Does midline head positioning decrease intraventricular hemorrhage or is it futile? Without a definitive trial, we will never know

Among the 135 million births in 2020, 0.6 million were extremely preterm (< 28 weeks’ gestation), and 1.4 million were very preterm (between 28 and < 32 weeks’ gestation) [1]. Intraventricular hemorrhage (IVH) remains a major concern for these infants, particularly those < 29 weeks’ gestation [2]. Midline head positioning (MHP) is a widely adopted intervention in care bundles for IVH prevention in preterm infants. However, high-quality evidence supporting the efficacy and effectiveness of MHP for IVH prevention is lacking. Here, we summarize the issues with the existing evidence on MHP, including its widespread adoption in care bundles on the basis of poor quality of evidence, and highlight the urgent need for a definitive trial to determine the causal role, if any, of MHP in IVH prevention.