Beyond the Image: Pitfalls, Cognitive Biases, and Safety Gaps in Non-Cardiac Neonatal Point-of-Care Ultrasound

Point-of-care ultrasound (POCUS) is now part of everyday work in neonatal intensive care, supporting diagnosis, procedures, and decisions in acutely unwell infants. Its spread has outpaced the development of training, credentialing, and quality assurance structures, and the neonatal literature rarely describes how and why the technique fails. In this perspective, we focus on non-cardiac neonatal POCUS (lung, cranial, and abdominal). We adapt existing frameworks into four error domains: indication, image acquisition, image interpretation, and clinical integration. We also separate errors that can occur in any ultrasound examination from those tied to the point-of-care setting, including confirmation, anchoring, and availability bias, time pressure, and fatigue. Using illustrative cases and comparative tables, we describe common look-alike findings, summarize thermal and mechanical bioeffects by organ, and discuss probe and gel hygiene in the neonatal unit. We then outline a stepwise pathway for training, supervision, credentialing, and quality assurance, and suggest practical safeguards: structured protocols and reports, simple debiasing habits, image archiving with periodic expert review, and close collaboration with radiology and cardiology. Seen in this way, investment in safety is part of the value of neonatal POCUS rather than an added cost.