Published online February 1, 2006
PEDIATRICS
Vol. 117
No. 2
February 2006, pp.
e164-e175
(doi:10.1542/peds.2005-0936)
A Survey of Delivery Room Resuscitation Practices in the United States
Tina A. Leone, MD,
Wade Rich, RRT and
Neil N. Finer, MD
Department of Pediatrics, Division of Neonatology, University of California, San Diego, San Diego, California
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ABSTRACT
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Objective. To determine current resuscitation practices of neonatologists in the United States.
METHODS. A 15-question survey was developed and mailed to neonatal directors in May 2004.
ELRESULTS. Of the total of 797 surveys mailed, 84 were returned undeliverable or unanswered and 450 were returned completed (63% response rate). Respondents were mainly (70%) from level III NICUs. Most programs resuscitate newborns in the delivery room (83%), rather than in a separate room. The number and background of individuals attending deliveries vary greatly, with 31% of programs having <3 individuals attending deliveries. Flow-inflating bags are most commonly used (51%), followed by self-inflating bags (40%) and T-piece resuscitators (14%). Pulse oximeters are used during resuscitation by 52% of programs, and 23% of respondents indicated that there was a useful signal within 1 minute after application. Blenders are available for 42% of programs, of which 77% use pure oxygen for the initial resuscitation and 68% use oximeters to alter the fraction of inspired oxygen. Thirty-two percent of programs use carbon dioxide detectors to confirm intubation, 48% routinely and 43% when there is difficulty confirming intubation. Preterm infants are wrapped with plastic wrap to prevent heat loss in 29% of programs, of which 77% dry the infant before wrap application. A majority of programs (76%) attempt to provide continuous positive airway pressure or positive end expiratory pressure (PEEP) during resuscitation, most commonly with a flow-inflating bag (58%), followed by a self-inflating bag with PEEP valve (19%) and T-piece resuscitator (16%). A level of 5 cm H2O is used by 55% of programs.
CONCLUSIONS. Substantial variations exist in neonatal resuscitation practices, some of which are not addressed in standard guidelines. Future guidelines should include recommendations regarding the use of blenders, oximeters, continuous positive airway pressure/PEEP, and plastic wrap during resuscitation.
Key Words: neonatal resuscitation • survey • practice variation • delivery room
Abbreviations: NRP—Neonatal Resuscitation Program • PEEP—positive end expiratory pressure • CPAP—continuous positive airway pressure • PPV—positive pressure ventilation • ELBW—extremely low birth weight
Attempts to revive depressed newborns immediately after birth have been made for hundreds of years. Dr James Blundell's description of the resuscitation of a "still-born" infant in 1834 is remarkably similar to procedures practiced currently, including evaluating the chord pulsations and attempting artificial respirations with a "tracheal pipe."1 The procedures involved in neonatal resuscitation have been organized into a sequential process of evaluation and interventions. With the help of the American Heart Association and the American Academy of Pediatrics, the Neonatal Resuscitation Program (NRP) was devised as a method of teaching large numbers of providers this organized process of neonatal resuscitation. The manual, printed originally in 1987 and now in its fourth edition, has been revised through discussions with experts in the field and consideration of available evidence. The program has been taught to >1.5 million providers and is used by many as a clinical guideline.2
A number of randomized trials have compared the use of room air versus 100% oxygen for initial neonatal resuscitation,3,4 and there is increasing interest in the use of continuous positive airway pressure (CPAP) starting at birth for extremely low birth weight (ELBW) infants. In addition, advancements in technology, including improved pulse oximetry, small, colorimetric, carbon dioxide detectors, and a variety of devices for providing positive pressure ventilation (PPV), have become available in recent years. Many of these practices are not discussed in the current resuscitation guidelines. To define current neonatal resuscitation practices, we surveyed neonatal directors throughout the United States.
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METHODS
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A survey was developed to address delivery room resuscitation practices and to determine the extent of variation or consistency that exists in neonatal programs in the United States. The survey consisted of 15 questions regarding the level of care, areas where infants are resuscitated, types of PPV used during resuscitation and transport, individuals attending deliveries, use of blended oxygen, pulse oximeters, and monitors, use of plastic wrap for ELBW infants, use of carbon dioxide detectors for intubation, and use of CPAP or positive end expiratory pressure (PEEP) during resuscitation (Appendix). The survey was mailed to all neonatal directors listed in the 2002 American Academy of Pediatrics directory of neonatologists/perinatologists in the United States. A second mailing was sent to nonrespondents 6 to 8 weeks after the initial mailing.
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RESULTS
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Surveys were mailed to 797 neonatal directors in the United States in May 2004. A total of 450 surveys (response rate: 63%) were completed and returned after the 2 mailings, plus 84 returned as undeliverable or unanswered; of those, 5 were from hospitals that did not have a delivery service. In a review of the responses, it was determined that 6 hospitals were represented by >1 survey response. These duplicate responses were not included in the results. Respondents were from all 50 states. Most respondents (314 respondents, 70%) were from level III, community, or regional NICUs. Another 63 respondents (14%) were from level IV or extracorporeal membrane oxygenation centers.
Most programs (374 programs, 83%) resuscitate newborns in the delivery room. The remaining programs resuscitate newborns in a room near the delivery room (75 programs, 17%) or in the NICU (30 programs, 7%). Usual resuscitation teams are composed of <3 individuals in 31% of programs. Team members may include neonatal attending physicians in 366 programs, fellows in 80 programs, attending pediatricians in 36 programs, pediatric residents in 177 programs, neonatal nurse practitioners in 214 programs, neonatal nurses in 400 programs, and respiratory therapists in 299 programs.
