The prevention of pressure ulcers (PUs) has become a hot topic, with significant investment of both time and money being devoted to reducing the number of pressure-related injuries acquired within the NHS. A number of babies on our neonatal unit developed facial PUs that were caused by continued pressure from non-invasive ventilation. This lead the unit to develop a team to review the causes, and formulate a plan for reducing PU incidence, focusing on premature babies of 25 to 30 weeks gestation. This article outlines the literature around neonatal pressure ulcers, and how the review team adapted practice on the unit.