The Golden Hour and beyond: A neuroprotection bundle to reduce intraventricular hemorrhage

Intraventricular hemorrhage (IVH) remains one of the most consequential complications facing extremely preterm infants, with enduring effects on survival and neurodevelopment. The first 60 min of life (the Golden Hour) offers a uniquely modifiable window to stabilize physiology, smooth cardio-cerebral transition, and implement neuroprotective strategies that may prevent or decrease the risk of IVH. This review synthesizes randomized trials, observational cohorts, and multicenter quality-improvement (QI) initiatives to define a pragmatic, evidence-based approach to Golden Hour care, and extends that approach through the first few days of life with targeted practices in positioning, handling, respiratory management, hemodynamic intervention, nutrition, blood product transfusions, analgesia/sedation, infection mitigation, and family engagement. We emphasize antenatal corticosteroids and maternal magnesium sulfate, delivery at tertiary centers, delayed umbilical cord clamping, meticulous thermoregulation, early use of continuous positive airway pressure and, if intubated, gentle use of ventilation, head-midline with head-of-bed elevation, early yet judicious cardiovascular support, restricted blood sampling, early parenteral nutrition, cautious oxygen targets with limited FiO₂ swings, caffeine therapy, restrictive platelet transfusion thresholds, tight sodium control, and structured nursing rounds with minimal stimulation. Checklists and tables model high-reliability care. While not every component is individually proven to reduce severe IVH, bundled and protocolized adoption has repeatedly improved proximate physiological targets and, in several initiatives, reduced IVH incidence. We propose an integrated, time-phased bundle for the Golden Hour and the following few days of life with implementation checklists.