Delivery Room Oxygen for Preterm Infants

For decades, neonatologists have grappled with defining the optimal approach to providing oxygen to preterm newborns in the delivery room. The recommendations for term newborns are more clear. Since 2010, the International Liaison Committee on Resuscitation (ILCOR) has recommended initiating resuscitation with 0.21 fraction of inspired oxygen (Fio2) rather than 1.0 Fio2 (pure oxygen) because of increased mortality rates associated with exposure to pure oxygen. However, the “oxygen dilemma” persists for resuscitation of preterm infants. Most preterm infants require supplemental oxygen during postnatal transition, but they are also particularly vulnerable to oxidative injury to developing organs. Acknowledging this delicate balance, the ILCOR recommends an initial low Fio2 (0.21-0.30) for delivery room resuscitation of preterm infants. This recommendation was most recently informed by a 2019 systematic review and meta-analysis in which there was no statistically significant difference in short-term mortality or morbidities between initial low and higher Fio2 for preterm infants. Authors of the ILCOR recommendations acknowledged the low level of certainty of the available evidence, with no clear signal of benefit or harm for either approach. Existing treatment recommendations, therefore, reflect a consensus-driven preference to avoid exposing preterm newborns to additional oxygen in the absence of proven benefits. The practice of using an initial lower Fio2 with subsequent titration to reach specified targets of oxygen saturation as measured by pulse oximetry (Spo2) has been widely adopted internationally for resuscitation of preterm infants.