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There is significant uncertainty regarding the optimal circulatory management of preterm infants, with research in the field limited by the paucity of safe, reproducible biomarkers of circulatory function. This review discusses the physiology and pathophysiology of circulatory function in preterm infants, describes the mode of action and evidence for and against commonly used and recently trialled inotropic therapies and provides recommendations for managing circulatory dysfunction in the transitional period and in the context of sepsis/necrotizing enterocolitis. We recommend a pragmatic approach of assessing multiple aspects of circulatory function (blood pressure alone correlates weakly with volume of flow) in each infant, tailoring therapy on the basis of the change in function desired and frequently reassessing response to intervention. [ABSTRACT FROM AUTHOR]

Point-of-care ultrasound (POCUS) has increasingly been used by neonatal providers in neonatal intensive care units in the United States. However, there is a lack of literature addressing the complexities of POCUS coding and billing practices in the United States. This article describes the coding terminology and billing process especially those relevant to neonatal POCUS. We elucidate considerations for neonatal POCUS billing framework and workflow integration. Directions on image storage and supporting documentation to facilitate efficient reimbursement, compliance with billing regulations, and appeal to insurance claim denial are discussed. Key Points Code neonatal POCUS procedure precisely allows accurate reimbursement and reduced errors in billing. Document details to support medical necessity and reimbursement claims effectively. Adhere to regulations to avoid audits, denials, and ensure proper reimbursement. [ABSTRACT FROM AUTHOR]

Objective Periviable premature rupture of membranes (PROM) counseling should describe maternal and neonatal outcomes associated with both immediate delivery and expectant management. Unfortunately, most published data focuses on neonatal outcomes and maternal risk estimates vary widely. We performed a meta-analysis to describe outcomes associated with expectant management compared with immediate delivery of periviable PROM. Study Design We performed a search on PubMed, MEDLINE, Web of Science, PROSPERO, Cochrane library, and ClinicalTrials.gov utilizing a combination of key terms. Published clinical trials and observational cohorts were included if published after 2000. Publications were selected if they included maternal and/or neonatal outcomes for both expectant management and immediate delivery. Gestational age range was limited from 14 to 25 weeks. The primary outcome was maternal sepsis. Secondary outcomes included chorioamnionitis, hemorrhage, laparotomy, and neonatal survival. Pooled risk differences (RDs) were calculated for each outcome using a random-effects model. Publication bias was assessed using funnel plots and Harbord test. Results A total of 2,550 studies were screened. After removal of duplicates and filtering by abstract, 44 manuscripts were reviewed. A total of five publications met inclusion for analysis: four retrospective and one prospective. Overall, 364 (68.0%) women underwent expectant management and 171 (32.0%) underwent immediate delivery. Maternal sepsis was significantly more frequent in the expectant group (RD, 4%; 95% confidence interval, 2–7%) as was chorioamnionitis (RD: 30%; p < 0.01) and any laparotomy (RD: 28%; p < 0.01). Neonatal survival in the expectant group was 39% compared with 0% in the immediate group (p < 0.01). Conclusion Women who undergo expectant management following periviable rupture of membranes experience significantly increased risks of sepsis, chorioamnionitis, and laparotomy. Overall, 39% of neonates survive to discharge. Knowledge of these risks is critical to counseling patients with this diagnosis. Key Points Expectant management associated with 4% increased risk of sepsis. Expectant management associated with 30% increased risk of chorioamnionitis. A total of 39% of neonates survived to discharge with expectant management. [ABSTRACT FROM AUTHOR]

