Research Open Access: Singh Et Al. Critical Care (2020) 24:65

Singh et al.
Critical Care (2020) 24:65

https://doi.org/10.1186/s13054-020-2787-9
RESEARCH Open Access
International evidence-based guidelines on

Point of Care Ultrasound (POCUS) for
critically ill neonates and children issued by
the POCUS Working Group of the European
Society of Paediatric and Neonatal
Intensive Care (ESPNIC)
Yogen Singh1,2*† , Cecile Tissot3†, María V. Fraga4, Nadya Yousef5, Rafael Gonzalez Cortes6, Jorge Lopez6,
Joan Sanchez-de-Toledo7, Joe Brierley8, Juan Mayordomo Colunga9, Dusan Raffaj10, Eduardo Da Cruz11,
Philippe Durand12, Peter Kenderessy13, Hans-Joerg Lang14, Akira Nishisaki15, Martin C. Kneyber16, Pierre Tissieres12,
Thomas W. Conlon15 and Daniele De Luca5,17
Abstract
Background: Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more
important in neonates and children where other monitoring techniques may be unavailable. POCUS Working
Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based
clinical guidelines for the use of POCUS in critically ill neonates and children.
Methods: Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS
and systematic review of relevant literature. A literature search was performed, and the level of evidence was
assessed according to a GRADE method. Recommendations were developed through discussions managed
following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA
voting method. AGREE statement was followed to prepare this document.
Results: Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and
abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on
moderate quality of evidence (B and C).
Conclusions: Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now
available. They will be useful to optimise the use of POCUS, training programs and further research, which are
urgently needed given the weak quality of evidence available.
Keywords: Neonate, Children, Ultrasound, Point of care ultrasound (POCUS), Paediatric intensive care unit (PICU),
Neonatal intensive care unit (NICU)
* Correspondence: [email protected]
Yogen Singh and Cecile Tissot equally contributed and shall be considered
as first authors
1
Department of Paediatrics - Neonatology and Paediatric Cardiology,
Cambridge University Hospitals and University of Cambridge School of
Clinical Medicine, Biomedical Campus, Hills Road, Cambridge CB2 0QQ, UK
2
Addenbrooke’s Hospital, Box 402, Cambridge, UK
Full list of author information is available at the end of the article
© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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Singh et al. Critical Care (2020) 24:65 Page 2 of 16
Introduction have developed POCUS training courses in the last

The incorporation of Point of Care Ultrasound (POCUS) 10 years, similarly to what had been done with previous
has represented a transformative change in clinical prac- ESPNIC guidelines [12]. Panellists selection was per-
tice, challenging the traditional diagnostic and proced- formed prior to the literature search and for logistic rea-
ural “art” of medicine, especially in acute care sons, the number of participants was limited to a
environments. It has emerged as “the new” clinical tool maximum of 20. These colleagues should have been
and it has displaced, in some way, the classical stetho- fairly representative of all POCUS fields and both Eur-
scope. It is performed and interpreted by the bedside ope and North America and include also non-ESPNIC
clinician with the intent of either answering a focused members. Moreover, at least one co-author should have
question or achieving a specific procedural goal. been an expert in guidelines development and super-
The use of POCUS by critical care providers has in- vised the whole methodology, while literature search was
creased significantly in recent years and adult emergency performed by each panellist for their sub-section. All in-
medicine had pioneered this field with the publication of vited experts agreed to participate. Details of the
guidelines for implementation of structured POCUS methods used to produce these guidelines are given in
training [1–7]. These efforts were translated into paedi- the additional file for online supplementary material (see
atrics through emergency medicine. Since then, POCUS Additional file 1). These guidelines followed relevant
has gained popularity and expanded across many paedi- ESPNIC internal procedures for manuscript endorse-
atric disciplines. However, unified guidelines on the use ment, and this included an external review by ESPNIC
of POCUS and training do not exist yet for the paediat- officers not included among the panellists. Guidelines
ric and neonatal critical care. have been prepared according to the international Ap-
Bedside goal-directed echocardiography has been the praisal of Guidelines, Research and Evaluation (AGREE)
first POCUS application in paediatric practice with [13]. Each recommendation is intended to be applied
guidelines for implementation. An expert statement was both for paediatric and neonatal patients, unless other-
published in 2011, followed by the United Kingdom Ex- wise specified.
pert Consensus Statement on Neonatologist Performed
Echocardiography (NPE) and recommendations for NPE Results
in Europe [8–10]. The Australian Clinician Performed A total of 41 recommendations on the use of POCUS in
Ultrasound (CPU) programme is a well-established aca- neonatal and paediatric critical care were discussed.
demic curriculum developed to train neonatologists in There was strong agreement on 22 recommendations
the use of POCUS, though applications are limited to after first-round voting. Following the discussion in an
the evaluation of the neonatal brain and heart [10, 11] in-person meeting among the experts (organised within
and the training programme is restricted to neonatal the 2018 ESPNIC congress (Paris, France)), 19 recom-
physiology. Non-cardiac POCUS may carry more oppor- mendations were re-worded and re-voted in the second
tunities for use as well as a number of benefits for both round (Fig. 1). There was agreement on 17 recommen-
patients and providers. However, the lack of guidelines dations and disagreement on 2 recommendations as
is a barrier to widespread adoption. summarised in Table 1 and discussed below.
