Neonatal clinical examination and selective ultrasound screening are not reliable for the early diagnosis of hip dysplasia: A retrospective cohort study.

AIM: To compare the incidence, clinical features and timing of initial treatment of early- and later-presenting developmental dysplasia of the hip (DDH) in infancy in the context of a risk-based selective ultrasound screening programme. METHODS: We conducted a retrospective observational study of infants born at a tertiary perinatal centre in Melbourne, Australia, between July 2016 and June 2020 and treated for DDH up to 18 months of age at a tertiary paediatric centre. The incidence of DDH was calculated for early- and later-presenting cases. Clinical features and ultrasound indications were analysed using multivariate logistic regression. RESULTS: There were 192 infants with DDH requiring treatment, 100 (52%) of which were not detected by universal neonatal hip examination and selective ultrasound screening based on risk factors (overall incidence 6.3 per 1000 livebirths). The median age at which treatment was commenced was delayed by 8 weeks for the later-presenting group compared to those detected through screening (16.7 vs. 7.9 weeks, P < 0.001). Skin crease asymmetry was associated with later presentation (adjusted odds ratio (aOR) 44.03, 95% confidence interval (CI) 9.99-333), whilst breech presentation (aOR 0.08, 95% CI 0.02-0.26) and Barlow/Ortolani test positivity (aOR 0.06, 95% CI 0.01-0.25) were associated with early presentation. Only 39 (1.45%) infants receiving a screening ultrasound had DDH. CONCLUSION: Approximately half of all infants with DDH were not detected by combining risk-based selective ultrasound screening with neonatal clinical findings, highlighting the failure of this screening method to reliably detect a significant proportion of dysplastic infant hips.

Effect of Bias Gas Flow on Tracheal Cytokine Concentrations in Ventilated Extremely Preterm Infants: A Randomized Controlled Trial.

BACKGROUND: The objective of this study was to determine whether ventilator bias gas flow affects tracheal aspirate (TA) cytokine concentrations in ventilated extremely preterm infants. METHODS: This is a randomized controlled trial in a tertiary neonatal unit in New Zealand. Preterm infants (<28 weeks' gestation/<1,000 g) requiring intubation in the first 7 days after birth were randomized to bias gas flows of 4 or 10 L/min. Cytokine concentrations in TA and plasma were measured at 24, 72, and 120 h after the onset of ventilation. The primary outcome measure was concentration of interleukin (IL)-8 in TA 24 h after the onset of mechanical ventilation. RESULTS: Baseline demographics were similar in babies randomized to 4 (n = 50) and 10 (n = 45) L/min bias gas flow. TA IL-8 concentrations were not different between groups. Plasma IL-8 concentrations decreased over time (p < 0.05). Respiratory support and incidence of bronchopulmonary dysplasia at 36 weeks' corrected gestational age were similar between groups. Fewer babies ventilated at 4 L/min developed necrotizing enterocolitis (NEC) ≥ stage 2 (n = 0 vs. n = 5; p = 0.02) and fewer died (n = 1 vs. n = 5, p = 0.06). CONCLUSIONS: Lower bias gas flow in ventilated extremely preterm infants did not alter TA cytokine concentrations but the lower incidence of NEC and mortality warrants further investigation.

Changed ophthalmic workload following introduction of digital retinal photography for retinopathy of prematurity screening.

BACKGROUND: ROP screening is vital in care of premature infants but is considered burdensome, difficult and time consuming for ophthalmologists. This study assessed the reduction in workload following the introduction of nurse-led WFDRI to a large neonatal nursery. METHODS: We report a retrospective audit of 628 infants screened for ROP in the years 2010, 2013 and 2019 at the Royal Women's Hospital, Victoria. The last complete year of screening for ROP using binocular indirect ophthalmoscopy (BIO) alone (2010) was compared with two subsequent years after the introduction of nurse-led WFDRI. The main outcome measures were the time taken to report and document WFDRI and the time taken to undertake BIO examination of a premature infant and document the results. RESULTS: The ophthalmologist's time taken to conduct BIO, review images and document the results per 100 patient examinations was reduced from 16.7 hours before introduction of WFDRI to 3.7 hours. Similarly, the weekly time spent on this component of ROP screening fell from 2.3 hours per week to 0.8 and 1.0 hours per week after introduction of WFDRI. CONCLUSIONS: The introduction of nurse-led WFDRI has resulted in a dramatic and sustained reduction in ophthalmologist workload involved in ROP screening in a large Australian neonatal nursery. This may result in improved retention of the ophthalmic workforce required to undertake ROP screening.

