Evidence-Based Practices for the Fetal to Newborn Transition

Judith S. Mercer, CNM, DNSc; Debra A. Erickson-Owens, CNM, MS, ; Barbara Graves, CNM, MN, MPH; Mary Mumford Haley, CNM, MS

Disclosures

J Midwifery Womens Health. 2007;52(3):262-272.

Room Air Versus Oxygen for Neonatal Resuscitation

Current research addressing the potential benefits and risks of use of oxygen versus room air for neonatal resuscitation included six intervention studies^{[64,65,66,67,68,69]} and a Cochrane Library review.^[70] The outcomes of these studies demonstrate no differences between the oxygen and room air groups in mortality, Apgar scores, time to first cry, time to onset of regular respirations, hypoxic ischemic encephalopathy, or neurologic follow-up examination results ( Table 5 ).^[71] One study evaluated markers of oxidative stress.^[68]

By the 1950s, it was recognized that the administration of high levels of oxygen to premature infants led to vasoconstriction of the retinal arteries followed by disordered vessel growth causing retrolental fibroplasias, now known as retinopathy of prematurity.^[72] Research in the late 1970s demonstrated that administration of 100% oxygen also reduced cerebral blood flow in the newborn infant.^[73,74]

Saugstad^[75] conducted animal studies, which suggested that the use of 100% oxygen during neonatal resuscitation might result in excess oxygen radicals and slower response to resuscitation. A pilot study with human infants supported the safety of using room air during newborn resuscitation.^[65] A follow-up multicenter, international quasiexperimental study of 599 infants weighing more than 1000 gm who required positive pressure ventilation for resuscitation (ResAir 2), found no differences in outcomes when infants were resuscitated with room air versus 100% oxygen ( Table 5 ).^[67]

To investigate the effect of supplemental oxygen on cerebral blood flow, Lundstom^[64] randomized 70 preterm infants to receive either room air (group I) or 80% oxygen (group II) during initial stabilization in the delivery room. The primary outcome of cerebral blood flow was significantly higher in group I randomized to room air (median 15.9; interquartile range 13.6-21.9 mL/100 g/min) compared to group II with 80% oxygen (median 12.3; interquartile range 10.7-13.8 mL/100 g/min; P < .0001) at 2 hours of age.

Vento et al.^[68,69] measured the effect of resuscitation with room air or 100% oxygen on levels of markers of oxidative stress in term infants delivered vaginally ( Table 5 ). Nineteen asphyxiated infants were randomized to resuscitation with room air, 21 were randomized to 100% oxygen, and 26 infants without asphyxia served as controls. The markers of oxidative stress were initially higher in the umbilical arteries of both the asphyxiated groups compared to the controls. At 72 hours of age, the oxygen group had levels of oxygen-free radicals that were statistically higher than the newborns in the room air group. By 28 days of age, the infants in the room air group had values similar to the values of the newborns in the control group, whereas the infants in the oxygen group continued to have statistically higher oxygen-free radical values than either the room air subjects or controls. Even a short exposure to 100% oxygen may result in prolonged oxidative stress.

The American Academy of Pediatrics/American Heart Association Neonatal Resuscitation Program provides an authoritative set of recommendations. The fifth edition of Textbook of Neonatal Resuscitation^[76] contains a significant change in the use of 100% oxygen from earlier editions. Although the authors continue to recommend the use of 100% oxygen, they acknowledge that research suggests that "less than 100% may be just as useful."^[77] The new guideline recommends use of room air at time of resuscitation, but if there is not an appropriate response within 90 seconds, oxygen is indicated.

