Pulse oximetry screening for critical congenital heart disease in the neonatal intensive care unit

Rethinking Pulse Oximetry Screening in the Level-IV Neonatal Intensive Care Unit

OBJECTIVE

This study aimed to evaluate the outcomes of newborn pulse oximetry screening in a level IV, tertiary care neonatal intensive care unit (NICU).

STUDY DESIGN

This is a retrospective cohort study of neonates who received newborn pulse oximetry screening after being admitted to a single-center, level-IV NICU between 2014 and 2021. Neonates with known critical congenital heart disease were excluded from the study.

RESULTS

Of the 4,493 neonates who had pulse oximetry screening, there were three positive screens (fail rate of 0.067%, 0.67 per 1,000 screened). The average age of screening was 818 hours. There were no positive screens of newborns who were admitted during their initial birth hospitalization and were screened while off oxygen. There were no new diagnoses of critical congenital heart disease (true positives) and there were no known false negatives.

CONCLUSION

The results bring into question whether pulse oximetry screening with the current AAP-endorsed algorithm should be re-evaluated for a level-IV NICU at a children's hospital. However, the results may not be generalizable to other NICU's where echocardiography and prenatal echocardiograms are not as readily available.

KEY POINTS

· Pulse oximetry has been shown to be effective in decreasing delayed diagnosis of critical congenital heart disease (CCHD); however, there are limited prior studies on newborn pulse oximetry in the NICU.. · In our study of over 4,000 neonates admitted to a level IV tertiary care NICU, there were no true positives (no new diagnoses of CCHD).. · Special considerations may be needed for pulse oximetry screening in the NICU setting..

Pulse Oximetry Screening and Critical Congenital Heart Disease in the State of Oregon

Late diagnosis of critical congenital heart disease (CCHD) is associated with higher levels of morbidity and mortality in neonates. Nearly all states have passed laws mandating universal pulse oximetry screening (POxS) of newborns to improve early detection rates of CCHD. We performed a retrospective chart review of all transthoracic echocardiograms (TTEs) interpreted by our institution on patients between 0 and 30 days of life in the years 2010 (prior to POxS) and 2015 (after POxS). Between 2010 and 2015, the number of neonatal TTEs interpreted by our institution decreased by 18.2%. In 2015, there were 46 neonates diagnosed with CCHD with a 78% prenatal detection rate. There was only one case of a true-positive POxS. Our study demonstrated that the initiation of POxS coincided with a significant decrease in neonatal TTEs, suggesting universal POxS may impart reassurance to primary providers leading to a decrease in TTE utilization.

Pulse Oximetry Values in Newborns with Critical Congenital Heart Disease upon ICU Admission at Altitude

Pulse oximetry screening for critical congenital heart disease (CCHD) has been recommended by the American Academy of Pediatrics (AAP). The objectives of this study are to describe saturation data, and to evaluate the effectiveness of AAP-recommended pulse oximetry screening guidelines applied retrospectively to a cohort of newborns with known CCHD at moderate altitude (5557 feet, Aurora, Colorado). Data related to seven critical congenital heart disease diagnoses were extracted from electronic health records (pulse oximetry, prostaglandin administration, and oxygen supplementation). Descriptive epidemiologic data were calculated. 158 subjects were included in this analysis; the AAP pulse oximetry screening protocol was applied to 149 subjects. Mean pre-ductal and post-ductal pulse oximetry values of the infants known to have CCHD at 24 h of life were 87.1% ± 7.2 and 87.8% ± 6.3, respectively. Infants treated with prostaglandins and oxygen had lower oximetry readings. The screening algorithm would have identified 80.5% of infants with known CCHDs (120/149 subjects). Additionally, sequential pulse oximetry screening based on the AAP-recommended protocol was able to identify a true positive screen capture rate of 80.5% at moderate altitude.

[Heart murmur in children less than 2 years-old: looking for a safe and effective referral strategy]

INTRODUCTION

Current guidelines in Spain recommend performing transthoracic echocardiography (TTE) in all children under 2 years of age with a heart murmur. In 2014, the American Paediatric Association published the first appropriate use criteria (AUC) for outpatient paediatric transthoracic echocardiography (TTE) to promote its cost-efficient use. The aim of this article is to analyse the AUC and other clinical factors as predictors of congenital heart disease (CHD) in children less than 2 years of age with a heart murmur, and to develop a safe and efficient referral strategy.

