There is no consensus regarding which type of endotracheal tube or method of fixation should be employed in neonates. We use oral endotracheal tubes held in place by a flange tied to a bonnet. In three very preterm infants the ligatures holding the bonnet to the flange caused pressure necrosis to the ear while the infants suffered poor perfusion due to profound hypotension. Permanent ear deformities have resulted. CONCLUSION: extra vigilance and precautions are required to prevent iatrogenic problems in sick, very prematurely born infants.