Supplementary Material for: Oxygen during neonatal resuscitation: Too much vs too little, does it matter?

Background: Oxygen has been a key component of neonatal resuscitation for nearly two centuries. Based on clinical trials that demonstrated worse outcomes when neonatal resuscitation was initiated with 100% oxygen, there was a change in approach to using 21% oxygen at initiation of ventilation for newborns at birth. However, for extremely preterm newborns lower oxygen levels lead to early hypoxia and bradycardia leading to higher rates of severe intraventricular hemorrhage and death. The balance between hyperoxia and hypoxia related injury needs further refinement and may not be generalizable to all gestations and birth conditions.
Summary: This article reviews the current evidence on oxygen use during delayed cord clamping, during resuscitation of term and preterm neonates, during chest compressions, after return of spontaneous circulation and in the post-resuscitation phase, and the impact of hyperoxia.
Key messages: Supplemental oxygen during neonatal resuscitation is actively being investigated by researchers worldwide to fill the knowledge gap to avoid hypoxia and hyperoxia while improving neonatal outcomes. Until further evidence emerges, we recommend starting resuscitation in the delivery room of very low birth weight infants with an FiO2 of 0.3 to 1, probably in the lower part of this scale, and titrating-up by 10-20% every 30 seconds to achieve target SpO2 for age. An SpO2 of 80-85% should be targeted by 5 minutes after birth.