The optimal initial oxygen concentration for resuscitation and stabilization of preterm infants (<32 weeks gestation) has been examined in a recent paper (Lakshminrusimha et al., 2026). Current guidance from the International Liaison Committee on Resuscitation (ILCOR) and the Neonatal Resuscitation Program (NRP) recommends initiating oxygen within a broad range of 30–100%. While this reflects uncertainty in the evidence base, it also presents practical challenges for clinicians seeking consistent and effective protocols in the delivery room.
Historically, recommendations favored fixed oxygen concentrations, ranging from 100% oxygen to room air or narrower ranges based on gestational age. However, accumulating data suggest that lower initial oxygen concentrations may be insufficient for many extremely preterm infants. In particular, failure to achieve a preductal oxygen saturation (SpO2) of at least 80% within the first five minutes after birth has been associated with increased risks of mortality and major complications, including severe intraventricular hemorrhage.
The authors highlight that preterm infants represent a heterogeneous population, and a uniform approach to oxygen initiation is unlikely to be optimal. Observational data indicate that a substantial proportion of infants born at earlier gestational ages do not reach target saturations when resuscitated with approximately 30% oxygen. In response, the paper proposes a gestational age–based strategy in which more immature infants are started on higher inspired oxygen concentrations, followed by rapid titration guided by continuous SpO2 monitoring.
This approach remains within current guideline limits but introduces a more structured framework for clinical practice. Oxygen concentration is adjusted at short intervals based on the difference between observed and target saturations, emphasizing dynamic management rather than fixed initial settings.
Emerging clinical and experimental evidence suggests that higher initial oxygen concentrations may improve early respiratory transition, pulmonary blood flow, and oxygenation in extremely preterm infants. Some studies have demonstrated improved achievement of target saturations and enhanced breathing effort without clear short-term increases in oxidative stress. However, the available evidence remains limited, and the long-term effects of early exposure to higher oxygen concentrations are not yet well established.
The paper also highlights ongoing challenges, including variability in oxygen delivery during non-invasive ventilation and delays between setting adjustments and effective delivery. These factors complicate titration and underscore gaps in current resuscitation practice.
Overall, the authors advocate for institution-specific protocols incorporating gestational age–based strategies, careful titration, and systematic data collection. They emphasize the need for prospective studies, large registries, and innovative trial designs to better define optimal oxygen strategies for preterm infants.
These research discussions are of particular interest to SurePulse who’s vision is a world where baby-centred innovation transforms neonatal outcomes. SurePulse is developing a wireless, multi-parameter monitoring device, which has the potential to be used straight after birth, even during delayed cord clamping, to provide Clinicians with quick and accurate vital signs information to inform treatment decisions.
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