Objective The objective of this study was to test the hypothesis that simulation training improves echocardiography skills. Study Design In this prospective study, 43 participants (16 neonatologists, 26 neonatology fellows, and 1 nurse practitioner) were tested on the simulator after 4 hours of didactic sessions on topographical cardiac anatomy and standard echocardiographic views. Participants were given 20 minutes to obtain and save the standard views. After the simulation hands-on training for 8 hours over 3 days, they were tested again. Each image was scored from 0 to 3 based on the image quality. Pre- and postsimulator training data were compared using both automated and visual scoring methods. Results After the hands-on simulator training, the automated median (interquartile) score for the quality of acquired images increased from 36 (22, 43) to 55 (48, 58), p < 0.0001. The increase was similar using visual scoring. The number of views with acceptable or good image quality (scores of 2 or 3) increased from 11 (6, 16) to 20 (17, 21), p < 0.0001. The neonatology fellows and faculty, as well as those with or without prior echocardiography experience, demonstrated significant improvement. Conclusions Echocardiography simulation is an effective tool in improving echocardiography skills among neonatology care providers.

Abstract Background Foramen ovale (FO) is an obligate fetal shunt that typically resolves after birth, although patency throughout life is not uncommon. The natural history of patent FO (PFO) is known in term infants, but less is known about its course in extremely preterm infants. We describe the echocardiographic changes in FO size from birth to discharge in extremely low birth weight (ELBW) infants in this retrospective study. Methods Cohort was divided based on size of FO at birth. Size of FO at discharge was measured and evaluated relative to postnatal weight gain. Demographics and clinical outcomes were compared between the two groups. Results Of the 54 ELBW infants, 50 were born with FO less than 3 mm in diameter (small), and 4 were born with FO greater than 3 mm (large). Of small defects, the majority (44/50, 88%) did not increase in size with weight gain, and minority (6/50, 12%) increased in size, and three of these 6 patients, FO grew to be slightly larger than 3 mm. In contrast, all large defects (4 of 4, 100%) nearly doubled in size with postnatal growth. These 4 ELBW infants with enlargement of FO had a flap valve evident on echocardiogram obtained prior to discharge, and subsequently closed on outpatient follow-up echocardiograms, although time to resolution was variable (6 months – 3 years). One infant had presumptive resolution because of the presence of flap valve. Conclusion No maternal or neonatal demographic characteristics were predictive of FO enlargement, although, demonstrable flap valve on discharge echocardiogram correlated with resolution of FO on outpatient follow-up echocardiogram. Therefore, based on our data, we recommend that ELBW infants born with large FO should have echocardiographic re-evaluation of the atrial septal opening prior to discharge, to specify the presence of a flap valve or lack thereof, which is an important detail that can help a neonatologist determine the need for outpatient cardiac follow-up.

Objective Pulmonary hemorrhage is a rare but severe complication of extremely low birth weight (ELBW) infants. The association of hemodynamically significant patent ductus arteriosus (hsPDA) and the diameter of the foramen ovale (FO) with pulmonary hemorrhage has not been reported. Study Design Case control study of ELBW infants with and without pulmonary hemorrhage. Each ELBW infant with an echocardiogram within 48 h of pulmonary hemorrhage was analyzed. Result 16 infants with pulmonary hemorrhage were matched with 32 controls by birth weight and gestational age. Echocardiogram showed hsPDA in all infants and those with pulmonary hemorrhage had significantly smaller patent FO [PFO] (1 vs 2.4 mm, p < 0.01) (OR 0.007; 95% CI 0.00007, 0.67 p = 0.03). Incidence of pulmonary hemorrhage was 8.9%. Conclusion ELBW infants with hsPDA who experienced pulmonary hemorrhage had a significantly restricted or closed FO. Evaluation of FO should be considered with serial echocardiograms when evaluating for hsPDA.