As more acute care providers invest in POCUS tech-
nology, it is critically important to define POCUS main A. Recommendations for use of cardiac POCUS
purposes, establish formal training and develop accredit- 1. POCUS should not be used as a screening tool
ation guidelines, in order to maximise POCUS benefits for diagnosing congenital heart defects in
and reducing risks. neonates and children, unless neonatologists/
Therefore, the European Society for Paediatric and paediatric intensivists have received an advanced
Neonatal Intensive Care (ESPNIC) assembled a group of echocardiography training specifically for this
international paediatric POCUS key opinion leaders to purpose—strong agreement (quality of evidence
create evidence-based guidelines for the use of current A). The goal of cardiac POCUS is to obtain
and emerging POCUS applications in the neonatal physiological and haemodynamic information to
(NICU) and paediatric intensive care units (PICU) by aid in clinical decision making. If any structural
any clinician working in these units. abnormality are suspected or diagnosed while
performing cardiac POCUS, a formal
Methods echocardiogram should be performed by a
Three lead authors, one neonatologist (YS), one paediat- paediatric cardiologist [8–11, 14]. POCUS
ric intensivist (DDL) and one paediatric cardiologist should not be used as a screening tool for
(CT), identified expert colleagues who significantly con- diagnosing congenital heart defects, unless
tributed with publications in the POCUS field and/or neonatologists/paediatric intensivists have
collapsibility (< 50%) is a sign of increased right

atrial pressure (above 10 mmHg) [15–17]. Con-
versely, a collapsed IVC may be suggestive of
hypovolemia. Clinicians performing POCUS
should be aware of its limitations especially in
children on mechanical ventilation and neonates
(especially when an umbilical central venous
catheter is placed) in whom no validated norma-
tive data yet exist [18, 19]. Moreover, mechan-
ical ventilation (especially with high mean
airway pressure), spontaneous breathing effort
and some concomitant conditions may reduce
the reliability of IVC evaluation to predict fluid
responsiveness [20].
3. POCUS may be helpful to assess fluid
responsiveness in neonates and children—strong
agreement (quality of evidence D). The variation
of velocity-time integrals (VTIs) measured at
the left ventricular outflow tract (LVOT), using
pulse wave Doppler (PWD) in apical 5-chamber
view, during inspiration and expiration has been
reported to predict volume responsiveness. A
variation of > 15% has been reported to have a
high predictive value with a sensitivity and spe-
cificity exceeding 90% [21, 22]. This has been
validated in several studies, including many
studies involving mechanically ventilated chil-
dren [16, 23–31]. Accurate measurement of VTI
needs acquisition of apical 5-chamber view and
good alignment of ultrasound beam with the
across LVOT like any other Doppler assessment,
which requires advanced ultrasonography skills.
Hence this recommendation is particularly for
neonatal/paediatric intensivists with advanced
Fig. 1 Flow chart of the methodology used in POCUS guidelines POCUS skills.
and consensus development 4. POCUS may be helpful for qualitative
assessment of cardiac function on visual
inspection in neonates and children—strong
received an advanced echocardiography training agreement (quality of evidence D). POCUS
specifically for this purpose. should be used for qualitative assessment of
2. POCUS may be helpful to assess cardiac filling cardiac contractility (“eyeballing” assessment) in
(preload assessment) and intravascular volume multiple views such as apical 4-chamber (A4C),
status in neonates and children—strong parasternal long (PLAX) and short-axis (PSAX)
agreement (quality of evidence D). Cardiac filling and sub-costal short-axis views [8, 15]. Sub-
may be qualitatively assessed in apical windows costal views may be very helpful in patients
and semi-quantitatively assessed by interrogat- where parasternal or apical views impossible or
ing inferior vena-cava (IVC) size and variation sub-optimal, and in younger children or neo-
during the cardiorespiratory cycle. During this nates where sub-costal views may provide even
evaluation, the eventual presence of right heart better image quality.
failure or elevated intra-abdominal pressure 5. POCUS is helpful for semi-quantitative assess-
should be taken into consideration. In non- ment of cardiac function in neonates and chil-
ventilated adults and children with normal right dren [however, a detailed functional assessment
atrial pressure, IVC collapse during inspiration should be performed by a person with advanced
is > 50%. A dilated IVC with decreased echocardiography training]—agreement (quality
Table 1 Summary of recommendations on the use of POCUS in the neonatal and paediatric critical care
No. Recommendation Level of Quality of
agreement evidence
1. POCUS should not be used as a screening tool for diagnosing congenital heart defects in neonates and children, Strong A
unless neonatologists/paediatric intensivists have received an advanced echocardiography training specifically for agreement
this purpose
2. POCUS may be helpful to assess cardiac filling (preload assessment) and intravascular volume status in neonates Strong D
and children agreement
3. POCUS may be helpful to assess fluid responsiveness in neonates and children Strong D
agreement
4. POCUS may be helpful for qualitative assessment of cardiac function on visual inspection in neonates and Strong D
children agreement
5. POCUS is helpful for semi-quantitative assessment of cardiac function in neonates and children [however, a de- Agreement C
tailed functional assessment should be performed by a person with advanced echocardiography training]
6. POCUS is helpful for assessment of pulmonary artery systolic pressure in pulmonary hypertension in neonates and Strong B
children agreement
7. POCUS is helpful for semi-quantitative assessment of pulmonary hypertension in neonates and children Strong B
agreement
8. POCUS is helpful to diagnose pericardial effusion in neonates and children Strong B
agreement
9. POCUS is helpful to guide pericardiocentesis in neonates and children Strong B
agreement
10. POCUS should be used to assess the patency of ductus arteriosus in neonates and children Strong A
agreement
11. POCUS may be used to detect vegetation to make or exclude the diagnosis of endocarditis [however, a definitive Disagreement D
diagnosis requires a detailed assessment by a paediatric cardiologist].
