Factsheet
Neonatal Respiratory
Guideline Summary
A summary of the seventh European Consensus Guidelines on the Management of Respiratory Distress Syndrome, based on literature up to 2025. Each recommendation is shown with the GRADE level the guideline gives it.1
The bottom line
The aim of RDS management is to maximise the number of infants who survive without lung injury: non-invasive respiratory support where possible, surfactant given early by a technique that avoids intubation and, if mechanical ventilation is needed, lung-protective strategies for the shortest time possible.1
0.6
Starting FiO₂ for infants <29 weeks (B2)
200 mg/kg
Initial dose of poractant alfa, better than 100 mg/kg (A1)
90–94%
SpO₂ target for infants <28 weeks receiving oxygen (B2)
Reading the grades. The guideline uses the GRADE system. The letter is the quality of evidence: A high, B moderate, C low, D very low certainty. The number is the strength of recommendation: 1 strong, 2 weak or conditional. Grades appear exactly as in the guideline. Anything below marked
guideline text is discussed in the guideline but is not a graded recommendation.
1
Summary of changes
The guideline lists these changes from the previous version.1
- Prenatal management is largely unchanged, with more emphasis on confirming preterm labour so that antenatal steroids are used more judiciously.
- Cord clamping. The guideline suggests physiologically-based cord clamping rather than a time-based approach, with emphasis on thermal care before the cord is cut if the equipment is available.
- Starting oxygen. Starting FiO₂ 0.6 rather than 0.3 at birth for infants <29 weeks should reduce bradycardia and the need for chest compressions and adrenaline, although there are no differences in other outcomes.
- Surfactant prophylaxis has reappeared for extremely preterm infants now that less invasive surfactant administration (LISA) is available, with emphasis on videolaryngoscopy for LISA catheter placement or intubation because first-pass success is greater.
- Non-invasive ventilation. NIPPV rather than CPAP now seems the most effective mode of non-invasive respiratory support (NRS), both after initial stabilisation and after mechanical ventilation, although there is no unified approach to how best to provide it.
- Surfactant threshold. For babies who have not had prophylactic surfactant, the FiO₂ 0.3 threshold is unchanged, with more emphasis on using lung ultrasound, where possible, to diagnose RDS regardless of FiO₂ in babies with signs of respiratory distress.
Prenatal care
Recommendations
Place of birthMothers at high risk of preterm birth <28–30 weeks should be transferred to perinatal centres experienced in managing RDS B1
Cervical screeningUltrasound screening of the cervix in high-risk pregnancies, and in women with a short cervix in mid-pregnancy, guides vaginal progesterone in singleton pregnancies to increase gestation at delivery and reduce perinatal mortality and morbidity A1
Symptoms of preterm labourCervical length and biomarker measurements should be considered to prevent unnecessary use of tocolytics and/or antenatal steroids B2
Antenatal steroidsOffer a single course to all women at high risk of preterm delivery, from when the pregnancy is considered potentially viable up to 34 completed weeks, ideally at least 24 h before birth A1
Repeat steroidsA single repeat course may be given in threatened preterm birth before 32 weeks if the first course was given at least 1–2 weeks earlier A2
Magnesium sulphateShould be given to women with imminent delivery before 32 weeks A1
TocolysisConsider short-term oxytocin antagonists or calcium channel blockers in very preterm pregnancies, to allow completion of a steroid course and/or in utero transfer B1
Guideline text
The best interval between antenatal steroids and delivery is more than 24 h and less than 7–10 days; beyond 7–10 days the benefit is reduced. Steroids should only be given to women highly likely to deliver preterm, as 40–50% of women who receive them deliver at term. Magnesium sulphate reduces cerebral palsy at 2 years by about 30%, although longer-term benefits are less clear, and a reduction may be seen when it is given as little as 4 h before delivery. In pre-labour rupture of membranes, co-amoxiclav should be avoided because of its association with necrotising enterocolitis.1
