key: cord-0005897-3r673cbx authors: nan title: ESPNIC 2011: 22nd Annual Congress of the European Society of Paediatric and Neonatal Intensive Care date: 2011-10-28 journal: Intensive Care Med DOI: 10.1007/s00134-011-2387-x sha: 5d0ba57db7a38f75267ab224deee5ef14451218a doc_id: 5897 cord_uid: 3r673cbx nan Medical Topic 2 -Neonatal respiratory failure (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) Background and aim: Meconium aspiration syndrome produces natural surfactant inhibition with serious neonatal complications. A comparative study was carried out to evaluate surfactant bronchial lavage therapy efficacy in term infants with meconium aspiration syndrome. Methods: By a random clinical essay we studied term newborns with meconium aspiration syndrome treated in a neonatal care intensive unit, divided in two groups. Group A received surfactant bronchial lavage, B isotonic saline bronchial lavage. Oxygenation index, unit stay days, days of mechanical ventilation, weight, gender and gestational age was study variables. Data analysis was non parametric. Results: Sixteen patients were included, 8 for each group, 9 (56.25%) girls and 7 (43.75%) boys, with gestational age average of 40.62 weeks and 3.083 kg of weight. Statistical difference for best improvement was determined by surfactant bronchial lavage group in: ventilation days (p = 0.007), unit days stay (p = 0.001), oxygenation index at third (p = 0.007) and fourth day (p = 0.028), maximum ventilation pressure at fifth day (p = 0.038) and inspired oxygen fraction in fourth (p = 0.028) and fifth day (p = 0.038). Not differences exist in gender comparison. Conclusions: Surfactant bronchial lavage is more effective for improve in minor time meconium aspiration syndrome patients conditions, and low stay medical costs. Methods: Data was collected retrospectively from electronic patient record systems. Data on Antenatal scans, delivery details, postnatal ventilatory management and mortality were collected. Standard statistical methods were used. Results: Total of 35 pregnancies had antenatal diagnosis of CDH. Eight pregnancies were terminated. The outcome of 30 live born infants is shown in Figure 1 . Fifteen (50%) of live born infants survived to discharge. The nonsurvivors had an earlier in utero diagnosis of CDH, lower lung-head ratio (LHR) on antenatal scans, lower birth weight and Apgars (Table 1 ). All the ventilatory parameters were significantly worse and the use of inotropes was higher in nonsurvivors. Background and aim: Transient tachypnea of the newborn (TTN) is considered as a benign and self-limited respiratory disease. A small subset of these neonates progressively increases their oxygen requirement and requires mechanical ventilation for acute lung injury (ALI). The aim of this population-based case-control study was to identify factors associated with subsequent development of ALI among term neonates initially diagnosed with TTN. Methods: Between 2003 and 2008, neonates born in Burgundy between 37 and 41 weeks' gestation and admitted to the neonatal care units within 48 h of life for respiratory distress were screened. Infants with bacterial infection, meconium aspiration syndrome, asphyxia and congenital malformations were excluded. ALI cases were defined as follows: mechanical ventilation [24 h; PaO 2 /FiO 2 ratio \300; bilateral alveolar infiltration on chest radiograph and absence of left atrial hypertension. Each case was compared to two controls, randomly selected among neonates with TTN that did not progress to ALI. Results: Sixty-four neonates met the criteria for ALI. Severe complications (pneumothorax, persistent pulmonary hypertension, hospitalacquired infection) were encountered in 35 infants. The mortality rate was zero. Three factors were associated with an increased risk for ALI: age at the onset of the disease C60 min; SpO 2 /FiO 2 ratio at the time of admission to the neonatal care unit B250 and decrease in the SpO 2 /FiO 2 ratio during the 5 h following the admission. Conclusion: ALI was an infrequent but severe disease. The SpO 2 / FiO 2 ratio allowed prompt identification of infants at high risk for ALI among neonates initially recognised as TTN. In the mask and prongs groups, 15 (12-24)% and 20 (14-26)%, respectively, was deposited supraglottically; most of this in the nose. The gut contained 5 (4-11)% and 9 (0-18)%, respectively. Objective: To evaluate the effects of SP-A addition to the exogenous surfactant, regarding to the pulmonary dynamic compliance (CD), the ventilatory pressure (VP), the maximum lung volume (V 30 ) and the homogeneity of alveolar expansion. Methods: After c-section, 27 days preterm rabbits were ventilated using a ventilator plethysmograph-system. At 5 min ventilation animals were randomized into three study groups: Surfactant (surfactant 100 mg/kg-Butantan surfactant, Brazil, 25 mg lipids/ml), SP-A (surfactant 100 mg/kg with addition of 5% SP-A), and Control Group (no surfactant treatment). CD, VP and Vt were recorded each 5 min. After 20 min ventilation animals were deeply sedated with sodium pentobarbital (25 mg/kg, IP) and a quasi-static pressure-volume curve was performed to determine maximum lung-volume at 30 cm H 2 O (V 30 ). Following sacrificed, the lungs were reinflated at 30 cm H 2 O, the pressure was reduced to 10 cm H 2 O with tracheal ligation and lung was removed and fixed using 10% formalin. Lung slices were evaluated for mean alveolar size (Lm) and distortion index (DI). Statistical analysis was by ANOVA One Way with repeated measures, significance was set at p = 0.05. Results: Background and aims: The purpose of this audit was to use propofol, a hypnotic agent, as a first line induction agent in place of morphine, atropine, and suxamethonium as an induction agent for all nonemergency neonatal endotracheal intubation. We hypothesized that propofol aids intubation by allowing the continuation of spontaneous breathing, as suggested by Ghanta et al. Severe desaturation noted only in one out of 30, no evidence of hypotension noted in any babies. Conclusions: Propofol is more effective or equally effective to the morphine, atropine, and suxamethonium regimen as an induction agent to facilitate neonatal nasal endotracheal intubation. Being only one drug to use there are potential less chances of drug errors. Importantly, hypoxemia was less severe, probably because of the maintenance of spontaneous breathing. The shorter duration of action would be advantageous in a compromised infant. Neonatology, University of Lie`ge, CHU de Lie`ge (CHR), 2 Nomics, Lie`ge, Belgium Background: Ventilator respiratory mechanics (RM) monitoring, while widely available, remains rarely used in clinical practice to follow trends and to differentiate different respiratory status. The aim of this study is to evaluate a new approach to provide RM from selected optimal breaths and its ability to improve the discrimination of RM parameters between patients. Methods: Ten minutes recordings from ten newborns ventilated in Assist/Control with variable diseases and gestational age were analysed. Ventilator provided RM data (Resistance, Compliance, Time constant, Tidal volume and C20/C) every 10 s (VRM, Ventilator RM). Continuous pressure and flow recordings were used to reconstruct respiratory waves and loops. Visual assessment determined assisted leak-free optimal respiratory cycles used to calculate RM values (SRM, selected respiratory cycles RM). To assess the discriminating power of each method, we compared each patient with the 9 others with Student t-tests. All 45 ''t'' values obtained for VRM and ARM were then compared by paired t-test. Results: Differences in discriminating power are all significant (p \ 0.0001) Conclusions: In our unselected patients, data provided by selected breaths are 2 to 3 times more discriminating than averaged values provided by ventilator. Improving discriminating power of ventilator monitoring may help in assessing disease status and following trends. Application to clinical practice needs automation of such selection. Neonatology, University of Lie`ge, CHU de Lie`ge (CHR), 2 Nomics, Lie`ge, Belgium Background: Ventilator respiratory mechanics (RM) monitoring remains rarely used to differentiate different respiratory status. The study aim is to evaluate new monitoring software selecting optimal breaths and its ability to improve discrimination of RM parameters. Methods: Ten minutes recordings from ten newborns with variable diseases ventilated in SIMV then Assist/Control were analysed. Ventilator provided RM data (Resistance, Compliance, Time constant, Tidal volume and C20/C) every 10 s (VRM, Ventilator RM). From pressure and flow continuous recordings, new computer software automatically determined assisted leak-free optimal respiratory cycles. RM values were calculated from those optimal cycles in both modes (ARM, Automatic cycles' selection RM). To assess the discriminating power of both methods, each patient was compared with others by t-tests. All ''t'' values obtained were then compared by paired t-test. Results: In two patients, selection in SIMV did not provided enough optimal cycles. For the remaining 8 patients, 28 values by RM parameter for each mode and method were analysed. 't' values (mean ± SD) Cdyn Time constant Tidal volume C20/C ARM A/C 11 ± 12* 9 ± 7* 10 ± 8* 8 ± 6* 8 ± 7** ARM SIMV 16 ± 19* a 9 ± 6* 13 ± 12* 7 ± 4* 15 ± 17* a VRM A/C 6 ± 7 6± 3 6 ± 7 5 ± 2 5± 4 VRM SIMV 7 ± 8 5± 3 6 ± 5 3 ± 2 5± 5 a p \ 0.05 AC versus SIMV * p \ 0.01 ARM vs. VRM, ** p \ 0.05 Conclusions: In our unselected patients, power to highlight differences between patient's doubles with data provided by new software compared to ventilator values, either in A/C or in SIMV. Results: LUS of 97 newborns with a median GA 33 weeks (range 26-40) were reviewed. LUS showed a white lung in 21 out of 22 patients treated with surfactant. Three out of 24 newborns with white lung on LUS did not need surfactant. Overall, accuracy of sonographic white lung for surfactant administration was: sensitivity 95%, specificity 96%, positive and negative likelihood ratios 23.9 and 0.05, respectively. Conclusions: LUS was helpful in evaluation of newborns with respiratory distress who are at risk of RDS. The sonographic picture of a white lung (i.e. B-lines confluent and no lung spared areas) is strongly suggestive of need for surfactant administration. References: Background and aims: Lung-protective ventilation (i.e. use low tidal volume-Vt) has been shown to reduce mortality in critically ill adults. Subsequently, the use of low Vt has been universally adopted in mechanically ventilated children. Yet, it remains undetermined whether there is a relation between Vt and mortality in critically ill children. We performed a systematic review of observational studies to assess this relationship. Methods: MEDLINE, EMBASE and CINAHL were electronically searched (inception-May 2011) for studies reporting on the effects of Vt on mortality in mechanically ventilated children. Data about study design, ventilator characteristics and mortality were extracted. Data were pooled and analyzed using Review Manager. Results: Seven studies were identified, comprising 1,604 patients. Five to them did not find a relation between Vt and mortality. Two studies yielded opposing results: in one high Vt was associated with increased mortality whereas in the other it was independently associated with reduced mortality. Of these 7 studies, 5 were eligible for meta-analysis. Pooled analysis (N = 5 studies) showed that Vt C 8 ml/kg was not associated with higher mortality rates than Vt \8 ml/kg (OR 1.09, 95% CI 0.79, 1.51). However, significant heterogeneity was observed (I 2 = 64%). Similar results (N = 4 studies) were found using 10 ml/kg as cut-off (OR 1.23, 95% CI 0.56, 2.70 I 2 = 66%). Conclusion: Current data could not confirm a relationship between Vt and mortality. However, significant heterogeneity was observed. Yet, our findings question the use of mortality as outcome for future trials. Background and aims: Lung-protective ventilation (i.e. low tidal volume-Vt) has been shown to reduce mortality and multiple organ system failure in critically ill adults. The relationship between Vt and acute kidney injury (AKI) in mechanically ventilated children has not been studied. We hypothesized that children ventilated with Vt \8 ml/kg during the first 48 h of mechanical ventilation (MV) had less AKI than with Vt C 8 ml/kg. Methods: Demographical and clinical data of children \18 years consecutively admitted to the pediatric intensive care unit (PICU) of the Beatrix Children's Hospital (June 2009-August 2010) were retrospectively collected. Primary measure of outcome was AKI as defined by the pRIFLE criteria. Patients were dichotomized in two groups according to mean Vt during the first 48 h of MV: group I (Vt \8 ml/kg during) and group II (Vt C 8 ml/kg). Results: Three-hundred patients were included: 106 (35.3%) in group I and 194 (64.7%) in group II. Baseline demographics and estimates of disease severity (PRISM II score) were comparable between the two groups. The occurrence of AKI was comparable between the two groups (12.3% vs. 14.4%, p = 0.60). There was also no correlation between the prevalence of AKI and amount of Vt (p = 0.83). Also, in children with impaired oxygenation (SpO 2 /FiO 2 \315, N = 167) the prevalence of AKI was comparable between both groups (20.0% vs. 17.0%, p = 0.63). Conclusion: Tidal volume was not associated with AKI in mechanically ventilated children. Background: Pulmonary function after surfactant therapy has not yet been investigated using Electrical Impedance Tomography (EIT). Objective was to investigate pulmonary function in children with respiratory failure treated with nebulisation of surfactant. Methods: Three ventilated infants with respiratory failure received surfactant (60 mg/kg BW, diluted in 10 mL 0.9% NaCl) via an Aeroneb Ò nebulizer. Next to spirometry and hemodynamics, D relative impedance changes (RIC) by EIT as surrogate lung function parameters were recorded, reflecting regional distribution of V T (amplitude of RIC) and changes in EELV (minima of RIC). Data was recorded before, 1, 6, and 12 h after surfactant application. Respirator settings were kept unchanged. RDS-score was assessed by chest x-ray before, 1 and 3 days after intervention. Results: Improved gas exchange was detected after nebulisation of surfactant. D minima of RIC (EELV) increased significantly (p \ 0.001), especially in the dorsal lung areas. After nebulisation, V T shifted from ventral to middle towards dorsal lung areas. RDS score is displayed in Table 1 . in a next step clinical relevance of nebulisation of surfactant has to be proven in comparison to bolus application. Conclusion: In this general PICU population EtCO 2 capnography did not reliably reflect PaCO 2 . Background and aims: Bronchiolitis is the commonest reason for children under the age of 1 year to be admitted to hospital. Respiratory syncytial virus (RSV) is associated with profound immune changes involving Th1/Th2 lymphocytes and peripheral lymphopenia. In this study we compared lymphocyte changes in bronchiolitis with different viral infections. There was an inverse correlation between lymphocyte count and PICU length of stay (r = 0.28, p \ 0.01). Conclusions: Children admitted to PICU with RSV bronchiolitis become lymphopenic compared with those infected with rhinovirus or parainfluenza. The intensity of lymphopenia correlated with PICU length of stay. Further studies are needed evaluate the underlying mechanism for these changes and possible long term effects. Background and aims: The use of neuromuscular blockade (NMB) negatively affects the distribution of ventilation in adults. It is unknown whether this also occurs in mechanically ventilated children. We tested the hypothesis that the use of NMB was associated with a decreased aeration of the lung dependent zones. Methods: All children requiring NMB were eligible for this prospective study. They were ventilated in a time-cycled, pressure limited mode with pre-set tidal volume. Respiratory system compliance (Crs) and resistance (Rrs), peak inspiratory pressure (PIP), mean airway pressure (MAP), and parameters for gas exchange (PaCO 2 and PaO 2 ) were recorded before and during administration of rocuronium 1 mg/kg i.v. Center of ventilation (CoV) was assessed using electrical impedance tomography (EIT). A CoV \50% indicates ventral ventilation. Data are expressed as mean ± standard error. Statistical analysis was done using the paired t-test. Results: So far, six children were enrolled (mean weight 5.7 ± 1.1 kg). PIP (30.5 ± 3.9 vs. 25.5 ± 4.4 cm H 2 O), Crs 2.6 ± 0.4 vs. 2.4 ± 0.4 mL/cm H 2 O, Rrs 108.8 ± 14.9 vs. 107.7 ± 11.2 cm H 2 O/ L/sec and oxygenation index (15.9 ± 3.0 vs. 11.8 ± 2.1) were not significantly changed after NMB. The CoV was 49.0 ± 0.8 before and dropped to 45.2 ± 1.3% during the use of NMB (p = 0.06) indicating more ventilation towards to the non-dependent zones. Conclusions: The use of NMB resulted in more ventilation towards non-dependent zones in children. A larger sample size is necessary to confirm these findings. Background and aims: Acute respiratory distress syndrome (ARDS) is a devastating clinical syndrome. Angiotensin-converting enzyme (ACE) and its effector peptide angiotensin (Ang) II have been implicated in the pathogenesis of ARDS. Recently a counter-regulatory enzyme of ACE, i.e. ACE2 that degrades Ang II to Ang-(1-7), was discovered offering a novel treatment modality for this syndrome. As the involvement of the ACE and ACE2 in ARDS is still far from clear, we addressed the role of the two enzymes in both human disease and an animal model of ARDS. Methods: ACE and ACE2 activity was measured in bronchoalveolar lavage fluid (BALF) from children with or without ARDS following viral lower respiratory tract infection requiring ventilatory support. In rats, ARDS was induced by intratracheal administration of LPS followed by mechanical ventilation. During mechanical ventilation animals were treated with normal saline (placebo), Losartan (Ang II receptor antagonist) or with a protease-resistant, cyclic form of Ang-(1-7) (cAng-(1-7)). Results: BALF ACE activity was enhanced, whereas ACE2 activity was reduced, both in human ARDS as well as in the experimental model. This was matched by enhanced BALF levels of Ang II and reduced levels of Ang-(1-7) in the experimental model. Therapeutic intervention with cAng-(1-7) attenuated the inflammatory mediator response, markedly decreased lung injury scores and improved lung function, as evidenced by increased oxygenation. Intensive Care Med (2011) 37 (Suppl 2):S315-S442 Conclusions: Our data indicate that ARDS develops due to reduced pulmonary levels of Ang-(1-7) and that suppletion of this peptide halts the development of ARDS. Aim: To describe histopathological changes in the lungs of 10 rats with ARDS after using salbutamol and heliox. Material and method: Rat-model ARDS was designed in 10 Wistar albino male rats by intratracheal instillation of physiological saline solution in respect of German and Hafner's study. Anesthetized and tracheotomized rats were pressure-controlled ventilated with 100% oxygen. Rat lung parenchyma lavage was done with 5 9 6 ml of physiological saline solution per animal every half an hour through 210 min. There were four group: Control group (n = 10), salbutamol (Ventolin Ò ) group (n = 10; 0.2 mg/kg/dose) heliox (He:O 2 = 50:50) group (n = 7) and salbutamol (Ventolin Ò ) group (n = 8; 2.5 mg/ dose). Third goup received 50:50 heliox:O 2 for 1 h continuously. Results: We found a significant difference statistically between heliox and the dosage of 0.2 mg/kg of salbutamol group according to hyaline membrane formation (p = 0.008). Mean grade of HM was recorded in heliox group as 1.78. That of second group was 2.90. The difference was significant statistically between second and fourth group in terms of hemorrhage (p = 0.0001). The mean grade of hemorrhage in second group was higher than that of fourth group. While the mean grade of HM was lower in heliox group, the grade of hemorrhage was high. Conclusion: In our study is the first study to show the treatment effect of heliox: O 2 in ARDS. In our study, 2.5 mg/dose ventolin nebules inhalation intratracheal in four cycles with 15 min breaks showed that it can be helpful to decrease the hemorrhage of lung parenchyma during the management of ARDS in practice. Neonatal Intensive Care Unit, National Maternity Hospital, Holles Street, 2 Metabolism Laboratory, St Vincent's University Hospital, 3 Department of Endocrinology, Children's University Hospital, Temple Street, 4 UCD School of Medicine and Medical Science, University College, 5 Royal College of Surgeons of Ireland, Dublin, Ireland Background and Aim: Vitamin D deficiency (\50 nmol/l) is associated with negative effects on bone health and other chronic diseases. Vitamin D deficiency is associated with Tuberculosis, other respiratory morbidities. We have previously reported a high incidence of low vitamin D in a cohort of preterm very low birth weight (VLBW) infants. We aimed to assess co-morbidities associated with Vitamin D deficiency in this population. Methods: Serum 25-hydroxy-vitamin D (25-OH-D) levels were assessed in 100 preterm VLBW infants (B.wt\1.5 kg,\32 weeks gestation), admitted to a tertiary referral NICU prior to additional oral multivitamin supplements, although infants were supplemented in TPN since birth. Data on demographics and other biochemistry was also collected. Results: 100 babies had a 25-OH-D level with 23 [ 50 nmol/l (mean ± SD: 65.6 ± 14.8 nmol/l) and 77 had levels \50 nmol/l (36.8 ± 7.4 nmol/l). Comparing those babies with 25-OH-D \50 nmol/l with those [50 nmol/l, there was no significant difference with regard to ethnicity; birth weight, gestation, gender, Apgar scores, antenatal steroids, requirement for resuscitation, intubation or surfactant, duration of IPPV. However, duration of NPCAP, Oxygen therapy, home oxygen requirement, and chronic lung disease were significantly increased in infants who were Vitamin d sufficient at the time they started oral supplements. However, these infants were significantly chronologically older at the time of sampling and exposed to greater TPN vitamin d. Conclusions: Recognition of vitamin D deficiency is important due to potential long term effects. Vitamin D sampling of mothers and infants at birth, discharge is required to assess the impact of vitamin d deficiency on preterm outcomes. Background: Common respiratory tract disorders can be categorized into two major gruops: (1) obstructive disorders (reversible: Asthma, Irreversible: COPD). (2) Restrictive disorders which include pulmonary fibrosis and interstitial lung disease. The main causes of pulmonary obstructive disease are known to be the followings; Oxidative stress, free radicals, Allergens Inflammation provoking agents. The common medications prescribed for patients suffering from this disease, possess lots of side effects. Methods and materials: In this study, we put the patients into 2 groups each of 40 patients. One group was only treated with standard therapies including: b 2 agonist, corticosteroids, and the second group received Extract of Chlorella Vulgaris (ECV: ALGOMED; Germany) as adjunctive therapy to the standard therapy as mentioned above. ECV (900 mg/day) was administered to these patients 3 times daily for 2 months. Different parameters indicative of patient's response to therapy were analyzed, including: patient's quality of life (QOL) based on St. George's respiratory questionnaire, Spirometry parameters (FEV 1 , FEV 1 /FVC, FEF 25-75% , FVC), blood tests (Oxidative stress related parameters including: Glutathione synthetase/peroxidase, super oxide Dismutase (SOD). The above parameters were determinate both before the initiation of therapy and after treatment. Results: The results indicated that ECV as additive therapy significantly improved patient's QOL (p = 0.01), improved spirometry indicas (p = 0.01), reduced oxidative stress related parameters (p = 0.05) and increased the antioxidative profile of these patients (p = 0.05). In conclusion: The results of present study suggested that ECV additive treatment by induction of antioxidative properties in COPD patients can be used in clinical setups. The British Thoracic Society guidelines state that in infants with chronic lung disease (CLD), oxygen saturations below 90% are associated with an increased risk of apparent life threatening events (ALTE) and saturations below 92% may be associated with suboptimal growth. They recommend that, when assessing infants for the suitability of long term oxygen therapy (LTOT), pulse oximetry should be measured for 6-12 h and that oxygen saturations should be maintained at 93% or above. This audit aims to identify national compliance with the BTS guidelines for assessing suitability of LTOT in CLD. Methods: Guidelines for assessment for suitability for LTOT were obtained via telephone survey. Results: Sixty-five randomly selected English NICUs were contacted and 48 responded. 