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Reid ES, Leiter SM, Silverwood H, Cunnington A, Ranson K, Brown J, Noone M. Implementation of preductal and postductal oxygen saturation screening in babies born in a district general hospital. Arch Dis Child Educ Pract Ed 2024; 109:147-150. [PMID: 38331466 DOI: 10.1136/archdischild-2023-325304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 12/01/2023] [Indexed: 02/10/2024]
Affiliation(s)
- Emma S Reid
- Department of Paediatrics, West Suffolk NHS Foundation Trust, Bury Saint Edmunds, UK
| | - Sarah M Leiter
- Department of Paediatrics, West Suffolk NHS Foundation Trust, Bury Saint Edmunds, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Holly Silverwood
- Department of Paediatrics, West Suffolk NHS Foundation Trust, Bury Saint Edmunds, UK
| | - Amy Cunnington
- Department of Paediatrics, West Suffolk NHS Foundation Trust, Bury Saint Edmunds, UK
| | - Karen Ranson
- Department of Paediatrics, West Suffolk NHS Foundation Trust, Bury Saint Edmunds, UK
| | - Jacqueline Brown
- Department of Paediatrics, West Suffolk NHS Foundation Trust, Bury Saint Edmunds, UK
| | - Martina Noone
- Department of Paediatrics, West Suffolk NHS Foundation Trust, Bury Saint Edmunds, UK
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Shahid ASMSB, Alam T, Ackhter MM, Islam MZ, Parvin I, Shaima SN, Shahrin L, Ahmed T, Chowdhury F, Chisti MJ. Factors Associated with Congenital Heart Disease in Severely Malnourished Children under Five and Their Outcomes at an Urban Hospital, Bangladesh. Children 2021; 9:children9010001. [PMID: 35053626 PMCID: PMC8773990 DOI: 10.3390/children9010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/25/2021] [Accepted: 12/15/2021] [Indexed: 11/18/2022]
Abstract
Congenital heart disease (CHD) is one of the most common types of birth defect with a high morbidity and mortality, particularly in severely malnourished children under five. In this study, we aim to identify the predicting factors for CHD and their outcomes. 694 malnourished children under five years of age admitted between April 2015 and December 2017 constituted the study population. Of them, 64 were cases of CHD, and by comparison 630 were without CHD. CHD was diagnosed clinically and confirmed by echocardiogram. 64% of the cases had a single defect. Cases were more likely to be present with diarrhea, cough, respiratory distress, cyanosis, hypoxemia, hypoglycemia and hypernatremia on admission. The cases also had a high proportion of severe sepsis, bacteremia, heart failure, respiratory failure and death, compared to those without CHD. Cough (95% CI = 1.09–18.92), respiratory distress (95% CI = 1.46–5.39) and hypoxemia (95% CI = 1.59–6.86) were found to be the independent predictors for CHD after regression analysis, and their early identification might be helpful to lessen ramifications, including mortality, in such populations, especially in resource-limited settings.
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Affiliation(s)
- Abu Sadat Mohammad Sayeem Bin Shahid
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka 1212, Bangladesh; (T.A.); (M.M.A.); (M.Z.I.); (I.P.); (S.N.S.); (L.S.); (T.A.); (M.J.C.)
- Correspondence:
| | - Tahmina Alam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka 1212, Bangladesh; (T.A.); (M.M.A.); (M.Z.I.); (I.P.); (S.N.S.); (L.S.); (T.A.); (M.J.C.)
| | - Mst. Mahmuda Ackhter
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka 1212, Bangladesh; (T.A.); (M.M.A.); (M.Z.I.); (I.P.); (S.N.S.); (L.S.); (T.A.); (M.J.C.)
| | - Md. Zahidul Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka 1212, Bangladesh; (T.A.); (M.M.A.); (M.Z.I.); (I.P.); (S.N.S.); (L.S.); (T.A.); (M.J.C.)
| | - Irin Parvin
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka 1212, Bangladesh; (T.A.); (M.M.A.); (M.Z.I.); (I.P.); (S.N.S.); (L.S.); (T.A.); (M.J.C.)
| | - Shamsun Nahar Shaima
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka 1212, Bangladesh; (T.A.); (M.M.A.); (M.Z.I.); (I.P.); (S.N.S.); (L.S.); (T.A.); (M.J.C.)
| | - Lubaba Shahrin
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka 1212, Bangladesh; (T.A.); (M.M.A.); (M.Z.I.); (I.P.); (S.N.S.); (L.S.); (T.A.); (M.J.C.)
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka 1212, Bangladesh; (T.A.); (M.M.A.); (M.Z.I.); (I.P.); (S.N.S.); (L.S.); (T.A.); (M.J.C.)
| | - Fahmida Chowdhury
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Dhaka 1212, Bangladesh;
| | - Mohammod Jobayer Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka 1212, Bangladesh; (T.A.); (M.M.A.); (M.Z.I.); (I.P.); (S.N.S.); (L.S.); (T.A.); (M.J.C.)
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Sankaran D, Siefkes H, Ing FF, Lakshminrusimha S, Poulain FR. Critical Congenital Heart Disease Detection in the Screening Era: Do Not Neglect the Examination! AJP Rep 2021; 11:e84-e90. [PMID: 34150354 PMCID: PMC8208842 DOI: 10.1055/s-0041-1727275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 02/05/2021] [Indexed: 11/08/2022] Open
Abstract
Pulse oximetry oxygen saturation (SpO 2 )-based critical congenital heart disease (CCHD) screening is effective in detection of cyanotic heart lesions. We report a full-term male infant with normal perfusion who had passed the CCHD screening at approximately 24 hours after birth with preductal SpO 2 of 99% and postductal SpO 2 of 97%. Detection of a loud systolic cardiac murmur before discharge led to the diagnosis of pulmonary atresia (PA) with ventricular septal defect (PA-VSD) by echocardiogram. The infant was transferred to a tertiary care center after initiation of prostaglandin E1 (PGE1) therapy. Throughout the initial course, he was breathing comfortably without respiratory distress or desaturations on pulse oximetry. We believe that this is the first documented report of PA missed by CCHD screening. Thorough and serial clinical examinations of the newborn infant proved vital in the timely diagnosis of this critical disease. We review the hemodynamics and the recent literature evaluating utility of CCHD screening in the diagnosis of PA-VSD. Pulse oximetry-based CCHD screening should be considered a tool to enhance CCHD detection with an emphasis on detailed serial physical examinations in newborn infants.
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Affiliation(s)
- Deepika Sankaran
- Division of Neonatology, Department of Pediatrics, University of California, Davis, Sacramento, California
| | - Heather Siefkes
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of California, Davis, Sacramento, California
| | - Frank F Ing
- Division of Pediatric Cardiology, Department of Pediatrics, University of California, Davis, Sacramento, California
| | - Satyan Lakshminrusimha
- Division of Neonatology, Department of Pediatrics, University of California, Davis, Sacramento, California
| | - Francis R Poulain
- Division of Neonatology, Department of Pediatrics, University of California, Davis, Sacramento, California
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Boyd SM, Staub E, Browning Carmo K. Improving diagnostic accuracy in neonates with left heart obstruction in a transport setting. J Paediatr Child Health 2021; 57:26-32. [PMID: 32776675 DOI: 10.1111/jpc.15102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/09/2020] [Accepted: 07/17/2020] [Indexed: 11/30/2022]
Abstract
AIM Differentiating left heart obstruction (LHO) from other severe illness in the neonatal period is challenging, and important for guiding clinical management. The aim of this study was to identify factors distinguishing LHO from non-LHO in neonates. METHODS A retrospective, cohort study of neonates referred to the Newborn and Paediatric Emergency Transport Service, New South Wales, with suspected LHO during the epoch 1996-2016. RESULTS A total of 273 neonates were included; 240 with confirmed LHO. Administration of prostaglandin E1 to infants with a structurally normal heart was not associated with impaired acid-base or oxygenation status. Pre-transport diagnostic accuracy of LHO was 74.4%; sensitivity 84.5%, positive predictive value 86.0%. On multivariable logistic regression, hepatomegaly (odds ratio 2.54; 95% confidence interval 1.05-6.16) was associated with confirmed LHO. CONCLUSIONS A low threshold for prostaglandin E1 infusion should be maintained in infants with suspected LHO. Hepatomegaly is associated with a diagnosis of LHO and may be more useful than other parameters in predicting the condition.
