Objective. The limited literature available to date suggests that the use of delivery room cardiopulmonary resuscitation (DR-CPR) is associated with very poor outcomes, especially for extremely low birth weight infants. We reviewed the cumulative experience of the Vermont Oxford Network to determine the actual utilization of DR-CPR and the neonatal outcomes of such infants.
Methods. A retrospective review of information available in the Vermont Oxford Network Database for the years 1994 to 1996. The data set was collected from 196 neonatal units who participate in the Network (data for infants 401 to 500 g were from 1996 only). Infants were eligible for study if they received DR-CPR defined as the administration of chest compressions and/or epinephrine in the delivery room as noted on the Vermont Oxford Network Database record.
Results. Information regarding survival was available for 27 707 newborns with birth weights from 501 to 1500 g, and 497 infants with birth weights from 401 to 500 g. There were 24 001 (86.6%) survivors. Overall DR-CPR was given to 9.3% of infants from 401 to 500 g and 6% of infants from 501 to 1500 g, 82.1% receiving chest compressions, and 66.7% receiving epinephrine. Survival of infants receiving DR-CPR was 23.9% for infants of 401 to 500 g, and 63.3% for infants of 501 to 1500 g, compared with 16.7% and 87.9% for infants in these weight groups not receiving DR-CPR. Survival was greater for infants of 501 g or greater without DR-CPR compared with those who received this intervention within each 250-g birth weight subgroup. For infants of <1000 g, survival was 53.8% with DR-CPR compared with 74.9% without. Head ultrasounds were available for 95.5% of all surviving infants and 96.7% of infants who received DR-CPR. Overall, any grade of intraventricular hemorrhage (IVH) occurred more frequently in infants who received DR-CPR (38%) than in those who did not (21%). Grade 3 or 4 (severe) IVH was seen in 15.3% of infants who received DR-CPR compared with 4.9% of the infants who did not. Overall, survival without severe IVH occurred in 52.2% of DR-CPR infants compared with 81.3% of infants who did not require this intervention.
Conclusion. The majority of very low birth weight and extremely low birth weight infants who receive DR-CPR survive, and at least half of such infants who survive do not have evidence of severe IVH. Further follow-up studies are required to determine the long-term neurodevelopmental outcome of such infants. The current study does not support the previously noted poor outcome in extremely low birth weight infants who receive DR-CPR.
- BW =
- birth weight •
- CPR =
- cardiopulmonary resuscitation •
- DR =
- delivery room •
- VLBW =
- very low birth weight •
- DR-CPR =
- delivery room cardiopulmonary resuscitation •
- ELBW =
- extremely low birth weight •
- IVH =
- intraventricular hemorrhage •
- HR =
- heart rate
In the current teaching of neonatal resuscitation, recommendations for the use of cardiac compressions and intratracheal or intravenous epinephrine are to be applied for any newborn requiring such resuscitation without regard to birth weight (BW) or gestation.1 The original description of the use of intratracheal epinephrine in neonates did not provide a detailed description of the infants but noted that 3 of the 10 infants successfully resuscitated eventually died.2
Although a number of previous studies have reviewed the outcomes of infants who required cardiopulmonary resuscitation (CPR) in the neonatal intensive care unit, these studies tended to exclude infants who required such intervention in the delivery room (DR).3 ,4 Davis5 described the outcome for 156 infants of <1000 g during a 3-year period, June 1989 to May 1992, at one institution. She noted that there were no survivors among infants of <500 g who were resuscitated. Of the 62 infants with BW between 500 to 750 g, 57% of those who received only ventilatory support (n = 50), survived, compared with none of the 8 who received cardiac compressions with or without epinephrine. Three of 69 infants of 751- to 1000-g BW required cardiac compressions for 1 to 15 minutes, and all survived, as did 4 of 7 who also required epinephrine. This study, however, lacked the power to conclude that CPR was futile for such infants. Jain et al6 reviewed information from a large perinatal network in Illinois, with information on 81 242 mother-infant pairs during a 5-year period, 1982 to 1986. They reported that all but 1 of 58 infants who had an Apgar of 0 at 10 minutes died with the single survivor being abnormal. These authors had information on 10 infants of 750 g or less, the majority of whom seemed to respond to the initial resuscitation in the DR. Nevertheless, similar to the observations of Davis,5 all of these infants died in the neonatal period. Sims et al7 reviewed the use of adrenaline and atropine in neonatal resuscitation during a 5-year period at Manchester in the United Kingdom. All of their 5 infants of 28-weeks gestation or less who required such treatment at delivery died3 or were severely handicapped.2More recently Rennie8 noted that there were only 2 of 11 normal survivors from their very low birth weight (VLBW) population at Cambridge in the United Kingdom from 1989 to 1993 who required DR-CPR, although further details were not provided.