52% carry out pulse oximetry monitoring predischarge in infants with CLD to assess need for LTOT. Of these, target saturations were variable, 8% using 93%, 52% below and 40% above this. Although 43% monitored over the recommended time period, 48% monitored for over 12 and 2% for less than 6 h. Conclusions: Only 4% of units contacted carry out pulse oximetry to assess suitability for LTOT as per BTS guidelines. This suggests that some infants requiring LTOT may not receive this, increasing the risk of ALTE and poor growth. Others may receive unnecessary LTOT, with the associated expense and inconvenience. Local review supports this. These results suggest the need for increasing the awareness of the BTS guidelines amongst English neonatal units. Objectives: To obtain a neonatal network perspective of the prevalence of chronic lung disease (CLD) in preterm babies\31 + 0 weeks gestation. Methods: The outcomes of all premature babies \31 + 0 weeks gestation with a diagnosis of CLD (oxygen requirement at 36 weeks corrected gestational age) were studied using the Badger system. The review was over a 12 month period between 01/04/09 and 31/03/2010 in the Southern West Midlands Newborn Network (SWMNN). Results: In the 12 month period there were 437 babies\31 + 0 weeks gestation who were admitted to the 7 neonatal units across the SWMNN. Of these babies, 72 were diagnosed with CLD. However, 8 babies did not clinically meet the criteria for CLD (i.e. Badger error) and were therefore excluded. 6 babies left the SWMN, thereby leaving a total of 58 babies with CLD in the SWMN. The median gestational age was 27 weeks and median birth weight was 867 grams. There were 39 males (67%) and 19 females (33%). 3 (5%) babies received postnatal steroids. 2 (3%) died after a diagnosis of chronic lung disease had been made. 15 (26%) babies were discharged on home oxygen. 41 (71%) babies were discharged home without oxygen. Conclusions: Chronic lung disease poses significant morbidity in preterm babies less than 31 weeks gestation. There is a male predominance of this condition with few babies receiving post-natal steroids. 26% of babies with CLD in this age group are discharged home on oxygen in our neonatal network. Pediatric Cardiology, University Giessen-Marburg, Giessen, 2 Neonatal Intensive Care Unit, University Mannheim, Mannheim, Germany, 3 University Glasgow, Glasgow, UK Background: Despite the prognostic value of intrauterine lung volume measurements, congenital diaphragmatic hernia (CDH) often remains a therapeutic ''black box''. We quantified different factors in the postnatal management especially targeting early ventilator induced lung injury on the pulmonary outcome on day 56. Methods: Retrospective matched pair's case-control study. 66 patients with CDH were included. Average gestational age was 36 ± 1.25 weeks, birth weight 2,771 ± 441 g. Pairs were matched according to lung-to-head ratio, gestational age and birth weight. Patients with other severe birth defects and perinatal asphyxia were excluded. The following factors were noted; lung damage secondary to early ventilation, oxygen therapy for pulmonary hypertension, pulmonary infection, chylothorax and duration of ventilation. Results: CDH patients without chronic lung disease (CLD) (n = 17, 25.7%) or mild disease (n = 16, 24.2%) were compared to those with moderate (n = 20, 30.3%) or severe CLD (n = 13, 19.7%). 33 (51%) 33 patients required ECMO-therapy-n = 4 (12.5%) had no or mild CLD and n = 29 (88%) had moderate or severe CLD. Poorer pulmonary outcome was associated with infections (p \ 0.0001), longer ventilation period (p \ 0.0001), longer supplementation of oxygen (p = 0.009) and chylothorax (p = 0.047). Conclusions: Many postnatal factors affect pulmonary outcome. Lung injury secondary to ventilation in the early postnatal period plays a key role. Measuring additional hemodynamic variables and individually tailored therapy could help reducing the incidence of CLD. With optimization of pulmonary and systemic perfusion (e.g. using ECMO) early surgical correction of diaphragmatic herniae und especially reduction of time on invasive ventilation should be main targets of the therapeutic approach. 10.9% were with moderate BPD, 2.7%-with severe BPD. The BPD frequency reduced progressively: from 100% at 23 gw or birthweight \600 g to 0% at 33 gw and 7% at birthweight 1,401-1,500 g. Mild BPD was more likely if gestational age was [27 gw. The need for ventilator support increased from 1.5 (± 2.8) days (non-BPD group) to 50.2 (± 20.1) days (severe BPD), p \ 0.05. Patient ductus arteriosus was diagnosed in 25.4%; pneumothorax in 3% of the BPD infants compared with 1.7% and 0.5% of non-BPD infants respectively, p \ 0.05. Sepsis and pulmonary hemorrhage were found more frequently in the BPD group too. Paediatric Intensive Care, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, The Netherlands, 2 Paediatric Intensive Care, CHU Kremlin-Bicetre, Paris, France, 3 Paediatric Intensive Care, University Medical Center Groningen, Beatrix Children's Hospital, 4 Groningen Research Institute for Asthma and COPD, Groningen, The Netherlands Background and aims: Non-invasive ventilation (NIV) might be a suitable alternative to conventional mechanical ventilation (CMV) for infants with respiratory syncytial virus (RSV) infection. We tested the hypothesis that infants \6 months with RSV managed with NIV required a shorter duration of ventilatory support (DVS) than CMV. Methods: We performed a retrospective two-center study of infants \6 months consecutively admitted to a center primarily using NIV (Group I) or a center exclusively using CMV (Group II). Patients with upper airway disease, immunodeficiency, cystic fibrosis and neuromuscular disease were excluded. Primary outcome was DVS. Multivariate regression analysis was used to identify the independent contribution of ventilatory mode. Results: Data of 229 (group I 179, group II 50) infants was studied. They were comparable with respect to age, gestational age, prematurity and weight; PRISM II score (5.2 ± 3.0 vs. 12.0 ± 5.8, p \ 0.001) and prevalence of BPD (37.4% vs. 2.0, p \ 0.001) was significantly higher in group I. Hypoxia was more profound in group II (SpO 2 95.3 ± 7.2 vs. 80.5 ± 11.8%, p \ 0.001). DVS was significantly shorter in group I (7.5 ± 3.6 vs. 3 Background and aims: Non-invasive ventilation is being increasingly used in pediatric critical care, albeit it is still debated for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). No definite data are available for the prediction of NIV outcome in such selected population. We aimed at identifying which factors might affect NIV failure in pediatric ALI/ARDS patients. Methods: A retrospective cohort study, using comprehensive predictivity analysis was performed. All children admitted to pediatric intensive care unit during 4 years for ALI/ARDS were reviewed. Basic, clinical, physiological parameters and their change after 1 h of NIV were considered and subjected to univariate analysis. Candidate prognostic variables were then subjected to multicollinearity scrutiny and logistic regression. Finally, variables significant at the logistic regression were subjected to predictivity analysis. Results: The number of organ failure at the admission (NOF) is a strong predictor for NIV failure (odds ratio: 5.26; p = 0.004). In details, having only one organ failure provides a probability of NIV success of 85.7% (sensitivity 87%; specificity 49%). 1 NIV failure will be predicted and avoided for each 4 cases in which the presence of other organ failures will be incorporated into the clinical decision. Conclusions: NOF significantly predicts the NIV failure. Children with no organ failures other than ALI/ARDS may safely be treated with NIV. Background and objectives: Nasal high frequency oscillatory ventilation through nasal prongs (nHFOV) has been proposed to combine the advantages of oscillatory pressure waveform and of non-invasive interface. We aimed at studying the effect of oscillation amplitude and inspiratory time on the pressure transmission and stroke volume delivered through different nasal prongs. Methods: A bench model of nHFOV was built connecting SM3100A oscillator tubing's to a neonatal lung model, via two differently sized nasal prongs. A standard circuit with no nasal prongs was used as control. Tidal volume (T v ), oscillatory pressure ratio (DP dist/ DP prox ) and ventilation (DCO 2 ) were measured across a range of amplitudes and with inspiratory time (IT) set at 33 and 50%. Measurements were performed with a low-dead space hot wire anemometer coupled with a pressure transducer, specifically validated for neonatal ventilation. Results: Using both nasal prongs, T v , DP dist/ DP prox and DCO 2 were 83, 40 and 71%, respectively, of the control circuit. No differences were noticed between small and large prongs. T v and DP prox were linked by a quadratic relationship and T v plateaus for amplitude values [65 cm H 2 O. DP dist/ DP prox shows the same tendency. Same results were obtained with both prongs and with increasing IT. On the whole, mean T v was higher with IT at 50% than at 33% (2.4 mL vs. 1.4 mL; p \ 0.001). Conclusions: Changing oscillation amplitude has a significant effect on ventilation during nHFOV through nasal prongs and this seems greater than that obtained by varying the frequency. 50% IT always provides an higher T v delivery and ventilation. Intensive Care Med (2011) 37 (Suppl 2):S315-S442 Background and aims: Non invasive ventilation (NIV) has been shown to improve acute respiratory failure in infants with severe bronchiolitis. But NIV is limited in young infants (high leakage interface; failure of pneumatic triggering). Neurally adjusted ventilatory assist (NAVA), as it uses the electrical activity of the diaphragm to control the timing and pressure of the ventilation delivered, should improved NIV in these cases. The aim of this study was to evaluate the feasibility and tolerance of non invasive neurally adjusted ventilatory assist (NIV NAVA) in young infants with severe bronchiolitis. Methods: We conducted a prospective non-controlled clinical study during winter 2010-2011 in the paediatric intensive care units of two university hospital. Infants presenting with severe bronchiolitis with NIV criteria were eligible. Results: Eighteen patients were included in our study (mean age 41 days; mean weight 3.7 kg). NIV NAVA was achieved for all patients, and successful for 16 patients (89%). The median duration of NIV NAVA was 45 h. It was well tolerated with no need of analgesia or sedation. After 6 h of NIV NAVA, mean pH improved from 7.29 to 7.39 (p \ 0.001), mean PCO 2 decreased from 61 to 51 mmHg (p \ 0.001), and there was a significant reduction in respiratory distress signs measured by the RDAI score (p \ 0.05). Conclusions: NIV NAVA is feasible and well tolerated in young infants with severe bronchiolitis. In our study it successfully reduced the respiratory distress signs and improved gas exchange, even with high leakage interfaces. 2) l/min/m 2 , EVLWI 12.6 (4.6-29) ml/kg. Figure 1 shows the relation between EVLW indexed to predicted body weight and age. Methods: The patients were divided into four groups: Group 1, 16 infants who underwent operations for congenital heart disease on cardiopulmonary bypass; Group 2, four infants who underwent offcardiopulmonary bypass operations for congenital heart disease; Group 3, nine infants who died from congenital heart disease prior to surgical treatment; and Group 4 (control group), five infants with no congenital heart disease and who died from other causes. The myocardial injuries and oxidative stress mechanisms were assessed by histopathology and immunohistochemistry and were quantified by morphometrical analyses. Results: Contraction band necrosis and dystrophic calcification were found primarily in infants of Group 1. Coagulation necrosis and healing were prominent in Group 2, while infants without repair (Group 3) showed mainly colliquative myocytolysis. The control group showed no significant myocardial lesions. Conclusions: Lipid peroxidation was the principal mechanism of oxidative stress accounting for the myocardial lesions. The diversity of the lesions observed in these hearts seemed to indicate a large spectrum of cell damage due to inadequate myocardial perfusion, especially when these infants underwent surgery. Oxidative mechanisms could be a common mediator in the pathogenesis of myocardial injuries, resulting in changes in the permeability of the cell membrane, cell death, and intracellular calcium overload. Objectives: Perioperative myocardial damage still remains the most common cause of morbidity and death after technically successful surgical correction. However, the situation is further complicated in patients with complex congenital cardiac malformations repair which developed septic shock/sepsis. The aim of the present study was to analyze the correlation between cell damage and oxidative stress in congenital heart disease (CHD) and septic patients' submitted to cardiac surgery. Methods: The infants were divided into three groups: Group 1, 16 cases who underwent operations for CHD on cardiopulmonary bypass (CPB) with clinically diagnosed cardiogenic shock; Group 2, six cases who underwent operations for CHD on CPB in whom septic shock/sepsis developed, and Group 3 (control group), five cases with no CHD or sepsis/septic shock who died from other causes. The myocardial injuries and oxidative stress mechanisms were assessed by histopathology and immunohistochemistry for hydroxinonenal (4-HNE) and nitrotyrosine (3-NT), and were quantified by morphometrical analyses. Results: Contraction band necrosis and dystrophic calcification were found primarily in infants of Group 1. Colliquative myocytolysis, coagulation necrosis and healing were prominent in Group 2. The control group showed no significant myocardial lesions. Conclusions: Lipid peroxidation demonstrated by 4-HNE was the principal mechanism of oxidative stress accounting for the myocardial lesions observed in group 1. On the other hand, an increased concentration of 3-NT proteins adducts were observed in human septic hearts, suggesting that protein nitration could be the most prevalent oxidative stress mechanism found in septic patients. . Simultaneously obtained measurements of COUD (2-4 injections of isotonic saline at body-temperature 0.5-1 mL/kg/ session) and COTT (transit time flow probe (Transonic Systems Inc., Ithaca, NY) placed on the ascending aorta) were performed before and immediately after CPB. Agreement between methods was analyzed by the Bland-Altman diagram. Results: Twenty-six measurement-sessions (total 72 measurements) were performed. 11 sessions did not have shunts and 15 had shunts detected. The correlation coefficient for the whole group was r = 0.955; error 2 SD/mean = 29.3%. For pts without shunts correlation was r = 0.97; error 2 SD/mean = 20.7%. Figure 1 depicts the Bland-Altman plot of simultaneous measurements of CO by TT and UD methodology. The coefficient of variation (CV) for COTT was 3.3% for all pts and 2.3% for no-shunt pts, and for COUD 5.1% respectively 3.8%. Objective: To perform a systematic review and a meta-analysis of the effects of balloon atrial septostomy on perioperative brain injury in neonates with transposition of the great arteries. Data source: A systematic review of the literature was conducted to identify all observational studies that included neonates born with transposition of the great arteries that had perioperative evidence of brain injury. Study selection and data extraction: The search strategy produced three prospective and two retrospective cohort studies investigating the association between balloon atrial septostomy and brain injury totalling 10108 patients. In 2 studies outcome was represented by the presence at discharge of a coded diagnosis of a clinically evident stroke whilst in 3 studies outcome was represented by the finding of preoperative brain injury identified by magnetic resonance scans. Data synthesis: The overall brain injury rate for neonates who underwent balloon atrial septostomy versus control patients was 60 of 105 (57.1%) versus 45 of 105 (42.9%) (pooled odds ratio, 1.9; 95% confidence intervals, 0.9-3.8; P = 0.08). A subgroup analysis of the three studies that used preoperative brain injury as primary outcome found no significant association between balloon atrial septostomy and brain injury (pooled odds ratio, 2.69; 95% confidence intervals, 0.6-11.1; P = 0.17). Balloon atrial septostomy frequency was 22.4% (2273/10108) with reported rates ranging from 20 to 75%. Results: Sixty-three patients were analyzed (32 cases and 31 controls). There were no differences between groups regarding age, weight, sex, RACHS and baseline clinical data. No side effects (intolerance, hypotension, arrhythmias) were observed. Three patients died among controls and 1 in the levosimendan group (p: 0.35). There were no significant differences on length of mechanical ventilation (6.9 ± 8 vs. 5.9 ± 5 days, p: 0.54) and PICU stay (14 ± 14 vs. 11 ± 8 days, p: 0.26). Post-operative heart rate tended to be lower in levosimendan patients, with a significant difference at 6 (159 ± 15 vs. 169 ± 14 bpm, p: 0.008), 12 (158 ± 14 vs. 166 ± 15 bpm, p: 0.037), and 24 h (158 ± 13 vs. 165 ± 14 bpm, p: 0.046). Lactate levels tended to be lower in the levosimendan group, with a significant difference at PICU admission (5.1 ± 2 vs. 6.9 ± 3 mg/dl, p: 0.015) and after 6 h (3.9 ± 2 vs. 5.4 ± 3 bpm, p: 0.05). No differences were found on vasopressors, diuresis, mixed venous saturation and brain natriuretic peptide levels. Conclusions: Levosimendan infused in neonates undergoing cardiac surgery was well tolerated but its efficacy on postoperative hemodynamic and metabolic parameters of RACHS 3-4 neonates is questionable. Figure 1 ) have shorter appearance time (a) and abnormal upslope or''extra hump'' (b). In left to right shunts ( Figure 2 ) the asymmetry in the down slope (d) increases the area under the curve, which is proportional to the shunt magnitude. Objectives: Children with congenital heart defects often have impaired growth after birth, with catch-up-growth after surgery. We previously studied metabolism and nutritional status in 47 children undergoing cardiac surgery. 17% was acutely malnourished at surgery (\-2SD weight-for-age (WFA)). We now evaluated long-term growth. Methods: Subjects were grouped by WFA at surgery; group 1\-2SD and group 2 C-2SD. WFA, height-for-age (HFA) and weight-forheight (WFH) were compared between groups at birth, surgery, 1 year after surgery and last-follow-up (LFU). Results as mean ± SEM or median (min-max); statistics by T-tests. Results: 47 children (24 male) with age at surgery of 1.7 (0.2-16.6) years were studied. LFU was at 6.9 (3.2-9.5) years. WFA and HFA in Figure 1 . WFA in group 1 was significantly lower at birth, surgery and 1 year but not different from group 2 at LFU. HFA and WFH were only significantly lower in group 1 at surgery. Overall WFA and HFA at LFU were significantly lower than zero (p = 0.013, p = 0.002, respectively), WFH was not. . They were then transferred to the nearby local tertiary centre soon after birth. One delivered locally as per network agreement. Postnatally 12/21 (57%) babies were transferred to tertiary centre. 9 babies (43%) were managed locally, 6/9 were due to local network agreement, 1/9 died at 3 h of age and 2/9 were not transferred as very stable after birth. Final outcome: 6/12 (50%) babies died in tertiary centre, 1/9 (11%) died in local unit. Conclusion: Most common cause for failure to comply with guidelines were obstetric reasons, but inadequate beds in tertiary centres are an ongoing issue and it is essential that doctors and nurses in these level 2 units keep themselves updated in management of these babies should such a situation arise. Objectives: Pediatricians often have to treat the parents and sometimes, the family, rather than just the child. A major difference between pediatrics and adult medicine is that children are too minors to make decisions for themselves. The issues of guardianship, privacy, legal responsibility and informed consent must always be considered in every pediatric procedure. In present paper we reviewed the literature and try to show the conflict aspects of the medical ethics of pediatrics field in related subjects. Background and aims: Child abuse is referred to all actions that can cause physical, psychological, emotional or social damage (action or omission). The aim of this research was to identify the frequency of child abuse syndrome in a private Hospital. Methods: It is an ambispective, cross-sectional, observational and analytical study, carried out at ''Hospital Betania'', Puebla, Mexico, during the period 2010-2011 (April 30). The variables that were considered were: Age, gender, mechanism of aggression, aggressor, more frequently found injuries, evolution (improvement/death). For the data analysis we used measures of central tendency and frequencies. Results: We found 43 cases of child abuse were identified, with a greater proportion of males affected (60%), the ages of these children oscillated between 1 day and 15 years old, with an average of 2.7 years. Most frequently the aggressors were indirect relatives and among the most common injuries we found: Craneoencephalic traumatism, burns and contusions. The evolution in 98.3% was towards the improvement, with one case of a dead newborn. Conclusions: The child abuse syndrome is a reality that can be found in any socioeconomic atmosphere, for this reason the early identification of cases derived from the child abuse is mandatory. Once confirmed, it is obligatory to denounce. Background and aims: To assess practice of withholding and withdrawing hydration and nutrition from neonates in EOL situations. Methods: A 3 months prospective multicenter survey (November 15, 2010 to February 15, 2011) was conducted in 14 Neonatal Intensive Care Units (NICUs) from Ile de France. We included all newborns for whom withholding or withdrawing active treatments were discussed. Results: Discussion on withholding or withdrawing active treatments was considered in 54 of 1272 (4.2%) newborns. Active treatments were withheld and withdrawal in 44 cases (all died in NICUs). Ten decisions to continue active treatment were done. Nutrition and hydration were withdrawal or withheld from 14 neonates (31.8%). Other life sustaining treatments were also withdrawal (5 mechanical ventilation, 3 inotropic drugs). Two infants had no chance to survive, 8 ''no purpose situation'', 4 were autonomously breathing, but their quality of life was judged extremely poor. Death occurred 3 days following nutrition/hydration withdrawal. Conclusion: Decisions to withhold or withdrawal life-sustaining treatments from EOL newborns are common. We report the first experience of neonatal withdrawal nutrition and hydration in a French regional study. This practice is controversial, because nutrition and hydration are considered as a basic care. Withdrawal them must be discussed with parents, nurses and other staff before its application, because it will be difficult for parents and nurses to accept. Background and aims: In France, nEOL decision-making procedure is a medical prerogative. Parents are informed, but they don't participate directly to the decision-making process. We assessed changes toward parental involvement in nEOL decision making process 5 years following Leonetti's law. Methods: A 3 months (November 15, 2010 to February 15, 2011) prospective survey conducted in fourteen NICUs in Ile de France. All certified neonatologists (n = 92) participating to nEOL decisionmaking received a 14 items questionnaire. Results: The response rate was 84.7%. Sixty-four (83%) of neonatologists considers nEOL decision-making as medical prerogative and will refuse direct participation of parents if requested. Only 9% of respondents accepted parent's request. During the study period, nEOL decision-making concerned 54 of 1272 neonates (4.2%). Parent's opinion was explored through serial meetings with mean interview duration of 49 min. Fathers attended the interview less often than mothers (10.6% vs. 3.3%) and more frequently refused unreasonable obstinacy (48.8% vs. 37.7%). Mothers tended to not express their opinion (16.4% vs. 8.2%) and to request continuing active treatment (18.8% vs. 9.8%) more frequently than fathers. Most of parents (66.6%) were informed of the medical decision-meeting date, but none participated. Thirty-nine (72%) of parents were immediately informed about the decision. Conclusion: French neonatologists consider that nEOL decisionmaking should be made by doctors. Parent's views were explored through serial meetings. Neonatologists feel they should shoulder the EOL decision responsibility mostly to protect parents against guilt and grief. Background and aims: In 2005, French legislature enacted a law concerning patient's rights at the EOL (Leonetti's law), which prohibits active euthanasia, avoid unreasonable obstinacy in investigations and treatment, authorise withholding and withdrawing useless active treatments and administration of sedatives and analgesics, even at the risk of hastening death. Methods: We questioned the validity of the Leonetti's law in neonatal EOL decision-making. All certified neonatologists participating to end of life decision-making in the fourteen neonatal intensive care units ( Objectives: Cardiac surgery with cardiopulmonary bypass is associated with the development of systemic inflammatory response syndrome (SIRS) that often leads to organ failure or dysfunction. Infused particles may contribute to inflammatory syndromes as they have been shown to induce thrombogenesis, deterioration of microcirculation and modulation of immunoresponse. In a randomized, prospective trial we assessed the effect of particle retentive in-line filtration on reducing major complications in critically ill children (Clinical Trials.gov ID NCT 00209768). Methods: Children admitted to the interdisciplinary paediatric intensive care unit of a tertiary university hospital were assigned either to control or interventional group the latter receiving infusion filters (Pall ELD96LLCE/NOE96E, Braun Intrapur Lipid/Intrapur Neonat Lipid) throughout complete infusion therapy. Prior to this study, infusion regiment was optimized to prevent precipitation and incompatibilities of solutions and drugs. One of the primary objectives was a reduction in the incidence of SIRS. Results: 300 children (112 female, 188 male) patients suffered from cardiac disease and most of them (n = 226) were admitted after surgery for congenital heart disease with or without cardiopulmonary bypass. Preliminary assessment demonstrated a significant reduction in the incidence of SIRS for the interventional group (95% CI, 38 vs. 54; filter vs. control group; P \ 0.05). Conclusions: With an incidence of 36.7% SIRS is a frequent complication in neonatal and paediatric cardiac intensive care medicine. In-line filtration is most effective reducing the incidence of SIRS to 24.8% and offers a novel therapeutic option. Results: None of the 42 women treated with CMV-HIG showed severe side effects. In 4 cases CMV-HIG was given after maternal seroconversion and positive CMV-PCR amniotic fluid testing (therapeutic group, TG). 