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Affiliation(s)
- Stephanie M Boyd
- Newborn and Paediatric Emergency Transport Service (NETS) New South Wales, Sydney, New South Wales, Australia.,Grace Centre for Newborn Intensive Care, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Eveline Staub
- Department of Neonatology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Kathryn Browning Carmo
- Newborn and Paediatric Emergency Transport Service (NETS) New South Wales, Sydney, New South Wales, Australia.,Grace Centre for Newborn Intensive Care, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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Izhar FM, Abqari S, Shahab T, Ali SM. Clinical score to detect congenital heart defects: Concept of second screening. Ann Pediatr Cardiol 2020; 13:281-288. [PMID: 33311915 PMCID: PMC7727906 DOI: 10.4103/apc.apc_113_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 05/07/2020] [Accepted: 06/27/2020] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Fazil M Izhar
- Department of Pediatrics, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - Shaad Abqari
- Department of Pediatrics, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - Tabassum Shahab
- Department of Pediatrics, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - Syed Manazir Ali
- Department of Pediatrics, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
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Khammari Nystrom F, Petersson G, Stephansson O, Johansson S, Altman M. Diagnostic values of the femoral pulse palpation test. Arch Dis Child Fetal Neonatal Ed 2020; 105:375-379. [PMID: 31597727 DOI: 10.1136/archdischild-2019-317066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 08/15/2019] [Accepted: 09/24/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To calculate diagnostic values of the femoral pulse palpation to detect coarctation of the aorta or other left-sided obstructive heart anomalies in newborn infants. DESIGN Population-based cohort study. SETTING Stockholm-Gotland County 2008-2012. PATIENTS All singleton live-born infants without chromosomal trisomies, at ≥35 gestational weeks, followed-up until 1-2 years of age. MAIN OUTCOME MEASURES Diagnostic values and ORs for the femoral pulse test and subsequent diagnosis of coarctation of the aorta or left-sided obstructive heart malformation. RESULTS Among the 118 592 included infants, 432 had weak or absent femoral pulses at the newborn examination. Seventy-eight infants were diagnosed with coarcation of the aorta and 48 with other left-sided obstructive heart malformations. The diagnostic values for the femoral pulse palpation test to detect coarctation of the aorta were: sensitivity: 19.2%, specificity: 99.6, positive predictive value: 3.5% and negative predictive value: 99.9%. For left-sided heart malformations: sensitivity: 8.3%, specificity: 99.6%, positive predictive value: 0.9% and negative predictive value: 100%. Sensitivity for coarctation of the aorta increased from 16.7% when examined at <12 hours of age to 30.0% at ≥96 hours of age. CONCLUSIONS The femoral pulse test to detect coarctation of the aorta and left-sided heart malformations has limited sensitivity, whereas specificity is high. As many infants with life-threatening cardiac malformations leave the maternity ward undiagnosed, further efforts are necessary to improve the diagnostic yield of the routine newborn examination.
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Affiliation(s)
- Fatine Khammari Nystrom
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
| | - Gunnar Petersson
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden.,Division of Obstetrics and Gynecology, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Stefan Johansson
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science and Education, Sodersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Maria Altman
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
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Ward K, Dixon L, Cloete E, Gentles T, Bloomfield F. Health professionals' views of newborn pulse oximetry screening in a midwifery-led maternity setting. "It's a good thing to do, but fund it!". Midwifery 2019; 81:102593. [PMID: 31812128 DOI: 10.1016/j.midw.2019.102593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 11/29/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To understand from health professionals who care for newborns their views on the introduction of pulse oximetry screening for the detection of hypoxaemia in a midwifery-led maternity setting. Although oximetry screening for newborns is internationally accepted, national screening is not yet introduced in New Zealand. In this context, we drew on maternity carers' reflections during a feasibility study of oximetry screening to provide perspectives on barriers and enablers to universal screening. METHODS Data were generated from nine focus groups during five months of 2018 in two north island regions of New Zealand. Participants' (n = 45) opinions about the use of oximetry screening in newborns were analysed thematically using an inductive approach. FINDINGS Overall, participants stated pulse oximetry screening was easy to do, non-invasive, and worthwhile. Midwives were reassured by screening that provided evidence of either a healthy baby or a need for urgent review. From participants' reports, we identified three themes: (1) oximetry screening for newborns is reassuring, practical and worthwhile; (2) midwifery services workload expectations and under-resourcing will hinder universal screening, and (3) location of the baby at the time of screening could impede universal access. CONCLUSION AND IMPLICATIONS FOR PRACTICE Midwives viewed implementing a national pulse oximetry screening programme as sensible but problematic unless resourced and funded appropriately. Policymakers should view the concerns of midwives about human and physical resources as significant and account for the need to resource this screening programme appropriately as a priority before implementation.
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Affiliation(s)
- Kim Ward
- The Liggins Institute, University of Auckland, Auckland, New Zealand.
| | - Lesley Dixon
- New Zealand College of Midwives, Christchurch, Auckland, New Zealand
| | - Elza Cloete
- The Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Tom Gentles
- Starship Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Frank Bloomfield
- The Liggins Institute, University of Auckland, Auckland, New Zealand
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Banait N, Ward-Platt M, Abu-Harb M, Wyllie J, Miller N, Harigopal S. Pulse oximetry screening for critical congenital heart disease: a comparative study of cohorts over 11 years. J Matern Fetal Neonatal Med 2019; 33:2064-2068. [PMID: 30332903 DOI: 10.1080/14767058.2018.1538348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: Pulse oximetry (POS) has been proposed as a screening tool for CCHD in newborn. The aim was to identify the effect of POS on the rate of diagnosis after discharge and survival to one year in cases with CCHD.Material and Methods: All cases of CCHD from three tertiary level hospitals in the Northern region of UK between 1st January 2001 and 31st December 2011 were identified from the Northern Congenital Abnormality Survey (NorCAS). A retrospective cohort study comparing screened and unscreened population for CCHD was undertaken. The main outcome was post discharge diagnosis rate and mortality at one year between the cohorts.Results: Total number of births during the 11 years was 138,176. A total of 147 cases had CCHD, 59 diagnosed postnatally. Five and eight cases were diagnosed after discharge in the screened and the unscreened cohort respectively. The rate of post-discharge diagnosis in the screened population was 7/100,000 and 13/100,000 in the unscreened population with a relative risk of 0.52 (CI 0.2 to 1.42). Mortality at one year in postnatally diagnosed cases was five and one in the screened and unscreened cohorts respectively.Conclusion: With good antenatal detection rates, POS did not have a statistically significant impact in identifying cases of CCHD, when added to the present screening process of antenatal ultrasound and postnatal examination. The same conclusion cannot be made for regions with lower antenatal detection rates; perhaps it may be more appropriate to consider pulse oximetry as a screening tool for hypoxemia of any cause.Brief rationaleThis is the first study evaluating the contemporaneous post-discharge diagnosis rate between screened and unscreened populations. The rate of post-discharge diagnosis was 7/100,000 in the screened and 13/100,000 in the unscreened populations. However, this did not achieve statistical significance and in a setting with high antenatal diagnosis a very large study would be required to demonstrate efficacy of POS.
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Affiliation(s)
- Nishant Banait
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, NICU, Newcastle upon Tyne, UK
| | - Martin Ward-Platt
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, NICU, Newcastle upon Tyne, UK
| | | | | | - Nicola Miller
- National Congenital Anomaly and Rare Disease Registration Service, Public Health England North East, Newcastle upon Tyne, UK
| | - Sundeep Harigopal
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, NICU, Newcastle upon Tyne, UK
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Cloete E, Bloomfield FH, Sadler L, de Laat MWM, Finucane AK, Gentles TL. Antenatal Detection of Treatable Critical Congenital Heart Disease Is Associated with Lower Morbidity and Mortality. J Pediatr 2019; 204:66-70. [PMID: 30292491 DOI: 10.1016/j.jpeds.2018.08.056] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 08/06/2018] [Accepted: 08/22/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To establish the impact that timing of diagnosis and place of birth have on neonatal outcomes in those with readily treatable critical congenital heart disease. STUDY DESIGN This was a population-based study with a complete national cohort of live-born infants with transposition of the great arteries and aortic arch obstruction in New Zealand between 2006 and 2014. Timing of diagnosis, place of birth, survival to surgery, in-hospital events, and neonatal mortality were reviewed. Live births with a gestation of ≥35 weeks and without associated major extracardiac anomalies were included for analysis. RESULTS A total of 166 live-born infants with transposition of the great arteries and 87 with aortic arch obstruction were included. Antenatal detection increased from 32% in the first 3 years to 47% in the last 3 years (P = .05). During the same period, neonatal mortality decreased from 9% to 1% (P = .02). No deaths occurred after surgical intervention. An antenatal diagnosis was associated with decreased mortality (1/97 [1%] vs 11/156 [7%]; P = .03) and birth outside the surgical center was associated with increased risk of mortality (11/147 [7%] vs 1/106 [1%]; P = .02). Those with an antenatal diagnosis required fewer hours of mechanical ventilation (P = .02) and had shorter durations of hospital stay (P = .05) compared with those diagnosed >48 hours after birth. CONCLUSIONS The mortality risk for transposition of the great arteries and critical aortic arch obstruction is greatest before cardiac surgery. Improved antenatal detection allowing delivery at a surgical center is associated with reduced mortality.