12. POCUS is helpful to distinguish between respiratory distress syndrome (RDS) and transient tachypnoea of the Agreement B
neonate (TTN)
13. POCUS is helpful to detect pneumonia in neonates and children Agreement B
14. POCUS is helpful to semi-quantitatively evaluate lung aeration and help the management of respiratory interven- Agreement B
tion in acute respiratory distress syndrome (ARDS) in neonates and children
15. POCUS is helpful to recognise meconium aspiration syndrome (MAS) Agreement C
16. POCUS is helpful for descriptive purposes in viral bronchiolitis but cannot provide a differential aetiological Strong C
diagnosis agreement
17. POCUS is helpful to accurately detect pneumothorax in neonates and children Strong B
agreement
18. POCUS is helpful to insert chest tube or perform needle aspiration in neonatal tension pneumothorax Strong B
agreement
19. POCUS is helpful to detect pleural effusions in neonates and children Strong B
agreement
20. POCUS is helpful to guide thoracentesis in neonates and children Strong B
agreement
21. POCUS is helpful to evaluate lung oedema in neonates and children Agreement C
22. POCUS is helpful in detecting anaesthesia-induced atelectasis in neonates and children Agreement C
23. POCUS-guided technique should be used for internal jugular vein (IJV) line placement in neonates and children Strong A
agreement
24. POCUS-guided technique is helpful for subclavian vein line placement in neonates and children Strong B
agreement
25. POCUS-guided technique is helpful for femoral line placement in neonates and children Strong B
agreement
26. POCUS-guided technique is helpful for arterial catheters placement in children Agreement B
27. POCUS-guided technique is helpful for peripherally inserted central catheters in children Agreement B
28. POCUS is helpful to locate catheter tip position in neonates and children Strong C
agreement
29. POCUS is helpful to detect cerebral blood flow changes in neonates and children Agreement B
Table 1 Summary of recommendations on the use of POCUS in the neonatal and paediatric critical care (Continued)
No. Recommendation Level of Quality of
agreement evidence
30. POCUS should be used to detect germinal matrix and intraventricular haemorrhage (IVH) in neonates Strong A
agreement
31. POCUS is helpful to detect cerebral blood flow patterns suggesting the presence of cerebral circulatory arrest in Agreement C
children with fused skull bones
32. POCUS is helpful to detect cerebral blood flow changes secondary to vasospasm in patients with traumatic brain Agreement C
injury and non-traumatic intracranial bleeding.
33. POCUS is helpful to detect changes in optic nerve sheath diameter (ONSD) indicative of raised ICP in children Agreement B
with fused skull bones
34. POCUS is helpful to detect cerebral midline shift in neonates and children Agreement C
35. POCUS is helpful for detection of free intra-abdominal fluid in neonates and children Strong C
agreement
36. POCUS may detect parenchymal changes of abdominal organs in neonates and children [although for a definitive Agreement D
diagnosis a detailed assessment should be performed by a paediatric radiologist]
37. POCUS may detect obstructive uropathy in neonates and children [although for a definitive diagnosis a detailed Agreement D
assessment should be performed by a paediatric radiologist]
38. POCUS may assess bowel peristalsis in neonates and children Agreement D
39. POCUS may recognise hypertrophic pyloric stenosis [although for a definitive diagnosis a detailed assessment Disagreement D
should be performed by a paediatric radiologist]
40. POCUS my guide peritoneal drainage or aspiration of peritoneal fluid in neonates and children Strong D
agreement
41. POCUS is helpful to detect signs of necrotising enterocolitis [although for a definitive diagnosis a detailed Agreement C
assessment should be performed by a paediatric radiologist or a person with specific advanced ultrasound
training]
of evidence C). POCUS can be used to assess assessment of pulmonary hypertension by evalu-
cardiac function semi-quantitatively by assessing ating the interventricular septal position and
ejection fraction (EF) and fraction shortening movement at the end of systole and by assessing
(FS) [14, 15]. In experienced hands, POCUS can flow direction and velocities across a patent
be used for further assessment of left and right ductus arteriosus and/or foramen ovale [14, 15].
ventricular function as summarised in Table 2 8. POCUS is helpful to diagnose pericardial
[14, 15, 32–45]. However, a detailed assessment effusion in neonates and children—strong
of cardiac function should be performed by a agreement (quality of evidence B). Pericardial
neonatologist/paediatric intensivist with ad- effusion can reliably be seen on POCUS by
vanced echocardiography training or a paediat- using multiple echocardiographic views [15, 46].
ric cardiologist. Cardiac tamponade should be detected within
6. POCUS is helpful for the assessment of the SAFE (Sonographic Assessment of liFe
pulmonary artery systolic pressure in pulmonary threatening Events) algorithm dedicated to
hypertension in neonates and children—strong recognise the main causes of life-threatening
agreement (quality of evidence B). In the events in children [47].
presence of tricuspid regurgitation, pulmonary 9. POCUS is helpful to guide pericardiocentesis in
artery systolic pressure (PASP) can be reliably neonates and children—strong agreement
estimated using bedside POCUS. In the absence (quality of evidence B). Ultrasound-guided peri-
of right outflow tract obstruction, the cardiocentesis has lower complication rates
regurgitation velocity represents the difference compared to the traditional landmark technique
in pressure between the right atrium and the [48–50].
right ventricle. PASP is derived using a modified 10. POCUS should be used to assess the patency of
Bernoulli equation [14, 15, 32]. ductus arteriosus—strong agreement (quality of
7. POCUS is helpful for semi-quantitative assess- evidence A). Cardiac POCUS can reliably be
ment of pulmonary hypertension in neonates used to assess patency of ductus arteriosus in
and children—strong agreement (quality of evi- preterm infants [8–10]. In experienced hands, it
dence B). In the absence of tricuspid regurgita- may be used for hemodynamic evaluation of the
tion, POCUS can be used for semi-quantitative ductus arteriosus [8, 10].