Unlabelled: Targeted echocardiographic assessments of haemodynamic status are increasingly utilised in many settings. Application in the neonatal intensive care units (NICU) is increasingly demanded but challenging given the risk of underlying structural lesions. This statement follows discussions in UK led by the Neonatologists with an Interest in Cardiology and Haemodynamics (NICHe) group in collaboration with the British Congenital Cardiac Association (BCCA) and the Paediatricians with Expertise in Cardiology Special Interest Group (PECSIG). Clear consensus was agreed on multiple aspects of best practice for neonatologist-performed echocardiogram (NoPE)-rigorous attention to infection control and cardiorespiratory/thermal stability, early referral to paediatric cardiology with suspicion of structural disease, reporting on standardised templates, reliable image storage, regular skills maintenance, collaboration with a designated paediatric cardiologist, and regular scan audit/review. It was agreed that NoPE assessments should confidently exclude structural lesions at first scan. Practitioners would be expected to screen and establish gross normality of structure at first scan and obtain confirmation from paediatric cardiologist if required, and subsequently, functional echocardiography can be performed for haemodynamic assessment to guide management of newborn babies. To achieve training, NICHe group suggested that mandatory placements could be undertaken during core registrar training or neonatal subspecialty grid training with a paediatric cardiology placement for 6 months and a neonatology placement for a minimum of 6 months. In the future, we hope to define a precise curriculum for assessments. Technological advances may provide solutions-improvements in telemedicine may have neonatologists assessing haemodynamic status with paediatric cardiologists excluding structural lesions and neonatal echocardiography simulators could increase exposure to multiple pathologies and allow limitless practice in image acquisition.Conclusion: We propose developing training places in specialist paediatric cardiology centres and neonatal units to facilitate training and suggest all UK practitioners performing neonatologist-performed echocardiogram adopt this current best practice statement.What Is Known: Neonatologist-performed echocardiogram (NoPE) also known as targeted neonatal echocardiography (TNE) or functional ECHO is increasingly recognised and utilised in care of sick newborn and premature babies. There are differences in training for echocardiography across continents and formal accreditation processes are lacking.What Is New: This is the first document of consensus best practice statement for training of neonatologists in neonatologist-performed echocardiogram (NoPE), jointly drafted by Neonatologists with interest in cardiology & haemodynamics (NICHe), paediatric cardiology and paediatricians with expertise in cardiology interest groups in UK. Key elements of a code of practice for neonatologist-performed echocardiogram are suggested. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular magnetic resonance (CMR) is increasingly used in newborns with congenital heart disease. However, reporting on ventricular volumes and mass is hindered by an absence of normative data in this population. Design/methods: Healthy term (37–41 weeks gestation) newborns underwent non-sedated, free-breathing CMR within the first week of life using the 'feed and wrap' technique. End-diastolic volume (EDV), end-systolic volume (ESV) stroke volume (SV) and ejection fraction (EF) were calculated for both left ventricle (LV) and right ventricle (RV). Papillary muscles were separately contoured and included in the myocardial volume. Myocardial mass was calculated by multiplying myocardial volume by 1.05 g/ml. All data were indexed to weight and body surface area (BSA). Inter-observer variability (IOV) was performed on data from 10 randomly chosen infants. Results: Twenty healthy newborns (65% male) with a mean (SD) birth weight of 3.54 (0.46) kg and BSA of 0.23 (0.02) m2 were included. Normative LV parameters were indexed EDV 39.0 (4.1) ml/m2, ESV 14.5 (2.5) ml/m2 and ejection fraction (EF) 63.2 (3.4)%. Normative RV indexed EDV, ESV and EF were 47.4 (4.5) ml/m2, 22.6 (2.9) ml/m2 and 52.5 (3.3)% respectively. Mean LV and RV indexed mass were 26.4 (2.8) g/m2 and 12.5 (2.0) g/m2, respectively. There was no difference in ventricular volumes by gender. IOV was excellent with an intra-class coefficient > 0.95 except for RV mass (0.94). Conclusion: This study provides normative data on LV and RV parameters in healthy newborns, providing a novel resource for comparison with newborns with structural and functional heart disease. [ABSTRACT FROM AUTHOR]

Ultrasound Superior Vena Cava (SVC) flow assessment is a common measure of systemic and cerebral perfusion, although accuracy is limited. The aim of this study was to evaluate whether any improvements in accuracy could be achieved by measuring stroke distance from the instantaneous mean velocity, rather than from peak velocity, and by directly tracing area from images obtained with a high frequency linear probe. Paired phase contrast magnetic resonance imaging (PCMRI) and ultrasound assessments of SVC flow were performed in a pilot cohort of 7 infants. Median postnatal age, corrected gestation and weight at scan were 7 (2–74) days, 34.8 (31.7–37.2) weeks 1870 (970–2660) g. Median interval between PCMRI and ultrasound scans was 0.3 (0.2–0.5) h. The methodology trialed here showed a better agreement with PCMRI (mean bias −8 mL/kg/min, LOA −25–+8 mL/kg/min), compared to both the original method reported by Kluckow et al. (mean bias + 42 mL/kg/min, LOA −53–+137 mL/kg/min), and our own prior adaptation (mean bias + 23 mL/kg/min, LOA −25–+71 mL/kg/min). Ultrasound assessment of SVC flow volume using the modifications described led to enhanced accuracy and decreased variability compared to prior techniques in a small cohort of premature infants. [ABSTRACT FROM AUTHOR]