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Affiliation(s)
- Elza Cloete
- Liggins Institute, University of Auckland, Auckland, New Zealand.
| | | | - Lynn Sadler
- Women's Health, Auckland City Hospital, Auckland, New Zealand
| | | | - A Kirsten Finucane
- Pediatric and Congenital Cardiac Services, Starship Children's Hospital, Auckland, New Zealand
| | - Thomas L Gentles
- Pediatric and Congenital Cardiac Services, Starship Children's Hospital, Auckland, New Zealand
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Uzun O, Kennedy J, Davies C, Goodwin A, Thomas N, Rich D, Thomas A, Tucker D, Beattie B, Lewis MJ. Training: improving antenatal detection and outcomes of congenital heart disease. BMJ Open Qual 2018; 7:e000276. [PMID: 30555930 PMCID: PMC6267317 DOI: 10.1136/bmjoq-2017-000276] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 09/07/2018] [Accepted: 09/16/2018] [Indexed: 11/03/2022] Open
Abstract
Objectives This study describes the design, delivery and efficacy of a regional fetal cardiac ultrasound training programme. This programme aimed to improve the antenatal detection of congenital heart disease (CHD) and its effect on fetal and postnatal outcomes. Design setting and participants This was a prospective study that compared antenatal CHD detection rates by professionals from 13 hospitals in Wales before and after engaging in our 'skills development programme'. Existing fetal cardiac practice and perinatal outcomes were continuously audited and progressive targets were set. The work was undertaken by the Welsh Fetal Cardiovascular Network, Antenatal Screening Wales (ASW), a superintendent sonographer and a fetal cardiologist. Interventions A core professional network was established, engaging all stakeholders (including patients, health boards, specialist commissioners, ASW, ultrasonographers, radiologists, obstetricians, midwives and paediatricians). A cardiac educational lead (midwife, superintendent sonographer, radiologist, obstetrician, or a fetal medicine specialist) was established in each hospital. A new cardiac anomaly screening protocol ('outflow tract view') was created and training on the new protocol was systematically delivered at each centre. Data were prospectively collected and outcomes were continuously audited: locally by the lead fetal cardiologist; regionally by the Congenital Anomaly Register and Information Service in Wales; and nationally by the National Institute for Cardiac Outcomes and Research (NICOR) in the UK. Main outcome measures Patient satisfaction; improvements in individual sonographer skills, confidence and competency; true positive referral rate; local hospital detection rate; national detection rate of CHD; clinical outcomes of selected cardiac abnormalities; reduction of geographical health inequality; cost efficacy. Results High levels of patient satisfaction were demonstrated and the professional skill mix in each centre was improved. The confidence and competency of sonographers was enhanced. Each centre demonstrated a reduction in the false-positive referral rate and a significant increase in cardiac anomaly detection rate. According to the latest NICOR data, since implementing the new training programme Wales has sustained its status as UK lead for CHD detection. Health outcomes of children with CHD have improved, especially in cases of transposition of the great arteries (for which no perinatal mortality has been reported since 2008). Standardised care led to reduction of geographical health inequalities with substantial cost saving to the National Health Service due to reduced false-positive referral rates. Our successful model has been adopted by other fetal anomaly screening programmes in the UK. Conclusions Antenatal cardiac ultrasound mass training programmes can be delivered effectively with minimal impact on finite healthcare resources. Sustainably high CHD detection rates can only be achieved by empowering the regional screening workforce through continuous investment in lifelong learning activities. These should be underpinned by high quality service standards, effective care pathways, and robust clinical governance and audit practices.
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Affiliation(s)
- Orhan Uzun
- Department of Paediatric Cardiology, University Hospital of Wales, Cardiff, UK.,School of Sport and Exercise Sciences and College of Engineering, Swansea University, Medical Physics and Biomedical Engineering, Swansea, UK
| | - Julia Kennedy
- School of Health Sciences, Cardiff University, Cardiff, UK
| | - Colin Davies
- Department of Radiology, Royal Glamorgan Hospital, Llantrisant, UK
| | - Anthony Goodwin
- Department of Paediatrics, Princess of Wales Hospital, Bridgend, UK
| | - Nerys Thomas
- Department of Radiology, University Hospital of Wales, Cardiff, UK
| | - Delyth Rich
- Department of Obstetric of Gynaecology, Nevill Hall Hospital, Abergavenny, UK
| | - Andrea Thomas
- Public Health Wales, Antenatal Screening Wales, Cardiff, UK
| | - David Tucker
- Public Health Wales, Congenital Anomaly Register Information Service, Swansea, UK
| | - Bryan Beattie
- Department of Paediatric Cardiology, University Hospital of Wales, Cardiff, UK
| | - Michael J Lewis
- School of Sport and Exercise Sciences and College of Engineering, Swansea University, Medical Physics and Biomedical Engineering, Swansea, UK
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Singh Y, Mikrou P. Use of prostaglandins in duct-dependent congenital heart conditions. Arch Dis Child Educ Pract Ed 2018; 103:137-140. [PMID: 29162633 DOI: 10.1136/archdischild-2017-313654] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 10/03/2017] [Accepted: 10/09/2017] [Indexed: 11/03/2022]
Abstract
Congenital heart disease (CHD) remains a leading cause of infant mortality, which is even higher in infants with undiagnosed duct-dependent CHDs. Up to 39%-50% of infants with critical CHD are being discharged undiagnosed from the hospital. Infants with duct-dependent critical CHD remain well during the fetal period and may deteriorate when the ductus arteriosus (commonly called 'duct') closes after birth. It is critical to open or maintain ductus arteriosus patent in infants with duct-dependent CHDs. Prostaglandin E1 (alprostadil marketed as 'Prostin VR ') and prostaglandin E2 (dinoprostone) are used to maintain a patent ductus arteriosus and the dose of medication depends on the clinical presentation. Delay in starting prostaglandin infusion can have deleterious effects on infants and can even lead to death. These infants often present as an emergency, and professionals caring for these infants need to have a good understanding of these conditions and medications used for ductal patency.
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Affiliation(s)
- Yogen Singh
- Department of Neonatology and Paediatric Cardiology, Cambridge University Hospitals NHS Foundation Trust and University of Cambridge, Cambridge, UK
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Serinelli S, Arunkumar P, White S. Undiagnosed Congenital Heart Defects as a Cause of Sudden, Unexpected Death in Children. J Forensic Sci 2018; 63:1750-1755. [PMID: 29601638 DOI: 10.1111/1556-4029.13779] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 01/30/2018] [Accepted: 02/28/2018] [Indexed: 12/01/2022]
Abstract
Despite advances in the diagnosis and treatment of congenital heart defects (CHDs), these defects are still an important cause of sudden, unexpected death in young children. This retrospective study identified 64 cases of CHDs presenting as a cause of sudden, unexpected death in a busy, urban Medical Examiner's Office pediatric population between 2006 and 2016. The majority of cases (52 of 64, 81%) were infants. Interestingly, 52% of cases were undiagnosed prior to autopsy. Ventricular septal defects and atrioventricular septal defects were the most common simple (14%) and complex (17%) malformations observed, respectively. In many cases, there were coexistent simple and/or complex defects. Most of the cases diagnosed with CHD prior to autopsy (48%) had undergone some type of surgical repair. This study highlights the importance of considering undiagnosed CHDs as a cause of sudden, unexpected death, particularly in young children.
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Affiliation(s)
- Serenella Serinelli
- Medical Examiner's Office, Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza-University of Rome, Rome, 00185, Italy
| | | | - Steven White
- Cook County Medical Examiners' Office, Chicago, IL, 60612
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Abstract
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.