Table 2 Semi-quantitative systolic ventricular function measures that might be used by the clinician with more evolved training in
cardiac POCUS. Normative values are taken from the available literature on the topic [32–45] and represent the best reference data
available so far, although, in some cases, specific level for a different class of patients’ age are lacking
Parameter View Measurement Reference values
LV fraction shortening PSAX, PLAX, LV intraluminal diameter change 28–46% for all ages
(FS%) (2D or M
mode)
LV ejection fraction A4C, A2C Percentage change of LV volume between end-diastole and end-systole 55–80% for all ages
(Simpson’s method)
E-point septal PLAX (2D or Distance between anterior leaflet of the mitral valve and intraventricular > 7 mm in adults predictive of
separation (EPSS) M mode) septum during the diastolic phase. This measurement is associated with severe LV dysfunction *
LV systolic volume.
LV output (stroke A5C, PLAX Product of VTI measured by pulse wave Doppler at LVOT in A5C and Z-scores available for different
volume) LVOT cross-sectional area measured in PLAX ages and should be used;
neonates: 150–400 ml/kg/min
Mitral annular plane A4C Systolic excursion of lateral (or medial) mitral annulus toward apex to Z-scores available for different
systolic excursion assess LV systolic function. ages and should be used;
(MAPSE) term neonates: > 8 mm (8–11
mm)
Adults 12–14 mm (< 8 mm
predictive of severe LV
dysfunction)
RV output (stroke PSAX or Product of VTI measured by pulsed-wave Doppler at RVOT and RVOT Z-scores available for different
volume) sweep PLAX cross-sectional area ages and should be used;
neonates: 150–400 ml/kg/min
Tricuspid annular plane A4C Systolic excursion of lateral (or medial) tricuspid annulus toward apex to Term neonates: > 8 mm (8–11
systolic excursion assess RV systolic function. mm)
(TAPSE) Children–Z-score available;
generally > 12 mm (12–17 mm)
Adults or grown-up children >
17 mm (17–25 mm)
A4C Apical 4 chamber view, A5C Apical 5 chamber view, A2C Apical 2 chamber view, PSAX parasternal short-axis view, PLAX parasternal long-axis view, M mode
motion mode, LV left ventricle, LVOT left ventricular outflow tract, VTI velocity time integral
*No data are available in neonates or children
11. POCUS may be used to detect vegetations to B. Recommendations for use of lung POCUS
make a diagnosis of endocarditis [however, a 1. POCUS is helpful to distinguish between
definitive diagnosis requires a detailed respiratory distress syndrome (RDS) and
assessment by a paediatric cardiologist or a transient tachypnoea of the neonate
person with advanced echocardiography (TTN)—agreement (quality of evidence B). RDS
training]—disagreement (quality of evidence D). is characterised by a poorly aerated lung with
There was no agreement on using POCUS for the absence of A-lines, presence of small “sub-
the diagnosis of endocarditis. Detecting pleural” consolidations and diffuse white lung
vegetations to make a diagnosis of endocarditis (confluent B-lines). Conversely, in TTN, the
should be done by more expert (paediatric interstitial pattern alternates with areas of near-
cardiologist or by an intensivist with advanced normal lung (with A-lines). Pleural line thicken-
POCUS skills, and not expected to rule out by ing might be seen in late preterm and term ba-
neonatal and paediatric intensivists with bies [53–61]. The double lung point has been
competencies in basic POCUS). However, proposed as a pathognomonic finding [62, 63]
intracardiac masses may be detected on POCUS but it is debated, as it does not seem necessary
examination and should be referred to a for TTN diagnosis if normal lung areas are evi-
paediatric cardiologist or a neonatologist/ dent [64]. High inter-observer agreement be-
paediatric intensivist with advanced tween physicians with different lung ultrasound
echocardiography training [51, 52]. (LUS) expertise has been reported, which makes
the differential diagnosis between RDS and TTN
Semi-quantitative systolic ventricular function mea- reliable, irrespective of the operator [65]. In pre-
sures that may be used in POCUS have been sum- term neonates with RDS, various studies showed
marised in Table 2 [32–45]. that a semiquantitative ultrasound evaluation of
lung aeration is very predictive of the need for bronchiolitis are similar to those seen during
surfactant [66, 67] and, therefore, this POCUS influenza outbreaks [87] but it is not currently
tool is helpful to decide about surfactant re- possible to differentiate between different forms
placement and improve its timeliness [68]. of viral respiratory infections.
