The use of echocardiography for the evaluation of the cardiovascular well-being of term and preterm infants is gaining significant interest. The aim of echocardiography in this setting is to provide hemodynamic information in real time in order to support bedside clinical decision making (1,2,3). This approach is perceived to enhance clinical judgment, provide a better understanding of active physiological processes, and monitor the response to treatment. Combination of clinical examination and bedside echocardiography has been shown to facilitate clinical decision making (4). There is some evidence that routine use of echocardiography on the neonatal unit might lead to early identification of cardiovascular compromise that could facilitate clinical management (5), potentially improving short-term outcomes (6,7). There is growing literature highlighting the potential merits of echocardiography in the identification of cardiovascular compromise and guiding neonatal cardiovascular care (4,6,8,9). There is a need to ensure standardization of training and clinical practice guidelines, with quality assurance systems in place to maintain safe dissemination of this practice. There are currently two published guidelines in neonatal echocardiography with recommendations for training and an accredited structured training program with accreditation in neonatal cardiac ultrasound. The practice guidelines and recommendations for the use of echocardiography (Targeted Neonatal Echocardiography (TNE)) and Expert consensus statement on Neonatologist performed echocardiography (NoPE) in the United Kingdom were published in the last 5 y (10,11). However, some aspects of these two guidelines are difficult to implement in a pan European setting. The Australian Society of Ultrasound in Medicine has developed and implemented a basic training and accreditation process in Australia encompassing cardiac, brain, and abdominal ultrasound that is difficult to adopt in Europe (http://www.asum.com.au). As a result, a working group under the auspices of the European Society for Paediatric Research and the European Society for Neonatology was convened to devise a consensus statement for neonatologist performed echocardiography training taking into account the heterogeneous nature of training facilities, personnel, and infrastructure across Europe. In this statement, we aim to (i) highlight the difficulties in implementing the current TNE and UK guidelines in a European setting; (ii) define the training facilities and infrastructure necessary for optimal training conditions; (iii) identify training standards applicable across Europe; and (iv) discuss some practical aspects including a suggested governance structure for oversight of training and continued quality assurance. We have elected to use the term neonatologist performed echocardiography (NPE) as used in the UK guideline because it identifies the person performing the assessment and the target organ assessed. This consensus statement deals with NPE for assessment of hemodynamic function in infants with a structurally normal heart (patent ductus arteriosus (PDA) and patent foramen ovale included). Although confirmation of normal structural anatomy is within the remit of this practice, diagnosis and management of congenital heart disease (CHD) is beyond the scope of this guideline. This practice should always remain under the remit of pediatric cardiology services. Preterm and term infants with clinical or echocardiographic suspicion of CHD should be immediately referred to a pediatric cardiologist. Neonatology services in Europe are very heterogeneous in nature and include Level 1 and 2 units, stand-alone Level 3 maternity units, those colocated with adult services, and quaternary maternity units located either physically with, or in the vicinity of, a children’s hospital. More importantly, the proximity between pediatric cardiology services and neonatal intensive care units (NICUs) are very variable across Europe. In general, pediatric cardiology services in Europe are under pressure and might not be adequately resourced to take in an additional influx of echocardiography trainees outside a dedicated cardiology fellowship program. As a result, a “one size fits all” approach for NPE training and accreditation in Europe may not be feasible. The American Society of Echocardiography/European Association of Echocardiography/Association for European Paediatric Cardiology guideline for TNE training is an ideal example of a structured approach to standardize training and maintenance of competence (11,12). Our consensus group fully endorses large sections of those guidelines including the background and indications, practical aspects, the suggested approach to the various clinical indications (Sections 1 and 2), and we suggest the reader to refer to the sections for a comprehensive overview of those topics. However, certain aspects of the proposals for training are currently not achievable in a European context. The guideline proposes a two-phase process of a core training period followed by an advanced period of training, both lasting 4–6 mo. During the core period, the candidates should carry out >150 scans and review a further 150 scans, 80% of which should be structurally abnormal. This training is mandated to be carried out in an echocardiography laboratory under the direction of the pediatric cardiology service. Following an unspecified assessment process, the candidate moves on to the advanced stage for another period of 4–6 mo and an additional 150 scans and 150 study reviews. The suggested place of training is the NICU for the advanced phase. However, direct or indirect supervision and coordination by the pediatric cardiology service are mandated during this phase of training as well. This approach to training has faced difficulties in lead North American centers and is not feasible in Europe where pediatric cardiology services...

One of the major challenges of neonatal intensive care is the early detection and management of circulatory failure. Routine clinical assessment of the hemodynamic status of newborn infants is subjective and inaccurate, emphasizing the need for objective monitoring tools. An overview will be provided about the use of neonatologist-performed echocardiography (NPE) to assess cardiovascular compromise and guide hemodynamic management. Different techniques of central blood flow measurement, such as left and right ventricular output, superior vena cava flow, and descending aortic flow are reviewed focusing on methodology, validation, and available reference values. Recommendations are provided for individualized hemodynamic management guided by NPE.

