A core curriculum for pediatric lung ultrasound: an expert consensus

Abstract

Background

Lung ultrasound is a valuable tool for pediatricians, aiding in diagnosis and procedural safety while reducing radiation exposure. Its application has significantly increased. However, unlike some other medical specialties, structured ultrasound training is not consistently integrated into pediatric residency programs, resulting in variable skill acquisition among national practitioners. This lack of standardization necessitates the development of a comprehensive educational framework.

Main body

A standardized, longitudinal core curriculum for pediatric lung ultrasound is developed through a consensus of nationally recognized experts. The proposed model defines progressive proficiency levels, each with specific clinical competencies, skills, and measurable milestones. An integrated assessment strategy, combining written examinations and objective structured clinical examinations, is recommended to evaluate both theoretical knowledge and practical application. Furthermore, the curriculum outlines a hands-on practical pathway, requiring supervised clinical procedures and tutor validation at each proficiency level. The article also addresses key challenges hindering the widespread adoption of curricula in pediatrics, including a shortage of qualified instructors, limited access to resources and training time, and the need for robust quality assurance measures and standardized image interpretation protocols.

Conclusion

The proposed core curriculum offers a structured educational platform to promote the systematic acquisition of lung ultrasound skills among pediatricians. Addressing the identified barriers is essential for the successful integration of lung ultrasound into pediatric clinical practice, ultimately improving diagnostic accuracy and enhancing patient care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13052-025-02089-2.

Background

Lung ultrasound (LUS) offers pediatricians a suitable tool to address specific issues in clinical practice, narrow differential diagnoses, and improve the security of routine procedures [1]. Clinicians perform and interpret LUS to answer a focused question or achieve a specific procedural goal [2]. Ultrasound is suitable for pediatric patients, offering a radiation-free alternative to computed tomography and X-rays [3]. Moreover, children’s unique body composition, marked by a higher cartilage-to-bone ratio and a lower fat-to-lean mass proportion, provides superior acoustic windows that further enhance ultrasound’s utility. However, suboptimal cooperation in younger patients can complicate ultrasound examinations [2, 4].

Indeed, the use of LUS has significantly increased over the last two decades in many settings, and is routinely used to assess children with suspected bronchiolitis, pneumonia, pleural effusions, or trauma [5].

A lung ultrasound core curriculum is often taught in other specialties, such as emergency medicine, where it is a core component of the Graduate Medical Education Program Requirements for residency training [6]. Despite its rapid diffusion, pediatric residency programs do not consistently include structured training. Consequently, much disparity persists in the acquisition of quantitative and qualitative skills. In a 2021 national survey, only 7.8% of pediatric residents in Italy reported that their residency school offered an official lung ultrasound training program, although more than 95% considered it a fundamental part of their curriculum [7]. Incorporating LUS into the residents’ curriculum still does not solve the problem for hospitalists already in practice. Nevertheless, hands-on training programs and continued subsequent longitudinal training courses can help hospitalists gain confidence [8]. Several training courses are already in place, but there is an urgent need to develop a standardized plan to ensure that participants acquire the necessary proficiency required. As ultrasound is operator-dependent, appropriate education and training are essential to help clinicians avoid pitfalls and make the right clinical decisions.

A group of nationally recognized experts in this field, who are among the authors of this paper, conducted a comprehensive analysis of the principal impediments associated with this issue. This evaluation facilitated the identification of critical educational gaps and culminated in the consensual formulation of a detailed blueprint for an integrated core curriculum focused on pulmonary ultrasound for pediatricians. We propose a longitudinal model curriculum as an educational platform to integrate lung ultrasound into assessments of the response to clinical care in pediatric settings.

