Prevalence and clinical significance of cardiac murmurs in neonates

Pulse Oximetry Screening for Critical Congenital Heart Defects in Newborn Babies

Pulse oximetry screening (POS) was first described over 20 years ago. However, in recent years, major clinical trials have demonstrated consistent test accuracy for the detection of critical congenital heart defects (CCHD). International uptake of POS has progressed well over the last 10 years with most major high-income countries now recommending screening. This review describes the evidence base which has led to this, the current debate regarding choice of screening algorithm, and the future areas for further research.

Major congenital heart defects are rarely diagnosed after newborns' hospital discharge with modern screening

AIM

Our aim was to assess undiagnosed congenital heart defects (CHD) after newborns' hospital discharge in patients with a murmur or CHD suspicion, to find out the signs that predict CHDs and to estimate the costs of the examinations.

METHODS

We reviewed retrospective medical records of patients (n = 490) referred for the evaluation of CHD suspicion during 2017-2018.

RESULTS

The median age of the patients was 2.5 (IQR 0.5-7.4) years. Sixty-three (13%) patients had an abnormal echocardiography. Neither ductal-dependent nor cyanotic CHDs were found. Cardiac interventions were performed for 14 out of 63 (22%) patients. Clinical signs indicating CHDs were murmur grade ≥3 (10/11 [91%] vs. 53/479 [11%], p < 0.001) and harsh murmur (15/44 [34%] vs. 48/446 [11%], p < 0.001). Abnormal electrocardiography did not indicate CHD (8/40 [20%] vs. 55/447 [12%], p = 0.165). The total cost of the examinations was 259 700€. The share of the cost of studies assessed as benign was 59%.

CONCLUSION

Only a few CHDs were found after newborn hospital discharge among patients who received foetal and newborn screening and were examined due to CHD suspicion. The high number of benign murmurs in children leads to many referrals, resulting in unnecessary healthcare costs.

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

Objectives

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

Design

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

Setting

Maternity Unit of the KBTH, Accra, Ghana.

Participants

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

Intervention

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

Main Outcome Measure

Abnormal CPE features and their corresponding echocardiogram findings.

Results

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

Conclusion

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

Funding

None declared.

Pulse Oximetry Screening for Detecting Critical Congenital Heart Disease in Neonates

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

Fifteen-minute consultation: Cardiac murmurs in the Newborn Infant Physical Examination (NIPE)

The finding of a cardiac murmur on the initial newborn examination is common but may be a source of anxiety for practitioners due to worries about missing critical congenital heart defects (CHDs). This article aims to provide an approach to this common finding, in particular, reviewing the evidence base behind features of the history, examination and subsequent non-specialist investigations which may increase the likelihood of CHDs. The aim of this structured approach is to give clinicians confidence in dealing with this common clinical finding, to be able to pick out those infants most at risk of having critical CHDs.

A Case of Delayed Presentation of Transposition of the Great Arteries

INTRO

Transposition of the great arteries (TGA) is a rare cyanotic congenital heart defect (CHD) typically presenting the first month of life. Late presentations may occur in patients with associated cardiac anomalies allowing for mixing of oxygenated and deoxygenated blood, such as ventral septal defects or large atrial septal defects (ASD). We present a case of a late-presenting TGA with no ventral septal defect, and only small ASD and patent ductus arteriosus (PDA).

CASE

A 2-month-old female infant presented to a rural emergency department with respiratory distress for 1 day. On arrival, she was cyanotic with only mild improvement in oxygen saturations on 15-L non-rebreather. Grade IV/VI murmur was noted, and prostaglandin E was started. She required intubation after becoming apneic and was transported to the local pediatric referral hospital. There, echocardiography showed dextro-type TGA, with 8-mm ASD with minimal gradient, small PDA with left to right flow, and ventral septal bowing. She underwent balloon septostomy and then atrial switch, which was well tolerated.

DISCUSSION

Our case is unique because of the patient's late presentation and prior lack of symptoms, given minimal levels of blood mixing though small ASD and PDA. Most TGA cases are now identified during prenatal ultrasound or with CHD screening pulse oximetry before discharge from the newborn nursery; however rare cases of late-presenting TGA may exist.

CONCLUSION

Practitioners must maintain consideration of TGA, even after the newborn period, despite advances in newborn CHD screening in infants who present with new-onset respiratory distress without infection.

Diagnostic value of pulse oximetry combined with cardiac auscultation in screening congenital heart disease in neonates

OBJECTIVE

This study aimed to investigate the feasibility and reliability of pulse oximetry combined with cardiac auscultation in screening neonatal congenital heart disease (CHD).

METHODS

This was a retrospective, observational, screening study. All newborns included in the study were at the Second Affiliated Hospital of Wenzhou Medical University from July 2019 to January 2020. Primary screening of CHD was conducted by pulse oximetry combined with cardiac auscultation assays. Indices, including sensitivity, specificity, the positive/negative predictive value, the positive/negative likelihood ratio, and the diagnostic odds ratio, were calculated. The area under the relative operating characteristic curve of the subjects was measured.