PATIENTS AND METHOD

Case-control study conducted with children less than 2 years of age, referred from Paediatric Primary Care to Paediatric Cardiology during a 4-year study. A predictive model for CHD was determined using multivariate analysis.

RESULTS

A total of 688 patients were included, with 129 (19%) cases of CHD. An age less than 3 months (adjusted odds ratio [ORa] 3.8 [1.5-8.4], p=.030) and fulfilling AUC (ORa 16.3 [9.4-28.3], p<.001) were predictors of CHD. Concurrent infection (ORa 0.6 [0.2-0.8], p<.001) and a negative neonatal screening with pulse oximetry (ORa 0.1 [0.05-0.4], p=.001) decreased the risk of CHD. The referral strategy that included these criteria had a 98% sensitivity, 39% specificity, and positive and negative predictive values of 27% and 99%, respectively. It could not diagnose 2% of CHD (all mild), and showed a 32% TTE reduction rate compared to our current strategy.

CONCLUSION

To refer children less than 3 months old, fulfilling AUC, without a concurrent infection, or without negative neonatal pulse oximetry screening, is a safe and efficient strategy for the management of heart murmur in children under 2 years of age.

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

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

Evaluation of critical congenital heart defects screening using pulse oximetry in the neonatal intensive care unit

OBJECTIVE

To evaluate the implementation of early screening for critical congenital heart defects (CCHDs) in the neonatal intensive care unit (NICU) and potential exclusion of sub-populations from universal screening.

STUDY DESIGN

Prospective evaluation of CCHD screening at multiple time intervals was conducted in 21 NICUs across five states (n=4556 infants).

RESULTS

Of the 4120 infants with complete screens, 92% did not have prenatal CHD diagnosis or echocardiography before screening, 72% were not receiving oxygen at 24 to 48 h and 56% were born ⩾2500 g. Thirty-seven infants failed screening (0.9%); none with an unsuspected CCHD. False positive rates were low for infants not receiving oxygen (0.5%) and those screened after weaning (0.6%), yet higher among infants born at <28 weeks (3.8%). Unnecessary echocardiograms were minimal (0.2%).

CONCLUSION

Given the majority of NICU infants were ⩾2500 g, not on oxygen and not preidentified for CCHD, systematic screening at 24 to 48 h may be of benefit for early detection of CCHD with minimal burden.

Evaluation of a Screening Program to Detect Critical Congenital Heart Defects in Newborns

OBJECTIVES

To report the results of and to identify problems with implementing a screening program to detect critical congenital heart defects (CCHDs) in newborns by using differential pulse oximetry (POx).

METHODS

Charts of all live-born infants from 4 Yale-New Haven health system hospitals in Connecticut between January 1 and December 31, 2014, were reviewed.

RESULTS

Of 10 589 newborns, 171 (1.6%) underwent an echocardiogram before screening, 10 320 (97.5%) were screened by POx, and 98 (0.9%) were not screened. Thirteen newborns (0.1%) were diagnosed with a CCHD. No infants with CCHDs were identified through POx screening (POxS) alone. Eleven (85%) were already suspected of having a CCHD lesion on the basis of prenatal ultrasound, 1 (8%) was diagnosed because of clinical concern before undergoing screening, and 1 (8%) had a false-negative screening result, but a CCHD was identified after an echocardiogram was performed because a murmur was heard. Four infants with a positive POx screen showed noncritical cardiac lesions by echocardiogram. The majority of infants were screened within the recommended 24 to 72 hours of age interval and had POx screens that were interpreted and documented correctly. Of 10 316 infants with negative POx screens, 52.1% were still in the Yale-New Haven Hospital health system at 1 year of age and no CCHD lesions were listed in their charts.

CONCLUSIONS

Although a CCHD screening program was effectively implemented, perhaps because most children with a CCHD (85%) were detected antenatally by ultrasound, in our hospital system POxS did not lead to a substantial increase in the early identification of CCHDs.