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Don't stop now? How long should resuscitation continue at birth in the absence of a detectable heartbeat?
  1. Dominic JC Wilkinson1,2,3,
  2. Ben Stenson4
  1. 1Faculty of Philosophy, Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
  2. 2Robinson Institute, Discipline of Obstetrics and Gynaecology, University of Adelaide, Adelaide, Australia
  3. 3John Radcliffe Hospital, Oxford, UK
  4. 4Neonatal Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
  1. Correspondence to Dr Dominic Wilkinson, Oxford Uehiro Centre for Practical Ethics, Suite 8, Littlegate House, St Ebbes St, Oxford OX1 1PT, UK; dominic.wilkinson{at}

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Shah and colleagues from Western Australia present the latest in a series of papers, suggesting that outcomes for infants who have received prolonged resuscitation in the delivery room are more favourable than before.1 They report 13 near-term infants who had an Apgar score of 0 at 10 min and were admitted to intensive care. Five of the 13 infants survived and 4 of the 5 appeared to have normal development at 1–2 years of age (one of the infants had hearing impairment). One of the five survivors developed severe spastic quadriplegia.1

Similar findings were reported recently in this journal by Kasdorf et al.2 They reported nine infants managed in a New York hospital, and combined their results with data from three of the therapeutic hypothermia trials and one other previously published report.3 In total, Kasdorf et al2 analysed a cohort of 90 infants with an Apgar score of 0 at 10 min who were admitted to intensive care. Fifty per cent of the infants survived to discharge from hospital, and 49% of the survivors were developmentally normal at follow-up at 1–2 years.2 Longer-term developmental outcome data are available for a subgroup of these infants who were enrolled in the US NICHD cooling trial.4 Twenty four infants in that trial had an Apgar score of 0 at 10 min. Eleven (46%) survived to age 6–7 years, and 5/11 (46%) had mild or no disability at follow-up.4

Considered together, these results are in striking contrast to earlier studies and should cause us to question current recommendations in consensus resuscitation guidelines. A systematic review in 2007 identified 94 infants from eight reports.5 Seventy eight infants (83%) died, while 10/13 (76%) of survivors with available long-term follow-up were severely impaired. The authors concluded that the outcome for infants with an …

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