Neonatal target oxygen levels for preterm infants
- Richard Martin, MD
Richard Martin, MD
- Section Editor — Neonatology
- Professor, Pediatrics, Reproductive Biology, and Physiology & Biophysics
- Case Western Reserve University School of Medicine
Oxygen supplementation is an important component of intensive neonatal care for the preterm infant. Ideally, oxygen administration provides adequate oxygenation for the metabolic needs of the neonate while avoiding the consequences of both hypoxemia and hyperoxia. However, it remains clinically challenging to define the optimal target levels of oxygen, especially in preterm infants.
Establishing neonatal target oxygen level for the preterm infant is discussed here. Oxygen delivery and monitoring and mechanical ventilation in the newborn are discussed separately. (See "Noninvasive oxygen delivery and oxygen monitoring in the newborn".)
SpO2 AND PaO2
Normal values for hemoglobin oxygen saturation (SpO2) reach or exceed 80 percent within 10 minutes of birth in term and healthy preterm infants without supplemented oxygen . In general, arterial partial pressure of oxygen (PaO2) values of 50 to 80 mmHg are adequate to meet metabolic demands of the neonate. In preterm infants, lower levels (PaO2 40 to 50 mmHg) are acceptable, partly due to the relative greater proportion of fetal hemoglobin (HbF).
Use of SpO2 for targeting oxygen levels — For neonates who receive supplemental oxygen therapy, established neonatal target oxygen levels are based on hemoglobin oxygen saturation (SpO2) since most neonatal intensive care units (NICUs) use continuous noninvasive pulse oximetry, which measures SpO2, to monitor oxygenation. Periodic arterial blood gas (ABG) samples are obtained that measure arterial oxygen tension (PaO2) to further refine safety and efficacy of oxygen therapy and correlate with pulse oximetry measurements, especially for infants at risk for either hypoxemia or hyperoxemia.
However, ABG measurements require blood sampling, either through indwelling catheters or percutaneous puncture of a palpable artery. ABG measurements may change during percutaneous punctures as the infant responds to the procedure, so clinicians should be mindful of this in interpreting the results. (See "Noninvasive oxygen delivery and oxygen monitoring in the newborn", section on 'Pulse oximetry' and "Noninvasive oxygen delivery and oxygen monitoring in the newborn", section on 'Arterial blood gas measurement'.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Dawson JA, Kamlin CO, Vento M, et al. Defining the reference range for oxygen saturation for infants after birth. Pediatrics 2010; 125:e1340.
- Quine D, Stenson BJ. Arterial oxygen tension (Pao2) values in infants <29 weeks of gestation at currently targeted saturations. Arch Dis Child Fetal Neonatal Ed 2009; 94:F51.
- Castillo A, Sola A, Baquero H, et al. Pulse oxygen saturation levels and arterial oxygen tension values in newborns receiving oxygen therapy in the neonatal intensive care unit: is 85% to 93% an acceptable range? Pediatrics 2008; 121:882.
- Cummings JJ, Polin RA, Committee on Fetus and Newborn, American Academy of Pediatrics. Noninvasive Respiratory Support. Pediatrics 2016; 137.
- Supplemental Therapeutic Oxygen for Prethreshold Retinopathy Of Prematurity (STOP-ROP), a randomized, controlled trial. I: primary outcomes. Pediatrics 2000; 105:295.
- SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network, Carlo WA, Finer NN, et al. Target ranges of oxygen saturation in extremely preterm infants. N Engl J Med 2010; 362:1959.
- Schmidt B, Whyte RK, Asztalos EV, et al. Effects of targeting higher vs lower arterial oxygen saturations on death or disability in extremely preterm infants: a randomized clinical trial. JAMA 2013; 309:2111.
- BOOST II United Kingdom Collaborative Group, BOOST II Australia Collaborative Group, BOOST II New Zealand Collaborative Group, et al. Oxygen saturation and outcomes in preterm infants. N Engl J Med 2013; 368:2094.
