The Aortic Valve as a Landmark for Ultrasound Guided Umbilical Artery Catheter Placement

The Aortic Valve as a Landmark for Ultrasound Guided Umbilical Artery Catheter Placement | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article The Aortic Valve as a Landmark for Ultrasound Guided Umbilical Artery Catheter Placement Mohamed Sakr, Orna Rosen, Mimi Kim, Mamta Fuloria, Megan Carney, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6537736/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Objective Umbilical artery catheters (UAC) are common in the neonatal intensive care unit. Frequently, catheter locations are suboptimal. Point of care ultrasound (POCUS) is reliable and safe. The objective of this study was to determine if visualizing the aortic valve (AV) with POCUS could be a landmark for UAC positioning. Study Design This was a prospective, retrospective controlled study. The retrospective group included neonates with a UAC insertion depth calculated by (3×birth weight(kg) + 9). The experimental group used POCUS and identified the level of the AV for UAC placement. Results Each group had thirty neonates. The groups were similar in gestational age, p = 0.11 and median birth weight (p = 0.12). In the control group, 16 neonates (54%) required repositioning and between 2–6 X-Rays. None of the UACs in the experimental group needed repeat X-Rays (p < 0.001). Conclusion The AV location identified using POCUS can reduce the need for multiple XRs for UAC placement. Health sciences/Medical research/Outcomes research Scientific community and society/Scientific community Figures Figure 1 Figure 2 Background Umbilical artery catheters (UAC) are currently amongst the most common central access devices used in sick preterm and term infants admitted to the neonatal intensive care units (NICU). They are often required for continuous blood pressure monitoring and frequent blood sampling. In addition, UACs may be used for parenteral nutrition as well as medication administration. (‎1‎,2). The depth of the UAC insertion may be calculated based on various methods, such as the shoulder–umbilicus length graph ( 3 ) and the birth weight-based formula ( 4 ). Frequently, catheters are placed sub-optimally, necessitating re-adjustments, repeat XRs and thus additional radiation exposure and delay of medical care. Recently, the Society for Pediatric Radiology together with the American Society for Radiologic Technologists raised a campaign called “Image Gently” with a goal to raise awareness of radiation risks in children and recommend the use of alternative imaging modalities when possible ( 6 , 7 ). Verification of central line position may account for nearly 25% of radiation exposure in the NICU. ( 8 )Point of Care Ultrasound (POCUS) is reliable, feasible, and without exposure to radiation. Bedside ultrasound (US) offers the possibility of direct visualization of the catheter and the vessels both during the insertion period and final positioning. This technique reduces the need for multiple catheter manipulations, radiation exposure and allows earlier safe usage of the catheter ( 9 – 12 ). Despite the advantages associated with the use of POCUS, it is not widely used to assess the UAC position. The objective of this study was to determine if the AV location visualized by POCUS can be used as a landmark for optimal tip positioning of the UAC. Methods Study design: This was a single-center, prospective, retrospective controlled study. The study was approved by the Institutional Review Board at the Albert Einstein College of Medicine. The study was conducted at a level IV NICU in the Bronx, NY. Consent was waived by the IRB because of the minimal to no risk nature of this study to patients. Patients: Neonates who were admitted to the NICU and required UAC placement for clinical care management were included. The birth weight-based formula (3×birth weight (kg) + 9) was used to determine the UAC location for the 30 neonates in the retrospective group. Neonates with an umbilical venous catheter were excluded. Neonates whose electronic medical records had inconsistent data between providers’ notes, radiology reports, or the number of XRs obtained for manipulation of the UAC were also excluded. The prospective experimental cohort included 30 neonates where the UAC insertion was performed under US guidance by one investigator (author MS). Large-for-gestational age (LGA) was defined as birthweight for gestational age > 90th percentile, appropriate-for-gestational-age (AGA) as the 10th–90th percentile, and small-for-gestational-age (SGA) as < 10th percentile in boys and girls on the Fenton growth curve, respectively ( 13 ). Interventions: In the prospective group, UACs were placed by neonatal fellows, nurse practitioners, and physician assistants. Two techniques were used for UAC placement: the 2-provider and 1-provider methods. The two-provider technique involves one provider inserting the UAC while the second uses POCUS to immediately confirm placement and guide adjustments before securing. The single-provider technique requires an extended sterile field, from the nipple line to the groin, and allows the single provider to insert and then use POCUS to adjust the line. The depth of UAC insertion was calculated based on the birth weight-based formula, (‎4), and POCUS imaging was performed immediately after insertion using a Sonosite Edge US system (FUJIFILM Sonosite, WA, USA). For neonates less than 1000 grams, the HSL25x / 13 − 6 MHz (FUJIFILM Sonosite, WA, USA) transducer was used whereas for neonates more than 1000 grams, L38xi / 10 − 5 MHz (FUJIFILM Sonosite, WA, USA) transducer was used. Catheters were visualized as a sharply contrasting double-contoured echoic structures. The UAC tip was considered adequately positioned on POCUS if it was at the level of a perpendicular line projecting from the AV to the vertebral column (Fig. 1 -Video 1). All POCUS studies were recorded for analysis. Catheter manipulations were recommended for suboptimal UAC positioning on POCUS in real time. Once UAC placement was deemed optimal, the catheter was secured, and an anterior-posterior XR of the chest and abdomen was obtained. The clinical team made the final decision on catheter tip position using radiographic findings. Outcomes The primary outcome was the number of XRs performed for each patient until the UAC tip was in an optimal position between the thoracic vertebrae 6–9. The secondary outcome was the number of manipulations performed until the UAC tip was in optimal position. Statistical Methods: All data were summarized using standard descriptive statistics including means and medians for continuous data and counts and