Defining and assessing competence in clinical ultrasound

Competency is the ability of healthcare professionals to integrate knowledge, skills, values, and attitudes into clinical practice [9]. The I-AIM model (indication, acquisition, interpretation, and medical decision-making) defines four main skills of ultrasound: recognizing when to make an ultrasound, performing technical skills in image acquisition, interpretation of images, and incorporating those ultrasound findings into clinical decision-making [4, 10]. Assessing competence means defining well-established stages of expertise. Bloom’s reviewed taxonomy identifies different domains of learning such as cognitive, affective, and psychomotor, each of whom has specific proficiency levels classified from “novice” to “minimally trained” to “well trained” to “expert” [11].

Although the Accreditation Council for Graduate Medical Education (ACGME) recommends the performance of a minimum number of examinations as a parameter to define clinical ultrasound proficiency, studies point out that diverse ultrasound applications have different learning curves [12, 13]. Data from the literature regarding lung ultrasound curves differs. Blehar et al. showed a plateau point in 39 lung examinations [12], but most of the studies were in favor of a steeper curve for ultrasound beginners [14, 15]. Overall, the turning point in the curve seems intermediate, higher than bladder ultrasound and lower than echocardiography [12]. Plateaus on learning curves represent areas where a cluster of novices, on average, is unlikely to improve further [16]. The curves are statistical exemplifications. Hence, they do not reassume the actual individual learning stage, as individuals could benefit from further repetitions beyond the plateau [13]. This is the reason why the plateau points are not strictly comparable to the achievement of an expertise level.

There is no consensus on the best method for assessing a certain competence stage.

A written examination provides a standardized and reproducible method, even if it fails to assess image acquisition [9]. Although evaluating theoretical knowledge is essential, it is inadequate as a lone method to assure expertise. Furthermore, in the pediatric setting, LUS requires not only a solid ultrasound background but also well-established competencies in pediatric pathophysiology and morbidity [10]. An image review lets educators assess skills asynchronously. It enables progressive acquisition of longitudinal competencies but lacks some essentials. Due to the absence of faculty, this method lacks prompt and immediate acquisition of practical skills in terms of probe location. Moreover, the learner cannot discover any eventual missing findings simultaneously [17]. The Objective Structured Clinical Examination (OSCE) offers an exam format that allows learners to be evaluated in a uniform, standardized, reliable, and objective way. Educators usually set up the OSCE as a series of stations to simulate real clinical scenarios and assess specific tasks [18]. A major drawback of this method is the large amount of time and the high cost involved. Additionally, the OSCE is designed to reproduce a real-life clinical context; however, it does not assess a learner’s attitude in a real setting [19]. The Standardized Direct Observational Tool (SDOT) uses a prearranged checklist to assess a novice’s skills in executing supervised ultrasound scans [20]. It can be applied to real clinical scenarios or in a simulated context. In the same way as the OSCE, it is quite objective and reproducible, but it has a high cost of feasibility and is time-consuming [21]. The SDOT assesses holistic performance within a given context, whereas the OSCE evaluates specific skills and competencies through a series of standardized stations. All the main differences between SDOT and OSCE are summarized in Table 1. Direct observation during a clinical shift appears to be an effective way of evaluating competence, as it enables students to engage directly with clinical practice. It covers all different levels of competencies in real time. Owing to the variability of daily clinical scenarios, this approach lacks standardization and reproducibility [22].

Table 1.

The different nuances of SDOT and OSCE in clinical skills assessment

	Standardized Direct Observation Tool (SDOT)	Objective Structured Clinical Examination (OSCE)
Focus	holistic performance	specific skills and competencies in stations
Setting	real-world or simulated	primarily simulated with standardized equipment
Scenario	variable	highly standardized for all candidates
Structure	standardized criteria	highly structured stations with specific tasks
Timing	variable	fixed time limit per station, multiple stations
Assessment	observer evaluates unfolding performance	examiners at each station score specific tasks

There is no consensus on the most suitable tool for evaluating ultrasound competencies [9]. Hence, instructors should balance the limitations and benefits of each technique. In this proposal, we adopt an assessment strategy composed of a written test to measure the learner’s sub-competencies of LUS knowledge and image interpretation, and an OSCE to test how the novice integrates ultrasound scans with clinical decision-making and practice.

