Gentler Breathing Care for Babies Born Too Soon: What Europe's Updated Guideline Means for Families

A plain-language guide to Sweet et al.'s European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2025 — what is new since 2022, and how sure the experts are

European newborn experts have updated their guide to caring for premature babies whose lungs are not yet ready to breathe easily. The 2025 version favours gentler care: waiting until a baby breathes steadily before clamping the cord, using soft nasal support instead of a breathing tube where possible, and giving lung medicine through a very thin tube. The experts rate the evidence behind many changes as moderate or low.

Why some babies born early struggle to breathe

When a baby is born many weeks early, the lungs are often not finished growing. They do not yet make enough surfactant, a natural soapy coating that keeps the tiny air sacs in the lungs from collapsing each time the baby breathes out. Without it, breathing is hard work, and the baby may grunt, breathe fast or pull in at the ribs. Doctors call this respiratory distress syndrome, or RDS. Babies with RDS are cared for in the neonatal intensive care unit (NICU), the hospital ward for sick and premature newborns, where they may need help with breathing for days or weeks.

The new European guideline shares figures from a large network of NICUs that show both how far care has come and how far it still has to go [1]. In 2024, about 3 out of 4 babies born at 24 to 26 weeks of pregnancy survived. But about 60% of babies at these early ages develop bronchopulmonary dysplasia (BPD), a long-lasting lung condition that gentler breathing care aims to prevent, and nearly 9 in 10 of them needed a breathing machine. The whole guideline is built around one aim: helping more babies survive without lung injury.

How care for these babies has changed over the years

This is the seventh version of the European guideline. The first appeared in 2007 and it has been updated every three years since 2010 [1]. That first version was frank about what was not yet known: many things done for premature babies at birth, including how much oxygen to give and how to inflate their lungs, were not based on strong evidence [2]. Even then, the experts hoped to avoid breathing machines where possible by using CPAP, which stands for continuous positive airway pressure. CPAP blows a gentle, steady stream of air through small prongs or a mask on the nose to keep the lungs open.

A year later, an important study tested this idea. The COIN trial (nasal CPAP or a breathing tube at birth) was led from the Royal Women's Hospital in Melbourne, Australia, and included 610 babies born at 25 to 28 weeks. About 34 in every 100 babies started on CPAP died or developed BPD, compared with about 39 in every 100 babies given a breathing tube, a difference that could have been due to chance. Babies started on CPAP needed surfactant half as often, although more of them had an air leak from the lung (about 9 in 100 compared with 3 in 100) [3]. Over the following years, doctors moved away from giving surfactant to every tiny baby straight after birth and instead began giving it to babies who showed signs of RDS [1][4]. The 2022 version of the guideline brought that gentler approach together, and two European medical societies formally supported it [4].

How a guideline like this is made

The 2025 guideline was written by 14 specialists from 11 countries: newborn doctors and one expert in pregnancy care. They read the research published up to 2025 and turned it into practical advice [1]. Each piece of advice carries a letter showing how certain the evidence is, from A (high) to D (very low), and a number showing how strongly it is recommended: 1 means strong and 2 means weak or conditional. This is based on a widely used grading method that sorts advice into strong and weak recommendations [5]. A "2" means that good doctors may reasonably make different choices for different babies.

It helps to know how the guideline was produced. The grant that paid for travel to one face-to-face meeting of the experts, in Gdansk, came from Chiesi, a drug company that makes a surfactant medicine and a caffeine medicine. Some authors have worked as advisers to that company, one author invented a resuscitation trolley used to care for babies while the cord is still attached, and two authors are chief editors of the journal that published the guideline [1]. The authors disclosed all of this openly. The paper does not describe a formal voting process, and unlike the 2022 version, it does not say that any medical society has endorsed it.

What is new at the moment of birth

The biggest change happens in the first minutes of life. Instead of clamping the umbilical cord after a fixed number of seconds, the guideline now prefers to keep the cord attached until the baby is breathing steadily, where this can be done safely [1]. A large analysis of earlier studies found that waiting at least a little while before clamping, rather than clamping immediately, helped more premature babies survive to go home [6]. The Aeration, Breathing, Clamping (ABC3) trial, run in all the major newborn centres in the Netherlands with 669 babies born before 30 weeks, then tested waiting for steady breathing. Survival without serious illness was similar, about 71 in 100 compared with 68 in 100. But babies needed fewer blood transfusions, fewer developed a later infection (about 27 in 100 compared with 33 in 100), and parents felt less anxious. Babies were slightly cooler on arrival in the NICU [7], and the guideline also stresses warm rooms, plastic wraps and warming mattresses during this time.