RESULTS

A total of 3327 neonates were enrolled, among whom 139 were diagnosed with CHD and the incidence of CHD was 4.2%. The sensitivity, specificity, diagnostic odds ratio, and area under the relative operating characteristic curve of pulse oximetry combined with cardiac auscultation were 89.9%, 94.7%, 169.0, and 0.923, respectively.

CONCLUSIONS

Pulse oximetry combined with cardiac auscultation is a novel screening method with acceptable accuracy and feasibility for neonatal CHD. This combination method is worth promoting widely.

Early detection of significant congenital heart disease: The contribution of fetal cardiac ultrasound and newborn pulse oximetry screening

Fetal cardiac and newborn pulse oximetry screening has greatly facilitated the detection of cardiac abnormalities, which may be serious with potentially dire neonatal consequences. The prenatal diagnosis of a serious cardiac abnormality allows the attending obstetrician to organise the much safer in-utero transfer of the fetus for delivery at a tertiary centre, particularly if there is evidence of a duct-dependent lesion that may require the infusion of Prostaglandin E1 to maintain duct patency pending surgical intervention. Newborn pulse oximetry alerts the paediatrician that the baby may have a significant cardiac abnormality, which warrants further elucidation prior to discharge, rather than for the baby to represent unwell a few days later. Despite these advances, serious cardiac abnormalities may be missed on screening. Their detection then falls back onto the clinical acumen of the attending paediatrician/family physician to review the history, carefully elicit and evaluate the clinical signs further aided by whatever investigations that may be available at the birthing hospital, frequently less resourced than the tertiary centres. At the outset, a brief synopsis is provided of the clinical findings that may point to a cardiac abnormality. That is followed by a critical review of the accuracy of prenatal and newborn pulse oximetry screening with emphasis on the lesions that may be missed. Suggestions are made as to how to improve the diagnostic accuracy.

Pattern of congenital heart disease among Egyptian children: a 3-year retrospective study

BACKGROUND

Congenital heart disease (CHD) is a multifactorial birth defect which has variable demographic characteristics among children in different geographical areas. This study aimed to detect the distribution of demographic data, perinatal risk factors, types, age, and mode of presentation of CHD among Egyptian children.

RESULTS

The medical records of 1005 patients were included. They were 545 males (54%) and 462 females (46%) with a ratio of 1.2:1. Acyanotic CHD was encountered in 79.2%. Isolated ventricular septal defect and tetralogy of Fallot were the most common acyanotic and cyanotic lesions, respectively. The majority was diagnosed within the first year of life (86.7%) and was born to young mothers (91.3%). The accidental discovery of a murmur was the most frequent presentation (35%). Heart failure was detected in 44%, audible murmurs in 74.4%, maternal illnesses in 54%, consanguinity in 44.6%, prematurity in 19.3%, assisted reproduction in 11.7%, family history of CHD in 9.2%, abortions in 7.1%, and extracardiac anomalies in 3.6% of the studied population. Down syndrome (DS) was the most commonly occurring chromosomal anomaly, and the atrioventricular septal defect was the most characteristic cardiac lesion found among them.

CONCLUSIONS

There is no sex predilection among Egyptian children with CHD. Most of the cases are diagnosed in early infancy. Accidental discovery of a murmur is the most common mode of presentation. A variety of predisposing risk factors are abundant in the Egyptian population. DS is the most common chromosomal anomaly linked to CHD. Establishment of a national medical birth registry containing all information about all births in Egypt is needed for adequate surveillance and monitoring of perinatal health problems and congenital birth defects so that preventive measures can be early implemented. Proper and detailed data collection should be fulfilled in the medical records of every single patient.

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

Introduction

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

Aims and Objectives

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

Materials and Methods

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

Observations and Results

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

Conclusions

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

Evaluation and diagnostic approach for heart murmurs in children

Heart murmurs are common in children. Most of them are innocent murmurs with normal heart anatomy and function, and only a few are pathologic murmurs with congenital heart anomaly or abnormal heart function. However, a heart murmur may be the sole symptom of serious heart disease. Therefore, careful evaluation of heart murmurs for distinguishing pathologic murmurs from innocent murmurs is important. Heart murmurs are described by their intensity, timing in the cardiac cycle, location, transmission, and quality. Murmurs, such as a holosystolic or diastolic murmur, of grade 3 or higher intensity, harsh quality, an abnormal S2, a systolic click, or increased intensity when the patient stands are more likely to be pathologic murmurs. Innocent murmurs are more likely to be systolic murmurs, with soft sounds, short duration, low pitch, and varying intensity with phases of respiration and posture (disappears with standing). Not only auscultation but also physical examination findings are important to evaluate heart murmurs. The gold standard test for the evaluation of any potentially pathologic murmur is echocardiography. For the appropriate use of echocardiography, close physical examination, including auscultation, is essential and requires considerable practice.