Heterogeneity in the duration of training among different specialties also persists [23]. Short-intensive courses are widespread among pediatricians, either on a basic level or with progressive advanced expertise. If the initial training is not followed by continued practice, knowledge retention may be poor [24]. Given the preceding considerations, a time-limited certificate attesting to the demonstrated level of proficiency is a requisite credential. Acquiring skills in LUS is similar to that of other competences, where the apprentice is not just presumed to individuate pathological findings, but also combines them with clinical data and ultimately impacts on the patient’s medical history. Considering this, it is possible that longitudinal protracted training combined with hands-on practice could result in better expertise. We adopt the indication, acquisition, interpretation, and medical decision-making (I-AIM) model as a blueprint to structure the steps of this curriculum [4].

The need for a standardized core curriculum

The proposed curriculum is designed to guide pediatricians from foundational to advanced levels of proficiency, ensuring a comprehensive and structured approach to lung ultrasound education.

The core curriculum was developed through a collaborative process involving multiple rounds of consensus-building among an expert panel. We defined key milestones for each level of proficiency, from foundational to masterclass, ensuring a clear progression of skills and knowledge.

The aim of LUS is to answer a clinical question in a dichotomous manner. Clinicians should acquire scans with an appropriate probe to detect meaningful findings that should be interpreted in the most appropriate manner in terms of anatomical structures and artifacts. Ultimately, these LUS evaluations can guide diagnostic and therapeutic approaches. The type and frequency of probe used could vary according to the age of the patient. Linear transducers with high frequencies are the most suitable for performing scans in newborns and infants [5]. Furthermore, the linear probe is the best way to examine the pleural line and its motion during breathing [5]. Low-frequency probes perform best for older children and adolescents [25]. B-mode images are usually sufficient, but can be augmented by an M-mode study (above all for pneumothorax evaluation and diaphragmatic movement assessment) [26]. Therefore, a methodical and systematic approach to lung exploration should be adopted.

Clinicians should divide each hemithorax into six areas utilizing two vertical lines (anterior and posterior axillary lines) and two horizontal lines (one above the diaphragm and the other 1 cm above the nipples). The lung areas are the anterior (between the sternum and the anterior axillary line), lateral (between the anterior and posterior axillary lines), and posterior (between the posterior axillary line and the spine) [27]. Consequently, 12 different lung fields are explored from right to left, cranial to caudal to ensure a complete exam. Anterolateral scans should be performed with the patient in the supine position, whereas the posterior thorax should be explored either with the patient seated or in lateral or prone decubitus. Both longitudinal and transverse scans ought to be used [28, 29].

Consensus methodology: the Delphi process

This core curriculum proposal was developed using a modified Delphi consensus methodology. The Delphi method uses a structured and iterative process that builds consensus among experts through a series of rounds with controlled feedback [30].

Our expert panel consisted of 12 nationally recognized specialists in pediatric lung ultrasound. This panel included pediatricians, radiologists, and medical educators from major Italian academic and clinical institutions.

The consensus process involved three distinct rounds, conducted between October 2024 and February 2025:

Round 1: initial review and rating

Panelists independently reviewed and rated a comprehensive list of statements covering curriculum components, proficiency milestones, and assessment tools. These statements were initially proposed by a core group (AM, LDS, AC, and RA) and supported by relevant literature. Feedback was collected anonymously via online questionnaires.

Round 2: revaluation and input

Aggregated results and anonymized comments from the first round were shared with the panel. Panelists then had the opportunity to revise their initial ratings and provide further input, especially in areas where consensus had not yet been reached.

Round 3: final resolution

The final round focused on resolving any remaining disagreements and finalizing the key statements that would define the curriculum framework.

The consensus was pre-defined as ≥ 80% agreement among panelists for each curriculum component and assessment method. Items not meeting this threshold were either revised or excluded based on panel feedback.

To quantify consensus, we used a grading system consistent with previous Delphi studies. For each item, the percentage of participants scoring ≥ 4 on a Likert scale was calculated and assigned a corresponding grade: ‘U’ for unanimous (100%) agreement, ‘A’ for 90–99% agreement, ‘B’ for 78–89% agreement, and ‘C’ for 67–77% agreement.

