Inadvertently injurious ventilation of preterm neonates in the delivery room can cause cerebral white matter (WM) inflammation and injury. We investigated the impact of an early high dose of recombinant human erythropoietin (EPO) on ventilation-induced WM changes in preterm lambs. METHODS: Injurious ventilation, targeting a VT of 15 ml kg-1 with no positive end-expiratory pressure (PEEP), was initiated for 15 min in preterm lambs (0.85 gestation). Conventional ventilation was continued for a further 105 min. Lambs received either 5000 IU kg-1 of EPO (EPREX(R): Vent+EPO; n = 6) or vehicle (Vent; n = 8) via an umbilical vein at 4 +/- 2 min. Markers of WM injury and inflammation were assessed using quantitative real-time PCR (qPCR) and immunohistochemistry and compared to a group of unventilated controls (UVC; n = 4). RESULTS: In Vent+EPO lambs compared to Vent lambs: (i) IL-1beta and IL-6 levels in the periventricular WM and IL-8 levels in the subcortical WM were higher (P <0.05 for all); (ii) the density of microglia within the aggregations was not different in the periventricular WM and was lower in the subcortical WM (P = 0.001); (iii) the density of astrocytes was lower in the subcortical WM (P = 0.002); (iv) occludin and claudin-1 mRNA levels were higher in the periventricular WM (P <0.02 for all) and (vi) the number of blood vessels with protein extravasation was lower (P <0.05). CONCLUSIONS: Recombinant human EPO had variable regional effects within the WM when administered during injurious ventilation. The adverse short-term outcomes discourage the use of early high dose EPO administration in preterm ventilated babies. This article is protected by copyright. All rights reserved.