2. POCUS is helpful to detect pneumonia in 6. POCUS is helpful to accurately detect
neonates and children—agreement (quality of pneumothorax in neonates and children—strong
evidence B). LUS signs of pneumonia are the agreement (quality of evidence B). In adults, LUS
presence of consolidations and dynamic air has a high diagnostic accuracy for the diagnosis
bronchograms, B-lines and pleural effusion. Ab- of pneumothorax [88, 89] and has been reported
normal pleural line and decreased lung sliding to be more sensitive than conventional
may be observed [58, 65]. LUS has been re- radiology [90]. Neonatal data confirm this high
ported to have higher diagnostic accuracy com- diagnostic performance for tension
pared with chest X-rays for the diagnosis of pneumothorax [91].
pneumonia [69]. However, there is no defined 7. POCUS is helpful to insert chest tube or
threshold for consolidation size or a consensual perform needle aspiration in neonatal tension
method of measurement. pneumothorax—strong agreement (quality of
3. POCUS is helpful to semi-quantitatively evalu- evidence B). LUS should not only be used to
ate lung aeration and help the management of diagnose pneumothorax but also to provide
respiratory intervention in acute respiratory dis- static guidance for pleurocentesis [91]. Thus,
tress syndrome (ARDS) in neonates and chil- POCUS should be used to identify lung margin,
dren—agreement (quality of evidence B). LUS in hemidiaphragm and sub-diaphragmatic organs
neonatal and paediatric ARDS shows bilateral throughout the respiratory cycle before needle
diffuse areas of reduced lung aeration with areas or tube insertion to safely avoid them.
of the interstitial syndrome and consolidations, 8. POCUS is helpful to detect pleural effusions in
pleural line abnormalities and pleural effusion neonates and children—strong agreement (quality
[70–73]. Although current diagnostic criteria for of evidence B). Policy statements in adults
ARDS do not yet include LUS, it represents a recommend the use of LUS for the detection of
useful tool for its detection [73, 74]. Several LUS effusions and evaluation of pleural fluid volume to
aeration scores are used to semi-quantitatively guide management [55, 92, 93]. In children, LUS
measure the effect of fluid restriction, alveolar shows high accuracy in the diagnosis of
recruitment and surfactant administration [75– pneumonia-related pleural effusion [47].
79]. Scores based on the main lung ultrasound 9. POCUS is helpful to guide thoracentesis in
semiology (including A lines, alveolar-interstitial neonates and children—strong agreement
pattern and presence of consolidations) should (quality of evidence B). Ultrasound-guided thora-
be preferred over the simple B lines count, as centesis reduces the risk of complications and
they describe better the lung aeration and have increases success rates [55, 92, 93]. It should be
been validated with various techniques [80]. used to identify lung margin, hemidiaphragm
4. POCUS is helpful to recognise meconium and sub-diaphragmatic organs throughout the
aspiration syndrome (MAS)—agreement (quality respiratory cycle before needle or tube insertion
of evidence C). MAS is now recognised as a to safely avoid them.
cause of neonatal ARDS [73] and shares the 10. POCUS is helpful to evaluate lung oedema in
same LUS findings. However, this LUS pattern neonates and children—agreement (quality of
is dynamic and changes with the spread of evidence C). Although LUS is accurate in
meconium plugs during mechanical ventilation detecting extra-vascular lung fluid [94], it can-
[81, 82]. not distinguish between cardiogenic and non-
5. POCUS is helpful for descriptive purposes in cardiogenic oedema [55, 94]. LUS has been used
viral bronchiolitis but cannot provide a in children to evaluate cardiogenic lung oedema,
differential aetiological diagnosis—strong by assessing extravascular lung fluid counting
agreement (quality of evidence C). LUS signs in numbers of B-lines after cardiac surgery [79].
viral bronchiolitis consist of pleural line However, extravascular lung water may obvi-
irregularities, “sub-pleural” consolidations and ously be affected by the pressure delivered dur-
areas with interstitial pattern [83–85]. Good ing mechanical ventilation. Thus, in these
concordance between operators has been shown conditions, LUS globally evaluates the lung aer-
in wheezing infants [86]. LUS findings in viral ation rather than extravascular lung fluid.
11. POCUS is helpful in detecting anaesthesia- children—agreement (quality of evidence B). A

induced atelectasis in neonates and children—a- paediatric RCT comparing US-guided versus
greement (quality of evidence C). LUS may be landmark PICC placement showed higher first-
used to monitor this complication during anaes- attempt cannulation rate, successful PICC posi-
thesia that may potentially lead to hypoxemia tioning rate and shorter time to success when
[95]. ultrasound was used [119]. Similar findings are
C. Recommendations for use of vascular POCUS in supported by adult literature [120].
line placement 6. POCUS is helpful to locate catheter tip position
1. POCUS-guided technique should be used for in neonates and children—strong agreement
internal jugular vein (IJV) line placement in (quality of evidence C). A trial and two
neonates and children—strong agreement observational studies in the paediatric and
(quality of evidence A). Robust paediatric data neonatal population have suggested that US
favour ultrasound guidance for IJV cannulation may decrease radiation and number of line
compared to landmark technique [96–100]. manipulations by confirming PICC tip position
Multiple studies have repeatedly shown after placement [121–123] and could be
decreased risk of cannulation failure and arterial considered a complement to conventional
puncture, higher success rates on first attempt radiography [124].
