Lighthouse project: Baby simulator doll Paul helps to train emergency scenarios with preterm babies

Lighthouse project: Baby simulator doll Paul helps to train emergency scenarios with preterm babies

A guest article by Dr Rangmar Goelz and Dr Karen Kreutzer from the University Children’s Hospital Tübingen

Last year, the neonatal ward in the University Clinic Tübingen/Germany started, as one of the first clinics in Germany, to train emergency situations with the help of a baby simulator doll. As this in one of our lighthouse projects in the area “Education and training”, we spoke to Dr Rangmar Goelz and Dr Karen Kreutzer and asked them how the simulation trainings have been implemented into their training schedules and if the trainings have proven to be successful.

Hands-on training with the baby simulator doll Paul © University Clinic Tübingen

The University Children’s Hospital Tübingen is one of the first clinics in Germany that is using a baby simulator doll for training purposes. How did that come about?
We already started training our staff in a simulation laboratory 12 years ago. This laboratory was initially used for trainings in anaesthesiology, but it was soon used in paediatrics as well.
At the beginning we only had a doll weighing 4–5 kg. This of course was too big, but it was good enough to practice various emergency scenarios. During these trainings even the biggest sceptics in our team were able to experience how real it feels and how the blood pressure increases in such a simulated emergency situation. So right from the beginning we were completely convinced about the concept of simulation trainings in general.

For how long are you using the simulator doll Paul and why did you make the decision to integrate it into your trainings?
We heard about the simulator doll Paul at a congress and we immediately contacted the manufacturer. Paul was the missing piece to make the simulation even more realistic and adapt it even better to our every-day work at the hospital. So we were very happy when we finally received our own Paul. As the costs for the doll are quite high, we appreciated the financial support we received from the local newspaper “Schwäbisches Tagblatt”, the foundations Dachtel hilft kranken Kindern  and Lichtblick e.V. , and our own parent initiative for ill children  of the University Children’s Hospital Tübingen. 

How do you integrate Paul into your simulation trainings in your hospital?
In the beginning we practiced mostly in our simulation laboratory because we also had to first become familiar with the doll. It is quite surprising how similar it is with a real preterm baby and how small and fragile it is. We practiced using the doll in different scenaries covering first stabilisation measures and the typical associated ermergency situations. Recently we started training with Paul outside of the laboratory directly in the neonatal ward, as Paul has another great feature: he functions wirelessly via radio control, therefore we can hold our training sessions in the actual places of action which makes it even more realistic. 

How would you like to further develop the simulation trainings?
As I said, we are currently training for stabilisation scenarios that are typical for the emergency cases in the neonatal ward. But our goal is to do trainings directly in intensive care, but for this we need free beds in intensive care, which is at the moment very difficult.

What are the challenges you are facing?
One of the biggest challenges is to allocate the time that you need for the training units. The simulation trainings can only be conducted in a team, with the participation of nurses, the ward doctor, one or two senior doctors, and the training staff. This means that the trainings need to be scheduled very far ahead, and so far the trainings are not included in the general staff planning and need to be added on top. In Germany the number of nurses allocated to the care of preterm babies with very low birth weight was increased, so we now have more nursing staff. Unfortunately this not the case yet with doctors.

What changes and improvements were you able to achieve so far by practising with Paul?
The training conditions are becoming more and more realistic. So far we did not make a review of our experiences in the classical sense to show what the benefits of our baby simulation training really are. This would also exceed our administrative capacities. But maybe I could illustrate how we are benefitting from it by telling you about a situation the other day in our ward: In was in the middle of the night, and besides taking care of normal patients, we had a severe emergency situation and an emergency C-section of a very preterm baby. It was very late, everyone was stressed out and we had many other patients, but everything went perfectly smooth. This was a very satisfying and comforting experience for the whole team, which can be especially important even when all efforts fail and we cannot help the child in the end.

View more (article by Dr Jens-Christian Schwindt, founder of the baby simulator doll Paul)

View German version

Special thanks

Dr Rangmar Goelz, Chief Senior Physician and Deputy Medical Director, Department of Neonatology, University of Tübingen, Germany

Dr Karen Kreutzer, Senior Physician, Department of Neonatology, University of Tübingen, Germany











View more (website University Clinic Tübingen)


The simulator doll Paul is being used for trainings in the following clinics around the globe:

Women’s Guild Simulation Center for Advanced Clinical Skills Cedars Sinai Medical Center, Los Angeles, CA
The University of Tennessee Health Science Center, Memphis, TN
Old Dominion University, School of Nursing, Norfolk, VA
Children´s Hospital of Philadelphia, Philadelphia, PA
Johns Hopkins All Children’s Hospital, St Petersburg, FL
Johns Hopkins Medicine Simulation Center, Baltimore, MD

