Moving Beyond the Stethoscope:

Diagnostic Point-of-Care Ultrasound in

Pediatric Practice
Thomas W. Conlon, MD,a Akira Nishisaki, MD, MSCE,a Yogen Singh, MBBS, MD, DCH, FRCPCH,b Shazia Bhombal, MD,c
Daniele De Luca, MD, PhD,d,e David O. Kessler, MD, MSc,f Erik R. Su, MD,c Aaron E. Chen, MD,g María V. Fraga, MDg

Diagnostic point-of-care ultrasound (POCUS) is a growing field across all abstract

disciplines of pediatric practice. Machine accessibility and portability will only
a
continue to grow, thus increasing exposure to this technology for both Departments of Anesthesiology and Critical Care Medicine
and gPediatrics, Children’s Hospital of Philadelphia and
providers and patients. Individuals seeking training in POCUS should first Perelman School of Medicine, University of Pennsylvania,
identify their scope of practice to determine appropriate applications within Philadelphia, Pennsylvania; bCambridge University Hospitals
National Health Service Foundation Trust, Cambridge, United
their clinical setting, a few of which are discussed within this article. Efforts to Kingdom; cDepartment of Pediatrics, Lucile Packard
build standardized POCUS infrastructure within specialties and institutions Children’s Hospital Stanford, Palo Alto, California; dDivision
of Pediatrics and Neonatal Critical Care, Hopital Antoine
are ongoing with the goal of improving patient care and outcomes. Béclère, University Hospitals of South Paris, AP-HP, Paris,
France; ePhysiopathology and Therapeutic Innovation Unit,
Inserm U999, Université Paris-Saclay, Paris, France; and
f
Department of Emergency Medicine, Vagelos College of
Physicians and Surgeons, Columbia University, New York,
Point-of-care ultrasound (POCUS) is a specific clinical question, narrow New York
emerging as an essential addition to the differentials, guide clinical therapy, and
Drs Conlon and Fraga conceptualized, designed, and
21st-century pediatrician’s bag. direct consultations and disposition.4–9 drafted the initial manuscript; Drs Nishisaki, Singh,
Advances in ultrasound technology For this review, we assembled a group Bhombal, De Luca, Kessler, Su, and Chen contributed
have resulted in improved image of international pediatric POCUS to drafting sections of the manuscript; and all
quality and portability (Table 1). This leaders to discuss the basics of authors reviewed and revised the manuscript,
ultrasound image generation, assess the approved the final manuscript as submitted, and
has increased ultrasound accessibility
agree to be accountable for all aspects of the work.
to pediatric providers beyond scientific literature, and highlight
traditional imaging specialists, such as current and emerging POCUS
radiologists and cardiologists. In applications relevant to varied Editors’ note: This month’s State-of-the-Art Review
environments where imaging resources disciplines within pediatric practice. article is the first of 2 on point-of-care ultrasound.
are limited, diagnostic POCUS has The second article on interventional point-of-care
ultrasound will follow next month.
improved patient outcomes and even REVIEW OF ULTRASOUND PRINCIPLES
been used during spaceflight.1–3
Incorporation of diagnostic POCUS in Physics and Knobology
DOI: https://doi.org/10.1542/peds.2019-1402
clinical decisions is fundamentally Ultrasound is a sound wave traveling Accepted for publication Jun 19, 2019
different from the traditional practice through and interacting with human
model, in which a pediatric provider Address correspondence to Thomas W. Conlon, MD,
tissue. An ultrasound transducer Department of Anesthesiology and Critical Care
orders a study, waits for an external spends a short time emitting Medicine, Children’s Hospital of Philadelphia, 3401
service to acquire and interpret images, ultrasound waves via piezoelectric Civic Center Blvd, Philadelphia, PA 19104. E-mail:
and then applies the information within crystals. The same transducer then conlont@email.chop.edu
the clinical context. Diagnostic POCUS is spends time “listening” for the PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
dynamic; that is, the same provider can returning waves. Waves received by the 1098-4275).
perform and interpret the study, rapidly transducer are processed and Copyright © 2019 by the American Academy of
integrate this information within the converted into a two-dimensional Pediatrics
immediate clinical setting, and then image on a screen. The amplitude of
repeat the study to identify changes a returning wave is translated to the To cite: Conlon TW, Nishisaki A, Singh Y, et al.
associated with intervention. brightness of the image, and the return Moving Beyond the Stethoscope: Diagnostic
Point-of-Care Ultrasound in Pediatric Practice.
Diagnostic POCUS complements history time for a wave is translated to the
Pediatrics. 2019;144(4):e20191402
and physical examination to answer depth of the image. The frequency of

