Quicker response results in better SpO2 control - a comparison of 3 FiO2-titration strategies in ventilated preterm infants.

INTRODUCTION: The impact of SpO2 target ranges (TR) has been carefully studied; however, reports suggest a wide variation among infants and centres in maintaining the intended range. Little is known about the effectiveness of different approaches to manual control. Auto-SpO2 controllers are now available which show promise. OBJECTIVE: The aim was to compare two different protocol-driven manual strategies with different response requirements to each other, and a faster automated system (AveaCLiO2, Yorba Linda, CA, USA). MATERIALS AND METHODS: In a crossover design, each of the three FiO2/SpO2 approaches was implemented in three randomly assigned consecutive 2.5-hour runs. The two manual strategies (Attentive and Observational) were implemented by a trained operator. The primary endpoints were time in 1) SpO2 TR, 2) < 80% SpO2 and 3) >98% SpO2. RESULTS: Fifteen studies were completed. All three approaches resulted in good control, with time in the target range >60%. CLiO2 use reflected reduced exposure at the two SpO2 extremes. Post hoc analysis determined that the differences were more marked in the infants with more frequent desaturations. Likewise, in this group, the Attentive strategy performed better than the Observative. CONCLUSIONS: All three approaches provided excellent control of SpO2 in infants with infrequent desaturations, significantly better than typical routine care. In hard to manage infants with frequent desaturations, faster response appeared to result in better control. The potential of automating the tedious error prone FiO2 adjustment offers significant promise. If manual titration of FiO2 is to remain the usual method of care, additional studies are needed to identify optimal approaches.

Automated versus Manual Oxygen Control with Different Saturation Targets and Modes of Respiratory Support in Preterm Infants.

OBJECTIVE: To determine the efficacy and safety of automated adjustment of the fraction of inspired oxygen (FiO2) in maintaining arterial oxygen saturation (SpO2) within a higher (91%-95%) and a lower (89%-93%) target range in preterm infants. STUDY DESIGN: Eighty preterm infants (gestational age [median]: 26 weeks, age [median] 18 days) on noninvasive (n = 50) and invasive (n = 30) respiratory support with supplemental oxygen, were first randomized to one of the SpO2 target ranges and then treated with automated FiO2 (A-FiO2) and manual FiO2 (M-FiO2) oxygen control for 24 hours each, in random sequence. RESULTS: The percent time within the target range was higher during A-FiO2 compared with M-FiO2 control. This effect was more pronounced in the lower SpO2 target range (62 ± 17% vs 54 ± 16%, P < .001) than in the higher SpO2 target range (62 ± 17% vs 58 ± 15%, P < .001). The percent time spent below the target or in hypoxemia (SpO2 <80%) was consistently reduced during A-FiO2, independent of the target range. The time spent above the target range or at extreme hyperoxemia (SpO2 >98%) was only reduced during A-FiO2 when targeting the lower SpO2 range (89%-93%). These outcomes did not differ between infants on noninvasive and invasive respiratory support. Manual adjustments were significantly reduced during A-FiO2 control. CONCLUSIONS: A-FiO2 control improved SpO2 targeting across different SpO2 ranges and reduced hypoxemia in preterm infants on noninvasive and invasive respiratory support. TRIAL REGISTRATION: ISRCTN 56626482.

THE CONSEQUENCES OF FAILING ELECTIVE NONINVASIVE RESPIRATORY SUPPORT AS COMPARED TO IMMEDIATE INTUBATION: A POPULATION STUDY OF VERY LOW BIRTH WEIGHT NEONATES.

INTRODUCTION: Elective noninvasive respiratory support has become common. However, many neonates fail this procedure and they may require intubation. The aim of this study was to determine the relative outcome of very low birth weight neonates who failed noninvasive respiratory support compared to those that were initially intubated and mechanically ventilated. MATERIAL AND METHODS: We accessed the database of every neonate who received respiratory support in 18 hospitals in the central region of Poland and examined the records for a 7-year period. The evaluation encompassed 1667 neonates with very low birth weight who were potential candidates for elective noninvasive respiratory support. Three prospective primary outcome measures were assessed using logistic regression to control for differences in baseline risk. We also examined the length of respiratory support corrected for EGA. RESULTS: After controlling for significant baseline factors, we found that there was no statistically significant difference in mortality, severe retinopathy of prematurity (ROP) orsevere bronchopulmonary dysplasia (BPD) between infants failing noninvasive respiratory support and those electively intubated. However, their mortality and severe ROP were significantly higher than in those successfully treated with noninvasive respiratory support. Additionally, there was no difference in the length of mechanical ventilation or the length of all respiratory support between those that failed noninvasive support and those that were electively intubated. CONCLUSION: Our study suggests that in those preterm infants who are at a higher risk of failing noninvasive ventilation there is no compelling reason to administer elective intubation and mechanical ventilation immediately after birth. It seems that efforts should rather be made towards the implementation of the optimal non-invasive respiratory support.