Pulse oximetry screening (POS) has been shown to be an effective and non-invasive investigation that can detect up to 50-70% of previously undiagnosed congenital heart defects (CHDs). The aims of this study were to assess the accuracy of POS in detection of CHDs and its impact on the clinical practice. All the eligible newborn infants born between Jan 2015 and Dec 2019 in busy regional neonatal unit were included in the prospective observational study. Of the 25185 eligible infants, 189 (0.8%) infants had a true positive results: 6 had critical CHDs, 9 serious or significant CHDs, and a further 156/189 infants had significant non-cardiac conditions. 43 infants who had a normal POS were later (post-hospital discharge) diagnosed with following category of CHDs: 1 critical, 15 serious, 20 significant and 7 non-significant CHDs. POS sensitivity for detection of critical CHD was 85.7% and its specificity was 99.3%. However, its sensitivity for detection of all the major CHDs needing surgery during infancy was 33%.ConclusionPulse oximetry screening showed moderate and high sensitivity in detection of undiagnosed critical CHDs, however it failed to detect two-third of the major CHDs. Our study further emphasises the significance of adopting routine POS to detect critical CHDs in the clinical practice. However, it also highlights the need to develop new, innovative methods to detect other major CHDs missed by pulse oximetry screening and other current screening tools.

Point of Care Ultrasound (POCUS) refers to the use of portable ultrasound (US) applications at the bedside, performed directly by the treating physician, for either diagnostic or procedure guidance purposes. It is being rapidly adopted by traditionally non-imaging medical specialties across the globe. Recent international evidence-based guidelines on POCUS for critically ill neonates and children were issued by the POCUS Working Group of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC). Currently there are no standardized national or international guidelines for its implementation into clinical practice or even the training curriculum to monitor quality assurance. Further, there are no definitions or methods of POCUS competency measurement across its varied clinical applications.The Hippocratic Oath suggests medical providers do no harm to their patients. In our continued quest to uphold this value, providers seeking solutions to clinical problems must often weigh the benefit of an intervention with the risk of harm to the patient. Technologies to guide diagnosis and medical management present unique considerations when assessing possible risk to the patient. Frequently risk extends beyond the patient and impacts providers and the institutions in which they practice. Point-of-care ultrasound (POCUS) is an emerging technology increasingly incorporated in the care of children across varied clinical specialties. Concerns have been raised by clinical colleagues and regulatory agencies regarding appropriate POCUS use and oversight. We present a framework for assessing the risk of POCUS use in pediatrics and suggest methods of mitigating risk to optimize safety and outcomes for patients, providers and institutions.

INTRODUCTION:Simulators are increasingly used for training in echocardiography. However, there is no objective method to assess the skills acquired. Our objective was to develop and test an automated method to assess echocardiography skills.METHODS:To automate the image quality evaluation, we expanded our previously developed neonatal echocardiography simulator to enable recording of images of the 26 standard cuts and process the image quality. We then compared the automated and visual methods in scoring image quality of the echocardiograms obtained by 22 trainees.RESULTS:Each echocardiographic image representing a slice of a three-dimensional volume possesses 3 axes (X, Y, and Z) that correspond to the roll, pitch, and yaw angles of the transducer, respectively. Therefore, if the placement and orientation of the transducer are correct, the acquired image represents the appropriate cardiac window with the desired orientation in all 3 axes. The automated system gives a score of 0 if the transducer is not in the appropriate cardiac window. A score of 1, 2, or 3 is given if the image falls within the range of one, two, or three angles, respectively. There was no difference in the image quality score between automated and visual assessment methods (46.0 ± 13.0 vs 45.1 ± 14.4, P = .19). The two methods had excellent correlation (r = .95). The bias and precision were 0.9 and 8.8, respectively.CONCLUSIONS:The automated method is comparable to visual method for assessment of image quality. The automated process allows for instantaneous feedback and has the potential to standardize assessment of echocardiography skills of trainees.

We describe a case of an extremely low birthweight infant with a large patent ductus arteriosus and closed foramen ovale resulting in markedly increased pulmonary blood flow, pulmonary venous congestion, and pulmonary hemorrhage.

OBJECTIVE:This study aimed to determine the incidence of systemic to pulmonary collaterals (SPCs) in extremely low birth weight infants and to assess its clinical and hemodynamic significance beyond the neonatal period.STUDY DESIGN:Retrospective cohort study was conducted on 61 infants with echocardiogram performed at the time of discharge to determine the presence of SPC and to measure the right and left ventricular outputs and left atrium to aortic ratio. We compared two groups: small or no SPC (Group 1) to moderate or large SPC (Group 2) on demographics, clinical outcomes, and echocardiographic parameters.RESULTS:Sixty-one infants were included. The incidence of SPC was 57%; 21% of infants had moderate or large shunts and 31% had small SPC. Demographics, clinical outcomes, and echocardiographic parameters were not significantly different between small or no SPC and moderate to large SPC.CONCLUSION:More than half of the infants had SPC. The size of the shunt did not affect the clinical outcomes nor the echocardiographic parameters measured. All infants had cardiac output above the normative mean.