A complete list of approved statements on which this core curriculum is based is shown below:

Statement	Grade
1. This curriculum defines progressive proficiency levels, each with specific clinical competencies, skills, and measurable milestones.	A
2. The didactic component of the curriculum consists of at least 20 one-hour lectures spread over six months, covering essential items including ultrasound physics, modes, knobology, scan interpretation, and common artifacts.	B
3. The curriculum includes specific modules on lung ultrasound semiotics.	A
4. Focused cardiac ultrasound is integrated into the curriculum, covering probe handling, heart evaluation through different scans, assessment of cardiac function, and IVC assessment.	B
5. The curriculum outlines a hands-on practical pathway requiring supervised clinical procedures and tutor validation at each proficiency level.	A
7. At the foundational level, pediatricians must demonstrate the ability to operate the ultrasound machine effectively, identify normal lung structures, obtain standardized views, and understand basic ultrasound physics.	B
8. At the secondary level, providers are expected to acquire skills in detecting common abnormalities such as pneumothorax, pleural effusion, and pneumonia using validated diagnostic criteria, and integrate ultrasound with clinical data for diagnosis.	A
9. At the advanced proficiency level, trainees should be able to use ultrasound to guide management decisions in critically ill children and perform ultrasound-guided interventions.	B
10. At the masterclass level, pediatricians are expected to demonstrate image optimization expertise, design training modules, critically evaluate literature, and contribute to scholarly research in pediatric lung ultrasound.	A
11. Upon achieving a defined proficiency level, a time-limited certification subject to automatic expiry after four years is assigned, requiring reassessment by independent examiners.	B
12. An integrated assessment strategy combining written examinations and OSCE is recommended to evaluate both theoretical knowledge and practical application.	A
13. Written examinations are used to measure the learner’s sub-competencies of LUS knowledge and image interpretation.	B
14. OSCEs should be utilized to test how the trainee integrates ultrasound scans with clinical decision-making and practice simulated clinical scenarios.	A
15. Supervised clinical procedures, with tutors maintaining evidence of exams performed through registration forms and cloud storage, are essential for hands-on learning progression.	A

Didactics

We recommend a comprehensive didactics course consisting of at least 20 lectures, each approximately one hour long, spread over six months. These lectures can be delivered in person or supplemented with online support to ensure flexibility and accessibility. The course is designed to cover major topics in ultrasound education, including:

• Physical properties of ultrasound waves: this includes understanding the nature of ultrasound waves, such as frequency, wavelength, and velocity, which are crucial for interpreting ultrasound images.

• Overview of modes:

  • B-mode: provides two-dimensional images of tissues, useful for structural assessment.
  • M-mode: displays the movement of structures over time. It emits a single scan line and records the echoes along this line, plotting them graphically with time on the x-axis and depth on the y-axis.
  • Color flow doppler: combines anatomical information from B-mode ultrasound with velocity information derived from doppler techniques. It generates a color-coded map of blood flow superimposed on a B-mode ultrasound image, providing visual information about the direction and speed of blood flow in real-time.

• Knobology: understanding how to adjust settings like zoom, depth, gain, time gain compensation, organ presets, and conventions is essential for optimizing image quality.

• Essentials of scan interpretation: this involves recognizing tissue echogenicity (brightness) and different echostructures (e.g., hyperechoic, hypoechoic, anechoic).

• Common artifact: a substance or structure not naturally present in the matter being observed but formed by artificial means, as during the preparation of a microscope slide. The possible diagnostic role of artifacts is challenging to understand from both a physical and a semiological point of view. On the one hand, an artifact acts as an obstacle to sight, obscuring the true anatomy. On the other hand, it simultaneously provides information, potentially leading to irrepressible skepticism or, conversely, unexpected insights into the ineffable.