Early-onset vitamin B6-dependent epilepsy due to pathogenic PLPBP variants in a premature infant: A case report and review of the literature.

Vitamin B6-dependent epilepsies are a heterogeneous group of disorders characterized by decreased availability of the active cofactor pyridoxal-5'-phosphate (PLP). While pathogenic variants in ALDH7A1 or PNPO genes account for most cases of these disorders, biallelic pathogenic variants in PLPBP have been shown to cause a form of early onset vitamin B6-dependent epilepsy (EPVB6D). PLPBP is thought to play a role in the homeostatic regulation of vitamin B6, by supplying PLP to apoenzymes while limiting side-reaction toxicity related to excess unbound PLP. Neonatal-onset intractable seizures that respond to pyridoxine and/or PLP are a predominant feature of EPVB6D in humans. Unlike other causes of vitamin B6-dependent epilepsies; however, a specific biomarker for this disorder has yet to be identified. Here we present data from a premature infant found to have pathogenic variants in PLPBP and propose that prematurity may provide an additional clue for early consideration of this diagnosis. We discuss these findings in context of previously published genotypic, phenotypic, and metabolic data from similarly affected patients.

Higher Rates of Retinopathy of Prematurity after Increasing Oxygen Saturation Targets for Very Preterm Infants: Experience in a Single Center.

Randomized trials of oxygen saturation target ranges for extremely preterm infants showed increased survival but increased retinopathy of prematurity with higher compared with lower target ranges. In our center, changing from a target range of 88%-92% to 91%-95% has been associated with increased rates and severity of retinopathy of prematurity.

Videolaryngoscopy to Teach Neonatal Intubation: A Randomized Trial.

BACKGROUND: Neonatal endotracheal intubation is a necessary skill. However, success rates among junior doctors have fallen to <50%, largely owing to declining opportunities to intubate. Videolaryngoscopy allows instructor and trainee to share the view of the pharynx. We compared intubations guided by an instructor watching a videolaryngoscope screen with the traditional method where the instructor does not have this view. METHODS: A randomized, controlled trial at a tertiary neonatal center recruited newborns from February 2013 to May 2014. Eligible intubations were performed orally on infants without facial or airway anomalies, in the delivery room or neonatal intensive care, by doctors with <6 months' tertiary neonatal experience. Intubations were randomized to having the videolaryngoscope screen visible to the instructor or covered (control). The primary outcome was first-attempt intubation success rate confirmed by colorimetric detection of expired carbon dioxide. RESULTS: Two hundred six first-attempt intubations were analyzed. Median (interquartile range) infant gestation was 29 (27 to 32) weeks, and weight was 1142 (816 to 1750) g. The success rate when the instructor was able to view the videolaryngoscope screen was 66% (69/104) compared with 41% (42/102) when the screen was covered (P < .001, OR 2.81, 95% CI 1.54 to 5.17). When premedication was used, the success rate in the intervention group was 72% (56/78) compared with 44% (35/79) in the control group (P < .001, OR 3.2, 95% CI 1.6 to 6.6). CONCLUSIONS: Intubation success rates of inexperienced neonatal trainees significantly improved when the instructor was able to share their view on a videolaryngoscope screen.

Randomized controlled trial of oxygen saturation targets in very preterm infants: two year outcomes.