There is a great need for training in pediatric echocardiography. In addition to physicians being trained in pediatric cardiology and echocardiography technologists, neonatologist, pediatric intensivists, and other health care professionals may be interested in such training. Since, there is limited opportunity of training on live patients, echocardiographic simulators may be of help. No simulator with complete range of echocardiographic modalities is available for neonates and infants. The aim of this project was to develop a mannequin-based echocardiographic simulator capable of simulating full range of pediatric 2D, color flow Doppler, spectral Doppler, and M-mode echocardiograms. A mannequin, a laptop computer, a magnetic tracking device, and a six-degree freedom (6DOF) sensor incorporated in a dummy transducer serve as the hardware platform of the simulator. We obtained six to seven 4D echocardiographic datasets in DICOM format through five acoustic windows from each infant along with a complete set of 2D video clips of color flow, Doppler, and M-mode. The 4D datasets are sliced into 3D slices using the visualization toolkit and are displayed as 2D echocardiograms through the information obtained by the 6DOF sensor. The coordinates from specific 3D slices triggers display of video clips of color flow, M-mode, and Doppler echocardiogram. Software written in C++ programming language controls the basic function of the program. The main simulator screen displays the full range of 2D echocardiograms including color flow Doppler, spectral Doppler, and M-mode from each acoustic window, whereas the side screen display the position and motion of the cutting planes through a 3D heart model. The system includes a software module to perform hemodynamic measurements from specific video clips images. Our hybrid, mannequin-based pediatric echocardiography simulator provides full range of pediatric echocardiography training experience. This simulator may help training in pediatric echocardiography for which there is a growing demand in clinical medicine.

65 Table 1 Group 1: spontaneous closure (n=221) Group 2: treated (n=181) p value Birth Weight (grams)* 750 (640–869) 775 (645–870) NS Gestational Age (weeks)* 26 (25–27) 25 (24–27) NS Maternal Chorioamnionitis, n (%) 19 (8.6%) 24 (13%) NS Maternal Preeclampsia, n (%) 58 (26.2%) 52 (28.7%) NS Antenatal Steroids, n (%) 134 (60.6%) 111 (61.3%) NS Maternal Antibiotic use, n (%) 88 (40%) 76 (42%) NS Neonatal Gentamicin use, (days)* 6 (4–8) 7 (5–9) 0.0145 Neonatal Gentamicin use>7 days 28% 41% 0.004 *median (25th–75th%) n = number of patients, NS = non-significant 66 ASSOCIATION BETWEEN WEEKEND BIRTH AND NEONATAL OUTCOMES OF GOLDEN HOUR RESUSCITATION OF VERY LOW BIRTH WEIGHT INFANTS EH Carter*, H Lee, W Lapcharoensap, J Snowden. Oregon Health and Science University, Portland, OR; Stanford University, Palo Alto, CA 10.1136/jim-2017-000663.66 Purpose of study To characterise association between weekend deliveries and neonatal outcomes in the ‘golden hour’ after birth of very low birth weight (VLBW; <1500 g) infants. Methods used This was a population-based cohort study using the California Perinatal Quality Care Collaborative data for all VLBW births from 2010–2016. Outcomes assessed as proxies for quality of golden hour resuscitation included: death within 12 hours, chest compressions, epinephrine, intubation prior to continuous positive airway pressure (CPAP), 5 min APGAR <4, and admission hypothermia. Cross-tabulation was used to assess unadjusted associations. Summary of results Infants delivered on weekends were less likely to be prenatally diagnosed with intrauterine growth restriction, but were otherwise not significantly different in gestational age, ethnicity, sex, or maternal risk factors than those born during weekdays. Caesarean deliveries were less common on weekends (average 2862 weekday vs 2536 weekend) while vaginal deliveries were stable (average 1000) across all days. There was an association between weekend delivery and higher likelihood of chest compressions and lower 5 min APGAR, and a trend toward more epinephrine use (table 1). Conclusions In the resuscitation of VLBW infants, there is an association between weekend delivery and increased rate of chest compressions and lower 5 min APGAR. This could suggest a likelihood of more frequent deviation from optimal golden hour resuscitations on the weekend as compared to resuscitations on weekdays, although future research should assess robustness of findings to cofounder control. Abstract 66 Table 1 Unadjusted rates (%) of golden hour outcomes on weekends versus weekdays66 Table 1 Unadjusted rates (%) of golden hour outcomes on weekends versus weekdays Overall Weekday birth Weekend birth P Death within 12 hours* 123 (0.6%) 87 (0.5%) 36 (0.6%) 0.482 Resuscitation Chest compressions Epinephrine CPAP prior to intubation _ 1673 (6.3%) 907 (3.4%) 12 951 (63.4%) _ 1188 (6.1%) 642 (3.3%) 9452 (63.1%) _ 485 (6.9%) 265 (3.8%) 3499 (64.1%) _ 0.027 0.078