USING THE AUTOMATED FIO2- SPO2 CONTROL IN NEONATAL INTENSIVE CARE UNITS IN POLAND. A PRELIMINARY REPORT.

AIM: Analysis of the way in which a new method of implementing the automated control of oxygen therapy during respiratory support is applied in newborns with respiratory failure. MATERIAL, METHODS AND RESULTS: The AVEA-CLiO2 ventilator with automated FiO2- SpO2 control was used in our study of 121 newborns conducted between February 2014 and January 2015 in five neonatal intensive care units. A web-based database was used to gather information entered concurrently with using the FiO2- SpO2 control system. This included demographics, clinical status, clinical indications, as well as objective and subjective experience. Among the 121 newborns 94 were preterm and 27 were near-term (33-36 hbd). The primary indication for using the system was "routine management" of FiO2 during respiratory support and it was generally initiated within the first 2 days of life. Many of the newborns were managed with the system for more than a week. The control range was usually 90%-95% SpO2, though sometimes it was lower or wider. The control range was not related to the newborn's maturity or indication for use. The perception of more "frequent and persistent" SpO2 alarms was lower when the alarms were set loosely. There were no reports of the system not working effectively. CONCLUSIONS: We expect this first report of the routine use of automated FiO2- SpO2 control to be useful not only to other centers in Poland but also to all those adopting this important new technology. Our registry continues and we expect to have an update when we have experience with 1000 infants. Carefully controlled trials are also needed to refine the optimum use of automated FiO2- SpO2 control and to quantify its impact on neonatal outcomes.

Automated FiO2-SpO2 control system in neonates requiring respiratory support: a comparison of a standard to a narrow SpO2 control range.

BACKGROUND: Managing the oxygen saturation of preterm infants to a target range has been the standard of care for a decade. Changes in target ranges have been shown to significantly impact mortality and morbidity. Selecting and implementing the optimal target range are complicated not only by issues of training, but also the realities of staffing levels and demands. The potential for automatic control is becoming a reality. Results from the evaluation of different systems have been promising and our own experience encouraging. METHODS: This study was conducted in two tertiary level newborn nurseries, routinely using an automated FiO2-SpO2 control system (Avea-CLiO2, Yorba Linda CA, USA). The aim of this study was to compare the performance of the system as used routinely (set control range of 87-93% SpO2), to a narrower higher range (90-93%). We employed a 12-hour cross-over design with the order of control ranges randomly assigned for each of up to three days. The primary prospectively identified end points were time in the 87-93% SpO2 target range, time at SpO2 extremes and the distribution of the SpO2 exposure. RESULTS: Twenty-one infants completed the study. The infants were born with a median EGA of 27 weeks and studied at a median age of 17 days and weight of 1.08 kg. Their median FiO2 was 0.32; 8 were intubated, and the rest noninvasively supported (7 positive pressure ventilation and 6 CPAP). The control in both arms was excellent, and required less than 2 manual FiO2 adjustments per day. There were no differences in the three primary endpoints. The narrower/higher set control range resulted in tighter control (IQR 3.0 vs. 4.3 p < 0.001), and less time with the SpO2 between 80-86 (6.2% vs. 8.4%, p = 0.006). CONCLUSIONS: We found that a shift in the median of the set control range of an automated FiO2-SpO2 control system had a proportional effect on the median and distribution of SpO2 exposure. We found that a dramatic narrowing of the set control range had a disproportionally smaller impact. Our study points to the potential to optimize SpO2 targeting with an automated control system.

A multicenter randomized controlled trial comparing effectiveness of two nasal continuous positive airway pressure devices in very-low-birth-weight infants.