US Army Hospital Landstuhl/LRMC
Medical University Schleswig Holstein, Luebeck
Medical University Tuebingen
Municipal Hospital Dresden
Hospital Ernst von Bergmann, Potsdam
Children’s Hospital Passau

Medical University Vienna
General Hospital Klagenfurt
Medical University Salzburg
Medical University Sankt Poelten

Victoria Hospital Kirkcaldy


Acibadem University’s Centre of Advanced Simulation Education (CASE), Istanbul
Recep Tayyip Erdoğan Üniversitesi, Istanbul

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The role of fathers in breastfeeding

Men can play an important role when it comes to breastfeeding. Within our monthly topic of “Nutrition”, we wanted to get to the bottom of this issue and talked to a well-known expert in this field, Professor Michael Abou-Dakn, Head of Department at the Clinic for Gynaecology and Obstetrics at the St. Joseph’s Hospital Berlin Tempelhof, Germany.

Expert Professor Michael Abou-Dakn

To what extent do men influence women’s decision to breastfeed their child and the frequency and duration of breastfeeding?
International research and our own studies have shown that both the decisions whether women are going to breastfeed or not, as well as the duration of breastfeeding are very decisively influenced by men (fathers). This is particularly true for educationally deprived strata of society, where the influence of men is even more pronounced. What’s interesting is that the partners’ attitude, negative or positive, is frequently taken over by the women themselves.
We were also able to show that expectant fathers who are only briefly informed about the advantages of breastfeeding in a course and who receive essential information on breastfeeding support, are much more supportive later on when problems arise.

Can you observe any regional differences in this regard (e.g. within Europe) and if so, which?
The studies come from different countries and show similar effects. In particular, the influence of education on the initiation and duration of breastfeeding has been proven in many studies. Unfortunately, this also applies to the motivation of women.

According to current research findings, what are fathers’ reservations about breastfeeding based on?
For the most part it is the unawareness of the negative consequences of not breastfeeding. It’s a common believe that industrial substitute products are equal to natural breast milk, which is not the case. This is simply a misjudgement, because pregnancy itself changes the volume of the breast, and breastfeeding doesn’t have a significant influence. Abroad, the financial situation is often brought to the fore. Fortunately, this is less common in Germany due to existing maternity guidelines.

How has men’s behaviour changed over time and where is it heading (e.g. since the 1950s compared to today)?
The attitude towards the uniqueness of breast milk has changed in recent years for both men and women. Overall we haven’t achieved such a significant change with our breastfeeding promotion if you take in account our goal of encouraging as many women as possible to (exclusively) breastfeed their children, even after the first 6 months. Even after the minimum of an exclusive breastfeeding period of up to 5 months recommended in Germany, no significant changes can be observed in recent decades.

Merely the attitude and the initiation of breastfeeding have improved considerably. However, most men today are more intensely involved and included in health related issues and early child care, compared to the 50s. This is probably due to the changed roles of both parents. The introduction of parental leave for fathers was also very helpful here. Because of Scandinavian research we know, that this leads to fathers feeling more deeply involved into parenting, and from own research I can affirm you, that men have an increasing interest in health related aspects during pregnancy and postpartum period. This can be used for corresponding educational work, which is already done by the German network for young families (Netzwerk Junge Familie), the European Foundation for the Care of Newborn Infants (EFCNI), and the German Federal Center for Health Education (BZgA).

To what extent can fathers encourage their partner to breastfeed and positively support her breastfeeding behaviour?
As so often, it is primarily about a positive emotional support of the partner. Pressure, no matter in which direction, is always stressful and often leads to a difficult start to breastfeeding. I am convinced that every woman can breastfeed and every child wants to be breastfed, but often the beginning is not easy and can contribute to failure. Partners who lovingly and empathetically accompany their wife are particularly helpful. This also means that women are relieved in everyday life. We were also able to show that men who are informed about breastfeeding problems and who have got to know and understood suggestions for solutions, as well as midwives or experts in breastfeeding, are helpful counsellors who can motivate their women to continue breastfeeding even in the case of initial irritations.

Special thanks to

Professor Michael Abou-Dakn
Head of Department at the Clinic for Gynaecology and Obstetrics
St. Joseph’s Hospital Berlin Tempelhof


View German version

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Human milk banking

A guest article by Professor Jean-Charles Picaud, President of European Milk Bank Association (EMBA)

Professor Jean-Charles Picaud

Health benefits of breastfeeding are well-known in healthy term infants. These benefits are even greater in preterm infants as human milk (HM) feeding reduces the risk of complications associated with prematurity, such as digestive intolerance, necrotising enterocolitis, sepsis, retinopathy of prematurity (ROP) and bronchopulmonary dysplasia. As these benefits specifically present in preterm infants are dose-dependent, babies should receive as much HM as possible. It can be mother’s own milk when available. If not or partially available, donor HM is recommended by the World Health Organization (WHO) as the best alternative. Finally, when both are not available, these infants should be fed with a specific formula covering nutritional needs. Benefits of HM feeding are probably related both to HM properties and to the avoidance of formula.

