Belinda Chan

Background/Objectives: Hypoxic–ischemic encephalopathy (HIE) remains a leading cause of neonatal death and long-term neurodisability. Cardiovascular dysfunction commonly accompanies HIE and influences neurological recovery, yet it is difficult to recognize because conventional clinical signs correlate poorly with the myocardial function. This review summarizes the current evidence on cardiac dysfunction in neonates with HIE, with particular attention to the diagnostic tools used to evaluate cardiovascular function and the clinical outcomes associated with myocardial injury. Methods: We conducted a narrative review informed by a systematic, reproducible search of four databases (PubMed, Embase, Cochrane Library, and Web of Science) from 2000 to 2026, using a Population–Concept–Context framework to identify studies of term and near-term neonates (≥35 weeks gestation) with HIE or perinatal asphyxia reporting a measure of cardiac dysfunction (electrocardiographic, biomarker, echocardiographic, or clinical hemodynamic). Records were screened and selected using Covidence systematic review software; eligible studies were original, primary-data reports with a minimum sample size of 20 neonates. Findings were synthesized narratively and grouped thematically by diagnostic modality and clinical outcome. Results: Eighty-one studies met the pre-specified eligibility criteria following a systematic multi-database search and structured screening process. As a subset of included studies are secondary analyses or overlapping cohorts, an aggregate patient count is not reported. Reported prevalence of cardiac dysfunction varied widely with the definition applied, reaching 70–90% when multimodal assessment was used. Blood pressure, heart rate, urine output, and lactate were inconsistently reliable indicators of myocardial function, and ejection fraction and fractional shortening often remained normal despite injury. Tissue Doppler imaging and speckle-tracking strain appeared to be more sensitive, with impaired left ventricular global longitudinal strain associated with brain injury. The right ventricle was more commonly and severely affected, with reduced TAPSE, RV fractional area change, and RV strain associated with death or MRI-defined injury. Each additional 24 h of inotropic support was associated with increased odds of adverse short- and long-term outcomes by 14% and 12%, respectively. Conclusions: Cardiac dysfunction is common and prognostically important but remains underrecognized by the routine clinical assessment and cardiovascular monitoring. Multimodal monitoring centered on TnECHO, near infra-red spectroscopy, and specific biomarkers may enable earlier, physiology-based management.

Bronchopulmonary dysplasia (BPD) remains a major long-term morbidity among preterm infants. As lung-protective strategies advance and survival of extremely premature neonates improves, BPD has evolved from a ventilator-induced inflammatory and fibrotic process to a disease marked by arrested pulmonary vascular and alveolar development—pulmonary vascular disease. Within this evolving phenotype, pulmonary hypertension (PH) has emerged as a critical yet underrecognized complication. BPD-associated pulmonary hypertension (BPD-PH) is increasingly linked to higher mortality and worse clinical outcomes, but its pathophysiology, screening strategies to detect early changes, and optimal management remain incompletely understood. This review delineates the pathophysiology of BPD-PH, linking impaired pulmonary vascular development with subsequent maladaptation influenced by genetic, prenatal, and postnatal factors. The phenotypic and hemodynamic spectrum of BPD-PH is further subclassified using echocardiographic markers to support a physiology-based approach to diagnosis and management. We also propose a pragmatic algorithm for screening, evaluation, and longitudinal follow-up. Collectively, this review highlights the need for physiology-driven strategies and clinical studies to improve outcomes in these neonates.