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PEDIATRICS Volume 144, number 4, October 2019:e20191402 STATE-OF-THE-ART REVIEW ARTICLE
TABLE 1 POCUS Machine Types and Characteristics
Machine Type Strengths Weaknesses Size Approximate Cost, $
(USD)
Console High-level image processing and quality Large machine size, wt, Full platform, often left stationary ∼85 000–300 000
portability in an examination or operating and higher
room
Transesophageal echocardiography, other Expense, including
hardware-based special modalities maintenance
Postprocessing modalities Ease of use for novices
Wide array of pediatric-specific customization Few have batteries for
portability and data
protection
Portable and/or Size and mobility Less pediatric customizability Cart-based, often detachable as ∼25 000–75 000 and
compact (eg, probes) than a full a laptop configuration higher
console
Typically offers most core ultrasound modalities Decreased imaging quality
with measurement and image storage function; compared with a console
complete spectrum of POCUS applications
Some advanced functionality seen in consoles Expense, including
may be available maintenance
Pediatric probes available
Procedural Size and mobility; some mountable in rooms or on Diagnostic capabilities limited Stand-based or mountable small- ∼15 000 and higher
procedure carts footprint machines designed
primarily for procedural
guidance
Simplified interface for fast workflow Advanced imaging functions
unlikely
Simple tablet-shaped design in most for easy Limited probe and/or
maintenance pediatric options
Image storage and
measurement may not be
as precise if present
Ultraportable Rapid deployment for transport and critical Readily misplaced Handheld or tablet-based design ∼2000–16 000
situations for mobility
Ease of use for novices Limited probe and/or
pediatric options
Some products have a multifunction probe Dependent on battery
longevity
Expense Limited image quality and
optimization options
Image storage and
measurement not as
precise (if present)
May require purchase of
tablet or smartphone and
monthly subscription
USD, United States dollars.
a Retail costs are estimated and approximated for the US market. Final costs to providers and institutions are dependent on additional purchasing factors and may vary widely.

the emitted wave is dependent on the pleural assessment in which the Image quality can be optimized by
probe used, with modifications made target for interrogation lies close to the following best practice: (1)
by the provider. In general, the higher the probe. Conversely, low-frequency Choose the right probe for study.
the frequency, the higher the image probes have good penetration Consideration of not only the
resolution, although this is at the but do not have the axial or ultrasound wave frequency but
expense of limited penetration. longitudinal resolution found in also the probe footprint (ie, size
High-frequency probes are therefore higher-frequency probes. For of the probe relative to the
ideal for evaluation of superficial example, a curvilinear probe site of image acquisition) and
structures. Linear probes have (2–5 MHz) is ideal for abdominal appropriate probe preset (ie,
the highest frequencies, ranging assessment, which requires adequate commercially developed software
from 8 to 22 MHz, and are often used tissue penetration for visualization specific to the POCUS study type)
for vascular-access procedures or of structures. should be undertaken. (2) Adjust the

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2 CONLON et al
depth of the image. Image resolution displays the brightness and depth of Ergonomics
and interpretation is best optimized the structure on the screen as a two- Optimizing provider, patient, and
when a target organ is located in the dimensional image. (2) M (motion) machine position is essential to
middle of the image and surrounding mode is a one-dimensional consistently obtaining high-quality
structures can be visualized. (3) measurement set through the studies. For procedural guidance, it is
Adjust the gain of the image. In scanning plane and plotted over time. essential that the provider, procedural
principle, image quality is optimized This allows for point-in-time site, and ultrasound screen are in the
when the structure that should measurement, such as fractional same line of vision. Typically, an
appear bright (fascia, bone, and air) shortening of the diameter of the left ultrasound probe should gently touch
appears bright and the structure that ventricle (LV). (3) Doppler ultrasound a patient’s body surface without
should appear black (blood, urine, visualizes movement. Typically, blood strong pressure. This is particularly
and bile) appears black. Within the flow (color Doppler for the presence important when a targeted organ is
black-white spectrum are varied and direction of flow, pulsed-wave easily collapsible (ie, central or
shades of gray that arise from the Doppler for flow velocities at a set peripheral vein), although some
scanned medium. The dynamic range depth, and continuous-wave Doppler studies require pressure as
settings of the machine can increase for flow velocities at a set beam) or a diagnostic component of the
or decrease the number of shades tissue movement (tissue Doppler) are assessment (eg, deep venous
visualized to further optimize an measured with this technology. thrombosis or appendicitis
image. The brightness of a structure evaluation). The hand holding a probe
is described as hyperechoic, should be anchored to the patient’s
Understanding Artifacts
hypoechoic, or isoechoic and is body surface, typically using the fifth
relative to the surrounding tissue. Pediatric providers should be aware digit as a contact, to avoid unintended
Anechoic brightness can be used to of common artifacts generated by probe sliding. Especially in small
describe a structure that is ultrasound (Table 2, Fig 1 A–E). infants, small movements may cause
completely black on the screen. The Understanding the reason why significant changes in the image.
amplitude of a returning wave, and a particular artifact is generated is
therefore its corresponding important because it will allow
brightness, is dependent on the wave- pediatric providers to use the artifact
for image quality optimization, make HEMODYNAMIC POCUS
tissue interaction (ie, absorption,
scattering, reflection, and refraction). a proper diagnosis, or avoid Hemodynamic POCUS, also referred
misinterpretation. A good example is to as functional, focused, or targeted
There are 3 commonly used lung ultrasound, which relies on the echocardiography, provides
ultrasound modes: (1) B (brightness) use of artifacts (or their absence) to physiologic information regarding
mode is the most basic image, which identify pathologic processes. preload, contractility, and afterload

