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Saugstad OD, Lakshminrusimha S. To intubate or not to intubate, is that the question? Pediatr Res 2024; 95:1685-1687. [PMID: 38341489 DOI: 10.1038/s41390-024-03073-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 01/12/2024] [Indexed: 02/12/2024]
Affiliation(s)
- Ola Didrik Saugstad
- Department of Pediatric Research, University of Oslo, Oslo, Norway.
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Satyan Lakshminrusimha
- Department of Pediatrics, University of California at Davis Children's Hospital, Sacramento, CA, USA
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Mamidi RR, McEvoy CT. Oxygen in the neonatal ICU: a complicated history and where are we now? Front Pediatr 2024; 12:1371710. [PMID: 38751747 PMCID: PMC11094359 DOI: 10.3389/fped.2024.1371710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/17/2024] [Indexed: 05/18/2024] Open
Abstract
Despite major advances in neonatal care, oxygen remains the most commonly used medication in the neonatal intensive care unit (NICU). Supplemental oxygen can be life-saving for term and preterm neonates in the resuscitation period and beyond, however use of oxygen in the neonatal period must be judicious as there can be toxic effects. Newborns experience substantial hemodynamic changes at birth, rapid energy consumption, and decreased antioxidant capacity, which requires a delicate balance of sufficient oxygen while mitigating reactive oxygen species causing oxidative stress. In this review, we will discuss the physiology of neonates in relation to hypoxia and hyperoxic injury, the history of supplemental oxygen in the delivery room and beyond, supporting clinical research guiding trends for oxygen therapy in neonatal care, current practices, and future directions.
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Affiliation(s)
- Rachna R. Mamidi
- Division of Neonatology, Oregon Health & Science University, Portland, OR, United States
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3
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Schmölzer GM, Asztalos EV, Beltempo M, Boix H, Dempsey E, El-Naggar W, Finer NN, Hudson JA, Mukerji A, Law BHY, Yaskina M, Shah PS, Sheta A, Soraisham A, Tarnow-Mordi W, Vento M. Does the use of higher versus lower oxygen concentration improve neurodevelopmental outcomes at 18-24 months in very low birthweight infants? Trials 2024; 25:237. [PMID: 38576007 PMCID: PMC10996184 DOI: 10.1186/s13063-024-08080-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 03/29/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Immediately after birth, the oxygen saturation is between 30 and 50%, which then increases to 85-95% within the first 10 min. Over the last 10 years, recommendations regarding the ideal level of the initial fraction of inspired oxygen (FiO2) for resuscitation in preterm infants have changed from 1.0, to room air to low levels of oxygen (< 0.3), up to moderate concentrations (0.3-0.65). This leaves clinicians in a challenging position, and a large multi-center international trial of sufficient sample size that is powered to look at safety outcomes such as mortality and adverse neurodevelopmental outcomes is required to provide the necessary evidence to guide clinical practice with confidence. METHODS An international cluster, cross-over randomized trial of initial FiO2 of 0.3 or 0.6 during neonatal resuscitation in preterm infants at birth to increase survival free of major neurodevelopmental outcomes at 18 and 24 months corrected age will be conducted. Preterm infants born between 230/7 and 286/7 weeks' gestation will be eligible. Each participating hospital will be randomized to either an initial FiO2 concentration of either 0.3 or 0.6 to recruit for up to 12 months' and then crossed over to the other concentration for up to 12 months. The intervention will be initial FiO2 of 0.6, and the comparator will be initial FiO2 of 0.3 during respiratory support in the delivery room. The sample size will be 1200 preterm infants. This will yield 80% power, assuming a type 1 error of 5% to detect a 25% reduction in relative risk of the primary outcome from 35 to 26.5%. The primary outcome will be a composite of all-cause mortality or the presence of a major neurodevelopmental outcome between 18 and 24 months corrected age. Secondary outcomes will include the components of the primary outcome (death, cerebral palsy, major developmental delay involving cognition, speech, visual, or hearing impairment) in addition to neonatal morbidities (severe brain injury, bronchopulmonary dysplasia; and severe retinopathy of prematurity). DISCUSSION The use of supplementary oxygen may be crucial but also potentially detrimental to preterm infants at birth. The HiLo trial is powered for the primary outcome and will address gaps in the evidence due to its pragmatic and inclusive design, targeting all extremely preterm infants. Should 60% initial oxygen concertation increase survival free of major neurodevelopmental outcomes at 18-24 months corrected age, without severe adverse effects, this readily available intervention could be introduced immediately into clinical practice. TRIAL REGISTRATION The trial was registered on January 31, 2019, at ClinicalTrials.gov with the Identifier: NCT03825835.
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Affiliation(s)
- Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, Edmonton, AB, T5H 3V9, Canada.
