Association Between Oxygen Saturation Targeting and Death or Disability in Extremely Preterm Infants in the Neonatal Oxygenation Prospective Meta-analysis Collaboration

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Abstract

There are potential benefits and harms of hyperoxemia and hypoxemia for extremely preterm infants receiving more vs less supplemental oxygen.

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Most cited references 25

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A new and improved population-based Canadian reference for birth weight for gestational age.

M Kramer, R W Platt, S Wen … (2001)

Existing fetal growth references all suffer from 1 or more major methodologic problems, including errors in reported gestational age, biologically implausible birth weight for gestational age, insufficient sample sizes at low gestational age, single-hospital or other non-population-based samples, and inadequate statistical modeling techniques. We used the newly developed Canadian national linked file of singleton births and infant deaths for births between 1994 and 1996, for which gestational age is largely based on early ultrasound estimates. Assuming a normal distribution for birth weight at each gestational age, we used the expectation-maximization algorithm to exclude infants with gestational ages that were more consistent with 40-week births than with the observed gestational age. Distributions of birth weight at the corrected gestational ages were then statistically smoothed. The resulting male and female curves provide smooth and biologically plausible means, standard deviations, and percentile cutoffs for defining small- and large-for-gestational-age births. Large-for-gestational age cutoffs (90th percentile) at low gestational ages are considerably lower than those of existing references, whereas small-for-gestational-age cutoffs (10th percentile) postterm are higher. For example, compared with the current World Health Organization reference from California (Williams et al, 1982) and a recently proposed US national reference (Alexander et al, 1996), the 90th percentiles for singleton males at 30 weeks are 1837 versus 2159 and 2710 g. The corresponding 10th percentiles at 42 weeks are 3233 versus 3086 and 2998 g. This new sex-specific, population-based reference should improve clinical assessment of growth in individual newborns, population-based surveillance of geographic and temporal trends in birth weight for gestational age, and evaluation of clinical or public health interventions to enhance fetal growth. fetal growth, birth weight, gestational age, preterm birth, postterm birth.

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Retinopathy of prematurity.

Ann Hellström, Lois E. H. Smith, Olaf Dammann (2013)

The immature retinas of preterm neonates are susceptible to insults that disrupt neurovascular growth, leading to retinopathy of prematurity. Suppression of growth factors due to hyperoxia and loss of the maternal-fetal interaction result in an arrest of retinal vascularisation (phase 1). Subsequently, the increasingly metabolically active, yet poorly vascularised, retina becomes hypoxic, stimulating growth factor-induced vasoproliferation (phase 2), which can cause retinal detachment. In very premature infants, controlled oxygen administration reduces but does not eliminate retinopathy of prematurity. Identification and control of factors that contribute to development of retinopathy of prematurity is essential to prevent progression to severe sight-threatening disease and to limit comorbidities with which the disease shares modifiable risk factors. Strategies to prevent retinopathy of prematurity will depend on optimisation of oxygen saturation, nutrition, and normalisation of concentrations of essential factors such as insulin-like growth factor 1 and ω-3 polyunsaturated fatty acids, as well as curbing of the effects of infection and inflammation to promote normal growth and limit suppression of neurovascular development. Copyright © 2013 Elsevier Ltd. All rights reserved.

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Target ranges of oxygen saturation in extremely preterm infants.

