Oxygen saturation as a screening test for critical congenital heart disease: a preliminary study

Diagnostic accuracy of combined screening algorithm for early detection of congenital heart disease among term newborns in India

OBJECTIVE

To determine the validity of a screening algorithm based on combination of clinical examination and pulse oximetry, for early detection of congenital heart disease (CHD) in term newborns. CHD is the most frequent major congenital anomaly, with prevalence of 6-12 per 1000 live births. Clinical examination alone may fail to detect CHD in more than 50% of affected newborns. Recent studies have concluded that pulse oximetry has a high sensitivity and specificity as a screening tool for critical CHD.

SETTING

JSS Hospital, Mysuru, Karnataka, India.

METHODS

In this prospective observational study, all term neonates delivered at the hospital were included. The screening algorithm consisted of seven clinical parameters and pulse oximetry screening guidelines recommended by the American Academy of Paediatrics. Term newborns with the presence of any one of the above parameters in the algorithm were considered screen-positive. Echocardiography was done in all screen positives. Newborns were classified into those with and without CHD, based on echocardiography findings at birth and clinical examination and echocardiography findings at follow-up at 6 weeks.

RESULTS

Among 1009 term neonates included in the study, CHD was detected in 57 (5.6%) with cyanotic CHD in 12. The sensitivity and specificity of combined screening to detect CHD was 71.93% and 95.8%, respectively. The positive predictive value was 50.62% and the negative predictive value was 98.28%.

CONCLUSION

Screening for CHD with a simple comprehensive algorithm, integrating clinical evaluation and pulse oximetry, has moderate sensitivity and high specificity in detecting CHD in term newborns. Further work is needed to evaluate this form of screening.

Pulse Oximetry Screening for Detecting Critical Congenital Heart Disease in Neonates

Background Congenital heart disease (CHD) leads to significant morbidity in the neonatal population and is a crucial disorder behind early infancy death rates. Most have a critical congenital heart defect (Cr CHD) out of all the heart defects found in babies. A subgroup of cardiac anomalies needs surgery or catheter intervention during the neonatal period. Pulse oximetry is a good screening tool to detect cr CHD in neonates. This study aims to assess the effectiveness of pulse oximetry as a screening tool in a rural setting.  Methods This was a hospital-based prospective observational study. All consecutively born neonates whose parents consented to the study were subjected to pulse oximetry on all four limbs. Their peripheral arterial oxygen saturation was measured on days one, two, and three of life, starting four hours after birth. Babies detected with cyanotic congenital heart disease (CCHD) before birth are not a part of this study. All those with arterial oxygen saturation of less than 95% or a difference of saturation of more than 3% in the upper and lower limbs were considered suspects for Cr CHD and subjected to echocardiography. Results Among 5874 neonates studied, researchers found 164 babies to have significant hypoxemia on pulse oximetry, and 44 CHD were detected on echocardiography within the first three days of life (positive predictive value (PPV) 12.2%). The physician referred all of them to a higher center before further delay. Thirty-four babies with other congenital heart diseases were found using pulse oximetry examination. Also, 108 cases of hypoxemia due to other causes were found and monitored.  Conclusion Critical congenital heart diseases are a significant cause of death among neonates and require early diagnosis and emergent medical and surgical management. They are associated with hypoxemia, and this principle can be used to screen them using a pulse oximeter.

Pulse Oximetry Screening for Congenital Heart Defects in the Newborn Nursery: A Review for the General Pediatrician

Congenital heart defects are a heterogenous group of disorders that may present in varied ways early in life. Of particular importance within the category of congenital heart defects are "critical" congenital heart defects, which require surgery, interventional catheterization, or prostaglandin dependence before intervention by age 1 month or 1 year, depending on which definition is used. Because of the time-sensitive element of identifying such lesions, the question is raised: how can children affected by critical congenital heart defects best be identified? One strategy that has been used since the mid-1990s is a pulse oximetry screening assessment, which detects such abnormalities in neonates and has led to improved child health outcomes across the United States and the world. This article will serve as a review of the critical congenital heart defect pulse oximetry screening tool for general pediatricians and those who care for infants. [Pediatr Ann. 2022;51(11):e411-e413.].

Pulse oximetry as a screening test for congenital heart disease in newborns

BACKGROUND

Congenital heart disease (CHD) can be fatal if not diagnosed at the early phases of life. Available diagnostic tools for screening critical CHD are mostly invasive and costly.

AIM

The current study aimed to validate the use of pulse oximetry as a non-invasive and cost-effective tool to screen critical CHD.

MATERIAL AND METHODS

This observational study was conducted in a tertiary care teaching institute. A total of 1,082 asymptomatic term neonates (aged 2-24 h) were screened by pulse oximetry and clinical examination for the detection of critical CHD. Neonates with abnormal pulse oximetry and clinical examination findings were subjected to confirm the presence of CHD.

RESULTS

The incidence of critical CHD in asymptomatic newborns was found to be 0.5% (5/1000 live births). Echocardiography confirmed five cases of critical CHD. Pulse oximetry alone could detect 80%, and clinical examination alone could detect 60% of the CHD cases, while combining both methods gave 100% detection rate.

CONCLUSION

Pulse oximetry is a simple, cost-effective, and reliable tool to diagnose critical CHD. In majority of the newborns who have not undergone fetal echocardiography, the underlying critical CHD can be missed, and in such cases, pulse oximetry screening offers an effective way to minimise the undiagnosed discharge risk.

Effects of universal critical CHD screening of neonates at a mid-sized California congenital cardiac surgery centre

INTRODUCTION

CHD affects over 1 million children in the United States. Studies show decreased mortality from CHD with newborn cardiac screening. California began a screening programme on 1 July, 2013. We evaluated the effect of mandatory screening on surgical outcomes at Loma Linda University Children's Hospital since 1 July, 2013.

METHODS

We evaluated all infants having congenital heart surgery at Loma Linda University Children's Hospital between 1 July, 2013 and 31 December, 2018. Primary target diagnoses include hypoplastic left heart syndrome, pulmonary atresia with intact ventricular septum, tetralogy of Fallot, total anomalous pulmonary venous return, transposition of the great arteries, tricuspid atresia, and truncus arteriosus. Secondary target diagnoses include aortic coarctation, double outlet right ventricle, Ebstein anomaly, interrupted aortic arch, and single ventricle. Patients were stratified by timing of diagnosis (pre-screen, screen positive, and screen negative). Primary end points were post-operative length of stay, operative mortality, absolute mortality, and actuarial survival.

RESULTS

The cohort included 274 infants. Of these, 79% were diagnosed prior to screening (46% prenatally). Only 38% of those screened were positive, with 13% of the cohort having a "missed diagnosis."

CONCLUSIONS

Primary targets were more likely to be diagnosed by screening (53%), while secondary targets were unlikely to be diagnosed by screening (10%) (p = 0.004). Outcomes such as length of stay, operative mortality, and actuarial survival were not different based on timing of diagnosis (p > 0.05). Despite late diagnosis, those not diagnosed until after screening did not have adverse outcomes.