OBJECTIVE: Many studies suggest nasal continuous positive airway pressure is an effective and relatively complication-free means of respiratory support in premature infants. However, only limited data exist regarding the practical aspects of nasal continuous positive airway pressure delivery, including the best way to provide the positive airway pressure. DESIGN: Our aim was to compare the results of treatment using two different nasal continuous positive airway pressure devices: variable flow Infant Flow and constant flow nasal continuous positive airway pressure in two different groups of very-low-birth-weight infants in a multicenter randomized controlled trial. The indication groups were elective to avoid intubation and weaning from mechanical ventilation. SETTING: Twelve leading tertiary care neonatal centers in Poland. PATIENTS: Among 276 infants (weighing between 750-1500g, with a gestational age ≤32 wks) enrolled, 51% were randomized to receive Infant Flow and 49% to receive constant flow nasal continuous positive airway pressure. MEASUREMENTS AND MAIN RESULTS: Treatment success (i.e., no need for intubation/reintubation) occurred in 75% of our patients with a nonstatistically significant advantage seen with Infant Flow. The incidence of severe nasal complications and necrotizing enterocolitis were statistically significantly lower in the infants treated with Infant Flow. In our study, factors associated with elective nasal continuous positive airway pressure failure were birth weight ≤1000 g, gestational age ≤28 wks, clinical risk index for babies score >1, and PaO(2)/FIO(2) ratio of <150. Only birth weight ≤1000 g was associated with weaning failure. CONCLUSIONS: We found fewer severe nasal complications but no statistically significant advantage in treatment success in infants assigned to Infant Flow nasal continuous positive airway pressure compared with those assigned to constant flow nasal continuous positive airway pressure treatment. Significant risk factors of treatment failure include small size, maturity, and severity of respiratory distress syndrome.

[Thermal comfort in preterm babies. Infra-red colour thermography findings. Preliminary report]. / Ocena komfortu cieplnego u noworodków urodzonych przedwczesnie przy uzyciu metody termografii w podczerwieni - doniesienie wstepne.

OBJECTIVE: To assess the thermal comfort of clinically stable neonates with normal body temperature by using infra-red colour thermography (THY). MATERIAL AND METHODS: 32 babies were enrolled in the study. The axillary temperature was maintained in the range 36.6-37.0 degrees C and the air temperature in the incubator remained within the neutral range according to Hey and Katz. Temperature distribution was measured by THY The abdomen and foot skin temperature, as well as the difference between both parameters were recorded. Thermal comfort for THY was defined as a difference between core and peripheral temperatures (Deltat) in the range of 1 to 2 degrees C. RESULTS: Thermal comfort defined according to THY criterion was fulfilled only in 12 patients (37.5%). We found Deltat< 1 degree C in 14 patients (43.8%), and Deltat>2 degrees C in 6 patients (6.3%). Thermal comfort defined by standard care varied from founded by THY p<0.0001. High foot temperature >or=35.0 degrees C in THY was found as a determinant for Deltat< 10 degrees C. Multivariate logistic regression analysis found gestational age <30 weeks to be connected with the risk of hyperthermia [odds ratio 8.4 (95% Cl 1.2-61.2). CONCLUSIONS: We concluded that there is a risk for hyperthermia in prenaturely, immature babies when nursed in standard neutral temperature. Infra-red colour thermography gives additional information which can be used for further studies on determination of optimal thermal comfort in newborn.

[Evaluation of sick neonates' medical interventions in maternity units before transport to reference centres]. / Ocena jakosci przygotowania chorego noworodka w macierzystym oddziale noworodkowym do transportu miedzyszpitalnego.

