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BMJ 2010; 340 doi: (Published 26 May 2010) Cite this as: BMJ 2010;340:c2740

Researchers inch towards safer management for very premature babies

Choosing the best oxygen therapy for very premature babies involves balancing the risk of retinopathy associated with too much oxygen and the risk of death associated with too little. In the latest trial, a low target for oxygen saturation cut the risk of severe retinopathy by half compared with a high target (8.6% v 17.9%; relative risk 0.52, 95% CI 0.37 to 0.73) but increased the risk of death before discharge by a significant 27% (19.9% v 16.2%; 1.27, 1.01 to 1.6). A completely safe oxygen strategy remains elusive, says an accompanying editorial (doi:10.1056/NEJMe1004342).

The researchers planned a high oxygen saturation target of between 91% and 95% and a low target of between 85% and 89% for babies born between 24 and 28 weeks’ gestation. In reality, the actual difference in oxygen saturation between the two groups was much smaller, with considerable overlap. The extra deaths among babies managed with the lower target was described by the authors as “a major concern.”

The same trial also compared two different management strategies in the delivery room: immediate intubation and treatment with surfactant versus continuous positive airway pressure through the nose (nasal CPAP). About half of the babies in each group either died or developed bronchopulmonary dysplasia—the combined primary outcome (relative risk with nasal CPAP 0.95, 0.85 to 1.05). In secondary analyses, nasal CPAP was associated with a shorter period of ventilation, a reduced requirement for postnatal corticosteroids, and a lower chance of intubation. One third of the babies assigned nasal CPAP were intubated in the delivery room, usually for resuscitation. Two thirds received surfactant at some point during the trial. The editorial concludes that aiming for nasal CPAP as an initial strategy is associated with important benefits and few side effects.

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