3 children were born asymptomatically cCMVinfected and remained asymptomatic in the follow-up (12-24 months). One fetus of the TG had sonographic symptoms of cCMV-infection (IUGR, microcephalia) prior to CMV-HIG-administration, was born with cCMV-disease and suffered from impaired mental, motor, acoustical and visual skills with 32 month. 38 women received CMV-HIG after maternal seroconversion and unknown CMV-status of their fetus prior to the treatment (multinominal group, MNG). 30 children (30/39; 77%; 1 9 twins) showed no cCMV-infection; 9 (9/39; 23%) infants were cCMV-infected. 8 of them were born and remained asymptomatic (follow up 1-36 months). One pregnancy was interrupted after CMV-detection in the amniotic fluid. This fetus showed no sonographic symptoms of cCMV-disease. Results: The clinical manifestations of LOGNS were clinically more significant than those of GPS, including higher rate of hypotension, leucopenia, metabolic acidosis, thrombocytopenia, and coagulopathy (all P \ 0.005). The sepsis-contributed case fatality rate was 7.7% (8 of 104) in the LOGNS, not significantly different from that of GPS (6 of 146, 4.1%) (P = 0.225). In the neonates with late-onset sepsis, neither lower birth body weight nor extreme prematurity significantly increased the risk of mortality. Neonates with cholestasis, neonates who experienced recurrent sepsis, and neonates who were on high frequency oscillatory ventilator at onset of sepsis were more likely to die than their peers with late-onset sepsis ( Methods: The patient is the product of the fourth gestation, without abnormalities during pregnancy, delivery at 39 weeks of gestation, weight 3500 grs (p50), height 52 cms (p50). She started with bilateral edema in the lower extremities, without fever, hiporexia or irritability. Evaluated 48 h after onset of symptoms. During initial evaluation, she presents a blood pressure above the 95 percentile for her age. Lab tests were taken, reporting normocytic normochromic anemia, proteinuria, dislypidemia and hypoalbuminemia. Next day showed signs of desquamation in hands and feet. VDRL determination was positive 1:128 (maternal 1:8). FTA-Abs also was positive. Results: The diagnosis of CNS was confirmed, Penicillin G treatment was started for 10 days with an excellent response and resolution of proteinuria 2 weeks after the beginning of the treatment. Conclusion: Usually, products infected with syphilis presents ictericia, hepatosplenomegaly, fever and macular rash. This case was really interesting because the first manifestation was edema which led us to the diagnosis of CNS. Background: Although seasonal influenza viruses have been associated with a high rate of hospitalization but low mortality among children, the effect and severity of 2009 H1N1 influenza in children are unknown. Objective: Establish a relation between the clinical presentation and the risk factors during Influenza A H1N1 complications. Methods: We conducted a retrospective case series involving children from 0 to 21 years old in whom 2009 H1N1 influenza was diagnosed on reverse-transcriptase polymerase-chain-reaction assay and who were admitted to a third level hospital in Monterrey, Mexico between April 2009 and April 2010. We recovered age, weight, gender, number of hospitalization days, number of sick days prior to admission and seasonal influenza immunization status. Lymphocyte/monocyte ratio was obtained retrospectively. The Hak score was applied to these patients as a predictor of influenza severity. Conclusions: The higher incidence of disease was between 0 and 4 years old. Obesity as a risk factor for complications seems to have no role in this age group. Past history of asthma, epilepsy or cerebral palsy were found as risk factors for complicated influenza. Previous seasonal influenza immunization probable confers a cross protection against H1N1-Influenza A. Mycoplasma pneumoniae represented a frequent coinfection agent. Lymphocyte/monocyte ratio could be a good predictor of disease. The Hak score could be a good predictor of complications in patients not younger than 4-years-old. Objectives: To determine the incidence of health care associated infection and BSI, identify microbiological agents and determine the risk factors. Methods: A prospective study during a 6 month period (July to December 2010) was realized. The diagnosis of health care associated infections was based on the CDC criteria. Two groups were formed: group A-with BSI and group B-without health care associated infection. Intrinsic and extrinsic risk factors were compared. Results: There were 171 admissions. Health care associated infections were identified in 20 (11.7%) and 6 (3.5%) of these were from the bloodstream. The most frequently isolated microorganisms were Gram positive. There were no differences in the intrinsic risk factors in the two groups apart from age. The average age in group A (3.5 months) was lower than in group B (55 months, p = 0.031). Although there were no differences in exposure to extrinsic risk factors between the groups, the average duration of central venous catheters use, invasive mechanical ventilation and urinary catheterization was significantly higher in group A (10. 3 Intensive Care Unit, Our Lady's Children Hospital Crumlin, 5 Neonatal Intensive Care Unit, National Maternity Hospital, Dublin, Ireland Background: Protein C synthesised in the liver and released in circulation as an inactive zymogen. When activated it has significant anti-inflammatory and cytoprotective effects. Clinical trials of activated protein c (APC) in sepsis have been controversial and no benefit was seen in paediatric patients. Aim: To compare neutrophils responses to lipopolysaccaride (LPS) ± APC stimulation in children in paediatric intensive care at the time of evaluation for sepsis (PICU: n = 10) compared with healthy paediatric (Paed Con: n = 11) and adult controls (Adult: n = 10). Methods: Whole blood was incubated with LPS ± APC and TLR4, CD11b expression, and reactive oxygen intermediate (ROI) release from neutrophils was examined by flow cytometry. Results: PICU patients had significantly decreased endotoxin responses compared with adults and paediatric controls for ROI, CD11b and TLR4. APC did not alter the expression of these markers at baseline and did not abrogate the LPS response. Vitamin D deficiency is a public health problem worldwide. We study the relationship between 25-hydroxy vitamin D, markers of allergy and markers of disease control and severity among Egyptian children with asthma. Methods: A cross-sectional study of 185 Egyptian asthmatic child (defined as physician-diagnosed asthma and either at least two respiratory symptoms or asthma attacks in the previous year) age range (5-12 years, 105 males). Study participants completed a protocol that included questionnaires, spirometry, measurements of serum total IgE, and peripheral blood eosinophil count to study the relation between 25-hydroxyvitamin D levels and this markers of allergy and asthma severity. Statistical difference between individual groups was tested by t-test. Correlation was tested by Pearson's test. Results were considered significant if p B 0.05. Statistical analysis was done using SPSS software. Results: Asthmatic child, 65 (35%) had insufficient levels of vitamin D (B20 ng/mL), vitamin D levels were significantly and inversely associated with total IgE (p = 0.03) eosinophil count. (p = 0.03) significant positive correlation was obtained between vitamin D level and pulmonary function tests in those asthmatic children (p = 0.01) increase in vitamin D levels was associated with reduced times of any hospitalization in the previous year (The study revealed that vitamin D insufficiency was highly prevalent in Egyptian asthmatic children (p = 0.03), also with the use of antiinflammatory medications in the previous year (p = 0.01). Our results indicate that, lower levels of vitamin D are associated with increased level of allergy and asthma severity markers in Egyptian asthmatic children. Background and purpose: Neonatal liver abscess is a rare entity and usually arise in the setting of sepsis in patients with several other morbid conditions. We present two cases of hepatic abscess in preterm neonates and an approach to discuss diagnostic and therapeutic measures. Methods: Retrospective reviewed of the two cases of neonatal liver abscess diagnosed in our NICU in the current year. Results: Two premature babies of 26 and 27 weeks of gestation developed this uncommon complication. Both of them presented features of nosocomial infection with abdominal distension, hepatomegaly and poor digestive tolerance. The two patients had history of umbilical catheterization. Blood culture revealed Staphilococcus epidermidis in the first case. Enterococcus faecalis and Staphylococcus capitis were isolated at blood and cerebrospinal fluid culture of the second. Persistence of positive blood culture with elevated reactants despite appropriate antibiotic treatment prompted to do an abdominal ultrasound which showed at both cases, a solitary avascular cystic mass in the right lobe of the liver with well defined margin and hypoecoic center. The decision to perform an imaging-guided percutaneous aspiration was made depending on the size of the collection and failure to respond to antibiotics. Only one patient needed it. The microbiological study of the pus isolated Staphylococcus epidermidis. Both patients completed antibiotic treatment with vancomycin during 21 days. Serial sonography and clinical follow-up showed complete clinical remission. Conclusion: Neonatal hepatic abscesses are rare but should enter the differential diagnosis of a neonate with ongoing sepsis and previous history of umbilical catheterization. Failure to respond to antibiotic therapy necessitates interventional drainage. Background: A departmental audit in Craigavon Area Hospital, a district general hospital in the United Kingdom, highlighted that the current policy where all babies with prolonged rupture of membranes (PROM) have screening blood tests performed may not be the best way of detecting babies with early onset sepsis and that regular recording of observations over the first 12 h of life maybe more sensitive. This raised concerns that babies who became unwell may not have been picked up as soon as possible and therefore the opportunity to intervene at an earlier stage was being missed. Methods: The quality improvement project involved the development and implementation of a Neonatal Early Warning Score (NEWS) chart for recording observations in newborn babies. Intensive Care Med (2011) 37 (Suppl 2):S315-S442 Results: The introduction of the NEWS chart has allowed the department to respond to the audit results by switching from screening bloods to regular observations as the method of detecting early onset sepsis in neonates with PROM. It is hoped that it will be possible to identify babies who become unwell at an earlier stage therefore ensuring a better outcome. Conclusions: Early warning scoring systems have been shown to be an effective tool in promoting patient safety in adult medicine and it is expected that the NEWS chart will produce similar results in neonatology. Objectives: To report significant sub-glottic stenosis in a 7-month-old boy following intubation with a cuffed endotracheal tube. Methods: The infant was intubated for 2 days post ASD repair of a Tetralogy of Fallot with an uncuffed tube. Parainfluenza virus was isolated from nasopharyngeal aspirate on day 10 post-op. On day 24 post-op the patient was noted to have stridor. He developed respiratory distress and increased work of breathing on day 27 and was transferred to PICU for a trial of CPAP. On day 28 flexible laryngoscopy showed [50% subglottic narrowing with vocal cord movement. The infant was re-intubated with a cuffed oral 2.5 mm ID and transferred to a paediatric ENT centre. Dexamethasone was administered and the cuff deflated the same day. Results: On Day 32 microlaryngoscopy showed 41% sub-glottic stenosis with an ischaemic ulcerated area in the posterior subglottis and circumferential ischaemia of the glottis. Conclusion: This infant developed a significant sub-glottic injury following an acute parainfluenza infection requiring intubation with a cuffed endotracheal tube for respiratory distress. The use of cuffed endotracheal tubes in children is becoming more common as research shows no significant difference in morbidity to un-cuffed tubes [1] . However, this case leads us to consider due caution in the use of cuffed tubes in children with acute infection of the airway. We also believe the use of cuffed endotracheal tubes should be of short duration with cuff pressures monitored continuously according to clinical research and manufacturers' guidelines. Reference: We assessed the impact of intravenous fluconazole prophylaxis in ELBW infants on the incidence of invasive candidiasis in Neonatal Intensive Care Unit. Methods: ELBW infants born during the pre-prophylaxis era (Jan 2004-Dec 2006) were compared with post-prophylaxis era (Aug 2007-July 2010). Infants \750 g or \27 weeks born during prophylaxis era received fluconazole prophylaxis for 6 weeks or as long as they had intravenous access. Demographic and clinical data were collected. The two groups were compared for baseline demographics, risk factors for candidiasis and the incidence of invasive candidiasis. Results: 6 of 53 (11.3%) \750 g infants developed invasive candidiasis during pre-prophylaxis era compared to 1 of 88 (1.13%) during post-prophylaxis era. There was no adverse events or the emergence of fluconazole resistant Candida sp. with fluconazole prophylaxis. Before & after antifungal prophylaxis Conclusions: In the fluconazole prophylaxis era there is a reduction of 83% in invasive fungal sepsis in\27 weeks gestation infants and in \750 g infants. This study suggests that a targeted fluconazole prophylaxis regimen for ELBW infants is safe and effective in significantly reducing invasive candidiasis. Objective: To determine the prevalence of bacterial co-infection in infants admitted to our PICU with RSV positive bronchiolitis and assess whether screening CSF is justified. Methods: We conducted a retrospective cohort study using data from our operational database and electronic patient record over a 5 year period (2006-2010). Patients \12 months of age who were admitted to PICU with a RSV positive nasopharyngeal aspirate (NPA) were reviewed. Data was collected on a standardised proforma and collated on to an electronic database. Results: 61 patients met the inclusion criteria. 32% were\28 days of age, 56% aged 1-6 months and 9.8% 6-12 months. 88% of patients had blood cultures taken, of which 12.9% were positive. The only organism cultured from blood in our group was coagulase-negative staphylococcus (CONS). CSF was sampled in 27.8% of the study group and was negative in all but one patient, who had a VP (ventriculoperitoneal) shunt 'in situ', again this was CONS. Further results are tabulated. Conclusions: Our results suggest that CSF sampling is not required in patients admitted to PICU with RSV. Cultures from other sites were significant and helpful in guiding antibiotic therapy. A. Grosse Lordemann, C. Dohna-Schwake Childrens Department I, University Hospital of Essen, Essen, Germany Background/aims: The purpose of this study was to collect information about the epidemiology of children with septic shock and to determine adherence to current treatment guidelines in a single tertiary care center. Methods: A 5-year retrospective review of our PICU patient database was performed. We identified children who met clinical criteria for septic shock according to the ACCM definition. Results: Overall we identified 62 cases of septic shock (mean age 9.2 years). 76% of the children had underlying comorbidity. 13 patients died before discharge (mean age 6.5 years) accounting for a mortality of 21%. The main causes of infections were either primary bacteremia (34%) or respiratory (16%). The patients who survived were older and had significantly higher pH and lower lactate levels when compared to the group of nonsurvivors. However, base deficit, CRP, invasive ventilation and the need of dialysis were not significantly different between the two groups. The nonsurvivors received more fluids than those who successfully reversed shock. However, the overall administration of fluids in the first 60 min after diagnosis of shock remained significantly below the ACCM-PALS guideline recommendations in both groups. Conclusion: We found that septic shock is a major health problem in children with a mortality of 21% in our cohort. Overall, adherence to the current ACCM-PALS guidelines according to fluid administration was poor. We are currently planning a multicenter study to evaluate data of children with septic shock in the Rhein-Ruhr-Area. Complications or hospitalisations, if only patients with abnormal scans receive antimicrobials. Methods: Children with possible pneumonia had lung sonography and when abnormal, also a chest x-ray. If symptoms persisted despite normal scans they had both. Antibiotic treatment was withheld if imagings were normal and all patients followed-up for 3 months. Results: In 2098 episodes of acute respiratory infections 680 were suspected of pneumonia and scanned: 100 were abnormal of which 92 also x-rayed. In them 70.6% (65/92) x-rays were abnormal and 29.3% (27/92) normal. In 50 episodes with normal scans children were also x-rayed for persistent symptoms, only one showed a consolidation. There was a strong correlation between an abnormal PA chest x-ray and abnormal lung sonography (p \ 0.0001). Only 101/685 episodes received antibiotics. The 572 episodes with suspected pneumonia but normal scans not receiving antibiotics had no complications or hospitalisations. Mean age was 5.5 years. In the pneumonia group girls outnumbered the boys by twofold. Conclusions: Transthoracic ultrasonography in children detected lower airway involvement more frequently than a single PA chest x-ray. No complications were recorded if antibiotic treatment was withheld in those with normal ultrasound scans. Of all organ failures, renal was most predictive of death. Age was similar, but there was an excess of boys in non-survivors. Survivors were admitted earlier post-transplant than non-survivors [59.7 (2.00) vs. 89.1 (3.33) days p = 0.05]. Survivors more often had autologous transplants (58% vs. 12.5% p = 0.045), but those who died had more matched related or unrelated transplants. Neuroblastoma was a more common primary diagnosis in survivors (48% vs. 0% p = 0.014) although haematogenous conditions were more common in non-survivors (87.5% vs. 33% p = 0.014). Survivors were more often admitted with sepsis (67% vs. 25% p = 0.049), but renal failure on admission predicted death (37.5% vs. 3% p = 0.019). Conclusions: Preadmission factors have a profound effect on PICU outcome in this group. This may arise from the underlying diagnosis that required non-autologous transplantation. This alone may be responsible for our findings. They also tell us more about risks and benefits of BMT, enabling clinicians and parents to make more informed decisions and researchers to better understand how to reduce mortality in oncology children. Methods: Prospective, transversal, comparative and analytical study in a third care level unit, under a non probabilistic sample, taking part children's and their parents, was realized. Frequency of healthy food consumption instrument and quality life inventory (COOP-DAR-MOUTH) were applied both. We took patients one blood sample for inflammation markers (leukocytes, albumin, PRC, VSG and fibrinogen), establishing chronic condition and gender groups. Data analysis was non parametric. Results: Fifty patients and one of his parents were included, 29 (58%) with cancer and 21 (28%) non cancer patients, with an average age of 10.8 years. Statistical difference existed in PCR level (p = 0.038), cholesterol (p = 0.023) and Tpt (p = 0.041) determined by women and oncologic patients. Not difference exist (p [ 0.05) between parents and patients quality of life perception. Not healthy food consumption predominated, and not association was founded between inflammation and the others variables. Conclusions: Inflammation is not associated with dietetic habits and quality of life in studied patients, seems to be secondary to his pathology and treatment. Background and aims: Metabolic syndrome is one of the most important problems in developing countries. In chronic diseases often emphasized more in treatment of primary condition forgetting pres-ence of co-morbidities. Study estimate association between low grade inflammatory markers and metabolic syndrome components in patients with chronic conditions. Methods: By probabilistic sample we realized under prospective, transversal, comparative and analytical design, a study in a group of children with chronic diseases attended in a third care level unit. Groups by gender and type of condition was established, taking blood samples for markers of systemic inflammation and metabolic syndrome. Besides arterial tension, weight and height of patients were registered. Analysis data was parametric. Results: One hundred patients take part, 50 women and same men number, with 7.8 years age average. Metabolic syndrome presented in 16 (16%) patients; 6 (37.50%) women and 10 (62.50%) men, without difference (p [ 0.50). In 66 (66%) cardiovascular risk was high, with difference determined by women (p = 0.01), as well as, in BMI (p = 0.04) and waist (p = 0.02). Oncological patients determined difference in albumin level (p = 0.008) and waist/hip index (p = 0.02). Cholesterol showed relation with PCR (r = 0.995) and VSG (r = 0.897); waist/hip index with albumin (r = 0.854) and systolic arterial tension (r = 0.920). Conclusions: Relation between certain systemic inflammatory markers and metabolic syndrome components in patients with chronic diseases. We must be alert to treat co-morbidity associated with primary conditions. According to the period of manifestation, neonatal GBS infections are divided into early-(EOD) and late-onset disease (LOD). LOD is almost exclusively associated with meningitis, whereas EOD results frequently in septicaemias and pneumonias. We showed that GAPDH is an extracellular virulence factor of GBS that induces host production of interleukin-10 (IL-10) early upon bacterial infection. Here we investigate whether immunity to neonatal GBS infection could be achieved through maternal vaccination against bacterial GAPDH. Before pregnancy, female mice were immunized or not (sham-immunized) with rGAPDH and infected intra-vaginally with GBS in the late gestational period. Pups born from rGAPDH-immunized mothers were protected against GBS infection, even against the highly virulent clone ST-17. In contrast, all pups born from sham-immunized mothers died within 48 h after birth. Severe cases of GBS infections are characterized by a lack of neutrophil recruitment into infected organs. Interestingly, anti-rGAPDH or anti-IL-10R treatment of pups before GBS infection resulted in increased neutrophil numbers and lower bacterial load in infected organs. Therefore, neutralizing antibodies produced in rGAPDH-immunized mothers protect the progeny against lethal GBS infections by blocking IL-10 production and enabling neutrophil recruitment to infected tissues. These results uncover a novel mechanism for GBS virulence in a neonatal host that could be neutralized by vaccination or immunotherapy, preventing both EOD and LOD. Conclusions: Our findings suggest the lack of high quality evidence in this area and related ambiguity in national guidance have contributed to diverse local approaches. Observed discrepancies between obstetric and neonatal guidelines may put infants at further risk of infection. A common national or international approach would permit a prospective evaluation of an EOGBS prevention strategy and generate an evidence base which will benefit future guidelines. Results-Conclusions: A positive HBsAg was found in 33 (6.4%) of parturients. 