- Dept. of Pediatrics, University of Alberta, Edmonton, Canada.
| | - Elizabeth V Asztalos
- Department of Newborn & Developmental Paediatrics, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON, Canada
| | - Marc Beltempo
- Departement of Pediatrics, Montreal Children's HospitalMcGill University Health CenterMcGill University, Montreal, QC, Canada
| | - Hector Boix
- Division of Neonatology, Dexeus Quironsalud University Hospital, Barcelona, Spain
| | - Eugene Dempsey
- INFANT Research Centre, University College Cork, Cork, Ireland
| | - Walid El-Naggar
- Department of Paediatrics, Dalhousie University, Halifax, Canada
| | - Neil N Finer
- School of Medicine, University of California, San Diego, CA, USA
- Sharp Mary Birch Hospital for Women and Newborns, San Diego, USA
| | - Jo-Anna Hudson
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NF, Canada
| | - Amit Mukerji
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Brenda H Y Law
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, Edmonton, AB, T5H 3V9, Canada
- Dept. of Pediatrics, University of Alberta, Edmonton, Canada
| | - Maryna Yaskina
- Women and Children's Health Research Institute (WCHRI), University of Alberta, Edmonton, Canada
| | - Prakesh S Shah
- Department of Pediatrics, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Ayman Sheta
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
| | - Amuchou Soraisham
- Department of Pediatrics, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
- Alberta Childrens Hospital Research Institute, University of Calgary, Alberta, Canada
| | - William Tarnow-Mordi
- Trials Centre, National Health and Medical Research Council Clinical, University of Sydney, Camperdown, Australia
| | - Max Vento
- Department of Pediatrics, La Fe University and Polytechnic Hospital, Valencia, Spain
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Berisha G, Kvenshagen LN, Boldingh AM, Nakstad B, Blakstad E, Rønnestad AE, Solevåg AL. Video-Recorded Airway Suctioning of Clear and Meconium-Stained Amniotic Fluid and Associated Short-Term Outcomes in Moderately and Severely Depressed Preterm and Term Infants. CHILDREN (BASEL, SWITZERLAND) 2023; 11:16. [PMID: 38255330 PMCID: PMC10814005 DOI: 10.3390/children11010016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/11/2023] [Accepted: 12/20/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND The aim of this study was to investigate delivery room airway suctioning and associated short-term outcomes in depressed infants. METHODS This is a single-centre prospective observational study of transcribed video recordings of preterm (gestational age, GA < 37 weeks) and term (GA ≥ 37 weeks) infants with a 5 min Apgar score ≤ 7. We analysed the association between airway suctioning, breathing, bradycardia and prolonged resuscitation (≥10 min). For comparison, non-suctioned infants with a 5 min Apgar score ≤ 7 were included. RESULTS Two hundred suction episodes were performed in 19 premature and 56 term infants. Breathing improved in 1.9% of premature and 72.1% of term infants, and remained unchanged in 84.9% of premature and 27.9% of term infants after suctioning. In our study, 61 (81.3%) preterm and term infants who were admitted to the neonatal intensive care unit experienced bradycardia after airway suctioning. However, the majority of the preterm and more than half of the term infants were bradycardic before the suction procedure was attempted. Among the non-airway suctioned infants (n = 26), 73.1% experienced bradycardia, with 17 non-airway suctioned infants being admitted to the neonatal intensive care unit. There was a need for resuscitation ≥ 10 min in 8 (42.1%) preterm and 32 (57.1%) term infants who underwent airway suctioning, compared to 2 (33.3%) preterm and 19 (95.0%) term infants who did not receive airway suctioning. CONCLUSIONS In the infants that underwent suctioning, breathing improved in most term, but not preterm infants. More non-suctioned term infants needed prolonged resuscitation. Airway suctioning was not directly associated with worsening of breathing, bradycardia, or extended resuscitation needs.
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Affiliation(s)
- Gazmend Berisha
- The Department of Paediatric and Adolescent Medicine, Akershus University Hospital, P.O. Box 1000, 1478 Lørenskog, Norway; (A.M.B.); (E.B.)
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, P.O. Box 1171, 0318 Oslo, Norway; (L.N.K.); (B.N.); (A.E.R.)
- The Department of Anaesthesia and Intensive Care Unit, Stavanger University Hospital, P.O. Box 8100, 4068 Stavanger, Norway
| | - Line Norman Kvenshagen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, P.O. Box 1171, 0318 Oslo, Norway; (L.N.K.); (B.N.); (A.E.R.)
- Department of Paediatrics and Adolescent Medicine, Østfold Hospital Trust Kalnes, P.O. Box 300, 1714 Grålum, Norway
| | - Anne Marthe Boldingh
- The Department of Paediatric and Adolescent Medicine, Akershus University Hospital, P.O. Box 1000, 1478 Lørenskog, Norway; (A.M.B.); (E.B.)
| | - Britt Nakstad
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, P.O. Box 1171, 0318 Oslo, Norway; (L.N.K.); (B.N.); (A.E.R.)