Diagnostic values of the femoral pulse palpation test

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.

Congenital heart disease diagnosed with echocardiogram in newborns with asymptomatic cardiac murmurs: a systematic review

BACKGROUND

More than 50% of newborns with congenital heart disease (CHD) are unrecognized at birth; however, the use of echocardiogram (Echo) for diagnosing CHD in newborns with asymptomatic, non-syndromic cardiac murmurs (ANCM), has not been systematically reviewed yet. We aimed to identify the incidence of CHD diagnosed with Echo and systematically review whether Echo should be recommended in this patient group.

METHODS

The methodology utilized in this systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Using the MEDLINE, EMBASE, Web of Science, and Cochrane Library databases, we performed a systematic review of publications reporting CHD diagnosed with Echo in newborns with cardiac murmurs. The quality of the included studies was evaluated using the Study Quality Assessment Tools developed by the National Institutes of Health.

RESULTS

Of the 630 studies screened, six cohort studies, four cross-sectional studies, and two case reports were included in this review. The incidence of cardiac murmurs ranged from 0.6-8.6%. Among the 1928 newborns with ANCM, 719 (37.3%) were diagnosed with Echo as having CHD, and ventricular septal defect was the most common congenital malformation. More than 50% of the newborns showed moderate CHD necessitating outpatient cardiology follow-up, and 2.5% had severe CHD requiring immediate interventions, such as cardiac catheterization and heart surgery.

CONCLUSIONS

In this systematic review, a high incidence of CHD in newborns with ANCM was detected using Echo. This indicates that the use of Echo for diagnosing CHD in healthy newborns with cardiac murmurs could be helpful in earlier detection of CHD, thereby improving clinical outcomes for newborns with severe CHD.

Iron-deficiency anaemia in children with congenital heart diseases at a teaching hospital in Ghana

Background

Uncorrected congenital heart lesions in children keep them in a state of constant hypoxia with compromised quality of life and reduced life expectancy. This requires early diagnosis and interventions including prevention and treatment of the resultant anaemia. Unfortunately, congenital heart disease (CHD) often goes unrecognized and thus untreated.

Objectives

We determined the occurrence of CHD in children below 15 years at the Komfo Anokye Teaching Hospital (KATH), assessed the prevalence of relative iron deficiency anaemia in that cohort and the use of iron supplementation in these patients.

Methods

We conducted a cross-sectional study, using a structured data collection tool, by retrospectively reviewing patient records from December 2015 to January 2010. Data was also obtained prospectively from January 2016 to March 2016.

Results

Eighty cases (44 females and 36 males) of CHD were encountered. Tetralogy of Fallot was the most common (48.8%) CHD. Cases of cyanotic congenital heart disease were reported at autopsy. Of the 80 cases, 48 (72.7%) had signs of relative iron deficiency. Thirty (62.5%) of the 48 patients did not receive iron supplementation. In 14 cases, full blood count was not determined and yet 10 patients received iron at sub-optimal doses (<3 mg/kg/day) and one was given iron at 6 mg/kg/day.

Conclusion

CHD is a common phenomenon among newborns at KATH. Use of iron supplementation was suboptimal. Compliance with guidelines on the use of iron as well as structures for early detection of CHD for definitive interventions are advocated.

Newborn pulse oximetry screening in the context of a high antenatal detection rate of critical congenital heart disease

AIM

Assess the potential additional benefit from pulse oximetry screening in the early detection of critical congenital heart disease in a country with a well-developed antenatal ultrasound screening programme.

METHODS

Live-born infants, pregnancy terminations and stillbirths from 20 weeks' gestational age, between 2013 and 2015, with critical cardiac defects defined as primary or secondary targets of pulse oximetry screening were identified. Critical defects were those resulting in the death of a fetus or an infant in the first 28 days after birth, or a defect requiring intervention in the first 28 days.

RESULTS

Two hundred and sixty-eight infants and Fetuses were identified. Antenatal detection rates improved from 69% to 77% over the study period. An associated co-morbidity improved antenatal detection rates. Twenty-seven live-born infants were diagnosed after discharge: 15 aortic arch obstruction (AAO); 10 d-loop transposition of the great arteries (d-TGA), and two total anomalous pulmonary venous drainage (TAPVD). Of these, five with AAO, nine with d-TGA and likely both with TAPVD could potentially have been detected with oximetry screening.

CONCLUSION

The antenatal detection of critical cardiac anomalies continues to improve in New Zealand. Despite high antenatal detection rates for most lesions, universal postnatal oximetry screening has the potential to improve early detection.