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Abstract and Introduction
Effect of Maternal Analgesia on Newborn Transition
The Timing of Umbilical Cord Clamping
Room Air Versus Oxygen for Neonatal Resuscitation
Conclusion
References

Randomized, Controlled Trials on Cord Clamping in Full-Term Infants
Authors, Year, Location	Study Population	Cord Management Placement of Infant	Significant Results	Comments
Chaparro et al. (2006)^[32]; Mexico	Women 37-42 wks; singleton pregnancy, vaginal birth, normal pregnancies, plan to breastfeed for 6 mo, no smokers; no IUGR or major anomalies (excluded after birth); 358 infants randomized	EC: CC at 10 s (mean = 16.5 s); DC: CC at 2 minutes (mean = 94 s); Level: held at the level of the uterus	POV: At 6 mo, DC infants had higher MCV (81 vs. 79.5 fL; P = .001), ferritin (51 vs. 34 mL; P = .0002), and total body iron (48 vs. 44 \0x03BCg/dL, P = .0003) than EC infants. Diff HCT in NB period: 62% vs. 60%; P = .003. After birth, HCT > 70%: DC 13% vs. EC 8%; P < .15. Jaundice: DC 17% vs. EC 14%; P ≤ .36	Largest study to date to look at any long-term outcomes. Conservative in that they used only a 2-min delay. No significant differences in HGB or HCT at 6 mo, but iron stores increased by 27-47 mg in infants with DC. No harmful effects noted.
Cernadas et al. (2006)^[33]; Argentina	276 term infants; vaginal and cesarean birth, no complications, normal pregnancies	EC: CC at 15 s (n = 93); IC: CC at 1 min (n = 91); DC: CC 3 min (n = 92)	POV: Venous HCT at 6 hrs: EC 54% vs. IC 57% vs. DC 59%. HCT < 45% highest with EC at 6 and 24 hrs. HCT > 65% was highest in DC at 6 and 24 hrs without clinical symptoms	No harmful effects were seen. At 24-48 hrs, 16.9% of infants with EC had HCT < 45%. No increase in maternal postpartum hemorrhage. Authors recommend DC.
Emhamed, van Rheenen, and Brabin (2004)^[35]; Libya	Women 37-42 wks; singletons; excluded for major congenital anomalies, maternal complications; tight nuchal cord, need for resuscitation; 102 infants > 2500 gms	EC: immediate (n = 45); DC: after cord stopped pulsating (n = 57); oxytocic after CC	DC infants had significantly higher HCT (53% vs. 49%; P = .004) and Hgb 17.1 vs. 18.5 g/dL (P = .0005) at 24 hrs. Three DC infants had polycythemia with no symptoms; two EC infants needed phototherapy	No perinatal complications from DC in this study. Authors recommend DC as a safe, simple intervention to increase red cell mass.
Gupta and Ramji (2002)^[34]; India	Term infants (n = 102) born to anemic mothers (HGB < 10 g/dL); vaginal birth, no resuscitation needed at birth; no major congenital anomalies	EC: immediate (n = 53); LC: when placenta in vagina (n = 49); Infant held 0-10 cm below introitus	At 3 mos of age (n = 58), infants with LC had higher serum ferritin levels (118 vs. 73; P = .001). Odds risk for anemia at 3 mos was 7.7 times higher for the EC group (95% CI, 1.84-34.9)	EC Infants weighed 2707 gms, LC infants 2743 g. Iron stores in neonates born to anemic mothers can be improved by LC (jaundice and polycythemia not addressed)

CC = cord clamping; DC = delayed cord clamping; EC = early cord clamping; HCT = hematocrit; HGB = hemoglobin; IC = intermediate cord clamping; IUGR = intrauterine growth restriction; MCV = mean corpuscular volume; NB = newborn; LC = late cord clamping; POV = primary outcome variable.