Oxygen blenders are available in the delivery room in 189 programs (42%). Among programs with blenders available, 146 (77%) initiate resuscitation with a fraction of inspired oxygen of 1.0. The decision to vary oxygen levels is made with the help of pulse oximetry in 129 programs (68%) with blenders. The remaining programs with blenders use color or other clinical signs to adjust the fraction of inspired oxygen. Among all responding programs, pulse oximeters are available in the delivery room in 233 programs (52%). Among programs using oximeters, 53 (23%) reported that the oximeters are applied and functioning within the first 1 minute of life in most cases. Respondents reported the use of other types of monitors, such as heart rate or temperature monitors, in the delivery room in 274 programs (61%).
PPV is provided in the resuscitation area with flow-inflating bags in 231 programs (51%), self-inflating bags in 178 programs (40%), and T-piece resuscitators in 63 programs (14%). When infants are being transported from the resuscitation area to the NICU, devices used to provide PPV include flow-inflating bags in 198 programs (44%), self-inflating bags in 144 programs (32%), transport ventilators in 110 programs (24%), and T-piece resuscitators in 49 programs (11%). More than 1 device is used to provide PPV in the resuscitation area in 30 programs (7%) and during transport to the NICU in 71 programs (16%).
CPAP or PEEP is used in the delivery room in 342 programs (76%). Devices used to provide CPAP or PEEP in the delivery room include flow-inflating bags (198 programs, 58%), self-inflating bags with PEEP valves (88 programs, 25%), T-piece resuscitators (66 programs, 19%), ventilators (46 programs, 13%), and other devices (26 programs, 7%). More than 1 device is used in 65 programs that provide CPAP or PEEP in the delivery room. The level of CPAP used is 5 cm H2O in 191 programs (56%), 4 cm H2O in 49 programs (14%), 6 cm H2O in 47 programs (14%), and 7 cm H2O in 2 programs (0.5%). Criteria for providing CPAP/PEEP are delivery to all infants requiring PPV in 214 programs (63%), to all preterm infants of <1500 g in 66 programs (19%), and to select infants in 95 programs (27%).
A carbon dioxide detector is used to confirm intubation in 145 programs (32%), of which 136 programs use a qualitative carbon dioxide detector (eg, Pedicap [Nellcor Puritan Bennett, Pleasanton, CA]) and 9 programs use a quantitative carbon dioxide detector (eg, end-tidal carbon dioxide detector). Of programs using carbon dioxide detectors, 69 (48%) use the device for every intubation and 63 (43%) use the device when there is difficulty determining successful intubation.
ELBW infants are wrapped in plastic to prevent heat loss in 129 programs (29%). When plastic wrap is used for ELBW infants, it is applied after the infant is dried in 99 programs (77%).
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DISCUSSION
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This survey of neonatal directors in the United States is, to our knowledge, the largest survey of delivery room resuscitation practices available. Because we solicited responses from directors, the actual practices of individual providers may not be represented. However, much of the information obtained in this survey is related to available equipment and intent to use different practices. The results of this survey are most reflective of practices in advanced-level neonatal units; 84% of our responses were from level III or IV units. Therefore, the survey is less representative of resuscitation practices in level I and level II units. We are reporting the level of unit that was indicated by the respondents on the survey forms. According to the directory used to identify directors, 85% of the units included were considered at least level III (subspecialty care including the designations IIIA–IIID) or were listed as a freestanding children's hospital. Therefore, the response rate among levels does not seem to be different. Since the mailing of our survey, an American Academy of Pediatrics policy statement from the Committee on Fetus and Newborn provided new recommendations for levels of neonatal care. Therefore, what was labeled as level IV (extracorporeal membrane oxygenation) on our survey would now be called level IIIC.5
There is a lack of uniformity in the numbers of individuals who attend deliveries, as well as the composition of the team. The NRP manual states that there should be a minimum of 2 resuscitators attending every delivery. In our own experience, the tasks involved in a complicated resuscitation, including airway management, suctioning, heart rate monitoring, and oxygen saturation monitoring, are performed more easily with a minimum of 3 individuals. We asked participants to indicate the number and discipline of members of their "usual resuscitation team." It was of interest that 31% of programs have usual teams composed of 2 individuals. We received a number of comments indicating that institutions select the team, size, and composition on the basis of the expected problems at delivery. In fact, it is probably frequent practice that the number of team members and the team composition are determined by the specific circumstances of the delivery.
Providing adequate thermoregulation for preterm infants is especially important. The EPICure study showed that admission temperatures of 
35°C among infants of <26 weeks' gestation were associated with increased mortality rates.6 The occurrence of hypothermia (admission temperature of 35°C) in that study was 29.6% among infants born at 25 weeks, 42.7% among infants born at 24 weeks, and 58.3% among infants born at 23 weeks. At least 2 prospective randomized trials reported the benefit of polyethylene wrap for preventing heat loss among ELBW infants.7,8 In those studies, the resuscitators dried the infants' head and placed the polyethylene wrap over the body without drying, and they found an improvement in admission temperatures for infants of <28 weeks' gestation. Direct application of the wrap without drying reduces evaporative and convective heat losses.9 Additional measures to improve infant admission temperatures may include elevation of the temperature of the room, use of a preheated radiant warmer, and, in our own experience, use of servo-controlled probes to prevent the radiant warmer from shutting down after 15 minutes of non–servo-controlled operation.10 Although more studies are needed to determine the short- and long-term benefits of the use of occlusive wrap, the data available at the present time suggest that this is a relatively simple intervention that can prevent heat loss among ELBW infants.
