How effectively can clinical examination pick up congenital heart disease at birth?

Diagnostic Accuracy of Physical Examination and Pulse Oximetry for Critical Congenital Cardiac Disease Screening in Newborns

BACKGROUND

Newborns with a critical congenital heart disease left undiagnosed and untreated have a substantial risk for serious complications and subsequent failure to thrive. Prenatal ultrasound screening is not widely available, nor is postnatal echocardiography. Physical examination is the standard for postnatal screening. Pulse oximetry has been proposed in numerous studies as an alternative screening method. This systematic review and meta-analysis aims to determine the diagnostic accuracies of both screening methods separately and combined.

METHODS

A systematic literature search of the Embase, PubMed, and Global Health databases up to 30 November 2023 was conducted with the following keywords: critical congenital heart disease, physical examination, clinical scores, pulse oximetry, and echocardiography. The search included all studies conducted in the newborn period using both physical examination and pulse oximetry as screening methods and excluded newborns admitted to the intensive care unit. All studies were assessed for risk of bias and applicability concerns using the QUADAS-2 score. The review adhered to the PRISMA 2020 statement guideline.

RESULTS

Out of 2711 articles, 20 articles were selected as eligible for meta-analysis. Cumulatively, the sample included 872,549 screened newborns. The pooled sensitivity of the physical examination screening method was found to be 0.69 (0.66-0.73 (95% CI)) and specificity was found to be 0.98 (0.98-0.98). For the pulse oximetry screening method, the pooled sensitivity and specificity yielded 0.78 (0.75-0.82) and 0.99 (0.99-0.99), respectively. The combined method of screening yielded improved diagnostic characteristics at a sensitivity and specificity of 0.93 (0.91-0.95) and 0.98 (0.98-0.98, respectively.

CONCLUSIONS

The evidence indicates that combining both physical examination and pulse oximetry to screen for critical congenital heart disease exceeds the accuracy of either separate method. The main limitation is that solely newborns with suspected critical congenital heart disease were subjected to the reference standard. We recommend adapting both methods to screen for critical congenital heart diseases, especially in settings lacking standard fetal ultrasound screening. To increase the sensitivity further, we recommend increasing the screening time window and employing the peripheral perfusion index.

Cardiovascular physical examination as a screening tool for congenital heart disease in newborns at a teaching hospital in Ghana

Objectives

To determine the usefulness of cardiovascular physical examination (CPE) as a screening tool in a low-resource setting for detecting congenital heart disease (CHD) in newborns delivered at the Maternity Unit of Korle Bu Teaching Hospital (KBTH), Accra, Ghana.

Design

A hospital-based cross-sectional study with a comparison group component.

Setting

Maternity Unit of the KBTH, Accra, Ghana.

Participants

Over eight months, newborns aged 1-14 days delivered at ≥ 34 weeks' gestation at the Maternity Unit, KBTH, were recruited into the study.

Intervention

Each newborn was examined using a set of CPE parameters for the presence of congenital heart disease. Those with suggestive features of CHD had a confirmatory echocardiogram test.

Main Outcome Measure

Abnormal CPE features and their corresponding echocardiogram findings.

Results

A total of 1607 were screened, with 52 newborns showing signs of CHD on CPE, of which 20 newborns were proven on echocardiogram to have congenital heart disease. Abnormal CPE parameter that was associated with CHD was murmur (P=0.001), dysmorphism (p=0.01), newborns with chest recessions (p=0.01) and lethargy (p=0.02). CPE's sensitivity, specificity, and positive and negative predictive values were 95%, 60.7%, 36.5% and 98,1%, respectively. The most common acyanotic CHD found was isolated atrial septal defect (ASD), followed by patent ductus arteriosus (PDA). The only cyanotic CHD found was a case of tricuspid atresia.

Conclusion

Cardiovascular physical examination at birth is an effective and inexpensive screening tool for detecting CHD in newborns, which can easily be utilised in low-resource settings.

Funding

None declared.

Clinical score to detect congenital heart defects: Concept of second screening

Introduction

Neonatal screening for congenital heart defects at birth can miss some heart defects, sometimes few critical ones, and the scenario is even worse in those neonates who had never undergone a neonatal checkup (home deliveries). Immunization clinic can serve as a unique opportunity as the second checkpoint for the screening of the children. A history- and examination-based test can serve as an effective tool to screen out children with heart defects.

Aims and Objectives

The aim of this study was to establish the sensitivity and specificity of a clinical screening tool for the identification of congenital heart defects at the first visit of an infant after birth for immunization.