Echocardiographic Evaluation in Neonates with Heart Murmurs

Auscultation of the heart is one of the most important tools of physical examination in neonates, which is very helpful in the diagnosis or rejection of congenital heart diseases (CHDs). The aim of this study is to investigate the causes of heart murmur in neonates hospitalized in neonatal unit in Imam Reza Hospital, Kermanshah, Iran. This cross-sectional study was conducted within the period of 18 months on neonates hospitalized in neonatal unit whose heart murmur, diagnosed through examination, and echocardiography was conducted to investigate the existence of CHD. In 62.1% of the cases, murmuring was auscultated within the first week after birth. Among 172 neonates with heart murmur, 25 subjects (14.5%) had normal echocardiogram, and others had abnormal echocardiogram in which ventricular septal defect (31.4%) was the most common CHD. Patent ductus arteriosus (23.3%) was the second common CHD found. Other defects were atrial septal defect, persistent foramen ovale, pulmonary stenosis, and tricuspid regurgitation. Among the neonates with CHD, 55 subjects were females and 92 cases were males. There was CHD history in previous siblings in 10 cases. In 73 neonates with CHD, the mother had not taken folic acid in the first trimester of pregnancy. A total of 14.5% of the hospitalized neonates suffered from innocent murmur, and the rest with heart murmur had abnormal echocardiography and suffered from CHD (85.5%). Heart murmur in neonates could be a symptom of CHD, and timely echocardiography is very important in diagnosing the type of disease.

Accuracy of cardiac auscultation in detection of neonatal congenital heart disease by general paediatricians

BACKGROUND

Challenges remain in the judgement of pathological murmurs in newborns at maternity hospitals, and there are still many simple major CHD patients in developing countries who are not diagnosed in a timely fashion. This study aimed to evaluate the accuracy of cardiac auscultation on neonatal CHD by general paediatricians.

METHODS

We conducted a prospective study at three hospitals. All asymptomatic newborns underwent auscultation, pulse oximetry monitoring, and echocardiography. Major CHD was classified and confirmed through follow-up. We evaluated the accuracy of various degrees of murmurs for detecting major CHD to determine the most appropriate standards and time of auscultation.

RESULTS

A total of 6750 newborns were included. The median age of auscultation was 43 hours. Cardiac murmurs were identified in 6.6% of newborns. For all CHD, 44.4% had varying degrees of murmurs. A murmur of grade ≥2 used as a reference standard for major CHD had a sensitivity of 89.58%. The false positive rate of murmurs of grade ≥2 for detecting major CHD was significantly negatively related to auscultation time, with 84.4% of false positives requiring follow-up for non-major CHD cardiac issues. Auscultation after 27 hours of life could reduce the false positive rate of major CHD from 2.7 to 0.9%.

CONCLUSIONS

With appropriate training, maternity hospital's paediatricians can detect major CHD with high detection rates with an acceptable false positive rate.

Should we start a nationwide screening program for critical congenital heart disease in Turkey? A pilot study on four centres with different altitudes

BACKGROUND

To investigate the feasibility of critical congenital heart disease (CCHD) screening test by pulse oximetry in four geographical regions of Turkey with different altitudes, before implementation of a nationwide screening program.

METHODS

It was a prospective multi-centre study performed in four centres, between December, 2015 and May, 2017. Pre- and post-ductal oxygen saturations and perfusion indices (PI) were measured using Masimo Radical-7 at early postnatal days. The results were evaluated according to the algorithm recommended by the American Academy of Pediatrics. Additionally, a PI value &lt;0.7 was accepted to be significant.

RESULTS

In 4888 newborns, the mean screening time was 31.5 ± 12.1 hours. At first attempt, the mean values of pre- and post-ductal measurements were: saturation 97.3 ± 1.8%, PI 2.8 ± 2.0, versus saturation 97.7 ± 1.8%, PI 2.3±1.3, respectively. Pre-ductal saturations and PI and post-ductal saturations were the lowest in Centre 4 with the highest altitude. Overall test positivity rate was 0.85% (n = 42). CCHD was detected in six babies (0.12%). Of them, right hand (91 ± 6.3) and foot saturations (92.1 ± 4.3%) were lower compared to ones with non-CCHD and normal variants (p &lt;0.05, for all comparisons). Sensitivity, specificity, positive and negative predictive values, and likelihood ratio of the test were: 83.3%, 99.9%, 11.9%, 99.9%, and 99.2%, respectively.

CONCLUSION

This study concluded that pulse oximetry screening is an effective screening tool for congenital heart disease in newborns at different altitudes. We support the implementation of a national screening program with consideration of altitude differences for our country.