- Department of Paediatrics and Adolescent Health, University of Botswana, Private Bag, Gaborone 0022, Botswana
| | - Elin Blakstad
- The Department of Paediatric and Adolescent Medicine, Akershus University Hospital, P.O. Box 1000, 1478 Lørenskog, Norway; (A.M.B.); (E.B.)
| | - Arild Erland Rønnestad
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, P.O. Box 1171, 0318 Oslo, Norway; (L.N.K.); (B.N.); (A.E.R.)
- Department of Neonatal Intensive Care, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Rikshospitalet, Nydalen, P.O. Box 4950, 0424 Oslo, Norway;
| | - Anne Lee Solevåg
- Department of Neonatal Intensive Care, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Rikshospitalet, Nydalen, P.O. Box 4950, 0424 Oslo, Norway;
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Nerdrum Aagaard E, Solevåg AL, Saugstad OD. Significance of Neonatal Heart Rate in the Delivery Room-A Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1551. [PMID: 37761512 PMCID: PMC10528538 DOI: 10.3390/children10091551] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/08/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Heart rate (HR) is considered the main vital sign in newborns during perinatal transition, with a threshold of 100 beats per minute (bpm), below which, intervention is recommended. However, recent changes in delivery room management, including delayed cord clamping, are likely to have influenced normal HR transition. OBJECTIVE To summarize the updated knowledge about the factors, including measurement methods, that influence HR in newborn infants immediately after birth. Additionally, this paper provides an overview of delivery room HR as a prognostic indicator in different subgroups of newborns. METHODS We searched PubMed, EMBASE, and Google Scholar with the terms infant, heart rate, delivery room, resuscitation, pulse oximetry, and electrocardiogram. RESULTS Seven studies that described HR values in newborn infants immediately after birth were included. Pulse oximetry-derived HR percentiles after immediate cord clamping may not be applicable to the current practice of delayed cord clamping and the increasing use of delivery room electrocardiograms. Mask ventilation may adversely affect HR, particularly in premature and non-asphyxiated infants. Prolonged bradycardia is a negative prognostic factor, especially if combined with hypoxemia in infants <32 weeks of gestation. CONCLUSIONS HR assessment in the delivery room remains important. However, the cardiopulmonary transition is affected by delayed cord clamping, gestational age, and underlying conditions.
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Affiliation(s)
- Ellisiv Nerdrum Aagaard
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital Rikshospitalet, 0424 Oslo, Norway; (E.N.A.); (A.L.S.)
| | - Anne Lee Solevåg
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital Rikshospitalet, 0424 Oslo, Norway; (E.N.A.); (A.L.S.)
| | - Ola Didrik Saugstad
- Department of Pediatric Research, University of Oslo, 0424 Oslo, Norway
- Department of Pediatrics, Robert H Lurie Medical Research Center, Northwestern University, Chicago, IL 60611, USA
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Sweet DG, Carnielli VP, Greisen G, Hallman M, Klebermass-Schrehof K, Ozek E, te Pas A, Plavka R, Roehr CC, Saugstad OD, Simeoni U, Speer CP, Vento M, Visser GH, Halliday HL. European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update. Neonatology 2023; 120:3-23. [PMID: 36863329 PMCID: PMC10064400 DOI: 10.1159/000528914] [Citation(s) in RCA: 115] [Impact Index Per Article: 115.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/12/2022] [Indexed: 02/17/2023]
Abstract
Respiratory distress syndrome (RDS) care pathways evolve slowly as new evidence emerges. We report the sixth version of "European Guidelines for the Management of RDS" by a panel of experienced European neonatologists and an expert perinatal obstetrician based on available literature up to end of 2022. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, appropriate maternal transfer to a perinatal centre, and appropriate and timely use of antenatal steroids. Evidence-based lung-protective management includes initiation of non-invasive respiratory support from birth, judicious use of oxygen, early surfactant administration, caffeine therapy, and avoidance of intubation and mechanical ventilation where possible. Methods of ongoing non-invasive respiratory support have been further refined and may help reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation by targeted use of postnatal corticosteroids remains essential. The general care of infants with RDS is also reviewed, including emphasis on appropriate cardiovascular support and judicious use of antibiotics as being important determinants of best outcome. We would like to dedicate this guideline to the memory of Professor Henry Halliday who died on November 12, 2022.These updated guidelines contain evidence from recent Cochrane reviews and medical literature since 2019. Strength of evidence supporting recommendations has been evaluated using the GRADE system. There are changes to some of the previous recommendations as well as some changes to the strength of evidence supporting recommendations that have not changed. This guideline has been endorsed by the European Society for Paediatric Research (ESPR) and the Union of European Neonatal and Perinatal Societies (UENPS).