percentages for categorical data. The percentage of UACs placed and visualized on US in the prospective group was computed, along with corresponding 95% confidence intervals (CI). The percentage of UAC tips optimally positioned on XRs that did not require further manipulation was compared between the prospective and retrospective groups by computing the difference in proportions and 95% CIs, and by applying chi-square or Fisher’s exact test as appropriate. In addition, the number of XRs taken until tip position was deemed optimal by the clinical team was compared between the prospective and retrospective groups using the Wilcoxon rank sum test or Cochran– Armitage test for trend, depending on the distribution of the outcome. The projected sample size was 30 subjects in each cohort. With this sample size, the precision (as measured by the width of the 95% CI) with which the percentage of UACs placed and visualized on US can be estimated in the prospective group was +/- 18%. For comparison between the prospective and retrospective groups, the study had at least 80% power with a two-sided Type I error rate of 5% to detect an absolute difference of 32% or greater in the percentage of UAC tips optimally positioned on XRs that did not require further manipulation. This effect size was determined by our expectation that < 60% in the prospective group and ~ 90% in the retrospective group will require additional XRs. Results Patients: There were 269 neonates admitted to the NICU who had a UAC between June 2021 and December 2023. Study enrollment is shown in the flow diagram (Fig. 2 ). Data on the primary outcome was extracted for 30 patients in the retrospective group and 30 patients in the prospective POCUS guided insertion group. The baseline characteristics of the infants in both groups were similar (Table 1 ). The median (IQR) gestational age was 32.2 weeks (27.5, 35.5) in the retrospective group (p = 0.11) and 26.9 weeks (24.6, 33.6) in the prospective group. The median (IQR) birth weight was 1245 grams (918, 2423) and 901 grams (675, 1970) in the prospective and retrospective group, respectively (p = 0.12) and there was no difference in weight for gestational age between the groups. A single provider technique was used in 11/30 (36.7%) cases. Table 1 Neonatal Characteristics at Baseline Variables Standard, N = 30 POCUS, N = 30 p-value* Gestational Age 0.11 Median (IQR) 32.21 (27.49, 35.49) 26.93 (24.61, 33.57) Birthweight 0.12 Median (IQR) 1245 (918, 2423) 901 (675, 1970) Gender 0.59 Male 20 (67%) 18 (60%) Female 10 (33%) 12 (40%) Weight for GA > 0.99 AGA 22 (73%) 23 (77%) LGA 2 (6.7%) 2 (6.7%) SGA 6 (20%) 5 (17%) Values are median (IQR) or count (%) *Wilcoxon rank sum test for continues variable; Pearson's Chi-squared test or Fisher's exact test for categorical variable Primary Outcome: In the retrospective group, 16 neonates (54%) required 2–6 XRs to confirm appropriate position (Table 2 ). In the prospective group, none of the neonates needed more than one XR (p < 0.001). Table 2 Primary and Secondary Outcomes Variables Retrospective N = 30 POCUS N = 30 p-value* Number of XRs 1 9 (30%) 4 (13%) Values are count (%) *Wilcoxon rank sum test for continues variable; Pearson's Chi-squared test or Fisher's exact test for categorical variable Secondary Outcome: In the retrospective group, 16 (54%) neonates required 1–5 manipulations for the UAC tip to be in an appropriate position (Table 2 ). In the prospective group, 25 (83%) neonates required 1–2 manipulations (p = 0.002). Discussion In this single-center, prospective, retrospective controlled study, POCUS guided UAC placement using the AV as a landmark was associated with fewer XRs. Every UAC inserted using POCUS and the AV location was optimally positioned on the first XR. Currently, there are several formulae that are used to estimate the necessary depth of the UAC insertion, including the one we used in the retrospective group. In an observational study to compare the accuracy of 11 different formulae that are widely used to guide UAC depth of insertion, 25–50% of UACs were not in optimal position at initial placement (‎5). Utilization of POCUS for UAC insertion allows for real time adjustments, obviating the need for repeated XRs. Our findings are consistent with previous studies suggesting that POCUS can effectively reduce the number of XRs required to confirm UAC tip position ( 11 , 14 – 16 ). Like the study conducted by Fleming ( 9 ), this study demonstrated a reduction in the number of X-rays required for UAC placement. Despite all the evidence, including studies conducted several decades ago, the integration of POCUS into routine clinical practice for neonatal central lines remains lagging. One of the primary constraints hindering the widespread utilization and acceptance of POCUS as a standard of care lies in the need for standardized scanning protocols. This includes the establishment of a consistent landmark, such as the AV, for accurate image acquisition and interpretation within this study. To our knowledge, this is one of the first studies identifying the AV as a specific landmark for optimal positioning of UACs. Over the last few years, POCUS has gained notable acceptance in the NICU field. Verifying central line positions is one of the increasingly exciting applications for its use. However, implementing the POCUS technique in the NICU requires a competent structure that encompasses providers’ training and credentialing ( 17 , 18 ). Using the AV as a landmark to aid in UAC tip positioning may ease standardizing the scanning technique and ultimately accepting US guided UAC positioning as the new standard of care. The AV is a relatively easy structure to identify because of its unique US appearance and relatively fixed anatomy (Fig. 2 ). Unlike other studies ( 9 ), we observed an increase in the number of manipulations per line to optimize tip position. This discrepancy may be attributed to the stringent requirement of aligning the UAC tip with the precise location of the aortic valve. Importantly, no more than two manipulations were necessary for any line in the prospective group. (Table 2 ) Utilizing our standardized protocol, we were able to visualize the UAC tip despite various pathologies. Seven infants (23%) in the study cohort had other pathologies; 2 pneumothorax, 2 congenital diaphragmatic hernia, 1 diaphragmatic eventration, 1 hydrops fetalis and 1 skeletal dysplasia. It is noteworthy to mention that in this study, 11 of the 30 UACs in the prospective group were inserted using the single provider technique. Although the study wasn’t powered to compare these two techniques; it seems that the single provider technique was