At present, more than 10 years after the first of the above observations, there are still no specific recommendations for the use of CPR for extremely low birth weight infants (ELBW). Such interventions are currently frequently used in the DR for the ELBW infant despite the previously noted literature.9 We therefore undertook to review the Vermont Oxford Network Database, which contains information from more than 200 neonatal units, and includes information regarding the use of chest compressions and epinephrine in the DR. This was done, in an effort to determine the current outcomes of the VLBW and ELBW (<1000 g) infants who receive such interventions compared with contemporary infants not receiving such interventions.
The organization and objectives of the Vermont Oxford Network have been described elsewhere.10–12 Participating hospitals submit data on inborn and outborn infants with BWs of 401 to 1500 g. This was a retrospective cohort study which included all Network inborn infants born in the years 1994 to 1996, who had no major birth defects and whose survival and resuscitation status during delivery (DR-CPR) were known. DR-CPR was defined as administration of either chest compression and/or epinephrine in the DR. The outcomes of interest were survival and worst grade of intraventricular hemorrhage (IVH) among infants who either received DR-CPR or not. IVH was graded using the Papile classification system.13
The Network collected data for all live-born infants 501 to 1500 g during all 3 study years; data collection for infants 401 to 500 g began in 1996. For this reason, the two BW categories were analyzed separately. Survival was defined as survival to hospital discharge either from the initial hospital or from a hospital to which the infant was transferred. Statistical analyses of outcomes by DR-CPR category were performed using χ2 tests. In the case of infants 501 to 1500 g, Mantel-Haenszel χ2 tests were performed after stratifying by 250-g BW category. A P value of <.05 was considered significant. No adjustments were made for multiple comparisons.
The Network Database included information for 28 066 infants born in 1994 to 1996 who met the eligibility criteria for this study (BW 401 to 1500 g, inborn, no major birth defect). Data regarding survival status and/or DR-CPR were missing for 359 infants leaving a sample of 27 707 infants cared for at 196 neonatal intensive care units.
The characteristics of infants in the two BW categories, 401 to 500 g and 501 to 1500 g, are shown in Table 1. Apgar scores were missing for 1.9% of the sample; other items had missing values in <0.2% of the cases. The infants weighing 401 to 500 g had a mean BW of 459 g and a mean gestational age of 23 weeks. Twenty-eight percent of these infants were delivered by cesarean section, 33% were exposed to antenatal corticosteroid treatment and the median Apgar scores were 2 at 1 minute and 2 at 5 minutes. The infants weighing 501 to 1500 g had a mean BW of 1053 g and a mean gestational age of 28 weeks. Sixty percent of these infants were delivered by cesarean section, 64% were exposed to antenatal corticosteroid treatment and the median Apgar scores were 6 at 1 minute and 8 at 5 minutes.
The percentage of infants in different BW categories who received cardiac compressions, epinephrine and DR-CPR (cardiac compressions and/or epinephrine) are shown in Table 2. DR-CPR was administered to 9.3% of the infants weighing 401 to 500 g. Overall, 6.0% of the infants weighing 501 to 1500 g received DR-CPR. The use of DR-CPR decreased from 12.3% for infants 501 to 750 g to 2.5% for infants 1251 to 1500 g.
The percentage of infants receiving DR-CPR is shown in relation to the 1-minute Apgar scores in Fig 1. For infants 501 to 1500 g, the percentage of infants receiving DR-CPR decreased with increasing 1-minute Apgar score (>65% for infants with a 1-minute Apgar score of 0 to <1% for infants with a score >3). This relationship was not evident for the infants 401 to 500 g in which <10% of infants with a 1-minute Apgar score of 0 received DR-CPR.
The 1-minute Apgar scores for infants who received DR-CPR are shown inTable 3. Data were available for 45 of the 46 infants 401 to 500 g and for 1595 of the 1618 infants 501 to 1500 g who received DR-CPR. Eighty-seven percent of the infants 401 to 500 g and 88% of the infants 501 to 1500 g who received DR-CPR had 1-minute Apgar scores of 3 or less.
The first major outcome analyzed for this study was survival. The survival of infants by DR-CPR status is shown in Table 4. For the BW category 401 to 500 g, 23.9% of the infants who received DR-CPR survived as opposed to 16.0% of the infants who did not receive DR-CPR (P = .17). For infants 501 to 1500 g, survival was less likely in those infants who received DR-CPR. Survival in this BW category was seen for 63.3% of the infants who received DR-CPR as opposed to 89.4% of the infants who did not receive DR-CPR (P < .001). Survival among infants 501 to 1500 g who received DR-CPR increased from 44.4% for infants 501 to 750 g to 82.5% for infants 1251 to 1500 g.