TABLE 2 Common Ultrasound Artifact Findings, Image Interpretation, and Diagnostic Assessment
Ultrasound Artifact Image Interpretation Diagnostic Assessment
Acoustic shadowing A structure that reflects most of ultrasound wave, resulting in Diagnostic clue for strong reflector (eg, gall stone or calcified
(Fig 1A) a bright image and underlying dark area structure)
Posterior acoustic Relative brightness behind a structure that is hypoechoic or Diagnostic clue for presence of an abscess in soft tissue
enhancement anechoic ultrasound
(Fig 1B)
Adjust gain to avoid missing free fluid in abdominal ultrasound
when evaluating structure behind urinary bladder
Reverberation artifact Presence of highly reflective structures makes ultrasound waves The presence of vertical lines in lung POCUS (known as B or Z
(Fig 1C) bounce multiple times before they return to a probe lines) is due to the apposition and reverberation of the visceral
and parietal pleura and can exclude the diagnosis of
pneumothorax
Mirror image (Fig 1D) Presence of strongly reflective surface refracts ultrasound wave The common appearance of normal lung (no parenchymal
in an altered direction; the returned wave is misinterpreted as disease, pleural effusion, or pneumothorax) in a right-upper —
though it comes from a deeper structure quadrant ultrasound is often visualized as the liver “mirrored”
over the diaphragm
Edge artifact (Fig 1E) A dark line generated by a lateral border of an anechoic circular Be aware of the presence of the artifact in image interpretation,
structure (eg, gall bladder) for example, avoid misinterpreting the artifact as acoustic
shadowing from a gall stone
Adapted from Boniface KS. Ultrasound basics: physics, modalities, and image acquisition. In: Brown SM, Blaivas MM, Hirshberg EL, et al, eds. Comprehensive Critical Care Ultrasound.
Mount Prospect, IL: Society of Critical Care Medicine; 2015.

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PEDIATRICS Volume 144, number 4, October 2019 3
 conditions to identify
pathophysiology and target therapies.
Hemodynamic POCUS does not aim to
identify congenital heart defects or
complex anomalies, which requires
pediatric cardiologist expertise,
although it may provide information
to suggest structural cardiac
abnormalities. Hemodynamic POCUS
is currently used in many NICUs and
PICUs around the world, and 2
American and European consensus
guidelines for neonatologists have
been published.11,12 However, despite
these guidelines, there remains
significant variation in practice.13
Hemodynamic POCUS can provide
invaluable information for indications
commonly encountered in varied
areas of pediatric practice,14 a few of
which we describe below.

Assessment of Volume Status and

Fluid Responsiveness
Fluid responsiveness is an increase in
stroke volume on fluid loading.15,16
Static measures, or single clinical
measurements at 1 point in time (eg,
central venous pressure, heart rate,
and arterial pressure), are unreliable
for assessing pediatric volume
responsiveness.17 Dynamic measures
for fluid responsiveness are those
altered by changes in intrathoracic
pressure associated with breathing.
Pediatric literature demonstrates that
quantification of changes in inferior
FIGURE 1
A, Arrow pointing to acoustic shadowing demonstrated in this transverse abdominal view. Ultra- vena cava (IVC) diameter as well as
sound waves are unable to penetrate bone (in this case, the vertebral body), thus resulting in a dark aortic outflow velocity are strong
field deep to the structure. The vertebral body is commonly used as a landmark when evaluating IVC predictors of fluid responsiveness
and aorta diameter for volume assessment. B, Posterior acoustic enhancement (arrow) on (Fig 2 A and B),17,18 although this has
a transverse view of a bladder (shown by the asterisk). This is a normal finding in bladder
assessment because ultrasound waves travel freely without loss of energy through a urine-filled yet to be validated in neonates.
bladder. Thus, ultrasound waves returning to the probe after having traversed the bladder will be
interpreted as being brighter than adjacent waves after having traversed through soft tissue. C, B Cardiac Function and Establishing
lines, or “comet tail artifacts,” are a type of reverberation artifact. B lines arise from the pleural Etiology of Shock
surface and can be seen in conditions in which pulmonary interstitial inflammation and edema
arise. D, Right-upper–quadrant view of the kidney (shown by the asterisk) and liver (shown with the Hemodynamic POCUS can
dagger symbol), with the bright, white line being the diaphragm. Well-aerated lungs will not allow qualitatively assess cardiac
ultrasound waves to be transmitted; thus, the image on the screen cranial to the diaphragm has the contractility (“eyeballing”) as well as
appearance of the liver, which is caudal to the diaphragm, resulting in a mirror artifact (shown by
the double-dagger symbol). E, Edge artifact whereby an ultrasound wave is deflected obliquely from
semiquantitatively assess LV function
a rounded surface, resulting in shadowing around the edges of that structure. In this case, there is by measuring fraction shortening.
soft shadowing along the edge of the carotid artery, which is identified by the arrows. Pediatric providers consistently
demonstrate rapid skill acquisition
and accurate interpretations in varied
hemodynamic POCUS
applications.19–22 Furthermore,