Cardiac Murmurs in Children: A Challenge For The Primary Care Physician

Congenital heart disease is present in almost 1% of live births and despite current progress in prenatal screening a significant percentage has delayed diagnosis or remain undiagnosed. A cardiac murmur may be the first or unique clinical sign of congenital heart disease in childhood, however, less than 1% of auscultated murmurs are of an organic cause. Distinguishing between an innocent and a pathologic murmur can be challenging and the experience of the examiner is crucial for identifying the distinctive properties of an innocent murmur. Timely diagnosis of underlying cardiovascular pathology is of great significance so that prompt management is provided and morbidity or mortality are restricted. Of similar importance is the avoidance of unnecessary anxiety for the parents and unreasonable referrals to Paediatric Cardiologists. Indications for referral include a medical history suggestive of a cardiac abnormality, such as the presence of relevant symptoms, the identification of abnormal findings on clinical examination, auscultatory findings suggestive of an organic murmur, and very young patient age. ECG and a chest X-ray are not usually part of the diagnostic approach of a child with a cardiac murmur, as they do not increase the success rate of diagnosing heart disease, as compared to a detailed medical history accompanied by a thorough physical examination. In conclusion, the recognition of suspicious distinctive features of cardiac murmurs is crucial and requires skills based on sufficient training and experience.

Can echocardiographic screening in the early days of life detect critical congenital heart disease among apparently healthy newborns?

BACKGROUND

Delayed diagnosis of critical congenital heart disease (CCHD) carries a serious risk of mortality, morbidity, and handicap. As echocardiography is commonly used to diagnose congenital heart disease (CHD), echocardiographic investigations in newborns may be helpful in detecting CCHD earlier and with higher sensitivity than when using other screening methods. The present study aimed to evaluate the effectiveness of echocardiographic screening for CCHD in a tertiary care center.

METHODS

A retrospective chart review was conducted among newborns delivered at Hamamatsu University Hospital between June 2009 and May 2016. The study included consecutive newborns who underwent early echocardiographic screening (within the first 5 days of life) performed by pediatric cardiologists, were born at ≥36 weeks of gestation, had a birthweight ≥2300 g, and were cared for in the well-baby nursery. Newborns admitted to the neonatal intensive care unit, as well as those with prenatal diagnosis of CHD and/or clinical symptoms or signs of CHD were excluded. Four CHD outcome categories were defined: critical, serious, clinically significant, and clinically non-significant.

RESULTS

A total of 4082 live newborns were delivered during the study period. Of 3434 newborns who met the inclusion criteria and had complete echocardiography data, 104 (3.0%) were diagnosed as having CHD. Among these, none was initially diagnosed as having critical or serious CHD. Of the 95 newborns who continued follow-up with a cardiologist, 61 (64%) were determined to have non-significant CHDs that resolved within 6 months of life. Review of excluded newborns revealed nine cases of critical or serious CHD; among these newborns, six were diagnosed prenatally and three had some clinical signs of CHD prior to hospital discharge.

CONCLUSIONS

In our tertiary care center, echocardiography screening within the first 5 days of life did not help improve CCHD detection rate in newborns without prenatal diagnosis or clinical signs of CHD. Echocardiographic screening may be associated with increased rate of false-positives (defects resulting in clinically non-significant CHDs) in newborns without prenatal diagnosis or suspicion of CHD.

Evaluation of Neonates With Suspected Congenital Heart Disease: A New Cost-Effective Algorithm

We assessed the value of existing guidelines for the evaluation of suspected congenital heart disease (CHD) in term neonates and propose a revised algorithm. Retrospective chart review of newborns referred for cardiac evaluation at a tertiary care center was performed. A total of 777 newborns qualified for the study. Among these, 3 critical and 8 major CHD were identified. The sensitivity of the combination of abnormal physical examination and pulse oximetry screening for major and critical CHD was 100%. The cost to detect a case of critical CHD, based on echocardiograms done for all abnormal electrocardiograms, was 3.4 times more than that incurred for performing this test on the basis of abnormal pulse oximetry and physical examination. Adding electrocardiogram to CHD screening increases cost without adding diagnostic yield. Based on our findings, we propose a revised algorithm for a systematic cost-effective approach to cardiac evaluation of term newborns with suspected CHD.

Heart murmurs and echocardiography findings in the normal newborn nursery

OBJECTIVE

To determine the clinical findings and management implications of echocardiograms performed on infants with murmurs in the nursery.

DESIGN

Retrospective cohort study conducted from January 2008 through December 2015. Patients in the study were followed by chart review for up to 5 years. In addition, a survey of nursery providers was conducted in February 2016.

SETTING

A single community hospital associated with a university.

PATIENTS

All 26 573 infants who received care in the normal newborn nursery were eligible for inclusion in the study. Infants with echocardiograms were analyzed. The survey was sent by e-mail to all 135 physicians who work in the nursery.

OUTCOME MEASURES

The primary outcomes include the specific findings on echocardiogram and whether the findings required an acute change in management, outpatient follow up, or were incidental findings. The primary survey question was how physicians would manage an otherwise asymptomatic newborn with a heart murmur.