The guideline also suggests starting babies born before 29 weeks on more oxygen at birth, 60% instead of 30%, then adjusting it using a sensor on the skin. The experts say this may mean fewer babies need chest compressions. A large trial called TORPIDO 30/60 (starting oxygen at 60% versus 30%), run in 31 maternity hospitals in 6 countries, found that death or brain injury happened in about 47 in 100 babies started on 60% oxygen and about 48 in 100 started on 30% [8]. The advice is graded "2", meaning it is a conditional recommendation. If a breathing tube is needed, the guideline now recommends a video laryngoscope, a tool with a small camera that helps doctors see where to place the tube; one review found it made success on the first try more likely [9].

Lung medicine without a breathing tube

Surfactant can be given as a medicine. The guideline's preferred way is to pass it through a very thin, soft tube into the windpipe while the baby keeps breathing on CPAP, without a breathing machine [1]. A review of 16 studies found this thin-tube method gave better results than giving surfactant through a full breathing tube [10]. In the CALI trial (caffeine plus surfactant through a thin tube), whose researchers were based at three hospitals in California, about 23 in 100 babies treated this way needed a breathing machine or had breathing failure in the first three days, compared with about 53 in 100 who had caffeine and CPAP alone [11].

For the very smallest babies, born before 28 weeks, who show early signs of RDS once they are settled on CPAP, the guideline now says doctors can consider giving surfactant in the first hour, before the breathing problem gets worse. This advice is graded "2". According to the researchers planning a large German trial called pro.LISA, giving surfactant this early to babies who need only a little extra oxygen had not yet been tested in a randomised trial, and their study will compare it with waiting [12]. The guideline also gives lung ultrasound, a painless scan at the cot-side, a bigger role in spotting which babies need surfactant; a review of seven studies found it predicted this well [13]. Adding a steroid called budesonide to surfactant did not help in two large trials, so it is not recommended [14][15].

Breathing support, oxygen levels and other care in the NICU

After birth, the guideline prefers nasal support, either CPAP or a version that adds gentle extra breaths through the nose, over a breathing machine [1]. A review of 17 studies found the version with extra breaths reduced the need for a breathing tube; most babies in those studies were born at about 28 to 32 weeks, so the result may not apply to the smallest babies [16]. Caffeine, a medicine used to treat pauses in breathing in premature babies, is now recommended from early on for babies born before 32 weeks.

For babies born before 28 weeks who need oxygen, the target blood oxygen level stays at 90% to 94%. Large studies found that aiming lower, at 85% to 89%, led to more deaths: about 1 in 5 babies in the lower-target groups died [17]. The guideline also updates when to give a blood transfusion, following a recent international guideline [18], encourages feeding with mother's milk from the first day when a baby is stable, and asks doctors to stop antibiotics early when tests show no infection.

What this might mean for your baby

If your baby is born early, you may see some of these changes in your hospital: the cord kept attached while the team helps your baby breathe, soft nasal prongs instead of a breathing tube, or surfactant given through a thin tube. Hospitals adopt guidelines at different speeds, and doctors adjust advice to each baby. You can ask the team how they manage cord clamping, whether your baby might receive surfactant through a thin tube, and how they decide on oxygen levels. Many of these choices carry a "2", so it is reasonable for teams to differ and to explain their reasons.

What researchers are working on next

Several big questions remain. The German pro.LISA trial will show whether giving surfactant early to the smallest babies truly helps [12]. The experts say new trials are needed to find the best oxygen level, and the best way to give nasal breathing support. They also point out that babies born at 22 to 23 weeks are largely left out of studies of gentler treatments, so less is known about them [1].

Bringing it together

The 2025 European guideline asks teams to be gentler from the very first minutes: keep babies warm, let them start breathing before the cord is clamped, support them through the nose, and give surfactant without a breathing tube where possible. Some of this advice rests on strong evidence and some on early findings, and the guideline is open about which is which.