The grades of IVH for surviving infants are shown in Table 5. Among surviving infants 401 to 500 g, data regarding IVH were available for 10 of the 11 infants who received DR-CPR and for all 72 infants who did not receive DR-CPR. In surviving infants 501 to 1500 g, head ultrasound evaluations were available for 991 of the 1024 infants who received DR-CPR and for 21 845 of the 22 879 infants who did not receive DR-CPR. For surviving infants 401 to 500 g, 5 of 10 infants who received DR-CPR and 72% of those who did not receive DR-CPR had no evidence of IVH on cranial ultrasound (grade 0). In this BW category, 20% of the infants who received DR-CPR and 6% of those who did not, had evidence of either grade 3 or 4 IVH. For the BW category of 501 to 1500 g, 62% of the infants who received DR-CPR and 79% of those who did not, had no evidence of IVH on cranial ultrasound (grade 0). Sixteen percent of those who received DR-CPR and 5% of those who did not, had evidence of either grade 3 or 4 IVH (P < .001).
The second major outcome analyzed for this study was survival without evidence of severe (grade 3 or 4) IVH (Table 6). Survival without severe IVH occurred in 17.7% of infants weighing 401 to 500 g who received DR-CPR and in 15.1% of those infants who did not receive DR-CPR (P = .63). For infants 501 to 1500 g, survival without severe IVH was less likely for infants who received DR-CPR. Survival without severe IVH was seen in 53.0% of the infants weighing 501 to 1500 g who received DR-CPR and 84.6% of those who did not receive DR-CPR (P < .001). For infants weighing 501 to 750 g who received DR-CPR, 37.2% survived without severe IVH; for infants 1251 to 1500 who received DR-CPR, 70.4% survived without severe IVH.
We found that 9% of infants 401 to 500 g and 6% of infants 501 to 1500 g were treated with either cardiac compressions or epinephrine in the DR. In addition, we observed that 11 of the 46 infants (23.9%) of 401 to 500 g and 292 of the 658 infants (44.4%) of 501 to 750 g who received DR-CPR survived. Although this survival rate is less than that seen for infants who did not receive DR-CPR, this is the first report to note such high rates of survival in this population. Survival was lower for infants who received DR-CPR compared with infants who did not receive DR-CPR in all BW categories except 401 to 500 g. We believe that these results reflect decisions regarding selection of infants for aggressive resuscitation and life support, rather than the effectiveness of resuscitation. To date there have been no survivors reported following DR-CPR for infants of <750 g apart from a small number of infants (total of 15) recently reported at the Society for Pediatric Research meeting9 ,14 including a recent retrospective review from a single institution which reported that intact survival is possible in the ELBW infant who received DR-CPR, including infants of <750-g BW.15 In this 4-year review of all ELBW inborn infants, 44 of 80 infants between 500 to 750 g survived. Eleven of these infants received DR-CPR using definitions similar to the present study and 9 survived. One infant was lost to follow-up, 4 were normal at up to 3 years of age, 3 were suspicious, and 1 was abnormal.
From our review, not only are there a significant number of survivors after DR-CPR, but also the majority of the children who survived did not have any IVH. Furthermore, only 20% of surviving infants from 401 to 500 g and 16% of surviving infants from 501 to 1500 g who received DR-CPR had a severe IVH.
As noted from Table 3, overall, 10.7% of infants who received DR-CPR had a 1-minute Apgar of 0, and the use of such resuscitation in this group would seem appropriate. Infants with a 1-minute Apgar of 0 have no heart rate (HR) at 1 minute and current teaching would support the use of both compressions and epinephrine in such circumstances. Forty-seven percent of infants who received DR-CPR had a 1-minute Apgar of 1. In these circumstances, from information available, it is impossible to determine if accepted indications existed to justify the use of either compressions or epinephrine or both. The indications for cardiac compressions include a HR <80 beats per minute and falling, or a HR <60 beats per minute after 15 to 30 seconds of positive pressure ventilation. Epinephrine is indicated for a HR <80 beats per minute despite a minimum of 30 seconds of adequate ventilation with 100% oxygen and chest compressions or a HR of zero.1 It is possible, although unusual, to have an Apgar of 1 and a 0 for HR. As a result, we cannot conclude that DR-CPR use followed current recommendations using the information available within the Database. Our review did demonstrate that chest compressions were used more frequently than epinephrine for every BW category as would be expected. Current practice regarding the National Resuscitation Program guidelines as applied to ELBW infants has never been prospectively evaluated. It is possible that a different approach is warranted for the very immature infant. A prospective study of current DR practices is needed.
