Clinical Guidelines (Nursing)

Oxygen saturation SpO2 level targeting in neonates

  • Introduction

    Oxygen is toxic and, through free radical damage, contributes to eye and lung injury. Excessive oxygen is associated with higher rates of retinopathy of prematurity (ROP) whilst inadequate oxygenation is associated with an increase in mortality in preterm infants. 
    Three large multi-centre randomised controlled trials have addressed the question of the most appropriate oxygen saturation targets to minimise the incidence of ROP without increasing other morbidities and mortality.  Based on this evidence, oxygen saturations should be targeted within the range of 91-95% in both preterm and term neonates.


    To provide medical and nursing staff at the Royal Children’s Hospital with clear parameters within which SpO2 levels should be maintained, in the neonate when they are receiving oxygen.

    Definition of Terms 

    • Premature Neonate:  Any neonate born before 37 weeks completed gestation
    • Gestational Age:  The number of weeks and days of completed gestation at birth
    • Corrected Age:  Gestational age at birth plus chronological age
    • SaO2:  Arterial oxygen saturation
    • SpO2:  Percentage of haemoglobin that is saturated with oxygen.  Used to estimate SaO2
    • ROP:  Retinopathy of Prematurity – an alteration of the normal retinal vascular development, mainly affecting premature neonates (<32 weeks gestation or 1250g birthweight), which can lead to visual impairment and blindness.  It can occur in neonates treated with any concentration of oxygen greater than 21%.
    • BPD:  Bronchopulmonary Dysplasia – a chronic lung disease, mainly affecting premature neonates, that develops after oxygen therapy and mechanical ventilation.  It is characterised by a decrease in alveolar number, development of cystic changes in the lungs and an oxygen requirement beyond 36 weeks corrected gestation.
    • EMR: electronic medical record


    Preterm and term infants receiving oxygen therapy should have their SpO2 measured continuously by pulse oximetry. 

    Link to Nursing Assessment Guideline.


    Alarm limits

    • All infants receiving oxygen therapy must have default SpO2 alarm limits set with the lower limit at 89% and the upper limit at 95%. 
    • These limits should be checked at the start of each nursing shift. 
    • For infants who no longer require oxygen therapy, or require it intermittently, the upper alarm limit may be set to 100% when the infant is in air. However, if the infant requires oxygen again; the upper alarm limit must be changed to 95%. 

    Adjustment to oxygen therapy based on saturation monitoring

    Any infant who has a recorded SpO2 persistently outside the targeted range should have their oxygen therapy adjusted by nursing or medical staff to maintain SpO2 within the specified range.

    If a significant increase in inspired oxygen (>10%) is required to maintain SpO2 then a medical review of that infant should be requested. 

    Special Considerations

    In the following instances, the above targeted oxygen saturations and alarm limits may not apply: 

    • Infants with cyanotic congenital heart disease 
    • Other lung pathologies e.g. congenital diaphragmatic hernia 
    • Infants preparing for discharge with home oxygen 
    • Any other infant at the discretion of the treating consultant. 

    For these infants the targeted range may be altered. Any deviation from the above guideline will be at the discretion of the treating consultant and will be documented in the medical notes and an appropriate order created in the EMR.

    Evidence Table

    Evidence table for this guideline can be viewed here


    • Askie, L.M., Henderson-Smart, D.J., Irwig, L., Simpson, J.M., (2002) BOOST, The Effect of Differing Oxygen Saturation Targeting Ranges on Long Term Growth and Development of Extremely Preterm Oxygen Dependent Infants. Pediatr Res 51:378.
    • Clucas, L., Doyles, L.W., Dawson, J., Dopnath, S., Davis, P.G. (2007). Compliance with alarm limits for pulse oximetry in very preterm infants. Pediatrics 119: 1056-1060.
    • Coe, K. (2007). Nursing Update on Retinopathy of Prematurity. JOGNN 36(3): 288-292.
    • Schmidt, B., Whyte, R.K., Asztalos, E.V., Moddemann, D. et al for the Canadian Oxygen Trial (COT) Group. (2013). Effects of targeting higher vs lower arterial oxygen saturations on death or disability in extremely preterm infants, A randomized controlled trial. JAMA 309 (20) 2111-2120.
    • SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network. (2010). Target ranges of oxygen saturation in extremely preterm infants. N Engl J Med 362:1959-1969.
    • The BOOST II United Kingdom, Australia, and New Zealand Collaborative Groups. (2013). Oxygen saturation and outcomes in preterm infants. N Engl J Med 368: 2094-2104.
    • Tin, W., Milligan, W.A., Pennefather, P., Hey, E. (2001). Pulse oximetry, severe retinopathy, and outcome at one year in babies of less than 28 weeks gestation. Archives of Diseases in Childhood Fetal Neonatal Edition. 84: F106-F110.
    • Tin, W., Gupta, S. (2007). Optimum oxygen therapy in preterm babies. Archives of Diseases in Childhood Fetal Neonatal Edition. 92: F143-F147.
    • Tin, W., Walker, S., Lacamp, C. (2003). Oxygen monitoring in preterm babies: too high, too low? Pediatric Respiratory Reviews 4: 9-14.
    • Vanderveen, D.K., Mansfield, T., Eichenwald, E.C. (2006). Lower oxygen saturation limits decrease the severity of retinopathy of prematurity. Journal of Aopos: American Association for Pediatric Opthalmology & Strabismus 10 (5): 445-8.


    Please remember to read the disclaimer.

    The development of this clinical guideline was coordinated by Trudy Holton, Clinical Nurse Educator, Butterfly Ward. Approved by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey, Executive Director Nursing Services. First published May 2009, current as of June 2016.