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Affiliation(s)
- David G. Sweet
- Regional Neonatal Unit, Royal Maternity Hospital, Belfast, UK
| | - Virgilio P. Carnielli
- Department of Neonatology, University Polytechnic Della Marche, University Hospital Ancona, Ancona, Italy
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Mikko Hallman
- Department of Children and Adolescents, Oulu University Hospital and Medical Research Center, University of Oulu, Oulu, Finland
| | - Katrin Klebermass-Schrehof
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Medical University of Vienna, Vienna, Austria
| | - Eren Ozek
- Department of Pediatrics, Marmara University Medical Faculty, Istanbul, Turkey
| | - Arjan te Pas
- Leiden University Medical Centre, Leiden, The Netherlands
| | - Richard Plavka
- Division of Neonatology, Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University, Prague, Czechia
| | - Charles C. Roehr
- Faculty of Health Sciences, University of Bristol, UK and National Perinatal Epidemiology Unit, Oxford Population Health, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Ola D. Saugstad
- Department of Pediatric Research, Oslo University Hospital Rikshospitalet, University of Oslo, Oslo, Norway
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Christian P. Speer
- Department of Pediatrics, University Children's Hospital, Wuerzburg, Germany
| | - Maximo Vento
- Department of Pediatrics and Neonatal Research Unit, Health Research Institute La Fe, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Gerry H.A. Visser
- Department of Obstetrics and Gynecology, University Medical Centre, Utrecht, The Netherlands
| | - Henry L. Halliday
- Department of Child Health, Queen's University Belfast and Royal Maternity Hospital, Belfast, UK
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Saugstad OD. Oxygenation of the newborn. The impact of one molecule on newborn lives. J Perinat Med 2023; 51:20-26. [PMID: 35848535 DOI: 10.1515/jpm-2022-0259] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/06/2022] [Indexed: 01/21/2023]
Abstract
Hypoxanthine is a purine metabolite which increases during hypoxia and therefore is an indicator of this condition. Further, when hypoxanthine is oxidized to uric acid in the presence of xanthine oxidase, oxygen radicals are generated. This was the theoretical basis for suggesting and studying, beginning in the 1990s, resuscitation of newborn infants with air instead of the traditional 100% O2. These studies demonstrated a 30% reduction in mortality when resuscitation of term and near term infants was carried out with air compared to pure oxygen. The mechanism for this is not fully understood, however the hypoxanthine -xanthine oxidase system increases oxidative stress and plays a role in regulation of the perinatal circulation. Further, hyperoxic resuscitation inhibits mitochondrial function, and one reason may be that genes involved in ATP production are down-regulated. Thus, the study of one single molecule, hypoxanthine, has contributed to the global prevention of an estimated 2-500,000 annual infant deaths.
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Affiliation(s)
- Ola Didrik Saugstad
- Department of Pediatric Research, University of Oslo and Oslo University hospital, Oslo, Norway
- Anne and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Bawa M, Gugino S, Helman J, Nielsen L, Bradley N, Mani S, Prasath A, Blanco C, Mari A, Nair J, Rawat M, Lakshminrusimha S, Chandrasekharan P. Initial Use of 100% but Not 60% or 30% Oxygen Achieved a Target Heart Rate of 100 bpm and Preductal Saturations of 80% Faster in a Bradycardic Preterm Model. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9111750. [PMID: 36421200 PMCID: PMC9689159 DOI: 10.3390/children9111750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/06/2022] [Accepted: 11/08/2022] [Indexed: 11/17/2022]
Abstract
Background: Currently, 21−30% supplemental oxygen is recommended during resuscitation of preterm neonates. Recent studies have shown that 58% of infants < 32 week gestation age are born with a heart rate (HR) < 100 bpm. Prolonged bradycardia with the inability to achieve a preductal saturation (SpO2) of 80% by 5 min is associated with mortality and morbidity in preterm infants. The optimal oxygen concentration that enables the achievement of a HR ≥ 100 bpm and SpO2 of ≥80% by 5 min in preterm lambs is not known. Methods: Preterm ovine model (125−127 d, gestation equivalent to human neonates < 28 weeks) was instrumented, and asphyxia was induced by umbilical cord occlusion until bradycardia. Ventilation was initiated with 30% (OX30), 60% (OX60), and 100% (OX100) for the first 2 min and titrated proportionately to the difference from the recommended preductal SpO2. Our primary outcome was the incidence of the composite of HR ≥ 100 bpm and SpO2 ≥ 80%, by 5 min. Secondary outcomes were to evaluate the time taken to achieve the primary outcome, gas exchange, pulmonary/systemic hemodynamics, and the oxidative injury. Results: Eighteen lambs (OX30-6, OX60-5. OX100-7) had an average HR < 91 bpm with a pH of <6.92 before resuscitation. Sixty seven percent achieved the primary outcome in OX100, 40% in OX60, and none in OX30. The time taken to achieve the primary outcome was significantly shorter with OX100 (6 ± 2 min) than with OX30 (10 ± 3 min) (* p = 0.04). The preductal SpO2 was highest with OX100, while the peak pulmonary blood flow was lowest with OX30, with no difference in O2 delivery to the brain or oxidative injury by 10 min. Conclusions: The use of 30%, 60%, and 100% supplemental O2 in a bradycardic preterm ovine model did not demonstrate a significant difference in the composite primary outcome. The current recommendation to use 30% oxygen did not achieve a preductal SpO2 of 80% by 5 min in any preterm lambs. Clinical studies to optimize supplemental O2 in depressed preterm neonates not requiring chest compressions are warranted.
