Pediatric Ultrasound: Benefits, Barriers, and Best Practices of Point of Care Tools

As imaging becomes more portable, pediatric ultrasound is no longer the exclusive domain of pediatric radiology, or even emergency medicine. The compact size and ease of use of Point of Care Ultrasound (POCUS)  have put bedside sonography in the hands of pediatric clinicians across critical care.¹ 

This trend follows evidence affirming POCUS' diagnostic and procedural value for little hearts, lungs, vessels, and other organs. High accuracy rates, patient satisfaction, exam speed, and safety compared with radiation-intensive modalities have helped POCUS become a go-to adjunct tool for NICU and PICU patient workups^1,2 

Still, the relative newness of POCUS in pediatric settings comes with limitations—namely, a lack of training. Guidance is also limited in pediatrics, with the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) being the first to provide recommendations in 2020.² These challenges can further exacerbate care variability when unstandardized scans go undocumented and unusable. 

So what should clinicians know to make the most of POCUS' pediatric promise despite the barriers? Recently, authors in Frontiers in Pediatrics explored the topic in a comprehensive paper.¹ Here's what their findings suggest. 

Benefits and Applications of POCUS: Critical Care 

Pediatric POCUS has utility across two clinical aims: to diagnose and to guide procedures.¹ 

Diagnostically, clinicians have found success using bedside pediatric ultrasound on the heart, lungs, abdomen, and brain. Procedural ultrasound can support vascular line placement, drains, and lumbar puncture. Except for lumbar puncture, these and other applications have corresponding guidance from the ESPNIC. 

Lung Diagnostics 

More children present to the PICU with acute respiratory failure than any other reason, and more children die of pneumonia than any other cause worldwide. With the prevalence of these concerns, imaging has become essential to assess lung form and function.¹ 

For pneumonia, POCUS has outperformed chest X-rays with high sensitivity-specificity rates of 96% and 93%, respectively. Rates for pneumothorax have been similarly high, even reaching 100% among infants.¹ 

Other assessments made possible with lung ultrasound include the identification of lung edema, atelectasis, and pleural effusions among children and neonates.^1,2 In infants specifically, POCUS can help detect meconium aspiration syndrome and differentiate between respiratory distress syndrome and transient tachypnoea of the neonate.² 

Cardiovascular Diagnostics 

POCUS has been found to support diagnostic assessments of cardiac structure and function in children, which is necessary in the common case of hemodynamic instability. This evidence extends to non-cardiologists. In one study, POCUS achieved more than 90% accuracy among non-cardiologist operators for determining ventricle performance and size, as well as diagnosing pericardial effusion.¹ 

POCUS may also be useful for determining fluid responsiveness among pediatric patients on a ventilator—based on one study with 92% and 85.5% sensitivity and specificity—although that use case may require additional training due to the technical complexities of various measures such as velocity time integral (VTI).¹ 

Another cardiac application is to assess pulmonary hypertension among babies and children, a recommendation that received a strong agreement from the ESPNIC. The group also issued a separate recommendation supporting the use of POCUS to assess pulmonary artery systolic pressure.² 

Abdominal Diagnostics 

Abdominal applications of pediatric POCUS include the detection of free fluid, parenchymal changes in organs, obstructive uropathy, and indications of necrotizing enterocolitis—although the latter three may require the expertise of a pediatric radiologist during diagnosis.² 

While using POCUS as part of the focused assessment with sonography in trauma (FAST) exam has not been shown to measurably improve care in pediatrics, it also hasn't shown harm. For this reason, clinicians should still learn the exam.¹ 

Neuro Diagnostics 

Children make good candidates for cranial ultrasound given the softness of their skull.² Cerebral ultrasound, in turn, supports the assessment of traumatic brain injury in addition to other applications. Frequently performed metrics include the transcranial doppler estimation (for intracranial pressure, brain death, cerebral autoregulation, and vasospasm) and optic nerve sheath diameter (for intracranial pressure).¹ 

Procedural Applications 

Children frequently need a central line, and with its known successes including fewer missed tries, ultrasound has become the standard to guide these placements.¹ Other procedural applications include POCUS-guided paracentesis, thoracentesis, chest tubes, and drainage of peritoneal fluid.^1,2 

Additional evidence supports pediatric sonography before performing lumbar puncture, a procedure that is associated with failure rates as high as 50%. POCUS may help to better orient the procedure by identifying interspaces and landmarks.¹ 

Overcoming Barriers with Best Practices 

The expansion of POCUS in the PICU and NICU depends on an institutional infrastructure that supports and standardizes its use—but no such infrastructure exists, at least not yet. 

In 2018, a national survey in the United States identified five needs in this area: training, credentialing, image storage, documentation, and quality assurance.³ Many challenges stemming from those areas link to the lack of guidelines and competencies for children's ultrasound, except for those from the ESPNIC. And those from other specialties are mixed, such as the fact that the American College of Emergency Physicians recommends 25 to 50 exams for competency while the Society of Critical Care Anesthesiologists encourages 50.¹ However, some ultrasound protocols do exist, such as the SAFE-R algorithm for NICU patients, which can be helpful in the absence of established guidelines.⁴ 

While pediatric specialties await the broader changes necessary to advance the use of POCUS at a child or baby's bedside, practitioners and hospital leadership can effect change on an individual or site-based level through the adoption of best practices. 

One opportunity is for providers to explore self-paced training materials, such as those offered by industry associations like the American Institute of Ultrasound in Medicine⁵ or from ultrasound manufacturers such as GE Healthcare's Learning Labs. Operators can improve their proficiency gradually as they work their way up to more advanced applications. 

And, with so many scans lost due to the absence of a central place to store them, hospital leadership should look toward developing a permanent repository system in which to retain scans. Keeping records intact and organized can not only benefit care continuity but also continued learning and development. 

What's Next for Pediatric POCUS 

The impact of pediatric POCUS across pediatric specialties will certainly benefit from standardization, formalized trainings, and guidelines—which may be one of the most-needed and anticipated developments on the bedside sonography horizon.^1,2,6 

Indeed, POCUS has a variety of applications in the NICU and PICU and is increasingly becoming a part of the clinician's toolkit. It may be small, but just like the patients it serves, it's mighty, too. After all, that's what makes it so powerful. 

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