Oxygen needs of a newborn lie in delicate balance. Under- and over-oxygenation both carry negative consequences that may impact the child’s life forever. In this article, we discuss and dissect the practice of oxygen administration in infants.

Too many infants suffer from unmet oxygen needs

Oxygen is one of the most commonly given therapy in neonatal wards, and forms an integral part of life support. Having said that, insufficient oxygenation, or hypoxaemia, is more common in the neonatal wards than expected. The World Health Organisation (WHO) estimates a whopping 23% of the 5.9 million annual child deaths are attributed to low birth weight, sepsis and birth asphyxia – all of which can result in hypoxaemia1. At least 13.3% of children with pneumonia may eventually suffer from hypoxaemia2.

The solution of ‘just give them oxygen’ errs dangerously close to oversimplifying a complex problem. Firstly, hypoxaemia is often not well recognised – either due to a lack of awareness or proper facilities, especially in smaller district hospitals. Secondly, infants may not be receiving enough oxygen for an appropriate duration1.

Having enough oxygen may be even more vital for premature infants than we once thought. Premature infants are at risk for developing a whole host of debilitating, life-long complications that are currently thought to be due to poor blood flow. A recent study published in the Journal of Neuroscience stakes a new claim that it is, in fact, poor oxygenation to blame.

Premature sheep neurons were found to display neuronal disturbances just one month after being exposed to low oxygen flow for as little as 25 minutes3.

(Left to right) Kiera Degener-O'Brien, Stephen Back, MD, PhD, and Ev McClendon, PhD, analysed the response of foetal subplate neurons to brain oxygenation disturbances. Their findings show lack of oxygen – not blood flow – delays brain maturation in preterm infants. Photo credit: Kristyna Wentz-Graff/Oregon Health & Science University
(Left to right) Kiera Degener-O'Brien, Stephen Back, MD, PhD, and Ev McClendon, PhD, analysed the response of foetal subplate neurons to brain oxygenation disturbances. Their findings show lack of oxygen – not blood flow – delays brain maturation in preterm infants. Photo credit: Kristyna Wentz-Graff/Oregon Health & Science University

Says principal investigator Stephen Back of the Oregon Health & Science University, "This brief exposure to low oxygen occurs frequently in preterm babies receiving care in a neonatal intensive care unit." By optimising oxygen delivery, many infants can be potentially saved from a lifetime of disability3.

"Given this new range of opportunity to promote brain repair, clinicians must critically rethink how to interact with, stimulate and handle preterm babies during intensive care treatment. This will help to better manage transient low-oxygen states and determine what the preterm brain can and cannot tolerate," he adds3.

The oxygen dilemma: When is it deemed ‘absolutely necessary’?

We can all agree that too little oxygen is bad. But in that case, what is the right amount to give? Little is known regarding optimal oxygen therapy in this group of patients, particularly in premature infants.

It is no secret that oxygen is dangerous in excess. Levels of oxygen saturation of more than 95% are thought to cause more harm than good in infants. Current practice accepts a target oxygen saturation ranges of between 88% and 94%. Besides high oxygen doses, the fluctuation between hypoxia and hyperoxia, as well as the chronicity of oxygen administration, may push the fragile premature infant into developing blindness (retinopathy of prematurity) and chronic lung disease (bronchopulmonary dysplasia)4.

Generally, many paediatricians may think twice before giving 100% oxygen to a new born child – unless absolutely necessary. Therein lies the problem – when is it deemed ‘absolutely necessary’?

Interestingly, both a randomised controlled trial and systematic review and meta-analysis found that premature infants that were resuscitated with room air had higher mortality rates and experienced long-term abnormal neurodevelopment outcomes compared to their counterparts that were resuscitated with 100% oxygen. Future research is required to pinpoint optimal oxygenation levels and improve clinical practice5.

Both hypoxia and hyperoxia are equally dangerous to the new born. Oxygen is thought by many to be a drug, and rightfully so. Closer attention towards a newborn’s oxygen status and early, appropriate action could be all that exists between a normal life and a life marred by disability. MIMS

Read more:
Too much oxygen for patients could be fatal
India: Death of 60 children in hospital caused by oxygen disruption; due to alleged unpaid bills
Revisiting skin-to-skin contact—a radical alternative to save premature babies

Sources:
1. http://apps.who.int/iris/bitstream/10665/204584/1/9789241549554_eng.pdf
2. http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(09)70071-4/fulltext
3. https://www.sciencedaily.com/releases/2017/11/171102180321.htm
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4225465/
5. https://www.2minutemedicine.com/resuscitation-of-extremely-premature-infants-with-room-air-may-increase-mortality/
6. https://news.ohsu.edu/2017/11/02/lack-of-oxygen-not-blood-flow-delays-brain-maturation-in-preterm-infants