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4 CONLON et al
FIGURE 2
A, Respiratory variation of the IVC measured by using M mode. In a spontaneously breathing patient, inspiration (I) with negative inspiratory force results
in inward movement of the IVC, whereas expiration (E) results in outward movement of the walls. Measurements can be made with threshold values
suggestive of fluid responsiveness. B, Respiratory variation of aortic flow velocity measured by pulsed-wave Doppler is another method to identify a fluid-
responsive patient.

hemodynamic POCUS, when detailed assessment of the causes of mortality.34 Hemodynamic POCUS can
compared with clinical examination the hemodynamic issues.”33 be used to diagnose PPHN, estimate
and laboratory-based data, alters our pulmonary artery pressure, direct
perceptions of underlying Pulmonary Hypertension therapies, and evaluate response
hemodynamic status and may change Persistent pulmonary hypertension of to therapy by serial reassessment.
our management.23,24 We know that the newborn (PPHN) is a common Signs of pulmonary hypertension,
cardiac output can be variable in cause of neonatal hypoxic respiratory such as hypertrophy with or
states of shock, such as sepsis, and insufficiency that results from without dilatation of right
that titration of therapies can a failure of normal circulatory ventricle (RV), enlarged right-sided
improve outcomes.25–27 Cardiac transition after birth. Most commonly, cardiac structures, and flattening
output can either be inferred or PPHN is secondary to impaired or of the interventricular septum,
directly measured within delayed relaxation of the pulmonary can be recognized by using
hemodynamic POCUS. In neonatology, vasculature due to diverse neonatal hemodynamic POCUS (Fig 3 A and
superior vena cava flow has been pulmonary pathologies, and its B).18,35 More advanced
used as a surrogate of cardiac presence is associated with high echocardiographic methods for the
output to determine systemic blood
flow during transitional circulation,
with a value . 40 mL/kg per minute
being associated with improved
neurologic outcomes and
survival.28–30

Clarifying an individual hemodynamic

profile through direct real-time
imaging may have important outcome
benefits for patients and force us to
challenge common paradigms and
algorithms.31 In fact, international
guidelines for resuscitation in shock
are increasingly embracing FIGURE 3
“echocardiography [as] the preferred A, Dilated RV (shown by the asterisk) relative to the LV (shown by the dagger symbol) suggesting
elevated right-sided pressure in an adolescent patient presenting to the emergency department
modality to initially evaluate the type
with pulmonary embolism. B, Parasternal short-axis view of the interventricular septum bowing into
of shock as opposed to more invasive the LV (shown by the dagger symbol) in a neonate, also suggestive of elevated RV (shown by the
technologies,”32 “enabl[ing] a more asterisk) pressure.

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PEDIATRICS Volume 144, number 4, October 2019 5
 Pneumonia
Pneumonia has consistent ultrasound
findings across ages, including areas
of consolidation with irregular
borders and air bronchograms (Fig 5
A and B, Supplemental Videos A and
B).39 Thoracic POCUS for assessment
of pneumonia seems equally useful
for neonates and older children. Two
recent studies demonstrated that
ultrasound findings have optimal
diagnostic accuracy and performed
better than conventional radiology to
diagnose neonatal pneumonia.46,47
This is confirmed by a recent
pediatric study showing that ∼60% of
pneumonia signs identified by lung
FIGURE 4 ultrasound were undetected by
Continuous-wave Doppler across the tricuspid valve in this parasternal short-axis view at the level of conventional radiology.48 Moreover,
the base measuring the peak regurgitant velocity. The velocity can be incorporated into the modified a randomized controlled trial of
Bernoulli equation to quantify RV pressure. thoracic POCUS versus conventional
radiology for pediatric pneumonia in
emergency departments showed no
estimation of pulmonary artery duration when it is incorporated into missing cases of pneumonia and
systolic pressure can be performed by practice.41,42 a 30% to 60% reduction in the use of
measuring pressure gradients across chest radiographs.49 These results are
the tricuspid valve (Fig 4), ventricular confirmed on a larger scale by
septal defect, and patent ductus LUNG POCUS
3 meta-analyses of thoracic
arteriosus. In patients with Well-aerated lungs cannot be directly ultrasound diagnostic accuracy in
pulmonary embolism and thrombus, visualized because of the high children, all reporting high specificity
ultrasound can demonstrate the acoustic impedance between soft and sensitivity.50–52
above findings as well as a direct tissue and air, resulting in ultrasound
visualization of a clot.36,37 wave reflection at the pleural line. As Studies also indicate that thoracic
lungs become diseased and less POCUS is useful and reliable in
Use of POCUS During aerated, different artifacts arise, and diagnosing pediatric pneumonia in
Cardiopulmonary Resuscitation on extreme ends of disease, lung different settings, including general
Rapid assessment with bedside parenchyma may be directly pediatric wards,53 PICUs,54
ultrasound can provide crucial visualized. Pathologic processes and emergency departments,55 and
information regarding the etiology of their corresponding ultrasound hospitals in developing countries56
cardiac arrest and provide critical findings are now well described in with high interrater agreement.
information for management. the pediatric thoracic POCUS Automated image analysis is under
Especially in patients with pulseless literature.43 Because lung POCUS investigation because it may provide
electrical activity, bedside ultrasound does not use ionizing radiation and is the diagnosis of pneumonia without
can differentiate etiologies such as readily available at the bedside, expert ultrasonographers and be
pericardial tamponade and trained providers envision the particularly useful in low-resource
pneumothorax, which lead to life- technology as a potential replacement countries.57
saving intervention.38,39 for chest radiography for a number of
Hemodynamic POCUS during cardiac pediatric thoracic conditions. A Pneumothorax and Pleural Effusion
arrest has not been well evaluated in formal program introducing lung Classic lung ultrasound signs of
pediatric populations40; therefore, ultrasound as the first-line imaging pneumothorax are the absence of
this practice must be thoughtfully technique in NICUs has reduced lung sliding and any parenchymal
integrated with high-quality radiation exposure by ∼70%.44 sign and the presence of the so-called
cardiopulmonary resuscitation, Integration of clinical data with lung stratosphere sign (also known as the
especially because adult studies have ultrasound complements diagnosis barcode sign) when using M mode
demonstrated prolonged pulse-check capabilities.45 (Fig 6, Supplemental Video).