51.5% of newborns were delivered naturally whereas 48.5% were delivered by Cesarean section. 48.5% concerned second partum, 27.3% were first partum and 24% were at least third partum. All neonates of HBsAg positive mothers were immunized immediately after birth with the Hepatitis B vaccine and given human immunoglobulin against Hepatitis B intramuscularly. A significant correlation was found only between the HBsAg presence and nationality as 12.6% of the 33 parturients were Roma, 6.4% were foreign nationals and 5.1% were Greek nationals. It is a known fact that neonates which are exposed to HBV during labour have a 90% probability of becoming chronic carriers. In a recent pan-Hellenic study the percentage of latent Hepatitis B in parturients was 2.2% whereas the respective percentage in our hospital is higher. This highlights the need of pre-partum screening for HBV in all pregnant women, especially in the foreign and Roma populations for the timely immunization and prophylaxis of neonates. Background and aims: Neurological outcome is frequently poor in newborns with meningitis. The purpose of this study was to analyse clinical, laboratory, neuroimaging and electrophysiological characteristics of newborns with meningitis and to identify factors that are related to poor prognosis. Methods: Inpatient charts of 21 newborns with meningitis were studied retrospectively. Correlations between clinical, laboratory, neuroimaging and neurophysiological characteristics and neurological outcome at the age of 3 months were studied. Results: Twenty-one newborns (gestational age 32 to 41 weeks, birth weight 1320 to 4320 g) were admitted at the age of 1 to 28 days. Purulent meningitis was diagnosed in 11 and nonpurulent in 10 newborns. At admission the WBC count was 2800 to 28000/lL, CSF WBC count 500-3800/lL, CSF glucose 0.0-3.3 mg/dL, CSF protein 1.4-7.6 g/L. Neurological evaluation at the time of admission revealed severe abnormalities in 6, moderate in 5 cases and mild abnormalities in 10 cases. EEG was abnormal in 6 cases. Neuroimaging studies showed abnormalities in 16 cases. Neurological assessment at the age of 3 months was normal in 6 and abnormal in 15 infants. It was abnormal in all premature infants, in those with birth weight \2500 g, in the case of bacterial aetiology, in infants with WBC count \4000/lL, CSF glucose .18 mg/dL and CSF protein [1.7 g/L, but only neurological assessment in the neonatal period was significantly related with neurological outcome (p \ 0.05). Conclusions: Among factors studied only neurological assessment in the neonatal period was significantly related to neurological outcome. Results: Fifty-two children were included. The median age was 6.2 weeks. High risk factors for severe disease were present in 7 and the median PRISM II score was 9 (IQR 5.5-11.0). Fever was present in 37. C-reactive protein median value was 2.3 mg/ dl (IQR 0.6-6.9). Chest x-ray showed pulmonary consolidation (20) and atelectasis (10). Airway secretions were positive for bacteria in 26 children: most frequently Haemophilus influenzae (18) and Streptococcus pneumoniae (6); 7 had more than one microorganism isolated. Three children didn't receive antibiotics. Mechanical ventilation was required in 41: non invasive in 18 (median 2.5 days) and invasive (IV) in 24 (median 4.0 days). Median length of stay in PICU was 5 days. No patient died. Children with positive bacterial cultures were older ([6 weeks, p = 0.005) and had higher lactates on admission (p = 0.018); comorbidity, higher PRISM score, abnormality on chest x-ray and requirement of IV were not predictive of positive cultures. be on the rise in developed countries like United Kingdom with the continuing influx of immigrants and refugees, as well as the return of travellers and soldiers from endemic areas. We present case report from UK, of a 14 year old Asian boy, who presented to a general paediatrician with a 2 month history of painless, gross, terminal haematuria. He also had general symptoms of malaise, early fatigability with poor appetite and was a known carrier of thalassemia trait. On Full blood count, his haemoglobin was 11.4 gm/dl with eosinophilia 0.71 9 10 9 (Normal range 0.04-0.40). An ultrasound scan of urinary tract revealed localised thickening of bladder located towards the trigone. This raised suspicion of rhabdomyosarcoma of bladder. An urgent cystoscopy was performed which revealed multiple lesions in the area of trigone, studded with white spots within the lesion. Punch biopsy was done which showed eggs of Schistosoma haematobium and the inflammatory mass constituted eosinophilic infiltration. History was revisited and it was discovered that he had travelled to Malawi, where his father was working. As a treatment two doses of Praziquantel was given and patient will be followed up with ultrasound scan later to assess the bladder lesions. (1) . Typically late onset GBS is associated with bacteraemia and meningitis. This case report describes a case of late onset GBS presenting as parotitis. GBS parotitis is rarely reported (2) and this case highlights the importance of consideration of GBS in the initial investigation and management of neonatal parotitis. Methods: A case based report of late onset GBS serotype III on the neonatal unit presenting as acute parotitis, with overlying cellulitis and sepsis, confirmed by blood culture. Objectives: Veno-arterial extracorporeal membrane oxygenation (va-ECMO) is a rescue therapy for neonates with severe respiratory insufficiency. An important complication is intracranial hemorrhage (ICH). In previous studies we demonstrated that bladderbox alarms during va-ECMO resulted in significant changes of mean arterial blood pressure (MABP), cerebral blood flow (CBF) and cerebral blood volume (CBV). The objective of this study was to determine the effect of blood withdrawals on the occurrence of bladderbox alarms, cerebral oxygenation and hemodynamics. Methods: In this prospective observational study in newborns (n = 11), blood withdrawals were studied using near infrared spectrophotometry. Based on concentration changes of cerebral oxyhemoglobin (cO 2 Hb) and deoxyheamoglobin (cHHb) changes in hemoglobin oxygenation index (cHbD=cO 2 Hb-cHHb) and total hemoglobin (ctHb=cO 2 Hb+cHHb) were calculated, reflecting changes in CBF and CBV, respectively. Physiologic parameters and bladderbox alarms were continuously measured. MABP and the occurrence of bladderbox alarms were continuously registered. Results: 133 blood withdrawals were analyzed. Small volume blood withdrawals (\5 mL) did not result in bladderbox alarms or significant changes in cHbD or ctHb. On the contrary, 40% of large volume blood withdrawals (range 5-9 mL, n = 10) resulted in bladderbox alarms and a significant decrease of MABP and cHbD. Conclusions: There were significant differences in evidence of fetal distress and in umbilical arterial pH. All infants were neurologically normal. It is unclear how relevant the intrapartum differences are and while nuchal loops/knots may be associated with adverse outcomes, our study was not sufficiently powered and a larger prospective study is needed. We found the neuro-behavioural scoring easy to administer, and has many applications in the NICU. Discussion: 683 cases were identified (0.2/1000 births). There were 3 cases of persistent neurological morbidity (0.4/1000 births). This small number seems surprising. We know that UCP can induce a total asphyxia. This is compensated for by redistribution of systemic and cerebral blood flow so that the brainstem and basal ganglia are prioritised due to metabolic demand. In total asphyxia, compensation fails, with rapid cell death. This pattern is reflected here, with most infants either intact or suffering brain stem death. Any disability tended to reflect basal ganglia injury. Our study explains the pattern of high mortality in the absence of significant neurological morbidity. Objective: The main goal of treatment after traumatic or post-anoxic brain injury is the prevention of secondary brain injury. Mild hypothermia (33-34°C) may improve outcomes in these patients. Aim of the study was to evaluate patient's condition after traumatic or postanoxic brain injury treated using mild induced hypothermia on admission and at discharge. Methods: Study included 40 children (mean age 10.2 ± 1.0 years) after traumatic or post-hypoxic brain injury treated using mild induced hypothermia. GCS (Glasgow Coma Scale) and PIM2 (Pediatric Index of Mortality2) were measured on admission. Patients were divided in two groups according to the type of brain injury. Outcomes using GOS (Glasgow Outcome Scale), PICU hospitalisation and ventilation length were compared in both groups. Results: 29 (72.5%) patients after severe head trauma, 11 (27.5%) patients with post-anoxic brain injury were included. Average GCS in patients after severe head trauma was 6.07 ± 0.4 points, average PIM2 in these patients was 6.0% ± 0.4. Average GCS in patients with postanoxic brain injury was 5.6 ± 0.7 points; (p [ 0.05), average PIM2 in these patients was 30.6% ± 9.4; (p \ 0.05). There were no differences in protocol starting time and reaching goal temperature time. The duration of cooling protocol was longer in trauma group: 54.3 ± 3.3 vs. 31.8 ± 3.1 h (p \ 0.05). Average GOS in patients after severe head trauma was 3.6 ± 0.9 points, in patients with post-anoxic brain injury 5 ± 0 points, (p \ 0.05). Traumatic brain injury group had longer ventilation and PICU hospitalisation time. Conclusions: Mild hypothermia is a safe method for treating brain injury and can result in favorable outcomes. Results: In this study the presence of the mother in the hospital, has increased. We didn't find any variable difference (gestational age, Apgar score, weight and height at birth, in stability time and at discharge time) between two study groups. Duration of antibiotic using, patent ductus arteriosos, sepsis, apnea and death increased in incubator group and these differences were significant. Exclusive Breastfeeding was better and earlier in kmc group. Satisfactory research showed that personnel and parents were satisfied from kmc care. In this study showed that kmc care reduce mortality, develop exclusive breastfeeding, cause better emotional relation between parents and neonates, reduce sepsis, decreased patent ductus arteriosis and reduce duration of antibiotic using. In kmc group parental and personnel satisfaction is more than incubator care group. Since the success of kmc implementation and follow-up for the proper function and protection of mothers related to doctors and personnel knowledge and experience, the importance and necessity of training courses in this respect is obvious. (baseline) and on day 7 were similar in cooled and control infants, but were significant lower on day 3 in cooled infants (Table) . ALT errors of metabolisms/DKA/HHS/pulmonary oedemas. Specific antidotes, expert advice, toxicological assays may not always be rapidly achievable/reliable, because absorbed circulating poisons were rapidly cleared, and occasionally in older children ingestions of multiple psychotropics were common. In high concentrations, intracellular poisons disrupt mitochondrial functions causing cellular death/multiorgan dysfunction/failures, especially hepatic dysfunctions mimicking infective hepatitis/Reyes syndrome. Instances where multiple aetiological factors including acute poisonings co-exists in cryptogenic encephalopathies were on record. A proximate aetiological diagnosis will be beneficial from the context of nosology, logistics planning, proffering deterrent options/directing invasive instrumentations such as RRTs (HP/HF)/ECMO) etc. Methodology: On the basis of the historical, clinico-patho-radiological certainty/confidence with which the diagnosis of poisoning related neurotoxicities/encephalopathies were achieved, the cases were classified systematically into subsets using a pragmatic modifiable descriptive classification system. The putative poisonous agents were itemized/annotated, the neuritoxidromes, the seizure patterns/ other neurological aspects of poisonings were reviewed. Relevant grey literature were examined. Limitations of the plausible interventions/deterrent options were discussed. Results: 181 cases of putative acute poisonings were examined, 91were historically/clinically undoubtful, but laboratory/toxicological back up/definite infective antecedent were lacking, and as such were considered probable cases, presenting with features suggestive of miscellanous subsets of neurotoxicities/neurotoxidromes, ranging from hyperpyrexias (n = 49), stupor (n = 28), somnolence (n = 26), drowsiness (n = 20), deeply comatose (n = 17), prostration (n = 15), dizziness (n = 13), dystonic reactions (n = 11), cephalgias (n = 9), nystagmus/oculogyric crisis (n = 7), hypothermia (n = 6), convulsive seizures (n = 7), mostly GTC/automaticities/coincidental systemic features. Pharmaceuticals meant for adult relatives, domestic/agrarian products were implicated most. In (n = 17), poisoning events were indeterminate/presumptive or co-incidental/incidental with trauma/infections/etc. Other remarkable features were contemporaneous antipsychotics ingestions in three sibs, anueploidy (n = 1), maternal epilepsy (n = 2), unexpected sibling deaths (n = 5). Conclusions/importance: When ever neurological features were inconsistent/non-specific, acute poisonings should be considered/ excluded, especially in the younger aged, where reliable histories could be unachievable. However, occasionally, basic evaluations/ interventions may suffice. For these aetiologically ambiguous subsets, their evaluations/interventions may need to be more inclusive. Background: Electro-encephalography (EEG) is used to provide objective information on cerebral function following cardiac arrest (CA) and as a prognosticator 1 . Aim: • To investigate the correlation of EEG following out-of-hospital cardiac arrest (OOHCA) in children and outcome. Inclusion criteria: • Background and aims: Predicting brain damage in preterm infants has always been a challange in NICU all over the world. Ultrasonography only detects major lesions and MRI is difficult to abtain in several Units. In this study our purpose is to verify if background electrical activity at aEEG can predict brain damage in preterm infant. Methods: 27 preterm babies between 26 and 30 weeks of gestational age was investigated for electrical activity during the first 24 h of life with aEEG. The averaged signals were analysed off-line. Background activity was classified into three patterns categories: discontinuous low-voltage pattern (minimal amplitude \3 lV), discontinuous high voltage pattern (minimal amplitude between 3 and 5 lV) and continuous pattern. Results: Results of 27 babies 5 had discontinuous low-voltage pattern, 22 had discontinuous high voltage and continous pattern. Among the five babies with unfavorable patter 3 showed grade 4 IVH and one multiple subcortical PLV at 40 weeks of postmenstrual age. The other 22 showed normal cerebral USG or minor abnormality. Conclusions: Discontinuous low voltage pattern at aEEG in preterm babies could be expression of severe brain damage and/or altered maturation. The positive predicting value of aEEG for detecting brain damage was 80% in this range of gestational age. Introduction: Troponin-T is a sensitive marker of asphyxia in term infants and indicative of the myocardial injury sustained during a hypoxic-ischaemic insult perinatally. The clinical severity of neonatal encephalopathy (NE) has been previously correlated with elevated Troponin-T. Intensive Care Med (2011) 37 (Suppl 2):S315-S442 Aims: To examine the relationship between Troponin-T and the distribution of brain injury on MRI in infants with NE. Methods: Serum Troponin-T was sampled in infants with NE in a tertiary level NICU from 07/06 to 12/07. MRI brain scans were performed (day 5-10) and were retrospectively scored according to the Barkovich System of scoring MRI brain abnormalities in term infants with perinatal asphyxia. The distribution of the abnormalities were compared to the maximum serum Troponin-T level of each infant. Results: 19 infants with NE were included. Elevated Troponin-T levels correlated significantly with abnormalities in the watershed (W) distribution but not in the basal ganglia (BG) or combined basal ganglia/watershed (BG/W) distribution (p = 0.045). Conclusions: A significant association was found between elevated Troponin-T and abnormalities in the watershed distribution on MRI scan. Infants with brain injury on MRI following perinatal asphyxia who have elevated troponin may have a definitive pattern of brain injury but further study with a larger sample size is required to confirm this hypothesis. Significantly higher cumulative dose of IV salbutamol was found in hyperglycemic children treated with IV insulin (n = 41) compared with hyperglycemic children not treated (n = 63) (P = 0.008, adjusted for PRISM P = 0.022). However, the maximum glycemia level was also significantly higher in the treated group (P \ 0.001). No differences were found in duration of IV salbutamol administration and length of stay in PICU. Conclusions: The use of IV insulin in children with severe acute asthma and hyperglycemia does not decrease the use of IV salbutamol or length of stay. Since this protocol is labour-intensive and has a possible risk of hypoglycemia, withdrawal of this protocol should be considered. 84%] hospitals had same threshold for babies of Insulin dependant diabetic mother. 8 units had lower threshold to intervene, i.e \2.5 mmol/l for this group and \2 for the rest. One hospital had higher threshold i.e \2 for this group and \2.6 mmol/l for the rest. There were variation in the POCT, blood gas analyser was used in 17/59 (29%), yellow springs analysers in 7/59(12%) hemocue were used in 4/59 (7%) and the rest 59% used varying glucometers. Intensive Care Med (2011) 37 (Suppl 2):S315-S442 Conclusion: There is an urgent need for consensus on POCT of glucose and large prospective studies. It is worrying that operational thresholds still vary among units, establishing network guidelines will be a step forward in this regard. Results: BG over 110 mg/dl was in 89.9% patients. No differences were presented in prevalence of hyperglycemia between studied groups. Peak BG (p \ 0.001, resp. p \ 0.01), intensity of hyperglycemia (p \ 0.001, resp. p \ 0.01) and hyperglycemic index (p \ 0.001, resp. p \ 0.001) were significantly higher in children with primary resp. secondary ARDS in comparison with no ARDS. There was no significant difference between primary or secondary ARDS. Admission BG was significantly higher in primary ARDS than in secondary and elevation of admission BG during 48 h increase the risk of ARDS two times. Negative correlation between paO2/FiO2 and peak blood glucose (r = 0.626) resp. hyperglycemic index (r = 0.502) was established. Conclusion: The severity of hyperglycemia is negative predictive factor of lung injury and ARDS development. Higher peak blood glucose, intensity of hyperglycemia and hyperglycemic index are associated with severity of ARDS. Pregnancy related oxidative stress is well documented by now. Literature reports suggest causes of oxidative stress belonging to metabolic pathways perturbations and immune system response to pregnancy. Maternal oxidative stress may influence foetus antioxidant systems. Blood systems fighting with oxidative stress include antioxidant enzymes present in erythrocytes. We have considered of interest to study antioxidant systems performance in venous and cord blood erythrocytes. The study included 200 pregnant women with normal pregnancies: gestation longer then 37 weeks and fetal weight more then 2700 galso no pathologies associated to the mother or to the new born child. Venous and cord blood have been collected at birth. On erythrocytes lysates catalase, superoxide dismutase, glutathione transferase, glutathione peroxidase activities and total and non protein thiols level (mainly glutathione) have been determined. Statistical analysis performed revealed a linear correlation of superoxide dismutase activity in cord blood erythrocytes with the enzyme activity in mother venous blood. No other correlations have been identified. Superoxide dismutase, catalase, glutathione peroxidase activities were significantly higher in mother venous erythrocytes while glutathione transferase was higher in cord blood. No statistical significant differences have been found between thiol levels, both protein and non protein. Objective: The present study was to investigate the role of SOCS3 knockdown in leptin-induced Stat3 activation in vitro. Methods: We first constructed the lentiviral RNA interference (RNAi) vectors of rat SOCS3 gene and evaluated the effects of silencing SOCS3 gene expression by siRNA in rat glioma cells. Three gene-specific sequences of siRNA targets for SOCS3 were designed, and the complementary DNA containing both sense and antisense oligonucleotides was synthesized. After phosphorylation and annealing, the double-stranded DNA was cloned respectively to corresponding pRNA-lentivector-VGFP to construct pRNA-Lenti-SOCS3-VGFP recombinants with U6-containing promoter, target sequence and PolyIII terminator. Three target sequences were correctly cloned to corresponding pRNA-lentivector-VGFP, and the effects of RNAi to reduce gene expression were further evaluate by real-time PCR. To examine the role of SOCS3 knockdown in leptininduced Stat3 activation, the glioma cells were cultured and transfected respectively with pRNA-Lenti-SOCS3-VGFP, or pRNA-Lenti-Control-VGFP by Lipofectamine 2000 after 80% cell confluence, 48 h later, cells were stimulated or not with 100 nM leptin for 10 min, cell lysates were prepared and proteins were quantified, and Western blot analyses were performed for leptin-induced Stat3 phosphorylation. Results: The target sequence of siRNA-SOCS3 was successfully cloned to pRNA-lentivector-VGFP, and the RNAi protocol specifically reduced expression of SOCS3 mRNA by approximately 80%. Stats3 activation was significantly greater in cells transfected with pRNA-Lenti-SOCS3-VGFP compared with their controls. Objectives: Hypodipsia-hypernatremia syndrome is connected with hypothalamic osmoreceptor dysregulation of thirst. Mineralocorticoid excess is very rare in childhood, with the exception of the secondary hyperaldosteronism in patients with cardiac and renal diseases and chronic volume depletion. Methods: A 1 year 3 month old girl with neurologic and psychologic developmental delay presented with prolonged fever and muscle hypotonia. The laboratory tests excluded infectious genesis of the condition and established hypernatremia-sodium 163-158 mmol/l, potassium 3.9-4.2 mmol/l, hyperaldosteronism 1153 pmol/l (r 55-470) and elevated plasma renin activity (PRA) 31.6 ng/ml/h (r 0.3-3.5). The differential diagnostic investigations directed to hypodipsia as the most probable cause. Active oral rehydration together with Spironolactone treatment restored the electrolyte status, but with still elevated aldosterone and PRA. Abdominal CT did not found source of autonomous production of renin or aldosterone. Cerebral MRI visualized dysgenesis of corpus callosum, a structural defect which can be associated with thirst regulation disturbance. The child was found to have a single central maxillary incisor, which together with the dysgenesis of corpus callosum directed to an incomplete form of the corresponding syndrome. Results: The ability to achieve positive water balance was enough to maintain normal serum sodium, aldosterone and PRA without Spironolactone treatment, which led to improvement in child's development. Intensive Care Med (2011) 37 (Suppl 2):S315-S442 Objective: To evaluate the value of insulin and arginine provocation test in children with short stature and the effect of recombinant human growth hormone in children with GH deficiency. Methods: GH provocation tests were performed with insulin and arginine in 65 short stature children aged 5-12 years, the GH concentrations were determined by RIA, and 35 children with peak GH concentration less than 10 ng/ml were referred to as GH deficiency and treated with r-hGH replacement therapy, and 27 children were treated for 12 months. Body height and body weight were monitored every month, the concentrations of T 3 , T 4 , TSH, IGF-1 and glucose were measured every 3 months, and the bone age was examined every 6 months. Results: The accuracy of insulin provocation test (80%) was significantly higher compared with arginine provocation test (66.7%), and the accuracy of both insulin and arginine provocation tests was 96.6%. In insulin provocation test, nadir glucose occurred during the 15-30 min after insulin injection, and there was significant positive relationship between nadir glucose level and BMI. The GHD children with GH therapy for 12 months had obviously increased in body height and height velocity. Conclusion: The accuracy of insulin provocation test is better than arginine provocation test, and combination of drug provocation tests are more accurate than single drug provocation test. The GH replacement therapy for GHD children is effective, and the body height and height velocity are obviously increased, witch is helpful for improving adult height. Objectives: To study clinical factors and hormonal changes associated with hyperglycemia in critically ill children and the relationship between these factors and mortality and length of stay in intensive care. Patients and methods: 31 patients aged between 1 and 204 months with hyperglycaemia defined as 2 blood glucose measurements greater than 180 mg/dL, separated by at least 2 h were included. Clinical severity assessment performed by PIM2, PRIMS and PELOD scales, determination of glucose, glycosuria, insulin, C peptide, cortisol and ACTH, somatomedin C, growth hormone (GH), TSH, free T4 and treatment with inotropic drugs and insulin were registered at the time of diagnosis of hyperglycemia, and 24 and 72 h after. Results: Initial blood glucose was 264.6 mg/dL and decreased gradually to 125 mg/dL after 72 h. The initial blood glucose was not correlated with any other factor. Blood glucose at 24 and 72 h correlated with levels of insulin and C-peptide and the values of PRISM and PELOD. 