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Affiliation(s)
- Maria N Plana
- Clinical Biostatistics Unit, Ramón y Cajal Hospital (IRYCIS), CIBER Epidemiology and Public Health (CIBERESP)Carretera de Colmenar Km 9.100MadridSpain28034
| | - Javier Zamora
- Clinical Biostatistics Unit, Ramon y Cajal Institute for Health Research (IRYCIS), CIBER Epidemiology and Public Health (CIBERESP), Madrid (Spain) and Women’s Health Research Unit, Centre for Primary Care and Public Health, Queen Mary University of LondonLondonUK
| | - Gautham Suresh
- Baylor College of MedicineSection of Neonatology, Department of PediatricsHoustonTexasUSA
| | | | - Shakila Thangaratinam
- Women's Health Research Unit, Barts and The London School of Medicine and Dentistry, Queen Mary University of LondonCentre for Primary Care and Public Health58 Turner StreetLondonUKE1 2AB
| | - Andrew K Ewer
- University of BirminghamInstitute of Metabolism and Systems ResearchBirmingham Women's HospitalEdgbastonBirminghamUKB15 2TT
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Du C, Liu D, Liu G, Wang H. A Meta-Analysis about the Screening Role of Pulse Oximetry for Congenital Heart Disease. Biomed Res Int 2017; 2017:2123918. [PMID: 29376068 PMCID: PMC5742437 DOI: 10.1155/2017/2123918] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 11/20/2017] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Caiju Du
- Cardiovascular Surgery, Affiliated Hospital of Weifang Medical University, 2428 Yuhe Road, Kuiwen District, Weifang, Shandong Province 261031, China
| | - Dianmei Liu
- Imaging Center, Affiliated Hospital of Weifang Medical University, 2428 Yuhe Road, Kuiwen District, Weifang, Shandong Province 261031, China
| | - Guojing Liu
- Operating Room, Affiliated Hospital of Weifang Medical University, 2428 Yuhe Road, Kuiwen District, Weifang, Shandong Province 261031, China
| | - Huaixin Wang
- Emergency Department, Yidu Central Affiliated Hospital of Weifang Medical University, 4138 Linglong South Road, Qingzhou, Shandong Province 262550, China
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Schena F, Picciolli I, Agosti M, Zuppa AA, Zuccotti G, Parola L, Pomero G, Stival G, Markart M, Graziani S, Gagliardi L, Bellan C, La Placa S, Limoli G, Calzetti G, Guala A, Bonello E, Mosca F; Neonatal Cardiology Study Group of the Italian Society of Neonatology. Perfusion Index and Pulse Oximetry Screening for Congenital Heart Defects. J Pediatr 2017; 183:74-79.e1. [PMID: 28153478 DOI: 10.1016/j.jpeds.2016.12.076] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 11/09/2016] [Accepted: 12/30/2016] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate the efficacy of combined pulse oximetry (POX) and perfusion index (PI) neonatal screening for severe congenital heart defects (sCHD) and assess different impacts of screening in tertiary and nontertiary hospitals. STUDY DESIGN A multicenter, prospective study in 10 tertiary and 6 nontertiary maternity hospitals. A total of 42 169 asymptomatic newborns from among 50 244 neonates were screened; exclusion criteria were antenatal sCHD diagnosis, postnatal clinically suspected sCHD, and neonatal intensive care unit admission. Eligible infants underwent pre- and postductal POX and PI screening after routine discharge examination. Targeted sCHD were anatomically defined. Positivity was defined as postductal oxygen saturation (SpO2) ≤95%, prepostductal SpO2 gradient >3%, or PI <0.90. Confirmed positive cases underwent echocardiography for definitive diagnosis. Missed cases were identified by consulting clinical registries at 6 regional pediatric heart centers. Main outcomes were incidence of unexpected sCHD; proportion of undetected sCHD after discharge in tertiary and nontertiary hospitals; and specificity, sensitivity, positive predictive value, and negative predictive value of combined screening. RESULTS One hundred forty-two sCHD were detected prenatally. Prevalence of unexpected sCHD was 1 in 1115 live births, similar in tertiary and nontertiary hospitals. Screening identified 3 sCHD (low SpO2, 2; coarctation for low PI, 1). Four cases were missed. In tertiary hospitals, 95% of unsuspected sCHDs were identified clinically, whereas only 28% in nontertiary units; in nontertiary units PI-POX screening increased the detection rate to 71%. CONCLUSIONS PI-POX predischarge screening provided benefits in nontertiary units, where clinical recognition rate was low. PI can help identify coarctation cases missed by POX but requires further evaluation in populations with higher rates of missed cases.
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Kardasevic M, Jovanovic I, Samardzic JP. Modern Strategy for Identification of Congenital Heart Defects in the Neonatal Period. Med Arch 2016; 70:384-388. [PMID: 27994302 PMCID: PMC5136435 DOI: 10.5455/medarh.2016.70.384-388] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 09/15/2016] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
| | - Ida Jovanovic
- University Children's Hospital Tirsova, Belgrade, Serbia
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Guthrie S, Bienkowska-Gibbs T, Manville C, Pollitt A, Kirtley A, Wooding S. The impact of the National Institute for Health Research Health Technology Assessment programme, 2003-13: a multimethod evaluation. Health Technol Assess 2016; 19:1-291. [PMID: 26307643 DOI: 10.3310/hta19670] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme supports research tailored to the needs of NHS decision-makers, patients and clinicians. This study reviewed the impact of the programme, from 2003 to 2013, on health, clinical practice, health policy, the economy and academia. It also considered how HTA could maintain and increase its impact. METHODS Interviews (n = 20): senior stakeholders from academia, policy-making organisations and the HTA programme. Bibliometric analysis: citation analysis of publications arising from HTA programme-funded research. Researchfish survey: electronic survey of all HTA grant holders. Payback case studies (n = 12): in-depth case studies of HTA programme-funded research. RESULTS We make the following observations about the impact, and routes to impact, of the HTA programme: it has had an impact on patients, primarily through changes in guidelines, but also directly (e.g. changing clinical practice); it has had an impact on UK health policy, through providing high-quality scientific evidence - its close relationships with the National Institute for Health and Care Excellence (NICE) and the National Screening Committee (NSC) contributed to the observed impact on health policy, although in some instances other organisations may better facilitate impact; HTA research is used outside the UK by other HTA organisations and systematic reviewers - the programme has an impact on HTA practice internationally as a leader in HTA research methods and the funding of HTA research; the work of the programme is of high academic quality - the Health Technology Assessment journal ensures that the vast majority of HTA programme-funded research is published in full, while the HTA programme still encourages publication in other peer-reviewed journals; academics agree that the programme has played an important role in building and retaining HTA research capacity in the UK; the HTA programme has played a role in increasing the focus on effectiveness and cost-effectiveness in medicine - it has also contributed to increasingly positive attitudes towards HTA research both within the research community and the NHS; and the HTA focuses resources on research that is of value to patients and the UK NHS, which would not otherwise be funded (e.g. where there is no commercial incentive to undertake research). The programme should consider the following to maintain and increase its impact: providing targeted support for dissemination, focusing resources when important results are unlikely to be implemented by other stakeholders, particularly when findings challenge vested interests; maintaining close relationships with NICE and the NSC, but also considering other potential users of HTA research; maintaining flexibility and good relationships with researchers, giving particular consideration to the Technology Assessment Report (TAR) programme and the potential for learning between TAR centres; maintaining the academic quality of the work and the focus on NHS need; considering funding research on the short-term costs of the implementation of new health technologies; improving the monitoring and evaluation of whether or not patient and public involvement influences research; improve the transparency of the priority-setting process; and continuing to monitor the impact and value of the programme to inform its future scientific and administrative development.
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Plana MN, Zamora J, Suresh G, Fernandez-Pineda L, Thangaratinam S, Ewer AK. Diagnostic accuracy of pulse oximetry screening for critical congenital heart defects. Hippokratia 2015. [DOI: 10.1002/14651858.cd011912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Maria N Plana
- Clinical Biostatistics Unit. Ramón y Cajal Hospital (IRYCIS). Francisco de Vitoria University (UFV Madrid). CIBER Epidemiology and Public Health (CIBERESP); Cochrane Collaborating Centre; Carretera de Colmenar Km 9.100 Madrid Spain 28034
| | - Javier Zamora
- Ramon y Cajal Institute for Health Research (IRYCIS), CIBER Epidemiology and Public Health (CIBERESP), Madrid (Spain) and Queen Mary University of London; Clinical Biostatistics Unit; Ctra. Colmenar km 9,100 Madrid Madrid Spain 28034
| | - Gautham Suresh
- Dartmouth-Hitchcock Medical Center; Department of Pediatrics, Neonatal Division; One Medical Center Drive Lebanon NH USA 03576-001
| | | | - Shakila Thangaratinam
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London; Centre for Primary Care and Public Health; 58 Turner Street London UK E1 2AB
| | - Andrew K Ewer
- University of Birmingham; School of Clinical and Experimental Medicine; Birmingham Women's Hospital Edgbaston Birmingham UK B15 2TT
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Abstract
This article presents an approach for identification of infants with congenital heart disorders. These disorders are difficult to diagnose because of the complexity and variety of cardiac malformations; additionally presentation can be complicated by age-dependent physiology. By compiling data from the history and the physical examination, the emergency physician can identify lesion category and initiate stabilization procedures. Critical congenital cardiac lesions can be classified as left-sided obstructive ductal dependent, right-sided obstructive ductal dependent, and shunting or mixing. The simplified approach categorizes infants with these lesions respectively as "pink," "blue," or "gray." The emergency provider can provide life-saving stabilization until specialized care can be obtained.