- Askie LM, Darlow BA, Davis PG, et al. Effects of targeting lower versus higher arterial oxygen saturations on death or disability in preterm infants. Cochrane Database Syst Rev 2017; 4:CD011190.
- Manja V, Lakshminrusimha S, Cook DJ. Oxygen saturation target range for extremely preterm infants: a systematic review and meta-analysis. JAMA Pediatr 2015; 169:332.
- Manja V, Saugstad OD, Lakshminrusimha S. Oxygen Saturation Targets in Preterm Infants and Outcomes at 18-24 Months: A Systematic Review. Pediatrics 2017; 139.
- Poets CF, Roberts RS, Schmidt B, et al. Association Between Intermittent Hypoxemia or Bradycardia and Late Death or Disability in Extremely Preterm Infants. JAMA 2015; 314:595.
- BOOST-II Australia and United Kingdom Collaborative Groups, Tarnow-Mordi W, Stenson B, et al. Outcomes of Two Trials of Oxygen-Saturation Targets in Preterm Infants. N Engl J Med 2016; 374:749.
- Walsh MC, Di Fiore JM, Martin RJ, et al. Association of Oxygen Target and Growth Status With Increased Mortality in Small for Gestational Age Infants: Further Analysis of the Surfactant, Positive Pressure and Pulse Oximetry Randomized Trial. JAMA Pediatr 2016; 170:292.
- Di Fiore JM, Martin RJ, Li H, et al. Patterns of Oxygenation, Mortality, and Growth Status in the Surfactant Positive Pressure and Oxygen Trial Cohort. J Pediatr 2017; 186:49.
- Navarrete CT, Wrage LA, Carlo WA, et al. Growth Outcomes of Preterm Infants Exposed to Different Oxygen Saturation Target Ranges from Birth. J Pediatr 2016; 176:62.
- Bancalari E, Claure N. Oxygenation targets and outcomes in premature infants. JAMA 2013; 309:2161.
- Polin RA, Bateman D. Oxygen-saturation targets in preterm infants. N Engl J Med 2013; 368:2141.
- Sears JE, Pietz J, Sonnie C, et al. A change in oxygen supplementation can decrease the incidence of retinopathy of prematurity. Ophthalmology 2009; 116:513.
- Martin RJ, Wang K, Köroğlu O, et al. Intermittent hypoxic episodes in preterm infants: do they matter? Neonatology 2011; 100:303.
- van Zanten HA, Tan RN, van den Hoogen A, et al. Compliance in oxygen saturation targeting in preterm infants: a systematic review. Eur J Pediatr 2015; 174:1561.
- Lim K, Wheeler KI, Gale TJ, et al. Oxygen saturation targeting in preterm infants receiving continuous positive airway pressure. J Pediatr 2014; 164:730.
- Hagadorn JI, Furey AM, Nghiem TH, et al. Achieved versus intended pulse oximeter saturation in infants born less than 28 weeks' gestation: the AVIOx study. Pediatrics 2006; 118:1574.
- Claure N, D'Ugard C, Bancalari E. Automated adjustment of inspired oxygen in preterm infants with frequent fluctuations in oxygenation: a pilot clinical trial. J Pediatr 2009; 155:640.
- Hallenberger A, Poets CF, Horn W, et al. Closed-loop automatic oxygen control (CLAC) in preterm infants: a randomized controlled trial. Pediatrics 2014; 133:e379.
- Waitz M, Schmid MB, Fuchs H, et al. Effects of automated adjustment of the inspired oxygen on fluctuations of arterial and regional cerebral tissue oxygenation in preterm infants with frequent desaturations. J Pediatr 2015; 166:240.
- Van Zanten HA, Kuypers KLAM, Stenson BJ, et al. The effect of implementing an automated oxygen control on oxygen saturation in preterm infants. Arch Dis Child Fetal Neonatal Ed 2017; 102:F395.