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6 CONLON et al
 preterm infants.72,73 A similar
correlation has been demonstrated
between lung ultrasound scores and
oxygenation in adult patients.74 Thus,
a new protocol, called echography-
guided surfactant therapy (also
known as ESTHER), has been recently
proposed to guide surfactant
replacement in preterm neonates
treated with continuous positive
airway pressure. Use of the protocol
improved the timeliness of surfactant
therapy and reduced the duration of
invasive ventilation.75

FIGURE 5 ABDOMINAL POCUS

A, Subpleural consolidation (arrow) and either B-line patterns or, in this instance, diffuse hyper-
echoic appearance of the underlying lung suggesting pulmonary edema or inflammation can be The use of abdominal POCUS is
seen early in bacterial pneumonias as well as in bronchiolitis, RDS, pediatric acute respiratory common for several clinical
distress syndrome and meconium aspiration syndrome. B, The lung (shown by the asterisk) in
severe pneumonia may appear “hepatized” (ie, resembling the solid organ architecture of the liver; presentations across the pediatric age
shown by the dagger symbol; diaphragm marked by the arrow) and is often surrounded by pleural spectrum, such as abdominal pain or
effusion (black). emesis. Therefore, abdominal POCUS
is an important diagnostic adjunct for
Semiquantification of pneumothorax complications and is therefore a variety of clinical situations.
volume is feasible and has been recommended by current
Abdominal Pain
previously described.58 Two international guidelines.68 No specific
diagnostic studies demonstrated that pediatric data are available; however, Abdominal POCUS can help diagnose
lung ultrasound may be sensitive and this is a well-recognized use of many specific conditions and enhance
specific to detect pneumothorax in ultrasound. medical decision-making in
neonates,59,60 and case reports undifferentiated abdominal pain by
suggest similar usefulness in critically Neonatal Respiratory Distress narrowing and expediting the
ill children.61,62 Thoracic POCUS
Syndrome and Need for Surfactant workup.76 Familiarity with abdominal
Replacement sonography may even allow an astute
is safe and useful to quickly guide
chest drainage or needle aspiration Lung POCUS assists in the diagnosis sonologist to pick up rare diagnoses
in neonates with pneumothorax.63 of neonatal respiratory failure.39 of abdominal pain, such as ascaris
These data are consistent with Moreover, it is useful to guide lumbricoides infection.77
adult critical care data showing surfactant administration in neonates
with respiratory distress syndrome Appendicitis
that lung ultrasound has
a comparable specificity, but higher (RDS). Surfactant should be Acute appendicitis is the most
sensitivity, than conventional considered in preterm infants with common childhood surgical
radiology for the diagnosis of RDS when continuous positive airway emergency associated with
pneumothorax.64 pressure fails and within the first abdominal pain and benefits from
hours of life to maximize its effect.69 early recognition. To minimize
Pleural effusion is easily visualized as Surfactant is usually administered radiation, ultrasound should be the
an extrapulmonary hypoechoic image when the inspired oxygen fraction is initial imaging modality in
between the parietal and visceral beyond a given threshold.70,71 assessment (Fig 8, Supplemental
pleural membranes. Effusions are However, inspired oxygen cannot Video).78 Skilled operators can
commonly categorized as simple or adequately describe oxygenation and achieve accuracy that approximates
complex, which has assisted in may increase after the optimal time that of computer tomography
guiding treatment course (Fig 7 A and frame for surfactant administration. imaging.79,80 Combining POCUS with
B).65,66 Thoracentesis and chest tube Semiquantitative POCUS lung scores other imaging modalities in
placement for pleural effusion are describing lung aeration strongly a stepwise approach is another way
commonly performed under correlate with oxygenation and are to improve overall diagnostic
ultrasound guidance in adult critical accurate in predicting need for accuracy, decrease costs, and reduce
care.67 This is shown to reduce surfactant in preterm and extremely computer tomography scan

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PEDIATRICS Volume 144, number 4, October 2019 7
 be easily learned by trainees (Fig 10
A and B, Supplemental Video).86,87 In
addition to helping in making the
diagnosis, ultrasound may help reveal
signs of ischemia or other high-risk
features that may prompt surgical
management as opposed to typical
reduction.88 Echogenic foci within the
bowel wall, representing intraluminal
air, can also be seen in other diseases
associated with bowel-wall necrosis,
such as necrotizing enterocolitis in
newborns.89