  • Acoustic shadowing: occurs when structures absorb or reflect ultrasound waves, creating dark areas.
  • Acoustic enhancement: brighter areas behind structures that allow more sound to pass through.
  • Mirror image: reflections that mimic structures on the opposite side of a strong reflector.
  • Reverberation: repeated echoes between two strong reflectors.
  • Ring-down: a series of echoes from small gas bubbles or metal objects.
  • Twinkle artifact: seen with calcifications or air, producing a sparkling effect.

Lung ultrasound

• Technical terms and probe handling: understanding the proper selection and positioning of the probe along the thorax is crucial for effective scanning.

• Comparison of scanning systems: different systems may be used based on patient’s anatomy and clinical context, such as linear or curvilinear probes.

• Lung ultrasound semiotics:

  • A lines: horizontal reverberations indicating normal lung.
  • B lines: vertical artifacts suggesting interstitial edema or fibrosis.
  • White lung: indicates consolidation or severe edema.

• Pleural effusion:

  • Simple effusions: fluid accumulation without significant complications.
  • Complex effusions: may include fibrin strands or loculations.

• Consolidations:

  • Differential diagnosis between pneumonia and atelectasis based on air bronchograms and consolidation patterns.
  • Static and dynamic air bronchograms: indicate air-filled bronchi within consolidated lung tissue.

Focused cardiac ultrasound

• Technical terms and probe handling: proper probe selection and positioning are critical for obtaining clear cardiac views.

• Heart evaluation through different scans:

  • Parasternal long axis: provides a view of the left ventricle and mitral valve.
  • Parasternal short axis: offers a cross-sectional view of the ventricles.
  • Apical 4 chamber: visualizes all four heart chambers.
  • Subxiphoid view: useful for assessing the inferior vena cava and pericardial space.

• Assessment of cardiac function:

  • Coarse fraction ejection: estimates left ventricular ejection fraction.
  • Overall contractility: assesses the heart’s pumping efficiency.
  • Pericardial effusion: fluid accumulation in the pericardial space.

• Assessment of Inferior Vena Cava (IVC) and its ratio with the abdominal aorta:

  • IVC diameter: helps assess volume status and cardiac function.
  • IVC/Aorta ratio: provides additional information on cardiac preload and potential right heart strain.

Proficiency assessment

The development of a robust and meticulously calibrated quality assessment instrument is crucial within a structured curriculum, facilitating systematic evaluation of trainee progression and ensuring that pediatricians acquire the necessary skills to effectively integrate lung ultrasound into their clinical practice. Each tier in this assessment scale should correspond to specific privileges for which the pediatrician is authorized to perform, with clear milestones to mark the transition from novice to expert. At the foundational level, pediatricians must demonstrate the ability to operate the ultrasound machine effectively, adjusting depth, gain, and probe selection for pediatric lung ultrasound using high-frequency linear probes (7.5–10 MHz) for high-resolution images. They should accurately identify normal lung structures and landmarks, such as lung sliding and the pleural line, and obtain standardized views of lungs in various patient positions (e.g., sitting, supine). This foundational knowledge is essential for distinguishing between normal and abnormal findings, which is critical for early detection of respiratory issues. Moreover, pediatricians at this level should be familiar with basic ultrasound physics, including understanding the principles of reflection, refraction, and attenuation, to optimize image quality and avoid misinterpretation. They should also be able to recognize common artifacts such as reverberation, shadowing, and know how to adjust the machine settings to minimize these issues. Additionally, they should understand the importance of maintaining proper probe ergonomics to prevent fatigue and ensure accurate image acquisition.

In terms of the theoretical foundation, a multiple-choice examination will be used to assess trainees at each level upon completion of our proposed series of lessons, to evaluate their knowledge acquisition at each stage of the proficiency pyramid.