Delivery room stabilisation
Recommendations
Deferred cord clampingIf the clinical condition allows, defer clamping for 60 s or longer A1
Intact-cord stabilisationIf stabilisation with an intact cord (PBCC) can be safely undertaken, longer deferred cord clamping is preferable, especially in infants <34 weeks A1
Cord milkingIf deferred cord clamping is not feasible, consider umbilical cord milking in infants ≥28 weeks B2
DeviceT-piece devices should be used rather than self-inflating or flow-inflating bag and mask B1
BreathingBreathing should be stimulated C2 and supported with CPAP A1. If spontaneous breathing does not start within 30–60 s, start ventilation breaths
Starting pressuresExpert consensus: CPAP at least 6 cmH₂O and peak inspiratory pressure 25 cmH₂O D2
Starting FiO₂Controlled with a blender: 0.6 for <29 weeks, ≥0.30 for 29–31 weeks, 0.21 for ≥32 weeks. Adjust up or down guided by pulse oximetry B2
5-minute targetSpO₂ 80% or more (and heart rate >100/min) within 5 min for babies <32 weeks C2
IntubationReserve for babies not responding to positive pressure ventilation via face mask or nasal prongs A1. Use a videolaryngoscope and colorimetric capnography if available B1
Thermal careFor babies <32 weeks: room temperature ≥23 °C, plastic bags or occlusive wrapping under radiant warmers, and humidified gas. Additional measures such as a thermal mattress during delayed cord clamping. Avoid hyperthermia A1
Guideline text · physiologically-based cord clamping
PBCC means clamping the cord only once the infant has achieved respiratory stability, rather than at a set time. It is a suggestion in the guideline’s summary of changes, not a separate graded recommendation. In the largest trial of PBCC against time-based clamping there was less need for top-up transfusions, less late-onset sepsis and less parental anxiety, but no overall difference in intact survival; intact survival was higher only in the centres that used it most, suggesting a learning curve. Cord milking raises concern about intraventricular haemorrhage in infants <28 weeks.1
Guideline text · starting oxygen
No clear differences in major outcomes have been shown between starting with higher (>0.6) or lower (<0.3) FiO₂. Recent trials suggest less need for chest compressions and adrenaline when starting at 0.6 rather than 0.3 in infants <29 weeks. An individual patient data review of 1,055 babies <32 weeks suggests starting at 0.9 may be better than <0.3, but the difference between 0.9 and 0.5–0.65 is less clear.1
Surfactant therapy
Recommendations
TimingSurfactant should be given early in the course of the disease while on NRS A1
<28 weeksConsider selective prophylaxis within the first hour of life for infants with early signs of RDS after stabilisation B2
<32 weeks, intubatedIf intubation is needed for stabilisation, give surfactant as soon as possible A1
>28 weeksGive surfactant to infants with worsening RDS A1. Suggested protocol: on NRS with mean airway pressure ≥6 cmH₂O, FiO₂ ≥0.3, or where lung ultrasound suggests surfactant need A1
RouteThin catheter is the preferred route in spontaneously breathing preterm babies A1, with a videolaryngoscope C2
Supraglottic airwayMay be used for surfactant delivery in larger infants B2
DoseAn initial dose of 200 mg/kg is better than 100 mg/kg of poractant alfa A1
Repeat dosesA second, and occasionally a third, dose should be given if there is ongoing evidence of RDS, such as a persistent high oxygen requirement, and other problems have been excluded A1
Other conditionsSurfactant can be used for RDS complicated by congenital pneumonia C2 and can improve oxygenation after pulmonary haemorrhage C1
Natural surfactants available in Europe — guideline text
Poractant alfa (porcine)100–200 mg/kg; volume 1.25–2.5 mL/kg
Beractant (bovine)100 mg/kg; volume 4 mL/kg
Bovactant (bovine)50 mg/kg; volume 1.2 mL/kg
Evidence discussed in the guideline