equally successful as the two-provider technique. The single provider technique may need extra training and a larger sterile field. However, employing a single-provider technique can enhance efficiency, which may be particularly valuable in the face of current healthcare staffing shortages. Our study has its limitations, including using a retrospective control group, which presents several potential disadvantages. These include selection and temporal bias particularly by the degree of providers’ competency inserting the lines. As this study was done at an academic institution, some lines may have been placed by experienced providers, while others were just starting their neonatal careers. Fortunately, in this study there was no difference in the relevant baseline characteristics and the control group was chosen from patients who had a UAC inserted in the year immediately before the recruitment of the prospective cohort to ensure a similar level of provider experience. As retrospective data may be incomplete or inaccurate making it difficult to reliably analyze and draw meaningful conclusions, a thorough review and validation of the retrospective data was performed to ensure accuracy and completeness. POCUS requires additional training and standard optimal protocols to be successful; this may limit generalizability of this study. We aimed to standardize all aspects of the scanning protocol including views, landmarks, orientations as well as machine specification and parameter settings. Following our proposed technique along with brief bedside training, providers were oriented and able to identify various landmarks. Finally, none of the study groups included patients with congenital heart disease except for patients with interatrial communications and patent ductus arteriosus. Further studies are needed to evaluate POCUS guided UAC placement in this subset of neonates. Conclusion Using the AV landmark with POCUS may reduce the number of XRs needed to confirm optimal positioning of UACs. Further studies are needed to evaluate utilizing the single provider POCUS technique and whether POCUS reduces the time needed to commence use of the UAC. Declarations Conflict of Interest: The authors have no conflicts of interest to disclose. Ethics approval and consent to participate: The study was approved by the Institutional Review Board at the Albert Einstein College of Medicine. Consent was waived by the IRB because of the minimal to no risk nature of this study to patients. The study was performed in accordance with the Declaration of Helsinki. Availability of Data and Materials: all datasets on which the conclusions of the paper rely will be made available to referees at submission and to readers promptly upon request. Funding : No funding was secured for this study. Author Contributions: MS: Conceptualization (formulation or evolution of overarching research goals and aims); Conducting research and investigation process (Conceived and designed the analysis, Collected the data); Manuscription writing, review and editing OR: Conceptualization (formulation or evolution of overarching research goals and aims); Conducting research/ investigation process (Conceived and designed the analysis); Manuscription review and editing MK: Conceptualization (evolution of overarching research goals and aims); Development or design of methodology, performed the data analysis and interpretation; Manuscription writing, review and editing MF: Conceptualization (supporting), Manuscript writing, review and editing MC: Data collection SN: Manuscript review and editing References Anderson J, Leonard D, Braner DA, Lai S, Tegtmeyer K. Umbilical vascular catheterization in neonates. N Engl J Med. 2008;359: e18. Furdon SA, Horgan MJ, Bradshaw WT, Clark DA. Nurses' guide to early detection of umbilical arterial catheter complications in infants. Adv Neonatal Care. 2006 Oct. 6 (5):242–56; quiz 257 – 60. Dunn PM. Localization of the umbilical catheter by post-mortem measurement. Arch Dis Child 1966; 41(215): 69–75. Shukla H, Ferrara A. Rapid estimation of insertional length of umbilical catheters in newborns. Am J Dis Child 1986; 140(8): 786–788. Lean WL, Dawson JA, Davis PG, Theda C, Thio M. Accuracy of 11 formulae to guide umbilical arterial catheter tip placement in newborn infants. Arch Dis Child Fetal Neonatal Ed. 2018;103(4):F364-F369. doi: 10.1136/archdischild-2017-313039 . Epub 2017 Aug 17. Applegate K. Image Gently: A campaign to promote radiation protection for children worldwide. S Afr J Rad. 2015;19(2): Art. #919, Goske, M.J., Applegate, K.E., Butler, P.S. et al. Image Gently: Partnerships to promote radiation protection for children worldwide. Pediatr Radiol 41, 207–209 (2011). Scott MV, Fujii AM, Behrman RH, Dillon JE. Diagnostic ionizing radiation exposure in premature patients. J Perinatol. 2014;34(5):392–5. Fleming SE, Kim JH. Ultrasound-guided umbilical catheter insertion in neonates. J Perinatol. 2011;31:344–9. Oppenheimer DA, Carroll BA, Garth KE, Parker BR. Sonographic localization of neonatal umbilical catheters. AJR Am J Roentgenol 1982;138(6):1025–1032. George L, Waldman JD, Cohen ML, Segall ML, Kirkpatrick SE, Turner SW et al. Umbilical vascular catheters: localization by two-dimensional echocardio/aortography. Pediatr Cardiol 1982; 2(3): 237–243. Meinen RD, Bauer AS, Devous K, Cowan E. Point-of-care ultrasound use in umbilical line placement: a review. J Perinatol. 2020;40(4):560–566. doi: 10.1038/s41372-019-0558-8 . Epub 2019 Nov 22. PMID: 31758061. Fenton, T. R., & Kim, J. H. (2013). A systematic review and meta-analysis to revise the Fenton preterm infant growth chart. The Journal of Pediatrics, 163(2), 571–576. Saul D, Ajayi S, Schutzman DL, Horrow MM. Sonography for complete evaluation of neonatal intensive care unit central support devices: a pilot study. J Ultrasound Med. 2016;35(7):1465–73. Garg AK, Houston AB, Laing JM, MacKenzie JR. Positioning of umbilical arterial catheters with ultrasound. Arch Dis Child 1983;58(12):1017–1018. Madar RJ, Deshpande SA. Reappraisal of ultrasound imaging of neonatal intravascular catheters. Arch Dis Child - Fetal and Neonatal Edition 1996;75(1):F62–F64. Dan L. Stewart, Yasser Elsayed, María V. Fraga, Brian D. Coley, Aparna Annam, Sarah Sarvis Milla, COMMITTEE ON FETUS AND NEWBORN AND SECTION ON RADIOLOGY; Use of Point-of-Care Ultrasonography in the NICU for Diagnostic and Procedural Purposes. Pediatrics December 2022; 150 (6): e2022060052. Dan L. Stewart, Yasser Elsayed, María V. Fraga, Brian D. Coley, Aparna Annam, Sarah Sarvis Milla, THE COMMITTEE ON FETUS AND NEWBORN AND SECTION ON RADIOLOGY, Section on Radiology Executive Committee, 2021–2022; Use of Point-of-Care Ultrasonography in the NICU for Diagnostic and Procedural Purposes. Pediatrics December 2022; 150 (6): e2022060053. Additional Declarations There is NO conflict of interest to disclose. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: revise 12 May, 2025 Review # 1 received at journal 09 May, 2025 Review # 2 received at journal 08 May, 2025 Reviewer # 2 agreed at journal 05 May, 2025 Reviewer # 1 agreed at journal 03 May, 2025 Reviewers invited by journal 30 Apr, 2025 Submission checks completed at journal 29 Apr, 2025 First submitted to journal 28 Apr, 2025 Unknown event 28 Apr, 2025 Editor assigned by journal 26 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6537736","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":450431216,"identity":"90fbc9a8-0850-47b5-b5a0-4752f65c4875","order_by":0,"name":"Mohamed Sakr","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYFACHhDBDMRsIIZNAlgwoYB4LWkJYDrBgHgthyFaGPBo0W3vPfjpRoU1g3z7sbTPlXvO5/HLdyd+eGDAIM8vdgCrFrMz55Klc86kMxicSTs888yz28WSbbybJYAOM5w5OwG7lhs5BtK5bYeBLklvZmw4cDtxwzHeDSAtCQa3cWox/p377zCDfP9zkJZzIC2bfxDQYiad23CYgeFG2mGglgMgLdvw23LmjJl1zjGgX248SwZqSU6c2Za7zSLBQAK3X473GN/OqQGGWH+aMVCLXWI/89nNN39U2MjzS2PXAgP1DWgCEniVj4JRMApGwSjADwBtfmEijdW6vQAAAABJRU5ErkJggg==","orcid":"","institution":"Montefiore Einstein","correspondingAuthor":true,"prefix":"","firstName":"Mohamed","middleName":"","lastName":"Sakr","suffix":""},{"id":450431217,"identity":"99a9de77-1b0a-4b32-a743-5835574367a2","order_by":1,"name":"Orna Rosen","email":"","orcid":"","institution":"Montefiore Einstein","correspondingAuthor":false,"prefix":"","firstName":"Orna","middleName":"","lastName":"Rosen","suffix":""},{"id":450431218,"identity":"e4d4d1a9-a2ad-4f07-955f-d8eea1590b26","order_by":2,"name":"Mimi Kim","email":"","orcid":"","institution":"Montefiore Einstein","correspondingAuthor":false,"prefix":"","firstName":"Mimi","middleName":"","lastName":"Kim","suffix":""},{"id":450431219,"identity":"837bf8ca-52a8-4cb2-829c-0f2c6187c09f","order_by":3,"name":"Mamta Fuloria","email":"","orcid":"","institution":"The Children's Hospital at Montefiore","correspondingAuthor":false,"prefix":"","firstName":"Mamta","middleName":"","lastName":"Fuloria","suffix":""},{"id":450431220,"identity":"cccdaede-e721-4e8c-b8d5-19b67a4afe65","order_by":4,"name":"Megan Carney","email":"","orcid":"","institution":"Mount Sinai Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Megan","middleName":"","lastName":"Carney","suffix":""},{"id":450431221,"identity":"1687555b-56e1-4eaa-8a54-ceb0b72f5bb5","order_by":5,"name":"Sheri Nemerofsky","email":"","orcid":"https://orcid.org/0000-0003-1549-5176","institution":"Children's Hospital at Montefiore","correspondingAuthor":false,"prefix":"","firstName":"Sheri","middleName":"","lastName":"Nemerofsky","suffix":""}],"badges":[],"createdAt":"2025-04-27 03:30:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6537736/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6537736/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82300721,"identity":"f5041d2c-8e10-43a7-a8e7-efcc4e55a9ac","added_by":"auto","created_at":"2025-05-08 20:50:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":248503,"visible":true,"origin":"","legend":"\u003cp\u003eTransducer position and ultrasound images of an UAC\u003c/p\u003e\n\u003cp\u003e(A) A phased array transducer is positioned over the xiphisternum in the midline sagittal plane with the orientation indicator pointing towards the head (12 o'clock). (B) An ultrasound image of an UAC (sharply contrasting double-contoured echoic structure) using a phased array transducer. (C) A linear transducer is positioned over the xiphisternum in the midline sagittal plane with the orientation indicator pointing towards the head (12 o'clock). (D) An ultrasound image of an UAC using a linear transducer.\u003c/p\u003e\n\u003cp\u003eAV: Aortic valve, LA: Left atrium, RV: Right ventricle, UAC: Umbilical artery catheter\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6537736/v1/7400952a67783b16b6525585.png"},{"id":82301418,"identity":"9e0cda7e-798f-48a1-9426-ae8bac56cc09","added_by":"auto","created_at":"2025-05-08 20:58:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":65671,"visible":true,"origin":"","legend":"\u003cp\u003eStudy\u003cstrong\u003e \u003c/strong\u003eFlow Diagram\u003c/p\u003e\n\u003cp\u003ePOCUS: Point of care ultrasound; UAC: Umbilical artery catheter; UVC: Umbilical vein catheter, XR: X-Rays\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6537736/v1/3a1657260fe1c4a9028cd491.png"},{"id":82301421,"identity":"e82c43e3-d256-47d4-865b-fea6917121a1","added_by":"auto","created_at":"2025-05-08 20:58:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":905532,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6537736/v1/1192d04a-1bf4-4fb4-a489-a3d98b3d86a1.pdf"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose.","formattedTitle":"The Aortic Valve as a Landmark for Ultrasound Guided Umbilical Artery Catheter Placement","fulltext":[{"header":"Background","content":"\u003cp\u003eUmbilical artery catheters (UAC) are currently amongst the most common central access devices used in sick preterm and term infants admitted to the neonatal intensive care units (NICU). They are often required for continuous blood pressure monitoring and frequent blood sampling. In addition, UACs may be used for parenteral nutrition as well as medication administration. (\u0026lrm;1\u0026lrm;,2). The depth of the UAC insertion may be calculated based on various methods, such as the shoulder\u0026ndash;umbilicus length graph (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) and the birth weight-based formula (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Frequently, catheters are placed sub-optimally, necessitating re-adjustments, repeat XRs and thus additional radiation exposure and delay of medical care.\u003c/p\u003e \u003cp\u003eRecently, the Society for Pediatric Radiology together with the American Society for Radiologic Technologists raised a campaign called \u0026ldquo;Image Gently\u0026rdquo; with a goal to raise awareness of radiation risks in children and recommend the use of alternative imaging modalities when possible (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Verification of central line position may account for nearly 25% of radiation exposure in the NICU. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)Point of Care Ultrasound (POCUS) is reliable, feasible, and without exposure to radiation. Bedside ultrasound (US) offers the possibility of direct visualization of the catheter and the vessels both during the insertion period and final positioning. This technique reduces the need for multiple catheter manipulations, radiation exposure and allows earlier safe usage of the catheter (\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Despite the advantages associated with the use of POCUS, it is not widely used to assess the UAC position. The objective of this study was to determine if the AV location visualized by POCUS can be used as a landmark for optimal tip positioning of the UAC.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design:\u003c/p\u003e \u003cp\u003eThis was a single-center, prospective, retrospective controlled study. The study was approved by the Institutional Review Board at the Albert Einstein College of Medicine. The study was conducted at a level IV NICU in the Bronx, NY. Consent was waived by the IRB because of the minimal to no risk nature of this study to patients.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients:\u003c/h2\u003e \u003cp\u003eNeonates who were admitted to the NICU and required UAC placement for clinical care management were included. The birth weight-based formula (3\u0026times;birth weight (kg)\u0026thinsp;+\u0026thinsp;9) was used to determine the UAC location for the 30 neonates in the retrospective group. Neonates with an umbilical venous catheter were excluded. Neonates whose electronic medical records had inconsistent data between providers\u0026rsquo; notes, radiology reports, or the number of XRs obtained for manipulation of the UAC were also excluded. The prospective experimental cohort included 30 neonates where the UAC insertion was performed under US guidance by one investigator (author MS). Large-for-gestational age (LGA) was defined as birthweight for gestational age\u0026thinsp;\u0026gt;\u0026thinsp;90th percentile, appropriate-for-gestational-age (AGA) as the 10th\u0026ndash;90th percentile, and small-for-gestational-age (SGA) as \u0026lt;\u0026thinsp;10th percentile in boys and girls on the Fenton growth curve, respectively (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInterventions:\u003c/h3\u003e\n\u003cp\u003eIn the prospective group, UACs were placed by neonatal fellows, nurse practitioners, and physician assistants. Two techniques were used for UAC placement: the 2-provider and 1-provider methods. The two-provider technique involves one provider inserting the UAC while the second uses POCUS to immediately confirm placement and guide adjustments before securing. The single-provider technique requires an extended sterile field, from the nipple line to the groin, and allows the single provider to insert and then use POCUS to adjust the line.\u003c/p\u003e \u003cp\u003eThe depth of UAC insertion was calculated based on the birth weight-based formula, (\u0026lrm;4), and POCUS imaging was performed immediately after insertion using a Sonosite Edge US system (FUJIFILM Sonosite, WA, USA). For neonates less than 1000 grams, the HSL25x / 13\u0026thinsp;\u0026minus;\u0026thinsp;6 MHz (FUJIFILM Sonosite, WA, USA) transducer was used whereas for neonates more than 1000 grams, L38xi / 10\u0026thinsp;\u0026minus;\u0026thinsp;5 MHz (FUJIFILM Sonosite, WA, USA) transducer was used. Catheters were visualized as a sharply contrasting double-contoured echoic structures. The UAC tip was considered adequately positioned on POCUS if it was at the level of a perpendicular line projecting from the AV to the vertebral column (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e-Video 1). All POCUS studies were recorded for analysis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eCatheter manipulations were recommended for suboptimal UAC positioning on POCUS in real time. Once UAC placement was deemed optimal, the catheter was secured, and an anterior-posterior XR of the chest and abdomen was obtained. The clinical team made the final decision on catheter tip position using radiographic findings.\u003c/p\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eThe primary outcome was the number of XRs performed for each patient until the UAC tip was in an optimal position between the thoracic vertebrae 6\u0026ndash;9. The secondary outcome was the number of manipulations performed until the UAC tip was in optimal position.\u003c/p\u003e\n\u003ch3\u003eStatistical Methods:\u003c/h3\u003e\n\u003cp\u003eAll data were summarized using standard descriptive statistics including means and medians for continuous data and counts and percentages for categorical data. The percentage of UACs placed and visualized on US in the prospective group was computed, along with corresponding 95% confidence intervals (CI). The percentage of UAC tips optimally positioned on XRs that did not require further manipulation was compared between the prospective and retrospective groups by computing the difference in proportions and 95% CIs, and by applying chi-square or Fisher\u0026rsquo;s exact test as appropriate. In addition, the number of XRs taken until tip position was deemed optimal by the clinical team was compared between the prospective and retrospective groups using the Wilcoxon rank sum test or Cochran\u0026ndash; Armitage test for trend, depending on the distribution of the outcome. The projected sample size was 30 subjects in each cohort. With this sample size, the precision (as measured by the width of the 95% CI) with which the percentage of UACs placed and visualized on US can be estimated in the prospective group was +/- 18%. For comparison between the prospective and retrospective groups, the study had at least 80% power with a two-sided Type I error rate of 5% to detect an absolute difference of 32% or greater in the percentage of UAC tips optimally positioned on XRs that did not require further manipulation. This effect size was determined by our expectation that \u0026lt;\u0026thinsp;60% in the prospective group and ~\u0026thinsp;90% in the retrospective group will require additional XRs.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatients:\u003c/h2\u003e \u003cp\u003eThere were 269 neonates admitted to the NICU who had a UAC between June 2021 and December 2023. Study enrollment is shown in the flow diagram (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Data on the primary outcome was extracted for 30 patients in the retrospective group and 30 patients in the prospective POCUS guided insertion group.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe baseline characteristics of the infants in both groups were similar (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The median (IQR) gestational age was 32.2 weeks (27.5, 35.5) in the retrospective group (p\u0026thinsp;=\u0026thinsp;0.11) and 26.9 weeks (24.6, 33.6) in the prospective group. The median (IQR) birth weight was 1245 grams (918, 2423) and 901 grams (675, 1970) in the prospective and retrospective group, respectively (p\u0026thinsp;=\u0026thinsp;0.12) and there was no difference in weight for gestational age between the groups. A single provider technique was used in 11/30 (36.7%) cases.