The inhibiting effect of opioids on intestinal motility is a cause of particular concern in extremely low birth weight (ELBW; birth weight <1000 g) infants with decreased peristalsis. An ELBW infant (birth weight 740 g) born after 26 + 1 week of gestation had an uneventful clinical course during the first few days of life. Sudden deterioration occurred on day 8 with metabolic acidosis, hyperglycemia and frequent apnea with secondary bradycardia. A chest X ray demonstrated the presence of air beneath the diaphragm. Intestinal perforation was suspected and the infant was taken to theater for laparotomy. For pain management, a 22 G epidural catheter was inserted via the caudal approach and threaded to a mid-thoracic level. Epidural ropivacaine was administered intraoperatively and for 48 h postoperatively. The infant was extubated on the following day. Opioids were not required or given at any stage during or after surgery. Peristalsis was present on auscultation as early as 3 h after surgery, the first stool was passed on the same day. Enteral nutrition was resumed early and tolerated well, full enteral feeding was rapidly achieved. Our case shows that the technique of caudal anesthesia is feasible in ELBW infants. We speculate that intestinal motility and establishment of full enteral feedings may be achieved earlier by epidural ropivacaine in cases of abdominal surgery in ELBW infants.