and decreased incidence of complications [100– D. Recommendations for use of cerebral POCUS
104]. 1. POCUS is helpful to detect cerebral blood flow
2. POCUS-guided technique is helpful for changes in neonates and children—agreement
subclavian venous line placement in neonates (quality of evidence B). Children are especially
and children—strong agreement (quality of amenable to cranial ultrasound since their skulls
evidence B). The subclavian and brachiocephalic remain not yet ossified and their fontanelles
veins have been cannulated in children and open [125, 126]. Alterations in cerebral blood
neonates (including preterm ones) with in-plane flow allow inferences to be made regarding
visualisation, and this seems the easiest ap- brain pathology and raised intracranial pressure
proach [105–107]. However, there is no firm (ICP) [127, 128]. Estimation of flow velocities
consensus about the best technique, i.e., supra- and calculation of pulsatility (PI) and resistance
clavicular vs infra-clavicular, or in-plane vs out- indexes (RI) are useful tools for non-invasive
of-plane [101, 108]. Multiple cases series of chil- monitoring of ICP [129]. Age-dependent normal
dren and neonates reported higher success rates values of blood velocities in different vessels and
and decreased incidence of complications indexes have been previously published [130].
favouring ultrasound use compared to landmark Paediatric data are not yet sufficient to support
technique. Therefore, ultrasound-guided sub- its use and caution must be taken when inter-
clavian cannulation in neonates and children is preting results [131, 132].
safe, doable and is advised over a blind cannula- 2. POCUS should be used to detect germinal
tion technique [101, 107–112]. matrix and intraventricular haemorrhage (IVH)
3. POCUS-guided technique is helpful for femoral in neonates—strong agreement (quality of
line placement in neonates and children—strong evidence A). Intraventricular haemorrhage and
agreement (quality of evidence B). Paediatric parenchymal bleeding remain a frequent and
trials comparing US-guided femoral line place- serious complication in extremely preterm
ment with landmark technique showed higher infants. POCUS is a useful clinical tool to detect
overall success rate and on the first attempt as IVH and parenchymal changes [133], and
well as fewer needle passes [113–116]. assesses the severity according to Papile’s
4. POCUS-guided technique is helpful for arterial classification [134, 135]. In environments where
catheters placement in children—agreement imaging resources are limited, brain POCUS
(quality of evidence B): a few high-quality studies should be used for the diagnosis of IVH which
have found that US-guided arterial line place- may aid in the redirection of care.
ment is faster (shorter time to success and lower 3. POCUS is helpful to detect cerebral blood flow
number of attempts) and has higher first- patterns suggesting the presence of cerebral
attempt cannulation rates regardless of the loca- circulatory arrest in children with fused skull
tion [117, 118]. bones—agreement (quality of evidence C).
5. POCUS-guided technique is helpful for Transcranial doppler has been used to establish
peripherally inserted central catheters (PICC) in the presence of cerebral circulatory arrest [135,
136] by evaluation of the middle cerebral Abdominal POCUS is widely used as a clinical
(MCA) and basilar artery. The following tool for the management and diagnosis of pa-
patterns are compatible with cerebral tients with abdominal pathology [144–148].
circulatory arrest [126, 136]: (a) oscillating Evaluation of free fluid is particularly useful
waveform or sustained reversal of diastolic flow, when sudden clinical deterioration and
(b) small systolic spikes and disappearance of all hypotension occur and may provide insight into
intra-cranial flow, (c) no flow in MCA, (d) re- the ongoing pathophysiologic process [149,
versal of diastolic flow in extracranial Internal 150].
Carotid Artery (ICA) and (e) mean velocity in 2. POCUS may detect parenchymal changes of
MCA less than 10 cm/s for more than 30 min. abdominal organs in neonates and children
However, interpretation of this assessment must [although for a definite diagnosis a detailed
be done with caution. assessment should be performed by a paediatric
4. POCUS is helpful to detect cerebral blood flow radiologist]—agreement (quality of evidence D).
changes secondary to vasospasm in patients Basic ultrasound knowledge of abdominal organ
with traumatic brain injury and non-traumatic anatomy is essential during POCUS
intracranial bleeding—agreement (quality of evi- examination. Furthermore, a detailed assessment
dence C). Vasospasm of cerebral arteries results should be performed by a paediatric radiologist
in increased flow velocities. The Lindegaard ra- if abnormal abdominal organ structures are
tio (LR) is calculated by dividing mean velocity detected by POCUS [151, 152].
in MCA by mean velocity in ipsilateral extracra- 3. POCUS may detect obstructive uropathy in
nial ICA. As hyperaemia may also increase mean neonates and children [although for a definite
velocities, LR is useful to distinguish between diagnosis a detailed assessment should be
hyperaemia and vasospasm (3:6 ratio is consid- performed by a paediatric
ered a sign of mild vasospasm, and > 6 a sign of radiologist]—agreement (quality of evidence D).
severe vasospasm) [136]. A renal ultrasound is useful to easily detect the
5. POCUS is helpful to detect changes in optic presence of hydronephrosis even by novices
nerve sheath diameter (ONSD) indicative of [152–154]. Urinary retention can be evaluated
raised ICP in children with fused skull by POCUS assessing postvoid residual volumes.
bones—agreement (quality of evidence B). In the case of anuria, a simple obstruction
Measurement of the ONSD is suggestive of requiring a urinary catheter placement can be
papilledema and increased ICP [137, 138]; ruled out.
however, data conflict on threshold 4. POCUS may assess bowel peristalsis in neonates
measurements [137–140] and papilledema may and children—agreement (quality of evidence D).