RESULTS

Four hundred ninety-nine infants had echocardiograms, and over the study period the utilization of echocardiography increased from 1.02% to 2.56% (P < .001) of all infants. Three hundred fifty-four babies had echocardiography performed because of a heart murmur. One hundred sixty-three (46.0%) of these echocardiograms were normal and 160 (45.2%) had findings that did not require additional care. Twenty-three neonates (6.5%) had echocardiographic findings that necessitated outpatient follow-up and 8 neonates (2.3%) required neonatal intensive care due to the findings on their echocardiogram. In total, 14 infants (4%) would go on to require heart surgery or interventional cardiac catheterization. 63/135 (47%) physicians completed the survey, with wide variations in the management of newborns with heart murmurs.

CONCLUSIONS

The use of echocardiography in the normal newborn nursery has increased with time despite improved prenatal detection of heart disease and the use of pulse oximetry screening, and identifies significant heart disease in a small but important number of infants.

Pulse oximetry screening for critical congenital heart diseases at two different hospital settings in Thailand

OBJECTIVE

To evaluate the predictive abilities of pulse oximetry screening (POS) for critical congenital heart disease (CRIT.CHD) at two different hospital settings in Thailand.

STUDY DESIGN

The study was conducted in healthy newborns at Ramathibodi Hospital (RH), a university hospital and Maharat Nakhon Ratchasima Hospital (MH), a regional hospital. Positive POS was defined as oxygen saturation (SpO₂) <95% or difference between pre- and postductal SpO₂ >3%.

RESULTS

Of 11 407 live births, 10 603 (92.9%) newborns were enrolled with a follow-up rate at 1 month of 78.3%. Incidence of CRIT.CHD (per 1000 live births) at RH and MH were 5.7 and 2.7, respectively. POS could detect three newborns who would have had a missed diagnosis. Sensitivity of POS for CRIT.CHD at RH was 82.3% vs 100% at MH. Overall specificity was 99.9% and false-positive rate was 0.009%. Combination of POS and physical examination (PE) enhanced detection ability to 100% at both hospitals.

CONCLUSION

POS combined with PE improved detection of CRIT.CHD. Routine POS is useful in personnel-limited settings.

Clinical profile and pattern of congenital heart disease in infants of diabetic mother and infants of non-diabetic mother at a tertiary care hospital

OBJECTIVES

To assess the clinical manifestations and pattern of congenital heart diseases (CHD) in infants of diabetic mothers (IDMs) and infants of non-diabetic mothers.

METHODS

A prospective cross sectional study was carried out at tertiary care center over a period of thirty months. All neonates were included in this study if CHD were identified by echocardiography within this study period. Chi-square test and Fisher's exact test were used to compare between groups.

RESULT

Out of 62 neonates, IDMs and non-IDMs were equal in number, male and female ratio was 3 : 2, and majority were delivered by cesarean section (85.5%). Mean gestational age was 35 weeks, 62.3% were preterm, and 37.7% were term. Common clinical presentations were cardiac murmur (61%), and respiratory distress (43.5%). Less common presentations were low SaO2 (27.4%), tachycardia (24.2%), and cyanosis (24.2%). Common combination of presentations were murmur and tachypnea (38.7%); cyanosis and low SaO2 (24.19%); and low SaO2 and tachypnea 15(24.19). The common echocardiographic findings were atrial septal defect (ASD; 72.6%), patent ductus arteriosus (PDA; 45.2%), and ventricular septal defect (VSD; 25.8%). ASD (77.4% vs 67.7%) and VSD (35.5% vs 16.1%) were more in IDMs, and PDA (48.4% vs 41.9%) was more in non-IDMs. These differences were not significant between groups.

CONCLUSION

Clinical presentation and echocardiographic findings of CHD were similar in IDMs and non-IDMs.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Auscultation While Standing: A Basic and Reliable Method to Rule Out a Pathologic Heart Murmur in Children

PURPOSE

The distinction between physiologic (innocent) and pathologic (organic) heart murmurs is not always easy in routine practice, leading too often to unnecessary cardiology referrals and expensive investigations. We aimed to test the hypothesis that the complete disappearance of murmur on standing can exclude cardiac disease in children.

METHODS

From January 2014 to January 2015, we prospectively included 194 consecutive children aged 2 to 18 years who were referred for heart murmur evaluation to pediatric cardiologists at 2 French medical centers. Heart murmur characteristics while supine and then while standing were recorded, and an echo-cardiogram was performed.

RESULTS

Overall, 30 (15%) of the 194 children had a pathologic heart murmur as determined by an abnormal echocardiogram. Among the 100 children (51%) who had a murmur that was present while they were supine but completely disappeared when they stood up, only 2 had a pathologic murmur, and just 1 of them needed further evaluation. Complete disappearance of the heart murmur on standing therefore excluded a pathologic murmur with a high positive predictive value of 98% and specificity of 93%, albeit with a lower sensitivity of 60%.

CONCLUSIONS

Disappearance of a heart murmur on standing is a reliable clinical tool for ruling out pathologic heart murmurs in children aged 2 years and older. This basic clinical assessment would avoid many unnecessary referrals to cardiologists.