Materials and Methods

This is a cross-sectional observational study which the consecutive children presenting at 6 weeks of age for immunization or any child presenting for the first time (outborn delivery) till 6 months of age in the immunization clinic were subjected to detailed history and examination and findings were recorded on a predesigned pro forma and a clinical score was calculated. All these children were then subjected to echocardiography for confirmation of the diagnosis of congenital heart disease (CHD), and the sensitivity and specificity of the test were recorded.

Observations and Results

A total of 970 babies were screened, out of them 31 were diagnosed with CHD and 18 had undergone neonatal screening at birth. A clinical score of 3 or more had more chances of detecting CHD. The sensitivity of the cutoff score as 3 was 96.77% and specificity was 98.72, with a positive predictive value of 71.43%, a negative predictive value of 99.89%, and an accuracy of 98.66%.

Conclusions

The history- and examination-based tool is an effective method for early identification of CHD and can easily be used by peripheral workers working in remote places with poor resources enabling prompt referral.

Pulse oximetry as a screening tool for detecting major congenital heart defects in Indian newborns

OBJECTIVE

To evaluate the use of pulse oximetry as a screening tool for detecting major congenital heart defects (CHDs) in Indian newborns.

DESIGN

Cross-sectional observational study.

PATIENTS

In a community hospital of north India, babies born during a specific 8 h period of the day were recruited over a period of 3 years. Newborns with incomplete documentation were excluded.

INTERVENTION

Routine clinical examination, pulse oximetry and bedside echocardiography.

OUTCOME MEASURES

Any abnormalities in clinical examination and pulse oximetry were recorded. CHDs were diagnosed using bedside echocardiography. Accuracy of pulse oximetry, clinical examination and their combination for detecting major CHDs was calculated.

RESULTS

Among the 19 009 newborns screened, 70 had major CHDs at birth (44 serious, 26 critical). Pulse oximetry detected 39 major (sensitivity 55.7%, 95% CI 44.1% to 66.8%; specificity 68.3%, 67.6% to 68.9%) and 22 critical CHDs (sensitivity 84.6%, 66.5% to 93.9%; specificity 68.3%, 67.6% to 68.9%). Addition of pulse oximetry to clinical examination significantly improved sensitivity for major CHDs (35.7% (25.5% to 47.4%) to 75.7% (64.5% to 85.3%), p<0.01) and critical CHDs (11.5% (4.0% to 29.0%) to 84.6% (66.5% to 93.9%), p<0.01).

CONCLUSIONS

Pulse oximetry is a sensitive screening tool for detecting major CHDs in Indian newborns. It adds significant value to the current practice of using clinical examination as a sole screening tool for detecting major CHDs. However, specificity of pulse oximetry was much lower in our study. Possible reasons for low specificity could be non-repetition of pulse oximetry in newborns with initial lower saturations, high prevalence of infections and respiratory issues in our cohort and use of non-motion tolerant oximeter.

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.

Management of asymptomatic cardiac murmurs in term neonates

Approximately 2 % of newborn infants are noted to have cardiac murmur on routine postnatal examination. Our aim was to look at current evidence and practice in the management of asymptomatic cardiac murmur in term neonates. We performed a systematic literature review and a telephone survey of all neonatal units in the United Kingdom (UK). The systematic review of the literature did not support the routine practice of four-limb blood pressure (BP), chest X-ray (CXR), and electrocardiogram (ECG) in the assessment of asymptomatic cardiac murmur in term neonates. The survey had participation from 132 (68 %) of 193 neonatal units in the UK. In an asymptomatic term neonate with cardiac murmur, 124 (94 %) units perform pulse oximetry, 100 units (76 %) measure four-limb BP, 36 units (27 %) perform a CXR, and 52 units (39 %) perform an ECG. Eight-six units (65 %) have availability of in-house echocardiography services provided mainly by paediatricians with cardiology interest in special care units and neonatologists in neonatal intensive care units. Currently there is wide variation in practice in the management of asymptomatic cardiac murmur in term neonates. There is no evidence to support the routine use of four-limb BP, CXR, and ECG in the assessment of asymptomatic cardiac murmur in term neonates. Based on the evidence available, both structured clinical examination (including determining presence and quality of bilateral femoral pulses) and universal use of pulse oximetry are most important in identifying CHD in asymptomatic term neonates with cardiac murmur before discharge home.

Spectrum of paediatric cardiac diseases: a study of 15,066 children undergoing cardiac intervention at a tertiary care centre in India with special emphasis on gender

OBJECTIVES

To analyse the relative frequency and gender ratios in the procedures (both surgical and catheter-based interventions) performed for cardiac diseases in Indian children.

