitation, here to discuss the updates released on October 22nd to the Neonatal Resuscitation Program (NRP), now in its ninth edition.

Henry Lee (00:38.769) Yes, I’m excited to talk about that. As a neonatologist working in the NICU and delivery room, resuscitation is such an important part of our role — guiding that transition from fetus to newborn. The ninth edition of NRP represents tremendous work from the NRP Steering Committee and many others. I’m privileged to share some of those updates today.

Ben Courchia (01:15.682) Absolutely. It’s a huge team effort to publish these updates. NRP is one of the few things that truly connects all of us — regardless of where we practice, whether it’s a community or academic hospital.

Henry Lee (01:39.987) Exactly. I was just at a release event in Rotterdam for the International Liaison Committee on Resuscitation (ILCOR) guidelines. Dr. Helen Liley, Chair of the ILCOR Neonatal Resuscitation Group, made a point that resonated with me — the day of birth is the day in a person’s life when they’re most likely to need resuscitation. Many don’t, of course, but the advances in perinatal care from this global work have dramatically reduced perinatal mortality.

Ben Courchia (02:17.528) Wow.

Henry Lee (02:38.993) And that’s the ongoing goal of these groups — to continue improving those outcomes.

Ben Courchia (02:46.262) For people unfamiliar with the process, these updates happen on a schedule, correct? How do you go from one edition to the next?

Henry Lee (03:15.411) That’s right. I’ve had the privilege of participating in three main bodies involved in NRP and resuscitation guideline development. It starts with ILCOR — the International Liaison Committee on Resuscitation — which includes councils from around the world, including the American Heart Association (AHA) for the U.S. The neonatal group reviews evidence, performs systematic reviews and meta-analyses, and answers key clinical questions about neonatal resuscitation. These analyses feed into the AHA and American Academy of Pediatrics (AAP) guideline writing group, which works on a five-year cycle. They incorporate ILCOR evidence and fill remaining gaps to adapt guidance for U.S. and Canadian clinicians. That guideline was published October 22nd, 2025. The NRP Steering Committee then translates those guidelines into the Textbook of Neonatal Resuscitation and the associated educational program, including instructor materials. The ninth edition follows five years after the eighth.

Ben Courchia (06:14.606) That’s great context — and important for people to realize that this work continues between editions. At a high level, what defines this ninth edition?

Henry Lee (07:16.337) The central message remains the same: effective ventilation is the cornerstone of neonatal resuscitation. Everything else builds around that. What’s new is the introduction of the Neonatal Chain of Care. Borrowing from the adult “Chain of Survival,” this neonatal version acknowledges that resuscitation doesn’t occur in isolation — it starts with prevention (through good antenatal care and risk recognition), continues through effective resuscitation, and extends into post-resuscitation care and follow-up. The central link remains ventilation.

Ben Courchia (09:36.984) That makes sense. Let’s talk about preparation and those first moments after birth. The ninth edition places new emphasis on umbilical cord management. There’s now a formal cord management plan, and delayed or deferred cord clamping should last at least 60 seconds — up from 30 seconds. It also includes guidance on umbilical cord milking, particularly for non-vigorous term and late preterm infants (35–42 weeks), while excluding very preterm infants (28–34 weeks) based on Dr. Anup Katheria’s data.

Henry Lee (11:16.851) Exactly. Deferred cord clamping, sometimes called delayed cord clamping, was in the eighth edition but is now reinforced. Increasing evidence shows benefit from at least 60 seconds of clamping delay — and potentially longer — for both term and preterm infants. Cord milking, highlighted in Dr. Katheria’s MINVI trial, may benefit non-vigorous infants between 35–42 weeks. For preterm infants under 28 weeks, it’s not recommended due to potential harm. Between 28–34 weeks, evidence is still evolving. We’ve added new videos in the textbook demonstrating these practices.

Ben Courchia (15:33.254) The 60-second delay is open-ended — do you see that time

extending in the future?