Although there have been studies evaluating the use of pulse oximetry during neonatal resuscitation,11,12 there have been no prospective randomized trials comparing resuscitation with and without pulse oximetry. However, all infants with any form of distress are monitored continuously with pulse oximetry after admission to a NICU. Pulse oximeters not only provide information about oxygen saturation but also provide a continuous audible heart rate signal, allowing all team members to perform other tasks. In 1993, the American Association for Respiratory Care made a recommendation that pulse oximetry should be available for neonatal resuscitation.13 Of our survey respondents who use pulse oximeters, 23% indicated that they had useful readings within 1 minute. Although the onset of functionality may be variable, oximeters remain useful for monitoring the subsequent care of infants and are essential if clinicians wish to use a blender and to provide <100% oxygen. In the delivery room, the ideal pulse oximeter should be set to its lowest averaging time and highest sensitivity; one manufacturer has developed a probe that adjusts the oximeter to these settings automatically (LNOP Hi-Fi Trauma; Masimo Corp, Irvine, CA).
Although the current NRP recommendation is to resuscitate infants with 100% oxygen, increasing information suggests that room air may be as efficacious, especially for near-term and term infants, and may be associated with lower mortality rates.3,4 Almost all of these trials excluded infants of <1000 g; therefore, more information is required for very preterm infants. A compressed air source and a blender are required to deliver ranges of oxygen between 21% and 100%. When blenders and a compressed air source are available, teams can use pulse oximeters to adjust the amount of oxygen delivered to an appropriate level for the condition of the infant. Our experience in evaluating neonatal resuscitation suggests that infants spend far more time in the resuscitation area than is anticipated, and the use of blenders and oximeters in such circumstances can reduce unnecessary exposure to excessive oxygen levels, with associated toxicity.
For the delivery of positive pressure breaths, 51% of programs use flow-inflating bags and 40% use self-inflating bags. More than 1 device is available for resuscitation in 30 programs (7%). Although the current edition of the NRP guidelines does not mention the use of a T-piece resuscitator, 14% of programs surveyed use such a device. In an international survey of resuscitation practices, O'Donnell et al14 determined that a T-piece resuscitator was used in 30% of centers. In that survey, a self-inflating resuscitator was used most frequently, possibly reflecting the World Health Organization guidelines15 and the lack of an available gas source in some areas.
We have performed 2 mannequin-based evaluations of neonatal resuscitation devices, comparing flow-inflating bags, T-piece resuscitators, and, most recently, self-inflating bags.16,17 Our observations from these studies indicated that the T-piece resuscitator delivers the desired pressures most consistently and that both T-piece resuscitators and flow-inflating bags are capable of delivering end expiratory pressure as well as prolonged inflations. Self-inflating bags have a greater tendency to permit excessive pressures. Previous observations confirm that the T-piece resuscitator delivers desired pressures more consistently and may be easier to use for a variety of operators.18 To date, there has been no prospective study actively comparing any of these 3 types of devices in actual human resuscitations, and we think that such a study is necessary.
All infants who require assisted ventilation receive PEEP during mechanical ventilation, and numerous infants are treated for respiratory distress with various forms of CPAP. No current recommendation exists for the use of CPAP or PEEP in the delivery room, and there have been no prospective studies evaluating the efficacy of CPAP or PEEP in this environment. Many animal studies have demonstrated that CPAP/PEEP helps establish and maintain functional residual capacity, improve surfactant function, and reduce signs of lung injury.19–22 The severity of respiratory distress syndrome has correlated with the functional residual capacity at birth.23 In a previous survey, we determined that >70% of neonatologists used CPAP,24 and the current survey demonstrated that 76% of programs attempt to deliver CPAP/PEEP. This survey did not distinguish specifically between the use of CPAP and PEEP. It is apparent that CPAP and PEEP are used frequently during neonatal resuscitation and that future resuscitation guidelines need to discuss the appropriate role of CPAP and PEEP during resuscitation. Although our findings indicate that 56% of respondents target a pressure of 5 cm H2O, the optimal level of CPAP has not been determined and requires additional research.
Current NRP guidelines recommend the use of a carbon dioxide detector if there is any doubt about the placement of an endotracheal tube. Our survey revealed that 32% of programs use carbon dioxide detectors for confirmation of intubation. Interestingly, only 48% of programs that use carbon dioxide detectors do so routinely for every intubation. Previous studies by Repetto et al25 and Aziz et al26 demonstrated clearly that the use of carbon dioxide detectors reduces the amount of time required to determine that an endotracheal tube is in an incorrect location.
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CONCLUSIONS
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We think that the results of this survey will be useful in developing future revisions of the guidelines for neonatal resuscitation. Discussions within the guidelines should include all types of resuscitation devices currently being used, the role of blenders and pulse oximeters during resuscitation, and the use of plastic occlusive wrap for the prevention of heat loss among ELBW infants. We hope that this survey will help define areas where there is lack of uniformity and encourage the performance of prospective evaluations, so that future recommendations can be evidence based.