- OPTIMIST-A randomised 485 babies of 25–28 weeks, with the intervention blinded, to LISA surfactant or a sham procedure at an FiO₂ threshold of 30%. There was no significant difference in the primary outcome of death or BPD, but BPD in survivors was lower in treated infants (37% vs 45%), with less reported respiratory disease at 2 years. The guideline notes it is unclear whether the differences are due to the LISA method alone, as two-thirds of control infants also received surfactant.1
- CALI trial. Spontaneously breathing infants of 24 to 29+6 weeks with RDS received CPAP, caffeine and LISA, or CPAP and caffeine alone. Respiratory failure in the first 72 h was lower with LISA (23% vs 53%). Caffeine was given in both groups.1
- Lung ultrasound. With appropriate training, it is a reliable way to diagnose RDS within 2 h of age without more infants overall being treated. In a review of randomised trials including over 700 infants, its sensitivity for detecting poor aeration and surfactant need was 0.86, better than using FiO₂ 30% alone. Which scoring system should be the gold standard is still debated.1
- Infants of 22–23 weeks are considered a special group who are likely to need planned intubation and surfactant in the first minutes after birth.1
Oxygen supplementation beyond stabilisation
Recommendations
Saturation targetIn preterm babies <28 weeks receiving oxygen, 90–94% B2
BPD with pulmonary hypertensionConsider increasing target saturations B2
Alarm limitsSet to 89% and 95% D2
RetinopathyProtocols for screening and treating preterm babies for ROP should be in place A1
Guideline text
In the NeOProM collaboration, targeting 85–89% rather than 91–95% protected against retinopathy of prematurity, but mortality (RR 1.17; 95% CI 1.04–1.31) and necrotising enterocolitis (RR 1.25; 1.05–1.49) increased. Targeting 85–89% should be avoided; whether intermediate targets (88–93%) are better than higher targets (90–95%) remains uncertain and needs further randomised studies. Around 20% of babies with evolving BPD develop pulmonary hypertension.1
Non-invasive respiratory support
Recommendations
From birthNRS should be started from birth in all babies at risk of RDS who do not need intubation for stabilisation A1
Primary modeNasal CPAP at 6–8 cmH₂O or, if available, NIPPV (preferably synchronised) A2
EscalationBeing able to escalate from CPAP to NIPPV will reduce the need for invasive ventilation in some infants A1
Bi-level devicesBiPAP devices confer no advantage over CPAP alone A2
After extubationSynchronised NIPPV can reduce the need for re-ventilation and may reduce BPD A2
InterfaceShort binasal prongs or nasal mask, for NIPPV or nasal CPAP A2
High-flow nasal cannulaeHFNC reduces nasal discomfort and can be used as part of weaning NRS A2
NIPPV vs CPAP (guideline text)
As primary support: less need for intubation (RR 0.67; 0.56–0.81), with potential to reduce BPD if synchronised (RR 0.52; 0.27–1.00). After extubation: less re-intubation (RR 0.78; 0.70–0.87) and, if synchronised, possibly less air leak and BPD (RR 0.64; 0.44–0.95).1
HFNC vs CPAP (guideline text)
As primary support: more treatment failure with HFNC (RR 1.70; 1.41–2.06), but no overall increase in mechanical ventilation because failures can be rescued with CPAP (RR 1.04; 0.82–1.31), and less nasal injury (RR 0.49; 0.36–0.68).1
Guideline text · limitations
Most babies in the NIPPV studies were 28–32 weeks, so it is uncertain whether the findings apply to smaller infants, and the studies are heterogeneous. Trials used many different pressures, inspiratory times and rates, so optimal NIPPV settings cannot be advised. The HFNC studies focused on babies >28 weeks. In the ECLAT trial, extubating babies <28 weeks to higher CPAP (9–11 vs 6–8 cmH₂O) reduced the need for re-ventilation within 7 days.1
Mechanical ventilation
Recommendations
WhenMechanical ventilation should be used in babies with RDS when other methods of respiratory support have failed A1. Duration should be minimised B2
ModeLung-protective modes such as volume-targeted ventilation (rather than pressure-cycled) should be the first choice A1. NAVA and, if necessary, HFOV may be considered C2