persist despite normalisation of intracranial Bowel POCUS may be used to assess peristalsis
pressure. Therefore, it must be reminded that [155] but insufficient data yet exist correlating
this technique may have relevant measurement peristalsis with feeding tolerance. However, the
errors because of the narrow margins that presence of peristalsis has strong negative
distinguish pathological from normal. predictive value in adults for ileus and gut
6. POCUS is helpful to detect cerebral midline ischemia in adults [156].
shift (MLS) in neonates and 5. POCUS may recognise hypertrophic pyloric
children—agreement (quality of evidence C). stenosis [although for a definitive diagnosis a
Measurement of the distance from both detailed assessment should be performed by a
temporal bones to the centre of the third paediatric radiologist]—disagreement (quality of
ventricle through the temporal acoustic window evidence D )[157]
determines the presence of MLS [141, 142]. 6. POCUS may guide peritoneal drainage or
Minimal shifts (less than 5 mm) in adults have aspiration of peritoneal fluid in neonates and
proven to identify abnormal conditions [143]. children—strong agreement (quality of evidence
Yet, normative values for MLS identification in D). A paracentesis may be required for either
children have not been reported, and this may diagnostic or therapeutic purposes. POCUS
reduce the helpfulness of this application. should be used for pre-procedural planning,
E. Recommendations for abdominal POCUS identification of epigastric vessels and real-time
1. POCUS is helpful for the detection of free intra- ultrasonographic guidance. In adult studies, the
abdominal fluid in neonates and children—- use of ultrasound has been shown to decrease
strong agreement (quality of evidence C). both bleeding complications and the overall cost
of care for patients undergoing in-hospital para- patient population and specialty. Even within a unit,
centesis [158]. practice varies among clinicians and their expertise. We
7. POCUS is helpful to detect signs of necrotizing subdivided POCUS recommendations according to the
enterocolitis (NEC) [although for a definitive estimated level of training required for their use (Fig. 2),
diagnosis a detailed assessment should be and this may be helpful for their implementation.
performed by a paediatric radiologist or a person Defining a scope of practice is fundamental for
with specific advanced ultrasound POCUS, and these ESPNIC guidelines have been devel-
training]—agreement (quality of evidence C). oped for the targeted use of ultrasound in NICU and
Ultrasound may be a useful adjunct detecting PICU by any neonatologist or paediatric intensivist. For
changes consistent with NEC even when most diagnostic (heart, lungs, brain and abdomen) and
radiographs are inconclusive [159, 160]. procedural (line placement and fluid drainage) POCUS
Furthermore, radiographs have poor sensitivity in applications, these guidelines can be used at all ages in
the diagnosis of NEC [161, 162]. POCUS can children or neonates. However, while using cardiac
provide prognostic value identifying free fluid, POCUS in neonates, clinicians should be aware that un-
bowel wall thickness, pneumatosis intestinalis, diagnosed critical congenital heart defects can present
portal venous gas and vascular perfusion [159, just during this period. They should acknowledge the
163–166]. The International Neonatal limitations of skills, and it should not be used as a
Consortium’s NEC subgroup recently revisited screening tool for diagnosing or excluding congenital
the necrotizing enterocolitis (NEC) pathogenesis heart defects. A patient with a suspected critical con-
and new diagnostic criteria were proposed [167]. genital heart defect should be quickly referred to a
These were based on the so-called ‘two out of paediatric cardiologist, even if this implies out-of-
three’ model which includes pneumatosis intesti- hospital patient’s transportation. However, in cases of
nalis or portal venous gas by abdominal X-rays suspicion of a non-critical defect or for patients with low
and/or POCUS. POCUS was included since vari- pre-test probability a more expectative management can
ous studies demonstrated that it outperformed be provided. Moreover, the use of pulse-oximetry
conventional radiology to this end [159]. screening for congenital heart defects is useful and
should be integrated into the clinical decision-making
Discussion process, as internationally recommended [168, 169].
POCUS is increasingly being utilised in neonatal and These guidelines may help in standardising clinical
paediatric critical care as a valuable adjunct to clinical practice across acute care settings and physicians. It is
examination. The use of POCUS by the clinician is dif- not meant to be prescriptive, but rather to outline the
ferent than a complete diagnostic study by the specialist
and its role is dynamic—the same provider can perform
and interpret the study, rapidly integrate this informa-
tion within the current clinical setting, and then repeat
the study to identify changes associated with the inter-
vention. POCUS involves a focused assessment to an-
swer a specific question, and it provides anatomical and/
or physiological information to be integrated with clin-
ical and laboratory data and make timely and accurate
decisions possible. The statements on which panellists
disagreed concerned two particular indications (endocar-
ditis and hypertrophic pyloric stenosis), whose diagnosis
should be done by a detailed ultrasonography in the
hands of an expert paediatric cardiologist or radiologist.
The role of POCUS (i.e., point-of-care ultrasound per-
formed directly by neonatal/paediatric intensivists at the
bedside) for these indications is not clear, while the role
of ultrasound, in general, is indeed important.
There remains a significant variation in clinical prac-
tice—in indications, training program and clinical gov-
ernance. The application of POCUS in clinical practice Fig. 2 Estimated level of training required for the implementation of
POCUS recommendations. Recommendations are listed according to
is dependent on many factors including availability of
their progressive number for each section
ultrasound machines, providers, hospital setting, local
important features of structured POCUS applications in and methods of POCUS training should be a sensible
clinical practice. The use of these guidelines often will follow-up article to this one.
not have any cost implication for the equipment, as
ultrasound machine is almost always available in most Conclusions
neonatal and paediatric intensive care units. ESPNIC will Despite the lack of published evidence-based guidelines
promote the diffusion of these guidelines by appropriate specifically for its use in the neonatal and paediatric inten-
advertisement, links and presentation in the society con- sive care units, POCUS is increasingly being used. ESPNIC
gresses and training events. POCUS guidelines provide the substrate to optimise
These guidelines have strengths and limitations as any POCUS use in neonatal and paediatric critical care and
other. Strengths are represented by (1) the fairly subdi- guide future research steps according to currently unmet
vided multidisciplinary panellists’ group (including both needs. Guidelines may help in making the clinical practice
neonatologists and paediatric intensivists, expert in dif- standardised and clinical governance robust.
ferent POCUS areas and coming from different geo-
graphical regions), and (2) the use of a standardised Supplementary information
methodology. In several fields, these recommendations Supplementary information accompanies this paper at https://doi.org/10.