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ACKNOWLEDGMENTS
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We thank the following individuals, as well as those who chose not to be recognized, for taking the time to respond thoughtfully to the survey: Roy F. Davis, PhD, MD, Children's Hospital of Providence; Martha J. Strange, MD, Brookwood Medical Center; Waldemar A. Carlo, MD, University of Alabama at Birmingham; Fabian G. Eyal, MD, University of South Alabama; Guillermo Godoy, MD, Druid City Hospital Regional Medical Center; Robert W. Arrington, MD, University of Arkansas Medical Sciences, Arkansas Children's Hospital; R. Whit Hall, MD, University Hospital of Arkansas; John R. Steenbarger, MD, Flagstaff Medical Center; Mark L. Shwer, MD, Banner Thunderbird Hospital; Glenn W. Waterkotte, MD, Banner Desert Medical Center; David C. Hall, MD, St Joseph's Hospital Medical Center; Dariush Mehrabani, MD, St Joseph's Hospital Tucson; Allen Erenberg, MD, University of Arizona; S. K. Bosu, MD, Kaiser Foundation Hospital-Anaheim; Madhu R. Bhogal, MD, Bakersfield Memorial Hospital; Sudhir B. Patel, MD, Kern Medical Center; Asif J. Ahmad, MD, Kaiser Permanente Medical Center-Baldwin Park; Ann Marie Morris, MD, Kaiser Permanente Medical Center-Bellflower; Dick Powers, MD, Gilbert Duritz, MD, Alta Bates Medical Center; Paul Hinkes, MD, Providence St Joseph Medical Center; V. G. Muraligopal, MD, Arrowhead Regional Medical Center; Vallop Kanjanapone, MD, El Centro Regional Medical Center; David J. Golembeski, MD, Palomar Pomerado Health System; Asha N. Parikh, MD, Kaiser Foundation Hospital-Fontana; Veeraiah Chundu, MD, Fountain Valley Regional Hospital and Medical Center; Jagdish S. Bhatt, MD, Orange Coast Memorial Medical Center; John Madden, MD, St Jude Medical Center; Bruce M. Smith, MD, South California Permanente Medical Group-Harbor City; Jocelyn A. Alcantara, MD, Kaiser Permanente Medical Center-Hayward; Nalini Brahmbhatt, MD, Centinela Hospital Medical Center; Ronald Naglie, MD, Saddleback Memorial Medical Center; Murugesa Thangavel, MD, Antelope Valley Hospital; Andrew Hopper, MD, Loma Linda University School of Medicine Hospital; Arthus A. Strauss, MD, Long Beach Memorial Medical Center; Jose M. Perez, MD, St Mary Medical Center; Charles F. Simmons, MD, Cedars-Sinai Medical Center; John B. D'Ambola, MD, Kaiser Foundation Hospital, West Los Angeles; A. S. Moosa, MD, St Francis Medical Center; Nadarasa Vishveshwara, MD, Valley Children's Hospital; Joanne Collins, RCP, Frederick Murphy, MD, Memorial Medical Center; Sumitra Kommareddy, Beverly Hospital; Marian Adams, MD, El Camino Hospital; Leon Kelley, MD, Paradise Valley Hospital; Lawrence Wickham, MD, Hoag Memorial Hospital Presbyterian; Barry Halpern, MD, Northridge Hospital Medical Center; Arthur D'Harlingue, MD, Summit Medical Center; Philip V. Marinelli, DO, Tri-City Medical Center; Robert L. Hillyard, MD, St Joseph's Hospital, Children's Hospital of Orange County; Jack Sills, MD, University of California, Irvine Medical Center; James B. Schick, MD, St John's Regional Medical Center; Krisa Van Meurs, MD, Stanford University, Lucile Salter Packard Children's Hospital; Ricardo Liberman, MD, Huntington Memorial Hospital; Craig Traugott, MD, Mercy Medical Center, Redding; Allan Wolpe, MD, Redlands Community Hospital; Pradip K. Shah, MD, Kaiser Permanente Medical Center-Riverside; Mark L. Ziegler, MD, Kaiser Permanente Medical Center at Sacramento and Santa Sacramento; Andrew W. Wertz, MD, Sutter Medical Center Sacramento; Michael P. Sherman, MD, University of California, Davis Medical Center; Jana Kohler, cNNP, CNS, Natividad Medical Center; V. G. Muraligopal, MD, San Bernadino Medical Center; Martin McCaffrey, MD, Naval Medical Center San Diego; Steven L. Goldman, MD, California Pacific Medical Center; Susan Sniderman, MD, San Francisco General Hospital Medical Center; Edward C. Alderete, MD, Good Samaritan Hospital; W. James Silva, MD, Regional Medical Center of San Jose; Ronald S. Cohen, MD, Santa Clara Valley Medical Center; Karen Loftus, CNS, Katrina Tesmer, MD, Western Medical Center; Stephen Fernbach, MD, Kaiser Permanente Medical Center-Santa Clara; Magdy Ismail, MD, Dominican Santa Cruz Hospital; Maria Pierce, MD, Santa Rosa Children's Hospital; Harry Ackley, MD, Sutter Medical Center of Santa Rosa; Aaron Simko, MD, Dameron Hospital; Jeffrey A. Lindenberg, MD, San Joaquin General Hospital; Maureen Sims, MD, Olive View-University of California, Los Angeles Medical Center; Donna Wolpe, RCP, Encino/Tarzana Regional Medical Center; Michael Mah, MD, Los Robles Regional Medical Center; Jon Yamamoto, MD, Little Company of Mary Hospital; Jerry Schwartz, MD, Torrance Memorial Medical Center; Siamak Safar, MD, Ventura County Medical Center; Charles B. Scott, MD, John Muir Medical