5 patients died (16%). There was no relationship between glucose levels and mortality. Factors associated with mortality and prolonged stay in PICU were: heart disease, infection and the need for ECMO or CRRT. Patients who died had higher levels of cortisol and GH at diagnosis. Length of stay was associated with glycemia at 24 h and severity of illness scores. Conclusions: There was no relationship between blood glucose levels and hormonal changes in critically ill children with hyperglycaemia. Patients who died had higher cortisol and growth hormone values than survivors. Fig. 1 ). The monoclonal antibody Denosumab has proved highly effective in treating the hypercalcaemia secondary to osteoclastic function in this patient. Denosumab may be of use in treating other oncology patients with resistant hypercalcaemia. Context/Purpose: (CAH) is an AR disorder due to deficiencies of specific committed pathwayed enzymes in corticosteroid biosynthesis. 21-hydroxylase-deficiency (21HD), commonest, follows mutations in 2-genes (CYP 21 B/CY21 A) on the short-arm-ofchromosome-6. Cases present classically with salt-wasting, vomitingdiarrhoea, dehydration, FTT, adrenal-crisis, arrhythmias, syncope, early demise. Its non-classic-forms presents with normal genitalia at birth/latter precocious-puberty. Cases were prone to severe-bacterialinfections, the attenuated-expressivities were tilted to crises during infective events. Its clinico-patho-radiological-features were more likely to overlap with its differentials (pyloric stenosis, intussuceptions/intestinal-obstructions/FTT.) Methodology: Cases/clinico-auxio-patho-radiological/medical contents of relevance were examined, evaluated/investigated further for features consistent with CAH, against its differentials. Cases: The investigators experience with CAH is epitomized/represented by two cases of compatible-CAH with clinician identified ambiguous-genitalia/ultrasonographically demonstrated ovaries, against its differentials-represented by five cases of radiological/ ultrasonographically/intraopratively demonstrated intussceptions presenting atypically/non-classically with progressive abdominaldistensions/features suggestive of non bloody gastroenteritis (n = 2),in (n = 3)cases with blood-tinged-stools, not in the classically described red currant jelly pattern, in addition to four cases of pyloric stenosis with hypochloraemic-metabolic-acidosis. Although in the compatible CAH cases, inpatient pharmacotherapeutic interventions with inotropic-support, aminophylline, crystalloids/solute replacements sufficed tentatively, for its differentials extramural instrumentations were mandatory. Outcome measures were fair/ spectral, but were most guarded for the intussusceptions subsets. Conclusions/Importance: Since presentations of CAH/its differentials could be quite atypical, given its frequent deleterious consequences, a high index of suspicion will be implied for earlier case identification/apposite interventions. Although features of CAD/its differentials overlap considerable, their distinct emergent/ urgent/ongoing and follow up interventional approaches suggests the need for an exact initial diagnosis. This could be achieved by a higher index of suspicion, an in-depth historic inquiry, a comprehensive clinical evaluation/investigations, especially for the male infant presenting covertly. A transabdomino-pelvic-ultrasonography/basic biochemical evaluations could be adequate to achieve a clinically/therapeutically useful working diagnosis and should be recommended/undertaken at the first instance. Background: Blood lactate at birth as result of activated anaerobic glycolysis is a marker of perinatal asphyxia. Aim: To evaluate the dynamics of blood lactate, pH and base excess (BE) as a tool for assessing the severity of fetal hypoxia and predicting neonatal outcome. Methods: 79 neonates (C34 gestational weeks) were included and followed up until discharge: 43 with pathologic fetal hearth rate patterns and/or 1-minute Apgar score \7 (''asphyxia group''); 36 without obstetric or clinical signs of asphyxia (control group). Samples from umbilical artery (u.a.), capillary blood at 2 h and 12-24 h after birth were analyzed for blood lactate, pH and BE. Results: Lactate value (u.a.) was significantly higher (5.3 ± 3.4 mmol/l), pH and BE were lower (7.29 ± 0.05 and -14.1 ± 5.9 mmol/l) in the ''asphyxia group'' compared to the control group (2.7 ± 1.2 mmol/l, 7.29 ± 0.05 and -5.9 ± 3.3 respectively). The 2 h lactate-concentration increased significantly in infants with asphyxia (6.7 ± 4.7) compared to the controls (3.2 ± 1.1), the 12-24 h values were reduced in the main group (4.6 ± 1.5) and without changes in the controls ( Objective: Tight glycemic control with insulin has been shown to decrease morbidity and mortality in the pediatric intensive care unit (PICU), especially in (post-) cardiac surgery patients. However, hypoglycemia is a potential detrimental side effect. Decreasing glucose intake might be a safe alternative to prevent hyperglycemia. Objectives: Diarrhea is one of the major causes of mortality of infants in developing countries. Honey has an antimicrobial and anti-inflammatory. We study the effect of using pure honey as an adjuvant therapy to the oral rehydration solution in management of acute infantile diarrhea. Methods: The effect of floral honey on (200 patient 6-24 ms), suffering from acute diarrhea with mild to moderate dehydration. Divided into a control group and three honey treated groups (50 patients each). The control group received the WHO-ORS only. The other three received floral honey in various forms. All were observed for rehydration time, weight gain, amount of rehydration solutions consumed, vomiting, diarrhea and recovery time. Stool culture was done, stool pH, serum sodium and potassium. Results: In the pure honey-ORS group, the recovery time was 3.5 ± 2.88 days compared to 5.6 ± 3.8 days in the control group and 5.4 ± 3.7, 5.3 ± 3.8 in group I and III respectively, showing significant shorter recovery time (P \ 0.05) specially in cases of bacterial diarrhea. Also persistent diarrhea was significantly less in pure honey-ORS treated group than other groups (P \ 0.05). Statistical analysis was performed using SPSS program version 13 and the comparison between groups of patients and control were evaluated by the unpaired student's t-test differences were considered significant when (P \ 0.05). Conclusion: Honey is a non allergic, natural agent of high nutrient value. We observed a significant decrease in stool motions number and improvement in consistency in cases treated with pure honey + ORS. Background and aims: It is widely accepted that nutrition is crucial for many processes including neurodevelopment, and is particularly important in sick or premature infants. Determination of feed volume and weight gain are the most commonly used markers in measuring nutritional adequacy. We aimed to determine whether our practice of assessing and targeting daily feed volumes results in adequate calorie intake and weight gain in premature infants. Methods: This was a retrospective audit over a 6 month period of premature infants who were exclusively enterally fed. Data were collected on the quantity and type of milk (mothers own; donor; formula) on each occasion that the baby was weighed. The caloric intake was therefore calculated. Results: Data were collected for 32 infants with gestational age of 31-36 weeks on the 140 occasions that they were weighed. The majority (n = 23) received breast milk for at least part of their admission and 20 babies received donor milk at some stage. Babies received at least adequate volumes (according to unit policy) on 136 occasions. The average weight gain was 13 g/day but 11 babies had not regained their birth weight by 14 days of age. However, weight gain was superior in the 7 babies who achieved an intake of 120 kcal/kg/day, which approximates to ESPGHAN guidelines. Conclusion: This was a small audit which reflects our practice of caring for near term babies. We suggest that using daily calorie targets rather than volumes, alongside regular weighing, may be more effective in monitoring adequacy of nutrition. Background: Differences in incidence of spitting up among ethnic groups were not previously published. Nurses at our nursery observed that newborn infants of Ethiopian origin spit up more than other infants. Methods: Files of all newborn infants of Ethiopian origin mothers born in Hillel Yaffe medical center over 12 month were retrospectively surveyed. Control group of non-Ethiopian origin newborns were randomly selected. Exclusion criteria: preterm infants, admission to NICU and congenital birth defects. 3663 newborn infants were included. 55 of them were of Ethiopian origin. The control group included 167 infants that were randomly selected. Results: Newborn infants of Ethiopian origin spitted up 57% more than control infants (1.1 ± 1.6 vs. 0.7 ± 0.9, p = 0.045). The difference was more obvious when only infants who spitted up were analyzed (2.3 ± 1.7 vs. 1.5 ± 0.9, p = 0.002), though the percentage of spitting up infants was the same in the two groups (45% vs. 47%, p = 0.872). There was no difference in weight loss, days of hospitalization, bilirubin levels or nutrition type between the groups. Additionally, when the control group was divided to spitting up and non-spitting infants, the only difference was higher rate of bilirubin measurements in the spitting up infants group (83% vs. 69%, p = 0.023), however no difference was found in bilirubin levels (7.9 ± 2.7 vs. 8 ± 2.8, p = 0.709). Conclusions: Infants of Ethiopian origin spitted up more than control infants, although other clinical parameters were not affected. Spitting up, in the absence of other pathological signs, is benign. Background and Aim: Ready-to-use (RTU) industrially manufactured multichamber bags (MCBs) are widely available and used in adults but not in preterms. The study objective was to evaluate the flexibility of use of the first ready to use multi-chamber parenteral nutrition system (Ped3CB-A), with optional lipid bag activation, specially designed for administration to preterm infants. Methods: Prospective, open-label, multicenter, noncomparative, Phase III clinical trial, preterm infants were treated with Ped3CB-A for 5-10 consecutive days. Compatibility of potential additions to the reconstituted bag were provided by the manufacturer. Macronutrient, electrolyte, and mineral supplements directly administered in the activated bag were evaluated. Results: 97 (BW: 1382 ± 520 g; GA: 31.2 ± 2.5; PNA: 5.6 ± 6.1 d) were included in the per protocol analysis accounting for 854 perfusion days. Double-chamber bag activation was used for 32 perfusion days. Ped 3CB was used without supplementation on 657 infusion days (76.9%) in 54 infants (55.7%) Macronutrient supplementations represented in all 56 days of 854 (6.6%) in 20 infants (20.6%). However, supplementation directly in the chamber bag accounted for only 18 days of perfusion (2.1%) in 11 infants. Electrolytes and minerals supplementation represented in 387/854 (45.0%) days of perfusion in 65 infants. However, addition to the chamber bag accounted for 185 days of perfusion (21.7%) in 36 infants (37.1%). In all, 199 additions (mainly sodium, 95%) were made to the Ped3CB-A bags on 197 infusion days (23.1%) in 43 infants (44.3%). In conclusion: Ped3CB-A has the flexibility required to meet the varied and changing nutritional needs of preterm infants. Results: 97 (BW: 1382 ± 520 g; GA: 31.2 ± 2.5; PNA: 5.6 ± 6.1 d) were included in the per protocol analysis accounting for 854 perfusion days. Intakes were recorded daily and mean and maximum intakes were compared to ESPEN-ESPGHAN recommendations. Background and Aim: In adults, ready-to-use (RTU) industrially manufactured multichamber bags (MCBs) have been widely available for over 10 years. The guaranteed sterility and longer shelf-life of these MCB systems are major technological advances and minimize the risks of nutrient imbalances as well as of inadvertent contamination during compounding and storage. The study objective was to evaluate the ease of handling and practical use of the first ready to use multi-chamber parenteral nutrition system (Ped3CB-A), with optional lipid bag activation, specially designed for administration to preterm infants. Methods: Prospective, open-label, multicenter, noncomparative, Phase III clinical trial, preterm infants were treated with Ped3CB-A for 5-10 consecutive days. Responses were measured daily during the study using a questionnaire and a visual analog scale (VAS) completed by clinical (nursing and pharmacy) staff members and it was compared to the units' routine PN preparations. Results: 113 preterm infants were enrolled (BW: 1373 ± 501 g, GA: 31.3 ± 2.4 weeks gestational age) accounting for 934 bags were infused over the study course. Background and Aim: Multichamber bags (MCBs) are major technological advances not in use in pediatrics populations. The study objective was to evaluate the biological tolerance of the Ped3CB-A, with optional lipid bag activation, for preterm infants. Methods: Prospective, open-label, multicenter, noncomparative, Phase III clinical trial, preterm infants were treated with Ped3CB-A for 5-10 consecutive days. Biological parameters, including plasma electrolytes, minerals, urea, triglycerides, glucose, and bicarbonates were evaluated at baseline, on Day 5, and at the end of treatment. Any other abnormal laboratory values were reported as adverse events in the report form. Results: 97 (BW: 1382 ± 520 g; GA: 31.2 ± 2.5; PNA: 5.6 ± 6.1 d) were included in the per protocol analysis accounting for 854 perfusion days. Objective: High protein intakes have been associated with metabolic acidosis. This study evaluated base deficit (BD) values with optimal nutritional support according to recent recommendations, including higher protein intakes during early postnatal days. Methods: BD were evaluated in 102 infant with a birth weight \1250 g during the first 2 weeks of life. Analyses were evaluated during 3 periods of 5 days. Protein intake was 2.4 ± 0.3, 3.8 ± 0.6 and 4.0 ± 0.6 g/kg day on the first day, after 1 week and after 2 weeks respectively. Results: Simple correlation analyses demonstrated that BD decreased with postnatal age (r = -0.61, p \ 0.01), enteral feeding progression (r = -0.45, p \ 0.01), and protein intake (-0.31, p \ 0.01); and BD increased with birth weight (r = 0.11, p \ 0.01), blood creatinine value (r = 0.36, p \ 0.01), natremia (r = 0.19, p \ 0.01) and chloremia (r = 0.45, p \ 0.05). During first 5 days, multiple regression analysis demonstrated that the major independent factor influencing BD was birth weight, accounting for *7% of the value. Between 5 and 9 days, the major factor was chloremia, accounting for *16% of the value. Between 10 to 14 days, the major factor was blood creatinine value, accounting for *28% of the value. Objective: The aim of this study was to evaluate postnatal growth up discharge in extremely preterm infants after optimizing nutritional support based on most recent recommendations. Methods: A prospective non randomized, consecutive and observational study in \28 wks infants during a 2 years period. Results: 40 infants were included (BW = 901 ± 148 g, GA = 26.8 ± 0.8 weeks). First day nutritional intake was 38 ± 7 kcal/ kg day with 2.5 ± 0.4 g/kg day of protein. Mean intake during the first week of life was 78 ± 12 kcal/kg day with 3.2 ± 0.5 g/kg day of protein and 121 ± 9 kcal/kg day and 3.7 ± 0.2 g/kg day of protein during all the study period. Postnatal weight loss was limited to the first 2.6 ± 1.2 days of life and BW was regained after 6.5 ± 2.8 days. Weight z score loss was limited to the first 3 days of life and increased in weight z score occurred after 3 weeks. The same number of infants were SGA at birth (n = 4) and at discharge (n = 3). Conclusion: This study confirmed that the first week of life is a critical period and that early nutritional support is essential to promote growth. Postnatal growth may be optimized with a dramatic reduction of postnatal growth restriction in extremely preterm infants. Background: Infants often develop cumulative protein and energy deficits during the first week at the PICU. We use an aggressive feeding protocol to establish nutritional goals at day-2 post-admission. This study evaluated its efficacy at day-4 post-admission in relation to outcome. Objectives: Infants (1 month-1 year) admitted to our PICU in 2008-2009 with LOS C4 days were studied. Achievement of protein (minimal C1.8, optimal C2.5 g/kg/d) and energy (resting energy expenditure + 30%) goal intakes was determined. Nutritional status and clinical outcome variables were recorded. Data as median (range). Results: 101 infants (62 male) aged 2.5(11.0) months with various diagnoses were included. 28% was malnourished (\-2 SD weightfor-age) at admission. LOS was 9(140) days; 9% deceased, at median 23(105) days post-admission. At day-4 66% of all patients achieved minimal protein intake, 41% optimal protein intake, 82% energy goal intake. 82% was exclusively enterally fed. During admission 53% declined in SD weight-for-age. The proportion of infants loosing weight during admission was smaller in the group receiving optimal protein intake than in the group receiving less (9% vs 27%, p \ 0.05). Malnourished infants achieved nutritional goals more often than nonmalnourished (86% vs 53%, p \ 0.01), despite severer illness. LOS and mortality were not different between subjects who achieved nutritional goals and those who did not, neither between malnourished and non-malnourished subjects. Conclusions: At day 4 post-admission our feeding protocol was effective to achieve adequate energy intake in the majority of infants, but protein intake should be improved. Optimal protein intake may prevent weight loss during admission. Background: Crimean-Congo Haemorrhagic Fever (CCHF) is a viral zoonotic disease with a high mortality rate up to 50% in humans. The virus belongs to Nairovirus genus, Bunyaviridae family and is transmitted to humans through infected tick bite, contact with blood or tissues from infected livestock or nosocomially. CCHF manifestations include fever, myalgia, nausea, hemorrhages and in severe cases it leads to coma and finally death. Methods: From June 2000 till now, Iranian CCHF probable patients sera were collected throughout the country and sent according to safety procedures to the Laboratory of Arboviruses and Viral Haemorrhagic Fevers (National Reference Laboratory) to be tested by specific Elisa for IgM and IgG detection of anti-CCHF antibodies and by RT-PCR and Real time RT-PCR for analyzing the presence of a fragment of CCHF virus genome in their sera (s segment). Results and discussion: Due to the state of the art techniques used in our laboratory as National Reference Laboratory to detect accurately and rapidly (in one day time) the confirmed patients and our swift communication of the results to the CDC of Iran, besides thanks to the high quality supportive therapy, nursing care and Ribavirin given to the patients following their admission to the hospital, the current rate of mortality due to CCHF in Iran has dropped drastically to around 10%. Objective: To compare the use of a drugs calculator on a smartphone with use of the British National Formulary for Children (BNFC) for accuracy, speed and confidence of prescribing in a simulated paediatric emergency. Design: 28 doctors and 7 medical students in a paediatric department of a District General Hospital, were asked to prescribe both a dopamine infusion and an adrenaline infusion for a hypotensive child. For one calculation they used the BNFC as their reference source and for the other they used the ''PICU Calculator'' on the iPhone. Results: The drugs calculator on the smartphone was more accurate than the BNFC, with 28.6% of participants being able to correctly prescribe an inotropic infusion using the BNFC and 100% of participants being able to do so using the drugs calculator on the smartphone (p \ 0.0001). The smartphone calculator was 376% quicker than the BNFC with the average time saved being 5 min and 17 s per participant (p \ 0.0005). Participants were more confident in their prescription when using the drugs calculator on the smartphone with an average confidence score of 8.5/10 compared with 3.5/10 when using the BNFC (p \ 0.0005). Conclusions: Utilising the smartphone was significantly more accurate and faster, with prescribers more confident in their calculations, than use of the BNFC. This applied irrespective of clinical experience with medical students utilising the smartphone technology outperforming Consultant Paediatricians when they used the BNFC. Assessing participants' knowledge on basic CPR steps and using a score scale from 1 to 7, the mean total score was 3.1 ± 0.6. Only the 3.5% responded correct to all questions. Participants with previous CPR training experience had a 4-times greater possibility to know the CPR algorithm (OR 4.2; P \ 0.001), whereas for each year elapsed since the last training, this possibility was reduced by 20% (OR 0.81; P \ 0.001). Conclusions: Knowledge on pediatric CPR of health care professionals working in public hospitals of Western Greece is deficient. This should be attributed to the lack of certified courses and the large time intervals since the last CPR training. Background: Approximately 10% of the newborns require some degree of resuscitation at birth. Nearly 80% of very low weight (VLBW) babies\1500 g requires some assistance to begin breathing. Objective: To determine the need to initiate resuscitation procedures at delivery room in this group of neonates. Methods: Retrospective study including all VLBW infants born in our hospital between January 1 and December 31, 2010. Results: A total of 195 babies were enrolled 51% males. Median birth weight and gestational age(GA) were 1130 g and 29 + 3 respectively. 115 newborns require any degree of assistance at birth. 