Published online June 2, 2008
PEDIATRICS Vol. 121 No. 6 June 2008, pp. 1257 (doi:10.1542/peds.2008-0542)

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COMMENTARY

Oxygen for the Preterm Newborn: One Infant at a Time

Augusto Sola, MD

Mid Atlantic Neonatology Associates and Atlantic Neonatal Research Institute, Atlantic Health System, Morristown, New Jersey

The randomized trial by Wang et al¹ compares short-term outcomes of infants who were 23 to 32 weeks' gestation and initially were given 1 of 2 fraction of inspired oxygen (FIO₂) extremes (0.21 or 1.0) for delivery room resuscitation. "Too much" oxygen in the blood is a health hazard,^2,3 and health care providers are the only known cause of neonatal hyperoxemia. Wang et al show that 100% O₂ is not needed for most preterm infants during the transition period. Within 2 minutes, pulse oxygen saturation (SpO₂) may reach values that are associated with high PaO₂⁴ and release "dastardly chemicals."⁵ Likewise, infants can be made hyperoxemic without "pure O₂." If after the transition period the FIO₂ is increased "a little" (5%–10%) as a "precautionary routine" measure when not needed, then significant hyperoxemia can occur in a few seconds, as can be understood from cardiopulmonary physiology and the alveolar gas equation^2,6; therefore, pure oxygen or any preemptive FIO₂ increase should be eradicated from practice in the delivery room, NICU, surgical suite, or elsewhere.^6,7

The study by Wang et al¹ cannot provide answers for "best practice" because of its small sample size (n = 41), wide range of gestational ages (23–32 weeks), and 1-minute Apgar score >5 in 50%. "Best practice" on the basis of averaging would not be suitable, because O₂ needs and responses may be related to those factors. In addition, in this sample (mean birth weight: 1050 g; gestational age: 28 weeks; cord: pH 7.30; Apgar as mentioned), 93% "needed" positive pressure ventilation and 52% of those were not intubated.

Tissue oxygenation is a complex process^2,6 that we cannot monitor clinically. One day we may target cellular oxygenation and not just SpO₂. The actual low SpO₂ level that is tolerable by tiny infants during transition and in NICU remains undetermined, but a desired target can be achieved with adequate SpO₂ monitoring and best available knowledge. On the basis of SpO₂ values of only 18 infants, the authors recommend not using room air as the initial resuscitating gas for neonates who are 32 weeks' gestation; however, an infant of 25 weeks' gestation is not a tiny 32-week infant, and O₂ need is infant dependent. Room air as the initial gas may be sufficient for some but not for other infants who are 32 weeks' gestation, in whom FIO₂ will need to be increased very minimally or largely. Hyperoxemia and hypoxemia, as are understood today, can be avoided in each individual infant by progressively changing the FIO₂ to achieve "desired" SpO₂ values.

Quality of neonatal clinical care improves with the ability to discover errors, not the truth. Errors have been generalizing guidelines for FIO₂ in delivered gas, focusing on FIO₂ extremes (0.21 and 1.0) when there are 79 other options,⁸ giving O₂ at whimsical dosages and ignoring that a "normal" SpO₂ breathing supplemental O₂ can mean significant hyperoxia. The gap between knowledge and practice will decrease by improving education on neonatal oxygenation, eliminating the encumbrance that the things that we do know pose to our learning of things that we do not and by basing individual actions on careful assessment of infants' needs. We must continue to prevent or treat vigorously and not permit hypoxemia as we eradicate potentially damaging practices that for decades have led to hyperoxemia.

	FOOTNOTES

 
Accepted Feb 20, 2008.

Address correspondence to Augusto Sola, MD, Mid Atlantic Neonatology Associates and Atlantic Neonatal Research Institute, Atlantic Health System, 100 Madison Ave, Morristown, NJ 07960. E-mail: augustosolaneo{at}gmail.com

The author has indicated he has no financial relationships relevant to this article to disclose.

Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.

	REFERENCES

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6. Sola A. Oxygen in neonatal anaesthesia: friend or foe? Curr Opin Anaesthesiol. 2008; In press
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PEDIATRICS (ISSN 1098-4275). ©2008 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 Similar articles in PubMed 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 Sola, A. Search for Related Content PubMed PubMed Citation Articles by Sola, A. Related Collections Premature & Newborn Social Bookmarking                         What's this?