Impact of pulse oximetry screening to detect congenital heart defects: 5 years' experience in a UK regional neonatal unit

Pulse oximetry screening (POS) has been shown to be an effective, non-invasive investigation that can detect up to 50-70% of previously undiagnosed congenital heart defects (CHDs). The aims of this study were to assess the accuracy of POS in detection of CHDs and its impact on clinical practice. All eligible newborn infants born between 1 Jan 2015 and 31 Dec 2019 in a busy regional neonatal unit were included in this prospective observational study. A positive POS was classified as two separate measurements of oxygen saturation < 95%, or a difference of > 2% between pre- and post-ductal circulations. Overall, 23,614 infants had documented POS results. One hundred eighty nine (0.8%) infants had a true positive result: 6 had critical CHDs, 9 serious or significant CHDs, and a further 156/189 (83%) infants had significant non-cardiac conditions. Forty-three infants who had a normal POS were later diagnosed with the following categories of CHDs post-hospital discharge: 1 critical, 15 serious, 20 significant and 7 non-significant CHDs. POS sensitivity for detection of critical CHD was 85.7%, whereas sensitivity was only 33% for detection of major CHDs (critical and serious) needing surgery during infancy; specificity was 99.3%.Conclusion: Pulse oximetry screening showed moderate to high sensitivity in detection of undiagnosed critical CHDs; however, it failed to detect two-third of major CHDs. Our study further emphasises the significance of adopting routine POS to detect critical CHDs in the clinical practice. However, it also highlights the need to develop new, innovative methods, such as perfusion index, to detect other major CHDs missed by current screening tools. What is Known: • Pulse oximetry screening is cost effective, acceptable, easy to perform and has moderate sensitivity and high specificity in detection of critical congenital heart defects. • Pulse oximetry screening has been implemented many countries including USA for detection of critical congenital heart defects, but it is not currently recommended by the UK National Screening Committee. What is New: • To our knowledge, this is the first study describing postnatal detection and presentation of all the infants with congenital heart defects over a period of 5 years, including those not detected on the pulse oximetry screening, on the clinical practice. • It emphasises that further research required to detect critical congenital heart defects and other major CHDs which can be missed on the screening tools currently employed in clinical practice.

How to use saturation monitoring in newborns

Pulse oximetry is a first-line monitoring tool, used in neonatal medicine routinely as a part of continuous monitoring during intensive care. It is also used to guide response to resuscitation and as a screening tool for congenital heart disease. Despite its widespread use, many healthcare providers are unaware of the underlying principles and limitations of pulse oximetry in neonates. In this article, we will discuss the physiological and technological principles behind the use of saturation monitoring and its use in neonatal practice.

Role of Pulse Oximetry Screening for Detection of Life Threatening Congenital Heart Detects in Newborn

Most ofnewborns with Congenital Heart Defects (CHDs) can be detected by using echocardiography. However, if such defects are not diagnosed in earlier time, therefore a severe hypoxemia, shock, acidosis and death are considered of some potential sequelae. A prospective study from January 2012 to the end of 2013 was performed and 2181 neonates were enrolled in the study. The pulse oximetry screening (POS) for both hands and one foot were obtained within the first 3-6 hours of life, when post ductal saturation was below 90%, it was considered as a positive screening, while when the saturation is between 90-95% and the difference between pre-and post-ductal saturation was more than 3%, the baby was provisionally considered to be screening as a positive then echocardiography is planned. Among 100 positive POS babies, 45 (45%) of them were detected with CHS, 12 (12%) was with a major CHS and 33 (33%) was with a minor CHS. Out of 12 patients with a major CHD 6 of them (50%) were asymptomatic at the time of POS.POS result was a true negative in 2078 patients, a true positive in 45 patients, false negative in 3 patients, and false positive in 55 and 28/55 of the false positive rate with POS had other pathology. The false positive rate with pulse oximetry screening is (55/2081) = 0.26%. Sensitivity, specificity, positive and negative predictive value for POS in detection of major CHD were 80%, 97.29%, 17.9% and 99.80%, respectively. Pulse oximetry screening is significantly improving the detection of life threatening congenital heart disease at an early stage.

Pulse Oximetry Screening in Germany-Historical Aspects and Future Perspectives

In January 2017, pulse oximetry screening was legally implemented in routine neonatal care in Germany. The preceding developments, which were the prerequisite for this step, are described in the specific context of Germany's health care system. Continued evaluation of the method is imperative and may lead to modifications in the screening protocol, ideally in accordance with the efforts in other countries.

An Evaluation of the Addition of Critical Congenital Heart Defect Screening in Georgia Newborn Screening Procedures

Objectives Each year in the U.S., approximately 7200 infants are born with a critical congenital heart defect (CCHD). The Georgia Department of Public Health (DPH) mandated routine screening for CCHD starting January 2015. The current study evaluated hospital performance of the mandated CCHD screenings in Georgia. Methods Utilizing the DPH newborn screening surveillance system, data from 6 months before and after the mandate were analyzed for reports submitted and positive CCHD screening results. Chi square tests of independence were performed to examine the association between reporting of results for CCHD screening after the mandate and hospital nursery level [level I (well-baby/newborn); level II (special care); level III (neonatal intensive care unit-NICU)] and NICU submissions. Results In the 6 months following implementation, reports of the screening increased, but the DPH had not received information for approximately 40% of newborns. Hospitals with level III nurseries had poorer reporting rates compared to hospitals with level I or II nurseries. Newborn screening (NBS) cards submitted by NICUs were less likely to contain the CCHD screening results compared to cards submitted by regular Labor and Delivery units. Conclusions for Practice Further attention should focus on improving both CCHD screening and reporting of screening results within hospitals with level III nurseries and from NICUs at all hospital levels. Identifying and addressing the root of the issue, whether it be hospital compliance with CCHD screening or reporting of the results, will help to improve screening rates for all newborns, especially those most vulnerable.

Pulse oximetry screening for critical congenital heart defects

BACKGROUND

Health outcomes are improved when newborn babies with critical congenital heart defects (CCHDs) are detected before acute cardiovascular collapse. The main screening tests used to identify these babies include prenatal ultrasonography and postnatal clinical examination; however, even though both of these methods are available, a significant proportion of babies are still missed. Routine pulse oximetry has been reported as an additional screening test that can potentially improve detection of CCHD.

OBJECTIVES

• To determine the diagnostic accuracy of pulse oximetry as a screening method for detection of CCHD in asymptomatic newborn infants• To assess potential sources of heterogeneity, including:○ characteristics of the population: inclusion or exclusion of antenatally detected congenital heart defects;○ timing of testing: < 24 hours versus ≥ 24 hours after birth;○ site of testing: right hand and foot (pre-ductal and post-ductal) versus foot only (post-ductal);○ oxygen saturation: functional versus fractional;○ study design: retrospective versus prospective design, consecutive versus non-consecutive series; and○ risk of bias for the "flow and timing" domain of QUADAS-2.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2) in the Cochrane Library and the following databases: MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Health Services Research Projects in Progress (HSRProj), up to March 2017. We searched the reference lists of all included articles and relevant systematic reviews to identify additional studies not found through the electronic search. We applied no language restrictions.

SELECTION CRITERIA

We selected studies that met predefined criteria for design, population, tests, and outcomes. We included cross-sectional and cohort studies assessing the diagnostic accuracy of pulse oximetry screening for diagnosis of CCHD in term and late preterm asymptomatic newborn infants. We considered all protocols of pulse oximetry screening (eg, different saturation thresholds to define abnormality, post-ductal only or pre-ductal and post-ductal measurements, test timing less than or greater than 24 hours). Reference standards were diagnostic echocardiography (echocardiogram) and clinical follow-up, including postmortem findings, mortality, and congenital anomaly databases.

