Elements of the care bundle
| Element | Description | Optimal timing | Evidence base |
| Place of birth | Babies <27+0 weeks’ gestation (<28+0 weeks’ multiples) or <800 g who are born in a tertiary neonatal intensive care unit (NICU) | n/a | Extremely 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 steroids | Mothers who give birth at <34 weeks’ gestation receive at least one dose of antenatal steroids | Two 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 sulfate | Mothers who give birth at <30 weeks’ gestation receive antenatal magnesium sulphate | >4 hours and <24 hours prior to birth | Reduces the risk of cerebral palsy by 32%.26 |
| Intrapartum antibiotics | Mothers who are in active labour at any point prior to delivery receive intrapartum antibiotics | At least 4 hours prior to birth | Reduces 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 management | Babies born at <34 weeks’ gestation have their cord clamped | At or after 1 min of birth | Reduces mortality by 32% compared with early cord clamping.29 |
| Thermoregulation | Babies born at <34 weeks’ gestation have a normothermic temperature (36.5°C–37.5°C) | Within 1 hour of admission to the neonatal unit | 28% 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 |
| Ventilation | Babies 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 delivery | Reduces death or bronchopulmonary dysplasia by 27% and Intraventricular haemorrhage (grades 3–4) by 47% compared with pressure-limited ventilation modes.32 |
| Caffeine | Babies born at <30 weeks gestation and/or <1500 g receive caffeine therapy | Within first 24 hours of life | The odds of death or clinical disability decrease by 40.2%.33 |
| Early breast milk | Babies born at <34 weeks’ gestation receive first maternal breast milk | Within first 6 hours of life | Reduces the risk of necrotising enterocolitis by 38% compared with formula.34 |
| Multistrain probiotics | Babies born at <32 weeks’ gestation and/or <1500 g are started on multistrain probiotic | Within first 24 hours of life | The 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 hydrocortisone | Babies born at <28 weeks’ gestation are started on hydrocortisone | Within first 24 hours of life | The odds of survival without bronchopulmonary dysplasia significantly increase by 45% and the odds of death before discharge reduce by 30%.36 |
OR - Odds Ratio