When our patient relapsed, an alternative treatment was required, since therapies with steroids, rituximab and intravenous immunoglobulins proved to be ineffective. The role of splenectomy in refractory AIHA is still controversial [1] [2] [3] [4] . Although effective vaccinations are available, this surgical treatment should be avoided in children younger than 6 years of age, due to the risk of developing severe bacterial infections. According to local policy, drug-based immunosuppressive therapy is to be preferred. We therefore decided to adopt a combined therapy approach, with high doses of methylprednisolone (40mg/kg/day for 5 consecutive days), which was then tapered down over 20 days, and cyclophosphamide (10mg/kg/day for 10 consecutive days). This approach appeared to be feasible and encouraging, since we had previously successfully treated two pediatric cases of refractory AIHA with an identical approach [8, 9] . The administration of methylprednisolone and cyclophosphamide increased the already significant immunodepression which had resulted from prior therapies and further contributed to the severity of the infectious complication presented by our patient that required ECMO therapy. While in the ICU, the patient underwent various ventilatory treatments, some of which are not considered conventional. Modern ventilatory strategy in ARDS aims to provide viable gas exchange with high oxygen concentration and PEEP, while minimizing the injurious effects of mechanical ventilation by using low tidal volume ventilation (6mL/kg) [10] . Although other techniques such as the prone position, NOi and recruitment manoeuvres are effective in improving gas exchange, they did not prove effective in terms of survival [10] . Nevertheless, before ECMO, the only means of providing minimal acceptable oxygenation was to use both NOi and the prone position. Despite using low tidal volumes, a respiratory rate of up to 45 breaths/minute was necessary to obtain acceptable CO 2 levels, and the occurrence of pneumomediastinum demonstrated that we were unable to provide an effective protective ventilatory strategy. Thus, ECMO was the only real means of providing such a strategy, while allowing adequate gas exchange.