Donor HM is obtained from HM banks which collect, treat and deliver milk from mothers who have a surplus of milk and accept to donate. Donors are carefully screened through a medical interview and serological testing. Milk collection is then performed under strict hygiene conditions explained to the donors that accept to carry out this altruistic act. Human milk banks require a significant number of donors, which is easier when breastfeeding rates in the general population are high. It is crucial to explain to all lactating mothers how much their milk could support health and development of preterm infants. Information campaigns about prematurity and it consequences, together with information about how to help these babies by donating milk are essential, because mothers delivering healthy term infants are not always aware about the potential impact of their involvement in milk donation.

Another key point is the density of the HM banks network. The number of HM banks sharply increased worldwide during the past 15 years. There are presently 226 active HM banks in 25 European countries (plus Switzerland, Russia, and Serbia). This field is developing quickly in Europe and chances of having a milk bank not too far away and the possibility to collect milk of donors, are increasing.

Donated HM is stored and transported carefully while maintaining the cold chain. Holder pasteurisation (62.5°C during 30 min) is commonly used to apply heat treatment. It offers the best compromise between microbiological safety and a preservation of HM quality. The concentration of most components is preserved or moderately reduced after the holder pasteurisation. Some components are reduced, but, more importantly, only a few enzymes and cells are destroyed. Finally, pasteurised HM keeps its main properties and is efficient to reduce short-term and long-term morbidity.

Human milk banks are running according to national guidelines, which tend to harmonise the illustrated processes. The European Milk Bank Association (EMBA) will publish Guidelines for the implementation of HM bank and Guidelines for treat treatment of donor HM to support this harmonisation of practices before the end of 2018. Furthermore, EMBA will publish recommendations to fortify donated HM, which is essential to support postnatal growth of preterm infants. A good postnatal growth has been associated with improved further cognitive development.

HM banks are engaged in actions to improve the supply of donated HM to hospitalised preterm infants. They are the main beneficiaries as there is a large body of evidence about health benefits of HM feeding in this population of high risk patients. There are other indications such as digestive malabsorption syndrome, post-operative nutrition of gastroschisis, immunologic deficiencies, etc. If supplies of banked HM are sufficient, some countries proposed that donor milk may be dispensed by prescription for situations such as adoption or surrogacy, illness in the mother requiring temporary interruption of breastfeeding, health risk to the infant from the milk of the biological mother or death of the mother.

In some countries, some HM banks propose donated milk to mothers of healthy term infants with absent or insufficient lactation. This societal demand emerged recently and the main interest could be to avoid milk sharing or selling which can be deleterious for health of recipients. This indication should be carefully discussed and not accepted before all the needs of ill newborns are covered. Until that happens in Europe, the objective of European milk banks is to supply donor HM to all preterm infants who need it to get a HM feeding (mother’s own milk andor donor HM) during hospitalisation.

View more (website EMBA)

Special thanks
Professor Jean-Charles Picaud
President of European Milk Bank Association (EMBA)
President of French Human Milk Bank Association (ADLF)
Head of Department of Neonatal Intensive Care
Croix rousse hospital
103 Grande rue de la croix rousse
69004 Lyon, France

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Lighthouse Project: Human milk is the best for infants

A guest article by Dr Margarita Tzaki, Director of the Neonatology Department / NICU at ELENA VENIZELOU hospital in Athens, Greece

The ELENA VENIZELOU hospital in Athens, Greece, was founded in 1935 from a donation for the benefit of mothers and newborn babies. It was designed to provide the best care for them, so practicing rooming-in, based on the model of a maternity hospital in Lausanne, has been the only choice ever since its opening. In 1945, the neonatal intensive care unit (NICU) opened and in 1947, the first human milk bank was established to promote breastfeeding and provide breast milk to preterm babies.

Historical photo (c) ELENA VENIZELOU hospital

Medical literature from the early 1980’s and the tradition in hospital were the driving forces to feed preterm babies, from 1990, with fresh human milk from their mothers or pasteurised donor milk from mothers who had given birth in the hospital and who voluntarily donated their excess milk. Neonatologists and midwives from the neonatal intensive care unit and human milk bank supported women in breastfeeding. Through these years, it has become evident that providing human milk in the NICU is very rewarding for mothers and infants because they tolerate human milk feeding very well, reach full feeding quickly and we rarely see cases of necrotizing enterocolitis (NEC). In a group of extremely preterm babies under 27+0 weeks of gestational age that we studied from 2001 to 2012, among 222 babies with mGA* 25+1 and BW (birth weight) 795+168, the survival rate was 47.5% and the NEC rate was only 2.15%.