Center; Allen F. Fischer, MD, Kaiser Foundation Hospital Walnut Creek; Gilbert Martin, MD, Citrus Valley Medical Center-Queen of the Valley Campus; Frederick Shum, MD, Presbyterian Intercommunity Hospital; Thomas J. Sherry, MD, Kaiser Permanente Medical Center-Woodland Hills; Edward McNamara, MD, Watsonville Community Hospital; Barbara Quissell, MD, Presbyterian-St Luke's Medical Center; Mark S. Brown, MD, Medical Center of Aurora; Daniel Hall, MD, Children's Hospital; Delphine M. Eichorst, MD, Presbyterian-St Luke's Medical Center; Joe V. Toney, MD, Sky Ridge Medical Center; Alfonso F. Pantoja, MD, Exempla St Joseph Hospital; Adam Rosenberg, MD, University of Colorado Health Sciences Center; Ann B. Olewnik, MD, St Mary's Hospital; Beverly Anderson, MD, North Suburban Medical Center; S. N. Theofanidis, MD, Greenwich Hosital; Victor C. Herson, MD, Connecticut Children's Medical Center; Hema N. De Silva, MD, St Francis Hospital and Medical Center; A. M. Capriglione, MD, New Britain General Hospital; Richard A. Ehrenkranz, MD, Yale New Haven Children's Hospital; Mitchell J. Kresch, MD, Norwalk Hospital; Gerald B. Rakos, MD, Stamford Hospital; Siva Subramanian, MD, Georgetown University Hospital; Maria P. Ruiz, MD, Providence Hospital; Zacharia Cherian, MD, Washington Hospital Center; Michael J. Antunes, MD, Kent General Hospital; John L. Stefano, MD, Christiana Hospital; Antonio E. Pena, MD, Bethesda Memorial Hospital; Mary T. Newport, MD, Spring Hill Regional Hospital; Deogracias L. Caangay, MD, Healthpark Medical Center; David J. Burchfield, MD, University of Florida; M. Richard Auerbach, MD, Joe Di Maggio Children's Hospital; Bruce I. Schulman, MD, Joe DiMaggio Children's Hospital; D. Jim Rawlings, MD, Memorial Medical Center; R. D. Garrison, MD, Shands Jacksonville, University of Florida College of Medicine; Peter Gene Taves, MD, Lakeland Regional Medical Center; Julio D. Vallette, Jr, MD, Holmes Regional Medical Center; Andrew B. Kairalla, MD, Baptist Children's Hospital; Barry D. Chandler, MD, Plantation General Hospital; Eduardo H. Bancalari, MD, University of Miami/Jackson Memorial Hospital; Jose A. Adams, MD, Mount Sinai Medical Center; Jon W. Nagel, MD, Sacred Heart Hospital of Pensacola; Todd A. Patterson, DO, Tallahassee Memorial Hospital; Kenneth J. Solomon, MD, St Joseph's Women's Hospital; Victor A. Morales, MD, St Mary's Hospital; Francine D. Dykes, MD, Children's Healthcare of Atlanta at Egleston; W. Allen Blalock, MD, St Joseph Hospital, University Hospital; A. Vincent Brawley, MD, University Hospital; J. Michael Metcalf, MD, Wellstar Cobb Hospital; Louis I. Levy, MD, Medical Center of Columbus; J. Michael Armand, MD, DeKalb Medical Center; Dan Suskin, MD, Gwinnett Hospital System; Linda M. Sacks, MD, Memorial Health University Medical Center; Nancy B. Shull, MD, Memorial Health University Medical Center; Kenneth T. Nakamura, MD, Kapiolani Medical Center for Women and Children; Richard Flaksman, MD, Genesis Medical Center; Edward F. Bell, MD, University of Iowa; Mir Waziri, MD, Covenant Medical Center; Nick Harper, MD, St Luke's Regional Medical Center; Salil K. Gupta, MD, St Elizabeth's Hospital; Vivek Ghai, MD, Advocate Illinois Masonic Medical Center; Rohitkumar B. Vasa, MD, Mercy Hospital and Medical Center; Robin H. Steinhorn, MD, Northwestern University; Joseph A. Villalona, MD, Norwegian-American Hospital; Robert E. Kimura, MD, Rush University Medical Center; Kwang-Sun Lee, MD, University of Chicago Children's Hospital; William P. MacKendrick, MD, Evanston Hospital; Stavros P. Ionides, MD, Hinsdale Hospital; Jonathan K. Muraskas, MD, Loyola University Medical Center; David N. Sheftel, MD, Lutheran General Children's Hospital; James R. Hocker, MD, Children's Hospital of Illinois; Jose L. Gonzalez, MD, Rockford Memorial Hospital; Dennis T. Crouse, MD, Southern Illinois University School of Medicine; Miles J. A. Grant, MB, ChB, St Mary's Hospital for Women and Children of Evansville; Daniel Biehl, MD, Lutheran Children's Hospital; William J. Lewis, MD, Parkview Memorial Hospital; Cholemari Sridhar, MD, Methodist Hospital; James A. Lemons, MD, Indiana University Medical Center; Rosario S. Chua, MD, Lafayette Home Hospital; Donna A. Wilkins, MD, Ball Memorial Hospital; Wichest Boonyapredee, MD, Munster Community Hospital; Robert D. White, MD, Memorial Hospital of South Bend; Perry L. Clark, MD, University of Kansas School of Medicine; Jose I. Gierbolini, MD, Stormont-Vail Regional Health Center; Katherine Schooley, MD, Via Christi Regional Medical Center; Ward R. Rice, MD, St Elizabeth Medical Center South; Dan L. Stewart, MD, Baptist Hospital East; Terry Cohen, MD, Norton Suburban Hospital; David H. Adamkin, MD, University of Louisville School of Medicine; Ruth A. Shepherd, MD, Pikeville Medical Center; Amar Nijjar, MD, Christus St