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Kardasevic M, Kardasevic A. The importance of heart murmur in the neonatal period and justification of echocardiographic review. Med Arch 2015; 68:282-4. [PMID: 25568554 PMCID: PMC4240565 DOI: 10.5455/medarh.2014.68.282-284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Accepted: 06/06/2014] [Indexed: 12/21/2022] Open
Abstract
Introduction: Heart murmurs can be functional (innocent) and pathological (organic). Although it is not considered a major sign of heart disease, it may be a sign of a serious heart defect. In most cases the noise is initiation for cardiac treatment. Is it possible to differentiate on the basis of auscultation innocent from pathological heart murmur? In this article we present the results of ultrasonography of newborns with positive auscultation finding of the heart in the neonatal and early infancy period. Goal: To determine the role of murmurs in the heart detected by routine clinical examination in the neonatal period and early infancy, and to establish the legitimacy of cardiology consultation and ultrasound of the heart. Methods: A retrospective review of medical records in the period from January 1 to December 31, 2011 at the Maternity ward of Cantonal Hospital in Bihac 1899 children was born. In 32 neonates was registered a heart murmur, in the period from birth up to 6 weeks of life. All children with positive auscultation finding of the heart were examined echocardiography by ultrasound ALOCA 2000, multifrequency probe from 3.5 to 5 MHz, and used M-mode, 2-D, continuous, pulsed and color Doppler. Results: Of the 32 examined children regular echocardiographic findings had two children (6.25%), aberrant bunch of left ventricle 11 (34.37%), patent foramen ovale 5 (15.62%), atrial septal defect 3 children (9.37%), ventricular septal defect 8 children (25%), cyanogen anomaly 2 children (6.25%), stenosis of the pulmonary artery 1 child (3.12%). We see that 14 children (43.75%) had a structural abnormality of the heart that requires further treatment and monitoring. Conclusion: Echocardiography is necessary to set up or refute the diagnosis of structural heart defect in children with positive auscultation finding in the neonatal period.
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Studer MA, Smith AE, Lustik MB, Carr MR. Newborn pulse oximetry screening to detect critical congenital heart disease. J Pediatr 2014; 164:505-9.e1-2. [PMID: 24315501 DOI: 10.1016/j.jpeds.2013.10.065] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 09/26/2013] [Accepted: 10/23/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe current practice and clarify provider opinion in the US with regard to newborn pulse oximetry screening (NPOx) for critical congenital heart disease. STUDY DESIGN An internet-based questionnaire was forwarded to general pediatricians, neonatologists, and family medicine physicians. Physicians were surveyed regarding involvement in newborn medicine, knowledge of NPOx recommendations, and opinions regarding screening. NPOx protocol specifics were also queried. RESULTS Survey responses (n = 481) were received with 349 respondents involved in newborn medicine. Forty-nine percent (95% CI 44%-54%) of those involved in newborn medicine practice at a hospital with a NPOx protocol. Sixty-six percent of providers endorsed it as an effective tool, 20% required more education, 11% questioned its sensitivity, and 3% had no opinion. Sixty-five percent of providers were aware of recent state legislation mandating its use and 46% reported awareness of the addition of NPOx to the Recommended Uniform Screening Panel. Eighty-four percent of providers who practice at a hospital without a NPOx protocol were interested in its implementation. NPOx protocols varied and were not uniform with differences in time of test, location of probe, and values considered positive. CONCLUSIONS NPOx has grown in its prevalence and acceptance in clinical practice, yet is far from universal in its application and design despite the recent American Academy of Pediatrics endorsement and its addition to the Recommended Uniform Screening Panel. The majority of physicians involved in newborn medicine deemed it an effective tool.
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Affiliation(s)
- Matthew A Studer
- Department of Pediatrics, Tripler Army Medical Center, Honolulu, HI.
| | - Ashley E Smith
- Department of Pediatrics, Tripler Army Medical Center, Honolulu, HI
| | - Michael B Lustik
- Department of Clinical Investigation, Tripler Army Medical Center, Honolulu, HI
| | - Michael R Carr
- Department of Pediatrics, Pediatric Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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25
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Abstract
Approximately 1-2 per 1000 newborn babies have a cardiac defect that is potentially life-threatening usually because either the systemic or the pulmonary blood flow is dependent on a patent ductus arteriosus. A significant proportion of newborns with such cardiac defects are being discharged from well-baby nurseries without a diagnosis and therefore risk circulatory collapse and death. This risk is greatest for defects with duct-dependent systemic circulation, notably aortic arch obstruction, but is also significant in transposition of the great arteries, for example. The solution to this problem, apart from improving prenatal detection rates, is to introduce effective neonatal screening including routine pulse oximetry.
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Abstract
INTRODUCTION Babies with cardiac anomalies are often asymptomatic at birth, and many remain undetected despite routine newborn examination. We retrospectively assessed the effect of routine pulse oximetry in detection of such anomalies from a hospital birth population of 31 946 babies born between 1 April 1999 and 31 March 2009. METHOD 29 925 babies who were not admitted to the neonatal unit at birth underwent postductal oxygen saturation measurement before discharge. If saturation was below 95% an examination was performed. If this was abnormal or saturation remained low, an echocardiogram was performed. All babies with cardiac anomaly diagnosed before 1-year were identified from the region's fetal abnormality database. RESULTS Critical anomalies affected 27 infants (1 in 1180); 10 identified prenatally, 2 after echocardiogram was performed because of other anomalies, 2 in preterm infants, 2 when symptomatic before screening, 5 by oximetry screening, 1 when symptomatic in hospital after a normal screen and 5 after discharge home. Serious anomalies affected 50 infants (1 in 640); 8 identified antenatally, 7 because of other anomalies, 3 in the neonatal unit, 5 by pulse oximetry screening, 11 by routine newborn examination, and 16 after discharge home. CONCLUSIONS Routine pulse oximetry aided detection of 5/27 of critical and 5/50 of serious anomalies in this sample, but did not prevent five babies with critical and 15 with serious anomalies being discharged undiagnosed. Results from screening over 250 000 babies have now been published, but this total includes only 49 babies with transposition, and even smaller numbers of rarer anomalies.
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Affiliation(s)
- Sarah Prudhoe
- Consultant Neonatologist, Sunderland Royal Hospital, Neonatal Unit, Sunderland Royal Hospital, Sunderland, UK.
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Das S, Chanani NK, Deshpande S, Maher KO. B-type natriuretic peptide in the recognition of critical congenital heart disease in the newborn infant. Pediatr Emerg Care 2012; 28:735-8. [PMID: 22858747 DOI: 10.1097/PEC.0b013e3182624a12] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Infants with congenital heart disease having obstruction to the left ventricular outflow and ductal-dependent systemic circulation can present critically ill with shock. Prompt disease recognition and initiation of prostaglandins are necessary to prevent excess morbidity and mortality. We assessed a large cohort of newborn infants with ductal-dependent systemic circulation to determine if B-type natriuretic peptide (BNP) is consistently elevated at presentation, potentially aiding in diagnosis and treatment. METHODS The clinical records of infants with left-sided obstructive lesions admitted from January 2005 to June 2009 were reviewed. Infants were divided into 2 groups: group 1 was diagnosed with cardiogenic/circulatory shock at presentation, and group 2 consisted of infants with ductal-dependent systemic circulation without evidence of shock. B-type natriuretic peptide levels and other variables between the groups were compared. RESULTS All patients with critical congenital heart disease presenting with shock had elevated BNP levels, ranging from 553 to greater than 5000 pg/mL. Infants in group 1 (shock, n = 36) had significantly higher median BNP levels of 4100 pg/mL at presentation compared with group 2 patients (no shock, n = 86), who had a median BNP of 656 pg/mL (range, 30-3930 pg/mL; P < 0.001). Every 100 U of increase in BNP at presentation increased the likelihood of shock (odds ratio, 100; P < 0.001). CONCLUSIONS B-type natriuretic peptide is markedly elevated in neonates presenting in shock secondary to left-sided obstructive heart disease and is an important diagnostic tool to aid in the rapid identification and treatment of these patients.
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Thangaratinam S, Brown K, Zamora J, Khan KS, Ewer AK. Pulse oximetry screening for critical congenital heart defects in asymptomatic newborn babies: a systematic review and meta-analysis. Lancet 2012; 379:2459-2464. [PMID: 22554860 DOI: 10.1016/s0140-6736(12)60107-x] [Citation(s) in RCA: 217] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
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.