Pediatric Abdominal Trauma

In children with blunt abdominal
trauma, a focused assessment with
sonography for trauma (FAST)
protocol can help identify
hemorrhage in the intraperitoneal
cavity. Although no large studies have
FIGURE 6 demonstrated a clear benefit of
M mode capturing a “lung point,” which indicates the presence of a pneumothorax. The apposition of a single FAST evaluation, there is also
the parietal and visceral pleura in well-aerated lungs results in a bright, white line in M mode minimal harm from this study.90
(arrow, pleural line). Movement of the parietal and visceral pleura against one another in well- Dynamic or serial FAST evaluations
aerated lungs during inspiration and expiration creates lung slide and on M mode is characterized
by granularity below the pleural line (termed “seashore sign”). A pneumothorax creates an air-filled may help safely monitor pediatric
separation between the visceral and parietal pleura. Lung slide is no longer present and on M mode trauma patients and avoid
is characterized as the absence of lung-sliding straight lines (also termed barcode sign or unnecessary ionizing imaging tests.91
stratosphere sign). In this image, a patient is taking breaths with the presence of pneumothorax and
normal lung crossing the one-dimensional M-mode path on inspiration and expiration. On in- Forays into the use of abdominal
spiration, the aerated lung displaces the free air of the pneumothorax, resulting in lung slide and, POCUS to estimate stool burden in
thus, seashore sign. On expiration the lung moves away from the M-mode path, resulting in barcode constipation or in presedation
sign due to the free air between the visceral and parietal pleura, thereby preventing lung slide.
evaluation of stomach contents open
new avenues for future exploration of
usage.81–83 Even with limited Pyloric Stenosis this modality.92,93 The introduction of
training, providers can achieve Pyloric stenosis typically presents contrast-enhanced methods into the
a reasonable level of accuracy to help between 1 and 3 months of age and is POCUS arsenal will also introduce
guide further management.84 the most common surgical cause of new diagnostic possibilities for
nonbilious emesis in the newborn evaluation of solid organ injury and
Emesis (Fig 9, Supplemental Video). The disease.
primary method of diagnosis is
Vomiting in the newborn period can ultrasound. Pediatric emergency
represent a host of etiologies, both CEREBRAL POCUS
medicine physicians should feasibly
benign and emergent. POCUS can help perform this evaluation at the point Neurologic ultrasound has
rapidly differentiate more serious of care, which helps facilitate decisive increasingly become an application of
causes and expedite definitive management.85 interest, although brain imaging
management. Malrotation with modalities are frequently user
midgut volvulus, inflammatory dependent, extremely nuanced, and
bowel disease, and pancreatitis Intussusception and Necrotizing understudied. Direct neurosonology
have specific sonographic findings, Enterocolitis of the brain and its vessels is
yet these are not frequent Any child presenting with vomiting, complicated by view obstruction from
POCUS applications. Some of the abdominal pain, altered mental bone, although this is commonly
more common diagnostic status, or blood in the stool should be performed through open fontanelles
applications of POCUS include promptly evaluated for and represents the first-line
evaluation for pyloric stenosis intussusception. Several studies neuroimaging technique commonly
and intussusception. demonstrate that this application can performed in NICUs.94 It is

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8 CONLON et al
 and asking patients to move their
eyes while being assessed with
ultrasound in trauma and orbital
cellulitis has been described.96 In
situations in which the retina is
injured and separated from the
internal wall of the eye, the
separation of the tissue planes has
been detected by using ultrasound.97
This is potentially useful in the
assessment of patients with retinal
injury from abusive head trauma, and
additional studies regarding its
applicability as a survey instrument
FIGURE 7 are warranted. Ophthalmic
A, Simple pleural effusion (shown by the asterisk) at the costophrenic recess outlined by the
thoracic wall, lung (shown by the dagger symbol), and diaphragm (arrow). B, Complex pleural
ultrasound should be avoided
effusion with fibrinous stranding (arrows) outside the lung (shown by the dagger symbol). in situations in which there is
a known traumatic globe injury.
remarkably useful even in the hands plane above the upper eyelid. This is Furthermore, although ultrasound is
of novice leaners in low-resource particularly useful in clinical typically considered a low-risk
settings.95 Alterations in cerebral scenarios in which a pupillary diagnostic tool, the cornea can be
arterial flow allow inferences to be response is difficult to assess on damaged by the heat (thermal index),
made regarding brain pathology, physical examination because of vibration (mechanical index), and
although the current literature is congenital corneal opacification or radiation force (acoustic power) from
insufficient to support its use in in situations in which the eyelids ultrasound waves produced by the
POCUS applications because of cannot be opened because of edema machine. Machines often have an
difficulty distinguishing changes or injury (Fig 11 A and B, “ophthalmic safety mode” within
in blood flow velocity from Supplemental Video). The orbit and probe presets to minimize the
compression versus those due to its extraocular movements can also risk of injury during ophthalmic
intrinsic stenosis or changes in be inspected in these situations, examinations.
relative perfusion.
Ophthalmic ultrasound has also been
an extension of neurologic ultrasound
applications. The iris can be examined
by holding the probe in the coronal

FIGURE 8
Appendicitis characterized by an inflamed ap- FIGURE 9
pendix (arrow) with hyperechoic fat stranding Fluid-distended stomach (shown by the asterisk) and thickened pylorus (arrow) in a patient with
(shown by the asterisk). pyloric stenosis.