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Affiliation(s)
- Mausma Bawa
- Department of Pediatrics, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, NY 14260, USA
- Department of Pediatrics, Boston Children Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Sylvia Gugino
- Department of Pediatrics, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, NY 14260, USA
| | - Justin Helman
- Department of Pediatrics, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, NY 14260, USA
| | - Lori Nielsen
- Department of Pediatrics, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, NY 14260, USA
| | - Nicole Bradley
- Department of Pediatrics, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, NY 14260, USA
| | - Srinivasan Mani
- Department of Pediatrics, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, NY 14260, USA
| | - Arun Prasath
- Department of Pediatrics, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, NY 14260, USA
| | - Clariss Blanco
- Department of Pediatrics, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, NY 14260, USA
| | - Andreina Mari
- Department of Pediatrics, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, NY 14260, USA
| | - Jayasree Nair
- Department of Pediatrics, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, NY 14260, USA
| | - Munmun Rawat
- Department of Pediatrics, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, NY 14260, USA
| | - Satyan Lakshminrusimha
- Department of Pediatrics, Division of Neonatology, University of California Davis School of Medicine, Sacramento, CA 95817, USA
| | - Praveen Chandrasekharan
- Department of Pediatrics, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, NY 14260, USA
- Correspondence:
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9
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Physiology of neonatal resuscitation: Giant strides with small breaths. Semin Perinatol 2022; 46:151620. [PMID: 35715254 DOI: 10.1016/j.semperi.2022.151620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The transition of a fetus to a newborn involves a sequence of well-orchestrated physiological events. Most neonates go through this transition without assistance but 5-10% may require varying degrees of resuscitative interventions at birth. The most crucial event during this transition is lung inflation with optimal concentrations of oxygen. Rarely, extensive resuscitation including chest compressions and medication may be required. In the past few decades, significant strides have been made in our understanding of the cardiorespiratory transition at birth from a fetus to a newborn and the subsequent resuscitation. This article reviews the physiology behind neonatal transition at birth and various interventions during neonatal resuscitation.
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Chandrasekharan P, Gugino S, Koenigsknecht C, Helman J, Nielsen L, Bradley N, Nair J, Sankaran D, Bawa M, Rawat M, Lakshminrusimha S. Placental transfusion during neonatal resuscitation in an asphyxiated preterm model. Pediatr Res 2022; 92:678-684. [PMID: 35490196 PMCID: PMC9588497 DOI: 10.1038/s41390-022-02086-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 03/24/2022] [Accepted: 04/07/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Neonatal Resuscitation Program does not recommend placental transfusion in depressed preterm neonates. METHODS Our objectives were to study the effect of delayed cord clamping (DCC) with ventilation for 5 min (DCCV, n-5), umbilical cord milking (UCM) without ventilation (n-6), UCM with ventilation (UCMV, n-6), early cord clamping followed by ventilation (ECCV, n-6) on red cell volume (RCV), and hemodynamic changes in asphyxiated preterm lambs. Twenty-three preterm lambs at 127-128 days gestation were randomized to DCCV, UCM, UCMV, and ECCV. We defined asphyxia as heart rate <100/min. RESULTS The UCMV had the highest neonatal RCV as a percentage of fetoplacental volume compared to the other groups (UCMV 85.5 ± 10%, UCM 72 ± 10%, ECCV 65 ± 14%, DCCV 61 ± 10%, p < 0.01). The DCCV led to better ventilation (66 ± 1 mmHg) and higher pulmonary blood flow (75 ± 24 ml/kg/min). The carotid flow was significantly higher in UCM without ventilation. The fluctuations in carotid flow with milking were 25 ± 6% higher from baseline during UCM, compared to 6 ± 3% in UCMV (p < 0.01). CONCLUSIONS Cord milking with ventilation led to higher RCV than other interventions. Ventilation during cord milking reduced fluctuation in carotid flow compared to UCM alone. DCCV led to better ventilation and pulmonary blood flow but did not increase RCV. IMPACT The best practice of placental transfusion in a depressed preterm neonate remains unknown. Ventilation with an intact cord improves gas exchange and hemodynamics in an asphyxiated preterm model. Cord milking without ventilation led to lower red cell volume but higher carotid blood flow fluctuations compared to milking with ventilation. Our data can be translated to bedside and could impact preterm resuscitation.
