Meta-analysis of nasal interfaces versus face mask during respiratory support at birth in less than 37 weeks' gestation infants.

BACKGROUND

Approximately 10% of neonates require respiratory support at birth. Face mask is most commonly used during positive pressure ventilation, but the nasal interface may offer a more effective alternative. We conducted an updated meta-analysis to compare the effect of using a nasal interface versus face mask on mortality in preterm infants (<37 weeks' gestation) requiring respiratory support at birth.

METHODS

We systematically searched PubMed, EMBASE, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials from inception to November 2025 for randomized controlled trials (RCTs) comparing nasal interface and face mask during delivery room (DR) stabilization of infants <37 weeks' gestation. The primary outcome measure was neonatal death (<28 days) before hospital discharge.

RESULTS

Seven RCTs including 1270 infants were analyzed. There was no significant difference in neonatal death between nasal interface and face mask (RR 0.84, 95% CI 0.57-1.23; P = 0.37, I² = 0%). However, nasal interface significantly reduced DR intubations compared with face mask (RR 0.68, 95% CI 0.51-0.90; P = 0.007, I² = 32%).

CONCLUSIONS

In preterm infants <37 weeks' gestation, the choice of interface did not affect neonatal mortality, but the use of a nasal interface was associated with fewer DR intubations.

IMPACT: Nasal interfaces significantly reduce delivery room intubation in preterm infants without increasing mortality or major neonatal morbidities compared with face mask ventilation. Using a nasal interface compared during respiratory support at birth may be associated with a potentially clinically meaningful reduction in delivery room intubation, with a preserved safety profile. Adoption of nasal interfaces during delivery room stabilization may decrease early delivery room intubation. Reducing early intubation may support smoother cardiopulmonary transition and minimize procedure-related instability in vulnerable preterm infants. These findings provide evidence to inform practice recommendations and justify larger implementation studies evaluating long-term respiratory and neurodevelopmental outcomes.