OBJECTIVE: To assess whether an oxygen saturation (Spo2) target of 85%-89% compared with 91%-95% reduced the incidence of the composite outcome of death or major disability at 2 years of age in infants born at <28 weeks' gestation. STUDY DESIGN: A total 340 infants were randomized to a lower or higher target from <24 hours of age until 36 weeks' gestational age. Blinding was achieved by targeting a displayed Spo2 of 88%-92% using a saturation monitor offset by ±3% within the range 85%-95%. True saturations were displayed outside this range. Follow-up at 2 years' corrected age was by pediatric examination and formal neurodevelopmental assessment. Major disability was gross motor disability, cognitive or language delay, severe hearing loss, or blindness. RESULTS: The primary outcome was known for 335 infants with 33 using surrogate language information. Targeting a lower compared with a higher Spo2 target range had no significant effect on the rate of death or major disability at 2 years' corrected age (65/167 [38.9%] vs 76/168 [45.2%]; relative risk 1.15, 95% CI 0.90-1.47) or any secondary outcomes. Death occurred in 25 (14.7%) and 27 (15.9%) of those randomized to the lower and higher target, respectively, and blindness in 0% and 0.7%. CONCLUSIONS: Although there was no benefit or harm from targeting a lower compared with a higher saturation in this trial, further information will become available from the prospectively planned meta-analysis of this and 4 other trials comprising a total of nearly 5000 infants.

Continuous positive airway pressure failure in preterm infants: incidence, predictors and consequences.

BACKGROUND: Preterm infants ≤32 weeks' gestation are increasingly being managed on continuous positive airway pressure (CPAP), without prior intubation and surfactant therapy. Some infants treated in this way ultimately fail on CPAP and require intubation and ventilation. OBJECTIVES: To define the incidence, predictors and consequences of CPAP failure in preterm infants managed with CPAP from the outset. METHODS: Preterm infants 25-32 weeks' gestation were included in the study if inborn and managed with CPAP as the initial respiratory support, with division into two gestation ranges and grouping according to whether they were successfully managed on CPAP (CPAP-S) or failed on CPAP and required intubation <72 h (CPAP-F). Predictors of CPAP failure were sought, and outcomes compared between the groups. RESULTS: 297 infants received CPAP, of which 65 (22%) failed, with CPAP failure being more likely at lower gestational age. Most infants failing CPAP had moderate or severe respiratory distress syndrome radiologically. In multivariate analysis, CPAP failure was found to be predicted by the highest FiO2 in the first hours of life. CPAP-F infants had a prolonged need for respiratory support and oxygen therapy, and a higher risk of death or bronchopulmonary dysplasia at 25-28 weeks' gestation (CPAP-F 53% vs. CPAP-S 14%, relative risk 3.8, 95% CI 1.6, 9.3) and a substantially higher risk of pneumothorax at 29-32 weeks. CONCLUSION: CPAP failure in preterm infants usually occurs because of unremitting respiratory distress syndrome, is predicted by an FiO2 ≥0.3 in the first hours of life, and is associated with adverse outcomes.

Minimally-invasive surfactant therapy in preterm infants on continuous positive airway pressure.

OBJECTIVE: To evaluate the applicability and potential effectiveness of a technique of minimally-invasive surfactant therapy (MIST) in preterm infants on continuous positive airway pressure (CPAP). METHODS: An open feasibility study of MIST was conducted at two sites. Infants were eligible for MIST if needing CPAP pressure ≥7 cm H(2)O and FiO(2) ≥0.3 (25-28 weeks gestation, n=38) or ≥0.35 (29-32 weeks, n=23). Without premedication, a narrow-bore catheter was inserted through the vocal cords under direct vision. Surfactant (100 or 200 mg/kg Curosurf) was then instilled, followed by reinstitution of CPAP. Outcomes were compared between surfactant-treated infants and historical controls achieving the same CPAP and FiO(2) thresholds. RESULTS: Surfactant was successfully administered via MIST in all cases, with a rapid and sustained reduction in FiO(2) thereafter. For infants at 25-28 weeks gestation, need for intubation <72 h was diminished after MIST compared with controls (32% vs 68%; OR 0.21, 95% CI 0.083 to 0.55), with a similar trend at 29-32 weeks (22% vs 45%; OR 0.34, 95% CI 0.11 to 1.1). Duration of ventilation and incidence of bronchopulmonary dysplasia were similar, but infants receiving MIST had a shorter duration of oxygen therapy. CONCLUSION: Surfactant delivery via a narrow-bore tracheal catheter is feasible and potentially effective, and deserves further investigation in clinical trials.

Fluid recovery during lung lavage in meconium aspiration syndrome.