Breastfeeding supports the bonding process (c) ELENA VENIZELOU hospital

Although resources are limited in the hospital, through continuous education of health care personnel in the field of breastfeeding, its promotion in the well-baby nursery (a Baby-Friendly Hospital (BFH) since 2011) and in the NICU make a difference in the bonding process and in the early and long-term outcome. From 2015, doctors and nurses were educated in family-centred developmental care and from 2016, we implemented the FINE (Family and Infant Neurodevelopmental Education) programme in our practice in the NICU. This new approach resulted in happy babies and parents. It was really impressive to see that, after the implementation of practices that increase the contact with the parents, like Kangaroo care, extremely and low birth weight infants latched on to the nipple and were breastfed from 30-31 weeks corrected age. They were also discharged home at 36 weeks corrected age when parents knew their babies cues and were ready to take them home.

We really need a change in attitude, education and only very limited resources to promote breastfeeding in the NICU and to improve early and long term outcomes of the “graduates” of our intensive care units as well as the well-being of their families.

*mGA: mean value of birth weight according to the reference

View more (website HELENA VENIZELOU hospital)

Special thanks
Dr Margarita Tzaki
Director, Neonatology Department / NICU
ELENA VENIZELOU hospital in Athens, Greece


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Lighthouse Project: Palliative Care and grief counselling in Peri- und Neonatology

New guiding principles published – a remarkable project in the field of “Ethical decision-making and palliative care”

a guest article by Katarina Eglin from the German Federal association “Das frühgeborene Kind” e.V.

Terminal care and grief counselling always act as part at neonatal care facilities when children are either born very preterm or seriously ill. However, so far there wasn’t a suitable recommendation for action in the German speaking countries, which provides guidance for the healthcare team to deal professionally and competently with this burdening and challenging topic.

On this matter, experts as well as affected parents joined forces on behalf of the German Federal association “Das frühgeborene Kind” e.V. on an interdisciplinary level, to contribute their individual expertise for the development of a relevant recommended course of action. The task force PaluTiN (Palliative care and grief counselling in peri- and neonatology) was formed. During the past two years, the task force has developed ten guiding principles that also cover the antenatal period as well as the time after the baby has passed away. These guidelines were presented on this year’s annual meeting of the German neonatal society “Gesellschaft für Neonatologie und pädiatrische Intensivmedizin” (GNPI) in Rostock, Germany.

Cover PaluTiN principles

Brochure “Palliative care and grief counselling in peri- and neonatology”

Sometimes, the suspicion or diagnose of a life-shortening disease is made during pregnancy. Therefore, the principles aim at healthcare professionals and psychologic counsellors to give them practical support in assisting already expecting parents in these challenging situations. Based upon clinical studies as well as scientific literature, they provide valuable guidance taking contemporary and, if possible, all relevant aspects for palliative care and grief counselling into account, regarding the perinatal and neonatal phase.

The recommendations refer to similar situations and cases and deliberately provide options to act individually, because the needs of affected parents can strongly vary in such extraordinary circumstances. It is appropriate to come to know those needs with empathy and applying an appropriate procedure in every individual case.

The principles can play a supporting role in gaining confidence, professionalism, and empathy while interacting with a dying child and its closest relatives, who find themselves in an extremely vulnerable situation. Due to their emotional exceptional situation, affected families require an empathic and competent guidance.

The project was kindly funded within the realm of self-help facilitation by the health insurance company “KKH Kaufmännische Krankenkasse”.

As from August 2018, the printed principles are available for free as a brochure in German through the online shop of the federal association “Das frühgeborene Kind e.V.” at: .  The PDF version of the brochure is available for free download.  An English translation is planned.


Principles for palliative care and grief counselling in the peri- and neonatology

Principle 1: Needs and hopes as main focus

Principle 2: Empowering parenthood

Principle 3: Communication – qualified, honest, careful and transparent

Principle 4:  Weighing up therapy goals and treatment decisions together: step-by-step, sustainable and comprehensive in the long run

Principle 5: Advance care planning: pre-arrange treatment individually

Principle 6: Support during the dying phase

Principle 7: Grief counselling

Principle 8: Spirituality, religiosity, and pastoral care

Principle 9: Support systems: networks and interfaces

Principle 10: The team between care and self-care


Lighthouse Ethical decision making








View more: (in German)


Special thanks to
Katarina Eglin
German Federal association “Das frühgeborene Kind” e.V.