BACKGROUND

Not many studies are available in the developing countries with regard to the prevalence, relative frequency, or gender distribution of cardiac diseases in children. As universal newborn screening is not carried out for congenital cardiac diseases, the statistics are difficult to ascertain. Do female and male children with cardiac disease get equal parental preference in terms of surgical correction and catheter interventions in India? This question is also unanswered.

METHODS

Analysis of 15,066 consecutive Indian children aged <18 years who were operated upon or had catheter intervention at a single tertiary care centre. Relative frequency and male/female ratios of cardiac lesions in these children were determined and compared with the studies in literature.

RESULTS

Overall male/female ratio in the study was 1.4:1. Ventricular septal defect was the most common lesion (24.2%) with male/female ratio of 1.5:1, followed by tetralogy of Fallot (18.7%, 1.6:1), atrial septal defect (14.4%, 0.9:1) and so on. Male children dominated the total number of procedures performed.

CONCLUSION

In most of the individual cardiac lesions, the relative frequency was different from that of international studies. The gender ratio for the majority of the individual type of cardiac problems was different from that of international references. These findings may suggest a preference for the male child in the treatment of cardiac diseases in India, which could possibly be related to social causes.

Cardiac assessment in the neonatal population

Congenital heart defects are not uncommon among neonatal patients. Although most are benign, the prompt identification of a life-threatening anomaly is essential for rapid intervention and a positive treatment outcome. Cardiac defects may be identified in the newborn nursery with thorough and systematic physical assessment, including inspection, palpation, auscultation, and measurement of blood pressure and oxygen saturations. The ability of the nurse to identify irregular findings during physical assessment aids rapid identification and treatment.

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.

Cardiovascular symptoms and signs in evaluating cardiac murmurs in children

BACKGROUND

The aim of the present study was to determine the usefulness of cardiovascular symptoms and signs in the recognition of significant congenital heart lesions that required surgical or catheter interventions in different pediatric age groups.

METHODS

A retrospective chart review was carried out of 110 patients with significant heart anomalies that required surgical or catheter interventions (group I) and 113 children, presenting with cardiac murmurs, with congenital heart conditions not requiring any interventions. (group II).

RESULTS

Clinical symptoms or signs were significantly more common in group I than in group II subjects (85% vs 32%, P < 0.0001). The odds of having significant lesions requiring interventions in the presence of either cardiovascular symptoms or signs were 37.5 (95% confidence interval [CI]: 6.5-218.1) for neonates, 14.5 (95%CI: 4.7-51.7) for infants, and 8.0 (95%CI: 3.3-19.2) for children and adolescents. In neonates, the negative predictive values of the absence of symptoms or signs in isolation were relatively low at 64% and 65%, respectively. In children beyond infancy, the positive predictive values of the presence of symptoms or signs in isolation were also low at 62% and 68%, respectively.

CONCLUSIONS

Clinical assessment of cardiovascular symptoms and signs remains useful in the evaluation of the significance of pathological cardiac murmurs in children in the present era of technology. Nonetheless, the predictive values vary with different pediatric age groups.

Importance of timely diagnosis of congenital heart disease

Most important types of congenital heart disease can be recognized early during prenatal or neonatal screening. However, a substantial proportion of cardiac defects are not diagnosed in due time. Such delay may lead to serious complications or even death. This article reviews the impact of screening strategies upon the outcome in pediatric cardiac patients.

Should pulse oximetry be used to screen for congenital heart disease?

Ten studies (44 969 newborns, 71 severe defects) evaluating the usefulness of neonatal pulse oximetry (PO) screening in timely detection of congenital heart disease (CHD) were reviewed. PO showed a high specificity (99.9-99.99%), and the overall rate of detection of 15 individual defects with PO was 72% (range 46-100%), exceeding that of the clinical examination 58% (9-86%). Similar results were obtained for cyanotic CHD (89% v 69%, respectively). Without PO, discharge of apparently healthy infants with unknown CHD was 5.5 times and 4.1 times more likely in cyanotic CHD and all serious CHD, respectively. The paper describes the technical and practical details of first day and later screening. Diagnosis is reached earliest with first day screening, but it requires more resources. PO screening is not sensitive enough to serve as an independent screen, but along with the clinical examination it helps minimise the morbidity and mortality associated with discharge without diagnosis. Further research is needed for precise delineation of populations that would benefit from PO screening.

How effectively can clinical examination pick up congenital heart disease at birth?

Perspective on the paper by Patton and Hey (see page 263)