UNLABELLED: Lung lavage using two aliquots of 15 mL/kg of dilute surfactant was performed in 30 ventilated infants with severe meconium aspiration syndrome (MAS). Mean recovery of instilled lavage fluid was 46%, with greater fluid return associated with lower mean airway pressure at 24 h and a shorter duration of respiratory support. CONCLUSION: Recovery of instilled lavage fluid is paramount in effective lung lavage in MAS and must be afforded priority in the lavage technique.

High bias gas flows increase lung injury in the ventilated preterm lamb.

BACKGROUND: Mechanical ventilation of preterm babies increases survival but can also cause ventilator-induced lung injury (VILI), leading to the development of bronchopulmonary dysplasia (BPD). It is not known whether shear stress injury from gases flowing into the preterm lung during ventilation contributes to VILI. METHODS: Preterm lambs of 131 days' gestation (term = 147 d) were ventilated for 2 hours with a bias gas flow of 8 L/min (n = 13), 18 L/min (n = 12) or 28 L/min (n = 14). Physiological parameters were measured continuously and lung injury was assessed by measuring mRNA expression of early injury response genes and by histological analysis. Control lung tissue was collected from unventilated age-matched fetuses. Data were analysed by ANOVA with a Tukey post-hoc test when appropriate. RESULTS: High bias gas flows resulted in higher ventilator pressures, shorter inflation times and decreased ventilator efficiency. The rate of rise of inspiratory gas flow was greatest, and pulmonary mRNA levels of the injury markers, EGR1 and CTGF, were highest in lambs ventilated with bias gas flows of 18 L/min. High bias gas flows resulted in increased cellular proliferation and abnormal deposition of elastin, collagen and myofibroblasts in the lung. CONCLUSIONS: High ventilator bias gas flows resulted in increased lung injury, with up-regulation of acute early response genes and increased histological lung injury. Bias gas flows may, therefore, contribute to VILI and BPD.

Reduction in late-onset sepsis on relocating a neonatal intensive care nursery.

AIMS: The aims of this study were to compare rates of late-onset sepsis (LOS) in very preterm or very low birthweight infants before and after relocation to a new nursery and to determine risk factors for LOS. METHODS: The study was undertaken at The Royal Women's Hospital, Melbourne, which relocated to a new site in June 2008. Infants with birthweight <1500 g or <32 weeks' gestation, born between July and December 2007 (n= 149) and July and December 2008 (n= 152) were included. Each septic episode was identified from blood cultures taken from patients >48 h after birth and was categorised as definite, probable, uncertain or no sepsis. RESULTS: Overall, 117 infants had 218 septic episodes. The proportion of infants with clinical LOS decreased from 29.5% in 2007 to 22.4% in 2008 after the relocation, although this was not statistically significant. There was a significant (P < 0.05) reduction in the severity (definite LOS = most severe) of sepsis in 2008 compared with 2007, and in rates of coagulase-negative staphylococcal LOS. Significant risk factors for LOS were: lower birthweight (g; mean -351, 95% confidence interval (CI) -446, -256); lower gestational age (weeks; mean -2.3, 95% CI -2.8, -1.7) and presence of a percutaneous inserted central catheter (odds ratio (OR) 2.56, 95% CI 1.03, 6.67). CONCLUSIONS: There was a significant reduction in the severity of LOS in very preterm and/or very low birthweight infants that correlated with the relocation from the old to new nursery. Smaller and more immature infants with percutaneous central catheters were more at risk.

Improvement in mortality of very low birthweight infants and the changing pattern of neonatal mortality: the 50-year experience of one perinatal centre.

AIM: Neonatology is a relatively new sub-specialty so we aimed to review survival data in the context of advances in neonatal care. METHOD: Review of neonatal survival for very low birthweight babies over the last 50 years. RESULTS: In the data collected from a single tertiary neonatal unit, survival for babies 501-1000 g improved from below 10% in 1959 to over 60% in 2009. Similarly, survival for babies 1001 to 1500 g has improved from approximately 50% to over 90%. During the study period, death due to extreme prematurity or cardiorespiratory problems, namely respiratory distress syndrome, fell from 90% in 1964 to only 45% of neonatal deaths in 2008. CONCLUSION: In addition to reporting the remarkable improvement in neonatal survival over this period, we have highlighted items of historical context.

Enteral feeding practices in very preterm infants: an international survey.