Frances Cabrini Hospital; W. Robert Pace, MD, Louisiana State University, Earl K. Long Hospital; Steven B. Spedale, MD, Woman's Hospital-Baton Rouge; Harish C. Anand, MD, Meadowcrest Hospital; Ivan A. Villalta-Wehmeyer, MD, North Oaks Medical Center; Malektaj Yazdani, MD, East Jefferson General Hospital; Chih-Hao Lin, MD, Lake Charles Memorial Hospital; Brian M. Barkemeyer, MD, Children's Hospital of New Orleans; Staci M. Olister, MD, Medical Center of Louisiana at New Orleans; Victor E. Lunyong, MD, Memorial Medical Center; Harley G. Ginsberg, MD, Ochsner Clinic Foundation; Dana Rivera, MD, Methodist Hospital; William L. Gill, MD, Tulane Hospital for Children; Po-I Tseng, MD, Willis Knighton Center for Women's Health; Elizabeth R. Brown, MD, Boston Medical Center; Barbara A. Shepherd, MD, Floating Hospital for Children at Tufts New England Medical Center; Ronald K. Pye, MD, Caritas St Elizabeth's Medical Center; Bertha Kao, MD, Metrowest Medical Center; Bhavesh L. Shah, MD, Baystate Medical Center Children's Hospital; Frank Bednarek, MD, Univeristy of Massachussetts Memorial Health Care; Suzanne Rindfleisch, DO, Anne Arundel Medical Center; Alan D. Bedrick, MD, Franklin Square Hospital Center; Laurel G. Yap, MD, Harbor Hospital Center; Maureen M. Gilmore, MD, Johns Hopkins Bayview Medical Center; Lee Woods, Edward E. Lawson, MD, Johns Hopkins Hospital; Susan J. Dulkerian, MD, Mercy Medical Center; Thomas P. O'Brien, MD, Sinai Hospital of Baltimore; Howard J. Birenbaum, MD, Greater Baltimore Medical College; Renee E. Fox, MD, University of Maryland School of Medicine; Antoine K. Fomufod, MD, MPH, Prince George's Hospital Center; Tuvia Blechman, MD, Howard County General Hospital; Sharon C. Kiernan, MD, Holy Cross Hospital; Marc B. Perlman, MD, Central Maine Medical Center; Steven M. Donn, MD, University of Michigan Health System; Seetha Shankaran, MD, Wayne State University School of Medicine; Paul Holtrop, MD, St John Detroit Riverview Hospital; Sophie J. Womack, MD, Sinai-Grace Hospital, Detroit Medical Center; Ed Beaumont, MD, Devos Children's Hospital; Narasingrao Pampati, MD, North Oakland Medical Center; Khawar Mohsini, MD, Covenant Healthcare; Betty Go, MD, Providence Hospital; Steven St Charles, MD, Munson Medical Center; Karen G. Hufnagle, MD, William Beaumont Hospital; Derek K. Bair, MD, Oakwood Hospital and Medical Center; Robert J. Couser, MD, Children's Hospital of Minneapolis; Sixto F. Guiang III, MD, Fairview University Medical Center; Dana E. Johnson, MD, PhD, University of Minnesota Hospital and Clinic; Diane J. Camp, MD, North Memorial Healthcare; Garth Asay, MD, Mayo Clinic Rochester; Edward Martin, MD, St Cloud Hospital; Catherine Gatto, MD, Children's Hospital Clinics, St Cloud; Lynne D. Willett, MD, St Francis Medical Center; Elizabeth J. P. James, MD, Children's Hospital at University of Missouri; Howard W. Kilbride, MD, Children's Mercy Hospital; Michael B. Sheehan, MD, Truman Medical Center; Melinda R. Slack, MD, St John's Regional Health Center; Amit Mathur, MD, Washington University School of Medicine, St Louis Children's Hospital; Aaron Hamvas, MD, Washington University in St Louis; Corinne A. Walentik, MD, MPH, St Mary's Health Center, St Louis University; William J. Keenan, MD, St Louis University; Mike Maurer, Jr, MD, St John Mercy Medical Center; F. Sessions Cole, MD, St Louis Children's Hospital; Clinton B. White, MD, Forrest General Hospital, Memorial Hospital at Gulfport; John E. Rawson, MD, Mississippi Baptist Health System, Central Mississippi Medical Center; Dennis J. Hey, DO, Jeff Anderson Regional Medical Center; John H. Nading, MD, North Mississippi Medical Center; Kathleen Stevens, MD, St Vincent Healthcare; C. Janine Hester, NNP, Benefis Health Care; Janet L. Hiller, MD, Community Medical Center; Charles D. Yoder, MD, Mission Hospital; Carl L. Bose, MD, University of North Carolina Hospitals, Chapel Hill; Larry Brady, MD, Presbyterian Hospital; Carmen Herrera, MD, Duke University Medical Center; James J. Woods, DO, Womack Army Medical Center; J. Laurence Ransom, MD, Women's Hospital of Greensboro; James J. Cummings, MD, East Carolina University Brody School of Medicine; Thomas E. Young, MD, Wake Medical Center; Robert D. McArtor, MD, New Hanover Regional Medical Center; Robert G. Dillard, MD, Forsyth Memorial Hospital, Wake Forest University School of Medicine; T. Michael O'Shea, MD, Wake Forest University School of Medicine; Steven M. Block, MD, North Carolina Baptist Hosital; Indu Agarwal, MD, Meritcare Children's Hospital; Lawrence C. Bausch, MD, St Elizabeth's Regional Medical Center; Terence L. Zach, MD, Creighton University; David L. Bolam, MD, Nebraska Medical Center; Marcus C. Hermansen, MD, Southern New Hampshire Medical Center; Syed Ahmed, MD, Atlantic City Medical Center; Gary E. Stahl, MD, Children's