Response: Commentary: Enhanced Monitoring of the Preterm Infant during Stabilization in the Delivery Room

We read with interest Dr. Hutchon's commentary on our recent review entitled " Enhanced Monitoring of the Preterm infant during Stabilization in the Delivery Room " (1). We would like to thank him for his kind comments. He raised a number of important points related to one aspect of our review, namely heart rate acquisition in the delivery room. He was disappointed by our " characterization of the usefulness of Doppler ultrasound " in monitoring newborn heart rates (HR) and wondered why we " failed to comment on the impact of delayed cord clamping (DCC) on HR in the first minutes of postnatal life. " Our review specifically concerned the monitoring of preterm infant stabilization, and we are unaware of any studies, which have assessed the feasibility of Doppler ultrasound monitoring in this population of preterm infants (<32 weeks GA). Doppler ultrasound is certainly a useful method for monitoring newborn infant HR, but it is not commonly practiced, and its use has not been addressed by international guidelines on newborn stabilization (2, 3). Dr. Hutchon has shown that ultrasound HR is readily obtained immediately after birth in a newborn piglet weighing 1 kg (4). He has also shown that Doppler ultrasound can provide immediate heart sounds and that HR can be calculated through a polyethylene wrap from the moment of application in a mannequin model (1). Goenka et al. presented a study at the Pediatric Academic Societies and Asian Society for Pediatric Research meeting in 2014 on Doppler ultrasound in 92 stable infants >35 weeks gestation in the delivery room (5). They found that Doppler ultrasound measurements were feasible in term infants; HR values were comparable to both electrocardiogram (ECG) and pulse oximetry (PO) values; and that these values were available sooner than PO values. The published abstract from this study did not provide details on other important findings, including exact timeframes, in which Doppler ultrasound and ECG values were obtained. We await this detail in a future publication. Our practice is to have ECG available for HR monitoring, as an adjunct to PO monitoring, for all preterm deliveries <32 weeks gestation (6). This approach is based on a number studies in preterm infants, highlighting the feasibility, accuracy, and availability of HR data within seconds of application (7–10). Simulation training and enhanced teamwork is required to enhance ECG application times, and in our setting, continuous heart rate data are available …