Moving to a secondary level, providers are expected to acquire skills in detecting common abnormalities such as pneumothorax, pleural effusion, and pneumonia using validated diagnostic criteria and recognizing specific ultrasound patterns. They must also be able to integrate ultrasound with clinical data for diagnosis. This integration is essential for incorporating ultrasound into decision workflows that affect patient management and treatment, such as determining the need for antibiotics or thoracentesis. Additionally, at this level pediatricians should be able to communicate effectively with radiologists and other healthcare professionals to ensure comprehensive patient care, including discussing the limitations and advantages of lung ultrasound compared to other imaging modalities. They should also be familiar with the indications and contraindications for lung ultrasound in pediatric patients, ensuring appropriate use in various clinical scenarios. As trainees progress to the advanced proficiency level, they should be able to use ultrasound to guide management decisions in critically ill children, such as directing mechanical ventilation adjustments. They should also be capable of performing ultrasound-guided interventions like thoracentesis and lung recruitment maneuvers. Furthermore, they must be adept at interpreting complex lung ultrasound patterns and integrating these findings with other diagnostic modalities, such as chest X-rays and CT scans, to enhance patient care and reduce unnecessary radiation exposure. Additionally, advanced practitioners should be able to apply lung ultrasound in a variety of clinical contexts, including emergency medicine, critical care, and neonatology, adapting their skills to meet the unique needs of each setting. At the masterclass level, pediatricians are expected to demonstrate image optimization expertise by employing advanced techniques for lung ultrasound interpretation, such as using M-mode to assess lung sliding and power doppler to evaluate lung perfusion. They should be able to design training modules for lung ultrasound, focusing on image interpretation and clinical application, and critically evaluate literature on novel applications while contributing to scholarly research. This includes staying updated on the latest evidence-based practices and contributing to the development of new guidelines or protocols for lung ultrasound use in pediatric settings. Moreover, master-level pediatricians should be able to lead educational workshops, mentor junior colleagues, and develop innovative educational materials to enhance lung ultrasound skills across the healthcare team.

By achieving these milestones, pediatricians can ensure that they are providing the highest level of care using lung ultrasound, enhancing both diagnostic accuracy and treatment efficacy for their patients, and contributing to the advancement of pediatric lung ultrasound as a field.

All the aforementioned proficiency levels and their corresponding features are included in Table 2. Learning levels assembled in a progressive pyramid are shown in Fig. 1.

Table 2.

The levels of proficiency in ultrasound skills

Level	Skills	Privileges
Foundational	Operate ultrasound machine, identify normal lung structures, obtain standardized views, understand basic ultrasound physics.	Perform basic exams, identify normal structures and distinguish them from pathological items.
Secondary	Recognize common abnormalities (pneumothorax, pleural effusion, pneumonia), integrate ultrasound with clinical data, communicate with radiologists.	Differential diagnosis, therapeutic decisions.
Advanced	Guide management decisions in critically ill patients, perform ultrasound-guided interventions, interpret complex patterns.	Advanced management of critically ill patients, ultrasound-guided interventions.
Masterclass	Optimize images using advanced techniques, design training modules, contribute to research.	Educational leadership, development of innovative educational materials, academic research.

Fig. 1.

The lung ultrasound proficiency pyramid

Hands-on learning

To achieve a “Fundamental” proficiency level, a trainee is required to complete a minimum of thirty supervised clinical ultrasound procedures in a timeframe of six months, conducted under the guidance of an experienced tutor possessing no less than five years of expertise in both LUS application and pedagogical instruction. The tutor is asked to maintain evidence of exams performed through registration forms and cloud storage for images. The structure of a sample OSCE station is detailed within the Additional File 1.

The “Fundamental” knowledge includes:

• correct use of methodology: proper indications and limitations;

• appropriateness in performing LUS for the clinical evaluation;

• correct use of ultrasound machines and probes: select probes suitable for patient’s characteristics;

• correct maintenance of ultrasound equipment: proper cleaning and disinfection;

• execution of all relevant projections for the pathology being examined;

• correct interpretation of images obtained bedside.

To achieve a “Secondary” proficiency level, a trainee is required to complete a minimum of sixty ultrasound exams under tutor supervision in a timeframe of six months. For each instance of ultrasound performance, the trainee undergoes assessment across all domains delineated at the basic level, in addition to the integration of the technique within the patient’s clinical workflow. The tutor is asked to maintain evidence of exams performed through registration forms and cloud storage for images.

