Do We Know the Optimal Oxygen Concentration for Resuscitating a Premature Newborn

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.