Henry Lee (15:59.771) The recommendation is 60 seconds or more. Meta-analyses suggest even up to 120 seconds may help, especially in some preterm populations, but the logistics can be challenging in extremely preterm deliveries. More research will guide future changes.

Ben Courchia (17:11.788) Delaying cord clamping changes the timing of everything else — for example, the oxygen saturation targets now start at two minutes instead of one.

Henry Lee (18:29.235) Right. The one-minute row was removed from the target oxygen saturation table. During that first minute, teams should focus on deferred cord clamping and the initial steps — warming, drying, stimulating, and clearing the airway if needed. It’s also worth noting that suction has been removed from that initial sequence. The instruction is now “clear airway if needed.” Routine suctioning is no longer recommended unless there’s an obstruction.

Ben Courchia (20:58.936) What about skin-to-skin contact when things look normal?

Henry Lee (21:06.875) If the baby is term, has good tone, and is breathing or crying, skin-to-skin care with the parent is appropriate. Even if not all three criteria are met, it can often still be started with observation.

Ben Courchia (22:39.02) You mentioned ventilation as the foundation. There are changes in how we deliver it, correct?

Henry Lee (23:35.739) Yes. The initial oxygen concentration now varies by gestational age:- ≥35 weeks: start with 21% (room air)- 32–34 weeks: start with 21–30%- <32 weeks: consider >30% This reflects evidence that very preterm infants (<32 weeks) may benefit from slightly higher initial oxygen concentrations. Still, the emphasis is on titrating oxygen using pulse oximetry to target saturations — not on a fixed starting level.

Ben Courchia (27:09.742) And there are changes in ventilation rate and pressures too.

Henry Lee (28:08.307) Yes. The recommended ventilation rate is now 30–60 breaths per minute (previously 40–60). The initial peak inspiratory pressure (PIP) is standardized at 25 cm H₂O, though 20–25 is appropriate for preterm and 25–30 for term infants.

Ben Courchia (30:03.99) I love the new flexibility in corrective steps. Instead of following MR. SOPA rigidly, clinicians can prioritize the step most likely to help.

Henry Lee (31:01.361) Exactly. MR. SOPA (Mask adjustment, Reposition airway, Suction, Open mouth, Pressure increase, Alternate airway) remains a helpful mnemonic, but now the guidance allows clinicians to apply the most appropriate corrective step based on the clinical situation rather than strictly following sequence.

Ben Courchia (32:12.29) And for airway management, the endotracheal tube sizing table has been refined.

Henry Lee (33:14.673) Correct. There are now four categories instead of three:- <800 g (≤25 weeks): 2.5 mm, consider 2.0 mm if available- 800–1,200 g (26–28 weeks): 2.5 mm- 1,200–2,200 g (29–34 weeks): 3.0 mm- >2,200 g (>34 weeks): 3.5 mm or larger Wall charts and pocket cards will help with these cutoffs.

Ben Courchia (34:11.406) Before we wrap up — there are also new optional courses accompanying the ninth edition, correct?

Henry Lee (34:41.883) Yes. Three new modules:1. NRP Cardiac — focuses on initial management of newborns with critical congenital heart disease (CCHD).2. Resuscitation in the NICU — guidance for applying NRP principles to older infants within the NICU setting.3. Neonatal Education for Prehospital Professionals — for EMS teams who may deliver or care for newborns in the field (expected early 2026).

Ben Courchia (38:52.554) These updates were released October 22, 2025. Congratulations to you and the entire NRP and ILCOR teams for integrating new evidence into practice.

Henry Lee (39:33.299) Thank you, Ben. There’s a lot of new content in the textbook and videos, especially for instructors. The feedback from across the country has really improved the program.

Ben Courchia (40:26.976) The new textbook and cards are already available on the AAP website — go get your copy!

Ben Courchia (40:42.882) Thank you, Henry.

Henry Lee (40:45.159) Thanks, Ben.