Randomized, Controlled Trials on Cord Clamping in Full-Term Infants
Authors, Year, Location	Study Population	Cord Management Placement of Infant	Significant Results	Comments
Chaparro et al. (2006)^[32]; Mexico	Women 37-42 wks; singleton pregnancy, vaginal birth, normal pregnancies, plan to breastfeed for 6 mo, no smokers; no IUGR or major anomalies (excluded after birth); 358 infants randomized	EC: CC at 10 s (mean = 16.5 s); DC: CC at 2 minutes (mean = 94 s); Level: held at the level of the uterus	POV: At 6 mo, DC infants had higher MCV (81 vs. 79.5 fL; P = .001), ferritin (51 vs. 34 mL; P = .0002), and total body iron (48 vs. 44 \0x03BCg/dL, P = .0003) than EC infants. Diff HCT in NB period: 62% vs. 60%; P = .003. After birth, HCT > 70%: DC 13% vs. EC 8%; P < .15. Jaundice: DC 17% vs. EC 14%; P ≤ .36	Largest study to date to look at any long-term outcomes. Conservative in that they used only a 2-min delay. No significant differences in HGB or HCT at 6 mo, but iron stores increased by 27-47 mg in infants with DC. No harmful effects noted.
Cernadas et al. (2006)^[33]; Argentina	276 term infants; vaginal and cesarean birth, no complications, normal pregnancies	EC: CC at 15 s (n = 93); IC: CC at 1 min (n = 91); DC: CC 3 min (n = 92)	POV: Venous HCT at 6 hrs: EC 54% vs. IC 57% vs. DC 59%. HCT < 45% highest with EC at 6 and 24 hrs. HCT > 65% was highest in DC at 6 and 24 hrs without clinical symptoms	No harmful effects were seen. At 24-48 hrs, 16.9% of infants with EC had HCT < 45%. No increase in maternal postpartum hemorrhage. Authors recommend DC.
Emhamed, van Rheenen, and Brabin (2004)^[35]; Libya	Women 37-42 wks; singletons; excluded for major congenital anomalies, maternal complications; tight nuchal cord, need for resuscitation; 102 infants > 2500 gms	EC: immediate (n = 45); DC: after cord stopped pulsating (n = 57); oxytocic after CC	DC infants had significantly higher HCT (53% vs. 49%; P = .004) and Hgb 17.1 vs. 18.5 g/dL (P = .0005) at 24 hrs. Three DC infants had polycythemia with no symptoms; two EC infants needed phototherapy	No perinatal complications from DC in this study. Authors recommend DC as a safe, simple intervention to increase red cell mass.
Gupta and Ramji (2002)^[34]; India	Term infants (n = 102) born to anemic mothers (HGB < 10 g/dL); vaginal birth, no resuscitation needed at birth; no major congenital anomalies	EC: immediate (n = 53); LC: when placenta in vagina (n = 49); Infant held 0-10 cm below introitus	At 3 mos of age (n = 58), infants with LC had higher serum ferritin levels (118 vs. 73; P = .001). Odds risk for anemia at 3 mos was 7.7 times higher for the EC group (95% CI, 1.84-34.9)	EC Infants weighed 2707 gms, LC infants 2743 g. Iron stores in neonates born to anemic mothers can be improved by LC (jaundice and polycythemia not addressed)

Literature Overview on Infant Placement at Birth and Skin-to-Skin Care
Authors, Year, Study Type	Study Population	Style of Thermoregulation	Results	Comments
Carfoot, Williamson, and Dickson (2005)^[43]; RCT	204 term mother-baby pairs randomized to either group	Early SSC compared with RNC	Higher temps 1 hr after birth (P < .02); no difference in # breastfeeding at 4 mos, mothers more satisfied with SSC (90% vs. 50%)	Largest trial to date; supports no harm with SSC; found warmer infants and high maternal satisfaction with SSC
Vaidya, Sharma, and Dhungel (2005)^[44]; RCT	92 lactating mother-baby pairs followed up to 6 mos	Randomized to 15 min of SSC in the first hrs vs. RNC (babies dressed and given to mother)	Significantly more mothers in the SCC group were breastfeeding at 6 mos of age (77% vs. 38%)	Large study from a resource-poor country; well done; cultural differences may play a role
Fransson, Karlsson, and Nilsson (2005)^[45]; physiologic study	27 healthy term babies during first 2 days of life	Determine normal temperature patterns and variations and the influence of external factors	Skin temperature of baby was higher when with the mother, even if not skin-to-skin	Highest temperatures were recorded when baby was in close contact with mother, lowest when baby was in the cot
Anderson et al. (2003)^[1]; Cochrane review	Cochrane review of 806 participants in 17 studies	Early skin-to-skin contact, baby naked and prone on mother's bare chest versus routine hospital care	Increased scores for maternal love/touch/affection, increased maternal attachment behavior	Safety and breastfeeding success; editors recommended improving methodological and statistical integrity
Ferber and Makhoul (2004)^[46]; RCT	47 healthy mother-baby pairs	All infants had SSC for first 5-10 min. The SSC group had SSC from 15 min to 1 hr of life; control group had routine care in the nursery	At 4 hrs, infants in the SSC group slept longer (P = .02) with more quiet sleep time (P = .01) and had better flexion (P = .03) and less extension of limbs (P = .05)	SSC appears to influence state organization and motor coordination

