Table 1

Elements of the care bundle

ElementDescriptionOptimal timingEvidence base
Place of birthBabies <27+0 weeks’ gestation (<28+0 weeks’ multiples) or <800 g who are born in a tertiary neonatal intensive care unit (NICU)n/aExtremely preterm babies born in a non-tertiary unit are 2.3 times more likely to develop severe brain injury and 1.3 times more likely to die whether transported or not compared with controls.24
Antenatal steroidsMothers who give birth at <34 weeks’ gestation receive at least one dose of antenatal steroidsTwo doses 12–24 hours apart, >24 hours and <7 days prior to birth.Reduces the risk of neonatal death by 31%, necrotising enterocolitis by 54% and grade 3–4 intraventricular haemorrhage by 46%.25
Magnesium sulfateMothers who give birth at <30 weeks’ gestation receive antenatal magnesium sulphate>4 hours and <24 hours prior to birthReduces the risk of cerebral palsy by 32%.26
Intrapartum antibioticsMothers who are in active labour at any point prior to delivery receive intrapartum antibioticsAt least 4 hours prior to birthReduces risk of neonatal group B streptococcal sepsis in group B streptococcal colonised women by 86%.27
Reduces the risk of delivering within 48 hours by 29% and within a week by 21% and abnormal neonatal cranial ultrasound by 19%.28
Optimal cord managementBabies born at <34 weeks’ gestation have their cord clampedAt or after 1 min of birthReduces mortality by 32% compared with early cord clamping.29
ThermoregulationBabies born at <34 weeks’ gestation have a normothermic temperature (36.5°C–37.5°C)Within 1 hour of admission to the neonatal unit28% increase in mortality per 1°C decrease in body temperature.30
Moderate hypothermia associated with higher odds of intraventricular haemorrhage (OR 1.3) and death (OR 1.5) compared with a normothermic temperature.31
VentilationBabies born at <34 weeks’ gestation who are in need of invasive ventilation are given volume-targeted ventilation in combination with synchronised ventilation as the primary mode of respiratory support.On deliveryReduces death or bronchopulmonary dysplasia by 27% and Intraventricular haemorrhage (grades 3–4) by 47% compared with pressure-limited ventilation modes.32
CaffeineBabies born at <30 weeks gestation and/or <1500 g receive caffeine therapyWithin first 24 hours of lifeThe odds of death or clinical disability decrease by 40.2%.33
Early breast milkBabies born at <34 weeks’ gestation receive first maternal breast milkWithin first 6 hours of lifeReduces the risk of necrotising enterocolitis by 38% compared with formula.34
Multistrain probioticsBabies born at <32 weeks’ gestation and/or <1500 g are started on multistrain probioticWithin first 24 hours of lifeThe odds of death are 44% less and the odds of developing necrotising enterocolitis are between 45% and 69% less when receiving probiotics compared with a placebo.35
Prophylactic hydrocortisoneBabies born at <28 weeks’ gestation are started on hydrocortisoneWithin first 24 hours of lifeThe odds of survival without bronchopulmonary dysplasia significantly increase by 45% and the odds of death before discharge reduce by 30%.36
  • OR - Odds Ratio