OBJECTIVE: To evaluate enteral feeding practices in neonatal units in different countries and on different continents. DESIGN: A web-based survey of 127 tertiary neonatal intensive care units in Australia, Canada, Denmark, Ireland, New Zealand, Norway, Sweden and the UK. RESULTS: 124 units (98%) responded. 59 units (48%) had a breast milk bank or access to donor human milk (Australia/New Zealand 2/27, Canada 6/29, Scandinavia 20/20 and UK/Ireland 31/48). The proportion of units initiating enteral feeding within the first 24 h of life was: 43/124 (35%) if gestational age (GA) <25 weeks, 53/124 (43%) if GA 25-27 weeks and 88/124 (71%) if GA 28-31 weeks. In general, Scandinavian units introduced enteral feeds the earliest, followed by UK/Ireland. Continuous feeding was routinely used for infants below 28 weeks' gestation in almost half of the Scandinavian units and in approximately one sixth of units in UK/Ireland, but rarely in Australia/New Zealand and Canada. Minimal enteral feeding for 4-5 days was common in Canada, but rare in Scandinavia. Target enteral feeding volume in a 'stable' preterm infant was 140-160 ml/kg/day in most Canadian units and 161-180 ml/kg/day or higher in units in the other regions. There were also marked regional differences in criteria for use and timing when human milk fortifier was added. CONCLUSIONS: This study highlights areas of uncertainty and demonstrates marked variability in feeding practices. It provides valuable data for planning collaborative feeding trials to optimise outcome in preterm infants.

Improved neonatal survival and outcomes at borderline viability brings increasing ethical dilemmas.

With improvements in neonatal intensive care over the past five decades, the limits of viability have reduced to around 24 weeks' gestation. While increasing survival has been the predominant driver leading to lowering the gestation at which care can be provided, these infants remain at significant risk of adverse long-term outcomes including neuro-developmental disability. Decisions about commencing and continuing intensive care are determined in partnership with parents, considering the best interests of the baby and the family. Occasionally, clinicians and parents come to an impasse regarding institution or continuation of intensive care. Inevitably, these ethical dilemmas need to consider the uncertainty of the long-term prognosis and challenges surrounding providing or withdrawing active treatment. Further reduction in the gestational age considered for institution of intensive care will need to be guided by short- and long-term outcomes, community expectations and the availability of sufficient resources to care for these infants in the neonatal intensive care unit and beyond.

Does more protein in the first week of life change outcomes for very low birthweight babies?

BACKGROUND: Following publication of revised recommended nutrient intakes (RNI) for infants <1500 g, our intravenous nutrition (IVN) solutions were reformulated to deliver RNI in a restricted volume to ensure additional non-nutritional fluids did not detract from nutritional intake. An audit was performed to determine whether these changes achieved RNI and influenced growth, clinical or neurodevelopmental outcomes. METHODS: Two cohorts of 40 infants <1500 g were identified from a prospectively maintained database: babies born before and after reformulation of the IVN solutions. Data on nutritional intakes for the first 30 days of life, growth and clinical outcomes were collected. Neurodevelopmental outcomes at 18 months corrected age (CA) were obtained from a Bayley III assessment. Results are presented as mean ± SD. RESULTS: The 'after' group received significantly less fluid (105 ± 12 vs. 132 ± 15 mL/kg/day, P < 0.001) but more protein (3.2 ± 0.6 vs. 2.4 ± 0.5 g/kg/day, P < 0.001) in the first week of life. There were no differences in clinical outcome, growth z-scores at 4 weeks of age or neurodevelopmental outcome at 18 months CA between the 'before' and 'after' infants. Enteral protein intake in the first 2 weeks of life was positively associated with neurodevelopmental outcome (cognitive score r(2) = 0.13 P= 0.03, motor score r(2) = 0.27 P= 0.001). CONCLUSION: Although the new IVN regimen achieved intakes closer to RNI, there were no major effects on growth, clinical outcome or neurodevelopmental outcome at 18 months CA. Enteral protein intake in the first two weeks was positively associated with neurodevelopmental outcome, suggesting early enteral protein intake is important for optimal brain function.

Randomized controlled trial of lung lavage with dilute surfactant for meconium aspiration syndrome.