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Affiliation(s)
- Shakila Thangaratinam
- Women's Health Research Unit, Centre for Primary Care and Public Health, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
| | | | - Javier Zamora
- Clinical Biostatistics Unit, Hospital Ramon y Cajal (IRYCIS), Madrid, Spain; CIBER Epidemiologia y Salud Publica (CIBERESP), Madrid, Spain
| | - Khalid S Khan
- Women's Health Research Unit, Centre for Primary Care and Public Health, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Andrew K Ewer
- Birmingham Women's NHS Foundation Trust, Birmingham, UK; School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
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Ewer AK, Middleton LJ, Furmston AT, Bhoyar A, Daniels JP, Thangaratinam S, Deeks JJ, Khan KS. Pulse oximetry screening for congenital heart defects in newborn infants (PulseOx): a test accuracy study. Lancet 2011; 378:785-94. [PMID: 21820732 DOI: 10.1016/s0140-6736(11)60753-8] [Citation(s) in RCA: 194] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Andrew K Ewer
- University of Birmingham, School of Clinical and Experimental Medicine, Birmingham, UK.
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Israel SW, Roofe LR, Saville BR, Walsh WF. Improvement in Antenatal Diagnosis of Critical Congenital Heart Disease Implications for Postnatal Care and Screening. Fetal Diagn Ther 2011; 30:180-3. [DOI: 10.1159/000327148] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Accepted: 03/03/2011] [Indexed: 11/19/2022]
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Abstract
Hypoplastic left heart syndrome is a rare congenital heart defect in which the left side of the heart is underdeveloped. Surgical management of hypoplastic left heart syndrome has changed the prognosis of the condition that was previously regarded as fatal. We discuss surgical strategies based on staged procedures, with the right ventricle supporting both systemic and pulmonary circulation. We also discuss other management options, such as neonatal transplantation and the recent innovation of hybrid techniques. Surgical techniques and the understanding of the pathophysiology of this condition have been at the forefront of neonatal cardiac surgery and intensive care. The management of the syndrome remains a challenge because affected children grow into adolescence and adulthood posing various new problems and demands.
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Affiliation(s)
- David J Barron
- Department of Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK.
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Mahle WT, Newburger JW, Matherne GP, Smith FC, Hoke TR, Koppel R, Gidding SS, Beekman RH, Grosse SD. Role of pulse oximetry in examining newborns for congenital heart disease: a scientific statement from the AHA and AAP. Pediatrics 2009; 124:823-36. [PMID: 19581259 DOI: 10.1542/peds.2009-1397] [Citation(s) in RCA: 218] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Mahle WT, Newburger JW, Matherne GP, Smith FC, Hoke TR, Koppel R, Gidding SS, Beekman RH, Grosse SD. Role of pulse oximetry in examining newborns for congenital heart disease: a scientific statement from the American Heart Association and American Academy of Pediatrics. Circulation 2009; 120:447-58. [PMID: 19581492 DOI: 10.1161/circulationaha.109.192576] [Citation(s) in RCA: 164] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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de-Wahl Granelli A, Wennergren M, Sandberg K, Mellander M, Bejlum C, Inganäs L, Eriksson M, Segerdahl N, Agren A, Ekman-Joelsson BM, Sunnegårdh J, Verdicchio M, Ostman-Smith I. Impact of pulse oximetry screening on the detection of duct dependent congenital heart disease: a Swedish prospective screening study in 39,821 newborns. BMJ 2009; 338:a3037. [PMID: 19131383 PMCID: PMC2627280 DOI: 10.1136/bmj.a3037] [Citation(s) in RCA: 247] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- Anne de-Wahl Granelli
- Department of Paediatric Cardiology, Queen Silvia Children's Hospital, S-416 85 Göteborg, Sweden
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Chang RKR, Rodriguez S, Klitzner TS. Screening newborns for congenital heart disease with pulse oximetry: survey of pediatric cardiologists. Pediatr Cardiol 2009; 30:20-5. [PMID: 18654813 DOI: 10.1007/s00246-008-9270-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Revised: 05/13/2008] [Accepted: 06/30/2008] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Ruey-Kang R Chang
- Division of Cardiology, Department of Pediatrics, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 491, Torrance, CA 90509, USA.
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Mackie AS, Jutras LC, Dancea AB, Rohlicek CV, Platt R, Béland MJ. Can cardiologists distinguish innocent from pathologic murmurs in neonates? J Pediatr 2009; 154:50-54.e1. [PMID: 18692204 DOI: 10.1016/j.jpeds.2008.06.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Revised: 05/22/2008] [Accepted: 06/18/2008] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To determine the sensitivity and specificity of the clinical assessment of murmurs in neonates, as performed by pediatric cardiologists, and to identify clinical features that predict the presence of congenital heart disease (CHD) in this population. STUDY DESIGN Neonates (n = 201) referred for outpatient evaluation of a heart murmur were enrolled consecutively. After a clinical evaluation, the cardiologist documented whether the murmur was "likely innocent" or "likely pathologic." The cardiologist repeated his/her assessment after an electrocardiogram. Echocardiography served as the gold standard. RESULTS The median age was 12 days (range, 2-31 days). CHD was present in 113 of 201 (56%). Clinical assessment alone identified patients with CHD with a sensitivity of 80.5% (95% CI, 73.2-87.8), specificity of 90.9% (95% CI, 84.9-96.9), positive predictive value of 91.9% (95% CI, 86.6-97.3), and negative predictive value of 78.4% (95% CI, 70.4-86.4). The addition of an electrocardiogram did not improve these test characteristics. Features that were predictive of CHD were murmur quality (P < .0001), location (P = .02), and timing (P = .04). No patients requiring catheter or surgical intervention were missed by clinical assessment. CONCLUSIONS The prevalence of CHD in this referral population was high. Clinical assessment detected all complex CHD, although some simple lesions were missed. Murmur quality, location, and timing were predictive of CHD.
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Abstract
Background—
Prenatal diagnosis of aortic coarctation suffers from high false-negative rates at screening and poor specificity.
Methods and Results—
This retrospective study tested the applicability of published aortic arch and ductal Z scores (measured just before the descending aorta in the 3-vessel and tracheal view) and their ratio on 200 consecutive normal controls at a median of 22±0 gestational weeks (range, 15±4 to 38±4 weeks). Second, this study tested the ability of serial Z scores to distinguish fetuses with coarctation within a cohort with ventricular and/or great arterial disproportion detected at screening or fetal echocardiography. Third, it evaluated the diagnostic significance of associated cardiac lesions, coarctation shelf, and isthmal flow disturbance. We studied 44 fetuses with suspected coarctation at 24±0 weeks (range, 17±3 to 37±4 weeks). Receiver-operating characteristic curves were created. Logistic regression tested the association between
z
scores, additional cardiac diagnoses, and coarctation. Good separation was found of isthmal Z scores for cases requiring surgery from controls and false-positive cases, and receiver-operating characteristic curves showed an excellent area under the curve for isthmal Z score (0.963) and isthmal-to-ductal ratio (0.969). Serial isthmal Z scores improved to >−2 in suspected cases with normal outcomes; those requiring surveillance or surgery remained <−2. Minor lesions did not increase the diagnostic specificity of coarctation, but isthmal flow disturbance increased the odds ratio of true coarctation versus arch hypoplasia 16-fold.
Conclusions—
Isthmal Z scores and isthmal-to-ductal ratio are sensitive indicators of fetal coarctation. Serial measurements and abnormal isthmal flow patterns improve diagnostic specificity and may reduce false positives.
