Conservative versus Liberal Oxygenation Targets in Acutely Ill Children Across the Continuum of Care: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Abstract

Background: Supplemental oxygen is common in paediatric care, but target saturation is not standardised and excessive exposure has been associated with organ dysfunction and death. Objective: To compare conservative and liberal oxygenation targets for mortality, serious adverse events, length of stay, and treatment failure in acutely ill children. Methods: PubMed/MEDLINE, trial registers, and citation networks were searched to July 15, 2026 for randomised trials of lower versus higher oxygen saturation targets in children aged over 38 weeks corrected gestational age to 18 years. Risk of bias was assessed with RoB 2, certainty with GRADE, and outcomes with random-effects models. Results: Ten trials involving 5,171 children were included. Death occurred in 69/2,114 children managed conservatively and 71/2,121 managed liberally (risk ratio 0.99, 95% CI 0.72 to 1.37; risk difference −0.4 percentage points, 95% CI −1.2 to 0.4). Serious adverse events were similar (risk ratio 0.86, 95% CI 0.65 to 1.14). Hospital stay was shorter with conservative targets (standardised mean difference −0.28, 95% CI −0.52 to −0.04), with benefit confined to ward and emergency settings. Intensive care stay showed no clear difference. Treatment failure was more frequent with conservative care (risk ratio 2.63, 95% CI 1.43 to 4.84) without excess deaths. Conclusion: Conservative targets did not increase mortality or serious adverse events and shortened hospital stay outside intensive care. Their higher treatment-failure rate supports use only with close monitoring and prompt escalation.