Am J Perinatol
DOI: 10.1055/a-1933-7235
Review Article

Providing Positive End-Expiratory Pressure during Neonatal Resuscitation: A Meta-analysis

Ioannis Bellos
1   Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Division of Surgery, Athens University Medical School, National and Kapodistrian University of Athens, Greece
Anish Pillai
2   Department of Neonatology, Surya Children's Hospital, Mumbai, Maharashtra, India
Aakash Pandita
3   Department of Neonatology, Medanta Hospital, Lucknow, Uttar Pradesh, India
› Author Affiliations
Funding None.


Our objective was to conduct a systematic review and meta-analysis evaluating the effects of administering positive end-expiratory pressure (PEEP) during neonatal resuscitation at birth. Medline, Web of Science, Scopus, Cochrane Central Register of Controlled Trials, and databases were systematically searched from inception to 15 December 2020. Randomized controlled trials and cohort studies were held eligible. Studies were included if they compared the administration of PEEP using either a T-piece resuscitator or a self-inflating bag with a PEEP valve versus resuscitation via a self-inflating bag without a PEEP valve. Data were extracted by two reviewers independently. The credibility of evidence was appraised with the Grading of Recommendations, Assessment, Development, and Evaluations approach. Random-effects models were fitted to provide pooled estimates of risk ratio (RR) and 95% confidence intervals (CIs). Overall, 10 studies were included, comprising 4,268 neonates. This included five randomized controlled trials, one quasi-randomized trial, and four cohort studies. The administration of PEEP was associated with significantly lower rates of mortality till discharge (odds ratio [OR]: 0.60, 95% CI: 0.49–0.74, moderate quality of evidence). The association was significant in preterm (OR: 0.57, 95% CI: 0.46–0.69) but not in term (OR: 1.03, 95% CI: 0.52–2.02) neonates. Low-to-moderate quality evidence suggests that providing PEEP during neonatal resuscitation is associated with lower rates of mortality in preterm neonates. Evidence regarding term neonates is limited and inconclusive. Future research is needed to determine the optimal device and shed more light on the long-term effects of PEEP administration during neonatal resuscitation. This study is registered with PROSPERO with registration number: CRD42020219956.

Key Points

  • PEEP administration during neonatal resuscitation in the delivery room reduces mortality in preterm.

  • Evidence regarding term neonates is limited and inconclusive.

  • Future research is needed to determine the optimal device.

Data Availability Statement

All relevant data have been provided the manuscript. This study is registered with the Clinical Trial Registration (if any) with PROSPERO identifier: CRD42020219956.

Authors' Contributions

A.P. and I.B. conceptualized and designed the study, collected data, performed the initial analyses, and reviewed and revised the manuscript. A.P. wrote the initial manuscript and collected data. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Supplementary Material

Publication History

Received: 11 December 2021

Accepted: 12 August 2022

Accepted Manuscript online:
30 August 2022

Article published online:
09 November 2023

© 2023. Thieme. All rights reserved.

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