DATA COLLECTION AND ANALYSIS

We extracted accuracy data for the threshold used in primary studies. We explored between-study variability and correlation between indices visually through use of forest and receiver operating characteristic (ROC) plots. We assessed risk of bias in included studies using the QUADAS-2 tool. We used the bivariate model to calculate random-effects pooled sensitivity and specificity values. We investigated sources of heterogeneity using subgroup analyses and meta-regression.

MAIN RESULTS

Twenty-one studies met our inclusion criteria (N = 457,202 participants). Nineteen studies provided data for the primary analysis (oxygen saturation threshold < 95% or ≤ 95%; N = 436,758 participants). The overall sensitivity of pulse oximetry for detection of CCHD was 76.3% (95% confidence interval [CI] 69.5 to 82.0) (low certainty of the evidence). Specificity was 99.9% (95% CI 99.7 to 99.9), with a false-positive rate of 0.14% (95% CI 0.07 to 0.22) (high certainty of the evidence). Summary positive and negative likelihood ratios were 535.6 (95% CI 280.3 to 1023.4) and 0.24 (95% CI 0.18 to 0.31), respectively. These results showed that out of 10,000 apparently healthy late preterm or full-term newborn infants, six will have CCHD (median prevalence in our review). Screening by pulse oximetry will detect five of these infants as having CCHD and will miss one case. In addition, screening by pulse oximetry will falsely identify another 14 infants out of the 10,000 as having suspected CCHD when they do not have it.The false-positive rate for detection of CCHD was lower when newborn pulse oximetry was performed longer than 24 hours after birth than when it was performed within 24 hours (0.06%, 95% CI 0.03 to 0.13, vs 0.42%, 95% CI 0.20 to 0.89; P = 0.027).Forest and ROC plots showed greater variability in estimated sensitivity than specificity across studies. We explored heterogeneity by conducting subgroup analyses and meta-regression of inclusion or exclusion of antenatally detected congenital heart defects, timing of testing, and risk of bias for the "flow and timing" domain of QUADAS-2, and we did not find an explanation for the heterogeneity in sensitivity.

AUTHORS' CONCLUSIONS

Pulse oximetry is a highly specific and moderately sensitive test for detection of CCHD with very low false-positive rates. Current evidence supports the introduction of routine screening for CCHD in asymptomatic newborns before discharge from the well-baby nursery.

Pulse oximetry findings in newborns with antenatally diagnosed congenital heart disease

A retrospective review of admission preductal oxygen saturations of neonates with antenatally diagnosed critical congenital heart disease (CCHD) was performed to investigate the differences in newborn pulse oximetry (Pulsox) by specific CCHD diagnosis. Saturations were recorded at median of < 1 h (range < 1-9 h) after delivery. Data was stratified by CCHD diagnosis and analysed according to the three different admission Pulsox thresholds, ≤ 90, ≤ 92 and ≤ 95%. Of the 276 neonates studied, 208 were clinically well at admission, with no co-morbidities, gestation > 34 weeks and birth weight > 1.8 kg. A statistically significant increase in the proportion with low admission saturations was seen using ≤ 95% saturation threshold (72% (95% CI 66-78)) compared to ≤ 92% (52% (95% CI 46-59)) and ≤ 90% (46% (95% CI 39-52)). Sub-group analysis found the proportion of neonates with low saturations varied according to the specific CCHD diagnosis with only 20-42% of neonates with aortic stenosis, coarctation of the aorta and pulmonary stenosis having saturations ≤ 95%.

CONCLUSION

The proportion of neonates with low admission oxygen saturation varied by CCHD diagnosis with those without critically reduced pulmonary blood flow not having low admission saturations, in general, even using the ≤ 95% threshold which had the highest proportions of abnormal saturations. This data may assist developing Pulsox screening policies. What is Known: • The addition of pulse oximetry (Pulsox) screening to the routine newborn examination increases the sensitivity of CCHD detection. Pulsox screening is also highly specific for CCHD in asymptomatic neonates, with low false-positive rates. • Early diagnosis of CCHD improves patient outcomes in relation to both morbidity and mortality. What is New: • The proportion of affected infants with an abnormal Pulsox result varies by CCHD diagnosis and screening threshold. In our study using the ≤ 95% threshold gave the highest proportion of neonates with abnormal saturations at admission. • In general, Pulsox yield of abnormal results is low for CCHD diagnoses not associated with critically reduced pulmonary blood flow; however, increasing the Pulsox threshold increased the proportion of infants with an abnormal result.

A Meta-Analysis about the Screening Role of Pulse Oximetry for Congenital Heart Disease

OBJECTIVE

The opinions about the application of pulse oximetry in diagnosis of congenital heart disease (CHD) were debatable. We performed this meta-analysis to confirm the diagnostic role of pulse oximetry screening for CHD.

METHODS

Relevant articles were searched in the databases of Pubmed, Embase, Google Scholar, and Chinese National Knowledge Infrastructure (CNKI) up to April 2017. Data was processed in the MetaDiSc 1.4 software. Pooled sensitivity and specificity with 95% confidence interval (95% CI) were calculated to explain the diagnostic role of pulse oximetry screening for CHD. I2⩾50% or p < 0.05 indicated significant heterogeneity. Area under curve (AUC) of summary receiver operating characteristics (SROC) was calculated to assess its diagnostic accuracy. The robustness of overall results was evaluated by sensitivity analysis. Publication bias was evaluated by Deek's funnel plot.

RESULTS

22 eligible articles were selected. Pooled sensitivity and specificity were 0.69 (0.67-0.72) and 0.99 (0.99-0.99), respectively. The corresponding AUC was 0.9407, suggesting high diagnostic accuracy of pulse oximetry screening for CHD. Sensitivity analysis demonstrated that the pooled results were robust. Deek's funnel plot seemed to be symmetrical.

CONCLUSIONS

Pulse oximetry screening could be used to diagnose CHD. It shows high diagnosis specificity and accuracy.

A comparison of the incidence of undiagnosed congenital heart disease in hospital born and home born children

OBJECTIVE

To evaluate the incidence of otherwise undiagnosed congenital heart disease (CHD) in a population of children born in a hospital with routine pulse oximetry (RPO) screening compared to children born at home.

METHODS

We reviewed 15 years of births at 2 hospitals for incidence of undiagnosed CHD with RPO. The Health Department reviewed the same data for out of hospital births.

RESULTS

A total of 50,545 hospital births were screened and 1,274 children were born outside the hospital. There were 28 hospital-born babies diagnosed with cyanotic CHD prior to nursery discharge. Only one of these babies would not have been diagnosed without RPO. Three children were missed and there were 3 false positives. Sensitivity and positive predictive value of RPO was 25%, specificity and negative predictive value of RPO exceed 99%. The incidence of CHD requiring RPO diagnosis was roughly one birth per 50,000. Two children born at home with undiagnosed CHD were missed. One of these children presented with neonatal demise.

CONCLUSION

RPO screening is still valuable in diagnosing CHD only diagnosable with RPO. However, the incidence of CHD requiring RPO to diagnose is similar to other congenital diseases which are not mandated national screening tests. In our limited experience a patient is roughly 25 times more likely to have undiagnosed CHD if they are born outside of a hospital.

Modern Strategy for Identification of Congenital Heart Defects in the Neonatal Period

Introduction:

Congenital heart defects are the most common congenital anomalies and occur with an incidence from 0.8 to 1% per 1000 live births. In recent years, the pulse oximetry has become a strong candidate for detecting cyanogen congenital heart defects and in combination with routine clinical exam can improve diagnostic of congenital heart diseases.