Changes in the diagnosis of congenital cardiovascular malformations during the 1st year of life: impacts on epidemiological risk factor associations

Many epidemiological studies base their classification of congenital cardiovascular malformations in newborns upon a single, initial diagnosis. This study aimed to evaluate the effect of subsequent diagnostic investigations on the results of epidemiological studies. We used diagnostic codes from the Baltimore-Washington Infant Study from the time of birth and at ~1 year of age. Odds ratios and 95% confidence intervals were used to identify associations between changes in diagnoses and infant characteristics, time period, that is, before and after introduction of color flow Doppler imaging, and diagnostic variables. Of the 3054 patients with data at both time points, 400 (13.1%) had diagnostic changes. For congenital cardiovascular malformations of early cardiogenesis, such as laterality and looping defects, conotruncal malformations, and atrioventricular septal defects, significant associations were observed between diagnostic change and case infants large for gestational age (odds ratio=0.22, p=0.01), diagnosed initially by echocardiography only (odds ratio=2.05, p=0.001), or with non-cardiac malformations (odds ratio=0.60, p=0.03). For all other congenital cardiovascular malformations, significant associations were observed with echocardiography-only diagnosis (odds ratio=1.43, p=0.04) and non-cardiac malformations (odds ratio=0.57, p<0.001). We found no statistically significant differences between risk factor odds ratios calculated using initial diagnoses versus those calculated using 1-year update diagnoses. Changes in congenital cardiovascular malformation diagnoses from birth to year 1 interval were significantly associated with infant characteristics and diagnostic modality but did not materially affect the outcome of risk factor associations.

Obstructed Infradiaphragmatic Total Anomalous Pulmonary Venous Return in a 13-Day-Old Infant Presenting Acutely to the Emergency Department: A Case Report

BACKGROUND

Total anomalous pulmonary venous return (TAPVR) is an uncommon congenital heart defect. Obstructed forms are more severe, and typically present earlier in life, usually in the immediate newborn period, with symptoms of severe cyanosis and respiratory failure.

CASE REPORT

A 13-day-old boy presented to the emergency department (ED) with respiratory extremis. He appeared cyanotic and limp, and was found to have significant hypoxia with oxygen saturation of 40%. He had no improvement of oxygenation with bag-valve-mask ventilation despite a fraction of inspired oxygen near 100%. This gave clear indication that the hypoxia was caused by a shunt and not by hypoventilation, a ventilation/perfusion mismatch, or a barrier to diffusion. Next, the patient was intubated emergently. Broad spectrum antibiotics and fluid resuscitation with normal saline were initiated. A chest radiograph showed evidence of pulmonary edema vs. diffuse interstitial disease. Cardiology was consulted and evaluated the child with an echocardiogram, which revealed TAPVR with infradiaphragmatic obstructed veins. Once stabilized, he was transferred for definitive surgical repair. This is, to our knowledge, the first reported case of TAPVR with infradiaphragmatic obstruction presenting to the ED with hemodynamic and respiratory compromise beyond the first week of life. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Despite improvements in antenatal and newborn screening, congenital heart disease often remains an elusive diagnosis. Some patients with these critical lesions are discharged home before the manifestation of their disease becomes apparent. Once symptomatic, these patients often present to the ED in extremis. We conclude that it is important to recognize this presentation to ensure proper evaluation and early diagnosis. If misdiagnosed, many of the usual therapies for other diseases could be detrimental.

An update work of pulse oximetry screening for detecting critical congenital heart disease in the newborn

BACKGROUND

Congenital Heart Disease (CHD) is the commonest group of congenital malformations and affects 7-8 per 1000 live born newborns. Nevertheless, it is estimated that more than 50% of babies with undiagnosed CHD are not detected by routine neonatal cardiac examination.

AIM

To find the incidence of CHD in newborns and to determine the accuracy of pulse oximetry for detecting clinically unrecognized critical congenital heart disease (CCHD) in the newborns.

METHODS

Pulse oximetry was performed on clinically normal newborns within 4 hours of first day of life. Inclusion criteria: All newborns who were admitted in postnatal ward & Neonatal Intensive care unit (NICU). Exclusion criteria: babies and neonates with a prenatal diagnosis of duct dependent circulation. If oxygen saturation (SpO₂) was below 90%, then echocardiography was performed.

RESULTS

During the study period, 4926 live born neonates were examined. Nine out of 12 neonates with SpO2<90% had CCHD. Four neonates had tetralogy of Fallot (TOF), two had tricuspid atresia, two had transposition of great arteries (TGA) and one had truncus arteriosus. The incidence of CHD was 33.49 per 1000 live births and CCHD was 1.82 per 1000.  A pulse oximetry cut-off value of below 90% for detecting CCHD showed 90% sensitivity, 99.94% specificity, 75% positive predictive value (PPV) and 99.98% negative predictive value (NPV).