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNeonatal Characteristics at Baseline\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eStandard, N\u0026thinsp;=\u0026thinsp;30\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePOCUS, N\u0026thinsp;=\u0026thinsp;30\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestational Age\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMedian (IQR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e32.21 (27.49, 35.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.93 (24.61, 33.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBirthweight\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMedian (IQR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1245 (918, 2423)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e901 (675, 1970)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e20 (67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e10 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeight for GA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAGA\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e22 (73%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLGA\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e2 (6.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (6.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSGA\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e6 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eValues are median (IQR) or count (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e*Wilcoxon rank sum test for continues variable; Pearson's Chi-squared test or Fisher's exact test for categorical variable\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePrimary Outcome:\u003c/h3\u003e\n\u003cp\u003eIn the retrospective group, 16 neonates (54%) required 2\u0026ndash;6 XRs to confirm appropriate position (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In the prospective group, none of the neonates needed more than one XR (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrimary and Secondary Outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eRetrospective\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;30\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePOCUS\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;30\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of XRs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e14 (47%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e2\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e7 (23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e3\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e7 (23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e4\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1 (3.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e6\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1 (3.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of Manipulations\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e14 (47%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e7 (23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (70%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026gt;\u0026thinsp;1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e9 (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eValues are count (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e*Wilcoxon rank sum test for continues variable; Pearson's Chi-squared test or Fisher's exact test for categorical variable\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eSecondary Outcome:\u003c/h3\u003e\n\u003cp\u003eIn the retrospective group, 16 (54%) neonates required 1\u0026ndash;5 manipulations for the UAC tip to be in an appropriate position (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In the prospective group, 25 (83%) neonates required 1\u0026ndash;2 manipulations (p\u0026thinsp;=\u0026thinsp;0.002).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e In this single-center, prospective, retrospective controlled study, POCUS guided UAC placement using the AV as a landmark was associated with fewer XRs. Every UAC inserted using POCUS and the AV location was optimally positioned on the first XR. Currently, there are several formulae that are used to estimate the necessary depth of the UAC insertion, including the one we used in the retrospective group. In an observational study to compare the accuracy of 11 different formulae that are widely used to guide UAC depth of insertion, 25\u0026ndash;50% of UACs were not in optimal position at initial placement (\u0026lrm;5). Utilization of POCUS for UAC insertion allows for real time adjustments, obviating the need for repeated XRs.\u003c/p\u003e \u003cp\u003eOur findings are consistent with previous studies suggesting that POCUS can effectively reduce the number of XRs required to confirm UAC tip position (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Like the study conducted by Fleming (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), this study demonstrated a reduction in the number of X-rays required for UAC placement. Despite all the evidence, including studies conducted several decades ago, the integration of POCUS into routine clinical practice for neonatal central lines remains lagging. One of the primary constraints hindering the widespread utilization and acceptance of POCUS as a standard of care lies in the need for standardized scanning protocols. This includes the establishment of a consistent landmark, such as the AV, for accurate image acquisition and interpretation within this study. To our knowledge, this is one of the first studies identifying the AV as a specific landmark for optimal positioning of UACs.\u003c/p\u003e \u003cp\u003eOver the last few years, POCUS has gained notable acceptance in the NICU field. Verifying central line positions is one of the increasingly exciting applications for its use. However, implementing the POCUS technique in the NICU requires a competent structure that encompasses providers\u0026rsquo; training and credentialing (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Using the AV as a landmark to aid in UAC tip positioning may ease standardizing the scanning technique and ultimately accepting US guided UAC positioning as the new standard of care. The AV is a relatively easy structure to identify because of its unique US appearance and relatively fixed anatomy (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Unlike other studies (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), we observed an increase in the number of manipulations per line to optimize tip position. This discrepancy may be attributed to the stringent requirement of aligning the UAC tip with the precise location of the aortic valve. Importantly, no more than two manipulations were necessary for any line in the prospective group. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eUtilizing our standardized protocol, we were able to visualize the UAC tip despite various pathologies. Seven infants (23%) in the study cohort had other pathologies; 2 pneumothorax, 2 congenital diaphragmatic hernia, 1 diaphragmatic eventration, 1 hydrops fetalis and 1 skeletal dysplasia. It is noteworthy to mention that in this study, 11 of the 30 UACs in the prospective group were inserted using the single provider technique. Although the study wasn\u0026rsquo;t powered to compare these two techniques; it seems that the single provider technique was equally successful as the two-provider technique. The single provider technique may need extra training and a larger sterile field. However, employing a single-provider technique can enhance efficiency, which may be particularly valuable in the face of current healthcare staffing shortages.\u003c/p\u003e \u003cp\u003eOur study has its limitations, including using a retrospective control group, which presents several potential disadvantages. These include selection and temporal bias particularly by the degree of providers\u0026rsquo; competency inserting the lines. As this study was done at an academic institution, some lines may have been placed by experienced providers, while others were just starting their neonatal careers. Fortunately, in this study there was no difference in the relevant baseline characteristics and the control group was chosen from patients who had a UAC inserted in the year immediately before the recruitment of the prospective cohort to ensure a similar level of provider experience. As retrospective data may be incomplete or inaccurate making it difficult to reliably analyze and draw meaningful conclusions, a thorough review and validation of the retrospective data was performed to ensure accuracy and completeness.\u003c/p\u003e \u003cp\u003ePOCUS requires additional training and standard optimal protocols to be successful; this may limit generalizability of this study. We aimed to standardize all aspects of the scanning protocol including views, landmarks, orientations as well as machine specification and parameter settings. Following our proposed technique along with brief bedside training, providers were oriented and able to identify various landmarks. Finally, none of the study groups included patients with congenital heart disease except for patients with interatrial communications and patent ductus arteriosus. Further studies are needed to evaluate POCUS guided UAC placement in this subset of neonates.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eUsing the AV landmark with POCUS may reduce the number of XRs needed to confirm optimal positioning of UACs. Further studies are needed to evaluate utilizing the single provider POCUS technique and whether POCUS reduces the time needed to commence use of the UAC.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u0026nbsp;\u003c/strong\u003e The authors have no conflicts of interest to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e The study was approved by the Institutional Review Board at the Albert Einstein College of Medicine. Consent was waived by the IRB because of the minimal to no risk nature of this study to patients. The study was performed in accordance with the Declaration of Helsinki. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u0026nbsp;\u003c/strong\u003eall datasets on which the conclusions of the paper rely will be made available to referees at submission and to readers promptly upon request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: No funding was secured for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMS:\u0026nbsp;Conceptualization (formulation or evolution of overarching research goals and aims); Conducting research and investigation process (Conceived and designed the analysis, Collected the data); Manuscription writing, review and editing\u003c/p\u003e\n\u003cp\u003eOR:\u0026nbsp;Conceptualization (formulation or evolution of overarching research goals and aims); Conducting research/ investigation process (Conceived and designed the analysis); Manuscription review and editing\u003c/p\u003e\n\u003cp\u003eMK: Conceptualization (evolution of overarching research goals and aims); Development or design of methodology, performed the data analysis and interpretation; Manuscription writing, review and editing\u003c/p\u003e\n\u003cp\u003eMF: Conceptualization (supporting), Manuscript writing, review and editing\u003c/p\u003e\n\u003cp\u003eMC: Data collection\u003c/p\u003e\n\u003cp\u003eSN: Manuscript review and editing\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAnderson J, Leonard D, Braner DA, Lai S, Tegtmeyer K. Umbilical vascular catheterization in neonates. N Engl J Med. 2008;359: e18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFurdon SA, Horgan MJ, Bradshaw WT, Clark DA. Nurses' guide to early detection of umbilical arterial catheter complications in infants. Adv Neonatal Care. 2006 Oct. 6 (5):242\u0026ndash;56; quiz 257\u0026thinsp;\u0026ndash;\u0026thinsp;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDunn PM. Localization of the umbilical catheter by post-mortem measurement. Arch Dis Child 1966; 41(215): 69\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShukla H, Ferrara A. Rapid estimation of insertional length of umbilical catheters in newborns. Am J Dis Child 1986; 140(8): 786\u0026ndash;788.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLean WL, Dawson JA, Davis PG, Theda C, Thio M. Accuracy of 11 formulae to guide umbilical arterial catheter tip placement in newborn infants. Arch Dis Child Fetal Neonatal Ed. 2018;103(4):F364-F369. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/archdischild-2017-313039\u003c/span\u003e\u003cspan address=\"10.1136/archdischild-2017-313039\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2017 Aug 17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eApplegate K. Image Gently: A campaign to promote radiation protection for children worldwide. S Afr J Rad. 2015;19(2): Art. #919,\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoske, M.J., Applegate, K.E., Butler, P.S. et al. Image Gently: Partnerships to promote radiation protection for children worldwide. Pediatr Radiol 41, 207\u0026ndash;209 (2011).