Objective:

To apply the modern algorithm for early detection of congenital heart defects in order to improve the diagnosis in the neonatal period.

Patients and Methods:

This was a prospective study that included children born in Bihac Cantonal Hospital during 2012. The diagnostic algorithm included a clinical examination of the newborn, measuring of transcutaneous oxygen saturation with the pulse oximeter between 24 and 48 hours of life, and, in some cases, additional tests (cardiac ultrasound).

Results:

A total of 1,865 children were examined. The application of diagnostic protocol identified the existence of congenital heart defects in 29 children. In re-evaluating the auscultator and ultrasound findings, we identified congenital heart defects in 19 children.

Conclusion:

The application of the modern algorithm for early detection of congenital heart diseases in the neonatal period can significantly improve the making of diagnosis of these anomalies. The concept is simple, inexpensive and applicable in most maternity wards.

Lessons Learned From Newborn Screening for Critical Congenital Heart Defects

Newborn screening for critical congenital heart defects (CCHD) was added to the US Recommended Uniform Screening Panel in 2011. Within 4 years, 46 states and the District of Columbia had adopted it into their newborn screening program, leading to CCHD screening being nearly universal in the United States. This rapid adoption occurred while there were still questions about the effectiveness of the recommended screening protocol and barriers to follow-up for infants with a positive screen. In response, the Centers for Disease Control and Prevention partnered with the American Academy of Pediatrics to convene an expert panel between January and September 2015 representing a broad array of primary care, neonatology, pediatric cardiology, nursing, midwifery, public health, and advocacy communities. The panel's goal was to review current practices in newborn screening for CCHD and to identify opportunities for improvement. In this article, we describe the experience of CCHD screening in the United States with regard to: (1) identifying the target lesions for CCHD screening; (2) optimizing the algorithm for screening; (3) determining state-level challenges to implementation and surveillance of CCHD; (4) educating all stakeholders; (5) performing screening using the proper equipment and in a cost-effective manner; and (6) implementing screening in special settings such as the NICU, out-of-hospital settings, and areas of high altitude.

Aspects of pulse oximetry screening for critical congenital heart defects: when, how and why?

Pulse oximetry (PO) screening for critical congenital heart defects (CCHD) has been studied extensively and is being increasingly implemented worldwide. This review provides an overview of all aspects of PO screening that need to be considered when introducing this methodology. PO screening for CCHD is effective, simple, quick, reliable, cost-effective and does not lead to extra burden for parents and caregivers. Test accuracy can be influenced by targets definition, gestational age, timing of screening and antenatal detection of CCHD. Early screening can lead to more false positive screenings, but has the potential to detect significant pathology earlier. There is no apparent difference in accuracy between screening with post-ductal measurements only, compared with screening using pre-ductal and post-ductal measurements. However, adding pre-ductal measurements identifies cases of CCHD which would have been missed by post-ductal screening. Screening at higher altitudes leads to more false positives. Important non-cardiac pathology is found in 35-74% of false positives in large studies. Screening is feasible in neonatal intensive care units and out-of-hospital births. Training caregivers, simplifying the algorithm and using computer-based interpretation tools can improve the quality of the screening. Caregivers need to consider all aspects of screening to enable them to choose an optimal protocol for implementation of CCHD screening in their specific setting.

Screening for Critical Congenital Heart Disease

Screening for critical congenital heart disease (CCHD) was added to the United States Recommended Uniform Screening Panel in 2011. Since that time, CCHD screening with pulse oximetry has become nearly universal for newborns born in the United States. There are various algorithms in use. Although the goal of the screening program is to identify children who may have CCHD, most newborns who have a low oxygen saturation will not have CCHD. Further study is needed to determine optimal guidelines for CCHD screening in special settings such as the neonatal intensive care unit, areas in high altitude, and home births.

Clinical examination and pulse oximetry as screening for congenital heart disease in low-risk newborn

OBJECTIVE

To assess sensitivity, specificity, positive predictive value and negative predictive value of the cardiovascular physical examination (CPE) and of pulse oximetry in screening for congenital heart diseases (CHD) in asymptomatic newborn when prenatal ultrasound evaluation is negative for structural cardiac abnormalities.

METHODS

In this observational cohort study, 5750 asymptomatic newborns, admitted to nursery in a period of 2 years, underwent to CPE and determination of arterial oxygen saturation by pulse oxymetry between 48th and 72nd h of life.

RESULTS

Two hundred and ninty-eight newborns presented a suspected CPE; in 70% of cases, we found a transitional alteration and in only 17% of cases, the echocardiography examination performed for suspected CPE were completely negative. Three newborns were positive to pulse oximetry screening test but negative at CPE. After discharge, one case of critical CHD was diagnosed.

CONCLUSIONS

An accurate CPE performed by trained and experienced pediatricians is indicative of important cardiac structural alteration in more than 25%. The association of CPE and pulse oximetry allows to further improve the diagnostic accuracy.

Late detection of critical congenital heart disease among US infants: estimation of the potential impact of proposed universal screening using pulse oximetry

IMPORTANCE

Critical congenital heart disease (CCHD) was added to the Recommended Uniform Screening Panel for Newborns in the United States in 2011. Many states have recently adopted or are considering requirements for universal CCHD screening through pulse oximetry in birth hospitals. Limited previous research is directly applicable to the question of how many US infants with CCHD might be identified through screening.

OBJECTIVES

To estimate the proportion of US infants with late detection of CCHD (>3 days after birth) based on existing clinical practice and to investigate factors associated with late detection.

DESIGN, SETTING, AND PARTICIPANTS

Descriptive and multivariable analysis. Data were obtained from a multisite population-based study of birth defects in the United States, the National Birth Defects Prevention Study (NBDPS). We included all live-born infants with estimated dates of delivery from January 1, 1998, through December 31, 2007, and nonsyndromic, clinically verified CCHD conditions potentially detectable through screening via pulse oximetry.

MAIN OUTCOMES AND MEASURES

The main outcome measure was the proportion of infants with late detection of CCHD through echocardiography or at autopsy under the assumption that universal screening at birth hospitals might reduce the number of such late diagnoses. Secondary outcome measures included prevalence ratios for associations between selected demographic and clinical factors and late detection of CCHD.

RESULTS

Of 3746 live-born infants with nonsyndromic CCHD, late detection occurred in 1106 (29.5% [95% CI, 28.1%-31.0%]), including 6 (0.2%) (0.1%-0.4%) first receiving a diagnosis at autopsy more than 3 days after birth. Late detection varied by CCHD type from 9 of 120 infants (7.5% [95% CI, 3.5%-13.8%]) with pulmonary atresia to 497 of 801 (62.0% [58.7%-65.4%]) with coarctation of the aorta. In multivariable analysis, late detection varied significantly by CCHD type and study site, and infants with extracardiac defects were significantly less likely to have late detection of CCHD (adjusted prevalence ratio, 0.58 [95% CI, 0.49-0.69]).

CONCLUSIONS AND RELEVANCE

We estimate that 29.5% of live-born infants with nonsyndromic CCHD in the NBDPS received a diagnosis more than 3 days after birth and therefore might have benefited from routine CCHD screening at birth hospitals. The number of infants in whom CCHD was detected through screening likely varies by several factors, including CCHD type. Additional population-based studies of screening in practice are needed.