Although the results of the current study are encouraging regarding the short-term outcomes of VLBW infants who receive DR-CPR, more information is required regarding the longer-term neurodevelopmental function of such infants. Although the occurrence of severe IVH is associated with significantly increased risks of neurodevelopmental problems including cerebral palsy,16 there are many other factors, which are contributory to the infant's ultimate outcome.17 Although information regarding the occurrence of cystic periventricular leukomalacia was available within the database, there was not uniformity in the timing of ultrasound testing and interpretation for the detection of this abnormality and thus we did not report the frequency by weight group for this finding. For infants between 501 to 1500 g the occurrence of cystic periventricular leukomalacia was noted in 7.8% of infants receiving DR-CPR, compared with 3.9% of infants not requiring this intervention (P < .001).
It would seem from a review of the information in the Vermont Oxford Network Database that DR-CPR is used for the VLBW and ELBW infant with low Apgar scores. Whereas the previous published experience suggests that such intervention may be futile, the present study indicates that neonatal survival without severe IVH is likely for a substantial percentage of infants who receive such resuscitation. We did not review the use of CPR during the neonatal hospitalization after delivery, as such information is not routinely collected in the Vermont Oxford Network Database.
The retrospective cohort study design allows the evaluation of multiple outcomes and is useful when exposure is relatively infrequent. More importantly, this design removes bias in the ascertainment of exposure to DR-CPR because the data collection was completed prospectively before the initiation of the current review. The obvious limitations of the current study include its retrospective nature, the lack of standardization for the indications and actual conduct of DR-CPR, the lack of knowledge regarding the indications and approach to each infant resuscitation, and the postresuscitation care, and the lack of information regarding long-term infant neurodevelopmental outcomes. The retrospective cohort study design may not be able to account for confounding if such data were not collected or analyzed, does not allow one to establish causality, and may be contaminated by misclassification of exposure or outcome. In addition, such a methodology does not allow for a determination of a dose-response effect especially as applied to the use of DR-CPR. These limitations, however, in some or greater measure, apply to all studies published to date evaluating the use of CPR in the neonatal period.
The Vermont Oxford Network Database provides a very large and current database, which allowed us to report outcomes from as late as 1996. The wide variety of hospitals participating in the Network which includes community and regional academic neonatal intensive care units, ensures a broad relevancy to this information as practices captured in the Network Database are likely to be reflective of current countrywide experiences. In the future, follow-up information will become part of the Network Database, which will then allow even more critical evaluation of current neonatal treatment strategies.
In summary, we have reviewed the Vermont Oxford Network Database which contains information for liveborn infants from 401 to 1500 g and determined that a significant proportion of VLBW infants that receive CPR in the DR survive. In addition, the majority of survivors do not have evidence of IVH. Although we do not know whether DR-CPR was administered in accordance with published recommendations, we do know that a substantial number of VLBW and ELBW infants are receiving DR-CPR and surviving. There is a lack of information regarding the optimal approach to resuscitation of the ELBW infant, and the actual application of current neonatal resuscitation to such infants. Further information is urgently required regarding the indications, application, and longer-term neurodevelopmental outcome of DR-CPR so that we may fully assess its role in the initial treatment of these fragile infants.