Postnatal increase in oxygen promotes constriction of the patent ductus arteriosus (PDA). According to the findings of prospective observational studies, the clinical practice of targeting lower fractional oxygen saturation between 70 and 90% has been associated with a reduced incidence of severe retinopathy of prematurity (ROP) without affecting survival or neurodevelopmental disability at 1 year of age. Our objective was to investigate the impact of the use of a lower oxygen saturation target range on the incidence of early hemodynamically significant PDA (hsPDA) and the need for ductal ligation in extremely low birth weight (ELBW, <1000 g) infants. In this retrospective study, we analyzed data from 263 ELBW infants managed 4 years before (episode I: target oxygen saturation 89 to 94%) and after (episode II: target oxygen saturation 83 to 89%) implementation of the use of lower oxygen saturation limits in two neonatal intensive care units. Infants with a birth weight of 1000 to 1500 g were managed with the same oxygen saturation target range (89 to 94%) during both episodes, and they served as controls. Parametric and nonparametric tests were used as appropriate and multivariate logistic regression models were used to correct for confounders. There was an increase in the incidence of hsPDA (63.2 vs 74.8%, P=0.043), without an increase in the need for surgical ligation (24.2 vs 29.9%, P=0.3) after implementation of the lower oxygen saturation target range policy. After adjusting for confounders, there was an increase in the odds of having an hsPDA (odds ratio (OR) 1.77, 95% confidence interval (CI) (1.03 to 3.06), P=0.04) but the odds for ductal ligation did not change in episode II (OR 1.25, 95% CI (0.70 to 2.25), P=0.4). The incidence of ROP⩾stage III (50.7 vs 15.7%; P<0.0001) and the need for laser ablation (33.8% vs 8.7%; P<0.0001) were significantly reduced. There was no change in the incidence of hsPDA or ductal ligation in the control group. Targeting lower oxygen saturation limits to minimize periods of hyperoxemia in ELBW infants reduced the incidence of severe ROP and the need for laser ablation. The incidence of early hsPDA was increased; however, final closure rate and the incidence of surgical ligation of the ductus arteriosus were not affected.

Background Normal values of blood pressure are well established for healthy term newborn infants. In these infants, blood pressure increases rapidly during the first week and then gradually until 6 weeks of life. In contrast, most very low birth weight infants are not “healthy” and the normative value of blood pressure in these infants remains controversial. Methods Four hundred fifteen preterm infants with birth weights of 500 to 1,250 g were born at LAC+USC Medical Center between 1995 and 2005. Of these, 36 infants were excluded due to severe malformation or death during first week and the remaining 379 infants were entered in the study. Mean arterial pressure (MAP) was measured through an indwelling umbilical arterial catheter or peripheral arterial line. MAP values from each day were entered prospectively into the database. Lower limit of acceptable MAP was arbitrarily set at a value of gestational age (GA) plus 3 mm Hg at birth and appropriately adjusted for postnatal age. MAP lower than this limit triggered use of pressors and, if nonresponsive, addition of steroids. Results Conclusions Initial MAP among the extremely low birth weights is similar to those observed in infants > 1,000 g. MAP increased with increasing birth weight and advancing postnatal age in all weight groups. MAP observed in infants receiving pressors was similar to that seen in stable infants, who did not receive pressors. Our goal of maintaining MAP equal to GA +3 appears to be a reasonable target. Short- and long-term outcomes of these infants are in progress. Our data from a large number of preterm infants provide a basis for acceptable MAP values during the first week of life.