Background: A health partnership to improve hospital based neonatal care in Rwanda to reduce neonatal mortality was requested by the Rwandan Ministry of Health. Although many health system improvements have been made, there is a severe shortage of health professionals with neonatal training.Methods: Following a needs assessment, a health partnership grant for 2 years was obtained. A team of volunteer neonatologists and paediatricians, neonatal nurses, lactation consultants and technicians with experience in Rwanda or low-income countries was assembled. A neonatal training program was provided in four hospitals (the 2 University hospitals and 2 district hospitals), which focused on nutrition, provision of basic respiratory support with nasal CPAP (Continuous Positive Airway Pressure), enhanced record keeping, thermoregulation, vital signs monitoring and infection control. To identify if care delivery improved, audits of nutritional support, CPAP use and its complications, and documentation in newly developed neonatal medical records were conducted. Mortality data of neonatal admissions was obtained.Results: Intensive neonatal training was provided on 27 short-term visits by 10 specialist health professionals. In addition, a paediatric doctor spent 3 months and two spent 6 months each providing training. A total of 472 training days was conducted in the neonatal units. For nutritional support, significant improvements were demonstrated in reduction in time to initiation of enteral feeds and to achieve full milk feeds, in reduction in maximum postnatal weight loss, but not in days for regaining birth weight. Respiratory support with bubble CPAP was applied to 365 infants in the first 18 months. There were no significant technical problems, but tissue damage, usually transient, to the nose and face was recorded in 13%. New medical records improved documentation by doctors, but nursing staff were reluctant to use them. Mortality for University teaching hospital admissions was reduced from 23.6% in the 18 months before the project to 21.7%. For the two district hospitals, mortality reduced from 10% to 8.1%. A major barrier to training and improved care was low number of nurses working on neonatal units and staff turnover.Conclusion: This health partnership delivered an intensive program of capacity building by volunteer specialists. Improved care and documentation were demonstrated. CPAP was successfully introduced. Mortality was reduced. This format can be adapted for further training and improvement programs to improve the quality of facility-based care. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Periviable rupture of membranes counseling should describe maternal and neonatal outcomes associated with both immediate delivery or expectant management; unfortunately, most published data focuses on neonatal outcomes and maternal risk estimates vary widely. We performed a meta-analysis to describe outcomes associated with expectant management compared to immediate delivery of periviable PROM. METHODS: We performed a systematic review of the literature including published clinical trials and observational cohorts after the year 2000. Publications were selected if they included maternal and neonatal outcomes for both expectant management and immediate delivery. Gestational age range was limited from 14 to 25 weeks. The primary outcome was maternal sepsis. Secondary outcomes included chorioamnionitis, hemorrhage, laparotomy, and neonatal survival. Pooled risk differences were calculated for each outcome using a random effects model. Publication bias was assessed using funnel plots and Harbord test. RESULTS: A total of 2,550 studies were initially screened, and 44 manuscripts were reviewed. Of these, 5 publications met inclusion for analysis: 4 retrospective and 1 prospective. Overall, 61.1% of women chose expectant management. Expectant management was associated with a 4% increased risk of maternal sepsis, 30% increased risk of chorioamnionitis, and 28% increased risk of any laparotomy. Neonatal survival with expectant management was 34% compared to 0% with immediate delivery. CONCLUSION: Women who choose to undergo expectant management experience an increased risk of sepsis, chorioamnionitis, and laparotomy with only one-third of neonates surviving to discharge. Knowledge of these risks is critical to counseling patients with this diagnosis. [ABSTRACT FROM AUTHOR]