BACKGROUND: Interhospital transfer of the sick neonate should be an integral part of neonatal intensive care. However, it is essential that the referring hospital is able to provide the appropriate standard of care from birth up to the point of transfer. OBJECTIVE: To evaluate the quality of medical interventions before interhospital transport of sick neonates. MATERIAL AND METHODS: Retrospective study based on review of all transport records of530 neonates who were transported at the Neonatal Intensive Care Unit (NICU) in 2006. The examined variables included medical interventions in the maternity unit and transport team interventions before and during the transport. RESULTS: During the study period there was as a total of 530 transfers to Neonatology Departments, 325 of them (61.32%) were transferred to the NICU and 205 (38.68%) to the Special Care Unit. Within the group of neonates transported to the NICU, 51 (15.7%) infants had hypothermia, 65 (20%) had no venous access before the transport. The most common form of respiratory therapy was oxygen therapy (89 (27.4%) neonates), followed by mechanical ventilation (65 (20%) and NCPAP ventilation (50 (15.4%) infants). As a result of transport team interventions the number of children with hypothermia decreased to 27 (8.3%). Peripheral intravenous devices were inserted in 52 (16%) neonates. The number of infants transported on mechanical ventilation increased to 115 (35.4%), 56 (17.2%) babies received NCPAP and 53 (16.3%) were on supplemental oxygen. The highest number of transport team interventions was found in the group of extremely low birth weight infants. CONCLUSIONS: Inadequate medical preparation of sick neonates in maternity hospital for interhospital transport was the reason for the high incidence of transport team interventions before moving the neonate to the NICU.

Usefulness of the Apgar score: a national survey of Polish neonatal centers.

INTRODUCTION: The paper discusses the reliability of the Apgar score for evaluating newborns, particularly its usefulness in assessing the state of preterm or full term newborns born with hypoxia. AIM: The paper provides a sum-up of the opinions on usefulness and reliability of the Apgar score given by doctors from 255 NICUs. MATERIAL AND METHODS: Data for the analysis were gathered by means of a questionnaire opinion poll sent to 158 primary referral centers, 71 secondary referral centers and 26 tertiary referral centers. Respondents answered questions about value of the Apgar score assessment (highly valuable, limited value, always reliable), as well as overrating and underrating children born in good overall condition and children born with clinical and biochemical indicators of hypoxia. In the group of prematurely born babies, the data concerning newborns with very low (VLBW) and extremely low birth weight (ELBW) were analyzed separately RESULTS: 88.5% neonatologists claimed the use of the Apgar score in assessing newborn condition to be of little value and only 11.5% found this indicator useful and reliable. CONCLUSIONS: According to the majority of Polish neonatologists, Apgar score is not reliable in the assessment of term and preterm hypoxic newborns.

Comparative study of clinical characteristics of amniotic rupture sequence with and without body wall defect: further evidence for separation.

BACKGROUND: Amniotic rupture sequence (ARS) is a disruption sequence presenting with fibrous bands, possibly emerging as a result of amniotic tear in the first trimester of gestation. Our comparative study aims to assess whether there is a difference in the clinical pattern of congenital limb and internal organ anomalies between ARS with body wall defect (ARS-BWD) and ARS without BWD (ARS-L). METHODS: Among 1,706,639 births recorded between 1998 and 2006, 50 infants with a diagnosis of ARS were reported to the Polish Registry of Congenital Malformations. The information on 3 infants was incomplete, thus only 47 cases were analyzed. These infants were classified into groups of ARS-L (38 infants) and ARS-BWD (9 infants). RESULTS: The ARS-BWD cases were more frequently affected by various congenital defects (overall p < 0.0001), and in particular by urogenital malformations (p = 0.003). In both groups, limb reduction defects occurred in approximately 80% of cases; however, minor and distal limb defects (phalangeal or digital amputation, pseudosyndactyly, constriction rings) predominated in the ARS-L group (p = 0.0008). The ARS-L group also had a higher frequency of hand and upper limb involvement. CONCLUSIONS: This observation suggests that amniotic band adhesion in ARS-L takes place at a later development stage. Although limited by a small sample size, our study contributes to the growing evidence that both ARS entities represent two nosologically distinct conditions.

Ophthalmological aspects of Pierson syndrome.

PURPOSE: To study the ocular phenotype of Pierson syndrome and to increase awareness among ophthalmologists of the diagnostic features of this condition. DESIGN: Retrospective, observational case series. METHODS: A multicenter study of 17 patients with molecularly confirmed Pierson syndrome. The eye findings were reviewed and compared to pertinent findings from the literature. RESULTS: The most characteristic ocular anomaly was microcoria. A wide range of additional abnormalities were found, including posterior embryotoxon, megalocornea, iris hypoplasia, cataract, abnormal lens shape, posterior lenticonus, persistent fetal vasculature, retinal detachment, variable axial lengths, and glaucoma. There was high interocular and intrafamilial variability. CONCLUSIONS: Loss-of-function mutations in laminin beta2 (LAMB2) cause a broad range of ocular pathology, emphasizing the importance of laminin beta2 in eye development. Patients with Pierson syndrome can initially present with ocular signs alone. In newborns with marked bilateral microcoria, Pierson syndrome should be considered and renal function investigated.