99 were ventilated with Neopuff (82% of total resuscitated and 51% of total of VLBW neonates).95 newborns were intubated (49% of the total) and 50 of them received early surfactant (44% of total resuscitated). Very few babies required advanced resuscitation with cardiac massage and drugs(7% and 3% of total resuscitated respectively). When it comes to VLBW neonates, resuscitation procedures were more frequent in males (59%) with less weight (1013 vs 1291 g) and GA (27 + 3 vs 30 + 3). Multiple pregnancies were more frequent at no resuscitated group (39% vs 27%) 79% of no resuscitated neonates had received a full course of antenatal steroids and this percentage was higher compared to babies who had received a single or no doses. Regarding to delivery, eutocic delivery and elective cesarean were more frequent at nonresuscitated. Urgent cesarean was more common at resuscitated group. Apgar score was lower and Cribb index was higher at resuscitated. The placement of central venous catheter in ICU was carried out either by one of the expert in US guided puncture of the unit or by a novice completely supervised by the expert. Success and early complications were recorded. A comparison between novice and expert operators was also made. Results: 112 catheters were placed in 105 children. The median age and median weight were respectively 10 months and 7 kg. The success rate was 98% and early complication rate was 3.7%. No significant difference was found between expert and novice operators success. Conclusion: Supraclavicular US guided catheterization of the SCV in pediatric and neonatal ICU seems to be a promising technique in the context of emergency. It is safe, reliable, with few early complications. Background: Weaning constitutes a major challenge for the intensive care staff, so a reliable predictor of weaning failure is needed. ETCO2 is a valuable tool to evaluate ventilation because it provides the caregiver with breath-to-breath information. Patients and Methods: The study was conducted in pediatric intensive care unit of Ain Shams University. The study population consisted of thirty consecutive patients who were classified into successfully weaning group, which included 20 patients (67%) (Mean age 23.65 months), and Failed weaning group, which included 10 patients (33%) (Mean age 15.40 months). Weaning was considered successful if the patient sustained spontaneous breathing for more than 48 h after extubation. End tidal CO 2 was recorded during 3 phases of mechanical ventilation (Phase (1): immediately after ventilation. Phase (3): pre extubation period Phase (2): period between phases 1 and 3). Results: End tidal CO2 monitoring showed non significant difference between group 1 and group 2 during phase 1 (46.10 ± 8.77 versus 62.10 ± 5.97 mmHg P \ 0.05) and it was significantly higher among group 2 versus group 1 during phase 2 and phase 3 (49.11 ± 1.90 versus -41.26 ± 2.69 and 48.10 ± 1.85 versus 40.20 ± 2.67 mmHg respectively). There was a strong positive correlation between end tidal CO2 and PCO 2 (r=0.79 & P \ 0.05) Receiver operating characteristic (ROC) curves for End tidal CO2 revealed that the best cutoff value for capnometry to predict weaning success was \43.5 with sensitivity 90%, specificity 68% and PPV59%. NPV 93% and diagnostic accuracy of 75%. Conclusion: Capnometry is considered as a non invasive significant predictor for weaning success that can save repeated sampling. Variables considered were: gender, components of the triangle, auxiliary diagnostic procedures, found injuries and evolution. Results: From the 35 children included, 69% were male, the average age was 9.5 years old, the most common injuries were cerebral edema in 24 cases, related to cranioencephalic trauma, the most frequently used study was head computed tomography. The evolution in 94% of the cases was towards improvement. In all the cases there were at least one of altered aspect of the PAT (most commonly appearance). The PAT includes useful data to make a first general impression, it is useful for children with an illness or in trauma, for that reason it was implemented as a helpful tool in many programs of pediatric advanced life support. ''It is the paradigm of evaluation at first sight'', that is why we recommend its utilization. Conclusions: Results of our study have shown a good short-term prognosis. Further, prospective study is needed to assess a long-term outcome following in-hospital CPR. Introduction: Since premature and seriously ill neonates continue to be born in hospitals without an appropriate infrastructure, there is a continuous need for postnatal transfer to neonatal intensive care units (NICY). Purpose: To list the frequency, the main causes of neonatal transport in Attica and to examine a connection between the type of transport and the existence or not of NICY at the hospital of uptake. . Out-of-hours admissions were defined as night (20:00-08:00), weekend (Friday 18:00-Monday 07:00) or public holidays. PICU size was categorised into four bands based on average yearly admissions (\300, 300-500, [500-750 and 750+). Risk-adjusted odds ratios (OR) and 95% confidence intervals (CI) were estimated using random effects logistic regression models. Risk adjustment used the Paediatric Index of Mortality 2. Results: There were 58,829 admissions and 2,854 in-unit deaths. More out-of-hours admissions were emergencies, with higher observed and predicted mortality but with no increased risk-adjusted mortality (OR: 0.91; 95% CI 0.83-1.0; p = 0.048). There was a non-significant increase in risk-adjusted mortality in winter (Nov-Jan) (OR: 1.09; 0.99-1.19; p = 0.081). The smallest PICUs had significantly reduced risk-adjusted mortality (OR smallest vs. largest 0.67; 0.50-0.89; p = 0.005). Conclusions: There was no increase in risk-adjusted mortality for out-of-hours emergency admissions or winter admissions suggesting that PICUs provide consistent quality of care throughout the day and week and during winter. Lower risk-adjusted mortality in smaller PICUs requires further investigation into their patient case-mix. Patients received preemptive analgesia with rectal paracetamol before incision (10 mg/kg). In postoperative period all the patients had been receiving rectal paracetamol (10 mg/kg) every 8 h for 2 days. Blood samples were taken before anesthesia induction, during the operation and the next morning. We investigated prolactine, cortisol levels (IMMULITE). Also we assessed patient's pain with biobehavioral scales (NIPS, CHIPPS, CRIES). Results: Before operation there were age-related normal hormone levels. We observed intraoperative increase of prolactine concentration. On the 1st postoperative day prolactine concentration decreased significantly comparing to intraoperative levels. Levels of cortisol during anesthesia and on the first postoperative day also decreased comparing to preoperative levels. There was a statistically significant difference (p \ 0.05) between preoperative and postoperative levels of stress hormones. Biobehavioral scales in postoperative period showed 0-2 grades in all patients that indicated pain absence. Conclusion: decreasing of stress-hormones levels demonstrated that the preemptive analgesia with rectal paracetamol provides physiologically appropriate level of postoperative analgesia after neurosurgical operations in children. Objectives: Intensive care for children is initiated by local teams at the point of secondary care presentation. Adolescents make up just over 10% of admissions to PICU, with a different profile of illnesses compared to younger children. We examine if the treatment of adolescents pre-PICU admission is similar to the treatment received by younger children. Methods: We analysed retrieval data from a centralised paediatric intensive care retrieval service, prospectively collected between January 2009 and December 2010. Children retrieved from neonatal units were excluded. Data were compared according to age (greater and less than 12 years) using univariate analyses to explore referral reasons, care environments, interventions performed and predictors of mortality. Results: There were no significant differences in referral reasons or outcomes between adolescents and younger children. More adolescents were retrieved from emergency departments and adult ITU compared to younger children. Local teams performed more major interventions in adolescents, although the retrieval teams consequently performed fewer (p \ 0.001). The PIM2 scores for adolescents tend to be lower (p = 0.03) although similar proportions of adolescents and younger children had scores [30% Conclusion: Local teams are adept at initiating intensive care in adolescents, performing major interventions more readily in adolescents needing retrieval compared to younger children. Background and aims: The PRISM is the most frequently reported scoring system in PICU trials. We propose a graphic alternative for the complicated logistic function used to calculate the Predicted Mortality Rate (PMR) of PRISM score in post-operative children, and evaluate the impact of age on PRISM score. Intensive Care Med (2011) 37 (Suppl 2):S315-S442 Methods: The nomogram was constructed for the main age groups. From 1-19 years, the interval between two curves was 2 years. 8,371 points were calculated by data processing (Excel-Microsoft) for PRISM score values ranging from 0-76, with increments of 0.1, according to Pollack's formula (1988) for postoperative patients: PMR(ICU_death) = exp(r)/[1 + exp(r)] where r = 0.207 9 PRISM -0.005 9 (age_in_months) -0 433 9 operative status -4.782 (postoperative = 1). The operating range (OR) was defined as PRISM score from 11-40. Results: Eleven monotonic curves were generated (Fig. 1) . Patients with higher PMR are in younger patients (1 month group). Up to 11 of PRISM score, the PMR is lesser than 5% for all age groups. With the Prism of 40, the PMR is always higher than 88.5%. For the same PRISM score, non-operative patients had higher PMR than postoperative children. Conclusions: Nomogram by computer models could provide a graphical solution to prevent the lack of reporting of PRM of PRISM score, and could allow the quantification and understanding of the effect of postoperative status in trials of PICU Introduction: Over the past years infrared irradiation has gained increasing importance as a source of heat in the treatment of preterm infants. However, in our ward we have become aware of the fact that pulse oxymetry monitoring can be disturbed if the sensor is exposed to infrared light. The study should clarify how sensitively different oxygen sensors react at different distances from an infrared source. Method: Four different oxygen saturation sensors were tested. The sensors were attached to the index finger of two adult test persons and were exposed to infrared irradiation (Hydrosun 300N, Hydrosun Medizintechnik GmbH). The Hydrosun was localized at a distance of 100 cm and was then approached continuously until the recording on the monitor failed. Both test persons repeated the experiment 40 times with each sensors. Results: The Nellcor OxiMax Neonatal/Adult Oxygen sensor failed at a mean distance of 41.5 (±22.6) cm, the Nellcor SC Neo 1.5-5kg Softcare sensor at a distance of 14.6 (±5.1) cm, the Masimo Ò LNOP NeoPt-L sensor at a distance of 20.5 (±8.1) cm and the Masimo Set Ò LNOP Neo-L sensor at a distance of 13.8 (±4.1) cm. Conclusion: Dependently of their construction design, pulse oxymetry sensors are disturbed in their function by irradiation with broad-spectrum infrared light at different distances (p \ 0.001). This may be caused by the fact that the sensors cannot distinguish between the ambient light and the light that they produce themselves. The sensors tend to function better when they can fixed to the patient's skin more firmly and when they are protected against ambient light. Infants accounted for 24% of this cohort. Respiratory problems were the main reason for HDU care (22,50%), followed by neurological (5,11%) and cardiac (5,11%).These children resulted in 90 HDU days. With a difference in the cost of £400/-between the General Paediatric and HDU care, there was a potential loss of revenue of £72,000 annually if these children were not recognised and coded as HDU .11(68%) were transferred to Regional PICU and 5 (31%) to other hospitals. 9/16 (56%) were transferred by PICU team, 6 (37%) by the local team and 1 by the anaesthetic team. Majority of children were managed locally (28/44, 63%) which has implications for medical and nursing staff, also for the quality and cost of care. Background: We recently quantified the extent of ibuprofen on GFR based on aminoglycoside or vancomycin clearance (-18-22%). Since creatinaemia also is a clinical tool to estimate GFR, we wanted to evaluate if ibuprofen affects neonatal creatinaemia in ELBW (i.e. \1000 g, extremely low birth weight) infants. Methods: Retrospective study in 152 ELBWs. Clinical characteristics (birth weight, ventilation, respiratory disease) and creatinaemia (day 1, peak crea, day 7, 14, 21, 28) were extracted from the databases. Cases treated with ibuprofen were compared with cases not treated. Results: 77/152 ELBWs received ibuprofen (10-5-5 mg/kg). Birth weight (785 vs 820 g, p = .05), gestational age (26 vs 28 weeks, p = .0004), and disease characteristics, both respiratory (ventilatory support 14 vs 4 days, additional oxygen 45 vs 15 days) and nonrespiratory disease characteristics (full enteral feeding on day 38 vs 29 days p = 0.03, intracranial haemorrhage 32/77 vs 7/73, p \ 0.0001) were different. Creatinaemia at birth was not significantly different (0.72 vs 0.76 mg/dl), but from the peak creatinaemia onwards (1.2 vs 1.08 mg/dl), observations on day 7, 14 and 21 remained different with subsequent normalization on day 28. In a multiple regression model, ibuprofen administration was only a significant covariate of peak creatinaemia in combination with gestational age or weight. Gestational age was the prominent covariate. Conclusions: Ibuprofen administration results in increased creatinaemia (+10%) in the first 3 weeks of postnatal age. This does not merely reflect ibuprofen induced renal dysfunction, but also immaturity (gestational age, weight). In many acute leukemias, normal differentiation does not occur. However, in many cell lines derived from hematologic malignancies, differentiation or apoptosis can be induced by variety of agents. Despite advances in the treatment of acute lymphoblastic leukemia (ALL), in most patients long-term survival rates remain unsatisfactory, especially in T-cell derived ALL. Thus we studied the anticancer effects of fenretinide, 1a,25(OH)2D3, and bryostatin-1 in CCRF-CEM (T-cell derived) and Nalm-6 (B-cell derived) ALL cell lines. Using MTT assays, both cell lines were shown to exhibit increased inhibition of proliferation at micro and nanomolar concentrations and induce apoptosis via activation of caspase-3 pathway. Furthermore, for the first time we are reporting consistent anti-proliferative and apoptotic effects of Bryostatin-1 in ALL T-cell derived cell line with the lowest ED50. To evaluate the differentiation induction by fenretinide, 1a,25(OH)2D3, and bryostatin-1 in ALL cell lines, we assayed for the expressions of CD19, CD38 markers on Nalm-6 and CD7 marker on CCRF-CEM cell line. The flow cytometric analysis showed a significant increase in expression of CD markers in response to anticancer drug treatments. Overall results demonstrate that the anticancer agents used in this study are strong inhibitors of ALL cell proliferation and inducers of apoptosis and differentiation in vitro. These findings may be quite significant if these drugs are to be used for differentiation therapy of ALL patients in the clinic in the future. Further studies are warranted to establish the in vivo effect of these drugs particularly in patients with T-cell derived ALL. Background: Pharmacokinetic (PK) studies are difficult to conduct in neonates, due to the repeated need for blood sampling. A PK study of caffeine was undertaken using dried blood spots (DBS) taken opportunistically during other blood tests. We designed a qualitative study to investigate the acceptability of this novel technique to parents and nurses on the neonatal unit. Objective: To determine the acceptability of using DBS for pharmacokinetic research in premature infants. Methods: Nineteen parents, and thirty-one nurses were recruited during the pharmacokinetic study and participated in semi-structured interviews. Interviews were analysed through the constant comparative method. Results: Parents and nurses felt that research is important to improve outcomes for future neonates, although this was balanced by a need to protect the baby from undue harm or distress. The clinical condition of each baby was deemed important in deciding appropriate sampling volumes and times. Both groups expressed concern that larger sampling volumes would put the baby under additional stress, and lead to more blood transfusions. Opportunistic sampling was viewed positively by parents and nurses, as it avoided further pain to the baby and supported minimal handling. Both parents and nurses felt that using minimal blood volumes and opportunistic sampling made it easier for parents to consent, and so helped to facilitate successful recruitment. Background: The use of clinical dashboards in healthcare is not a new concept, but it is one that has not been widely adopted throughout neonatology in the UK Methods: The quality improvement project involved the development and implementation of a dashboard into a neonatal unit of a district general hospital in the UK to record performance against local, regional and national standards. Results: The dashboard has played a major role in inducing change within the neonatal unit. Data supplied on occupancy and activity levels was used to form a business case to successfully employ an additional ten neonatal nurses. In this particular instance the use of the dashboard quickly identified problems, induced change and subsequently provided a better standard of patient care. The dashboard is also used to display results of ongoing audits and track environmental cleanliness scores. The dashboard has proved particularly useful in keeping a record of the uptake of mandatory staff training where it acts as an informal reminder to staff that still need to complete their training. Conclusions: The dashboard has been successfully integrated into the neonatal unit where it has been a useful tool to monitor performance and induce change. Background: Prescription errors are frequent on ICUs. Prescribing is perceived as a low status task rather than an essential element of therapy. We describe the impact of an intervention to improve prescriptions and prescription error rates over 36 months Methods: We altered practice on our tertiary PICU in three stages: Formal consultant review of prescriptions on rounds, requesting error re-writes. Dedicated prescription desks were provided and prescribing elsewhere was forbidden. Interruption of the prescriber at this desk was also forbidden. Daily anonymous feedback from pharmacist was introduced also. These combined interventions were termed 'Zero-tolerance prescribing' (ZTP), following a similar approach in Cardiff, UK. Due to the powerful drug regimens available today, the disease of HIV has acquired a chronic character, with a longer life expectancy. The new medication has made it possible of mothers with HIV, that have a strong natural desire to have children, because they have the possibility of reducing the risk of HIV transmission from mother to child, with combination antiretroviral therapy, caesarean section and formula feeding. To monitor the health status of children born to HIV parents, feasibility project is being performed in a Neonatology Department in a hospital in Rome. In this exploratory study we will: 1) describe the socio-demographic and health information of 77 children and their HIV families included in the project; 2) describe the care continuity comparing 37 newborns of foreign HIV parents to 40 newborns of Italian HIV parents (use of health services, special tests). Although there are some elements of concern, the data indicate, due to medical progress achieved, women with HIV can now become pregnant with better prospects. However many of the pregnancies are not planned and many women still find HIV infection in pregnancy and despite antiretroviral treatment planning of the child in the first month of life and subsequent monitoring, these mothers often find it difficult to keep track of the follow-up, especially among foreign women, who have to face additional adversity stemming from economic and isolation hardship. One of the problems that persist in Moldova is that neonatologist involvement is seen as necessary only beginning the time when the child is born. Communication at prenatal stage between obstetricians and neonatologists is less effective, or generally lacking, including when pregnant at risk is already hospitalized. This cause difficulties in anticipation/management of sick newborns. These situations have repercussions both in the health of newborns, as well as staff satisfaction. And subsequent discussions on the evaluation of management errors of intra-and post-natal cases of death are focusing more on ''accusations'', than on constructive critics. Through involvement of obstetricians, neonatologists and midwifes and using Quality Management instruments was developed a clear protocol and algorithm (clinical criteria relevant to perinatal risk, timely period to involve the neonatologists, place of the couple opinion in order to avoid paternalism in medicine). During ''pilottest'' of the protocol (6 months) 152 pregnancies were considered as for perinatal risk group. Results: 42% of cases included medical decisions taken together; time of examination in common -less 24 h before birth; -active consultation period between 9:00-3:00 p.m. (involving heads of NICU); 65% of involved neonatologist filed ''more taken in consideration by their colleagues from obstetrics than before project''. Implementation of such project requires change of attitude and should be based more on team building activities, then only on clinical discussions. There was predominance of obstetricians working together in teams with other specialists than neonatologist, this showing that mother (psychological aspects) and child are seeing separately Objectives: Although simulator based training is increasingly used in medical training, there is paucity of studies proving its effectiveness. We have studied the effectiveness of our previously described simulator Echo Com for training echocardiography in congenital heart disease (CHD). Methods: The simulator consists of a life-sized neonatal manikin, an electromagnetic tracking system and a computer application. The application is linked with a data base of 3D echocardiographic data sets of CHD. For the present study we have chosen nine pairs of datasets with the following diagnoses: VSD, ASD, AVSD, TOF, TGA, ccTGA, TAC, HLHS and normal heart. The first set was presented to 10 beginners in echocardiography without clinical information. Participants were asked to scan the data and come up with a presumed diagnosis. All participants underwent a structured simulator based echocardiography training session by an expert afterwards. After training the study was repeated using different data sets of identical lesions. Pre-and post-training results were compared to evaluate the effectiveness of simulator based training. Background: Post cardiac surgery pediatric patient when admitted to intensive care usually supported with mechanical ventilation to maintain oxygenation and hemodynamic stability. In the special case we keep patients quite longer by put them on deep sedation even paralysed. This situation makes secretions accumulation on respiratory track, that influence oxygenation and hemodynamic stability. Ideally, Nurse has a major role to prevent the patient from instability hemodynamic by giving oxygen on endotracheal suction. Objectives: The purpose of this study is to analyse the effect of giving oxygen technique on endotracheal suctioning by using manual ventilation compare to mechanical ventilation on endotracheal suction to hemodynamic changes Methods: Quasi-experimental with control group study using purposive sampling technique involving 60 patients, who divided into 2 groups, control group (n = 30)by using manual, and intervention group (n = 30) using mechanical ventilation. The incidence of hemodynamic changes evaluated 5 min after providing the procedure. Results: The incidence of hemodynamic change was statistically significant between the group (p = 0.009), OR = 6.053. There is significant relation between giving oxygen by mechanical and manual ventilation on endotracheal suctioning and incidence of hemodynamic changes. It means that responder who wasn't given oxygen by mechanical ventilation on endotracheal suctioning had an opportunity to have hemodynamic changes 6 times risk greater than responder who was given oxygen by mechanical ventilation Conclusions: Supplemental oxygen with mechanical ventilation on endotracheal suctioning was effective to prevent hemodynamic changes. We strongly suggest to applying mechanical ventilation to give oxygen on endotracheal suctioning can prevent of hemodynamic instability Results: Research findings showed that most of kind child abuse by parents in these patients were: emotional abuse, neglect. Also contained a relation between sex, physical, emotional abuse (p \ 0.05). A direct relation between age and neglect (p = 0.002), also a direct relation between duration of disease and sexual abuse (p = 0.01), but there was a reverse relation between number of days of being Absent from school and neglect, physical abuse and total score of abuse (p \ 0.05).Also result showed that there was a significant relation between neglect and total scores of being abused and father's addiction. Conclusions: Significant meaningful between demographic characters such as, sex, age and duration of children's illness with child abuse in one side and parent's drug addiction on the other side was found. This reveals that some cultural points in community gives an important role to chronic illness in children to prepare doing abuse. Objectives: Tight glucose control in adult patients with severe brain injury is associated with reduced cerebral extracellular glucose availability and increased prevalence of brain energy crisis. Therefore target ranges for blood glucose levels during insulin treatment were set between 6 and 10 mmol/L in our protocol. The aim of this study was to evaluate the feasibility of our nurse driven protocol. Methods: This retrospective study included all children with (suspected) brain injury admitted between 2008-2011. Definitions: hyperglycemia blood glucose [10 mmol/L, hypoglycemia blood glucose \ 2.6 mmol/L. All data are expressed as median and range. Results: 128 children were admitted and hyperglycemia (12 mmol/L) was present in 20%. 