RCT = randomized, controlled trial; RNC = routine newborn care; SSC = skin-to-skin.

Literature Overview on Infant Placement at Birth and Skin-to-Skin Care
Authors, Year, Study Type	Study Population	Style of Thermoregulation	Results	Comments
Carfoot, Williamson, and Dickson (2005)^[43]; RCT	204 term mother-baby pairs randomized to either group	Early SSC compared with RNC	Higher temps 1 hr after birth (P < .02); no difference in # breastfeeding at 4 mos, mothers more satisfied with SSC (90% vs. 50%)	Largest trial to date; supports no harm with SSC; found warmer infants and high maternal satisfaction with SSC
Vaidya, Sharma, and Dhungel (2005)^[44]; RCT	92 lactating mother-baby pairs followed up to 6 mos	Randomized to 15 min of SSC in the first hrs vs. RNC (babies dressed and given to mother)	Significantly more mothers in the SCC group were breastfeeding at 6 mos of age (77% vs. 38%)	Large study from a resource-poor country; well done; cultural differences may play a role
Fransson, Karlsson, and Nilsson (2005)^[45]; physiologic study	27 healthy term babies during first 2 days of life	Determine normal temperature patterns and variations and the influence of external factors	Skin temperature of baby was higher when with the mother, even if not skin-to-skin	Highest temperatures were recorded when baby was in close contact with mother, lowest when baby was in the cot
Anderson et al. (2003)^[1]; Cochrane review	Cochrane review of 806 participants in 17 studies	Early skin-to-skin contact, baby naked and prone on mother's bare chest versus routine hospital care	Increased scores for maternal love/touch/affection, increased maternal attachment behavior	Safety and breastfeeding success; editors recommended improving methodological and statistical integrity
Ferber and Makhoul (2004)^[46]; RCT	47 healthy mother-baby pairs	All infants had SSC for first 5-10 min. The SSC group had SSC from 15 min to 1 hr of life; control group had routine care in the nursery	At 4 hrs, infants in the SSC group slept longer (P = .02) with more quiet sleep time (P = .01) and had better flexion (P = .03) and less extension of limbs (P = .05)	SSC appears to influence state organization and motor coordination

RCT = randomized, controlled trial; RNC = routine newborn care; SSC = skin-to-skin.

Oropharyngeal Suctioning at Birth*
Author, Year, Study Type*	Intervention and Sample Size	Significant Results	Comments
Cordero and Hon (1971)^[53]; non-randomized	Bulb suction (n = 41) vs. catheter suction (n = 46)	The catheter group developed severe arrhythmia (n = 7) and became apneic (n = 5)	First study to show that suctioning disrupted infant transition
Estol et al. (1992)^[51]; prospective, non-random trial (assigned by hour of birth)	Bulb suction (n = 20) vs. no suction (n = 20)	Respiratory resistance and lung compliance were not different at 10, 30, or 120 min	No significant differences between infants with and without suctioning; no advantage to infants from suctioning
Carrasco, Martell, and Estol (1997)^[50]; RCT	Immediate suction with catheter (n = 15) vs. no suctioning (n = 15)	Suctioned group had lower SaO2 between 1-6 min of life (P < .05); time to reach 86%-92% SaO2 shorter in nonsuctioned group	No respiratory distress in either group; no advantage to infants from suctioning
Waltman et al. (2004)^[52]; RCT	Bulb suction on perineum and just after birth (n = 10) vs. no suction (n = 10)	No difference in Apgar scores at 1, 5, or 10 min; higher heart rate [166-173 (n = 10) bpm] in no suction group compared to suction group (150-166 bpm); lower SaO2 from 10-20 min in non-suctioned group (although > 90%)	No benefits to the infants from suctioning demonstrated

Bpm = beats per minute.
*Study populations: All infants were vigorous term infants.

