Transition/Adaptation in the Delivery Room and Less RDS: “Don't Just Do Something, Stand There!”

I t is old news that neonatology has changed strikingly with the increased survival of smaller and smaller infants. However, to appreciate the results obtained using continuous positive airway pressure (CPAP) reported by Ammari et al in this issue of The Journal, let’s step back to the 1980s-prior to the frequent use of antenatal corticosteroids or surfactant therapy and to multiple changes in obstetric management of the delivery of low birth weight infants. Most infants b28 weeks gestation were ventilated, had multiple complications, and had a high mortality rate. Avery et al reported in 1987 that the use of CPAP in New York at Columbia University seemed to be associated with less bronchopulmonary dysplasia than did the ventilator management practiced by other neonatal units, an observation that was reinforced by similar comparisons by Van Marter et al in 1992. The weakness of the current report by Ammari et al1 is that it is simply their clinical experience with the use of CPAP to stabilize infants after delivery at Columbia from 1999 to 2002. We remain without randomized controlled trials designed to test the perceived benefits of CPAP, a gap that hopefully will be filled by ongoing trials. However, what I find remarkable about the report is the high percentage of infants with birth weights b1000 g who can breathe in the delivery room and who do not have severe respiratory distress syndrome (RDS). These 2 outcomes are contrary to the clinical experiences of many neonatologists and may be important to understanding the incidence of bronchopulmonary dysplasia.