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScott MV, Fujii AM, Behrman RH, Dillon JE. Diagnostic ionizing radiation exposure in premature patients. J Perinatol. 2014;34(5):392\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFleming SE, Kim JH. Ultrasound-guided umbilical catheter insertion in neonates. J Perinatol. 2011;31:344\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOppenheimer DA, Carroll BA, Garth KE, Parker BR. Sonographic localization of neonatal umbilical catheters. AJR Am J Roentgenol 1982;138(6):1025\u0026ndash;1032.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeorge L, Waldman JD, Cohen ML, Segall ML, Kirkpatrick SE, Turner SW et al. Umbilical vascular catheters: localization by two-dimensional echocardio/aortography. Pediatr Cardiol 1982; 2(3): 237\u0026ndash;243.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeinen RD, Bauer AS, Devous K, Cowan E. Point-of-care ultrasound use in umbilical line placement: a review. J Perinatol. 2020;40(4):560\u0026ndash;566. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41372-019-0558-8\u003c/span\u003e\u003cspan address=\"10.1038/s41372-019-0558-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2019 Nov 22. PMID: 31758061.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFenton, T. R., \u0026amp; Kim, J. H. (2013). A systematic review and meta-analysis to revise the Fenton preterm infant growth chart. The Journal of Pediatrics, 163(2), 571\u0026ndash;576.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaul D, Ajayi S, Schutzman DL, Horrow MM. Sonography for complete evaluation of neonatal intensive care unit central support devices: a pilot study. J Ultrasound Med. 2016;35(7):1465\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarg AK, Houston AB, Laing JM, MacKenzie JR. Positioning of umbilical arterial catheters with ultrasound. Arch Dis Child 1983;58(12):1017\u0026ndash;1018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMadar RJ, Deshpande SA. Reappraisal of ultrasound imaging of neonatal intravascular catheters. Arch Dis Child - Fetal and Neonatal Edition 1996;75(1):F62\u0026ndash;F64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDan L. Stewart, Yasser Elsayed, Mar\u0026iacute;a V. Fraga, Brian D. Coley, Aparna Annam, Sarah Sarvis Milla, COMMITTEE ON FETUS AND NEWBORN AND SECTION ON RADIOLOGY; Use of Point-of-Care Ultrasonography in the NICU for Diagnostic and Procedural Purposes. Pediatrics December 2022; 150 (6): e2022060052.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDan L. Stewart, Yasser Elsayed, Mar\u0026iacute;a V. Fraga, Brian D. Coley, Aparna Annam, Sarah Sarvis Milla, THE COMMITTEE ON FETUS AND NEWBORN AND SECTION ON RADIOLOGY, Section on Radiology Executive Committee, 2021\u0026ndash;2022; Use of Point-of-Care Ultrasonography in the NICU for Diagnostic and Procedural Purposes. Pediatrics December 2022; 150 (6): e2022060053.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-perinatology","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"jp","sideBox":"Learn more about [Journal of Perinatology](http://www.nature.com/jp/)","snPcode":"41372","submissionUrl":"https://mts-jper.nature.com/cgi-bin/main.plex","title":"Journal of Perinatology","twitterHandle":"@jperinatology","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6537736/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6537736/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eUmbilical artery catheters (UAC) are common in the neonatal intensive care unit. Frequently, catheter locations are suboptimal. Point of care ultrasound (POCUS) is reliable and safe. The objective of this study was to determine if visualizing the aortic valve (AV) with POCUS could be a landmark for UAC positioning.\u003c/p\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis was a prospective, retrospective controlled study. The retrospective group included neonates with a UAC insertion depth calculated by (3\u0026times;birth weight(kg)\u0026thinsp;+\u0026thinsp;9). The experimental group used POCUS and identified the level of the AV for UAC placement.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eEach group had thirty neonates. The groups were similar in gestational age, p\u0026thinsp;=\u0026thinsp;0.11 and median birth weight (p\u0026thinsp;=\u0026thinsp;0.12). In the control group, 16 neonates (54%) required repositioning and between 2\u0026ndash;6 X-Rays. None of the UACs in the experimental group needed repeat X-Rays (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe AV location identified using POCUS can reduce the need for multiple XRs for UAC placement.\u003c/p\u003e","manuscriptTitle":"The Aortic Valve as a Landmark for Ultrasound Guided Umbilical Artery Catheter Placement","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-08 20:50:14","doi":"10.21203/rs.3.rs-6537736/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"revise","date":"2025-05-12T07:17:48+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"This content is not available.","date":"2025-05-09T21:17:27+00:00","index":1,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2025-05-08T17:25:19+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-05-05T11:13:09+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-05-03T20:14:38+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2025-04-30T23:31:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-29T12:46:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Perinatology","date":"2025-04-29T00:43:21+00:00","index":"","fulltext":""},{"type":"checksFailed","content":"","date":"2025-04-28T13:10:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-27T03:25:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-perinatology","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"jp","sideBox":"Learn more about [Journal of Perinatology](http://www.nature.com/jp/)","snPcode":"41372","submissionUrl":"https://mts-jper.nature.com/cgi-bin/main.plex","title":"Journal of Perinatology","twitterHandle":"@jperinatology","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f06c1815-a053-491b-a62c-b495c022a205","owner":[],"postedDate":"May 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":47932039,"name":"Health sciences/Medical research/Outcomes research"},{"id":47932040,"name":"Scientific community and society/Scientific community"}],"tags":[],"updatedAt":"2025-08-19T13:05:59+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-08 20:50:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6537736","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6537736","identity":"rs-6537736","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}