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Affiliation(s)
- Hikoro Matsui
- From the Faculty of Medicine, Imperial College at Queen Charlotte’s and Chelsea Hospital (H.M., H.M.G.); Brompton Fetal Cardiology, Royal Brompton Hospital (H.M., M.M., H.J., H.M.G.); and Royal Brompton Hospital NHS Trust (M.R.), London, UK. Dr Mellander is now at the Department of Paediatric Cardiology, The Queen Silvia Children’s Hospital, Gothenburg, Sweden
| | - Mats Mellander
- From the Faculty of Medicine, Imperial College at Queen Charlotte’s and Chelsea Hospital (H.M., H.M.G.); Brompton Fetal Cardiology, Royal Brompton Hospital (H.M., M.M., H.J., H.M.G.); and Royal Brompton Hospital NHS Trust (M.R.), London, UK. Dr Mellander is now at the Department of Paediatric Cardiology, The Queen Silvia Children’s Hospital, Gothenburg, Sweden
| | - Michael Roughton
- From the Faculty of Medicine, Imperial College at Queen Charlotte’s and Chelsea Hospital (H.M., H.M.G.); Brompton Fetal Cardiology, Royal Brompton Hospital (H.M., M.M., H.J., H.M.G.); and Royal Brompton Hospital NHS Trust (M.R.), London, UK. Dr Mellander is now at the Department of Paediatric Cardiology, The Queen Silvia Children’s Hospital, Gothenburg, Sweden
| | - Hana Jicinska
- From the Faculty of Medicine, Imperial College at Queen Charlotte’s and Chelsea Hospital (H.M., H.M.G.); Brompton Fetal Cardiology, Royal Brompton Hospital (H.M., M.M., H.J., H.M.G.); and Royal Brompton Hospital NHS Trust (M.R.), London, UK. Dr Mellander is now at the Department of Paediatric Cardiology, The Queen Silvia Children’s Hospital, Gothenburg, Sweden
| | - Helena M. Gardiner
- From the Faculty of Medicine, Imperial College at Queen Charlotte’s and Chelsea Hospital (H.M., H.M.G.); Brompton Fetal Cardiology, Royal Brompton Hospital (H.M., M.M., H.J., H.M.G.); and Royal Brompton Hospital NHS Trust (M.R.), London, UK. Dr Mellander is now at the Department of Paediatric Cardiology, The Queen Silvia Children’s Hospital, Gothenburg, Sweden
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Reich JD, Connolly B, Bradley G, Littman S, Koeppel W, Lewycky P, Liske M. The reliability of a single pulse oximetry reading as a screening test for congenital heart disease in otherwise asymptomatic newborn infants. Pediatr Cardiol 2008; 29:885-9. [PMID: 18347842 DOI: 10.1007/s00246-008-9214-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- J D Reich
- The Watson Clinic LLP, The Watson Clinic Center for Research, 1600 Lakeland Hills Boulevard, Lakeland, FL 33805, USA.
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Reich JD, Connolly B, Bradley G, Littman S, Koeppel W, Lewycky P, Liske M. Reliability of a single pulse oximetry reading as a screening test for congenital heart disease in otherwise asymptomatic newborn infants: the importance of human factors. Pediatr Cardiol 2008; 29:371-6. [PMID: 17932712 DOI: 10.1007/s00246-007-9105-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2007] [Revised: 07/03/2007] [Accepted: 07/10/2007] [Indexed: 12/20/2022]
Abstract
BACKGROUND The use of routine pulse oximetry to detect neonates with undiagnosed congenital heart disease before nursery discharge has been studied. The reported sensitivities with asymptomatic patients have been less than expected and vary widely, bringing into question the reliability of the test. This study aimed 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 for screening asymptomatic newborn infants. METHODS Between December 26, 2003 and December 31, 2005, three hospitals in west central Florida performed pulse oximetry routinely on all newborns at the time of discharge. Patients who received a diagnosis of 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. The results were characterized as reliable, probe placed but reading not verifiable, or no evidence of probe placement. RESULTS Among the 7,962 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 Phases 1 and 2 (38% vs 60%; p < 0.0001). Optimal reliability (>95%) was obtained by a nurse with a licensed practical nurse degree or higher performing an assessment of at least 360 s. CONCLUSION Routine pulse oximetry was neither reliable nor an important diagnostic tool for our cohort. Important human factors (probe placement time, oximetry training, and nursing degree) have an impact on 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.
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Affiliation(s)
- J D Reich
- The Watson Clinic LLP, The Watson Clinic Center for Research, 1600 Lakeland Hills Boulevard, Lakeland, FL 33805, USA.
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Abstract
BACKGROUND Infants with cardiovascular malformations are usually asymptomatic at birth. Earlier diagnosis is likely to improve outcome. OBJECTIVE To examine trends in the diagnosis of potentially life-threatening cardiovascular malformations. METHODS Ascertainment of all cardiovascular malformations diagnosed in infancy in the resident population of one English health region between 1985 and 2004. Infants with life-threatening cardiovascular malformations were all with hypoplastic left heart, pulmonary atresia with intact ventricular septum, transposition of the great arteries or interruption of the aortic arch; and those dying or undergoing operation within 28 days with coarctation of the aorta, aortic stenosis, pulmonary stenosis, tetralogy of Fallot, pulmonary atresia with ventricular septal defect or total anomalous pulmonary venous connection. RESULTS Cardiovascular malformations were diagnosed in infancy in 4444 of 690,215 live births (6.4 per 1000) and were potentially life threatening in 669 (15%). Overall, 55 (8%) were recognised prenatally, 416 (62%) postnatally before discharge from hospital, 168 (25%) in living infants after discharge and 30 (5%) after death. Antenatal diagnoses increased from 0 to around 20% and no case was first diagnosed after death in the past 6 years. However, the proportion going home without a diagnosis remains around 25%. Malformations most likely to remain undiagnosed at discharge were coarctation of the aorta (54%), interruption of the aortic arch (44%), aortic valve stenosis (40%) and total anomalous pulmonary venous connection (37%). CONCLUSIONS One in three infants with a potentially life-threatening cardiovascular malformation left hospital undiagnosed. Better early diagnosis is likely to be achieved by further improvements in antenatal diagnosis and more widespread use of routine pulse oximetry.
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Affiliation(s)
- C Wren
- Department of Paediatric Cardiology, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK.
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Abstract
AIM Peripheral perfusion index (PPI) has been suggested as a possible method to detect illness causing circulatory embarrassment. We aimed to establish the normal range of this index in healthy newborns, and compare it with newborns with duct-dependent systemic circulation. DESIGN We conducted a case-control study. SETTING Our study population comprised 10,000 prospectively recruited newborns from Västra Götaland, Sweden. PATIENTS A total of 10,000 normal newborns and 9 infants with duct-dependent systemic circulation (left heart obstructive disease [LHOD] group) participated in the study. METHODS We conducted single pre- and postductal measurements of PPI with a new generation pulse oximeter (Masimo Radical SET) before discharge from hospital. RESULTS PPI values between 1 and 120 h of age show an asymmetrical, non-normal distribution with median PPI value of 1.70 and interquartile range of 1.18-2.50. The 5th percentile = 0.70 and 95th percentile = 4.50. All infants in the LHOD group had either pre- or postductal PPI below the interquartile range, and 5 of 9 (56%) were below the 5th percentile cut-off of 0.70 (p < 0.0001, Fisher's exact test). A PPI value <0.70 gave an odds ratio for LHOD of 23.75 (95% CI 6.36-88.74). CONCLUSION PPI values lower than 0.70 may indicate illness and a value <0.50 (1st percentile) indicates definite underperfusion. PPI values might be a useful additional tool for early detection of LHOD.
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Affiliation(s)
- A de-Wahl Granelli
- Department of Paediatrics, The Institute of Clinical Sciences, The Sahlgrenska Academy, Gothenburg University, Sweden
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42
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Benjamin JT, Romp RL, Carlo WA, Schelonka RL. Identification of Serious Congenital Heart Disease in Neonates after Initial Hospital Discharge. CONGENIT HEART DIS 2007; 2:327-31. [DOI: 10.1111/j.1747-0803.2007.00120.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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43
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Abstract
OBJECTIVE Congenital cardiovascular malformations (CCVMs) are relatively common with a prevalence of 5-10 per 1000 live births. Pulse oximetry screening is proposed to identify newborns with critical CCVMs which are missed by routine prenatal ultrasound and by pre-discharge physical examinations. The purpose of this study was to identify the number of infants with a delayed diagnosis of critical CCVMs potentially detectable by pre-discharge pulse oximetry screening. PATIENTS AND METHODS Hospital Discharge records in New Jersey from 199-2004 for infants with critical CCVMs were identified using ICD-9 codes. These records were matched to the Electronic Birth Certificate records to identify newborns who were discharged as normal newborns and were later admitted with a diagnosis of critical CCVMs. Chart review was completed on these cases to confirm a delay in diagnosis. RESULTS Chart reviews confirmed delayed diagnosis of critical CCVM in 47 infants out of 670,245 births. Coarctation of the Aorta was the most common delayed diagnosis. The age at final diagnosis varied from 3 days to 6.5 months. CONCLUSIONS Further examination of pulse oximetry as a routine newborn screening service is warranted. Implementation of pre-discharge pulse oximetry screening for newborns may improve the timely detection of asymptomatic critical CCVMs.
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Affiliation(s)
- Tajwar Aamir
- New Jersey Department of Health and Senior Services, Division of Family Health Services, Trenton, New Jersey 08625, USA.
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44
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Abstract
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.