Background: Point-of-care ultrasound (POCUS) has emerged as a valuable tool for rapid diagnosis, procedural guidance, and real-time clinical decision-making in neonatal and pediatric critical care. Despite its growing use in acute medicine, the evidence describing its implementation, utility, and impact in interfacility and prehospital transport settings remains limited. This scoping review aims to systematically map the current body of evidence on POCUS use during neonatal and pediatric transport and to identify knowledge gaps to inform future research, training, and clinical integration. Methods: A scoping review was conducted following PRISMA-ScR 2020 guidelines, searching PubMed, Embase, Scopus, CINAHL, and Web of Science for studies describing POCUS use during neonatal and pediatric transport. Results: Of 3676 unique articles identified, 20 met inclusion criteria, including 10 cohort studies, 3 case series, 4 case reports, 2 narrative reviews, and 1 textbook chapter. Fifteen studies reported extractable patient-level data and were included in quantitative synthesis, encompassing 4278 patients. Among these, 1153 (27.0%) patients were under 18 years old, and 576 (13.5%) had POCUS performed during transport. POCUS was primarily used for diagnostic assessment—mainly lung and cardiac imaging—with variability in protocols, operator training, and transport characteristics. Eleven studies (73.3%) reported that POCUS altered clinical management, influencing management in 106 (18.4%) patients through diagnostic clarification, resuscitation decisions, medical or ventilator adjustments, and changes in transport destination. Conclusions: Evidence suggests that POCUS supports clinical decision-making and timely intervention during neonatal and pediatric transport, though use remains inconsistent. Future studies should focus on developing structured training frameworks, validating transport-specific protocols, and assessing the impact of POCUS on clinical outcomes and transport safety.

Ultrasound is increasingly utilized during cardiac arrest in adult populations. The European Society of Pediatric and Neonatal Intensive Care and the American Academy of Pediatrics have published guidelines on the use of point-of-care ultrasound (POCUS) in neonates and children. However, there were no specific recommendations for its use during the Neonatal Resuscitation Program (NRP) algorithm. In this narrative review, we map the existing evidence to evaluate its role, potential benefits, and limitations of POCUS integration during neonatal resuscitation. The limited available studies, mostly case reports, suggest that POCUS can aid in the early identification of correctable or modifiable causes, evaluation of cardiac function, detection of heart rate or pulseless electrical activity, and guidance of resuscitative efforts. Significant gaps remain in knowledge, research studying its feasibility and benefits, and a lack of specific training and standardized protocols for integrating POCUS into the NRP algorithm, emphasizing the need for further research.

After nearly 3 years without a single central line-associated bloodstream infection (CLABSI), our neonatal intensive care unit (NICU) experienced a significant rise in CLABSI rates beginning in 2019. The increase coincided with changes made to the intravenous (IV) medication pump integration process, which added more safety checks and procedural steps. This study aimed to investigate the potential association between these process changes and increased CLABSI and non-CLABSI (bloodstream infection, BSI) rates prior to inclusion in a future QI project Key Driver Diagram. This observational pilot study used a mixed-methods approach, including statistical process control analysis to confirm a special-cause increase in CLABSI rate, human factors observations, and environmental microbiome sampling focusing on the equipment involved in the IV pump integration. We compared these findings to the CLABSI and BSI rates to identify temporal and geographic associations. Following the 2019 implementation of IV pump integration, statistically significant increases in CLABSI and BSI rates were observed. The enhanced safety checks added steps to IV medication administrations, with timestamp observation indicating up to 14 location changes around the bed spaces and a mean of 5.5 minutes for any IV medication administration. Environmental microbial sampling showed a 27% positivity rate. The highest microbial burden was found on patient-specific mobile equipment (30%) used during IV medication administration, including isolettes, IV hubs, and glove boxes, compared with other equipment (26%) like nursing computers or ventilators (p = 0.093). A strong overlap was observed between the microorganisms found in the NICU environment and those responsible for positive patient blood cultures, particularly coagulase-negative Staphylococcus (CONS). Though not statistically significant, the findings suggest that the added complexity and extended duration of the modified IV pump integration process may have increased the frequency of caregiver interactions with the NICU environment, exposing immune-vulnerable NICU patients to a higher risk of infection. Further human factors analysis and quality improvement efforts are necessary to simplify the IV medication administration process, reduce environmental microbial loads, and decrease infection rates.

Objectives To determine maternal, neonatal, and hospital factors influencing deferred cord clamping (DCC) compliance rates in preterm neonates. Methods Neonates born <33 weeks’ gestational age (GA) within the Neonatal Intensive Care Units of Canadian Neonatal Network during 2018–2022 were included. Units’ DCC quality improvement (QI) efforts were surveyed. The factors were stratified by <15 seconds (s) immediate cord clamping, 15–59 s early cord clamping, or ≥60 s DCC. Results Of 16,217 eligible neonates, only 45% received DCC ≥ 60 s. Maternal hypertension and antenatal steroid was asscoiated with higher DCC rates. Cesarean delivery (aOR 0.39, 95% CI 0.33–0.47), <26 weeks GA (aOR 0.25, 95% CI 0.21–0.30), and small-for-gestational-age status had lower DCC odds. Singleton birth, preterm labor, and fetal indications for delivery increased DCC likelihood. Hospital size and QI efforts did not impact DCC compliance. Conclusion Extreme preterm neonates or cesarean delivery are actionable QI targets to improve DCC compliance and neonatal outcomes.