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PEDIATRICS Volume 144, number 4, October 2019 9
 VASCULAR POCUS
Although clinician ultrasound in
vessel imaging has been described
much more in the procedural arena,
the technology has also been applied
to assessing thrombosis.100 Thrombi
extension through the vascular
system obstructs flow and can appear
cylindrical, pedunculated, and linear
and is often related to intravascular
devices, most commonly central
venous catheters.100 Techniques to
image the obstruction involve using
color-flow or spectral Doppler
(pulsed or continuous) to identify
FIGURE 10 aberrant flow at the level of the
A, Target sign identified in ileocolic intussusception. B, Outer layers (solid line) represent the thrombosis.
intussuspient bowel wall and lumen, whereas inner layers (dash line) represent intussusceptum
consisting of the bowel wall, lumen, and mesenteric fat. Noncompressibility of a vascular
structure is a concerning finding,
Measurement of the optical nerve obstructive hydrocephalus.98 suggesting the presence of
sheath diameter is suggestive of Conceivably, other patients with a thrombus. Lower-extremity
papilledema and increased chronic papilledema, such as those ultrasound scanning for thrombus
intracranial pressure (Fig 12); with pseudotumor cerebri and identification by bedside
however, sources conflict on craniosynostosis, would also have practitioners requires serial
threshold measurements, and wider baseline optic nerve sheath compression of thigh vessels from the
papilledema may persist despite diameters.99 inguinal ligament to the popliteal
normalization of intracranial fossa. This has been termed the 3-
pressure.94 Despite having some point compression technique because
elasticity, the sheath may in addition to the inguinal and
become stretched over time, as popliteal areas, the 3-point
seen in both shunted and nonshunted compression technique includes the
patients with a history of superficial femoral vein.101 The 3-
point technique has been
demonstrated to be superior to the 2-
point technique.101–103 It is crucial
that the operator recognize the
potential for dislodging thrombi with
serial compression, especially when
a thrombus can be directly visualized.
It is clear that pediatric patients
develop deep vein thrombosis for
reasons that are different from those
of adults; therefore, a pediatric study
in deep vein thrombosis screening is
needed.

SOFT TISSUE AND MUSCULOSKELETAL

POCUS

FIGURE 11 Soft Tissue

A, Pupil (shown by the asterisk) and sur- FIGURE 12 Similar to in adult studies, POCUS has
rounding iris (arrow) in transverse view with Optic nerve (shown by the asterisk) visualized
the eyelid closed. B, Consensual pupillary light in the anterior-posterior view of the eye and
been shown to improve the ability of
reflex of the eye with the eyelid remaining nerve head elevation noted within the vitreous pediatric clinicians to distinguish soft
closed. chamber (arrow). tissue abscesses from simple

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10 CONLON et al
cellulitis104 as well as to affect clinical as ultrasound-guided aspiration of
management.105 Foreign bodies in periosteal pus119 (Fig 15,
particular are notoriously difficult to Supplemental Video) may, in the near
diagnose and manage and are future, significantly improve
considered 1 of the leading causes of outcomes for children by facilitating
malpractice suits in emergency as well as expediting the diagnosis of
medicine.106 Ultrasound allows the organisms causing these
clinicians to diagnose the presence of infections.
foreign bodies as well as guide their
removal by allowing for visualization
of the orientation, size, and depth of CONSIDERATIONS FOR TRANSLATION TO
FIGURE 14 CARE
the object while avoiding adjacent Salter Harris type 2 fracture of the distal ra-
structures (vessels, nerves, etc; Fig 13 dius (arrow) not identified on initial Defining a scope of practice is
A and B).107 This is especially radiography. fundamental for bedside ultrasound
important for nonradio-opaque practice and is dependent on many
foreign bodies, for which fluoroscopy Hip Effusion and Dysplasia factors, including practice specialty,
would be rendered useless. Numerous studies have shown that local patient population, and hospital
POCUS can be used to diagnose structure. Three fundamental
Fractures elements should be considered when
pediatric hip effusions with high
There are numerous studies that have sensitivity and specificity compared determining if a POCUS application
established a role for POCUS as with radiography.115–117 Broadened should be included in practice: (1) Is
a screening test or diagnostic method use of POCUS for hip effusions will the clinical question amenable to
for suspected fractures, especially of likely translate to increased comfort ultrasound interrogation? (2) Is the
the long bones.108–110 Ultrasound can and skill with performing ultrasound- question answerable with discrete
also help identify radiographically guided diagnostic needle aspiration. qualitative or semiquantitative
occult fractures of the ankle and Small case series have shown that measures (ie present or absent; mild,
wrist111 (Fig 14) as well as there is potential for front-line moderate, or severe; etc)? (3) And is
radiographically occult avulsion providers to perform these types of this a clinical question I encounter
fractures,112 and it has been shown to procedures safely and frequently in my practice?
have higher discriminatory ability to competently.117 Ultrasound is also Amenability, measurability and
detect certain fractures, such as well known for the diagnosis of frequency allow for translation of
sternal fractures.113 Furthermore, congenital dysplasia of the hip and applications to learning objectives.
POCUS can be used to guide reduction may be performed by pediatricians, Defining scope of practice results in
attempts and potentially obviate the neonatologists, or radiologists.118 the identification of specific skills that
need for fluoroscopy,114 thereby
decreasing exposure to potentially Novel applications such as POCUS for
harmful ionizing radiation. the diagnosis of osteomyelitis as well