Background: Many pathologies seen in the preterm population are associated with abnormal blood supply, yet robust evaluation of preterm cardiac function is scarce and consequently normative ranges in this population are limited. The aim of this study was to quantify and validate left ventricular dimension and function in preterm infants using cardiovascular magnetic resonance (CMR). An initial investigation of the impact of the common congenital defect patent ductus arteriosus (PDA) was then carried out. Methods: Steady State Free Procession short axis stacks were acquired. Normative ranges of left ventricular end diastolic volume (EDV), stroke volume (SV), left ventricular output (LVO), ejection fraction (EF), left ventricular (LV) mass, wall thickness and fractional thickening were determined in “healthy” (control) neonates. Left ventricular parameters were then investigated in PDA infants. Unpaired student t-tests compared the 2 groups. Multiple linear regression analysis assessed impact of shunt volume in PDA infants, p-value ≤ 0.05 being significant. Results: 29 control infants median (range) corrected gestational age at scan 34+6(31+1-39+3) weeks were scanned. EDV, SV, LVO, LV mass normalized by weight and EF were shown to decrease with increasing corrected gestational age (cGA) in controls. In 16 PDA infants (cGA 30+3 (27+3-36+1) weeks) left ventricular dimension and output were significantly increased, yet there was no significant difference in ejection fraction and fractional thickening between the two groups. A significant association between shunt volume and increased left ventricular mass correcting for postnatal age and corrected gestational age existed. Conclusion: CMR assessment of left ventricular function has been validated in neonates, providing more robust normative ranges of left ventricular dimension and function in this population. Initial investigation of PDA infants would suggest that function is relatively maintained. [ABSTRACT FROM AUTHOR]

Background The aim of this study was to look for clinically significant adverse effects of chloral hydrate used in a large cohort of infants sedated for magnetic resonance imaging. Method Case notes of infants who underwent magnetic resonance imaging ( MRI) scanning from 2008 to 2010 were reviewed, with patient demographics, sedation dose, comorbidities, time to discharge, and side effects of sedation noted. Results Four hundred and eleven infants (median [range] postmenstrual age per weight at scan 42 [31+4-60] weeks per 3500 g [1060-9900 g]) were sedated with chloral hydrate (median [range] dose 50 [20-80] mg·kg−1). In three cases (0.7%), desaturations occurred which prompted termination of the scan. One infant (0.2%) was admitted for additional observation following sedation but had no prolonged effects. In 17 (3.1%) cases, infants had desaturations which were self-limiting or responded to additional inspired oxygen such that scanning was allowed to continue. Conclusion When adhering to strict protocols, MRI scanning in newborn infants in this cohort was performed using chloral hydrate sedation with a relatively low risk of significant adverse effects. [ABSTRACT FROM AUTHOR]

Background: The position of percutaneously inserted central venous catheters (longlines) in neonates is critical, as malpositioned longlines are associated with potentially fatal complications. Aim: To determine if cardiac ultrasound (two-dimensional (2D) and colour Doppler) is useful in evaluating longline position, when compared with the position identified by contrast radiography. Setting: Single level 3 neonatal unit. Participants: Forty-four neonates undergoing insertion of 24-gauge silastic longlines between July 2004 and September 2005. Methods: Infants who had a longline inserted underwent echocardiography by a novice and an experienced operator. Operators identified longline position using a 2D then colour Doppler echocardiography during a rapid bolus infusion of saline. The position was identified from contrast radiography by two independent observers. Results: Using 2D echocardiography, the novice and experienced operators could identify 41 and 59% of longlines, respectively. However, only 34% of longlines were identified by both operators. In 15 infants whose longline positions were identified by both operators, there was agreement in only eight infants (53%). Colour Doppler improved the experienced operator's success but did not assist the novice operator. For radiographs, there was 68% agreement on longline position between observers. The experienced echocardiographer located three (7%) longlines within the heart that from radiographs were thought to be in a proximal central vessel. Conclusions: This technique is experience-dependent and complements rather than replaces the use of contrast radiography. However, some infants with an apparently acceptable longline position on contrast radiography have longlines located within the heart on echocardiography. [ABSTRACT FROM AUTHOR]

In thirty-two neonates with congenital heart disease, who had failed umbilical venous catheter placement using traditional, "blind" techniques, real-time ultrasound-guidance and liver pressure were used to replace malpositioned umbilical venous catheters and achieve successful placement at the inferior cavoatrial junction. Real-time ultrasound guidance has become standard of care for central venous line placement in children outside the neonatal period but is a new and emerging technique for umbilical vessel catheterization. We sought to use real-time, point-of-care ultrasound to achieve successful central umbilical venous cannulation in patients for whom traditional blind placement techniques had failed. [Extracted from the article]

An abstract of the article "Quantification of aortic pulse wave velocity in preterm infants using 4D phase contrast MRI," by Kathryn Broadhouse, Anthony N. Price, Giuliana Durighel, Anna Finnemore, David J. Cox, A.D. Edwards, Joseph V. Hajnal and Alan Groves is presented.