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Lighthouse Project: the neonatal butterfly project – support for grieving parents and guidance for health professionals

The purple butterfly cot card

July is the month where we shed light on the complex and sensitive topic of ethical decision making and palliative care in neonatology and obstetrics. One outstanding project as part of this monthly topic, is the pioneer work of the neonatal butterfly project, a group of nurses, doctors and other academics, working with parents who have experienced the loss of their baby on a neonatal unit. However, the project does not only address health  professionals but also family members and friends with advice and lists support groups and other helpful contacts on their project page. 

The neonatal butterfly project wants to improve care for bereaved parents, by improving staff knowledge, understanding, and practice. Its network can look back on more than 10 years of experience within this subject, offering workshops for parents plus making information accessible to health care professionals concerning the experiences and needs of affected parents. The purple butterfly, the project’s logo, can be put on the cot of the surviving sibling in hospital or in the medical record and resembles the deceased brother or sister. Parents can write the name of their deceased child on the card. This shall raise awareness that the surviving baby had a brother or sister and that parents have not only welcomed a baby but are, at the same time, coping with the loss of another. The cot cards are freely available to hospitals worldwide. In approaching affected parents, asking them to share the experiences they’ve made in hospital after baby loss, the network gained valuable insight into the emotionally complex and challenging situation these parents have to face. Evaluating their feedback, the network conducted guidelines with concrete examples and cases, which serve as   practical guidance for health professionals how to best react when being confronted with bereaved parents. Unwillingly tactless or hurtful behaviour is often the result of insecurity, hence the neonatal butterfly guidelines shall help doctors and nurses to develop a self-confident yet sympathetic way to handle parents in such a difficult situation. Currently the guidelines are available in 5 languages.

Besides the guidelines, the project also offers experience reports from parents, sharing their very personal story. These stories enable the reader to get to know the thoughts and feelings a grieving mother or father has and how they experienced the behaviour of the people around them. Sometimes they met caring people but in other situations they had to deal with a lack of understanding for their needs and were hence put in uncomfortable situations.  Between 2016 and 2017, the network extended its offer and launched a film project with 8 families talking about their specific experience of baby loss.

Losing a baby is painfully tragic and requires self-confidence to share it with strangers. In order to protect the parents, the network introduced some access barriers so certain, sensitive information is only distributed to persons with a genuine interest in the matter. Access to material like films, parent stories or the guidelines requires an online registration. Other information like contacts to support groups or informative websites are offered without any restrictions.

View more: (project website)

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EFCNI roundtable on neonatal parenteral nutrition

On 4 July 2018, experts from various European countries came together in Munich, Germany, for the EFCNI roundtable on neonatal parenteral nutrition. Parenteral nutrition is a feeding therapy that provides nutrition through the veins to preterm or severely ill babies, who cannot (yet) be adequately fed by mouth or through a feeding tube.

Group picture of the EFCNI roundtable on neonatal parenteral nutrition

Participants of the EFCNI roundtable on neonatal parenteral nutrition

Among the 15 experts who attended the roundtable were neonatologists, pharmacists, and parent representatives from the United Kingdom, Sweden, Italy, Spain, France, Hungary, and Germany. The goal of the roundtable was to develop a concept for a position paper, which will highlight the importance of this life-saving treatment for preterm and severely ill babies and present strategies that support the implementation of the ESPGHAN guidelines as well as the development and implementation of national guidelines accordingly. Within the next months, the expert panel will write the position paper. Stay tuned for regular updates.

We would like to thank all participants for the fruitful discussions, their valuable contributions, and ideas. A warm thank you also goes out to Baxter for supporting this project with an unrestricted educational grant.

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There is a great need for urgent pan-European harmonisation

An interview with Professor Charles Christoph Roehr, President of the European Society for Paediatric Research, on the topic Medical care and clinical practice

In terms of medical practice in neonatology – in which fields do you see the most significant disparities between European countries?

Professor Charles C Roehr

Professor Charles C Roehr

This is a very good question. We see significant disparities on many levels, starting from the recognition of Neonatology as an individual Paediatric subspecialty. There are still a number of European countries in which the need for specialists in Neonatology is not formally recognised, with which come significant differences in the training of neonatal doctors and nurses, the acquisition of their skill sets and confidence levels. Dr Morten Breindahl and co-workers, as well as others, have flagged this as an important gap in the provision of medical care to neonatal patients and their families (Breindahl M et. al. Neonatology 2012; 103(1):74-82). This disparity is striking, since the European member states had previously agreed on a common European Neonatal Curriculum, as proposed by the European Society for Neonatology (now renamed into European Board of Neonatology, EBN – the educational arm of the European Society for Paediatric Research, ESPR). Given these structural uncertainties, it is comprehensible how difficult it is to formulate binding educational recommendations on a national and international level. The ESPR, via the EBN through its Chairman, Professor Maximo Vento (Valencia, Esp.), is doing its best by designing a common European Neonatal Curriculum (publication expected in April 2019) and by providing a university accredited online learning platform, NOTE (Neonatal Online Training and Education, University of Southampton) offering an evidence-based, University accredited, European curriculum to its participants.  


