TY - JOUR T1 - Recommendations in the face of uncertainty: should extremely preterm infants receive chest compressions and/or epinephrine in the delivery room? JF - Archives of Disease in Childhood - Fetal and Neonatal Edition JO - Arch Dis Child Fetal Neonatal Ed SP - 240 LP - 241 DO - 10.1136/archdischild-2019-318552 VL - 105 IS - 3 AU - Dominic Wilkinson AU - Neil Marlow AU - Dean Hayden AU - Helen Mactier Y1 - 2020/05/01 UR - http://fn.bmj.com/content/105/3/240.abstract N2 - The 2009 British Association of Perinatal Medicine (BAPM) framework recommended against advanced resuscitation measures (delivery room cardiopulmonary resuscitation, DR-CPR) in extremely preterm infants, noting that: “There is no evidence to support the use of epinephrine by any route, or chest compressions, during resuscitation at gestational age <26 weeks’.1 However, in the updated 2019 framework, published in this issue, the working group reached the opposite conclusion: ‘In the absence of sufficient evidence to justify a different approach in extremely preterm babies, if advanced resuscitation is considered appropriate, the Working Group recommends applying newborn resuscitation algorithms as used in more mature babies”.2 This was one of the more controversial elements of the new framework, generating a number of comments during the consultation phase. In this commentary, we will outline the arguments behind the changed recommendation.There are three essential reasons why neonatologists might be concerned about providing DR-CPR to extremely preterm infants. First, these measures seem to be antagonistic to the philosophy of providing gentle support and maintaining physiological stability in the critical early phase of their care. Sudden changes in intrathoracic pressure or blood pressure might increase the risk of intraventricular haemorrhage. Second, DR-CPR might be associated with such low survival that it is regarded as futile.3 Third, there may be a worry that even if infants survive after DR-CPR, they would be so severely impaired that it would have been better if they had died. The 2009 BAPM framework cites a single-centre study from the early 1990s, in which 9 of … ER -