Screening for critical congenital heart disease in newborns using pulse oximetry: evaluation of nurses' knowledge and adherence

PURPOSE

The purpose of this project was to evaluate the benefits of an online nursing education program addressing the significance and rationale of an evidence-based critical congenital heart disease (CCHD) screening protocol using pulse oximetry implemented on full-term newborns delivered at an academic obstetric referral center. The aim was to assess nurses' knowledge of the protocol and nurses' adherence to the protocol documentation before and after the education module was implemented.

SUBJECTS

Registered nurses working in the birthing center who completed the online knowledge tests and an education module.

DESIGN

A repeated-measures quality improvement study was conducted to assess nurses' knowledge of the evidence supporting CCHD screening by pulse oximetry and adherence to the correct documentation of the screening protocol before, immediately after, and 3 months following participation in an online education module.

METHODS

Nurses' knowledge of the CCHD screening protocol was determined by the number of correct answers on a 10-item online test administered before and after the education module. Adherence to correct documentation of the protocol before and after the education intervention was evaluated. The medical charts of 300 newborns delivered at the center with pulse oximetry readings performed after 24 hours of age and before discharge were randomly selected and reviewed.

RESULTS

A significant improvement in knowledge test scores was observed immediately after the education module (9.1 ± 1.0), relative to baseline (8.4 ± 1.2; paired t = 3.02, P = .0046). A significant increase in knowledge test scores measured at baseline, immediately after, and 3 months postintervention was also indicated (F = 3.25; df = 2, 24; P = .0564). Documentation of the protocol in the medical charts for the location of the readings significantly improved after the educational intervention (right hand: 28%, 83%, and 90%; right foot: 27%, 82%, and 89%; both P < .0001).

CONCLUSIONS

Providing education to staff before implementing new practice changes enhances their knowledge. Quality improvement monitoring is recommended to ensure nursing adherence to any practice change.

Evaluating the diagnostic gap: statewide incidence of undiagnosed critical congenital heart disease before newborn screening with pulse oximetry

Screening for critical congenital heart disease (CCHD) using pulse oximetry has been endorsed by the American Academy of Pediatrics and the American Heart Association. We sought to determine the incidence of undetected CCHD in Tennessee and the diagnostic gap of CCHD in Middle Tennessee prior to screening implementation. The Tennessee Initiative for Perinatal Quality Care (TIPQC) Undetected CCHD Registry is a quality improvement initiative established to identify neonates discharged from the nursery with undetected CCHD. The TIPQC database was queried and a simultaneous review of all neonates with CCHD in the Middle Tennessee region was performed to define the incidence and identify the pre-screen diagnostic gap of undetected CCHD at the time of hospital discharge. In 2011, of 79,462 live births in Tennessee, 12 newborns had undiagnosed CCHD (incidence 15 per 100,000; 95 % CI 9-26 per 100,000). Nine of 12 (75 %) had coarctation of the aorta (CoA). There were no deaths due to undiagnosed CCHD. In the Middle Tennessee region, 6 of 45 neonates with CCHD were missed, for a diagnostic gap of 13 % (95 % CI 6-26 %). Prior to implementation of CCHD screening using pulse oximetry, 12 Tennessee neonates with CCHD were missed by prenatal ultrasound and newborn examination. CoA was the most common lesion missed and is also the CCHD most likely to be missed despite addition of screening using pulse oximetry. Continued evaluation of the diagnostic gap with particular attention to missed diagnoses of CoA should accompany institution of CCHD screening programs.

Oxygen saturation nomogram in newborns screened for critical congenital heart disease

OBJECTIVE

To establish simultaneous pre- and postductal oxygen saturation nomograms in asymptomatic newborns when screening for critical congenital heart disease (CCHD) at ∼24 hours after birth.

METHODS

Asymptomatic term and late preterm newborns admitted to the newborn nursery were screened with simultaneous pre- and postductal oxygen saturation measurements at ∼24 hours after birth. The screening program was implemented in a stepwise fashion in 3 different affiliated institutions. Data were collected prospectively from July 2009 to March 2012 in all 3 centers.

RESULTS

We screened 13 714 healthy newborns at a median age of 25 hours. The mean preductal saturation was 98.29% (95% confidence interval [CI]: 98.27-98.31), median 98%, and mean postductal saturation was 98.57% (95% CI: 98.55-98.60), median 99%. The mean difference between the pre- and postductal saturation was -0.29% (95% CI: -0.31 to -0.27) with P < .00005. Its clinical relevance to CCHD screening remains to be determined. The postductal saturation was equal to preductal saturation in 38% and greater than preductal saturation in 40% of the screens.

CONCLUSIONS

We have established simultaneous pre- and postductal oxygen saturation nomograms at ∼24 hours after birth based on >13 000 asymptomatic newborns. Such nomograms are important to optimize screening thresholds and methodology for detecting CCHD.

Screening for critical congenital heart disease: advancing detection in the newborn

PURPOSE OF REVIEW

Screening for critical congenital heart disease (CCHD) using pulse oximetry was added to the recommended uniform screening panel through an endorsement by the Health and Human Services Secretary in September 2011. As organizations on both the macrolevels and microlevels consider implementation, research efforts and professional endorsements have been completed, providing important guidance moving forward.

RECENT FINDINGS

Screening for CCHD has been endorsed by the American Heart Association, American College of Cardiology, March of Dimes and American Academy of Pediatrics. In addition, strategies for best practice regarding implementation and a screening protocol for well babies are now available. Screening for CCHD as a complement to existing mechanisms has been added without need for additional staff, associated with improved detection, and shown to be cost effective with an incremental cost-effectiveness ratio of £24 000. Hospitals in Wisconsin assessed their readiness and reported that all had pulse oximetry equipment onsite and 74.4% had access to same-day neonatal echocardiography. Infants in neonatal care units need further consideration, as there were reports of CCHD missed.

SUMMARY

CCHD screening is easily implemented in community hospitals, and is cost effective, and some states may be better prepared for implementation than previously hypothesized.

Feasibility of implementing pulse oximetry screening for congenital heart disease in a community hospital

OBJECTIVE

Pulse oximetry has been recognized as a promising screening tool for critical congenital heart disease (CCHD). The aim of this research was to study the feasibility of implementation in a community hospital setting.

STUDY DESIGN

Meetings were conducted to determine an implementation plan. Pulse oximetry was performed on the right hand and foot after 24 h of age. Newborns with a saturation ≤ 95% or a ≥ 3% difference were considered to have a positive screen. Screening barriers, screening time and ability to effectively screen all eligible newborns were noted.

RESULT

From January 2009 through May 2010, of 6841 eligible newborns, 6745 newborns (98.6%) were screened. Of the nine infants with positive pulse oximetry screens, one had CCHD, four had CHD and four others were determined to have false positive screens. Average screening time was 3.5 min (0 to 35 min).

CONCLUSION

Pulse oximetry can be implemented successfully in community hospitals without an excessive number of false positives or additional nursing staff.

Pulse oximetry screening for critical congenital heart defects in asymptomatic newborn babies: a systematic review and meta-analysis

BACKGROUND

Screening for critical congenital heart defects in newborn babies can aid in early recognition, with the prospect of improved outcome. We assessed the performance of pulse oximetry as a screening method for the detection of critical congenital heart defects in asymptomatic newborn babies.

