The Neonatal Resuscitation Program (NRP) provides an evidence-based framework for assisting newborns at birth. These protocols account for the unique physiology of a baby transitioning from the womb to the outside world. A central component of the NRP guidelines involves the careful and controlled administration of oxygen to support the newborn’s breathing and ensure adequate oxygenation.
Initial Resuscitation and Oxygen Concentration
When a term or late-preterm infant requires breathing assistance, resuscitation begins with 21% oxygen, the same concentration as room air. This is a shift from older practices where 100% oxygen was often used. Using room air for initial support, like positive-pressure ventilation (PPV), is now the standard of care within the first minute of life, a period often called the “Golden Minute.”
This change is based on research showing most newborns can be resuscitated without high concentrations of supplemental oxygen. The goal is to help the baby achieve a stable heart rate and breathing. Starting with room air avoids the immediate risks of high oxygen levels, allowing the infant’s body to adapt more naturally.
For infants born before 35 weeks of gestation, resuscitation starts with a slightly higher oxygen concentration, between 21% and 30%. This adjustment accounts for the developmental immaturity of their lungs and other organs. The principle of starting low and adjusting as needed remains to avoid the potential harms of excessive oxygen.
Monitoring with Pulse Oximetry
A pulse oximeter is used to guide oxygen therapy during neonatal resuscitation. This non-invasive tool measures blood oxygen saturation (SpO2) in real-time. NRP guidelines specify placing the sensor on the right hand or wrist, a “pre-ductal” location, to measure oxygenated blood flow to the heart and brain.
The pulse oximeter readings are compared against target oxygen saturation levels that reflect the gradual increase expected in a healthy newborn. For example, the target SpO2 at one minute is 60-65%, increasing to 65-70% at two minutes, and reaching 85-95% by 10 minutes. These targets guide the medical team’s decisions.
These targets are goals to help direct clinical decisions, not rigid requirements. A newborn’s oxygen saturation is expected to rise slowly, and the pulse oximeter allows the team to see if the baby is following this pattern. The readings help determine if interventions are working or if adjustments are needed.
Titrating Oxygen Flow
Based on pulse oximetry readings, the medical team titrates, or adjusts, the oxygen concentration delivered to the infant. If a newborn’s SpO2 levels are below the target range, the oxygen is gradually increased using an oxygen blender. This device precisely mixes oxygen and air to help the baby reach target saturation levels without overshooting them.
This careful adjustment is continuous and especially important for preterm infants due to their vulnerability. The team increases or decreases the oxygen flow in small increments to maintain the baby within the desired saturation range.
A rapid increase in oxygen is recommended in one specific situation. If an infant’s heart rate remains below 60 beats per minute despite effective ventilation, the oxygen is increased to 100%. This is done while the team prepares for or begins chest compressions, as a persistently low heart rate indicates severe distress and requires maximum oxygen delivery.
The Rationale for Controlled Oxygen Use
The guidelines for oxygen use are designed to navigate the dangers of both too little and too much oxygen. Insufficient oxygen (hypoxia) can lead to injury in the brain and other organs. The goal of resuscitation is to prevent this outcome by ensuring the baby’s cells receive adequate oxygen.
Conversely, too much oxygen (hyperoxia) creates its own set of risks, which has driven the evolution of NRP guidelines. Exposing a newborn, particularly a preterm infant, to high oxygen concentrations leads to the production of damaging free radicals. This process, called oxidative stress, can harm the newborn’s delicate tissues.
This cellular damage is linked to serious long-term health problems, especially in preterm infants. Hyperoxia is a known risk factor for Retinopathy of Prematurity (ROP), an eye disease that can cause vision loss. It is also associated with Bronchopulmonary Dysplasia (BPD), a chronic lung disease with lasting effects on breathing. By using a controlled, data-driven approach, the guidelines aim to provide life-saving support while minimizing the potential for these complications.