Introduction Transient hyperglycemia (TH) develops in preterm infants on continuous glucose infusion despite receiving glucose infusion rates that matches their basal requirements. This has been attributed to a partially defective processing of proinsulin to insulin and relative insulin resistance requiring higher levels of insulin to achieve euglycemia. Treatment with insulin under euglycemic hyperinsulinemic clamp conditions in 4 clinically stable preterm infants has been shown to result in lactic acidosis. Objective To evaluate the effect of continuous insulin infusion during TH in sick, very low birth weight (VLBW) infants receiving total parenteral nutrition on lactic acidosis. Study Design Prospective, observational study of VLBW infants on continuous insulin infusion for TH with measurement of lactate levels. Results Values are expressed as mean and range. Seven VLBW infants with mean birth weight 738 g (538-1,263) and mean gestational age 26 wks (range 24-30) were on continuous insulin infusion for TH. All infants were on parenteral nutrition receiving protein and intralipids in addition to glucose initiated within 12 to 24 hours of life. Mean blood sugar level was 235 mg/dL (180-334) prior to start of insulin infusion at a mean dose of 0.04 U/kg/hr (0.01-0.05). Mean glucose infusion rate was 6.9 mg/kg/min (4.7-10.5). Mean lactate level prior to start of insulin infusion was 3.2 (0.7-8.1mmol/L) and mean lactate levels post insulin was 1.5 (0.5-3.8 mmol/L). Four of the 7 infants required 2 to 4 courses of insulin infusions for TH. One of the 4 neonates was septic with a congenital E. coli infection, and 3 were severely compromised at birth, requiring the use of pressors to stabilize their blood pressure. All infants received 1-3 insulin boluses of 0.1 unit/kg/dose prior to starting the insulin infusion. In all instances, the post-insulin infusion lactic acid levels were lower. None of the infants developed hypoglycemia during insulin infusion. Conclusions The use of continuous insulin infusion with or without an initial bolus dose for transient hyperglycemia in sick, VLBW infants is not associated with the development of lactic acidosis but may actually improve the preexisting acidosis. Our results are in favor of insulin infusion to correct the transient metabolic abnormalities and to maintain biological levels of insulin to achieve euglycemia during TH.

OBJECTIVE. We sought to investigate whether the increase in blood pressure and decrease in vasopressor support after hydrocortisone administration are associated with changes in systemic hemodynamics in neonates who receive high-dosage dopamine to maintain blood pressure at the lowest acceptable levels.METHODS. In this prospective, observational study, preterm and term neonates who required dopamine ≥15 μg/kg per minute to maintain minimum acceptable blood pressure received intravenous hydrocortisone 2 mg/kg followed by up to 4 doses of 1 mg/kg every 12 hours. Fifteen preterm and 5 term neonates without a patent ductus arteriosus composed the study population. Echocardiograms and vascular Doppler studies were performed immediately before the first dose of hydrocortisone and at 1, 2, 6 to 12, 24, and 48 hours thereafter.RESULTS. In the 15 preterm infants, during the first 12 hours of hydrocortisone treatment, the 28% increase in blood pressure paralleled that in the systemic vascular resistance without changes in stroke volume or cardiac output, whereas dopamine dosage decreased. By 24 hours, the dosage of dopamine continued to decrease, whereas stroke volume increased without additional changes in systemic vascular resistance. By 48 hours, dopamine dosage decreased by 72%; blood pressure and stroke volume increased by 31% and 33%, respectively; and systemic vascular resistance and cardiac output tended to be higher (14% and 21%, respectively) compared with baseline. Contractility, global myocardial function, and Doppler indices of blood flow in the middle cerebral and renal artery remained normal and unchanged. The findings in the 5 term infants showed a similar pattern for changes in cardiac function, systemic hemodynamics, and organ blood flow after hydrocortisone administration.CONCLUSIONS. In preterm and term neonates who require high-dosage dopamine to maintain blood pressure at the lowest acceptable levels, hydrocortisone improves blood pressure without compromising cardiac function, systemic perfusion, or cerebral and renal blood flow.