Abington Memorial Hospital, Eric J. Margolis, MD, Karen Strohecker, RN, CRNP, Nilima Ragavan, MD; Aiiku Hospital, Kazuhiko Kabe, MD, Yuko Takano, RN; Albany Medical Center, Joaquim M. Pinheiro, MD, Manuel M. Karunasiri, MD; Alexandria Hospital, Michael A. Holliday, MD, Michael Dwyer, MD; Anne Arundel Medical Center, Suzanne Rindfleisch, DO; Arnot-Ogden Medical Center, Robert Balcom, MD, Donna Boylan, NNP; Aultman Hospital, Martha W. Magoon, MD, Louis J. Heck, MD; Baptist Memorial Hospital, Esmond L. Arrindell, MD, James M. Hamlett, III, MD; Baylor University Medical Center, Jonathan Whitfield, MB, ChB, FRCPC, Pam S. McKinley, RN; Bellevue–The Women's Hospital, Stephen R. Pratt, MD, Maria D. Fort, MD; Bethesda Memorial Hospital, Lily J. Whetstine, MD, Cathy Kinney; Blank Children's Hospital, Robert Shaw, MD; Broward General Medical Center, Steven Haskins, MD, Brian Udell, MD; Bryn Mawr Hospital, Robert Stavis, PhD, MD; California Pacific Medical Center, Terri A. Slagle, MD, Kathleen Lewis, MD; Carle Foundation Hospital, Kim Gelke, MD, Stephanie Beever, RN, MS; Carillion Roanoke Community Hospital, Gilbert Frank, MD, Leah Sikozich; Center Universitaire De Sherbrooke, Charlotte Demers, MD, FRCPC, Andree Sirois, RN; Charite Kinderklinik, Ernst L. Grauel, MD, Angelika von Baehr, MD; Charleston Area Medical Center, Stefan Maxwell, MD, Trish Brant, NNP; Children's Hospital of Eastern Ontario–Ottawa General, Marc P. Blayney, MD, BCh, FRCPC; Children's Health Care–Saint Paul, Erik Hagen, MD; Children's Hospital Medical Center of Akron, John H. Vollman, MD, Deborah Giebner; Children's Hospital Oakland, Richard Powers, MD, David Durand, MD; Children's Hospital of Austin, James T. Courtney, MD, DeeAnn Townsley, RNC; Children's Hospital of Orange County, Sudeep Singh, MD, Carrie Worcester, MD; Children's Hospital of The King's Daughters/Sentara Norfolk General Hospital, Glen A. Green, MD, Marilyn M. Reininger, RN; Children's Hospital of Vienna–Glanzing, Andreas Lischka, MD, Astrid Kafer, MD; Children's Hospital of Wisconsin, Scott Smith, Janet Wilberg; Children's Mercy Hospital, Michael B. Sheehan, MD, Philip G. Pettett, MD; Children's Health Care–Minneapolis, Nathaniel Payne, MD, Sam Olsen; Christchurch Women's Hospital, Brian Darlow, MD, FRCP, FRACP, Nina Mogridge, RN; Columbia East Ridge Hospital, Lisa Winters, NNP, Vic Thomas, MD; Columbia Hospital at Medical City–Dallas, Eileen Milvenan, MD, Meridith Treen, MD; Columbia Hospital for Women, Parveen Chowdhry, MD, Kenneth Harkavy, MD; Columbia Medical Center of Plano, Randy C. Randel, MD, Gregg Lund, DO; Columbia Wesley Medical Center, Barry T. Bloom, MD, Paula Delmore, MSN; Community Medical Center, Janet H. Blanton, MD, Julie Bingham, RN; Connecticut Children's Medical Center, Victor C. Herson, MD, Sue Zaremba; Cook Children's Medical Center, Cody Arnold, MD, Elaine Adams, RN; Coral Springs Medical Center, Manuel Ortega, MD, Greg Melnick, MD; Crozer-Chester Medical Center, Catherine Partyka, MD, Marian M. Huang, MD; Dameron Hospital Association, Aaron Simko, MD, Carolyn Sanders, RN; Danube Hospital, Walter Sterniste, MD, OA, Michael Sacher, MD, DDZ; Dartmouth-Hitchcock Medical Center, William Edwards, MD, Candace Nattie, RN; Deaconess Medical Center, Ronald Shapiro, MD, Ann Seaburg, RN; Devos Children's Hospital, Ed Beaumont, MD, Dinah Sutton, RN; Driscoll Children's Hospital, Peter Serrao, MD, Yvonne Marshall, RN, Alfonso Prado, MD; Eastern Maine Medical Center, Mary Kate Davitt, MD, Fredrick Wirth, MD; Fitzgerald Mercy Hospital, David L. Schutzman, MD; Frankford-Torresdale Hospital, Carrie A. Hufnal-Miller, MD, Gita Jani, MD; Geisinger Children's Hospital, Bakulesh