FIGURE 15
Purulent supraclavicular periosteal fluid iden-
tified and drained under ultrasound guidance.
The provider is using the out-of-plane (short-
axis) technique and can directly visualize the
FIGURE 13 needle tip (arrow) within the fluid collection
A, Foreign body (arrow) with posterior shadowing (shown by the asterisk) identified on ultrasound immediately above the clavicle in the trans-
of the palmar aspect of the hand, which was unable to be visualized on radiography. B, Ultrasound verse plane, which is identified by its posterior
guided the extraction of this foreign body. shadowing (shown by the asterisk).

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PEDIATRICS Volume 144, number 4, October 2019 11
will necessarily require structured Although many consider the harm when an ultrasound machine is
training. Development of structured integration of new technologies to be readily available. We do POCUS
training creates a path to competency a risk in clinical practice, data suggest because we should. Regardless of
in practice. that not using ultrasound, when the specialty, we have an individual and
Literature supports rapid acquisition technology is available, may actually collective responsibility to improve
of skill when goals are defined and place providers at increased medical- our performance and the outcomes of
training is structured. Longjohn legal risk.123,124 Multidiscipline the children we serve. Ultrasound
et al20 described a 2-hour, didactic, courses in pediatric POCUS can be harbors the potential to realize those
15-patient training program for found around the world, although the ideals.
pediatric emergency medicine translation of this training to practice
providers to assess 3 hemodynamic requires infrastructural support that
CONCLUSIONS
ultrasound parameters: (1) LV is often not present within
function, (2) the presence of departments and institutions.125 Ultrasound technology is more
pericardial effusion from the Well-developed guidelines from adult readily available for providers beyond
parasternal long-axis view, and (3) and pediatric emergency medicine traditional imaging disciplines.
IVC respiratory variation from the leaders may help standardize and Pediatric diagnostic POCUS is
subcostal view. In patient care, grow local POCUS programs when being practiced in a variety of
studies performed by trained adopted.126,127 disciplines and has a meaningful
providers had good to very good impact in patient care. Defining
agreement with cardiologists across Finally, defining the scope of practice a provider’s scope of practice
all evaluative domains (k = 0.87, 0.77, may avoid conflicts with other helps identify appropriate
and 0.73, respectively). A recent specialists. We do not perform diagnostic applications and establish
meta-analysis of POCUS for accuracy diagnostic POCUS simply because we training toward competency
in identifying appendicitis found can. We have a fundamental belief development.
a 91% sensitivity and 97% sensitivity. that diagnostic POCUS makes us
The training and experience of better physicians within our own
providers were heterogenous within respective domains of expertise. In ABBREVIATIONS
the 21 evaluated studies, with at least undifferentiated shock, images FAST: focused assessment with
3 studies describing training courses characterizing pathophysiologic sonography for trauma
#1 hour.120 Although short amounts processes to guide fluids and IVC: inferior vena cava
of intensive training can train novice inotropes seems more elegant than LV: left ventricle
providers to be reliable in image making decisions by pressing on POCUS: point-of-care ultrasound
acquisition and interpretation, recent a nail bed. Waiting for a chest PPHN: persistent pulmonary
literature suggests that knowledge121 radiograph often neither expedites hypertension of the
and skills122 are difficult to maintain nor improves accuracy in clinical newborn
over time, and greater research decisions. Blind insertion of needle RDS: respiratory distress
should be focused on the best into a pericardial sac as the final syndrome
methods of sustaining excellence in intervention before a declaration of RV: right ventricle
practice. death does not align with doing no

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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PEDIATRICS Volume 144, number 4, October 2019 17
 Moving Beyond the Stethoscope: Diagnostic Point-of-Care Ultrasound in
Pediatric Practice
Thomas W. Conlon, Akira Nishisaki, Yogen Singh, Shazia Bhombal, Daniele De
Luca, David O. Kessler, Erik R. Su, Aaron E. Chen and María V. Fraga
Pediatrics 2019;144;
DOI: 10.1542/peds.2019-1402 originally published online September 3, 2019;

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 Moving Beyond the Stethoscope: Diagnostic Point-of-Care Ultrasound in
Pediatric Practice
Thomas W. Conlon, Akira Nishisaki, Yogen Singh, Shazia Bhombal, Daniele De
Luca, David O. Kessler, Erik R. Su, Aaron E. Chen and María V. Fraga
Pediatrics 2019;144;
DOI: 10.1542/peds.2019-1402 originally published online September 3, 2019;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/144/4/e20191402

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