Advances in neonatal cardiac imaging permit a more comprehensive assessment of myocardial performance in neonates that could not be previously obtained with conventional imaging. Myocardial deformation analysis is an emerging quantitative echocardiographic technique to characterize global and regional ventricular function in neonates. Cardiac strain is a measure of tissue deformation and strain rate is the rate at which deformation occurs. These measurements are obtained in neonates using tissue Doppler imaging (TDI) or two-dimensional speckle tracking echocardiography (STE). There is an expanding body of literature describing longitudinal reference ranges and maturational patterns of strain values in term and preterm infants. A thorough understanding of deformation principles, the technical aspects, and clinical applicability is a prerequisite for its routine clinical use in neonates. This review explains the fundamental concepts of deformation imaging in the term and preterm population, describes in a comparative manner the two major deformation imaging methods, provides a practical guide to the acquisition and interpretation of data, and discusses their recognized and developing clinical applications in neonates.

Objectives: To review the evidence from controlled clinical trials of neonates given equal daily aminoglycoside doses as extended interval dosing (dosage interval typically 24 hours in term and 36–48 hours in immature neonates) compared with traditional dosing (dosage interval typically 8–12 hours in term and 12–24 hours in immature neonates). Design: Systematic review and meta-analysis of controlled trials found in electronic databases, trial registers, and references in reviews and selected trials. Settings: The selected trials were blinded and assessed for methodological quality. Each trial’s own predefined criteria for treatment failure, nephrotoxicity, ototoxicity, and therapeutic serum drug concentrations were used. Subjects: Controlled trials of neonatal aminoglycoside treatment in which equal aminoglycoside daily doses were given at traditional and extended dosage intervals. Main outcome measures: Serum drug concentrations outside the therapeutic range. Treatment failure and toxicity. Results: Sixteen trials involving 823 neonates met the inclusion criteria for the systematic review. Twelve trials involving 698 neonates were included in the meta-analysis of the pharmacokinetics. Compared with traditional dosing, extended interval dosing was associated with a significantly lower risk of both peak (summary risk ratio 0.50, 95% confidence interval 0.26 to 0.94) and trough (0.36, 0.25 to 0.56) serum drug concentrations outside the therapeutic range. Accurate information on treatment failure was obtained in nine trials involving 555 neonates. One trial reported treatment failure. In this trial two neonates in the traditional dosing group did not respond to treatment within 72 hours. Nephrotoxicity was investigated in 589 neonates in 12 trials and ototoxicity in 210 neonates in four trials, with no significant differences between the two dosing regimens. Conclusions: Extended interval dosing of aminoglycosides in neonates is safe and effective, with a reduced risk of serum drug concentrations outside the therapeutic range.

Transthoracic echocardiography (TTE) is the most accessible noninvasive diagnostic procedure for the initial assessment of pediatric pulmonary hypertension (PH). This review focuses on principles and use of TTE to determine morphologic and functional parameters that are also useful for follow‐up investigations in pediatric PH patients. A basic echocardiographic study of a patient with PH commonly includes the hemodynamic calculation of the systolic pulmonary artery pressure (PAP), the mean and diastolic PAP, the pulmonary artery acceleration time, and the presence of a pericardial effusion. A more detailed TTE investigation of the right ventricle (RV) includes assessment of its size and function. RV function can be evaluated by RV longitudinal systolic performance (e.g., tricuspid annular plane systolic excursion), the tricuspid regurgitation velocity/right ventricular outflow tract velocity time integral ratio, the fractional area change, tissue Doppler imaging–derived parameters, strain measurements, the systolic‐to‐diastolic duration ratio, the myocardial performance (Tei) index, the RV/left ventricle (LV) diameter ratio, the LV eccentricity index, determination of an enlarged right atrium and RV size, and RV volume determination by 3‐dimensional echocardiography. Here, we discuss the potential use and limitations of TTE techniques in children with PH and/or ventricular dysfunction. We suggest a protocol for TTE assessment of PH and myocardial function that helps to identify PH patients and their response to pharmacotherapy. The outlined protocol focuses on the detailed assessment of the hypertensive RV; RV‐LV crosstalk must be analyzed separately in the evaluation of different pathologies that account for pediatric PH.

Neonatologists can use echocardiography for real-time assessment of the hemodynamic state of neonates to support clinical decision-making. There is a large body of evidence showing the shortcomings of conventional echocardiographic indices in neonates. Newer imaging modalities have evolved. Tissue Doppler imaging is a new technique that can provide measurements of myocardial movement and timing of myocardial events and may overcome some of the shortcomings of conventional techniques. The high time resolution and its ability to assess left and right cardiac function make tissue Doppler a favorable technique for assessing heart function in neonates. The aim of this review is to provide an up-to-date overview of tissue Doppler techniques for the assessment of cardiac function in the neonatal context, with focus on measurements from the atrioventricular (AV) plane. We discuss basic concepts, protocol for assessment, feasibility, and limitations, and we report reference values and give examples of its use in neonates.