Target Oxygen Levels and Critical Care of the Newborn

Despite our growing experience in the medical care of extremely preterm infants and critically ill neonates, there are serious gaps in the understanding and clinical application of the adaptive physiology of the newborn. Neonatal physiology is often misinterpreted and considered similar to that of adult physiology. The human psyche has been seriously influenced, both from an evolutionary and survival point of view, by the cause and effect of hypoxemia which is considered as a warning sign of impending death. Within this context, it is unimaginable for even the highly trained professionals to consider saturation as low as 65% as acceptable. However, all available data suggests that newborns can thrive in a hypoxemic environment as they are conditioned to withstand extreme low saturations in the fetal environment. An approach utilizing the benefits of the hypoxic conditioning would prompt the practice of optimal targeted oxygen saturation range in the clinical management of the newborn. Our current understanding of cyanotic congenital heart disease and the physiology of single ventricle circulation, where oxygen saturation in mid 70s is acceptable, is supported by clinical and animal studies. This article argues the need to challenge our current acceptable target oxygen saturation in the newborn and provides the reasoning behind accepting lower target oxygen levels in the critically ill newborn. Challenging the current practice is expected to open a debate paving the way to understand the risks of high target oxygen levels in the newborn compared with the benefits of permissive hypoxia in avoiding the associated morbidity and mortality of oxygen radical injury.