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Affiliation(s)
| | - Sylvia Gugino
- Department of Pediatrics, University at Buffalo, Buffalo, NY, USA
| | | | - Justin Helman
- Department of Pediatrics, University at Buffalo, Buffalo, NY, USA
| | - Lori Nielsen
- Department of Pediatrics, University at Buffalo, Buffalo, NY, USA
| | - Nicole Bradley
- Department of Pediatrics, University at Buffalo, Buffalo, NY, USA
| | - Jayasree Nair
- Department of Pediatrics, University at Buffalo, Buffalo, NY, USA
| | | | - Mausma Bawa
- Department of Pediatrics, University at Buffalo, Buffalo, NY, USA
| | - Munmun Rawat
- Department of Pediatrics, University at Buffalo, Buffalo, NY, USA
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Oei JL, Kapadia V, Rabi Y, Saugstad OD, Rook D, Vermeulen MJ, Boronat N, Thamrin V, Tarnow-Mordi W, Smyth J, Wright IM, Lui K, van Goudoever JB, Gebski V, Vento M. Neurodevelopmental outcomes of preterm infants after randomisation to initial resuscitation with lower (FiO 2 <0.3) or higher (FiO 2 >0.6) initial oxygen levels. An individual patient meta-analysis. Arch Dis Child Fetal Neonatal Ed 2022; 107:386-392. [PMID: 34725105 DOI: 10.1136/archdischild-2021-321565] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 10/04/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the effects of lower (≤0.3) versus higher (≥0.6) initial fractional inspired oxygen (FiO2) for resuscitation on death and/or neurodevelopmental impairment (NDI) in infants <32 weeks' gestation. DESIGN Meta-analysis of individual patient data from three randomised controlled trials. SETTING Neonatal intensive care units. PATIENTS 543 children <32 weeks' gestation. INTERVENTION Randomisation at birth to resuscitation with lower (≤0.3) or higher (≥0.6) initial FiO2. OUTCOME MEASURES Primary: death and/or NDI at 2 years of age.Secondary: post-hoc non-randomised observational analysis of death/NDI according to 5-minute oxygen saturation (SpO2) below or at/above 80%. RESULTS By 2 years of age, 46 of 543 (10%) children had died. Of the 497 survivors, 84 (17%) were lost to follow-up. Bayley Scale of Infant Development (third edition) assessments were conducted on 377 children. Initial FiO2 was not associated with difference in death and/or disability (difference (95% CI) -0.2%, -7% to 7%, p=0.96) or with cognitive scores <85 (2%, -5% to 9%, p=0.5). Five-minute SpO2 >80% was associated with decreased disability/death (14%, 7% to 21%) and cognitive scores >85 (10%, 3% to 18%, p=0.01). Multinomial regression analysis noted decreased death with 5-minute SpO2 ≥80% (odds (95% CI) 09.62, 0.98 to 0.96) and gestation (0.52, 0.41 to 0.65), relative to children without death or NDI. CONCLUSION Initial FiO2 was not associated with difference in risk of disability/death at 2 years in infants <32 weeks' gestation but CIs were wide. Substantial benefit or harm cannot be excluded. Larger randomised studies accounting for patient differences, for example, gestation and gender are urgently needed.