Regional Hospital at Cooper University Hospital; Harold Perl, MD, Hackensack Medical Center; Suhail Alsheikh, MD, Jersey City Medical Center; Shyan C. Sun, MD, St Barnabas Medical Center; Carlos Alemany, MD, Monmouth Medical Center; Lawrence Skolnick, MD, Morristown Memorial Hospital; Michael A. Graff, MD, Jersey Shore University Hospital; Frank Manginello, MD, Valley Hospital; Alberto M. Chavez, MD, Somerset Medical Center; Randi Axelrod, MD, Capital Health System at Mercer; Jerome J. Hric, MD, Rancocas Hospital; Yartha V. Reddy, MD, Lea Regional Hospital; John P. Kurlinski, MD, Sunrise Children's Hospital; Sean Ahn, MD, University Medical Center of Southern Nevada; Marc Leitner, MD, Summerlin Hospital; Stephen R. Missall, MD, St Mary's Regional Medical Center; Michael J. Horgan, MD, Children's Hospital at Albany Medical Center; Ivan Hand, MD, Jacobi Medical Center; Myra F. Mercado, MD, Our Lady of Mercy Medical Center; B. K. Rajegowda, MD, Lincoln Medical Center; Dominique Jean-Baptiste, MD, Brookdale Hospital Medical Center; Meena LaCorte, MD, Interfaith Medical Center; Paul L. Toubas, MD, State University of New York Downstate; Jerry Watman, MD, Coney Island Hospital; Frantz E. Brea, MD, Woodhull Medical Center; Bruce D. Ackerman, MD, Wyckoff Heights Hospital; Rita M. Ryan, MD, Women and Children's Hospital of Buffalo; Thomas F. Riley, MD, Sister's of Charity Hospital; Harriet S. Boxer, MD, Nassau University Medical Center; Edmund J. DiLello, MD, St John's Queens Hospital; Raymond J. Sanders, MD, Arnot Ogden Medical Center; Harry Moreau, MD, New York Hospital Medical Center of Queens; Sook J. Choi, MD, Queens Hospital Center; Dennis Davidson, MD, Schneider Children's Hospital, North Shore-Long Island Jewish Health System; Lita Isaacson, MD, Winthrop-University Hospital; John R. Stafford, Jr, MD, Northern Westchester Hospital; Richard A. Polin, MD, Children's Hospital of New York, Columbia University; Cathy Hansen, MD, David Bateman, MD, Harlem Hospital Center; Eva Duncan, MD, Lenox Hill Hospital; Ian R. Holzman, MD, Mount Sinai Medical Center; Pratibha Ankola, MD, Metropolitan Hospital Center; Martha Caprio, MD, New York University Medical Center; Maria D. Fort, MD, Bellevue Woman's Hospital; Stephen J. Kovacs, MD, Vassar Brothers Medical Center; C. Mohini Mehra, MD, Genesee Hospital; Nirupama Laroia, MN, Rochester General Hospital; Tim Stevens, MD, William M. Maniscalco, MD, University of Rochester Medical Center; Anantham Harin, MD, St Vincent's Medical Center; Philip Roth, MD, PhD, Staten Island University Hospital; Alan R. Spitzer, MD, State University of New York-Stony Brook; Edmund F. LaGamma, MD, Westchester Medical Center, New York Medical College; Prabhu Mehta, MD, Good Samaritan Hospital Medical Center; Jesus C. Jaile-Marti, MD, White Plains Hospital; Ralph J. Wynn, MD, Millard Fillmore Suburban Hospital; Martha W. Magoon, MD, Aultman Hospital; Jeffrey A. Whitsett, MD, Cincinnati Children's Hospital Medical Center; Ronald Holtzman, MD, Cleveland Clinic Foundation; M. Walsh, MD, MS, Case Western Reserve University; Stephen Welty, MD, Columbus Children's Hospital, Ohio State University; Craig W. Anderson, MD, Grant Medical Center; Leandro Cordero, MD, Ohio State University Hospital; Marc R. Belcastro, DO, Miami Valley Hospital; Vicente Romero, MD, St Rita's Medical Center; Prem L. Mehandru, MD, Lake Hospital System; Jerod M. Rone, MD, Springfield Community Hospital; Karl DeLuga, MD, Toledo Children's Hospital; Elena M. Rossi, MD, St Elizabeth Health Center; Marilyn B. Escobedo, MD, University of Oklahoma; A. Charles Hoffmeister, MD, Sacred Heart Medical Center; Patricia L. Jett, MD, Rogue Valley Medical Center; Patrick Lewallen, MD, Emanuel Children's Hospital; Linda D. Wallen, MD, Oregon Health and Science University; John V. McDonald, MD, Providence St Vincent Medical Center; T. Allen Merritt, MD, St Charles Medical Center; Ara S. Moomjian, MD, Abington Memorial Hospital; Robert L. Stavis, PhD, MD, Bryn Mawr Hospital, Larkenan Hospital; Michael J. Paszek, MD, Holy Spirit Hospital; Bakulesh D. Patel, MD, Geisenger Medical Center; Sambasivarao Voora, MD, St Vincent Health Center; Charles Palmer, MB, ChB, Pennsylvania State Children's Hospital, Milton S. Hershey Medical Center; John O. Chan, MD, Memorial Medical Center; Prem K. Marlapudi, MD, St Mary Medical Center; Joan Donahue, MD, Holy Redeemer Hospital; Endla K. Andlay, MD, Hahnemann University Hospital; Jeffrey Merrill, MD, Children's Hospital of Philadelphia, Hospital of the University of Pennsylvania; Phyllis A. Dennery, MD, Children's Hospital of Philadelphia, Hospital of the University of Pennsylvania; Jeanette R. Pleasure, MD, St Christopher's Hospital for Children; Albert L. Pizzica, DO, Northeastern Hospital; Jeffrey S. Gerdes, MD, Pennsylvania Hospital; Temple