Carbon dioxideWhen weaning, a modest degree of hypercarbia is reasonable provided the pH stays above 7.22 B2. Avoid pCO₂ <4.7 kPa (35 mmHg) on mechanical ventilation to reduce brain injury C1
Inhaled nitric oxideLimit to a therapeutic trial in hypoxic respiratory failure with documented pulmonary hypertension; stop if there is no response C2
Caffeine citrate20 mg/kg loading, 5–10 mg/kg maintenance, to facilitate weaning and prevent BPD A1. Prophylactic caffeine in standard doses for babies <32 weeks B1
DexamethasoneA short tapering course of low-dose dexamethasone should be considered in babies at high risk of death or BPD who remain on mechanical ventilation after 1–2 weeks A2
Analgesia and sedationOpioids should be used selectively, guided by clinical judgement and pain assessment D1. Routine morphine or midazolam infusions in ventilated preterm infants are not recommended A1
Ventilator settings — guideline text, not graded
Volume-targeted ventilationInitial tidal volume around 5 mL/kg; maximum PIP around 25–30 cmH₂O; backup rate around 30. Required tidal volumes are usually 5–7 mL/kg, tending to rise with postnatal age or evolving BPD
ExtubationPossible from a mean airway pressure of about 7–8 cmH₂O on conventional ventilation, or a continuous distending pressure of 8–9 cmH₂O on HFOV
Dexamethasone timingHarm outweighs benefit if given in the first week. After 7 days, in a baby still on the ventilator, BPD risk may be high enough to favour dexamethasone to help extubation. For every 10% increase in BPD risk, the risk of harm from steroids falls by around 3%; benefit outweighs harm when BPD risk is about 60%
Monitoring and supportive care
Recommendations
TemperatureCore temperature should be kept between 36.5 °C and 37.5 °C at all times C1
FluidsMost babies should start IV fluids at 70–80 mL/kg/day in a humidified incubator, although some very immature babies may need more C1. Tailor individually to serum sodium, urine output and weight loss D1
Parenteral nutritionStart from birth. Amino acids 1.5–2 g/kg/day from day one, quickly built up to 3.0 g/kg/day and not above 3.5 g/kg/day B2. Lipids 1–2 g/kg/day from day one, quickly built up to 3.0 g/kg/day as tolerated C2
Enteral feedingStart with mother’s milk from the first day if the baby is haemodynamically stable B2. Full enteral feeds can be considered for infants ≥30 weeks B2
AntibioticsUse judiciously and stop early when sepsis is ruled out D1
HypotensionTreatment is recommended when there is evidence of poor tissue perfusion, such as oliguria, acidosis and poor capillary refill. Treatment depends on the cause C2
Patent ductus arteriosusWhen pharmacological closure of a haemodynamically significant PDA is attempted, indomethacin, ibuprofen or paracetamol can be used with similar efficacy A2. Paracetamol is preferred with thrombocytopaenia or renal concerns B2
Transfusion thresholdsOn respiratory support: 11, 10 and 9 g/dL in weeks 1, 2 and 3. On no or minimal respiratory support: 10, 8.5 and 7 g/dL A2
Guideline text
Empirical antibiotics can be stopped after 24–36 h if cultures are negative and there is no laboratory evidence of sepsis. Saline boluses should be avoided: for hypotension in extremely preterm infants they do not raise blood pressure but reduce lung compliance and increase ventilator pressure requirements. Adding budesonide to surfactant does not affect clinical outcomes and has no role in early respiratory management.1
Background figures
Vermont Oxford Network data on nearly 60,000 babies born <1,500 g show that in 2024 around 75% of babies born at 24–26 weeks survived, while BPD remained high at 60%. Surfactant was given to nearly 90% at 24–26 weeks, 65% at 27–29 weeks and 32% at 30–32 weeks. Mechanical ventilation was used in nearly 90%, 55% and 25% respectively. The guideline notes good evidence that a gentler approach, limiting exposure to positive pressure ventilation, may increase survival without BPD, and that more work is needed to change clinical practice.1
Reference
- Sweet DG, Carnielli VP, Greisen G, Hallman M, Klebermass-Schrehof K, Lavizzari A, et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2025. Neonatology. 2026;123(4):1–26. DOI: 10.1159/000551062