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Affiliation(s)
- Ju Lee Oei
- Newborn Intensive Care Unit, The Royal Hospital for Women, Randwick, New South Wales, Australia .,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Vishal Kapadia
- Department of Pediatrics, Howard Hughes Medical Institute-University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - Yacov Rabi
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Ola Didrik Saugstad
- Department of Pediatric Research, Oslo University Hospital, Rikshospitalet, University of Oslo, Oslo, Norway
| | - Denise Rook
- Department of Pediatrics, Erasmus MC, Rotterdam, The Netherlands
| | - Marijn J Vermeulen
- Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Nuria Boronat
- La Fe Health Research Institute, La Fe University and Polytechnic Hospital, Valencia, Spain.,Division of Neonatology, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Valerie Thamrin
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - William Tarnow-Mordi
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - John Smyth
- Newborn Intensive Care Unit, The Royal Hospital for Women, Randwick, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Ian M Wright
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
| | - Kei Lui
- Newborn Intensive Care Unit, The Royal Hospital for Women, Randwick, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Johannes B van Goudoever
- Department of Pediatrics, Emma Children's Hospital AMC, Amsterdam, The Netherlands.,Department of Pediatrics, Amsterdam UMC-VUMC location, Amsterdam, The Netherlands
| | - Val Gebski
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Maximo Vento
- La Fe Health Research Institute, La Fe University and Polytechnic Hospital, Valencia, Spain.,Division of Neonatology, La Fe University and Polytechnic Hospital, Valencia, Spain
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12
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Baik-Schneditz N, Schwaberger B, Bresesti I, Fuchs H, Lara I, Nakstad B, Lista G, Vento M, Binder-Heschl C, Pichler G, Urlesberger B. Fetal to neonatal transition: what additional information can be provided by cerebral near infrared spectroscopy? Pediatr Res 2022:10.1038/s41390-022-02081-0. [PMID: 35597824 DOI: 10.1038/s41390-022-02081-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 04/04/2022] [Accepted: 04/12/2022] [Indexed: 11/09/2022]
Abstract
This narrative review focuses on the clinical use and relevance of cerebral oxygenation measured by NIRS during fetal to neonatal transition. Cerebral NIRS(cNIRS) offers the possibility of non-invasive, continuous, and objective brain monitoring in addition to the recommended routine monitoring. During the last decade, with growing interest in early and sensitive brain monitoring, many research groups worldwide have been working with cNIRS and verified the feasibility of cNIRS monitoring immediately after birth. Cerebral hypoxia during fetal to neonatal transition, defined as cerebral oxygenation values below10th percentile, seems to have an impact on neurological outcomes. Feasibility to guide clinical support using cNIRS to reduce the burden of cerebral hypoxia has been shown. It is well known that in some cases cerebral oxygenation follows different patterns than SpO2. Cerebral oxygenation does not only depend on systemic oxygenation, hemoglobin content and cerebral blood flow, but also on cardiocirculatory condition, ventilation, and metabolic parameters. Hence, measurement of cerebral oxygenation may uncover problems not detectable by standard monitoring. Therefore, applying NIRS can provide caregivers a more complete clinical overview, especially in critically ill neonates. In this review, we aim to describe the additional information which can be provided by cNIRS during fetal to neonatal transition. IMPACT: This narrative review focuses on the clinical use and relevance of cerebral oxygenation measured by near infrared spectroscopy (NIRS) during fetal to neonatal transition. During the last decade, interest on brain monitoring is growing continuously as the measurement of cerebral oxygenation may uncover problems which are not detectable by routine monitoring. Therefore, it will be crucial to have additional information to get a complete overview, especially in critically ill neonates in need of medical and respiratory support. In this review, we offer additional information which can be provided by cerebral NIRS during fetal to neonatal transition.
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Affiliation(s)
- Nariae Baik-Schneditz
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
| | - Bernhard Schwaberger
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
| | - Ilia Bresesti
- Division of Neonatology, Department of Paediatrics, "F. Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Hans Fuchs
- Division of Neonatology and Pediatric Intensive Care Medicine, Center for Pediatrics and Adolescent Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Inmaculada Lara
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Britt Nakstad
- Division of Pediatric and Adolescent Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Paediatric and Adolescent Health, University of Botswana, Gaborone, Botswana
| | - Gianluca Lista
- Division of Neonatology, "V.Buzzi" Children's Hospital, ASST-FBF-Sacco, Milan, Italy
| | - Maximo Vento
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Corinna Binder-Heschl
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
| | - Gerhard Pichler
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
| | - Berndt Urlesberger
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria.
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13
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Norman M, Nilsson D, Trygg J, Håkansson S. Perinatal risk factors for mortality in very preterm infants-A nationwide, population-based discriminant analysis. Acta Paediatr 2022; 111:1526-1535. [PMID: 35397189 PMCID: PMC9546293 DOI: 10.1111/apa.16356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/03/2022] [Accepted: 04/07/2022] [Indexed: 11/29/2022]
Abstract
Aim To assess the strength of associations between interrelated perinatal risk factors and mortality in very preterm infants. Methods Information on all live‐born infants delivered in Sweden at 22–31 weeks of gestational age (GA) from 2011 to 2019 was gathered from the Swedish Neonatal Quality Register, excluding infants with major malformations or not resuscitated because of anticipated poor prognosis. Twenty‐seven perinatal risk factors available at birth were exposures and in‐hospital mortality outcome. Orthogonal partial least squares discriminant analysis was applied to assess proximity between individual risk factors and mortality, and receiver operating characteristic (ROC) curves were used to estimate discriminant ability. Results In total, 638 of 8,396 (7.6%) infants died. Thirteen risk factors discriminated reduced mortality; the most important were higher Apgar scores at 5 and 10 min, GA and birthweight. Restricting the analysis to preterm infants <28 weeks’ GA (n = 2939, 16.9% mortality) added antenatal corticosteroid therapy as significantly associated with lower mortality. The area under the ROC curve (the C‐statistic) using all risk factors was 0.86, as determined after both internal and external validation. Conclusion Apgar scores, gestational age and birthweight show stronger associations with mortality in very preterm infants than several other perinatal risk factors available at birth.