To achieve an “Advanced” proficiency level, a trainee is required to complete a minimum of sixty ultrasound exams under tutor supervision. The tutor is asked to maintain evidence of exams performed through registration forms and cloud storage for images. At this stage, the trainee undergoes formal assessment by a national commission consisting in five distinct ultrasound performance evaluations on an annual basis. A candidate should achieve a minimum overall score of 60% to pass the examination, distributed across the following assessment domains: (i) 20% for the evaluation of the appropriateness of examination execution, (ii) 20% for the evaluation of the accuracy of ultrasound execution, (iii) 40% for the evaluation of the correlation with the final diagnosis, (iv) 20% for the evaluation of the correlation with other radiological instrumental investigations.

To achieve a “Masterclass” proficiency level, a trainee is required to develop advanced skills in specialized areas of pediatric LUS, such as neonatal or pediatric emergency ultrasound.

The trainee should participate in workshops/conferences to stay updated on the latest technologies and be engaged in peer review and quality improvement projects to enhance LUS practice within the department. He should also mentor junior colleagues in ultrasound techniques, contributing to the development of a robust training program.

Given that several lung ultrasound applications are still in their nascent stages and their influence on clinical pathways requires further development and validation, the significance of mentorship in this area remains pivotal. Once a certain proficiency level has been achieved, our experience indicates the critical importance of maintaining a consistent standard and engaging in continuous updates regarding novel ultrasound techniques, applications, and relevant literature.

Upon a pediatrician’s attainment of a defined proficiency level, evidenced by validated privileges, a certification of validation is assigned, subject to automatic expiry after a period of four years, whereupon LUS skills must undergo reassessment by independent examiners, irrespective of whether the physician sustains the current proficiency or advances to a subsequent level.

Barriers to curriculum development

The development of effective ultrasound curricula in pediatrics faces several key barriers, hindering its widespread adoption and optimal integration into clinical practice [31].

A significant challenge is the insufficient faculty expertise. A shortage of qualified instructors limits the ability to provide adequate training and supervision. This deficiency not only affects the quality of training but also impedes the development of sustainable ultrasound programs within pediatric departments [32]. Without a sufficient number of skilled faculty, it is quite hard to conduct hands-on training, provide mentorship, and ensure that trainees receive adequate feedback.

Resource constraints also play a pivotal role. Access to ultrasound equipment and dedicated training time are essential for effective LUS education. The lack of access to machines and limitations in scheduling availability for ultrasound rotations are also noteworthy limitations [33]. These logistical challenges, coupled with potential financial constraints that hinder the acquisition of necessary equipment, impede the integration of LUS training into already demanding pediatric programs. Nationally and worldwide the cost of ultrasound tools, maintenance, and the time required for training can be significant barriers for many institutions [33].

Moreover, time constraints and competing priorities within pediatric residency programs create a challenging environment for ultrasound curriculum implementation. With numerous educational requirements and clinical responsibilities, allocating sufficient time for LUS training, upskilling and recertification can be difficult [34].

Finally, ensuring quality assurance is crucial for proficiency. The development of robust quality assurance processes and standardized image interpretation protocols remains an issue [35]. This includes establishing guidelines for image acquisition, interpretation, and documentation, as well as implementing mechanisms for ongoing quality control and feedback.

Addressing these impediments necessitates a cohesive endeavor involving the training of qualified faculty, the allocation of adequate resources, and the establishment of rigorous quality assurance protocols, to which this document has provided a significant contribution.

Limitations of the proposed consensus

This consensus proposal is subject to several inherent limitations that warrant acknowledgement. Firstly, the curriculum’s development relied on expert opinion derived from a modified Delphi process. While systematic, this methodology remains susceptible to biases stemming from the selection and perspectives of the participating panelists. The exclusion of direct input from pediatric trainees and clinicians outside the expert group may further restrict the generalizability of the recommendations.