In your opinion, is there a need for pan-European harmonisation?
Indeed, I strongly believe there is a great need for urgent pan-European harmonisation: Newborn infants and their families should be able to expect the same level of proficiency and professionalism in care throughout Europe. Likewise, training on neonatal care should be according to a uniformly accepted syllabus, for doctors and nurses, as outlined above. The recognition of Neonatology as a Paediatric subspecialty should ideally be universal throughout Europe to ensure that a common standard is followed. Only in this way can patients receive the same level of care wherever their child is born, be it in Malaga (Spain), Malmö (Sweden), Bari (Italy), Bath (UK), Bucharest (Romania) or Tallinn (Estonia). The need for harmonisation of care within Europe has long been voiced by many eminent proponents within the neonatal community, i.e. from doctors, nurses and parent groups alike. Finally, a joint effort to build up a common syllabus of European Standards of Care for Newborn Health has been initiated. Expertly facilitated and led with great passion by EFCNI, a group of international experts is currently working on such standards, which will eventually ensure similar outcomes for all neonates born in Europe. 

How does the ESPR promote Paediatric research on a European level?
The ESPR is the biggest, most prolific and scientifically vibrant Paediatric research society in Europe. We are extremely proud of our extraordinarily active membership base and a faculty of highly respected international scientists from all over Europe and beyond. We stimulate scientific discourse first and foremost through our renowned annual conferences, the Congress of the European Academy of Paediatric Societies (EAPS) and the Congress of joint European Neonatal Societies (jENS), as well as Spring and Autumn Schools, in our membership discussion forum and though individual discourse. The ESPR is therefore the Paediatric society for active research in Europe. Recognising the strong desire for collaboration and exchange, the ESPR has initiated a generous European Research Grant programme. This programme has successfully funded several large, collaborative research projects with a budget of over 350,000 Euro in 2017 alone. The calls for this year will be published on our website as well as the ESPR social media channels in the coming weeks.

In which fields do you perceive transnational progress and where are backlogs?
The biggest backlog we see in the European landscape of Paediatrics is the disparity of national subspecialty recognition and the lack of an accepted Paediatric syllabus with pan-European endorsement throughout all member states of the European Union. However, progress is on the move with the installation of agreed European Standards of Care for Newborn Health. Now international and national policy-makers can refer to a very strong manuscript, endorsed by over 100 international specialists and organisations, to formulate uniform training guidelines and research conformity guidelines.

What is your wish for the future of neonatology? How would you wish the field to develop?
My vision for the future of Neonatal Medicine is for this great profession to evolve into a healthcare service which encompasses the care for a patient’s disease specific needs at the time of occurrence whilst fully embracing the need of his or her family to be involved in the planning and provision of care as partners. I wish for every newborn to be able to receive a common, high standard of care and thus to be given equal opportunity of positive outcomes, wherever they should be born on Europe, and beyond. Hence, I wish for every neonatal team to have adequate access to information on the care and training of care provision, be it nursing, medical, psychosocial or physical care to reach the one common goal, a healthy newborn in a healthy family and eventually contributing to a thriving human society which respects and cares for the needs of all its members.

Special thanks to
Professor Charles Christoph Roehr
President of the European Society for Paediatric Research (ESPR)


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Surfactant replacement therapy – a milestone in neonatology

The Respiratory Distress Syndrome (RDS) is a lung disorder that is mostly seen in preterm babies, especially those born before week 30. It is caused by a lack of surfactant, which is a substance that coats the inside of the lungs and prevents the small air sacs (alveoli) from collapsing.1

Drawn baby with highlighted lungsIn preparation for breathing air, fetuses begin producing surfactant during the third trimester of pregnancy through labour and delivery. Depending on the level of prematurity, the lungs of a baby born preterm may not be able to make (sufficient) surfactant, causing breathing difficulties within the first hours after birth. The resulting lack of oxygen can damage the baby’s brain or organs and lead to death if not treated properly.1

Nowadays, the surfactant replacement therapy is a crucial part of the management of RDS.2 The development of this therapy based on the discovery of surfactant is one of the biggest milestones in neonatology. Although it is still in the process of being further enhanced, surfactant replacement therapy has substantially reduced neonatal mortality in preterm babies over the last decades.3

