Beyond oxygen targets: the DOSE framework as a conceptual model for dynamic oxygen stewardship in retinopathy of prematurity

Vollständiger Abstract

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Retinopathy of prematurity (ROP) remains a major cause of preventable childhood blindness, and oxygen therapy continues to represent a central but complex component of neonatal care. Current oxygen management is largely guided by static peripheral oxygen saturation (SpO 2 ) target ranges, commonly around 90%–95%. However, target ranges alone may not fully capture the dynamic nature of oxygen exposure in preterm infants, including fluctuations, intermittent hypoxemia, hyperoxemic excursions, instability, and cumulative exposure over time. We propose the Dynamic Oxygen Stability and Exposure (DOSE) framework as a conceptual and hypothesis-generating model for dynamic oxygen stewardship in ROP prevention. DOSE integrates four interconnected domains: delivered oxygen input (dose), physiologic oxygenation output reflected by the SpO 2 response, oxygen stability or fluctuation control, and cumulative oxygen exposure over time. The novelty of DOSE does not lie in claiming that these individual elements are new, but in organizing them into a unified framework that may help explain why similar SpO 2 targets can produce different biologic oxygen experiences across infants and care settings. This framework does not replace existing oxygen saturation guidelines and is not yet a validated clinical score or predictive model. Rather, it provides a structured approach for future research, quality improvement, and prospective validation of dynamic oxygen-exposure metrics. DOSE also recognizes that ROP is multifactorial and that oxygen instability should be interpreted alongside prematurity severity, postnatal growth, inflammation, transfusion, nutrition, respiratory morbidity, screening access, and treatment availability. By shifting attention from static targets alone toward oxygen stability and cumulative exposure, DOSE may support future strategies for safer and more individualized oxygen stewardship in diverse neonatal settings.