At-a-Glance
Neonatal resuscitation: 2025 updates include higher endotracheal epinephrine dosing while access is obtained, mandate a fixed saline flush, and formally recognize IO access.
Pediatric dosing: Weight-based dosing alone misses key pharmacokinetic differences in infants that affect exposure and response.
Hepatitis B policy: CDC guidance moves away from the universal birth dose for infants of HepB-negative mothers, increasing counseling and follow-up demands.
New & Notable
Updated epinephrine dosing: IV epinephrine remains 0.01–0.03 mg/kg. A higher endotracheal dose of 0.05–0.1 mg/kg is recommended while vascular access is being established.¹
Standardized flush protocol: All intravascular epinephrine doses should be followed by a 3 mL normal saline flush, regardless of weight.¹
Expanded vascular access: Intraosseous access is formally recognized as a reasonable alternative route when umbilical venous catheterization is unsuccessful or not feasible.¹
Refined oxygen tiering: Initial oxygen concentration is stratified by gestational age with titration to preductal saturation targets.¹
Simplified ventilation terminology: Positive-pressure ventilation is replaced with ventilation or assisted ventilation.¹
Major research gaps: There are limited data comparing UVC and IO access and uncertainty around repeat epinephrine timing.¹
Practical implication: IO equipment should be pre-primed and immediately available.¹
Practical implication: Infants receiving epinephrine require early and frequent glucose monitoring.¹
Clinical Pearl
Weight-based dosing alone does not account for developmental pharmacokinetics.Infants have higher total body water, altered protein binding, and immature hepatic and renal function. These differences affect volume of distribution, free drug concentrations, and clearance.
Hydrophilic drugs require higher mg/kg doses to achieve therapeutic levels in the serum. Dosing intervals may need to be longer to account for decreased renal function. Infants are at higher risk of drug toxicity at appropriate doses and serum levels due to immature clearance pathways and low albumin levels.
Pediatric Pulse
CDC Approval of Major Change to Hepatitis B Immunization Schedule
On December 16, 2025, the CDC adopted the Advisory Committee on Immunization Practices’ recommendation to end the universal Hepatitis B birth-dose policy for infants born to mothers who test negative. This shift to individual decision-making permits deferral of the first dose until at least 2 months of age.²
The update rolls back the universal vaccination strategy in place since 1991. The American Academy of Pediatrics has cautioned that this change may increase transmission risk if screening or follow-up fails.³
References
Lee HC, Strand ML, Finan E, et al. Part 5: Neonatal resuscitation: 2025 American Heart Association and American Academy of Pediatrics guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Pediatrics. 2026;157(1):e2025074352.
Centers for Disease Control and Prevention. CDC fact sheet: hepatitis B immunization. Published 2025. Accessed December 23, 2025. https://www.cdc.gov/media/releases/2025/fact-sheet-hepatitis-b-immunization.html
American Academy of Pediatrics. AAP, CDC decision on universal birth dose of hepatitis B vaccine raises concerns. Published 2025. Accessed December 23, 2025. https://publications.aap.org/aapnews/news/33980/AAP-CDC-decision-on-universal-birth-dose-of
-Dr. Su