METHODS

In this systematic review, we searched Medline (1951-2011), Embase (1974-2011), Cochrane Library (2011), and Scisearch (1974-2011) for relevant citations with no language restriction. We selected studies that assessed the accuracy of pulse oximetry for the detection of critical congenital heart defects in asymptomatic newborn babies. Two reviewers selected studies that met the predefined criteria for population, tests, and outcomes. We calculated sensitivity, specificity, and corresponding 95% CIs for individual studies. A hierarchical receiver operating characteristic curve was fitted to generate summary estimates of sensitivity and specificity with a random effects model.

FINDINGS

We screened 552 studies and identified 13 eligible studies with data for 229,421 newborn babies. The overall sensitivity of pulse oximetry for detection of critical congenital heart defects was 76·5% (95% CI 67·7-83·5). The specificity was 99·9% (99·7-99·9), with a false-positive rate of 0·14% (0·06-0·33). The false-positive rate for detection of critical congenital heart defects was particularly low when newborn pulse oximetry was done after 24 h from birth than when it was done before 24 h (0·05% [0·02-0·12] vs 0·50 [0·29-0·86]; p=0·0017).

INTERPRETATION

Pulse oximetry is highly specific for detection of critical congenital heart defects with moderate sensitivity, that meets criteria for universal screening.

FUNDING

None.

Pulse oximetry screening for congenital heart defects in newborn infants (PulseOx): a test accuracy study

BACKGROUND

Screening for congenital heart defects relies on antenatal ultrasonography and postnatal clinical examination; however, life-threatening defects often are not detected. We prospectively assessed the accuracy of pulse oximetry as a screening test for congenital heart defects.

METHODS

In six maternity units in the UK, asymptomatic newborn babies (gestation >34 weeks) were screened with pulse oximetry before discharge. Infants who did not achieve predetermined oxygen saturation thresholds underwent echocardiography. All other infants were followed up to 12 months of age by use of regional and national registries and clinical follow-up. The main outcome was the sensitivity and specificity of pulse oximetry for detection of critical congenital heart defects (causing death or requiring invasive intervention before 28 days) or major congenital heart disease (causing death or requiring invasive intervention within 12 months of age).

FINDINGS

20,055 newborn babies were screened and 53 had major congenital heart disease (24 critical), a prevalence of 2·6 per 1000 livebirths. Analyses were done on all babies for whom a pulse oximetry reading was obtained. Sensitivity of pulse oximetry was 75·00% (95% CI 53·29-90·23) for critical cases and 49·06% (35·06-63·16) for all major congenital heart defects. In 35 cases, congenital heart defects were already suspected after antenatal ultrasonography, and exclusion of these reduced the sensitivity to 58·33% (27·67-84·83) for critical cases and 28·57% (14·64-46·30) for all cases of major congenital heart defects. False-positive results were noted for 169 (0·8%) babies (specificity 99·16%, 99·02-99·28), of which six cases were significant, but not major, congenital heart defects, and 40 were other illnesses that required urgent medical intervention.

INTERPRETATION

Pulse oximetry is a safe, feasible test that adds value to existing screening. It identifies cases of critical congenital heart defects that go undetected with antenatal ultrasonography. The early detection of other diseases is an additional advantage.

FUNDING

National Institute for Health Research Health Technology Assessment programme.

Evaluation of pulse oximetry screening in Middle Tennessee: cases for consideration before universal screening

OBJECTIVE

Pulse oximetry screening of asymptomatic newborns is suggested as a life-saving procedure for the timely detection of critical congenital heart disease (CHD) in asymptomatic newborns. We evaluated this screening and report cases that demonstrate problems with screening in a non-research setting.

STUDY DESIGN

An elective state-directed public health screening program was evaluated in Middle Tennessee; 14 564 infants were screened after 24 h of age and before discharge. The screening was performed in a non-research setting by nurses at the local hospitals. A parallel investigation of the methods and timing of diagnosis in Middle Tennessee revealed a surprisingly high incidence of antenatal diagnosis (66%).

RESULT

Using a saturation value of 94% as the defined normal, the positive predictive value was less than 1%, with 112 infants having a false positive case and 1 having a true positive case identified (incidence 1/34 775). The one true positive case was not referred for evaluation. One false-positive case resulted in a costly referral and hospitalization. Antenatal diagnosis when combined with physical examination detected 43 of 44 infants with critical CHD during the year-long evaluation.

CONCLUSION

Before universal screening can be implemented, a system of care must be defined to address the educational and referral issues raised by this report.

Clinical screening for Congenital heart disease at birth: a prospective study in a community hospital in Kerala

OBJECTIVE

To develop a clinical strategy for detection of Congenital heart disease (CHD) in the newborn through a combination of clinical signs and pulse oximetry.

DESIGN

Prospective longitudinal study.

SETTING

Community level hospital in the city of Kochi, Kerala.

PARTICIPANTS AND INTERVENTIONS

All consecutive newborns between June 2006 and February 2009 were prospectively screened for CHD, 48 hours after birth. The on-site pediatrician performed clinical screening. A study nurse recorded pulse oximetry in a lower extremity; value of <94% was defined as abnormal. Echocardiography was performed on site by a trained research officer. A 6-week clinical follow-up evaluation was done for all.

MAIN OUTCOME MEASURE

Detection of CHD by echocardiography.

RESULTS

Of 5487 babies screened, 425 (7.75%) had CHD. 17 (0.31%) had major CHD, two of whom (one ALCAPA and one large VSD) were missed during the initial evaluation. The rest were minor CHD (408 patients, 7.44%), most of which normalized by 6 weeks. On multivariate analysis, murmur, central cyanosis, abnormal precordial pulsations and abnormal pulse oximetry emerged as significant predictors of CHD. The sensitivity of clinical evaluation and pulse oximetry combined was 19% for all CHDs and 20% for major CHD; specificity was 88%.

CONCLUSIONS

In the community setting of a developing country, clinical evaluation and pulse oximetry after birth had a very low sensitivity for detection of CHD. Though an abnormal screening warrants prompt echocardiography, a 6 week clinical evaluation is recommended to ensure that major CHD is not missed.

Effectiveness of neonatal pulse oximetry screening for detection of critical congenital heart disease in daily clinical routine--results from a prospective multicenter study

Pulse oximetry screening (POS) has been proposed as an effective, noninvasive, inexpensive tool allowing earlier diagnosis of critical congenital heart disease (cCHD). Our aim was to test the hypothesis that POS can reduce the diagnostic gap in cCHD in daily clinical routine in the setting of tertiary, secondary and primary care centres. We conducted a prospective multicenter trial in Saxony, Germany. POS was performed in healthy term and post-term newborns at the age of 24-72 h. If an oxygen saturation (SpO(2)) of <or=95% was measured on lower extremities and confirmed after 1 h, complete clinical examination and echocardiography were performed. POS was defined as false-negative when a diagnosis of cCHD was made after POS in the participating hospitals/at our centre. From July 2006-June 2008, 42,240 newborns from 34 institutions have been included. Seventy-two children were excluded due to prenatal diagnosis (n = 54) or clinical signs of cCHD (n = 18) before POS. Seven hundred ninety-five newborns did not receive POS, mainly due to early discharge after birth (n = 727; 91%). In 41,445 newborns, POS was performed. POS was true positive in 14, false positive in 40, true negative in 41,384 and false negative in four children (three had been excluded for violation of study protocol). Sensitivity, specificity, positive and negative predictive value were 77.78%, 99.90%, 25.93% and 99.99%, respectively. With POS as an adjunct to prenatal diagnosis, physical examination and clinical observation, the percentage of newborns with late diagnosis of cCHD was 4.4%. POS can substantially reduce the postnatal diagnostic gap in cCHD, and false-positive results leading to unnecessary examinations of healthy newborns are rare. POS should be implemented in routine postnatal care.

