- Design
- Cochrane systematic review and meta-analysis of randomised trials
- Population
- 12 trials, 2,054 term and late preterm infants needing support at birth
- Primary outcome
- Mortality before discharge
- Effect
- RR 0.72 (0.57–0.91), I² 0%; low-certainty evidence
This updated Cochrane review included 12 randomised or quasi-randomised trials with 2,054 term and late preterm infants who needed respiratory support at birth, comparing air with supplemental oxygen to start resuscitation.
Starting with air may reduce death before discharge (RR 0.72, 95% CI 0.57–0.91; I² 0%; 10 trials, 1,879 infants; low-certainty evidence). There was little or no difference in moderate to severe hypoxic-ischaemic encephalopathy (RR 0.88, 0.71–1.10). Evidence on neurodevelopment was very uncertain. Risk of bias was high in most trials, and results did not differ between high-income and low- and middle-income countries.
Every included trial compared air with 100% oxygen without titration to saturation targets, so the review cannot say what starting concentration is best when titration is available. It supports what neonatal resuscitation guidance already favours for term infants, starting in air, and gives labour wards without blenders a clear default.
- Start resuscitation of term and late preterm infants in air rather than 100% oxygen.
- Titrate oxygen to pulse oximetry targets where an oximeter and blender are available.
- Prioritise effective ventilation; oxygen does not replace adequate inflation breaths.
- Make sure delivery areas without blenders know air is the default starting gas.
Why it matters
Reaching for 100% oxygen at birth is still common, and the evidence points the other way.
Don't overread it
All trials used 100% oxygen as the comparator without titration, so the best titrated starting concentration remains unknown.
The statistics, in plain English
An RR of 0.72 means about 28% fewer deaths before discharge with air. The certainty is low because most trials were at high risk of bias, but there was no inconsistency between them.
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