Despite ECMO being a well-accepted and established life-saving support for newborns, prematurity (<34 weeks of gestation) and low birth weight <2.0 kg are still considered relative contraindications due to the fear of intracranial bleeding complications.

In the last decades, outcome in extracorporeal life support for pre-term babies has improved, and morbidity dominated by intracranial bleedings has decreased.

With the introduction of new methodologies and technological development, the current ELSO guideline for ECMO (GA >34 w, BW > 2.0 kg) deserves to be challenge.

The authors suggest that Prem-ECMO (GA 32-33) could be considered when restricted to experienced high-volume neonatal ECMO centers, with closed monitoring and rigorous reporting to the ELSO registry, providing close targeting of oxygen delivery for prevention of retinopathy and being active participants in continuous development of technology and devices for improved biocompatibility for use in the neonate.