Ventilator-associated pneumonia (VAP) is one of the commonest nosocomial infection occurring in mechanically ventilated patients in the intensive care unit (ICU). We aimed to determine the incidence of occurrence of VAP in Neonatal ICU (NICU) in Abu El-Reish children's hospital, Cairo University, and to detect the most common etiological pathogens. 32 neonates on mechanical ventilation were subjected to careful history taking, clinical examination, routine investigations (complete blood picture, arterial blood gases, C- reactive protein, serum electrolytes, liver and kidney function tests), chest x-ray at least twice, blood culture and non bronchoscopic endotracheal culture. The commonest admission diagnosis was respiratory distress syndrome (50%), Complications were observed in 59.4% of cases. The incidence of VAP was 46.9% of the studied patients and the diagnosis depends on the endotracheal aspirate culture result, radiological and clinical findings. Endotracheal culture was positive in 14 cases (43.7%), while blood culture was positive in 5 cases (15.6%) with no significant similarity between the causative organism in the blood and endotracheal culture. Endotracheal culture was more sensitive and specific in VAP diagnosis than blood culture (sensitivity 93.3%, specificity 100%). Neonates with VAP had longer duration of mechanical ventilation (p=0.004). Gram-negative organisms were the major cause of VAP in the study (86.7%) and Klebsiella pneumoniae was the predominant isolate (80%) Outcome of neonates was 40.6% died and 59.4%discharged. VAP was significantly associated with almost 3-fold higher risk of neonatal mortality.