Published online August 1, 2006
PEDIATRICS
Vol. 118
No. 2
August 2006, pp.
847-848
(doi:10.1542/peds.2006-0457)
Neonatal Cardiopulmonary Arrest in the Delivery Room
Ori Toker-Maimon, MD
Leon J. Joseph, MB, ChB
Department of Pediatrics
Shaare Zedek Medical Center
Jerusalem 91031, Israel
Ruben Bromiker, MD
Michael S. Schimmel, MD
Department of Neonatology
Shaare Zedek Medical Center
Jerusalem 91031, Israel
Faculty of Health Sciences
Ben Gurion University of the Negev
Beer Sheva 84105, Israel
To the Editor.—
Cardiopulmonary arrest of a healthy term infant in the delivery room after an uneventful vaginal delivery is an extremely rare event.1,2
We recently encountered 2 such cases in term infants born after uneventful pregnancies and nonmedicated vaginal deliveries. In the first, infant breastfeeding was initiated in the delivery room, unobserved, immediately after birth. A short time later, the infant was found pale and motionless while still on the breast. After resuscitation and NICU care, the infant was discharged without obvious neurologic deficit. Similarly, the second infant initiated breastfeeding unobserved in the delivery room shortly after birth. A few minutes later, the mother noticed that the infant was motionless. After initial resuscitation, respiratory support and inotropic and anticonvulsive therapies were required. During his 3-month stay in the NICU, the results of all investigations, including septic workup, metabolic screen, and echocardiography, were normal. Follow-up examination has noted that the infant is severely neurologically impaired.
Our 2 cases are similar to 8 French cases described previously.1,2 All those infants were born to primiparous women after uneventful pregnancies and deliveries. In all of those infants, as with ours cases, the cardiopulmonary arrests occurred with the infants in a prone position on their mothers’ abdomen during the first breastfeeding maneuver.
We suggest 2 possible causes of the cardiorespiratory arrest: upper airway obstruction and/or increased vagal tone. Previous reports3–5 of catastrophic deterioration during and after breastfeeding have postulated oronasal obstruction. However, these cases occurred after the infants were discharged from the hospital. The alternative theory, implementing increased vagal tone as the cause of the cardiac arrest, is suggested by several studies. In newborns, during the postdelivery period, there is increased vagal tone,6 and thus this phenomenon can possibly be activated by the initial sucking by the infant on the mother’s nipple and/or compounded by initiation of the gastrin vagal axis.7,8 Support for this theory is the recent report of vagal overactivity and sudden infant death syndrome.9 In this study of 15 families with a history of sudden infant death syndrome in 1 sibling, a high percentage of subsequent siblings were found to have symptoms of vagal hyperreactivity, suggesting an autosomal dominant inheritance pattern for this phenomenon. On the other hand, the fact that all the reported cases of arrest in the delivery room occurred in primiparous (and thus inexperienced) mothers suggests that infant position and maternal feeding technique may be the more likely mechanism.
The American Academy of Pediatrics, in its 2005 policy statement regarding breastfeeding, states that "[h]ealthy infants should be placed and remain in direct skin-to-skin contact with their mothers immediately after delivery until the first feeding is accomplished."10 This policy clearly should continue to be encouraged. However, given our observation and the experience of others, we recommend that there be proper supervision and attendance by caregivers during the initial breastfeeding in the delivery room by inexperienced primiparous mothers. It is also clear that the careful monitoring and positioning of the infants during this period of maternal-infant bonding be done in an unobtrusive manner so as to allow the new mother-infant dyad the freedom to interact appropriately.11
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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics
