Intact Survival in Extremely Low Birth Weight Infants After Delivery Room Resuscitation Neil N. Finer, MD; Thomas Tarin, BS; Yvonne E. Vaucher, MD, MPH; Keith Barrington, MB, ChB, MRCP, FRCP; and Raul Bejar, MD ABSTRACT. Objective. None of the 20 previously re- ported infants weighing <750 g at birth who received cardiopulmonary resuscitation (CPR) in the delivery room (DR) survived. To clarify whether such resuscita- tion is futile in our center, we evaluated our experience with DR-CPR over a 4-year period. Study Design. We retrospectively reviewed the out- comes of all inborn infants with birth weights <1000 g at University of California, San Digeo Medical Center from January 1993 to December 1996. Surviving infants and matched control infants were followed for <40 months’ adjusted age using standardized neurodevelopmental as- sessments. Results. Of the infants with birth weight <1000 g born during this period, 29% (51/177) died, including 44% of those <750 g and 16% of those >750 g. Overall, 19 infants received DR-CPR, of whom 12 were <750 g. Of the infants who received DR-CPR, 79% (15/19) survived, including 10 of 13 infants <750 g and 5 of 6 infants >750 g. Of the 15 survivors, 10 were followed beyond 10 months’ adjusted age (median: 28 months). At last exam- ination, 70% were both neurologically and developmen- tally normal. Two infants had cerebral palsy with mild cognitive and severe motor developmental delay. Of 7 infants with birth weight <750 g, 6 had normal neurode- velopmental outcomes. The mean composite mental and motor scores of DR-CPR survivors were 93  10 and 89  25, respectively. No differences were found in neurologic or developmental outcome between DR-CPR survivors and control infants matched for gestational age, sex, and year of birth. Conclusions. Our results indicate that intact survival is possible for infants weighing <750 g at birth after DR-CPR. Pediatrics 1999;104(4). URL: http://www. pediatrics.org/cgi/content/full/104/4/e40; infant, prema- ture, cardiopulmonary resuscitation, neurodevelopment, survival, extremely low birth weight. ABBREVIATIONS. ELBW, extremely low birth weight; DR-CPR, delivery room cardiopulmonary resuscitation; DR, delivery room; IVH, intraventricular hemorrage; UCSD, University of California, San Diego; AA, adjusted age; NS, not significant. A ccording to American Academy of Pediatrics guidelines, cardiac compressions and intra- tracheal or intravenous epinephrine are indi- cated for neonatal resuscitation when severe brady- cardia does not resolve with effective positive pressure ventilation and 100% oxygen or when the infant is born with no heart rate. 1 However, there are no specific recommendations regarding the use of such resuscitative efforts for extremely low birth weight (ELBW) or extremely immature infants. No intact survivors have been described in pub- lished literature to date for infants with birth weight 750 g or 28 weeks’ gestation who received delivery room cardiopulmonary resuscitation (DR-CPR). 2–6 Despite these observations, current clinical practice includes DR-CPR for ELBW infants. To determine whether ELBW infants survive DR-CPR without sig- nificant neurodevelopmental abnormality, we re- viewed the neonatal and early childhood outcomes of ELBW infants born over a 4-year period in our institution who received CPR including epinephrine and/or chest compressions in the delivery room (DR). METHODS A retrospective chart review was conducted for all inborn infants with birth weight 1000 g from January 1993 through December 1996. Information was obtained regarding the DR-CPR, Apgar scores at 1 and 5 minutes, evidence of neonatal central nervous system injury, survival to discharge, and neurodevelop- mental follow-up. Infants with lethal congenital malformations or 23 weeks’ gestational age were excluded. Gestational age, re- corded as completed weeks, was determined from menstrual dates confirmed by early obstetrical ultrasound. If obstetrical ul- trasound confirmation was unavailable, gestational age was de- termined using the clinical estimate of the attending neonatologist that was recorded on admission. Infants were considered to have received CPR if chest compres- sions and/or intratracheal or intravenous epinephrine were used in the DR for resuscitation. Neonatal central nervous system abnormalities, identified by echoencephalography, included intraventricular hemorrhage (IVH) (grades 0 – 4), 7 ventricular dilatation (mild: 10 –11.9 mm, moderate: 12.0 –14.9 mm, and large: 15 mm), 8 and echolucencies (small/large). White matter injury was defined as the presence of grade 4 hemorrhage, echolucencies, or ventricular dilatation un- related to hemorrhage. DR-CPR survivors were enrolled at discharge in the University of California, San Diego (UCSD) Infant Special Care Follow-Up Program and were followed longitudinally from 4 to 40 months’ adjusted age (AA). Each DR-CPR survivor followed for 10 months’ AA was matched for gestational age, sex, and year of birth with a control infant who had not received CPR at any time before discharge from UCSD and also was enrolled in the Infant Special Care Follow-Up Program and followed for 10 months’ AA. Neurodevelopmental assessments included the Amiel-Tison From the Division of Neonatology, Department of Pediatrics, University of California, San Diego, California. This paper was presented in part at the Western Society for Pediatric Research; February 7, 1998; Carmel, CA; and the Society for Pediatric Research; May 2, 1998; New Orleans, LA. Received for publication Jul 30, 1998; accepted Apr 26, 1999. Reprint requests to (Y.E.V.) UCSD Medical Center, Division of Neonatol- ogy, 200 W Arbor Dr, 8774, San Diego, CA 92103-8774. E-mail: yvaucher@ ucsd.edu PEDIATRICS (ISSN 0031 4005). 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