D. Patel, MD; Good Samaritan Hospital, Horacio Falciglia, MD, David Levine, MD, Kimberly Hasselfeld, BSN; Greater Baltimore Medical Center, Siew-Jyu Wong, MD, Ambadas Pathak, MD; Hahnemann Hospital, Endla K. Anday, MD, H. S. Chawla, MD; Harris Methodist Hospital, Cody Arnold, MD; Health Care Corporation of St John's, W. L. Andrews, MD, M. Harvey, RN; Henrico Doctors' Hospital, Charles R. Frakes, MD, Casey G. Falterman, MD; Henry Ford Hospital, Sudhakar G Ezhuthachan, MD, Christine O. Newman, MS, RNC; Holy Cross Hospital, Steven P. Wyner, MD; Hospital Auxilio Mutuo, Awilda Rivera, MD, Aurea Lamboy, MD; Hospital Damas, Carlos Perez, MD, Edgard Diaz-Fernandez, MD; Howard County General Hospital, Bharti Razdan, MD, Tuvin Blechman, MD; Huntsville Hospital, Meyer E. Dworsky, MD, Linda S. Reynolds, RN, BSN; Inova Fairfax Hospital, Robin Baker, MD, Claire Pagano, RN; IWK-Grace Health Center, Alexander Allen, MD, Sharon Stone; Jackson-Madison County General Hospital, Donna-Jean Walker, MD; Joe Dimaggio Children's Hospital, Lester McIntyre, MD, M. Richard Auerbach, MD; Kaiser Foundation Hospital–Bellflower, Ann Marie Morris, MD, Kum Kum Bhasin, MD; Kaiser Foundation Hospital–Los Angeles, Ralph E. Franceschini, MD, David D. Wirtschafter, MD; Kaiser Foundation Hospital–San Diego, Howard A. Schneider, MD, Patricia Bromberger, MD; Kaiser Permanente, Shankar Bhatta, MD, David Braun, MD; Kaiser Permanente Hospital, Fontana, Dilip R. Bhatt, MD, Jacek Gogolou, MD, Asha Parikh, MD; Kandang Kerbau Hospital, Keng Wee Tan, MBBS, Poh Choo Khoo, MBChB, MRCP; Kennedy Memorial Hospital Systems, Jane A. Ierardi, MD, Renee Trautwein; Kinderabteilung General Hospital St Polten, Karl Zwiauer, MD, Martin Weissensteiner, MD; Kosair Children's Hospital, David Adamkin, MD, Tony Hilbert, RRT; Legacy Emanuel Children's Hospital, Patrick K. Lewallen, MD, Karen L. Waske, RN; Lenox Hill Hospital, Michael Giuliano, MD, Katherine Greene, RN; Lutheran General Children's Hospital, Bhagya L. Puppala, MD; Maine Medical Center, Alison Tito, NNP, Douglas Dramsfield, MD; Marshfield Clinic/St Joseph's Hospital, George J. Hoehn, MD, Edward C. Denny, MD; Mary Washington Hospital, Jyoti Amin, MD, Jun Kang, MD; McKay-Dee Hospital Center, J. Michael Clark, MD, Anne Anderson, MD; McKennan Hospital, Candace C. Caldwell, MD, Kandi R. McMenamy, MD; Mease Hospital Dunedin, Mary T. Newport, MD, Deborah L. Rogala, NNP; Medical Center Hospital of Vermont, Roger F. Soll, MD, Kathleen Leahy, RN, NNP; Medical Center of Delaware/Christiana Hospital, Stephen A. Pearlman, MD, Kathleen H. Leef, RNC; Medical College of Georgia, Jatinder Bhatia, MD, BS, Danene Carter, RN; Medical College of Pennsylvania, Jeanette Pleasure, MD, Alan B. Zubrow, MD; Medical University of South Carolina, W. Michael Southgate, MD, Myla Ebeling, BS; Memorial Health Care, Renee Gosselin, RN, Francis J. Bednarek, MD; Memorial Hospital of South Bend, Robert D. White, MD; Memorial Medical Center, Victor E. Lunyong, MD, Missy Schwah, RN, NNP; Memorial Medical Center, Linda M Sacks, MD, Nancy B. Shull, MD; Memorial Miller Children's Hospital, Arthur Strauss, MD, FAAP, Karol Norris, RN, MSN; Mercer Medical Center, Randi Axelrod, MD, Kerry I. Weiss, MD; Mercy Hospital and Medical Center, Rohitkumar Vasa, MD; Mercy Hospital South, Gerald P. Berkowitz, MD, Nancy Rutland, RN, NNP; Mercy Hospital of Pittsburgh, Barbara Israel, MD, Cheryl DiNardo, NNP; Mercy San Juan Hospital, Sarah Buxton, MD, Robert Kahle, MD; Meridia Hillcrest Hospital, Jeffrey Schwersenski, MD; Miami Children's Hospital, Ian P. Jeffries, MB, Mary E. Schwartz, ARNP; Miami Valley Hospital, Marc Belcastro, DO, Sue Mackey, RN; Mt Sinai Medical Center, Douglas P Powell, MD, Deborah Snyder-Miller, RN, NNP; New Hanover Regional Medical Center, Robert D. McArtor, MD, Susan Stone; Newark Beth Israel Medical Center, Lorraine Solecki, RN, David R. Brown, MD; North Bay Medical Center, Richard E. Bell, MD, David P. Treece, MD; North Memorial