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Affiliation(s)
- Mikael Norman
- Department of Clinical Science, Intervention and Technology Karolinska Institutet Stockholm Sweden
- Department of Neonatal Medicine Karolinska University Hospital Stockholm Sweden
| | - David Nilsson
- Department of Chemistry, Umeå University Umeå Sweden
| | - Johan Trygg
- Department of Chemistry, Umeå University Umeå Sweden
| | - Stellan Håkansson
- Department of Clinical Sciences, Pediatrics Umeå University Umeå Sweden
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14
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Kalikkot Thekkeveedu R, El-Saie A, Prakash V, Katakam L, Shivanna B. Ventilation-Induced Lung Injury (VILI) in Neonates: Evidence-Based Concepts and Lung-Protective Strategies. J Clin Med 2022; 11:jcm11030557. [PMID: 35160009 PMCID: PMC8836835 DOI: 10.3390/jcm11030557] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/05/2022] [Accepted: 01/19/2022] [Indexed: 02/04/2023] Open
Abstract
Supportive care with mechanical ventilation continues to be an essential strategy for managing severe neonatal respiratory failure; however, it is well known to cause and accentuate neonatal lung injury. The pathogenesis of ventilator-induced lung injury (VILI) is multifactorial and complex, resulting predominantly from interactions between ventilator-related factors and patient-related factors. Importantly, VILI is a significant risk factor for developing bronchopulmonary dysplasia (BPD), the most common chronic respiratory morbidity of preterm infants that lacks specific therapies, causes life-long morbidities, and imposes psychosocial and economic burdens. Studies of older children and adults suggest that understanding how and why VILI occurs is essential to developing strategies for mitigating VILI and its consequences. This article reviews the preclinical and clinical evidence on the pathogenesis and pathophysiology of VILI in neonates. We also highlight the evidence behind various lung-protective strategies to guide clinicians in preventing and attenuating VILI and, by extension, BPD in neonates. Further, we provide a snapshot of future directions that may help minimize neonatal VILI.
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Affiliation(s)
| | - Ahmed El-Saie
- Section of Neonatology, Department of Pediatrics, Children’s Mercy Hospital, Kansas City, MO 64106, USA;
- Department of Pediatrics, Cairo University, Cairo 11956, Egypt
| | - Varsha Prakash
- Department of Pathology, University of Mississippi Medical Center, Jackson, MS 39216, USA;
| | - Lakshmi Katakam
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Binoy Shivanna
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA;
- Correspondence: ; Tel.: +832-824-6474; Fax: +832-825-3204
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15
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Mathias M, Chang J, Perez M, Saugstad O. Supplemental Oxygen in the Newborn: Historical Perspective and Current Trends. Antioxidants (Basel) 2021; 10:1879. [PMID: 34942982 PMCID: PMC8698336 DOI: 10.3390/antiox10121879] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022] Open
Abstract
Oxygen is the final electron acceptor in aerobic respiration, and a lack of oxygen can result in bioenergetic failure and cell death. Thus, administration of supplemental concentrations of oxygen to overcome barriers to tissue oxygen delivery (e.g., heart failure, lung disease, ischemia), can rescue dying cells where cellular oxygen content is low. However, the balance of oxygen delivery and oxygen consumption relies on tightly controlled oxygen gradients and compartmentalized redox potential. While therapeutic oxygen delivery can be life-saving, it can disrupt growth and development, impair bioenergetic function, and induce inflammation. Newborns, and premature newborns especially, have features that confer particular susceptibility to hyperoxic injury due to oxidative stress. In this review, we will describe the unique features of newborn redox physiology and antioxidant defenses, the history of therapeutic oxygen use in this population and its role in disease, and clinical trends in the use of therapeutic oxygen and mitigation of neonatal oxidative injury.
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Affiliation(s)
- Maxwell Mathias
- Center for Pregnancy and Newborn Research, Department of Pediatrics, Section of Neonatal-Perinatal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Jill Chang
- Division of Neonatology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA; (J.C.); (M.P.); (O.S.)
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL 60611, USA
| | - Marta Perez
- Division of Neonatology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA; (J.C.); (M.P.); (O.S.)
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL 60611, USA
| | - Ola Saugstad
- Division of Neonatology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA; (J.C.); (M.P.); (O.S.)
- Department of Pediatric Research, University of Oslo, N-0424 Oslo, Norway
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