1186/s13054-020-2787-9.
are based upon a few studies with moderate/low evi-
dence or based upon experts’ opinions and this is a Additional file 1. Online supplementary material.
striking difference compared to similar guidelines in
adult critical care. In fact, authors answered to following Abbeviations
PICO questions: “Does point-of-care ultrasound for A4C: Apical 4-chamber; ARDS: Acute respiratory distress syndrome;
heart/lung/line placement/abdomen/brain provide any CPU: Clinician performed ultrasound; EF: Ejection fraction; ESPNIC: European
Society of Paediatric and Neonatal Intensive Care; FS: Fraction shortening;
clinical advantage in neonatal or paediatric intensive ICP: Intracranial pressure; IJV: Internal jugular vein; IVC: Inferior vena-cava;
care practice?” (supplementary methods). These ques- IVH: Intraventricular haemorrhage; LR: Lindegaard ratio; LUS: Lung ultrasound;
tions were purposely quite general, as POCUS is not a LVOT: Left ventricular outflow tract; MAS: Meconium aspiration syndrome;
MCA: Middle cerebral artery; MLS: Cerebral midline shift; NEC: Necrotizing
therapeutic intervention, but rather a diagnostic and enterocolitis; NICU: Neonatal intensive care unit; NPE: Neonatologist
monitoring technique and we expected few randomised performed echocardiography; ONSD: Optic nerve sheath diameter;
controlled trials or high-quality diagnostic accuracy PASP: Pulmonary artery systolic pressure; PI: Pulsatility index;
PICC: Peripherally inserted central catheters; PICU: Pediatric intensive care
studies about POCUS specifically aiming to improve any unit; PLAX: Parasternal long; POCUS: Point of care ultrasound; PSAX: Short
particular paediatric/neonatal outcome. Moreover, some axis; RDS: Respiratory distress syndrome; RI: Resistance index; TTN: Transient
of the POCUS applications may not be immediately used tachypnoea of the neonate; VTIs: Variation of velocity-time integrals
in all intensive care units as in ours, because of the spe- Acknowledgements
cific expertise required in some particular contexts (such Not applicable
as the extremely preterm neonates or non-sedated and
Authors’ contributions
non-collaborative patients). However, the existence of YS, CT and DDL conceptualised and designed the development of the
formal guidelines may help to improve the local expert- whole project. YS and CT wrote the first manuscript draft. DDL took care of
ise and foster new studies to expand knowledge in this the whole methodology and supervised the whole project. All authors
performed literature search and analysis, interpreted the literature data with
field and refine future recommendations. This is ex- their specific expertise, participate in meetings discussions and voted on
tremely important as further studies are warranted to recommendations and manuscript preparation. Moreover, all authors
demonstrate that POCUS actually improves patients’ critically reviewed the manuscript for important intellectual content,
approved it in its final version and agreed to be accountable for all aspects
management and outcome, similar to what has been of the work. The participation to the project did not entail any honorarium.
demonstrated in adult critical care [1–7, 55]. Another All authors read and approved the final manuscript.
concern is that the clinicians involved are all enthusiastic
Funding
users of POCUS and this may have theoretically contrib-
This project has no funding. ESPNIC provided technical and secretarial
uted to have ‘too positive’ recommendations. The ESP- assistance for free.
NIC POCUS Working Group recognises that there are
emerging indications for POCUS outside of those listed Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated
here and needs for future research steps. Publication of or analysed during the current study.
new literature may require future revision and ESPNIC
POCUS Working Group is willing to update guidelines Ethics approval and consent to participate
Not applicable.
accordingly every 3 years.
These guidelines may provide a substrate to develop a Consent for publication
POCUS curriculum and structured training programs, Not applicable.
which are urgently needed for quality assurance. This Competing interests
guideline paper is not a training statement: requirements The authors declare that they have no competing interests.
Author details 11. Australasian Society for Ultrasound Medicine. Proficiency & Appropriate Use
1
Department of Paediatrics - Neonatology and Paediatric Cardiology, Statement [Internet]. Available from: https://www.asum.com.au/files/public/
Cambridge University Hospitals and University of Cambridge School of SoP/Current/Paediatrics_and_Neo-Natal/Proficiency-and-Appropriate-Use-
Clinical Medicine, Biomedical Campus, Hills Road, Cambridge CB2 0QQ, UK. Statement-for-Neonatal-Ultrasound-G1.pdf.
2
Addenbrooke’s Hospital, Box 402, Cambridge, UK. 3Paediatric Cardiology, 12. Kneyber MCJ, de Luca D, Calderini E, Jarreau P-H, Javouhey E, Lopez-Herce
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12
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International evidence-based guidelines on

Introduction have developed POCUS training courses in the last

collapsibility (< 50%) is a sign of increased right

11. POCUS is helpful in detecting anaesthesia- children—agreement (quality of evidence B). A

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