Role of pulse oximetry in examining newborns for congenital heart disease: a scientific statement from the AHA and AAP

BACKGROUND

The purpose of this statement is to address the state of evidence on the routine use of pulse oximetry in newborns to detect critical congenital heart disease (CCHD).

METHODS AND RESULTS

A writing group appointed by the American Heart Association and the American Academy of Pediatrics reviewed the available literature addressing current detection methods for CCHD, burden of missed and/or delayed diagnosis of CCHD, rationale of oximetry screening, and clinical studies of oximetry in otherwise asymptomatic newborns. MEDLINE database searches from 1966 to 2008 were done for English-language papers using the following search terms: congenital heart disease, pulse oximetry, physical examination, murmur, echocardiography, fetal echocardiography, and newborn screening. The reference lists of identified papers were also searched. Published abstracts from major pediatric scientific meetings in 2006 to 2008 were also reviewed. The American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. In an analysis of pooled studies of oximetry assessment performed after 24 hours of life, the estimated sensitivity for detecting CCHD was 69.6%, and the positive predictive value was 47.0%; however, sensitivity varied dramatically among studies from 0% to 100%. False-positive screens that required further evaluation occurred in only 0.035% of infants screened after 24 hours.

CONCLUSIONS

Currently, CCHD is not detected in some newborns until after their hospital discharge, which results in significant morbidity and occasional mortality. Furthermore, routine pulse oximetry performed on asymptomatic newborns after 24 hours of life, but before hospital discharge, may detect CCHD. Routine pulse oximetry performed after 24 hours in hospitals that have on-site pediatric cardiovascular services incurs very low cost and risk of harm. Future studies in larger populations and across a broad range of newborn delivery systems are needed to determine whether this practice should become standard of care in the routine assessment of the neonate.

Role of pulse oximetry in examining newborns for congenital heart disease: a scientific statement from the American Heart Association and American Academy of Pediatrics

BACKGROUND

The purpose of this statement is to address the state of evidence on the routine use of pulse oximetry in newborns to detect critical congenital heart disease (CCHD).

METHODS AND RESULTS

A writing group appointed by the American Heart Association and the American Academy of Pediatrics reviewed the available literature addressing current detection methods for CCHD, burden of missed and/or delayed diagnosis of CCHD, rationale of oximetry screening, and clinical studies of oximetry in otherwise asymptomatic newborns. MEDLINE database searches from 1966 to 2008 were done for English-language papers using the following search terms: congenital heart disease, pulse oximetry, physical examination, murmur, echocardiography, fetal echocardiography, and newborn screening. The reference lists of identified papers were also searched. Published abstracts from major pediatric scientific meetings in 2006 to 2008 were also reviewed. The American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. In an analysis of pooled studies of oximetry assessment performed after 24 hours of life, the estimated sensitivity for detecting CCHD was 69.6%, and the positive predictive value was 47.0%; however, sensitivity varied dramatically among studies from 0% to 100%. False-positive screens that required further evaluation occurred in only 0.035% of infants screened after 24 hours.

CONCLUSIONS

Currently, CCHD is not detected in some newborns until after their hospital discharge, which results in significant morbidity and occasional mortality. Furthermore, routine pulse oximetry performed on asymptomatic newborns after 24 hours of life, but before hospital discharge, may detect CCHD. Routine pulse oximetry performed after 24 hours in hospitals that have on-site pediatric cardiovascular services incurs very low cost and risk of harm. Future studies in larger populations and across a broad range of newborn delivery systems are needed to determine whether this practice should become standard of care in the routine assessment of the neonate.

Retrospective correction for induced magnetic field inhomogeneity in measurements of large-vessel hemoglobin oxygen saturation by MR susceptometry

MR susceptometry-based blood oximetry relies on phase mapping to measure the difference in magnetic susceptibility between intravascular blood and surrounding tissue. The main source of error in MR susceptometry is the static field inhomogeneity caused by an interface between air and tissue or between adjacent tissue types. High-pass filtering has previously been used in conjunction with shimming to reduce the effect of low spatial-frequency modulations of the phase caused by large-scale induced magnetic fields. We demonstrate that high-pass filtering is not optimum for MR susceptometry because the results are sensitive to filter size. We propose an alternative method that acquires data without scanner-implemented default shimming, and fits, after appropriate weighting and masking, the static field inhomogeneity to a second-order polynomial. Compared to shimming the retrospective correction technique improved agreement between hemoglobin saturations measured in different segments of a vessel (femoral versus popliteal artery and vein) from three standard errors to less than one.

Impact of pulse oximetry screening on the detection of duct dependent congenital heart disease: a Swedish prospective screening study in 39,821 newborns

OBJECTIVE

To evaluate the use of pulse oximetry to screen for early detection of life threatening congenital heart disease.

DESIGN

Prospective screening study with a new generation pulse oximeter before discharge from well baby nurseries in West Götaland. Cohort study comparing the detection rate of duct dependent circulation in West Götaland with that in other regions not using pulse oximetry screening. Deaths at home with undetected duct dependent circulation were included.

SETTING

All 5 maternity units in West Götaland and the supraregional referral centre for neonatal cardiac surgery.

PARTICIPANTS

39,821 screened babies born between 1 July 2004 and 31 March 2007. Total duct dependent circulation cohorts: West Götaland n=60, other referring regions n=100.

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive and negative predictive values, and likelihood ratio for pulse oximetry screening and for neonatal physical examination alone.

RESULTS

In West Götaland 29 babies in well baby nurseries had duct dependent circulation undetected before neonatal discharge examination. In 13 cases, pulse oximetry showed oxygen saturations <or=90%, and (in accordance with protocol) clinical staff were immediately told of the results. Of the remaining 16 cases, physical examination alone detected 10 (63%). Combining physical examination with pulse oximetry screening had a sensitivity of 24/29 (82.8% (95% CI 64.2% to 95.2%)) and detected 100% of the babies with duct dependent lung circulation. Five cases were missed (all with aortic arch obstruction). False positive rate with pulse oximetry was substantially lower than that with physical examination alone (69/39 821 (0.17%) v 729/38 413 (1.90%), P<0.0001), and 31/69 of the "false positive" cases with pulse oximetry had other pathology. Thus, referral of all cases with positive oximetry results for echocardiography resulted in only 2.3 echocardiograms with normal cardiac findings for every true positive case of duct dependent circulation. In the cohort study, the risk of leaving hospital with undiagnosed duct dependent circulation was 28/100 (28%) in other referring regions versus 5/60 (8%) in West Götaland (P=0.0025, relative risk 3.36 (95% CI 1.37 to 8.24)). In the other referring regions 11/25 (44%) of babies with transposition of the great arteries left hospital undiagnosed versus 0/18 in West Götaland (P=0.0010), and severe acidosis at diagnosis was more common (33/100 (33%) v 7/60 (12%), P=0.0025, relative risk 2.8 (1.3 to 6.0)). Excluding premature babies and Norwood surgery, babies discharged without diagnosis had higher mortality than those diagnosed in hospital (4/27 (18%) v 1/110 (0.9%), P=0.0054). No baby died from undiagnosed duct dependent circulation in West Götaland versus five babies from the other referring regions.