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Affiliation(s)
- Pekka Valmari
- Department of Paediatrics, PO Box 8041, 96101 Rovaniemi, Finland.
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45
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Ruangritnamchai C, Bunjapamai W, Pongpanich B. Pulse oximetry screening for clinically unrecognized critical congenital heart disease in the newborns. Images Paediatr Cardiol 2007; 9:10-5. [PMID: 22368668 PMCID: PMC3232575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM To determine the incidence of clinically unrecognized critical congenital heart disease (CCHD) in the newborns by using pulse oximetric screening. METHODS Pulse oximetry was performed on clinically normal newborns at 24-48 hours of age. If screening oxygen saturation (SpO(2)) was below 95%, echocardiography was then performed. Data regarding true and false positives as well as negatives were collected and analyzed. RESULTS Pulse-oximetric screening was performed on 1847 clinically normal newborns. Low SpO2 (<95%) was found in three babies two of them had CCHD, including one with transposition of the great vessels, one with complete atrioventricular canal with moderate tricuspid regurgitation (sensitivity: 100%; specificity: 99.8%; positive predictive value: 100%; negative predictive value: 100%; accuracy: 99.8%). CONCLUSIONS In addition to routine physical examination in the newborn infants pulse oximetry may improve the early diagnosis CCHD in the newborn. If oxygen saturation in clinically normal newborns is below 95% at 24-48 hours of age, referral to a cardiology unit is suggested.
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Affiliation(s)
- C Ruangritnamchai
- Department of Pediatrics, Synphaet Hospital 9/99 Ramintra Road 8.5 Kunnayao Bangkok 10230, Thailand,Contact Information: Chatree Ruangritnamchai, Pediatrician (Cardiology), Synphaet Hospital, Bangkok, THAILAND Tel: +66(0)29485380-9 Fax: +66(0)29485813
| | - W Bunjapamai
- Department of Pediatrics, Synphaet Hospital 9/99 Ramintra Road 8.5 Kunnayao Bangkok 10230, Thailand
| | - B Pongpanich
- The Cardiac Children Foundation of Thailand Under the Royal Patronage of H.R.H. Princess Galyani Vadhana Krom Luang Naradhiwas Rajanagarindra, 4th Floor, The Royal golden Jubilee Building, 2 Soi Soonvijai, Petchburi Road, Bangkapi, Huay Kwang, Bangkok 10320, Thailand
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46
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Abstract
AIMS To assess what proportion of all cardiac abnormality can be suspected at birth when all clinical examination before discharge is undertaken by a small stable team of clinicians. METHODS A prospective audit of all the 14 572 births in a maternity unit only staffed by nurse practitioners between 1996 and 2003. RESULTS 1.2% of all babies born in the unit were found to have a structural defect (as confirmed by echocardiography) within a year of birth. The number not suspected before discharge declined over time, and only 6% were first suspected after discharge in the last four years of this eight year study. Four potentially life threatening conditions initially went unsuspected in 1996-8, but none after that. A policy of referring every term baby with a murmur at 1 day of age that was still present at 7-10 days resulted in 4.2% requiring cardiac referral; 54% of these babies still had a murmur when assessed one to two weeks later, and 33% had a structural defect. Parents said in independent, retrospectively conducted, interviews that they found it confidence building to have any possible heart defect identified early and the cause of any murmur clearly and authoritatively explained. CONCLUSIONS Effective screening requires experience and a clear, structured, referral pathway, but can work much better than most previous reports suggest. Whether staff bring a medical or nursing background to the task may well be of less importance.
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Affiliation(s)
- C Patton
- Maternity Unit, Wansbeck General Hospital, Ashington, Northumberland NE63 9JJ, UK.
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Arlettaz R, Bauschatz AS, Mönkhoff M, Essers B, Bauersfeld U. The contribution of pulse oximetry to the early detection of congenital heart disease in newborns. Eur J Pediatr 2006; 165:94-8. [PMID: 16211399 DOI: 10.1007/s00431-005-0006-y] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2005] [Accepted: 08/18/2005] [Indexed: 10/25/2022]
Abstract
UNLABELLED Approximately half of all newborns with congenital heart disease are asymptomatic in the first few days of life. Early detection of ductal-dependant cardiac malformations prior to ductal closure is, however, of significant clinical importance, as the treatment outcome is related to the time of diagnosis. Pulse oximetry has been proposed for early detection of congenital heart disease. The aims of the present study were: 1) to determine the effectiveness of a pulse-oximetric screening performed on the first day of life for the detection of congenital heart disease in otherwise healthy newborns and 2) to determine if a pulse-oximetric screening combined with clinical examination is superior in the diagnosis of congenital heart disease to clinical examination alone. This is a prospective, multi-centre study. Postductal pulse oximetry was performed between six and twelve hours of age in all newborns of greater than 35 weeks gestation. If pulse-oximetry-measured arterial oxygen saturation was less than 95%, echocardiography was performed. Pulse oximetry was performed in 3,262 newborns. Twenty-four infants (0.7%) had repeated saturations of less than 95%. Of these infants, 17 had congenital heart disease and five of the remaining seven had persistent pulmonary hypertension. No infant with a ductal-dependant or cyanotic congenital heart disease exhibited saturation values greater or equal to 95%. CONCLUSION postductal pulse-oximetric screening in the first few days of life is an effective means for detecting cyanotic congenital heart disease in otherwise healthy newborns.
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Affiliation(s)
- Romaine Arlettaz
- Clinic of Neonatology, University Hospital, Frauenklinikstrasse 10, CH-8091, Zurich, Switzerland.
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48
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Abstract
Prenatal treatment options for fetal heart disease are still limited but pharmacological treatment of fetal tachyarrhythmias is usually effective. Prenatal catheter interventions are likely to be an option in selected fetal cardiac defects in the future. Delivery should be at a tertiary care centre if the need for immediate neonatal transport is anticipated. When a cardiac problem is diagnosed in a fetus, the parents should be counselled by a paediatric cardiologist specialized in fetal cardiology in close co-operation with the obstetric team. The rate of termination is influenced by gestational age at diagnosis, the severity of the heart defect and the presence of associated malformations. In fetuses with isolated cardiac malformations who are in sinus rhythm with good myocardial function and no or trivial atrioventricular valve regurgitation, the risk of spontaneous intra-uterine death is low. Prenatal echocardiography has the potential to improve postnatal survival in infants with critical heart defects, especially those with duct-dependent systemic or pulmonary circulations.
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Affiliation(s)
- Mats Mellander
- Department of Paediatric Cardiology, The Queen Silvia Children's Hospital, 416 85 Göteborg, Sweden.
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50
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de Wahl Granelli A, Mellander M, Sunnegårdh J, Sandberg K, Ostman-Smith I. Screening for duct-dependant congenital heart disease with pulse oximetry: a critical evaluation of strategies to maximize sensitivity. Acta Paediatr 2005; 94:1590-1596. [PMID: 16381094 DOI: 10.1111/j.1651-2227.2005.tb01834.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To evaluate the feasibility of detecting duct-dependent congenital heart disease before hospital discharge by using pulse oximetry. DESIGN Case-control study. SETTING A supra-regional referral centre for paediatric cardiac surgery in Sweden. PATIENTS 200 normal term newborns with echocardiographically normal hearts (median age 1.0 d) and 66 infants with critical congenital heart disease (CCHD; median age 3 d). METHODS Pulse oximetry was performed in the right hand and one foot using a new-generation pulse oximeter (NGoxi) and a conventional-technology oximeter (CToxi). RESULTS With the NGoxi, normal newborns showed a median postductal saturation of 99% (range 94-100%); intra-observer variability showed a mean difference of 0% (SD 1.3%), and inter-observer variability was 0% (SD 1.5%). The CToxi recorded a significantly greater proportion of postductal values below 95% (41% vs 1%) in the normal newborns compared with NGoxi (p<0.0001). The CCHD group showed a median postductal saturation of 90% (45-99%) with the NGoxi. Analysis of distributions suggested a screening cut-off of <95%; however, this still gave 7/66 false-negative patients, all with aortic arch obstruction. Best sensitivity was obtained by adding one further criterion: saturation of <95% in both hand and foot or a difference of >+/-3% between hand and foot. These combined criteria gave a sensitivity of 98.5%, specificity of 96.0%, positive predictive value of 89.0% and negative predictive value of 99.5%. CONCLUSION Systematic screening for CCHD with high accuracy requires a new-generation oximeter, and comparison of saturation values from the right hand and one foot substantially improves the detection of CCHD.
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Affiliation(s)
- Anne de Wahl Granelli
- Department of Paediatric, Institute of Women's and Children's Health, The Sahlgren Academy, University of Gothenburg, Gothenburg, Sweden
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