Clinical and basic laboratory assessment of children for possible congenital heart disease

Cardiac auscultatory skills of academic family physicians: strength of association with an academic pediatric cardiologist

Aim. Heart murmur is common in children, and it is one of the main reasons for referral among children in primary care. The aim of this study is to evaluate agreement and consistency of normal, innocent, and pathologic murmur decision between academic family physicians and academic pediatric cardiologist. Methods. Seven hundred fifteen primary school children were examined by family physicians and paediatric cardiologist. Auscultatory examination was performed. Intensity, frequency, duration, quality, location, and radiation of the murmur were described if present. Agreement of normal, innocent, and pathologic murmur classification decision between family physician and paediatric cardiologist was analyzed by using kappa statistic. Results. Normal, innocent and pathologic murmurs were reported for 419, 228, and 54 children in family physicians' reports, respectively. Paediatric cardiologist agreed on 383 (91.4%) children as normal, 191 (83.7%) children having innocent murmur, and 19 (35.2%) children having pathologic murmur among family physician's reports. There was good consistency between family physicians and paediatric cardiologist (κ value = 0.679, 95% CI 0.630-0.727, P < .001). They agreed on the majority of normal and innocent murmur decisions. However family physicians reported pathologic murmur more frequently. Conclusion. Cardiac auscultatory skills of academic family physicians may be concordant with paediatric cardiologist.

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSIONS

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

The paediatrician and cardiac auscultation

The cardiac auscultation (CA) skills of paediatric residents and office-based paediatricians have recently been shown to be suboptimal. CA is known to have a high degree of specificity and sensitivity, and is inexpensive. New teaching aids and availability of surrogate patient heart sounds and murmurs now allow most physicians to acquire CA skills. These teaching aids should be available in all medical schools and in all postgraduate paediatric training programs. While the relationship between musicality and CA skill has not been proven, the author assumes this relationship to be valid. Specific learning objectives in CA should be established. Recognizing that the current trend is away from clinical examinations, students frequently are unaware that a CA learning deficit exists. Therefore, students' CA skills should be evaluated before medical school graduation and at the Royal College of Physicians and Surgeons specialty examination. Students with amusia (inability to distinguish pitch of sound) should be identified and consideration should be given to directing them away from a clinical specialty in which CA is important. Further study is required in the physiology of learning of CA. Appropriate action by medical school and paediatric postgraduate program directors and the Royal College will effect a higher standard of patient care by increasing CA skills, resulting in a more financially efficient system - something everyone is trying to achieve in these times of increasing medical care costs.

Heart murmurs recorded by a sensor based electronic stethoscope and e-mailed for remote assessment

BACKGROUND

Heart murmurs are common in children, and they are often referred to a specialist for examination. A clinically innocent murmur does not need further investigation. The referral area of the University Hospital is large and sparsely populated. A new service for remote auscultation (telemedicine) of heart murmurs in children was established where heart sounds and short texts were sent as an attachment to e-mails.

AIM

To assess the clinical quality of this method.

METHODS

Heart sounds from 47 patients with no murmur (n = 7), with innocent murmurs (n = 20), or with pathological murmurs (n = 20) were recorded using a sensor based stethoscope and e-mailed to a remote computer. The sounds were repeated, giving 100 cases that were randomly distributed on a compact disc. Four cardiologists assessed and categorised the cases as having "no murmur", "innocent murmur", or "pathological murmur", recorded the assessment time per case, their degree of certainty, and whether they recommended referral.

RESULTS

On average, 2.1 minutes were spent on each case. The mean sensitivity and specificity were 89.7% and 98.2% respectively, and the inter-observer and intra-observer variabilities were low (kappa 0.81 and 0.87), respectively. A total of 93.4% of cases with a pathological murmur and 12.6% of cases with an innocent murmur were recommended for referral.

CONCLUSION

Telemedical referral of patients with heart murmurs for remote assessment by a cardiologist is safe and saves time. Skilled auscultation is adequate to detect patients with innocent murmurs.