39 children were mechanically ventilated, in 18 of them intracerebral pressure was measured, 18 were hyperglycemic (14 mmol/L, range) and in 12 insulin treatment was given. The age of these children was 50 months (range 2-180). Five of then died within 30 h after admission. The 7 survivors were admitted for 18 days (10-37) on the PICU and treated with insulin for 52 h (range 3-160). Target glucose level were reached after 3 h (1-23). In 4 children during insulin treatment a glucose level \6 mmol/L was measured, hypoglycemia didn't occur. Conclusions: Only in a subgroup of children with traumatic brain injury insulin treatment was started for hyperglycaemia. In survivors duration of insulin treatment was relatively short compared with length of stay on the PICU. Use of our insulin protocol seems to be done in a safe way. Introduction: Critically ill patients are at risk for inadequate feeding and subsequent increased morbidity. In pediatric critical care, reported effects of feeding protocols and/or nutritional support teams are contradictory. Objectives: To measure the effect of a nutritional algorithm and the implementation of a nutritional support team on delivered nutrition during the first 10 days of admission on a tertiary PICU. Methods: We performed a single center observational study during 2 separate 10 months-periods. Patients with length of stay [3 days and mechanical ventilation were eligible for the study. The nutritional algorithm was based on early nurse-driven enteral feeding. Once a week and on demand, a nutritional support team, consisting of a pediatrician-intensivist, a research nurse, and a clinical dietician, reviewed the nutritional regimen of all patients, and advised the attending clinicians. Endpoints of the study were delivered percentages of predefined goals for energy and macronutrients during the first 10 days of admission. Results: The percentages of delivered enteral nutrition on day 1 doubled from 40 to 78% (p \ 0.01), and increased from 60 to 92% on day 2 (p \ 0.01) without increase of adverse gastro-intestinal events, compared to the control period. More than 85% of nutritional targets were reached on day 3, compared to day 4 before the protocol. Conclusions: The introduction of an early nutrition protocol, and the institution of a nutritional support team is an effective and safe tool to increase nutrition delivery on a PICU. Objectives: Parents' perception of the quality of care their infant receives can be influenced by many factors. This, in turn, impacts on their experience of neonatal care and may be related to outcomes. Our 20 cot, level 2 NNU was relocated within the maternity block to a newly constructed unit, with neonatal nurseries significantly bigger than the existing unit (198 m 2 vs 83.1 m 2 ). There was no planned change in staffing, equipment or intensity of unit activity. We assessed parental perceptions of the quality of care their infants received before & after relocation. Methods: Randomly selected parents completed an anonymous questionnaire comprising of non-hatched visual analogue scale questions on a variety of aspects of care prior to relocation, including communication, cleanliness and amount of space per patient. This was then repeated 6 months after relocation. Results: 15 questionnaires were completed in each group, the median gestational age at birth was 35 +4 (IQR 34 +4 -40 +0 ) prior to relocation and 30 +2 (IQR 27 +2 -39 +4 ) following relocation. 2/15 (13%) of patients prior to relocation had been treated at another NNU compared with 6/15 (40%) of patients following relocation. There was no statistical significance in any of the areas we assessed including; sufficiently skilled nursing & medical staff, communication between staff and parents, amount of space per patient, cleanliness, equipment quality and overall quality of care. Conclusion: Contrary to expectations, our study showed increasing the amount of space and refurbishing our unit did not impact on parental perception of the quality of care received by our babies. Intensive Care Med (2011) 37 (Suppl 2):S315-S442 Introduction: Pressure ulcers are often seen as a problem of adult patients. Nevertheless prevalence of pressure ulcers in general paediatrics in Switzerland is around 28%. In our PICU so far no guidelines for prevention of pressure ulcers exist. No tools for pressure ulcer risk assessment in German are available. These facts led to the presented practice development project. Methods: A literature search for pressure ulcer risk assessment tools and pressure ulcer prevention in PICU patients was performed in Cochrane LibraryÓ, PubMedÓ and CinahlÓ. Articles were reviewed and tested for their applicability in daily clinical routine. Findings from the literature and expert knowledge were the basis for the development of a guideline. Results: Tools for pressure ulcer risk assessment do exist in English but we considered them either too extensive or insufficient for daily use. Admission to PICU alone is a risk factor for pressure ulcers. We decided to set the assessment tool aside and consider all patients admitted to PICU at risk. Based on expert knowledge we created a flow chart as part of the guidelines: Within 6 h after admission inspection of the skin is performed. Based on this assessment preventative measures and the time point for the next skin assessment are planned. Conclusion: Care of PICU patients is getting more complex and prevention of pressure ulcers in these patients is often not of high priority. Therefore it is important that PICU nurses are aware of the risk for developing pressure ulcers and they understand preventative measures. The purpose of the research is establishing acoustical data in 14 infants crying (7 healthy infants and 7 sick infants). Infants' cries with colic and seven healthy infants, male and female, age one to three months were recorded by Zoom HD recorder with built-in stereo microphone, in pediatric ambulance in Zagreb. Results of acoustical cry analyses made by the Multi-Dimensional Voice Program (MDVP, Copyright 1990-2000, Kay Elemetrics). Descriptive statistics of acoustical data is obtained by Statistical for Windows, Ver. 5.0. Obtained data showed statistical differences in one parameter: number of unvoiced segments. However, certain differences in obtained data are exists in parameters: fundamental frequencies and degree of sub-harmonics. Infants with colic generally cry in inconsolable manner. Cries of group of infants with colic have less fundamental frequency variation than in group of healthy infants which confirm generally medical fact about monotonous cry in children with colic. Their cries begin suddenly and rise to higher frequencies than glide to the middle of spectra. Their cry in this research is characterized by less voiceless segments and higher degree of sub-harmonics than in healthy infants. This kind of research may help in establishing acoustical data in differing normal than pathological voices in diagnostic purposes. Importance of home mechanical ventilation (HMV) rise from an increase in the number of paediatric patients dependent on long-term mechanical ventilation. HMV is being increasingly employed to treat patients suffering from chronic respiratory failure for any reason. Home ventilation offers the best option for sick children's psychosocial development, social integration and quality of life for whole family. On the other side problems of paediatric home ventilation are its negative psychosocial impact on family life, limited home care resources, the financial burden, and the fact that the equipment is usually designed for adults. Awareness of the possibilities of longterm ventilation is essential in organising discussion of these therapeutic modalities with chronically ill children and their parents. Because institutional care for this group of patient in not possible ouside the PICU in Croatia, from our experience home care is good option for long-term care. After we establish that child, family and their home are ready for many criteria we start to implement the program. At the same time we coordinate with many other professionals, primary doctor on the first place. This present study aimed to examine the characteristics and outcomes of 7 children seen in our department. Our experience showed that HMV can be applied successfully in chronic respiratory failure patients in Croatia. nurse to each patient. The 'nurse case manager' is responsible and accountable for the continuous guidance of a patient from hospital admission to discharge. The implementation of 'nurse case management' on the Neonatal Intensive Care Unit (NICU) resulted in al large variation in operationalization of the concept. Despite several topdown initiated projects and guidelines nurses continually interpreted (professional) responsibilities differently. This caused differences in quality and continuity of provided care. The aim of this project was to study the view of the nursing team concerning nurse case management and to develop interventions needed for the case manager model to be effective. Methods: Using a 'normative re-educative strategy' the project aims to bring about a change in attitude, values and behavior of nurses. From a bottom-up perspective nurses were asked to participate in focus groups and survey feedback sessions in order to come to solutions. Results: Nursing case management is highly sensitive to deployment of staff, skill mix, competency levels and patient care needs. Training, up-to-date guidelines and structural peer review meetings as well as counseling were selected to help prevent confusion and lack of structure in the future. Conclusions: In order to successfully accomplish structural changes mentoring members of the nursing team to participate, preserving and developing professional nursing roles, are vital as well as support from the management team. In a future study the effects of choices and actions taken will be evaluated. [1] . The median age was 19 months (range 2 days-18 years), with 66% \12 months of age. There were 6 deaths in these children with PAs, all of whom were patients with non-device related PAs. Table 1 shows the breakdown of pressure areas. Conclusion: Our incidence of PAs is low in comparison to the US reported incidence of 18% in PICU patients [2] . There are a number factors that increase the risk of pressure area development in the PICU, including longer length of stay and children\6 months of age. Background and aims: Influenza A (H1N1) virus is a subtype of influenza A. In 2009, it was declared a pandemic by the WHO, and was noted to be a particularly dangerous strain for children. There was a comparatively high number of children admitted with respiratory illnesses over winter 2009-10, although the number of cases of H1N1 was not as high as had been feared. Due to the unknown nature of the virus, there were very strict isolation policies which had to be adhered to for possible cases of H1N1. Methods: Data was collected from all children admitted to our regional Paediatric Intensive Care Unit (PICU) with respiratory illness during the winter months. From this I analysed how many were H1N1 positive and how long the results took to return from the laboratory. Objectives: This audit explored whether introducing drug tabards reduced the number of interruptions during the administration process and improved patient care and safety, whilst maintaining a safe working environment. Methods: A prospective sample of twelve drug episodes during a 3 month period in a tertiary referral neonatal and paediatric intensive care unit were observed, as part of this covert observational study. Staff were observed during the course of the administration process for any interruptions, following the implementation of disposable red drug tabards across both intensive care units. Pre and post intervention data was collated and examined to see if high visibility tabards reduced the numbers of interruptions experienced by nurses during the medication administration process. Results: Interruptions continued to be problematic during the medication administration process despite the use of high visibility tabards. However, the numbers of recorded interruptions pre intervention were significantly higher -80% than those analysed following the implementation of the high visibility tabards -50%. Conclusions: Our audit demonstrates that interruptions continue to occur irrespective of a change in practice. The audit also demonstrates ''buy in'' by nursing staff, as 100% of nurses complied with wearing the red drug tabards during the medication administration process. However, further exploration is required into the effectiveness of both drug tabard use and investigation into minimising interruptions in the intensive care setting. experiences. Theoretical learning will be performed using a booklet of activities built similarly to children's booklets: with crosswords, mazes, pictures. All the questions in the booklet are based upon recommended literature, according to representative situations in the unit, while many different questions are devoted to the most important subjects, in order to ensure full understanding of the content. Summary: to raise the motivation for self-learning and eventually to raise the level of knowledge and to improve the treatment quality, a novel instruction method was introduced intended to deepen the knowledge in the simplest way, the way connecting us to our childhood, to the times when learning brought joy, happiness, and the wish to know more. Background: Transport of critically ill, unstable, children off paediatric intensive care (PIC) for urgent head CT is never without risk. A portable CT scanner, the ceretom, was introduced to a regional neuro-critical care lead centre in 2007. We have previously reported the positive impact on patient safety and staffing on the ICU. (1) We aim to describe the development of shared protocols and training for ceretom use. Methods: Descriptive process review. Results: Introduction of new equipment to PIC can be challenging, stressful and time consuming. Ceretom initially took significant positioning time to obtain a scan. Evidence was presented repeatedly to all teams of decreased risk of adverse patient events and a robust ceretom user group was developed (radiology, PIC consultant, senior nursing staff) which facilitated creation of shared protocols and risk assessments. Initially separate PIC and radiology team education developed into regular joint scenario training, which now provides practical guidance to all about their role in the provision of a scan. Following this the average time for scan is now 20 min, though the radiographer only needs be present for the actual 5 min scanning time and medical staff are not required. This compares to 1-2 Drs and 2 nurses being off PIC for up to 1 h for standard scans. Conclusion: CT scans on critically-ill children who are either too unstable to transfer to CT scan, or in whom the level of dependency, e.g. CVVH/ECMO, precludes transfer can now receive safe bedside head CT scans without leaving the PICU. Conclusion: There is an emerging need to develop educational materials for expecting parents regarding the safety, utility and benefits of providing VK for newborns in order to ensure that parents make an informed decision following the birth of their child. Objective: The purpose is to find the actual situations of parenting for children with combined vascular malformations. Combined vascular malformation is very rare and congenital diseases, and almost incurable. In Japan, this disease develops at the rate of 1/2,000,000 and the cause of this disease remains unknown, and thus treatment is still under development. Methods: Subjects were 2 fathers and 3 mothers with children who had combined vascular malformations. We interviewed them about their parenting. For ethical considerations, we explained about the purpose and methods of this study using written papers and obtained their consents. Results: We found 8 categories on the fathers' parenting and 10 categories on the mothers' parenting. Fathers' 8 categories are 'Confusion by a notice of the disease', 'The life style together with the disease', 'Support of children's independence and relieving children's pain', 'The role of the family', 'Request for teachers' cooperation in the school', 'Expectation for nurses' roles', 'Expectation for medical doctor' and 'The request of social welfare'. Mothers' 10 categories are 'Efforts to visit the hospital regularly', 'Home training for accepting disease', 'Support of children's independence and relieving children's pain', 'Increasing anxiety about children's future', 'Actual feeling of an advantage for being in hospital', 'Anxiety about human relationships in the hospital', 'the roles in the family', 'Request for teachers' cooperation in the school', 'Expectation for Nurses' roles' and 'The request of social welfare'. Conclusion: In general, fathers were watching over the children, while mothers were aiming at well discipline for them. Objective: Mothers with handicapped children become to possess a feeling of difficulty to take care of them at home as they grow up. The aim of our research is to clarify the mothers' worries for the training of their handicapped children at home. Methods: The subjects were 454 mothers with handicapped children. We distributed them questionnaires and extracted the replies regarding worries for home training. Then we analyzed them by qualitative descriptive method. Results: We obtained replies from 303 mothers. The response rate was 66.7%. Handicaps of their children included mental retardation (31%), autism (24%), physically handicap (13%), epilepsy (11%), Methods: Patients were eligible for this prospective observational study if they had received continuous infusion of benzodiazepines and/or opioids for more than 5 days. When doses were being tapered off, patients were repeatedly screened for withdrawal symptoms. Nurses used both the SOS and the Numeric Rating Scale-withdrawal, allowing to determine the cutoff score for the SOS. Sensitivity to change was determined by comparing SOS assessments per patient before and after additional administration of sedatives or opioids to reduce withdrawal symptoms based on a validated algorithm. Results: A total of 2506 paired SOS and NRS-withdrawal assessments were obtained in 118 children (median age 5.5 months; IQR 0-47 months). The median number of assessment per child was 13 (IQR 6-29) assessments over a median of 5 days (IQR 3-10). A cutoff score of 4 or higher for the SOS; resulted in a sensitivity and specificity of 0.85 and 0.91, respectively, as calculated against a NRSwithdrawal score of 4 or higher. The sensitivity to change was good, as the mean SOS score dropped from 5.9 (SD 1.9) before intervention to 3.4 (SD 2.5) after intervention (p \ 0.0001). Background: As more preterm-born children receive life-saving care and survive, more parents live through the Neonatal Intensive Care Unit experience. There has been a large body of research examining the experiences of mothers of preterm-born children, while studies focused exclusively on fathers are sparse, although increasing. Few studies focus on the years after the child's birth. Aim: To illuminate fathers' lived experience of the three years since their very preterm child was born. Method: This study is the second part of a longitudinal study following fathers of very preterm children with qualitative interviews. The first interview was conducted one to three months after their child's birth and the second approximately three years later. Open interviews with eight Swedish-speaking fathers were performed and analysed using a hermeneutic phenomenological method. Findings: The fathers' lived experience was described as a process towards a reorganization in life and they described a journey from past to present time. They had lived through the experience of having a preterm-born child and had adapted to living an ordinary family life. They were now able to believe in a future for the family as a whole. Fundamental themes were: restrictions in life, experiencing empowerment and building a secure base. Conclusion: The findings reveal that fathers undergo a fragile process in the first years after their very preterm child is born. An increased understanding of their experiences can guide professionals to include fathers' specific needs in the care during and after the hospitalization to a greater extent. Can information and communication technology (ICT) be used as way to support parents of preterm born children after discharge from the neonatal unit? This question was raised when the Neonatal nursing care at home by ICT (NeOHIT) project started. The aim of this presentation is to introduce the NeOHIT project and share some methodological perspectives on the research. The aim is also to present experiences of planning and implementing this ICT project as well as present some of the findings. It was found to be crucial to develop a number of different options of collaboration between the University and the hospital staff and also with the parents. Ethical considerations are of great importance and needed to be considered throughout the whole research process. The importance of developing collaboration between the researchers and the neonatal nurses during the implementation of this ICT research project was found to be of utmost importance. Findings shows that the use of ICT from both parental and staff perspective are supportive and facilitate the communication. This was highly valued by participants living in an area with long distance between the hospital and the families' homes. The development of ICT has after the project resulted in a new standard and is implemented as a new tool and in use at the neonatal unit. (1) Examine experience, feelings and role challenges of two clinical nurses becoming research nurses within the paediatric setting. (2) Discuss decisions around role implementation, adaptation, practicalities, and the journey into autonomously functioning research practitioners. (1) A qualitative reflective account on the experience of two nurses' transitional journey into research nursing. Aims: Determine whether there is a need to study the clinimetric properties and diagnostic quality of the COMFORTneo-scale when used during therapeutic hypothermia after perinatal asphyxia. Method: A quantitative pilot-study with a retrospective cohort was used. Data were collected from the status of 99 neonates with a gestational age C36 weeks. Neonates were divided into three groups: asphyxiated with therapeutic hypothermia (AH), asphyxiated (A) and reference group (R). The COMFORTneo score, the first within 6 h postpartum and then every 8 h up to 110 h postpartum (a total of fourteen scores per patient) were examined. Results: There were 611 different COMFORTneo scores recorded. The median of the COMFORTneo scores varied across time and group, respectively 8-10 (range 6-19) (AH), 7-15 (range 6-16) (A) and 10-12 (range 6-29) (R). A statistical significant difference was seen between the three groups at first measurement (p = 0.013), the third (p = 0.014), fifth (p = 0.026), sixth (p = 0.012) and ninth measurement (p = 0.035). Mean COMFORTneo scores over the total period of the individual neonates showed no significant differences between groups. Multivariate analysis to correct for the influence of medications and respiratory support on the COMFORTneo score was not possible due to the fact that the assumptions to perform such an analysis were not met. Conclusion: No firm conclusions can be drawn concerning the validity and reliability of the COMFORTneo-scale as a measurement of stress and comfort in asphyxiated neonates with therapeutic hypothermia. A new cut-off point for stress and comfort as measured with the COMFORTneo-scale for these neonates seems necessary. Purpose: The aim of the study was to investigate the burn-out level of NICU nurses and how it affects their quality of life. Design: The descriptive, cross-sectional study was used with 85 nurses working at the neonatal intensive care units. The study was conducted at the NICU of two state hospitals located in the north region of Turkey. Data of the study was gathered using a questionnaire to uncover the demographic and occupational characteristics of the nurses, and face to face interviews via Maslach Burnout Inventory (MBI), and Quality of Life Scale (WHOQOL-BreF). Findings: The score mean of emotional exhaustion was 14.90 ± 5.53, the score mean of depersonalization was 3.87 ± 2.77, and the score mean of personal accomplishment was 11.43 ± 4.63 for the nurses. The study results indicate that nurses experience burn-out at moderate levels in the areas of emotional exhaustion and personal accomplishment, and low levels of depersonalization, which are all sub-scales of burnout. While no relationship was determined between burnout and the sub-scale depersonalization, the quality of life and the sub-scale of environmental surroundings, personal accomplishment and social relationships area, there was a significant negative relationship between all other sub-scales. Conclusions: The study indicated that nurses experienced moderate burn-out in the sub-scales emotional exhaustion and personal accomplishment. The quality of life decreases as the burn-out levels of nurses increases. Clinical Relevance: In order to increase the quality of nursing care, burn-out-causing factors in the work place must be determined, and precautions must be taken to minimise them. Methods: This is a multiple triangulation study done in the nursing and midwifery faculty of medical sciences of Esfahan University. First, international care standards were extracted from the net, of 10 different countries. Second, using Delphi method, these standards were selected by a questionnaire as well as the viewpoints of 42 clinical experts in the country. Their suggestions regarding desirability and applicability of these standards and according to the executive and sociocultural situation in the country were investigated through a descriptive method. Results of this stage were analyzed via descriptive statistics. Results: In this Study, the majority of the participants (40.5%) had master degree. 