An abstract of the article "Validation of MRI quantification of biventricular cardiac function in term and preterm neonates," by Anna Finnemore, Anthony N. Price, Giuliana Durighel, Kathryn Broadhouse, David J. Cox, and Alan Groves is presented.

An abstract of the article "Analysis of neonatal cardiac function in infants with and without patent ductus arteriosus," by Kathryn Broadhouse, Anthony N. Price, Giuliana Durighel, Anna Finnemore, David J. Cox, A.D. Edwards, Joseph V. Hajnal, and Alan Groves is presented.

An abstract of the article "Frequency drift during intensive SSFP scanning: implications and solution for 3T neonatal CMR," by Anthony N. Price and colleagues is presented.

The article presents information on comparison of oxygen targeting measured with the help of Masimo pulse oximeter and Philips pulse oximeter in infants. It mentions that oxygen saturation as expected in infants gives an indication for mortality. Two graphs depicting oxygen saturation level measured with the help of Masimo SatShare interface and Philips module are presented.

The article presents an abstract on a paper titled "Impact of Neonatal Cardiac Receive-Array Coil on SNR and CNR in Newborn Infants," presented at the 2011 Society for Cardiovascular Magnetic Resonance (CMR)/Euro CMR Joint Scientific Sessions held in France.

The article presents a case study of a ex-preterm infant who has recovered from the staphylococcal sepsis and developed respiratory distress. The mean airway pressure on continuous positive airway pressure was increased in baby, and the chest X-ray and chest computed tomography showed an enlarge multiseptated right-sided pneumatocoele. He was treated with dexamethasone to reduce inflammation.

The article discusses the visualization of patent ductus arteriosus (PDA) by the use of four-dimensional (4D) phase contrast magnetic resonance imaging (PCMRI) in the preterm infant. Topics discussed include echocardiography offers the higher sensitivity for detection of PDA, quantitative analysis of hemodynamics throughout the cardiac cycle and the morphology of duct, thoracic vessels and blood flow also resolved.

Objective: To use cardiac MRI techniques to assess ventricular function and systemic perfusion in preterm and term newborns, to compare techniques to echocardiographic methods, and to obtain initial reference data.Design: Observational magnetic resonance and echocardiographic imaging study.Setting: Neonatal Unit, Queen Charlotte's and Chelsea Hospital, London, UK. Patients 108 newborn infants with median birth weight 1627 (580-4140) g, gestation 32 (25-42) weeks.Results: Mean (SD) flow volumes assessed by phase contrast (PC) imaging in 28 stable infants were left ventricular output (LVO) 222 (46), right ventricular output (RVO) 219 (47), superior vena cava (SVC) 95 (27) and descending aorta (DAo) 126 (32) ml/kg/min, with flow being higher at lower gestational age. Limits of agreement for repeated PC assessment of flow were LVO ±50.2, RVO ±55.5, SVC ±20.9 and DAo ±26.2 ml/kg/min. Mean (SD) LVO in 75 stable infants from three-dimensional models were 245 (47) ml/kg/min, with limits of agreement ±58.3 ml/kg/min. Limits of agreement for repeated echocardiographic assessment of LVO were ±108.9 ml/kg/min.Conclusions: Detailed magnetic resonance assessments of cardiac function and systemic perfusion are feasible in newborn infants, and provide more complete data with greater reproducibility than existing echocardiographic methods. Functional cardiac MRI could prove to be a useful research technique to study small numbers of newborn infants in specialist centres; providing insights into the pathophysiology of circulatory failure; acting as an outcome measure in clinical trials of inotropic intervention and so guiding clinical practice in the wider neonatal community. [ABSTRACT FROM AUTHOR]