[Aims and methodology of the Polish National programme for Standardisation of Clinical Practices in Neonatology and Paediatric Intensive Care. Edition 2007/2008]. / Cele i metodologia Ogólnopolskiego Programu Definiujacego i Standaryzujacego Praktyki Kliniczne w Neonatologii oraz Intensywnej Terapii Dzieciecej z uwzglednieniem dzieci urodzonych z mala i bardzo mala masa urodzeniowa ciala. Edycja 2007/2008.

In this paper we outline the aims and methods of the Polish National Programme for Standardisation of Clinical Practice in Neonatology and Paediatric Intensive Care, with special reference to infants with low and extremely low birth weight. The aim of this Programme is to adjust the diagnostic and therapeutic procedures to the latest guide lines and recommendations. The first stage consisted of a national level survey in order to identify the diversity of procedures implemented in Medical University Clinical Departments, Neonatology Units and Paediatric Intensive Care Units. The survey also served to confront the legitimacy of the used procedures with the current clinical knowledge and research. It is planned to repeat the survey 24 months after the implementation of the latest recommendations with the aim to assess the impact of the Programme on clinical practice. Partial stages of the Programme were started since 2006. The survey is coordinated by an independent statistics unit. The recommendations are developed on published standards.

[Recommended treatment of apnea in premature infants. A review based on literature and own experience]. / Leczenie bezdechów u noworodków przedwczesnie urodzonych - zalecenia opracowane na podstawie danych z pismiennictwa i doswiadczen wlasnych.

The authors reviewed the literature concerning different methods of treatment of apnea in premature infants. The authors consider that, apart from pharmacological treatment, noninvasive respiratory support methods play an important role in the prevention and treatment of newborns with apnea. The aim of the study is to present current recommendations concerning the principles of prevention and treatment of apnea in premature infants. The compiled recommendations are based on the data from literature and from the authors' own experiences.

[Analysis of infections in neonatal units in Poland]. / Analiza zakazen wystepujacych w oddzialach noworodkowych w Polsce.

UNLABELLED: The aim of the study was to analyse the data concerning infections in neonatal units and to assess the facilities for bacteriological diagnosis. MATERIAL: This national programme included 273 neonatal departments of which 175 were level I of referral, 72 departments were level II of referral, 26 units were level III of referral and 28 were paediatric intensive care departments. METHOD: was by use of anonymous questionnaires sent to the 273 neonatal departments. The questionnaire consisted of 15 questions concerning hospital infection, their diagnosis and treatment. Questions were standardized in a previous pilot study.The results are presented in 20 tables. They present bacteriological data routinely collected in the neonatal department, diagnostic criteria and antibiotic treatment. CONCLUSIONS: there is a need to introduce continous supervision concerning neonatal unit infections, which consists of coordinated and uniform procedures for material collection and pathogen identification.

[Current neonatal resuscitation practices in Polish neonatal units - national survey]. / Stan przygotowania pod wzgledem merytorycznym i organizacyjnym oddzialów neonatologicznych o róznym stopniu referencji do prowadzenia resuscytacji noworodka po urodzeniu.

AIM: We surveyed current neonatal resuscitation practices in Polish neonatal units to determine the factors, relevant to improving practices in this area. MATERIAL AND METHODS: The study was performed within the framework of the National Standardization Programme on Neonatal Practices and Procedures in 2007. An 11 question survey included questions concerning the frequency of neonatal resuscitation, type of procedure performed during resuscitation ie.: medicaments and oxygen administration, umbilical vein catetherisation, equipment availability, resuscitation of extremely preterm babies. The survey included also questions concerning problems in resuscitation and their causes. 420 questionnaires were sent out and 274 were returned completed (65.2% response rate). 266 units providing delivery room resuscitation were included in the study. RESULTS: Neonatal resuscitation procedures were needed significantly more frequently in the centres of the highest degree reference (p<0.001). There were also marked differences between the centres according to the frequency of umbilical vessels catetherisation and availability of the necessary medical equipment. In 44.6% of neonatal units, resuscitated newborns are successfully ventilated with room air. However, in 23.5% of the surveyed units, 100% oxygen is used for ventilation. The finding of great importance is that 30.7% of neonatal units stated the need for a trained resuscitator to attend a high risk pregnancy delivery and to resuscitate asphyxiated newborns. CONCLUSIONS: There are substantial differences in neonatal resuscitation practices in different neonatal centres. These findings should stimulate appropriate authorities to start an educational programme to establish suitable polices in newborn resuscitation.

