Respiratory distress syndrome (RDS) care pathways evolve slowly as new evidence emerges. We report the sixth version of "European Guidelines for the Management of RDS" by a panel of experienced European neonatologists and an expert perinatal obstetrician based on available literature up to end of 2022. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, appropriate maternal transfer to a perinatal centre, and appropriate and timely use of antenatal steroids. Evidence-based lung-protective management includes initiation of non-invasive respiratory support from birth, judicious use of oxygen, early surfactant administration, caffeine therapy, and avoidance of intubation and mechanical ventilation where possible. Methods of ongoing non-invasive respiratory support have been further refined and may help reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation by targeted use of postnatal corticosteroids remains essential. The general care of infants with RDS is also reviewed, including emphasis on appropriate cardiovascular support and judicious use of antibiotics as being important determinants of best outcome. We would like to dedicate this guideline to the memory of Professor Henry Halliday who died on November 12, 2022.These updated guidelines contain evidence from recent Cochrane reviews and medical literature since 2019. Strength of evidence supporting recommendations has been evaluated using the GRADE system. There are changes to some of the previous recommendations as well as some changes to the strength of evidence supporting recommendations that have not changed. This guideline has been endorsed by the European Society for Paediatric Research (ESPR) and the Union of European Neonatal and Perinatal Societies (UENPS).

Ann and Robert H Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine Chicago Illinois USA

Department of Child Health Queen's University Belfast and Royal Maternity Hospital Belfast UK

Department of Children and Adolescents Oulu University Hospital and Medical Research Center University of Oulu Oulu Finland

Department of Neonatology Rigshospitalet and University of Copenhagen Copenhagen Denmark

Department of Neonatology University Polytechnic Della Marche University Hospital Ancona Ancona Italy

Department of Obstetrics and Gynecology University Medical Centre Utrecht The Netherlands

Department of Pediatric Research Oslo University Hospital Rikshospitalet University of Oslo Oslo Norway

Department of Pediatrics and Adolescent Medicine Division of Neonatology Medical University of Vienna Vienna Austria

Department of Pediatrics and Neonatal Research Unit Health Research Institute La Fe University and Polytechnic Hospital La Fe Valencia Spain

Department of Pediatrics Marmara University Medical Faculty Istanbul Turkey

Department of Pediatrics University Children's Hospital Wuerzburg Germany

Division of Neonatology Department of Obstetrics and Gynecology General Faculty Hospital and 1st Faculty of Medicine Charles University Prague Czechia

Faculty of Health Sciences University of Bristol UK and National Perinatal Epidemiology Unit Oxford Population Health Medical Sciences Division University of Oxford Oxford UK

Leiden University Medical Centre Leiden The Netherlands

Regional Neonatal Unit Royal Maternity Hospital Belfast UK

University of Lausanne Lausanne Switzerland

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