Current Evidence for Practices Related to Management of Infants Born With Meconium-Stained Amniotic Fluid
Treatment	Recommendation	Reference	Study Details
Amnioinfusion	No benefit to infants found for the prevention of MAS	Fraser et al. (2005)^[54]	Multicenter RCT, women (n = 1998) in labor at term with MSAF stratified by presence of variable decelerations and randomly assigned to amnioinfusion or standard care. Amnioinfusion did not reduce risk of MAS, or perinatal death.
Intrapartum suctioning before delivery of shoulders	No benefit to any infants including high risk infants; suctioning of infant before delivery is not indicated	Vain et al. (2004)^[55]	RCT, blinded, infants (n = 1176) suctioned on perineum compared with infants (n = 1225) not suctioned. No difference in Apgar scores, respiratory distress, use of oxygen, need for ventilation, MAS (4% in each group), or death.
Endotracheal intubation and suctioning after birth of vigorous infants	No benefits to any infants; not recommended for vigorous infants	Wiswell et al. (2000)^[56]	RCT, vigorous term infants (n = 2094) with MSAF randomly assigned to intubation and suctioning or to expectant management. Intubation and suctioning did not result in lower incidence of MAS or other respiratory disorders.

MAS = meconium aspiration syndrome; MSAF= meconium-stained amniotic fluid; RCT = randomized, controlled trial.

Current Evidence for Practices Related to Management of Infants Born With Meconium-Stained Amniotic Fluid
Treatment	Recommendation	Reference	Study Details
Amnioinfusion	No benefit to infants found for the prevention of MAS	Fraser et al. (2005)^[54]	Multicenter RCT, women (n = 1998) in labor at term with MSAF stratified by presence of variable decelerations and randomly assigned to amnioinfusion or standard care. Amnioinfusion did not reduce risk of MAS, or perinatal death.
Intrapartum suctioning before delivery of shoulders	No benefit to any infants including high risk infants; suctioning of infant before delivery is not indicated	Vain et al. (2004)^[55]	RCT, blinded, infants (n = 1176) suctioned on perineum compared with infants (n = 1225) not suctioned. No difference in Apgar scores, respiratory distress, use of oxygen, need for ventilation, MAS (4% in each group), or death.
Endotracheal intubation and suctioning after birth of vigorous infants	No benefits to any infants; not recommended for vigorous infants	Wiswell et al. (2000)^[56]	RCT, vigorous term infants (n = 2094) with MSAF randomly assigned to intubation and suctioning or to expectant management. Intubation and suctioning did not result in lower incidence of MAS or other respiratory disorders.

MAS = meconium aspiration syndrome; MSAF= meconium-stained amniotic fluid; RCT = randomized, controlled trial.

