Is the Ideal Oxygen Concentration for Premature Newborn Resuscitation Known?

Abstract

Fetus develops in a relatively hypoxemic environment in utero; however, extremely premature infants need supplemental oxygen soon after birth at resuscitation. Reduced antioxidant defenses predisposes the premature infant to toxic effects of oxygen such as bronchopulmonary dysplasia (BPD) and brain injury. Guidelines were published in 2010 regarding oxygen concentrations to be administered along with the targeted oxygen saturations (SpO2) in the first ten minutes after birth in both term and premature infants. Since 2010, there is a widespread tendency to use lower fraction of inspired oxygen (≤0.3) at birth. Recent studies and meta-analysis do not provide sufficient evidence to indicate that initiating resuscitation with lower oxygen concentration (≤30% O2) at birth decrease BPD or other clinical outcomes in premature neonates. On the other hand, it is of concern that, it may increase mortality particularly in infants <28 weeks gestational age with no demonstrable benefit on clinical outcomes. Did the pendulum swing too quickly from 100% O2 to 21% O2 for resuscitation of these infants? Should we initiate resuscitation of all premature infants with >21% O2, meaning a change in neonatal resuscitation guidelines or conduct a rigorous multicenter trial to address this dilemma.