Published online January 2, 2007
PEDIATRICS Vol. 119 No. 1 January 2007, pp. 217a-219 (doi:10.1542/peds.2006-2714)

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LETTER TO THE EDITOR

The Need to Assess Benefits and Not Just Risks of 100% Oxygen for Newborn Resuscitation: In Reply

Ola Didrik Saugstad, MD, PhD
¹ Department of Pediatric Research
Rikshospitalet Medical Center
0027 Oslo, Norway

Siddarth Ramji, MD
² Department of Pediatrics
Maulana Azad Medical College
New Delhi 110002, India

Maximo Vento, MD, PhD
³ Servicio de Neonatologia
Hospital Universitario
Materno-Infantil La Fe
46009 Valencia, Spain

Rozycki's letter regarding our recent commentary¹ brings to attention some important aspects that should be considered when we discuss which oxygen concentration should be used for newborn resuscitation. Rozycki is completely right when he points out that most of the 1800 newborn children that up to now have been included in the 6 randomized or pseudorandomized studies performed in this field come from countries with low income. However, we have to consider the fact that most asphyxiated newborn infants are born in low-income countries. Therefore, we think that the material is relevant. A separate analysis of the children recruited from Spain, a country with significantly lower perinatal mortality than the United States, also shows a significant reduced mortality in newborns who are resuscitated with 21% compared with 100% O₂.² It has already been 13 years since our pilot study³ and 8 years since the large international multicenter study Resair 2⁴ were published. There has been ample time for other investigators from, for instance, the United States to set up their own studies. Why this has not been done we do not know.

The increased oxidative stress we have found in infants resuscitated with 100% O₂ has immediate consequences as seen in heart and kidney.^5,6 It is reasonable that these changes and similar changes in other organs such as the brain, adrenal glands, etc, so far not investigated clinically, could contribute to increased morbidity and mortality. We do not know at present if there will be any long-term consequences on organ function; however, the burden of proof that negative short-term and long-term effects do not appear should be on those, such as American Academy of Pediatrics, who promote the use of 100% O₂.⁷

Regarding the 30-second delay in response to resuscitation in infants exposed to 100% O₂, this has been confirmed in several studies.² We believe that such a delay may have several important consequences. Confronted with a lack of response, it may increase the aggressiveness of the resuscitation team. Because the new guidelines give only 30 seconds to move from one stage of resuscitation to the next, a 30-second delay in time to first breath may result in more children going through advanced cardiopulmonary resuscitation as chest compressions and drug administration. Therefore, this delay, in our opinion, is not an innocent byproduct of the hyperoxic therapy.

We agree that the 2 studies demonstrating a significant association between brief oxygen exposure at birth and childhood cancer^8,9 should be interpreted with caution, and we have done that. Still, the finding is interesting and should be concerning to everyone interested in this topic.

We totally agree with Rozycki that follow-up studies are needed. The only one performed thus far is our own, which showed that surviving newborn infants resuscitated with room air at birth are doing as well at 18 to 24 months of age as those who were resuscitated with 100% O₂.¹⁰ We, as well as others, have emphasized the need for more such follow-up studies.

We will also underline that we have never promoted the use of room air for newborn resuscitation, and we are open to the possibility that some term or near-term newborns may need supplemental O₂ (even 100%) for a short period of time. However, we are strongly convinced that the routine use of 100% O₂ is detrimental. The data showing this are in fact so convincing that the Canadian Paediatric Society¹¹ and the Swedish Neonatal Society (Mats Blennow, MD, PhD, Swedish Neonatal Society, written communication, 2006), for instance, have decided that newborn resuscitation should begin with room air. Also, US and other investigators recommend beginning newborn resuscitation with room air.^12–14

REFERENCES

1. Saugstad OD, Ramji S, Vento M. Oxygen for newborn resuscitation: how much is enough? Pediatrics. 2006;118 :789 –792[Free Full Text]
2. Saugstad OD, Ramji S, Vento M. Resuscitation of depressed newborn infants with ambient air or pure oxygen: a meta-analysis. Biol Neonate. 2005;87 :27 –34[CrossRef][Web of Science][Medline]
3. Ramji S, Ahuja S, Thirupuram S, Rootwelt T, Rooth G, Saugstad OD. Resuscitation of asphyxic newborn infants with room air or 100% oxygen. Pediatr Res. 1993;34 :809 –812[Web of Science][Medline]
4. Saugstad OD, Rootwelt T, Aalen AO. Resuscitation of asphyxiated newborn infants with room air or oxygen: an international controlled trial—the Resair 2 study. Pediatrics. 1998;102(1) . Available at: www.pediatrics.org/cgi/content/full/102/1/e1
5. Vento M, Asensi M, Sastre J, Lloret A, Garcia-Sala F, Vina J. Oxidative stress in asphyxiated term infants resuscitated with100% oxygen [published correction appears in J Pediatr. 2003;142:616]. J Pediatr. 2003;142 :240 –246[CrossRef][Web of Science][Medline]
6. Vento M, Sastre J, Asensi MA, Vina J. Room-air resuscitation causes less damage to heart and kidney than 100% oxygen. Am J Respir Crit Care Med. 2005;172 :1393 –1398[Abstract/Free Full Text]
7. American Heart Association. 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric basic life support. Pediatrics. 2006;117(5) . Available at: www.pediatrics.org/cgi/content/full/117/5/e989
8. Naumberg E, Bellocco R, Cnattingious S, Jonzon A, Ekbom A. Supplementary oxygen and risk of childhood lymphatic leukemia. Acta Paediatr. 2002;91 :1328 –1333[CrossRef][Web of Science][Medline]
9. Spector LG, Klebanoff MA, Freusner JH, Georgieff MK, Ross JA. Childhood cancer following neonatal oxygen supplementation. J Pediatr. 2005;147 :27 –31[CrossRef][Web of Science][Medline]
10. Saugstad OD, Ramji S, Irani SF, et al. Resuscitation of newborn infants with 21% or 100% oxygen: follow-up at 18 to 24 months. Pediatrics. 2003;112 :296 –300[Abstract/Free Full Text]
11. Canadian NRP Steering Committee. Addendum to the 2006 NRP textbook: recommendations for specific treatment modifications in the Canadian context. 2006. Available at: www.cps.ca/ENGLISH/prodev/NRP/addendum.pdf. Accessed November 1, 2006
12. Finer NN, Rich WD. Neonatal resuscitation: raising the bar. Curr Opin Pediatr. 2004;16 :157 –162[CrossRef][Web of Science][Medline]
13. Paneth N. The evidence mounts against use of pure oxygen in newborn resuscitation. J Pediatr. 2005;147 :4 –6[CrossRef][Web of Science][Medline]
14. Davis PG, Tan A, O'Donnell CP, Schulze A. Resuscitation of newborn infants with 100% oxygen or air: a systematic review and meta-analysis. Lancet. 2004;364 :1329 –1333[CrossRef][Web of Science][Medline]

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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Saugstad, O. D. Articles by Vento, M. Search for Related Content PubMed Articles by Saugstad, O. D. Articles by Vento, M. Related Collections Premature & Newborn Social Bookmarking                         What's this?