Objective To assess diagnostic point of care ultrasound (POCUS) use, presence of programmatic infrastructural elements, and barriers to implementation across neonatal perinatal medicine (NPM) programs in the United States. Study design Cross-sectional study. An online survey was distributed to leaders in education or POCUS at ACGME-accredited NPM fellowship programs. National trends were outlined using descriptive statistics and compared by program size. Result 79 of 99 (80%) NPM programs responded. Diagnostic POCUS was available at 71% (n = 56) of sites that responded. Key infrastructural elements were present at <45% of sites, with fellow training being the exception (71%). Many barriers to diagnostic POCUS program implementation were identified and they differed by program size. Conclusion Diagnostic POCUS is being increasingly adopted despite underdeveloped programmatic infrastructure. Identified barriers suggest a need for collaborative efforts to support the necessary infrastructural elements, and differences by program size suggest a need for tailored approaches for successful integration.

Congenital heart disease (CHD) affects 1% of live births globally. Infants with CHD often experience growth faltering and malnutrition due to increased metabolic demands, malabsorption, and feeding intolerance, further worsened by surgical interventions and frequent hospitalizations. Malnutrition in this population is linked to higher morbidity, extended hospital stays, and poor neurodevelopmental outcomes. The physiological diversity among CHD types presents significant challenges in developing a universal feeding strategy to optimize nutrition. This narrative review explores the interplay between CHD physiology and nutritional management. CHD types could be categorized into three hemodynamic groups—systemic hypoperfusion, global hypoxia, and pulmonary overcirculation—which help to consider a feeding approach based on such physiology. Nutritional management in these infants could be further tailored based on the disease severity, co-morbidities, and evolving hemodynamic changes. Based on clinical opinions, this review proposes a hemodynamic-focused risk-stratified feeding approach, considering ways that may enhance growth while possibly minimizing complications such as necrotizing enterocolitis (NEC), pulmonary overload, and worsening heart failure. This approach may help individualize nutritional management to address the complex needs of infants with CHD. Further quality improvement studies are needed to assess this approach. Beyond meeting macronutrient needs, micronutrients, including zinc, thiamine, magnesium, vitamin A, and calcium, potentially play a role in cardiovascular health. Given the complexity of nutritional management in these infants, a multidisciplinary team may be needed to optimize care, including cardiologists, neonatologists, pediatricians, dietitians, speech therapists, and pharmacists. With the current knowledge gap and lack of strong evidence, research should focus on nutritional interventions and study their potential impact on infant outcomes with CHDs.

Introduction: Dysphagia among infants, particularly high‐risk and preterm neonates, poses feeding challenges that can impact multiple systemic outcomes and delay hospital discharge. Limited therapeutic options for approved thickening agents for human milk and infant formula necessitate the exploration of alternatives, including banana puree.Method: This study investigated the feasibility of using banana puree as a thickening agent for hospitalized infants with dysphagia. The International Dysphagia Diet Standardisation Initiative (IDDSI) flow test determined optimal volumes of banana puree mixed with infant formulas or human milk to achieve desired liquid thickness levels. Nutrition analysis considered potassium intake and calories from carbohydrates to assess dietary composition.Result: Banana puree effectively achieved IDDSI Levels 1–3, with varying volumes required based on milk types and caloric concentrations. The nutrition analysis revealed the importance of restricting banana puree to 15% of feeding volumes to avoid exceeding recommended potassium levels while promoting appropriate nutrition.Conclusion: Banana puree represents a promising option for thickening feeds in infants with dysphagia, facilitating safe oral feeding opportunities, accelerating the introduction of oral feeding, and, potentially, improving long‐term outcomes. Further research is warranted to explore its impact on feeding progression, hospital stays, growth, patient outcomes, and feeding‐related behaviors compared with traditional thickening agents.