The greatest challenge for neonatologists today is how best to care for babies of extremely low birth weight, generally taken to be those born below 26 weeks' gestation, so-called Extremely Low gestational Age Newborns (ELGANS). Over the last few years, the style of care for these very delicate babies has become more individualized and gentler. Tailoring care to the individual needs of the individual baby was led by the introduction of the Newborn Individualized Developmental Care and Assessment programme (NIDCAP) . The gentler approach has been epitomized by the acceptance of lower blood pressure  and higher carbon dioxide levels  as well as the concept of assisting very small babies in their transition to extrauterine life, rather than resuscitating them .
The paper by Mehler et al.  in this addition of Acta Paediatrica adds to this mood by raising the possibility that a gentler approach in the delivery room may be beneficial for babies born at the margins of viability. They describe remarkable results for ELGANS cared for in Cologne, with an overall survival rate for babies of <26 weeks of 80%, and extraordinarily a survival rate of 82% for babies of 23 weeks' gestation. This compares extraordinarily well with results for inborn babies at my own institution, a large tertiary neonatal intensive care unit in Northwest England: between 2007 and 2010 there were no survivors below 24 weeks' gestation; at 24 weeks, 12/42 (29%) babies survived; and at 25 weeks, 22/41 (54%) babies survived; all survivors required added oxygen at 36 weeks by postmenstrual age. Mehler et al. extend discussion about the best way to manage these very immature infants by speculating that the apparent good effect observed at their institution was achieved by a unique package of care: regional anaesthesia was preferred to general anaesthesia; delivery was by caesarean section and the complete amniotic cavity containing foetus and placenta was removed from the uterus as gently as possible; surfactant was administered soon after birth without intubation by a fine endotracheal catheter during spontaneous breathing; respiratory support was by continuous positive airways pressure (CPAP) using a face mask with higher pressure levels than are generally used (8 cm of water, but only for the first 10–30 minutes after birth) without positive pressure ventilation – only 51% of all the babies <26 weeks and 48% of those at 23 weeks were treated with mechanical ventilation, which was by high-frequency oscillatory ventilation. Many of these treatment strategies are not in general use.
The report by Mehler et al. is fascinating but, as the authors themselves recognize, caution needs to be exercised before unquestioningly adopting their approach. It is an easy paper to criticize. It is a description of the outcome for 164 babies born at a single centre during a period of 6 years, when procedures were not uniform: the FiO2 was initially set to 0.6, but changed to 0.3 after 2008, and intubation was only undertaken if the baby's heart rate remained below 100 per minute, changed to 130 per minute after 2010. Outcome was compared with a very small historical control group comprising just 44 infants born during the preceding ten and half months only and, as the authors acknowledge, the babies included in this comparison group were only a fraction of infants actually delivered at 22 or 23 weeks' gestation during 2000 and 2001 when most children born at their institution at such early gestations were not treated. Furthermore, practices at their hospital in Cologne do not mirror those at other maternity hospitals. For example, while delayed cord clamping and placental transfusion were routinely practised, this is not generally done although there is good evidence to support this practice . Also, oral suction was only done immediately after birth if there was blood- or meconium-stained amniotic fluid, and this is also not the case in many other hospitals.
The observations from Cologne should not be ignored. Not only was there a low mortality for ELGANS (20%), but so was the incidence of bronchopulmonary dysplasia (18%), even amongst the most immature patients of 22 and 23 weeks' gestation (14%). The paper by Mehler et al. sets a challenge for neonatologists and the proposed bundle of care needs to be tested by randomized controlled trial.