Remarks

• The recommendation is conditional on shared decision-making with parents; this includes informing parents about the benefits and risks and the need for further research.
• Evidence was derived from trials that compared underwater (water-seal) “bubble” CPAP with mechanical ventilator CPAP or Infant Flow Driver (IFD) CPAP. All trials used commercially available devices and all used humidified blended oxygen–air.
• The GDG noted that the evidence on harms (increased nasal injury) was of uncertain clinical significance and the certainty of the body of evidence was low due to bias and imprecision.
• The GDG suggested that the nasal interfaces (i.e. prongs and cannulas) used with bubble CPAP machines should be carefully selected and that skilled nursing care is needed for the prongs and cannulas.
• The GDG also considered that careful selection, maintenance and monitoring of bubble CPAP devices is needed. Only commercially available bubble CPAP devices should be used; locally-manufactured or locally-adapted bubble CPAP devices should not be used.