References

  1. Sweet DG, Carnielli VP, Greisen G, et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2025. Neonatology. 2026;123(4):514-539. doi:10.1159/000551062 ↩
  2. Sweet D, Bevilacqua G, Carnielli V, et al. European consensus guidelines on the management of neonatal respiratory distress syndrome. J Perinat Med. 2007;35(3):175-186. doi:10.1515/jpm.2007.048 ↩
  3. Morley CJ, Davis PG, Doyle LW, Brion LP, Hascoet JM, Carlin JB. Nasal CPAP or intubation at birth for very preterm infants. N Engl J Med. 2008;358(7):700-708. doi:10.1056/NEJMoa072788 ↩
  4. Sweet DG, Carnielli VP, Greisen G, et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update. Neonatology. 2023;120(1):3-23. doi:10.1159/000528914 ↩
  5. Guyatt GH, Oxman AD, Kunz R, et al. Going from evidence to recommendations. BMJ. 2008;336(7652):1049-1051. doi:10.1136/bmj.39493.646875.AE ↩
  6. Seidler AL, Aberoumand M, Hunter KE, et al. Deferred cord clamping, cord milking, and immediate cord clamping at preterm birth: a systematic review and individual participant data meta-analysis. Lancet. 2023;402(10418):2209-2222. doi:10.1016/S0140-6736(23)02468-602468-6) ↩
  7. Knol R, Brouwer E, van den Akker T, et al. Physiological versus time based cord clamping in very preterm infants (ABC3): a parallel-group, multicentre, randomised, controlled superiority trial. Lancet Reg Health Eur. 2025;48:101146. doi:10.1016/j.lanepe.2024.101146 ↩
  8. Oei JL, Kirby A, Travadi J, et al. Targeted Oxygen for Initial Resuscitation of Preterm Infants: The TORPIDO 30/60 Randomized Clinical Trial. JAMA. 2026;335(6):523-530. doi:10.1001/jama.2025.23327 ↩
  9. Donaldson N, O'Donnell CPF, Roehr CC, et al. Video versus direct laryngoscopy for urgent tracheal intubation in neonates: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed. 2025;110(6):526-531. doi:10.1136/archdischild-2024-327555 ↩
  10. Abdel-Latif ME, Davis PG, Wheeler KI, De Paoli AG, Dargaville PA. Surfactant therapy via thin catheter in preterm infants with or at risk of respiratory distress syndrome. Cochrane Database Syst Rev. 2021;5(5):CD011672. doi:10.1002/14651858.CD011672.pub2 ↩
  11. Katheria A, Ines F, Banerji A, et al. Caffeine and Less Invasive Surfactant Administration for Respiratory Distress Syndrome of the Newborn. NEJM Evid. 2023;2(12):EVIDoa2300183. doi:10.1056/EVIDoa2300183 ↩
  12. Göpel W, Rausch TK, Mitschdörfer B, et al. A randomised controlled trial in preterm infants comparing prophylactic with selective "less invasive surfactant administration" (pro.LISA). Trials. 2023;24(1):612. doi:10.1186/s13063-023-07603-7 ↩
  13. Capasso L, Pacella D, Migliaro F, et al. Can lung ultrasound score accurately predict surfactant replacement? A systematic review and meta-analysis of diagnostic test studies. Pediatr Pulmonol. 2023;58(5):1427-1437. doi:10.1002/ppul.26337 ↩
  14. Manley BJ, Kamlin COF, Donath SM, et al. Intratracheal Budesonide Mixed With Surfactant for Extremely Preterm Infants: The PLUSS Randomized Clinical Trial. JAMA. 2024;332(22):1889-1899. doi:10.1001/jama.2024.17380 ↩
  15. Ambalavanan N, Carlo WA, Nowak KJ, et al. Early Intratracheal Budesonide to Reduce Bronchopulmonary Dysplasia in Extremely Preterm Infants: The Budesonide in Babies (BiB) Randomized Clinical Trial. JAMA. 2025;334(16):1452-1462. doi:10.1001/jama.2025.16450 ↩
  16. Lemyre B, Deguise MO, Benson P, Kirpalani H, Ekhaguere OA, Davis PG. Early nasal intermittent positive pressure ventilation (NIPPV) versus early nasal continuous positive airway pressure (NCPAP) for preterm infants. Cochrane Database Syst Rev. 2023;7(7):CD005384. doi:10.1002/14651858.CD005384.pub3 ↩
  17. Askie LM, Darlow BA, Finer N, et al. Association Between Oxygen Saturation Targeting and Death or Disability in Extremely Preterm Infants in the Neonatal Oxygenation Prospective Meta-analysis Collaboration. JAMA. 2018;319(21):2190. doi:10.1001/jama.2018.5725 ↩
  18. Deschmann E, Dame C, Sola-Visner MC, et al. Clinical Practice Guideline for Red Blood Cell Transfusion Thresholds in Very Preterm Neonates. JAMA Netw Open. 2024;7(6):e2417431. doi:10.1001/jamanetworkopen.2024.17431 ↩