The story of surfactant

The story of surfactant goes back to 1929, when the Swiss physiologist Kurt von Neergaard first suggested the presence of pulmonary surfactant based on his experiments with the lung of a pig.4,5 Similar experiments with the lungs of stillborn babies were repeated and further investigated by the pathologist Peter Gruenwald in New York after the second world war.5,6 Important contributions to the understanding of pulmonary surfactant and its importance in lung stability and mechanics of respiration came from Richard Pattle in England, Charles Macklin in Canada, and John Clements in the USA in the 1950s.5,7–9 In 1959, the American researchers Mary Allen Avery and Jere Mead discovered that a lack of surfactant is the cause of RDS.10 Despite the knowledge that RDS was a major problem and the cause of many deaths in preterm babies, their finding wasn’t taken much into account until a tragic event happened four years later.

Tragic death of John F. Kennedy’s son

Jacqueline Bouvier Kennedy, wife of John Fitzgerald Kennedy who was the president of the United States at that time, gave birth to their son Patrick on August 7th, 1963 at 35 weeks. Only two days after birth, Patrick died from RDS, back then known as hyaline membrane disease.5,11 Due to this event, RDS received public attention and became the focus of neonatal research.

The development of a therapy

Clinical trials with synthetic surfactant were started. The first successful observation in lambs was reported by Graham Liggins.12 In 1980, Tetsuro Fujiwara was the first who published results of a successful trial of surfactant treatment for respiratory distress syndrome in babies born preterm.13 This is when natural surfactant was launched as a treatment for RDS. Several surfactants have been developed and tested since then One of the most used surfactants was developed by Tore Curstedt and Bengt Robertson. The market approval for their medication was received in Europe in 1992 and in the USA in 1999.14

In general, natural, animal-derived surfactants containing proteins have turned out to be more effective than protein-free synthetic products.15 However, newer synthetic surfactants with protein analogues are being developed.5,16

Another focus of current research is the method of administration and in particular less invasive approaches. Whereas most preterm babies were intubated and ventilated in the first stages of the surfactant replacement therapy, it is now known that mechanical ventilation should be avoided whenever possible. Methods of maintaining babies on less invasive respiratory support have shown advantages in short and long-term outcomes, e.g. greater comfort and less chronic lung disease such as Bronchopulmonary dysplasia (BPD).2,17–20 The Less Invasive Surfactant Application (LISA) protocol developed by Angela Kribs et al. offers potential for the preservation of spontaneous breathing and the avoidance of mechanical ventilation (as already reported, see interview with A. Kribs ).17,18,20 It combines the administration of surfactant with continuous positive airway pressure (CPAP), which is a noninvasive form of respiratory assistance that supports spontaneous breathing. Surfactant is applicated during CPAP via a thin catheter.

It will be very exciting to see further developments, improvements and future innovations in this area!

A true lighthouse “project”

RDS used to be the leading cause of death in preterm babies.14 Saving hundred thousands of lives, the development of the surfactant replacement therapy for preterm babies suffering from RDS is a true lighthouse project for this month’s topic “Medical care & clinical practice”. Every step from the initial discovery of surfactant to the continuing development of less invasive administration methods has contributed greatly to the life of many children and families.


We’d like to thank Professor Christoph Härtel for his kind support and advice on this article.

