Vol.:(0123456789) Pediatric Drugs (2018) 20:417–428 https://doi.org/10.1007/s40272-018-0300-6 REVIEW ARTICLE Current Challenges in Neonatal Resuscitation: What is the Role of Adrenaline? Roberto Antonucci 1  · Luca Antonucci 2  · Cristian Locci 1  · Annalisa Porcella 3  · Laura Cuzzolin 4 Published online: 19 June 2018 © Springer International Publishing AG, part of Springer Nature 2018 Abstract Adrenaline, also known as epinephrine, is a hormone, neurotransmitter, and medication. It is the best established drug in neonatal resuscitation, but only weak evidence supports current recommendations for its use. Furthermore, the available evidence is partly based on extrapolations from adult studies, and this introduces further uncertainty, especially when con- sidering the unique physiological characteristics of newly born infants. The timing, dose, and route of administration of adrenaline are still debated, even though this medication has been used in neonatal resuscitation for a long time. According to the most recent Neonatal Resuscitation Guidelines from the American Heart Association, adrenaline use is indicated when the heart rate remains < 60 beats per minute despite the establishment of adequate ventilation with 100% oxygen and chest compressions. The aforementioned guidelines recommend intravenous administration (via an umbilical venous catheter) of adrenaline at a dose of 0.01–0.03 mg/kg (1:10,000 concentration). Endotracheal administration of a higher dose (0.05–0.1 mg/ kg) may be considered while venous access is being obtained, even if supportive data for endotracheal adrenaline are lack- ing. The safety and efcacy of intraosseous administration of adrenaline remain to be investigated. This article reviews the evidence on the circulatory efects and tolerability of adrenaline in the newborn, discusses literature data on adrenaline use in neonatal cardiopulmonary resuscitation, and describes international recommendations and outcome data regarding the use of this medication during neonatal resuscitation. Key Points Nearly 1% of newborns require extensive resuscitative measures and adrenaline is the only medication recom- mended in delivery room neonatal cardiopulmonary resuscitation. Recommendations about timing, appropriate dose, and route of administration of adrenaline are usually extrapo- lated from animal and adult studies; therefore, only weak evidence supports its use. The administration of adrenaline during neonatal resus- citation is associated with a high mortality rate and poor neurodevelopmental outcomes, even if a causal relation- ship between adrenaline use and outcomes cannot be established based on available data. At present, signifcant knowledge gaps remain, suggest- ing the need for gestational-age-specifc clinical studies to optimize the management of this medication and to investigate its safety profle. * Roberto Antonucci rantonucci@uniss.it 1 Pediatric Clinic, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy 2 Academic Department of Pediatrics, Children’s Hospital Bambino Gesù, University of Rome “Tor Vergata”, Rome, Italy 3 Division of Neonatology and Pediatrics, “Nostra Signora di Bonaria” Hospital, San Gavino Monreale, Italy 4 Department of Diagnostics and Public Health, Section of Pharmacology, University of Verona, Verona, Italy