Health Care, Diane J. Camp, MD, Garth E. Fletcher, MD; North Oaks Health Systems, Ivan A. Villalta, MD, Marcia Brewton, RNC, NNP; Northside Hospital, Wendy Troyer, MD, Susan Scheiber; New York University Medical Center–Bellevue Hospital Center, Karen D. Hendricks-Munoz, MD, MPh, Yang S. Kim, MD; New York University Medical Center–Tisch Hospital, Karen D. Hendricks-Munoz, MD, MPh, Martha C. Caprio; Osaka City General Hospital, Satoshi Kusuda, MD, Tae-Jang Kim, MD; Parkview Memorial Hospital, Joel W. Secrest, MD, Pat Carteaux, RN; Penn State University Children's Hospital, Keith Marks, MD, Kathleen L. Gifford, RN, Dennis J. Mujsce, MD; Pennsylvania Hospital, Jeffrey Gerdes, MD, Janet Creely, RN, CPHQ, CCM, Sorayo Abbasi, MD; Pinnacle Health Hospitals–Harrisburg Campus, Barry S. Yoss, MD, Kevin N. Lorah, MD; Pitt County Memorial Hospital, Arthur E. Kopelman, MD, Pamela Beacham, RNC, MSN, NNP; Plantation General Hospital/Sheridan Children's, Mitchell E. Stern, MD, Karley Kay Wigton, MSN, RNC; Presbyterian Hospital, Virginia Hallinan, MD; Presbyterian Hospital of Dallas, Gregg Lund, DO, Randy C. Randel, MD; Presbyterian/St Luke's Medical Center, Mark S. Brown, MD, Connie J. Rusk, NNP; Promina Kennestone Hospital, Patricia Hunt, RNC, NNP, Vickie Fox, RNC, NNP; Providence Alaska Medical Center, Roy F. Davis, PhD, MD, Sharon J. Hulman, RN; Providence St Vincent Medical Center, John V. McDonald, MD, Diane Waldo, RN; Riverside Hospital, Michael D. Shaw, MD, Joan Zala Boldt, RN; Rogue Valley Medical Center, Margaret J. Ingman, MD, Tracy Ritchie, RN, NNP; Rose Medical Center, Joe V. Toney, MD; Rotunda Hospital, Tom Clarke, MB, FRCPI, Tom Matthews, MD, FRCPI; Royal Hobart Hospital, R. G. Bury, MD; Royal Hospital for Women, Newborn Medicine, Peter Campbell, MD, BS, FRACP, Tony Yee, MD, BS; Sacred Heart Medical Center, Ronald Shapiro, MD, Dawn Knight, RN; Sacred Heart Medical Center, Igor Gladstone, MD, Rebecca Bent, MD; Samaritan Medical Center, Karl Komar, MD, Rebecca A. Askins; Scott and White Hospital, Charles E. Oltorf, MD, David R. Krauss, MP; Seton Medical Center, Becky Roberson, BSN, David Wermer, MD; Sinai Hospital of Baltimore, Mollie Wheatley, RN, CNNP, S. Lee Marban, MD, PhD; Sinai Samaritan Medical Center, Chandra R. Shivpuri, MD; Southern New Hampshire Regional Medical Center, Marcus C. Hermansen, MD, Mary C. Goetz, NNP; Southern Regional Medical Center, Francisco Velez, MD, Mary Ruth White, RN, CPHQ; Sparrow Hospital, Padmani Karna, MD, Karen Taylor; St Agnes Hospital, Howard J. Birenbaum, MD, Barbara A. Long, RN; St Barnabas Medical Center, Shyan C. Sun, MD, Kamtorn Vanquanichyakorn, MD; St Cloud Hospital, Norm Virnig, MD, Nancy Watkins, NNP; St Francis Hospital, Michael J. Lang, MD, Kathy Rossman, RRT, BSN; St Francis Hospital and Medical Center, Hema N. De Silva, MD; St Francis Medical Center, James R. Hocker, MD, Connie McConnell, RN; St John Hospital and Medical Center, Maria L. Duenas, MD, Ali Rabbani, MD; St John's Hospital, Ronald Deering, MD, Susan Fancher; St John's Mercy Medical Center, M. Michael Maurer Jr, MD, Linda Baker; St Joseph Hospital, Hector R Pierantoni, MD, Gail R. Werkman, RNC, MSN; St Joseph Hospital, David A. Belenky, MD, Alfonso F. Pantoja, MD; St Joseph's Hospital, Jeffery S. Garland, MD, Sue Kannenberg, RRA; St Joseph's Hospital and Medical Center, Montgomery Hart, MD, Marie King, RN; St Joseph's Hospital Health Center, Larry Consenstein, MD, Phyllis Palla, RNC, NNP; St Luke's Hospital, Lloyd Tinianow, MD; St Luke's Hospital–Kansas City, MO, Christine Preheim, BSN, NNP, Katherine Claflin, MD; St Luke's Memorial Hospital, M. A. Siriwardena, MD, Toni Klossner; St Luke's Regional Medical Center, Matthew S. Sell, MD; St Mary's Hospital, Ann B. Olewnik, MD, Cindy Gaines-Clark, RN, NNP; St Mary's Hospital Medical Center, Mary Emily Bussey, MD; St Peter's Medical Center, Thomas Hegyi, MD, Jeanne Curry, RNC; St Vincent Hospitals and Health Services, Deborah A. Franzek, MD, Patty