OBJECTIVE: To evaluate whether lung lavage with surfactant changes the duration of mechanical respiratory support or other outcomes in meconium aspiration syndrome (MAS). STUDY DESIGN: We conducted a randomized controlled trial that enrolled ventilated infants with MAS. Infants randomized to lavage received two 15-mL/kg aliquots of dilute bovine surfactant instilled into, and recovered from, the lung. Control subjects received standard care, which in both groups included high frequency ventilation, nitric oxide, and, where available, extracorporeal membrane oxygenation (ECMO). RESULTS: Sixty-six infants were randomized, with one ineligible infant excluded from analysis. Median duration of respiratory support was similar in infants who underwent lavage and control subjects (5.5 versus 6.0 days, P = .77). Requirement for high frequency ventilation and nitric oxide did not differ between the groups. Fewer infants who underwent lavage died or required ECMO: 10% (3/30) compared with 31% (11/35) in the control group (odds ratio, 0.24; 95% confidence interval, 0.060-0.97). Lavage transiently reduced oxygen saturation without substantial heart rate or blood pressure alterations. Mean airway pressure was more rapidly weaned in the lavage group after randomization. CONCLUSION: Lung lavage with dilute surfactant does not alter duration of respiratory support, but may reduce mortality, especially in units not offering ECMO.

Ventilator gas flow rates affect inspiratory time and ventilator efficiency index in term lambs.

BACKGROUND: Despite increasing survival in the smallest preterm infants, the incidence of chronic lung disease has not decreased. Research into ventilatory strategies has concentrated on minimising barotrauma, volutrauma and atelectotrauma, but little attention has been paid to the role of bias gas flow rates and the potential for rheotrauma or shear stress injury. Ventilated preterm infants frequently receive relatively high gas flow rates. OBJECTIVES: We hypothesised that altering bias gas flow rates would change the efficiency of ventilation and thereby affect ventilatory parameters. METHODS: We tested this hypothesis using an artificial lung followed by ventilation of 8 term lambs. RESULTS: Between flows of 2 and 15 l/min, inflation time (Ti) in the artificial lung was inversely related to the bias gas flow rate. In the ventilated lambs, Ti was inversely related to flow rates up to 10 l/min, with no statistically significant effect at flow rates >10 l/min. There were no adverse effects on gas exchange or cardiovascular parameters until a flow rate of 3 l/min was used, when inadequate gas exchange occurred. CONCLUSIONS: Ti is inversely associated with the bias gas flow rate. Flow rates much lower than those used in many neonatal units seem to provide adequate ventilation. We suggest that the role of ventilator gas flow rates, which may potentially influence shear stress in ventilator-induced lung injury, merits further investigation.

Repeat prenatal corticosteroid doses do not alter neonatal blood pressure or myocardial thickness: randomized, controlled trial.

OBJECTIVE: The goal was to determine whether repeat prenatal corticosteroid treatment alters blood pressure and myocardial wall thickness in neonates. METHODS: A randomized, double-blind, placebo-controlled trial was performed in a tertiary perinatal center. Mothers with a singleton, twin, or triplet pregnancy, at a gestational age of <32 weeks, who had received initial treatment with corticosteroid > or =7 days earlier and who were considered to be at continued risk of preterm birth were assigned randomly to receive additional weekly betamethasone or placebo treatment. One hundred forty-five infants born to 120 women were studied. Blood pressure in the first 4 weeks after birth or until hospital discharge and interventricular septal thickness and left ventricular posterior wall thickness in diastole 48 to 72 hours after birth were measured. RESULTS: There were no differences in mean, systolic, or diastolic blood pressures between infants in the placebo and repeat steroid groups. Blood pressures of infants in both groups were similar to published normal values. There were no differences between groups in interventricular septal thickness or left ventricular posterior wall thickness in diastole. In comparison with published normal ranges, however, 24% of infants had interventricular septal thickness and 32% of infants had left ventricular posterior wall thickness of >95th percentile. CONCLUSION: Exposure to repeat prenatal corticosteroid treatment did not increase neonatal blood pressure or myocardial wall thickness in infants who remained at risk of very preterm birth > or =7 days after an initial course of corticosteroid treatment.

The reliability of 2D and colour Doppler ultrasound in localising longline position.

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.