Room Air for Initiating Term Newborn Resuscitation: A Systematic Review With Meta-analysis

CONTEXT: The International Liaison Committee on Resuscitation prioritized to rigorously review the initial fraction of inspired oxygen (F-IO2) during resuscitation of newborns. OBJECTIVE: This systematic review and meta-analysis provides the scientific summary of initial Fio2 in term and late preterm newborns (>= 35 weeks' gestation) who receive respiratory support at birth. DATA SOURCES: Medline, Embase, Evidence Based Medicine Reviews, and Cumulative Index to Nursing and Allied Health Literature were searched between January 1, 1980 and August 10, 2018. STUDY SELECTION: Studies were selected by pairs of independent reviewers in 2 stages, with a Cohen's. of 0.8 and 1.0. DATA EXTRACTION: Pairs of independent reviewers extracted data, appraised risk of bias, and assessed Grading of Recommendations Assessment, Development and Evaluation certainty of evidence. RESULTS: Five randomized controlled trials (RCTs) and 5 quasi RCTs included 2164 patients. Room air (Fio2 0.21) was associated with a statistically significant benefit in short-term mortality compared with 100% oxygen (Fio2 1.0) (7 RCTs; n = 1469; risk ratio [RR] = 0.73; 95% confidence interval [CI]: 0.57 to 0.94). No significant differences were observed in neurodevelopmental impairment (2 RCTs; n = 360; RR = 1.41; 95% CI: 0.77 to 2.60) or hypoxic-ischemic encephalopathy (5 RCTs; n = 1315; RR = 0.89; 95% CI: 0.68 to 1.18). LIMITATIONS: The Grading of Recommendations Assessment, Development and Evaluation certainty of evidence was low for short-term mortality and hypoxic-ischemic encephalopathy and very low for neurodevelopmental impairment. CONCLUSIONS: Room air has a 27% relative reduction in short-term mortality compared with Fio2 1.0 for initiating neonatal resuscitation >= 35 weeks' gestation.