Waldemar A Carlo, Neil N Finer, Michele C Walsh … (2010)

Previous studies have suggested that the incidence of retinopathy is lower in preterm infants with exposure to reduced levels of oxygenation than in those exposed to higher levels of oxygenation. However, it is unclear what range of oxygen saturation is appropriate to minimize retinopathy without increasing adverse outcomes. We performed a randomized trial with a 2-by-2 factorial design to compare target ranges of oxygen saturation of 85 to 89% or 91 to 95% among 1316 infants who were born between 24 weeks 0 days and 27 weeks 6 days of gestation. The primary outcome was a composite of severe retinopathy of prematurity (defined as the presence of threshold retinopathy, the need for surgical ophthalmologic intervention, or the use of bevacizumab), death before discharge from the hospital, or both. All infants were also randomly assigned to continuous positive airway pressure or intubation and surfactant. The rates of severe retinopathy or death did not differ significantly between the lower-oxygen-saturation group and the higher-oxygen-saturation group (28.3% and 32.1%, respectively; relative risk with lower oxygen saturation, 0.90; 95% confidence interval [CI], 0.76 to 1.06; P=0.21). Death before discharge occurred more frequently in the lower-oxygen-saturation group (in 19.9% of infants vs. 16.2%; relative risk, 1.27; 95% CI, 1.01 to 1.60; P=0.04), whereas severe retinopathy among survivors occurred less often in this group (8.6% vs. 17.9%; relative risk, 0.52; 95% CI, 0.37 to 0.73; P<0.001). There were no significant differences in the rates of other adverse events. A lower target range of oxygenation (85 to 89%), as compared with a higher range (91 to 95%), did not significantly decrease the composite outcome of severe retinopathy or death, but it resulted in an increase in mortality and a substantial decrease in severe retinopathy among survivors. The increase in mortality is a major concern, since a lower target range of oxygen saturation is increasingly being advocated to prevent retinopathy of prematurity. (ClinicalTrials.gov number, NCT00233324.) 2010 Massachusetts Medical Society

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Author and article information

Journal

Title: JAMA

Abbreviated Title: JAMA

Publisher: American Medical Association (AMA)

ISSN (Print): 0098-7484

Publication date Created: June 05 2018

Publication date (Print): June 05 2018

Volume: 319

Issue: 21

Page: 2190

Affiliations

[1 ]National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia

[2 ]Department of Paediatrics, University of Otago, Christchurch, New Zealand

[3 ]Department of Pediatrics, University of California, San Diego

[4 ]Division of Neonatology, University of Pennsylvania, Philadelphia

[5 ]Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada

[6 ]Department of Neonatology, Royal Infirmary of Edinburgh, Edinburgh, Scotland

[7 ]Newborn Research, Royal Women’s Hospital, Departments of Obstetrics and Gynaecology, and Paediatrics, University of Melbourne, Melbourne, Australia

[8 ]Clinical Sciences, Murdoch Children’s Research Institute, Melbourne, Australia

[9 ]Department of Pediatrics, University of Alabama, Birmingham

[10 ]Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, England

[11 ]National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England

[12 ]Statistics and Epidemiology Unit, RTI International, Rockville, Maryland

[13 ]Statistics and Epidemiology Unit, RTI International, Research Triangle Park, North Carolina

[14 ]Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada

[15 ]Department of Neonatology, Tuebingen University Hospital, Tuebingen, Germany

[16 ]Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada

[17 ]Newborn Services, Auckland City Hospital, Auckland, New Zealand

[18 ]Royal Maternity Hospital, Belfast, Ireland

[19 ]Department of Child Health, Queen’s University, Belfast, Ireland

[20 ]EGA Institute for Women’s Health, University College London, London, England

[21 ]Department of Neonatal Medicine, James Cook University, Middlesbrough, England

[22 ]University of Cambridge, Department of Obstetrics and Gynaecology, Cambridge, England

Article

DOI: 10.1001/jama.2018.5725

PMC ID: 6583054

PubMed ID: 29872859

SO-VID: 37316520-8783-45f6-8576-56b5b490e763

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Association Between Oxygen Saturation Targeting and Death or Disability in Extremely Preterm Infants in the Neonatal Oxygenation Prospective Meta-analysis Collaboration

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Most cited references 25

A new and improved population-based Canadian reference for birth weight for gestational age.

Retinopathy of prematurity.

Target ranges of oxygen saturation in extremely preterm infants.

Author and article information

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Article

History

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