Room Air Versus Oxygen for Resuscitation: Randomized, Controlled Trials and Controlled Trials (1995 to Present)
Authors, Year, Type of Study	Study Population	Intervention and Application	Significant Results	Comments
Ramji et al. (2003)^[66]; quasi-randomized by date of birth	Term newborns needing resuscitation	RA (n = 210) vs. 100% 02 (n = 221)	No differences in mortality, heart rate, Apgar scores, time to first breath, HIE. Time to first cry: RA 2 min vs. 3 min in 02group (P = .008). Duration resuscitation: RA 2 min vs. 02 3 min (P = .000076)	No indication that 100% 02 offers benefits over RA. Resuscitation appears faster with RA
Saugstad et al. (2003)^[71]; follow-up	Infants in prior trials who had reached 18-24 mos	Follow-up of ResAir study (591 infants, of whom 410 available for follow-up)	No differences in: weight, length, developmental milestones, language development, hearing, or cerebral palsy between infants resuscitated with RA vs. 02	No long-term advantage to use of 100% 02. Study weakened by low (70%) follow-up rate
Vento et al. (2003)^[69]; blinded, randomized	Term infants needing resuscitation	RA (n = 51) vs. 100% 02 (n = 55)	No statistical difference in Apgar scores. Time to first cry: RA 1.4 min vs. 02 1.97 min (P < .05). Time to regular respirations: RA 5.3 min vs. O2 6.8 min (P < .05)	No advantage to 100% 02 use
Vento et al. (2001)^[68]; blinded, randomized	Asphyxiated term infants and normal controls	RA (n = 19) vs. 100% 02 (n = 21) vs. controls (n = 26)	No statistical difference in Apgar scores. Time to first cry: RA 1.2 min vs. 02 1.7 min (P < .05). Time to regular respirations: RA 4.6 min vs. 7.5 min (P < .05). Higher levels of markers of oxygen free radicals at 28 days in 02 vs. RA groups	Even a brief exposure to 100% 02 may cause prolonged oxidative stress
Saugstad et al. (1998)^[75]; quasi-randomized by date of birth, not blinded	BW >1000 gm, no major anomalies	RA (n = 388) vs. 100% 02 (n = 311)	No significant difference in mortality, HIE, ABG. Apgar 1 min: RA 5; 02 4 min (P = .004); no difference in Apgar 5 min; more infants w/5 min Apgar < 7 in 02 group (P = .03); Time to first breath: RA 1.1 min, 02 1.5 min (P = .004); first cry: RA 1.6 min, 02 2.0 min (P = .006)	25.7% "treatment failures" in RA switched to 02 at 90 sec; comparable to numbers in 02 group (29.8%) who had bradycardia and/or central cyanosis at 90 s

ABG = arterial blood gas; BW = birth weight; HIE = hypoxic ischemic encephalopathy; 02= oxygen; RA = room air.

Room Air Versus Oxygen for Resuscitation: Randomized, Controlled Trials and Controlled Trials (1995 to Present)
Authors, Year, Type of Study	Study Population	Intervention and Application	Significant Results	Comments
Ramji et al. (2003)^[66]; quasi-randomized by date of birth	Term newborns needing resuscitation	RA (n = 210) vs. 100% 02 (n = 221)	No differences in mortality, heart rate, Apgar scores, time to first breath, HIE. Time to first cry: RA 2 min vs. 3 min in 02group (P = .008). Duration resuscitation: RA 2 min vs. 02 3 min (P = .000076)	No indication that 100% 02 offers benefits over RA. Resuscitation appears faster with RA
Saugstad et al. (2003)^[71]; follow-up	Infants in prior trials who had reached 18-24 mos	Follow-up of ResAir study (591 infants, of whom 410 available for follow-up)	No differences in: weight, length, developmental milestones, language development, hearing, or cerebral palsy between infants resuscitated with RA vs. 02	No long-term advantage to use of 100% 02. Study weakened by low (70%) follow-up rate
Vento et al. (2003)^[69]; blinded, randomized	Term infants needing resuscitation	RA (n = 51) vs. 100% 02 (n = 55)	No statistical difference in Apgar scores. Time to first cry: RA 1.4 min vs. 02 1.97 min (P < .05). Time to regular respirations: RA 5.3 min vs. O2 6.8 min (P < .05)	No advantage to 100% 02 use
Vento et al. (2001)^[68]; blinded, randomized	Asphyxiated term infants and normal controls	RA (n = 19) vs. 100% 02 (n = 21) vs. controls (n = 26)	No statistical difference in Apgar scores. Time to first cry: RA 1.2 min vs. 02 1.7 min (P < .05). Time to regular respirations: RA 4.6 min vs. 7.5 min (P < .05). Higher levels of markers of oxygen free radicals at 28 days in 02 vs. RA groups	Even a brief exposure to 100% 02 may cause prolonged oxidative stress
Saugstad et al. (1998)^[75]; quasi-randomized by date of birth, not blinded	BW >1000 gm, no major anomalies	RA (n = 388) vs. 100% 02 (n = 311)	No significant difference in mortality, HIE, ABG. Apgar 1 min: RA 5; 02 4 min (P = .004); no difference in Apgar 5 min; more infants w/5 min Apgar < 7 in 02 group (P = .03); Time to first breath: RA 1.1 min, 02 1.5 min (P = .004); first cry: RA 1.6 min, 02 2.0 min (P = .006)	25.7% "treatment failures" in RA switched to 02 at 90 sec; comparable to numbers in 02 group (29.8%) who had bradycardia and/or central cyanosis at 90 s