University Hospital; Jacob J. Greenberg, MD, Mercy Hospital; Gerald D. Brown, MD, Reading Hospital and Medical Center; Sonia Hulman, MD, Crozer-Keystone Health System, Crozer Chester Medical Center; Jonathan Liss, MD, York Hospital; James F. Padbury, MD, Women and Infants Hospital of Rhode Island; Patricia Spitale, MD, Kent County Memorial Hospital; David H. Wells, MD, Greenville Memorial Hospital; Terry A. Marshall, MD, Self Memorial Hospital; Sami B. ElHassani, MD, Mary Black Memorial Hospital; David P. Munson, MD, Sioux Valley Hospital; Michael DeVoe, MD, East Tennessee State University; C. Martin, MD, Wellmont Holston Valley Medical Center; James M. Hamlett, MD, Baptist Women's Hospital; M. Bruce Jenkins, MD, Methodist Hospitals of Memphis; John M. Ferguson, MD, Methodist Hospital South, University of Tennessee Medical Group; Isaac John, MD, St Francis Hospital; Mubariz Naqvi, MD, Amarillo Hospital District, Texas Tech School of Medicine; Scott C. Tisdell, MD, Arlington Memorial Hosital; David E. Wermer, MD, Seton Medical Center; Audelio Rivera, MD, St David's Hospital; Arden C. Quintin, MD, Memorial Hermann Baptist Beaumont; A. Bharathi, MD, St Elizabeth Hospital; Gerardo Sanchez, MD, Brownsville Medical Center; Eileen Milvenan, MD, Trinity Medical Center; Jack D. McGowan, MD, Conroe Regional Medical Center; Jonathan M. Whitfield, MD, Baylor University Medical Center; Myra Wyckoff, MD, University of Texas Southwestern Medical Center; Garrett S. Levin, MD, Thomason Hospital, Texas Tech University Health Sciences Center; Harold Kolni, MD, Methodist Dallas Medical Center; Donald K. Nelms, MD, John Peter Smith Hospital; C. Joan Richardson, MD, University of Texas Medical Branch Hospital; Joseph Garcia-Prats, MD, Ben Taub General Hospital; Jose Garcia, MD, Lyndon Baines Johnson Hospital; Brenda H. Morris, MD, University of Texas Medical School at Houston; Michael E. Speer, MD, Baylor College of Medicine, Texas Children's Hospital; Tommy Leonard, MD, Baylor College of Medicine; Javier Ramirez-Lavin, MD, McAllen Medical Center; Robert E. Bennett, Jr, MD, Texas Tech University Health Science Center; Elizabeth Peters, MD, Medical Center of Plano; Steven R. Seidner, MD, University of Texas Health Science Center at San Antonio; David R. Krauss, MD, Scott and White Memorial Hospital, Texas A & M University College of Medicine; Stephen D. Minton, MD, Utah Valley Regional Medical Center; David M. Coulter, MD, University of Utah School of Medicine; Alan Silk, MD, Inova Fair Oaks Hospital; Jyoti S. Amin, MD, Mary Washington Hospital; Allen Majewski, MD, Virginia Baptist Hospital; Jamil H. Khan, MD, Children's Hospital of the King's Daughters, Sentara Norfolk General Hospital; David T. Carpenter, MD, Naval Medical Center, Portsmouth; Raymond Farhi, MD, HCA Chippenham Medical Center; Teresa F. Clawson, MD, Winchester Medical Center; Tom Hull, MD, Potomac Hospital; Roger F. Soll, MD, Fletcher Allen Health Care; Stephen Chentow, MD, Evergreen Hospital Medical Center; J. Craig Jackson, MD, Children's Hospital and Regional Medical Center; Thomas P. Strandjord, MD, University of Washington Medical Center, Evergreen Hospital Medical Center; Dennis Mayock, MD, University of Washington Medical Center; Ronald Shapiro, MD, Deaconess Medical Center; John C. Mulligan, MD, Tacoma General Hospital; Robert M. Skarin, MD, Yakima Valley Memorial Hospital; Joseph Brand, DO, St Vincent Hospital; Dennis T. Costakos, MD, Franciscan Skemp Mayo Health System; David P. Carlton, MD, University of Wisconsin and Meriter Hospital; Suzanne S. Toce, MD, Gundersen-Lutheran Medical Center; John D. Kenny, MD, St Mary's Hospital Medical Center; Chandra R. Shivpuri, MD, Sinai Samaritan Medical Center; Stephen C. Ragatz, MD, St Joseph Hospital Regional Medical Center; John W. Wolf, MD, St Mary's Hospital; G. Ganesh Konduri, MD, Medical College of Wisconsin; Paul R. Myers, MD, Children's Hospital of Wisconsin, Fox Valley; Raja R. Nandyal, MD, St Luke's Hospital; Nancy Herrell, MD, Waukesha Memorial Hospital; Carlos Lucero, MD, Raleigh General Hospital; Stefan R. Maxwell, MD, Charleston Area Medical Center Women and Children's Hospital; Renee S. Domanico, MD, Cabell Huntington Hospital; Janet Graeber, MD, West Virginia University School of Medicine; Richard Wilker, MD, Newton Wellesley Hospital, University Community Hospital.
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FOOTNOTES
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Accepted Jul 29, 2005.
Address correspondence to Tina A. Leone, MD, Division of Neonatology, University of California, San Diego, Medical Center, 200 W. Arbor Dr, MPF 1-140, MC 8774, San Diego, CA 92103. E-mail: tleone{at}ucsd.edu
Financial Disclosure: Dr Finer has received research support from Fisher-Paykel.
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