We thank Dr. Sinha and colleagues for their interest in our recently published recommendations on targeted neonatal echocardiography (TNE). The authors nicely explain the way they developed a TNE service at the Boston Medical Center. This can serve as an example of how our practice guidelines can be implemented by neonatal intensive care units (NICU). Organizing a 24-hour service 7 days a week is an important challenge for most units, which should not be underestimated when starting a TNE program. Therefore, collaborating with existing resources has obvious logistic advantages. Wherever possible, this implies maximal integration within existing echocardiography services. As Sinha et al. correctly state, this integrated model also influences the quality of care and improves the safety of the TNE service. For NICUs in hospitals without pediatric cardiology services, telemedicine links are a good solution. This can consist of the transfer of images to a referral center, as in the Boston approach, or of more advanced solutions, such as a live-scanning approach with trained neonatologists scanning under remote supervision of pediatric cardiologists. This uses Internet transmission with a two-screen device, one connected to the ultrasound machine on site and the second to a camera observing the operator. This allows the reviewing physician to provide direct instructions to the operator while scanning. The success of a TNE program is critically dependent on the training of the operators. We agree with Sinha et al. that echocardiographic training of neonatologists should go beyond informal self-directed learning, and we hope that our more formal extensive training model will improve operators’ diagnostic skills.

Because organizing a TNE service requires significant resources, there is a need to further scientifically prove the clinical benefit and demonstrate its impact on the clinical outcomes of patients admitted to NICUs. This will require carefully designed clinical research studies. Echocardiography is just a tool, and the major challenge is a better understanding of neonatal hemodynamics and the impact of perinatal disease on cardiovascular adaptation. Other techniques, such as cardiac magnetic resonance imaging and electrical impedance cardiography, could help in providing more information for understanding the pathophysiology of neonatal circulatory failure. We hope that our recommendations will help further the field and that well-trained neonatologists with interest in neonatal hemodynamics will develop the programs and perform the research required to improve cardiovascular care in the NICU.