45.2% of them were 36-45 years old. In addition, the majority of the participants had practical experience of 2-10 years, generally and 6-10 years, particularly in NICU. Finally, 14 standards related to caring during the phototherapy and according to 97.5-100% desirability rate were achieved. Discussion: In this study, final standards have been created. The results will be presented on site. Creating nursing standards by experts and deserved people leads to the increase in the quality of nursing care. Background: Since 2004 the heart surgery intensive care unit of the Zurich University Children's hospital has been offering an ECMO therapy for heart and lung failure. Due to the steady increase of cases, and also due to transfers from external hospitals for ECMO therapies, more nursing professionals are needed. In the past, our ECMO specialists were all trained in London (GOSH). Methods: The ECMO specialist team of the heart surgery intensive care unit has developed an ECMO training program in cooperation with the physicians and the cardio technicians of the Zurich University Children's hospital. The training program was established according to the current ELSO guidelines. The training is divided into a theoretical and a practical part. The theoretical base of the ECMO therapy is taught to the participants in a three-day course, and a first practical handling is rehearsed. Following the course the participants are trained in practice at the patient's bed by experienced ECMO specialists. Based on a portfolio the training process is documented and evaluated at the end and the participants are certified ECMO specialists. Results: The first training course was successfully accomplished in April 2011 with 12 nursing specialists. The evaluation of the first course revealed a high motivation and commitment of the participants and gave us important hints about the optimization. Conclusion: The learning process has proved its value for introducing nursing professionals into the highly complex care of children at the ECMO and for planning the learning steps continuously. Introduction: Preterm birth (\37 weeks) leads adverse perinatal outcomes, including neonatal and infant mortality and getting different sick.The aim of this study was to determine the effectiveness of home visit on mortality and morbidity of Preterm newborn. Method: This is a semi-experimental study in which Preterm newborn with fetal age of less than 37 weeks weighing below 2500 grams were placed in two groups of case (30 neonates) and control (30 neonates) randomly. Home visit was presented to case group for a period of 6 months after discharging from hospital. Control group received hospital routine cares and referred for visiting. Both groups were followed up for a period of 6 months. The samples of both groups were compared with each other from the view point of mortality and hospitalization. Collected data were analyzed using X 2 and independent T test. Results: The mortality during first six months of life of both groups did not show any difference (P [ 0.05). However, the number of inpatient cases of neonates and also the number of their disease cases not required to be hospitalized during first six months of life among case group was less than that of control group (P \ 0.05). The results of this study indicated that, carrying out home visit by health care givers results in reducing the number of inpatient cases of neonates during first six months of life. Therefore, it is suggested to appoint home visit as a part of health programs to improve neonathal health. Introduction: Diaper rash is one of the most common skin disorders, occurring in 50% of infants, with 5% having severe rash. In infants with diarrhea and the infants with diapers have seen more and more especially when it may not change every 4-6 h. Due to its complications on skin and anal area, it need to more attention by mothers and caregivers. Methodology: This is a descriptive-analytical research. We assess 231 mothers whom have infants 6-60 months with diarrhea. Data gathered through a researcher-administered questionnaire and interview by a professional. The validity of questionnaire confirmed through experts (Pediatricians, Faculty members in nursing, health professionals) and its reliability gained %93. Data analyzed by experts through SPSS version 16.00. Findings: Finding showed that the majority of mothers (%90) have not knowledge about caring of diaper rash after diarrhea. About gaining information about skin care of diaper said we have not more information and knowledge to care it effectively (%76). Analysis of questions about knowledge and performances highlighted that the mothers' knowledge about care of diaper rash was weak and their performances was weaker. The results after teaching through interview, showed that their knowledge was increased and they said this interview is more effective than others teaching methods. Discussion: Considering the weak result about knowledge and performance of mothers about diaper rash in infants with diarrhea and its complications, promotion of their knowledge suggested through health workshop and others training meeting by professional and governmental official is necessary. Intensive Care Med (2011) 37 (Suppl 2):S315-S442 Characterization of Group B streptococci recovered from infants with invasive disease in England and Wales Acute suppurative neonatal parotitis: case report Measurement of compliance with hand hygiene A PAEDIATRIC INTENSIVE CARE UNIT -IMPLEMENTATION OF EVIDENCE BASED PRACTICE Conclusions: Collected data underline a higher nursing workload and a more conspicuous number of average days of stay necessary to assist young children and elderly people over 75. However, these data pointed out only a statistically significant difference between infants (1-31 days) and the other age groups(NEMS 1-31 days and 14-65 years PREMATURE INFANTS? A SYSTEMATIC LITERATURE REVIEW TO THE EFFECTIVENESS OF INTERVENTIONS Mansvelt-van der Werf 1 , O. Helder 2 , A. van den Hoogen 3 Children's Hospital/Academic Medical Center Harvey cerebral palsy (8%), allergy (3%), congenital heart disease (2%) and others (8%) We found 5 categories and 15 subcategories as follows Sense of difficulty of home training; trial and error, difficulty of teaching, sense of fatigue, etc Reverse effects of home training; confusion about children's reaction, scolding too much when children can't follow mothers' instructions Troubles of home training; hardness to understand the difference of training between the handicapped children and their siblings, etc Conflict over home training; Conflict over endurance of children, difficulty to establish the mutual understanding Doubt about home training; doubt about necessity of home training Aims: This study was conducted to compare hemoglobin oxygen saturation (SPO 2 ) in two positions of side lying and supine in infants under mechanical ventilation. Methods: In a clinical trial 32 preterm infants under mechanical ventilation who had inclusion criteria were recruited in a simple convenient method. First they were placed in supine position for 120 min and then in side lying position for 120 min. Their SPO 2 were monitored by pulse oximeter and recorded each minute. Data analysis was done using SPSS (version 15). Methods: This study is a literature study based on nine original articles which includes 754 newborn infants, reviews, mandatory literature, procedures and other relevant literature. The infants in the study were 36 weeks or more in gestational age, were not to undergo surgical treatment within 3 days, or with major congenital abnormalities. Results: All the nine studies showed better neurological outcome in the cooled group. Adverse effects are common, but minor and not associated with cooling. Adverse outcomes include lower heart rate, hypertension, sepsis, intraventricular hemorrhage and lower rate of platelet activating factor. Prolonged blood coagulation time and thrombocytopenia is also common. Most of the infants needed mechanical ventilation and some underwent hypoglycemia. Renal failure, skin changes, lower morphine clearance, and increased morphine concentrations are also common adverse effects during hypothermia treatment. Seizures are also seen often. Conclusions: It is important that the neonatal intensive care nurse is well trained and has exquisite knowledge about the thermal effect on the inner organs. She also needs knowledge about the normal newborn infant and when to act upon the child and when to let the child rest. The studies show that hypothermia is a safe treatment as long as the child is closely monitored and kept under surveillance. The nurse also need a clear ethical and legal foundation.Background and aims: Cranial molding of preterm infants can result in a number of negative consequences. In the Dutch Neonatal Intensive Care Units (NICU) changing body and head position is used as an intervention to prevent cranial molding. A literature review was conducted to study the effects of interventions to prevent or reduce cranial molding of the preterm infant in NICU. Methods: A systematic literature review and critical appraisal according to the Cochrane Collaboration assessment criteria was performed. Results: Eight quantitative intervention studies meeting the inclusion criteria were identified. Most studies used the anterior-posterior biparietal (AP:BP) ratio as measurement of cranial molding. One multicentred quasi experimental study showed that infants who received regular repositioning had a statistical significant reduction of bilateral head flattening compared to infants who did not receive this intervention AP:BP ratio 1.35 vs. 1.55 (p = 0.05). The interventions used in the other seven studies were pressure relief mattresses, watermatresses or gel pillows. No or no statistical significant effect was found in these studies. Conclusions: Because literature was restricted, the evidence is poor and limited to one intervention: regular body repositioning. The repositioning has to be studied more extensively to confirm the result as well as to establish the long term and side effects on respiration and motor development. Other interventions have to be studied in well designed studies for their effect. Acknowledgements: We thank the Dutch Innovation and Research group NICU's for their support. Objectives: Placement of a peripheral IV's (PIVs) in neonates is considered to be easy and safe. However in premature newborns it may require several attempts and cause complications. The aim of this study was to identify factors that attribute to complications in peripheral IV-therapy. A secondary aim was to evaluate the rate of IV-complications as a rationale for future interventional studies. Methods: This observational prospective study took place from August 2010 to May 2011. Data were collected for all PIV placements. Patient characteristics, type of professional performing the procedure, location of PIV, fixation method, cannula size were recorded by the caregiving nurse on a case record form for all PIV procedures. All newborns admitted to the neonatal ICU were eligible for the study. Data were entered in SPSS 17.0 for analysis. Results: Data of 302 insertions were analyzed. The PIVs were in place for a mean of 1.5 days. The mean number of needle sticks required for PIV placement was 2.4. More than half of the PIVs (55.6%) were removed due to extravasations and leakage. Other reasons to remove a PIV were occlusion (9.9%), swelling of the skin (9.4%), and phlebitis (4.4%). Conclusion: This study shows that there is room for improvement with regard to the number of attempted PIV placements and complications. The constructed CRF can be used to evaluate interventions aimed at improving PIV-related therapy in the premature newborn. Objectives: We have recently observed an increase in the number of unplanned extubations (UE's) occurring in our regional Paediatric Intensive Care Unit. A review of these cases was undertaken in an attempt to determine causative factors in order to reduce the incidence. Methods: Relevant critical incident forms completed between August 2010 and April 2011 were examined. All information relating directly to the events was recorded. Results: 7 UE's were recorded during this period. 4 of these children required reintubation within 12 h. 3 remained extubated. 3 of the 7 children were undertaking weaning of sedation in preparation for extubation later that day. In 2 of the 7 cases the nurse caring for the child was also caring for another patient. The remaining 5 were being cared for by a nurse whose only responsibility was to that child. Conclusions: In previous studies, reduced staffing levels with nurses caring for more than one ventilated patient were highlighted as reasons for an increase in UE's [1] . Although we found this to be a possible contributing factor in 2 of the cases, the primary reason, ascertained from the incident forms, appeared to be undersedation. In light of our findings, review of our sedation policy is currently underway. Background and aims: The postpartum period is a transitional time for mother and baby, emotionally, socially, physiologically. Care in this period is critical not only for survival but also to the future of mothers and newborn babies. Research was planned experimentally to determine the effect of structured education and counseling activities to primipara mothers by nurses on baby care and being a mother during the first 3 months of postpartum period. The use of the local anesthetic EMLA Ò during painful procedures in children is becoming an increasingly common practice. Some of the techniques used seem to be more widely accepted than others. This study aimed to compare three techniques of EMLA Ò cream application in terms of the pain during the removal of the protective dressing and the venipuncture (VP) for the child, parents/accompanying persons and nurse. A prospective, randomized and controlled clinical study was performed in 142 children aged 4-14 years attending the Outpatient Consultation of Medical Specialties and Subspecialties of a Pediatric Hospital and in need of VP. Of the three techniques used, technique C (basis of a teat and an elastic bandage) was considered painless, whereas the standard technique (waterproof adhesive) was the most painful (p \ 0.05). The three techniques were effective in preventing pain in VP, and children, parents and nurses were unanimous in their preference for technique C. It was concluded that technique C is easy and quick to apply, costeffective and painless for the child, and that it is also the one preferred by parents and nurses. Thus, its use is recommended in this age group. Tel Aviv, Ramat Gan, IsraelAccording to professional books, the accepted practice in medicine is reference to dry facts, without emotions, thus the use of uncommon resources constitutes an ''antidote'' to regular learning. If the educator can use his imagination and to apply diverse techniques involving various senses and emotions, the trainee would be prevented from getting tired and would succeed better in the process of learning. The results of such learning would be higher than usual (Bradshaw & Lowenstein, 2007) . In the pediatric critical care department in Tel ha-Shomer Medical Centre, new personnel are continuously absorbed -and the successful absorption process is quite necessary here. It was decided to introduce revolutionary changes into the instruction method at the 2011: from then on, all the process will be connected to positive childhood Background: The high tech PICU environment carries a risk for errors and complications. To contain this risk, we work hard at optimizing safety and quality of care on our ward. One of the measures introduced to this aim is application of the Critical Nursing Situation index (CNSI). The aim of this study was to determine the incidence of protocol violations and how often a protocol violation could be corrected. Methods: The CNSI scores protocol violations in nine nursing care areas: basic care, circulation, respiration, digestive tract, infection parameters, invasive catheters, care for medication, ECMO and the central nervous system. The CNSI consists of 181 items scored by a trained nurse as: true (protocol violation), not true (=work according to protocol) or not applicable (for the patient under review). We analysed CNSI results obtained in randomly selected patients at the IC-Sophia Children's Hospital in the year 2009. Results: Fourteen nurses were trained to score the CNSI and interrater reliability was excellent (kappa 0.93 to 0.99). Altogether 238 CNSI forms in 127 patients were filled in. In total 11.7% of the applicable items were scored as a protocol violation. Direct or later correction of the protocol violation was feasible in 53.3% of the 986 violations. In 22.3%, the violation was purposeful due to specific patient situation. The number of protocol violations were not statistically significantly different between high care and intensive care patients (p = 0.86). Background: There is an increasing trend of parents refusing vitamin K (VK) prophylaxis for their newborn. Objective: To examine the basic knowledge and perceptions of expecting parents regarding newborn VK prophylaxis. Methods: We used anonymous questionnaires examining knowledge, perceptions, and cultural and religious barriers in a convenience sample of expecting parents-to-be during tours of the delivery rooms and postpartum units. Results: The questionnaire was completed by 219 participants; 151 were female, 66 were male. Eighty-five percent reported that they were expecting their first child and most of the women were in the third trimester of their pregnancy. Two-thirds of the participants had an academic degree yet exhibited a low level of knowledge regarding the necessity to provide VK to the newborn (22.5%), the source of the vitamin (15.5%), the action of the vitamin (34%) and the provision options available (29%). Expecting mothers exhibited more knowledge than fathers and many fathers reported ''not knowing.'' Few parents reported positive or negative perceptions towards providing VK. When examining the relationship between the knowledge and perceptions of first-time parents and the rest of the sample, no statistically significant differences were noted. However, more first-time parents reported that they had not yet decided whether they should provide VK once the baby was born (p \ 0.05). Almost mothers had a feeling of helplessness for home training because of the lack of effective communication with children. We thought that the mother's feeling and the reverse effects lead to the conflict over the home training for handicapped children. Introduction: Congenital and perinatal infections remain a stubborn and major cause of morbidity and mortality in infants throughout the world. The infant can also become infected from the vagina of the mother during birth. A congenital infection is an infection seen in the newborn infant that was acquired transplacentally during the first, second, or early third trimester. Aims: Intrauterine infection may occur quite early in pregnancy and remain undetected for months. Methods: Depending on the nature of infection, an appropriate sample is collected for laboratory identification. Authors performed a retrospective case series review at ten years care children's hospitals and publics pediatricians offices in Sarajevo. Results: The incidence of congenital infection in the fetus and newborn infant is relatively high at 1.5% in Bosnia and Herzegovina. The possibility of congenital or perinatal infection in neonates is usually considered because of the diagnosis of, or concern about a specificinfection in, a mother during pregnancy that can be transmitted to the neonate or because of clinical findings in the neonate at birth that suggest an infectious cause.Conclusion: While there are a large number of pathogens that can occasionally be harmful for the unborn child, some are of considerable public health impact, for example rubella, varicella, syphilis, hepatitis B, toxoplasmosis, or infections with cytomegalovirus (CMV) or human immunodeficiency virus (HIV). A more strategy has to be adopted if treatment needs to be given to the mother in order to prevent permanent damage of the child. Paediatric Intensive Care, Guys and St Thomas' NHS Foundation Trust, London, UK Background/aims: Pain assessment during hospitalisation in children is notoriously difficult due to the differences in emotional and cognitive development of this patient group (RCN, 2009 ). This task is made more difficult in the Peadiatric Intensive Care Unit (PICU) where children are often ventilated and sedated and therefore unable to verbally report pain. The aim was to explore the lived experience of PICU nurses in PICU regarding the assessment and management of pain. Methods: A focus group of 6 nurses of all grades was conducted and recorded using a semi-structured interview guide. Transcripts were analysed using a phenomenological approach with colaizzi's 7 procedural steps as a framework. Results: Pain assessment was felt to be lacking and the value of it diminished due to the lack of an algorithm to guide the process and lack of meaning assigned to the score. The current tool which was used was felt not to reflect pain behaviours and user fatigue was apparent. Staff felt that the pain assessment process needed to be improved, with education and the introduction of an appropriate tool for use in this patient group a priority. Conclusions: From the discussion it was apparent that Pain assessment needed to be formalised and improved in the PICU. This focus group prompted a review of the literature to identify a suitable pain score for use in the PICU and subsequent development of a new tool which is currently in the testing phase. Introduction: The SOS was found valid and reliable to screen for benzodiazepine and opioid withdrawal syndrome in PICU patients. We aimed to establish reliable cutoff scores and to test the scale's sensitivity to change in a large sample. Conclusions: With preparation and the right skill mix within a research team, studies can be run efficiently and effectively and the challenges presented by this complex group of patients can be overcome. User involvement in designing these studies and improving consent during this critical period would further enhance practice. Little is known about how nursing staff view their participation in clinical research, especially within neonatal care. It has been suggested that nurses are generally supportive of research, although participation may be influenced by time pressures, care of their patient, and limited experience of research. We designed a qualitative study to explore these influences. Objective: To explore neonatal nurses views of clinical research, and their perception of nurses' role in the research process. Method: Thirty-one nurses from a neonatal service participated in semi-structured interviews, which were analysed through the constant comparative method, assisted by NVivo software. Results: Nurses are supportive of clinical research, and recognise its importance in delivering the best care to their patients. Despite appreciating the benefits of research involvement, nurses see their primary role as advocates for the babies and their families, promoting clinical care above research. Nurses do not view themselves as involved in research, although they perform supportive tasks (such as collecting samples, recording data), and see this as part of their caring role. In particular, research is seen as an integral part of working in an intensive care unit, although nurses experience challenges in accessing and assimilating research information. Conclusions: Nurses play an important research role by promoting studies, collecting data, and acting as advocates for their patients. Although research support is seen as an integral part of their role, nurses do not feel engaged with the research process, influencing their level of participation, and thus the success of clinical research projects. Introduction: Anal fissure is a linear longitudinal defect in the lining of the anal canal extending usually from the dentate line to the anal verge. Anal fissures affect all age groups. The most dominant symptoms are pain and rectal bleeding. Anal fissure is a disease which affects quality of life of patients. Purpose: The purpose of this study is to determine problems of parents of children with anal fissure and their needs of the education. Material and method: In this descriptive study, the data were collected in between November 2010-January 2011. The data were collected using a 20-question survey form. The study sampling group is consisted of 25 children with diagnosis of anal fissure, and their parents whose admitted to pediatric surgical outpatient unit. In evaluation of data SSPS.15 was applied. Results: The 25 patients, included in the study, have 60% pain, 96% strain during stool, 56% have rectal bleeding, 76% cry during stool, 60% postpone the stool. It is determined that 56% of the parents have no information about anal fissure. All of the parents (%100) reported their information needs about the care and the treatment of anal fissure. Conclusions: In this study, it is determined that there was a lack of information in parents about anal fissure so it can be cause some wrong implications such as noncompliance with diet. It is recommended that parents of anal fissured children should be informed by information booklet, diet programs and compliance with the treatment.