Lighthouse Medical care and clinical practise


  1. pmhdev. Respiratory Distress Syndrome. PubMed Health. June 2014. Accessed May 30, 2018.
  2. Sweet DG, Carnielli V, Greisen G, et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome – 2016 Update. Neonatology. 2017;111(2):107-125. doi:10.1159/000448985
  3. Polin RA, Carlo WA, Newborn C on FA. Surfactant Replacement Therapy for Preterm and Term Neonates With Respiratory Distress. Pediatrics. 2014;133(1):156-163. doi:10.1542/peds.2013-3443
  4. Von Neergaard K. Neue Auffassungen über einen Grundbegriff der Atemmechanik. Die Retraktionskraft der Lunge, abhängig von der Oberflächenspannung in der Alveolen. Z Gesamte Exp Med. 1929;66:373-394.
  5. Halliday HL. The fascinating story of surfactant. J Paediatr Child Health. 2017;53(4):327-332. doi:10.1111/jpc.13500
  6. Gruenwald P. Surface tension as a factor in the resistance of neonatal lungs to aeration. Am J Obstet Gynecol. 1947;53(6):996-1007.
  7. Pattle RE. Properties, function and origin of the alveolar lining layer. Nature. 1955;175(4469):1125-1126.
  8. Macklin CC. The pulmonary alveolar mucoid film and the pneumonocytes. Lancet Lond Engl. 1954;266(6822):1099-1104.
  9. Clements J. Dependence of pressure-volume characteristics of lungs on intrinsic surface. Am J Physiol. 1956;187:592.
  10. Avery ME, Mead J. Surface properties in relation to atelectasis and hyaline membrane disease. AMA J Dis Child. 1959;97(5, Part 1):517-523.
  11. Altman LK, M.D. A Kennedy Baby’s Life and Death. The New York Times. Published July 29, 2013. Accessed June 5, 2018.
  12. Liggins GC. Premature delivery of foetal lambs infused with glucocorticoids. J Endocrinol. 1969;45(4):515-523.
  13. Fujiwara T, Maeta H, Chida S, Morita T, Watabe Y, Abe T. Artificial surfactant therapy in hyaline-membrane disease. Lancet Lond Engl. 1980;1(8159):55-59.
  14. Europäisches Patentamt/European Patent Office. Atemhilfe für Neugeborene: Tore Curstedt als Finalist für den Europäischen Erfinderpreis 2016 nominiert. Accessed June 12, 2018.
  15. Halliday HL. History of surfactant from 1980. Biol Neonate. 2005;87(4):317-322. doi:10.1159/000084879
  16. Curstedt T, Halliday HL, Speer CP. A unique story in neonatal research: the development of a porcine surfactant. Neonatology. 2015;107(4):321-329. doi:10.1159/000381117
  17. Kribs A, Roll C, Göpel W, et al. Nonintubated Surfactant Application vs Conventional Therapy in Extremely Preterm Infants: A Randomized Clinical Trial. JAMA Pediatr. 2015;169(8):723-730. doi:10.1001/jamapediatrics.2015.0504
  18. Göpel W, Kribs A, Härtel C, et al. Less invasive surfactant administration is associated with improved pulmonary outcomes in spontaneously breathing preterm infants. Acta Paediatr. 2015;104(3):241-246. doi:10.1111/apa.12883
  19. Dargaville PA, Aiyappan A, De Paoli AG, et al. Minimally-invasive surfactant therapy in preterm infants on continuous positive airway pressure. Arch Dis Child Fetal Neonatal Ed. 2013;98(2):F122-126. doi:10.1136/archdischild-2011-301314
  20. Härtel C, Paul P, Hanke K, et al. Less invasive surfactant administration and complications of preterm birth. Sci Rep. 2018;8(1):8333. doi:10.1038/s41598-018-26437-x
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Lighthouse project: a baby saving innovation – the Embrace infant warmer

One of our lighthouse projects in the field of Medical care is the Embrace warmer. It was designed to improve healthcare in low-resource settings to help vulnerable newborns survive and thrive.

Image: Embrace co-founder and Chief Business Officer Jane Chen with a baby kept in an Embrace warmer. © Embrace Innovations

When infants are born preterm, they lack the body fat that is necessary to regulate their own temperature. As a consequence, room temperature can feel freezing cold. Many hospitals in developing countries do not have consistent electricity and are unable to transport hypothermic newborns to get the care they need. A team around Jane Chen, co-founder of Embrace, a non-profit organisation with the mission of advancing maternal and child health by delivering innovative solutions to the world’s most vulnerable populations, has worked on a solution for this challenge. Their aim is to reduce the number of deaths each year among the 1 million preterm newborns in developing countries who don’t have access to lifesaving medical technology.

The Embrace warmer is an easy-to-use, portable, sleeping-bag-like transport incubator (humidicrib) and infant warmer that does not need continuous power supply. As a medical device designed for hospitals and ambulances, it is used in neonatal intensive care units and wards, as well as for transport, when skin-to-skin care (a part of Kangaroo Mother Care / KMC) is not possible. The Embrace warmer thus helps combat preventable and treatable complications related to prematurity and low birth weight, including neonatal hypothermia, a medical emergency that occurs when the body temperature drops too low, of less than about 95 F (35 C).

In an interview, co-founder Jane Chen talked about her vision: “One piece of my legacy will be making the Embrace warmer a standard of care, one that complements existing natural practices like skin-to-skin care. I want to ensure that every baby in need of temperature regulation can get it and that no baby dies from being cold. Beyond that, my legacy is about building a platform by which we, as an organisation, innovate really disruptive technology that can save babies and mothers around the world.”

The Embrace warmer was developed within a design class at Stanford University called Design for Extreme Affordability. The challenge was to build a baby incubator that costs less than 1 % of the cost of a traditional incubator, which is $20,000. This technology by Chen and her team has gained international recognition. Chen has even been honoured by former US President Obama at the White House, and her project is supported by numerous organisations, like the Clinton Global Initiative, and celebrities, like the singer Beyoncé. It has also been featured in various media around the globe.

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