Dresdow, RN, PSN; St Vincent Medical Center, Jose G. Urrutia, MD, Usha Gupta, MD; Sunrise Hospital and Medical Center, J. Parker Kurlinski, MD, Shari Chavez, RN; Sutter Memorial Hospital, Andrew W. Wertz, MD, Julie Joannides; Tacoma General Hospital, John C. Mulligan, MD, James Rawlings; Tallahassee Memorial Regional Medical Center, Gary Cater, DO, Cindy Platt, PA-C; Temple University Hospital, Eileen E. Tyrala, MD; Texas Tech University School of Medicine Amarillo, Mubariz Naqvi, MD, Phillip Platt, NNP; The Brooklyn Hospital Center, Meena LaCorte, MD, Patrick LeBlanc, MD, Kimon Violaris, MD; The Children's Hospital, Adam A. Rosenberg, MD, Camilla Shear McAleavey; The Children's Hospital of St Joseph's, Adel M. Zauk, MD, Denis DiLallo; The Children's Medical Center, M. David Yohannan, MD, Carlene Nihizer, RN, Jeffrey Pietz, MD; The Children's Regional Hospital at Cooper, Sherry E. Courtney, MD, MS, Grace Stuart; The Childrens Hospital–Greenville Memorial Medical Center, Jerry Ferlauto, MD, John Wareham, MD; The Flushing Hospital, Yves Verna, MD, Elaine R. Green, NNP; The Methodist Hospitals, Inc, Cholemari Sridhar, MD, Barbara Johnson, NNP; The Toledo Hospital, V. Krishnan, MD, MPH; The Women's Hospital of Greensboro, Allison DuBuisson, MS, J. Laurence Ransom, MD; Tod Children's Hospital, Brenda H. Douglass, MD, Michael J. Balsan, MD; Tokyo Women's Medical College, Hiroshi Nishida, MD, Jum Mishima, MD; Truman Medical Center, Gary Pettett, MD, Karla Thorstad; Tulane University Medical Center, Maria Pierce, MD; University Children's Hospital, Manfred Weninger, MD, Christina Kohlhauser, MD; University of Colorado Health Sciences Center, Susan F. Townsend, MD, Adam A. Rosenberg; University Of California Davis Medical Center, Jay M. Milstein, MD, Boyd W. Goetzman, MD, PhD; University of Kentucky Children's Hospital, Thomas H. Pauly, MD, Vicki L. Whitehead, RN; University of Louisville Hospital, Dan L. Stewart, MD, Alicia T. Roy, RN; University of Minnesota Hospital and Clinic, Fairview University Medical Center, Dana E. Johnson, MD, PhD, Marla Mills, RN, CPNP; University of South Florida, Tampa General, Robert M. Nelson, MD, MS, Catherine M. Groh, RN; University of Tennessee Medical Center, Mark E. Anderson, MD, Tara M. Burnette, MD; University of Texas Medical Branch, Galveston, Michael H. Malloy, MD, Margarette Allen; Vassar Brothers Hospital, Stephan J. Kovacs, MD, Valeria Ann Artigas, NNP; Via Christi Regional Medical Center–St Francis Campus, Juan Longhi, MD, Ed Otero, MD; Virginia Beach General Hospital, Robert J. Balcom, MD, T. Arthur Payne, MD; Waikato Hospital, David Bourchier, MD, Philip Weston, MD; West Boca Medical Center, Luiz A. Grajwer, MD, J. Schulman, MD; Woman's Hospital, W. Robert Pace, MD, Cliff Richardson, NNP; Women's College Hospital, Arne Ohlsson, MD, Denise Zayack, RN; Woodhull Hospital, Frantz Brea, MD, Carol Cupolo, PA; Yakima Valley Memorial Hospital, Robert M. Skarin, MD, Elizabeth L. Engelhardt, MD; York Hospital, Steven L. Shapiro, MD.
- Received November 5, 1998.
- Accepted February 19, 1999.
- Address correspondence to Neil Finer, MD, UCSD Medical Center, 200 W. Arbor Dr, 8774, San Diego, CA 92103-8774.
Reprint requests to (A.L.S.) Vermont Oxford Network, 444 S Union St, Burlington, VT 05401.
- ↵Bloom RS, Cropley C, and the AHA/AAP Neonatal Resuscitation Program Steering Committee. Textbook of Neonatal Resuscitation. American Heart Association; 1994
- Davis DJ
- Derleth DP,
- Barbaresi WJ
- Horbar JD,
- Badger GJ,
- Lewit EM,
- et al.
- Investigators of the Vermont-Oxford Trials Network Database Project: The Vermont-Oxford Trials Network
- Jankov RP,
- Asztalos EV,
- Skidmore MB
- ↵Finer NN, Tarin T, Vaucher YE, Barrington KJ. Outcome of delivery room CPR in the less than 1000 gm infant. Pediatr Res. 1998;43;173A
- Piecuch RE,
- Leonard CH,
- Cooper BA,
- et al.
- Wilson-Costello D,
- Borawski E,
- Friedman H,
- et al.
- Copyright © 1999 American Academy of Pediatrics