CONCLUSION

Introducing pulse oximetry screening before discharge improved total detection rate of duct dependent circulation to 92%. Such screening seems cost neutral in the short term, but the probable prevention of neurological morbidity and reduced need for preoperative neonatal intensive care suggest that such screening will be cost effective long term.

Screening newborns for congenital heart disease with pulse oximetry: survey of pediatric cardiologists

BACKGROUND

Controversies exist regarding the use of pulse oximetry for routine screening of newborns. This study aimed to evaluate current practices and opinions of pediatric cardiologists in relation to newborn screening for congenital heart disease (CHD) using pulse oximetry.

METHODS

Email invitations were sent to 1,045 pediatric cardiologists in North America. The survey was Internet based and included multiple-choice questions. Two repeat email reminders were sent after the initial invitation.

RESULTS

A total of 363 responses (35%) were returned. In terms of experience, 40% of the respondents had more than 20 years, 32% had 10 to 20 years, 21% had 5 to 10 years, and 6% had less than 5 years of experience. More than 90% agreed that an early diagnosis of CHD for newborns prevents morbidity and mortality. In terms of practice, 96% reported that all newborns are examined by a clinician before discharge, 29% reported that newborns get a pulse oximetry reading, and 1.4% (n = 5) reported the use of electrocardiogram. Only 58% of respondents thought that current practice is adequate for detecting significant CHD. With regard to their experience with pulse oximetry, 26% reported "too many false-positives," 21% described it as "prone to noise and artifact," and 30% viewed it as "very operator dependent." The overall support for mandated pulse oximetry screening was 55%. The support for mandate decreased with years of experience, with 76% of the supporters having less than 5 years, 58% of those having 5 to 10 years, 53% of those having 10 to 20 years, and 51% of those having more than 20 years of experience.

CONCLUSIONS

Pediatric cardiologists recognize that current practice is inadequate for detecting significant CHD. Slightly more than half of the pediatric cardiologists in this study supported a mandate for pulse oximetry screening, but there were many concerns, and the support decreased with increasing years of clinical experience.

Pulse oximetry screening at 4 hours of age to detect critical congenital heart defects

OBJECTIVE

The purpose of this prospective study was to assess the feasibility and reliability of pulse oximetry screening to detect critical congenital heart defects in a newborn nursery.

METHODS

The study was performed in a large urban hospital with an exclusively inborn population. Stable neonates who had a gestational age of >or=35 weeks and birth weight of >or=2100 g and in whom a critical congenital heart defect was not suspected were admitted to the newborn nursery. When the 4-hour pulse oximetry reading was <96%, pulse oximetry was repeated at discharge, and when the pulse oximetry reading remained at persistently <96%, echocardiography was performed.

RESULTS

Of 15299 admissions to newborn nursery during the 12-month study period, 15233 (99.6%) neonates were screened with 4-hour pulse oximetry. Pulse oximetry readings were >or=96% for 14374 (94.4%) neonates; 77 were subsequently evaluated before discharge for cardiac defects on the basis of clinical examination. Seventy-six were normal, and 1 had tetralogy of Fallot with discontinuous pulmonary arteries. Pulse oximetry readings at 4 hours were <96% in 859 (5.6%); 768 were rescreened at discharge, and 767 neonates had a pulse oximetry reading at >or=96%. One neonate had persistently low pulse oximetry at discharge; echocardiography was normal. Although 3 neonates with a critical congenital heart defect had a 4-hour pulse oximetry reading of <96%, all developed signs and/or symptoms of a cardiac defect and received a diagnosis on the basis of clinical findings, not screening results.

CONCLUSIONS

All neonates with a critical congenital heart defect were detected clinically, and no cases of critical congenital heart defect were detected by pulse oximetry screening. These results indicate that pulse oximetry screening does not improve detection of critical congenital heart defects above and beyond clinical observation and assessment. Our findings do not support a recommendation for routine pulse oximetry screening in seemingly healthy neonates.

The reliability of a single pulse oximetry reading as a screening test for congenital heart disease in otherwise asymptomatic newborn infants

Routine pulse oximetry has been studied to detect children with otherwise undiagnosed congenital heart disease prior to nursery discharge. The reported sensitivities in asymptomatic patients have been less than expected and vary widely, bringing into question the reliability of the test. The purpose of this study was to assess whether routine pulse oximetry contributes to identifying patients with critical congenital heart disease and to determine the reliability of a single pulse oximeter reading in screening asymptomatic newborn infants. Between December 26, 2003, and December 31, 2005, three hospitals in west central Florida performed a pulse oximetry routinely on all newborns at the time of discharge. Patients diagnosed with critical congenital heart disease during the study period were identified to assess whether the pulse oximetry reading initiated their diagnosis. In one hospital, the pulse oximeter data were evaluated for reliability. Downloaded data were compared to a log compiled by the nursery personnel, first without (phase 1) and then with (phase 2) their knowledge and additional training. Results were characterized as reliable, probe placed but reading not verifiable, or no evidence of probe placement. Of the 7962 infants who received oximetry testing, there were 12 postnatal diagnoses of critical congenital heart disease. None was initially identified by routine pulse oximetry. Pulse oximetry reliability improved substantially between phase 1 and phase 2 (38 v. 60%, p < 0.0001). Optimal reliability (>95%) was obtained by a nurse with a degree of LPN or higher performing an assessment of at least 360 seconds. Routine pulse oximetry was neither reliable nor an important diagnostic tool in our cohort. Important human factors (probe placement time, oximetry training, and nursing degree) impact single determination pulse oximetry reliability. With routine surveillance and quality improvement, the reliability of this test can be increased. Future studies to determine the effectiveness of pulse oximetry screening for the diagnosis of congenital heart disease in the asymptomatic newborn population must address these factors. Until such a study demonstrates acceptable sensitivity and clinical value, universal screening should not be instituted.

First day of life pulse oximetry screening to detect congenital heart defects

OBJECTIVE

To evaluate the efficacy of first day of life pulse oximetry screening to detect congenital heart defects (CHDs).

STUDY DESIGN

We performed a population-based prospective multicenter study of postductal (foot) arterial oxygen saturation (SpO(2)) in apparently healthy newborns after transfer from the delivery suite to the nursery. SpO(2) < 95% led to further diagnostic evaluations. Of 57,959 live births, 50,008 (86%) were screened. In the screened population, 35 CHDs were [corrected] classified as critical (ductus dependent, cyanotic). CHDs were prospectively registered and diagnosed in 658/57,959 (1.1%) [corrected]

RESULTS

Of the infants screened, 324 (0.6%) failed the test. Of these, 43 (13%) had CHDs (27 critical), and 134 (41%) had pulmonary diseases or other disorders. The remaining 147 infants (45%) were healthy with transitional circulation. The median age for babies with CHDs at failing the test was 6 hours (range, 1-21 hours). For identifying critical CHDs, the pulse oximetry screening had a sensitivity rate of 77.1% (95% CI, 59.4-89.0), specificity rate of 99.4% (95% CI, 99.3-99.5), and a false-positive rate of 0.6% (95% CI, 0.5-0.7).

CONCLUSIONS

Early pulse oximetry screening promotes early detection of critical CHDs and other potentially severe diseases. The sensitivity rate for detecting critical CHDs is high, and the false-positive rate is low.