[Delivery room resuscitation with room air and oxygen in newborns. State of art, recommendations]. / Zastosowanie tlenu i powietrza w resuscytacji noworodka po urodzeniu, aktualne poglady, zalecenia.

The authors present and discuss the current data, concerning delivery room resuscitation with oxygen and room air in neonates. On the ground of the results obtained from literature and the Polish National Survey on Paediatric and Neonatal Intensive Care, 2007/2008 issue, the authors give the following proposals regarding optimal oxygen treatment: 1. there is a need for optimizing tissue oxygenation in order to prevent injury caused by radical oxygen species; 2. newborn resuscitation should be monitored by measuring the haemoglobin saturation - the values above 90%, found in resuscitated newborn within the first minutes of life may be dangerous and cause tissue injury; 3. starting the resuscitation with oxygen concentration lower than 40% and adjusting it according to the effects of the procedure - the less mature infant the lower oxygen concentration at the beginning of resuscitation; 4. heart rate >100/min and SatO2Hb between 70-80% within the first minutes of life should not be an indication for increasing oxygen concentration.

[Weaning newborns from noninvasive ventilation]. / Zasady uwalniania noworodków z wentylacji neinwazyjnej.

The purpose of the study was to propose the recommendations for weaning infants from nasal continuous positive airway pressure (nCPAP) and nasal intermittent positive pressure ventilation (NIPPV). Despite the fact that both methods are commonly used for respiratory insufficiency in infants, detailed recommendations for weaning have not been described so far. The proposed recommendations are based on previously described data and a wide survey conducted among Polish neonatologists and intensive therapy paediatricians.

[Endotracheal suctioning in neonates and children]. / Toaleta dróg oddechowych u noworodków i dzieci leczonych w oddzialach intensywnej terapii.

Endotracheal suction is essential to keep the respiratory capacity of the bronchial tree. The aim of this study was to establish the principles reducing potential side-effects, like hypoxia, bradycardia, hypotension, arrhythmia, nosocomial infections. Analysing the literature we have selected the following major beneficial factors: 1:2 to 2:3 cathether - tracheal tube diameter ratio, individual adjustment of the suctioning frequency, maximal duration of the procedure capped at 10-15 sec., minimal effective suctioning pressure of 80-100 mmHg. We have also determined that the following procedures should be also taken into consideration: preoxygenation (only for unstable patients), sedation and analgesia. We have concluded with the comparison of the two suction systems, pointing out that, especially for unstable patients, closed-suction system proves more suitable.

[Parenteral nutrition in neonatal units: a survey of current practices in Poland]. / Zywienie pozajelitowe w oddzialach neonatologii w Polsce - analiza stosowanych praktyk.

UNLABELLED: The aim of the study was to assess parenteral nutrition methods in neonatal units in Poland. MATERIAL AND METHODS: Large scale questionnaire investigations concerning parenteral nutrition (PN) were carried out in neonatological centres in Poland. The questionnaires were distributed in the year 2007 to 463 wards. Three hundred and two neonatal wards (NW) and pediatric intensive care units (PICU) responded (65.2% response rate). RESULTS: The investigation revealed that only 129 NW (48%) and 27 PICU (96% PICU) of the studied neonatal units (156 centres - 52% of responders) declared PN as a method of treatment. Nutritional teams are rare (20% of NW and 35% PICU) and hospital pharmacy was very rarely involved in preparing nutritional mixtures (11% NW and 22% PICU). More than half of NW and nearly 30% of paediatric intensive care units (PICU) use inappropriately concentrated lipid emulsions. One third of NW do not use obligatory for children (particularly neonates) volumetric infusion pumps. Mean time of umbilical artery access was twice as long as recommended. Majority of centres regard the level of training in parenteral nutrition as insufficient. CONCLUSION: Assessment of parenteral nutrition practices in neonates in Poland revealed that significant number of centres did not follow the recommendations and that there is need for training and organization activities to improve the quality of current PN practices.