Oxygenation of the Immature Infant: A Commentary and Recommendations for Oxygen Saturation Targets and Alarm Limits

Abstract

Background: For 70 years, there has been a search for the optimal oxygenation of premature infants. In spite of the lack of evidence, guidelines have successively reduced oxygenation targets during these years. Objectives: (1) To present a summary of previously published meta-analyses of 5 randomized studies (NeOProM) which tested a low (85–89%) versus a high (91–95%) oxygen saturation target the first weeks after birth on outcome of immature newborn infants. (2) To present international recommendations for oxygenation the first weeks after birth. Methods: Data were retrieved from meta-analyses and reviews of these studies. Results: Mortality and necrotizing enterocolitis (NEC) are significantly higher in patients with a low saturation target (relative risk, RR 1.16 and 1.24, respectively), while severe retinopathy of prematurity (ROP) is reduced (RR 0.74), fortunately without a change in the rate of blindness. Severe intraventricular hemorrhage, patent ductus arteriosus, and bronchopulmonary dysplasia (defined physiologically) were not significantly affected by the oxygen targets in the range of these studies. Based on these data, it is recommended that SpO₂ targets from birth to 36 weeks postconceptional age for infants < 28 weeks gestational age (GA) should be between 90 and 94% (with alarm limits of 89 and 95%), respectively. It is recommended to keep infants small for GA well oxygenated within the suggested targets avoiding fluctuations. Conclusions: The ideal oxygen saturation targets for infants < 28 weeks GA are not known. Mortality, ROP, and NEC seem to be particularly oxygen-sensitive outcome variables. The optimal oxygen saturation for premature infants > 28 weeks GA has not been carefully studied.