ABG = arterial blood gas; BW = birth weight; HIE = hypoxic ischemic encephalopathy; 02= oxygen; RA = room air.

Room Air Versus Oxygen for Resuscitation: Randomized, Controlled Trials and Controlled Trials (1995 to Present)
Authors, Year, Type of Study	Study Population	Intervention and Application	Significant Results	Comments
Ramji et al. (2003)^[66]; quasi-randomized by date of birth	Term newborns needing resuscitation	RA (n = 210) vs. 100% 02 (n = 221)	No differences in mortality, heart rate, Apgar scores, time to first breath, HIE. Time to first cry: RA 2 min vs. 3 min in 02group (P = .008). Duration resuscitation: RA 2 min vs. 02 3 min (P = .000076)	No indication that 100% 02 offers benefits over RA. Resuscitation appears faster with RA
Saugstad et al. (2003)^[71]; follow-up	Infants in prior trials who had reached 18-24 mos	Follow-up of ResAir study (591 infants, of whom 410 available for follow-up)	No differences in: weight, length, developmental milestones, language development, hearing, or cerebral palsy between infants resuscitated with RA vs. 02	No long-term advantage to use of 100% 02. Study weakened by low (70%) follow-up rate
Vento et al. (2003)^[69]; blinded, randomized	Term infants needing resuscitation	RA (n = 51) vs. 100% 02 (n = 55)	No statistical difference in Apgar scores. Time to first cry: RA 1.4 min vs. 02 1.97 min (P < .05). Time to regular respirations: RA 5.3 min vs. O2 6.8 min (P < .05)	No advantage to 100% 02 use
Vento et al. (2001)^[68]; blinded, randomized	Asphyxiated term infants and normal controls	RA (n = 19) vs. 100% 02 (n = 21) vs. controls (n = 26)	No statistical difference in Apgar scores. Time to first cry: RA 1.2 min vs. 02 1.7 min (P < .05). Time to regular respirations: RA 4.6 min vs. 7.5 min (P < .05). Higher levels of markers of oxygen free radicals at 28 days in 02 vs. RA groups	Even a brief exposure to 100% 02 may cause prolonged oxidative stress
Saugstad et al. (1998)^[75]; quasi-randomized by date of birth, not blinded	BW >1000 gm, no major anomalies	RA (n = 388) vs. 100% 02 (n = 311)	No significant difference in mortality, HIE, ABG. Apgar 1 min: RA 5; 02 4 min (P = .004); no difference in Apgar 5 min; more infants w/5 min Apgar < 7 in 02 group (P = .03); Time to first breath: RA 1.1 min, 02 1.5 min (P = .004); first cry: RA 1.6 min, 02 2.0 min (P = .006)	25.7% "treatment failures" in RA switched to 02 at 90 sec; comparable to numbers in 02 group (29.8%) who had bradycardia and/or central cyanosis at 90 s

ABG = arterial blood gas; BW = birth weight; HIE = hypoxic ischemic encephalopathy; 02= oxygen; RA = room air.

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Evidence-Based Practices for the Fetal to Newborn Transition

Room Air Versus Oxygen for Neonatal Resuscitation

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