Secondly, the curriculum lacks prospective validation within authentic educational environments, meaning its efficacy in enhancing clinical skills and patient outcomes has yet to be empirically demonstrated. Furthermore, the variability of institutional resources, including access to ultrasound equipment, trained instructors, and dedicated training time, could significantly impede the feasibility of curriculum implementation.

Finally, consistent with all operator-dependent techniques, individual learning trajectories may diverge. Consequently, the proposed milestones may not comprehensively capture the intricate nuances of skill acquisition across diverse clinical settings.

Conclusions

This standardized longitudinal curriculum for pediatric lung ultrasound represents a necessary step towards ensuring consistent and high-quality training within the Italian pediatric community. By defining clear proficiency levels, integrating robust assessment methods tailored to the Italian context, and addressing existing barriers to implementation within Italian healthcare settings, this framework aims to empower pediatricians with the necessary skills to effectively utilize lung ultrasound in their clinical practice.

Additionally, ongoing efforts should be directed towards developing innovative educational tools in Italian, expanding faculty expertise through dedicated national training programs, and establishing standardized quality assurance protocols in accordance with Italian healthcare standards to ensure the sustained proficiency and optimal application of pediatric lung ultrasound in Italy. The evolution of artificial intelligence and tele-ultrasound technologies also holds promise for enhancing training accessibility and providing remote expert guidance within the Italian healthcare network.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

LUS

Lung ultrasound

I-AIM

model indication, acquisition, interpretation, and medical decision-making

ACGME

Accreditation Council for Graduate Medical Education

OSCE

Objective structured clinical examination

SDOT

Standardized Direct Observational Tool

Glossary

White lung

An ultrasonographic pattern characterized by a uniformly hyperechoic lung appearance, resulting from the confluence of numerous B-lines. This finding is indicative of severe interstitial syndrome, commonly observed in conditions such as pulmonary edema, pneumonia, or acute respiratory distress syndrome

Twinkle artifact

A color doppler ultrasonography phenomenon manifested as a rapidly changing, kaleidoscopic mosaic appearing distal to a highly reflective object, such as a calculus or calcification. This artifact facilitates the detection of small, subtle structures that may not be readily discernible on conventional gray-scale imaging

B-lines

Vertical, hyperechoic lines originating from the pleural line and extending to the bottom of the ultrasound screen without attenuation. The presence of multiple B-lines signifies elevated pulmonary water content, as observed in pulmonary edema or various interstitial lung diseases

A-lines

Horizontal, repetitive, hyperechoic linear artifacts running parallel to the pleural line. Their presence signifies normally aerated lung parenchyma, indicating a healthy lung

Consolidation

A tissue-like area within the lung, often referred to as “hepatization” due to its resemblance to liver parenchyma. This finding typically arises from pneumonia or atelectasis and frequently shows air bronchograms

Air bronchogram

An air bronchogram describes bright, branching structures visualized within a consolidated pulmonary area on ultrasound. These structures represent air-filled bronchi surrounded by fluid or consolidated tissue

M-mode

An ultrasound imaging modality that depicts tissue motion over time. In the context of lung ultrasound, it is employed to assess pleural movement and aid in the diagnosis of pneumothorax, differentiating between the “seashore sign” indicative of normal lung and the “barcode sign” associated with pneumothorax

Author contributions

AMM, LDS, DB, PT, AV and RA conceptualized, drafted and wrote the manuscript. AMM, LDS, GLN, CB, MAM, AC, AC and RA acquired, analyzed and interpreted the data. AMM, LDS, GLN, CB, MAM, AC, AC and RA edited the manuscript content and provided writing assistance. AMM, LDS, DB, PT, AV and RA critically revised and proofread the manuscript.

All authors have read and agreed to the published version of the manuscript.

Funding

this work was supported by the Italian Ministry of Health with current research funds.

Data availability

the datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

not applicable.

Consent for publication

not applicable.

Competing interests

the authors declare that they have no competing interests.