CONCLUSION

Pulse oximetry is safe, feasible and noninvasive and also used to screen for CCHD. It is the nice method to detect the CHD along with the physical examination of neonates by medical personal.

Is pre-discharge echocardiography indicated for asymptomatic neonates with a heart murmur? A retrospective analysis

OBJECTIVE

The purpose of this study was to determine whether a murmur detected on routine pre-discharge examination of asymptomatic newborn children in the first 48 hours of life warrants further investigation with echocardiography.

METHODS

We conducted a retrospective review of all echocardiography studies of neonates born at Jordan University Hospital between August, 2007 and June, 2014. Findings on physical examination as well as the indication of the echocardiographic studies were reviewed. We included asymptomatic neonates for whom echocardiographic studies were carried out due to the sole indication of a heart murmur on routine pre-discharge neonatal physical examination.

RESULTS

Of 309 asymptomatic newborns with murmurs on pre-discharge examination, echocardiography revealed 68 (22%) cases of CHD, with 18 (6%) designated as significant heart disease with anticipated intervention during infancy or childhood. The most common abnormality was ventricular septal defect occurring in 36 cases. Critical heart diseases detected included hypoplastic left heart syndrome in two and aortic valve stenosis in four newborns.

CONCLUSIONS

Although most asymptomatic neonates with heart murmurs have normal hearts, a small percentage may have significant heart disease. The decision to refer an asymptomatic newborn with a murmur for echocardiography before discharge from the hospital remains controversial and must be supported by other evidence such as murmur characteristics and local trends in parental compliance with follow-up well-baby visits.

The impact of the National Institute for Health Research Health Technology Assessment programme, 2003-13: a multimethod evaluation

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.

Diagnostic accuracy of heart murmur in newborns with suspected congenital heart disease

BACKGROUND

The correlation between heart murmur and congenital heart disease (CHD) is complex and varies with observed population.

METHODS

Ninety consecutive newborns (41 with heart murmur and 49 controls) were routinely examined with auscultation and echocardiography. Intensity and characteristics of heart murmur, presence and type of CHD were recorded. Echocardiographic findings were considered as benchmark.

RESULTS

Heart murmur was related to the presence of ostium secundum [odds ratio (OR) 4.2], patent ductus arteriosus (OR 11.9), tricuspidal regurgitation (OR 9.5), muscle ventricular septal defect (VSD) (OR 12.3), membranous VSD (OR 9.7), and any CHD (OR 26.7) (P < 0.05 in all cases). Diagnostic accuracy of clinical examination with a finding of heart murmur was 83%, lower if considering single CHD (58-69%), negative predictive value 90%, and positive predictive value 76%. Patients with any CHD, tricuspidal regurgitation and muscle VSD were characterized by a more intense heart murmur. In case of concomitant multiple CHD, intensity of heart murmur correlated with the number of congenital heart anomalies.

CONCLUSION

Diagnostic accuracy of heart murmur at clinical examination (83%) declines when single CHDs are considered. Higher negative predictive value and lower positive predictive value suggest an echocardiographic second-level confirmation in the case of heart murmur at clinical examination suspected for CHD, probably unnecessary in the case of negative auscultative findings. Heart murmur intensity correlates with the number of concomitant congenital heart anomalies.

[Heart murmurs in asymptomatic children: When should you refer?]

Heart murmurs are common in children and adolescents. Although most are innocent, an isolated heart murmur in asymptomatic children may be the sole finding indicating serious heart disease. Historical elements of familial heart disease, cardiovascular symptoms and a well-conducted medical examination can identify children with an increased risk of heart disease. The distinction between an innocent heart murmur and a pathologic heart murmur is not always easy for primary care physicians because most of them have little experience with auscultation searching for congenital heart malformation. Echocardiography provides a definitive diagnosis of heart disease but is not required in case of innocent murmur. Inappropriate pediatric cardiologist and echocardiographic referral leads to useless and expensive examinations, resulting in a work overload for pediatric cardiologists. The objective of this review is to provide the keys to differentiate innocent and pathologic murmurs, and to help physicians decide on the optimal diagnostic strategy.

Beyond Critical Congenital Heart Disease: Newborn Screening Using Pulse Oximetry for Neonatal Sepsis and Respiratory Diseases in a Middle-Income Country

BACKGROUND

Studies on pulse oximetry screening for neonatal sepsis and respiratory disease in a middle-income country are lacking. Newborn screening for critical congenital heart disease (CCHD) using pulse oximetry is an effective and life-saving strategy in developed countries. While most studies have reported false-positive results during CCHD screening, they have not elaborated on the detected disease types. We studied the effectiveness and outcomes of pulse oximetry newborn screening for non-cardiac hypoxemic diseases such as neonatal sepsis, respiratory diseases, and CCHD in a middle-income country.

METHODS AND FINDINGS

In a pilot study performed at the University Malaya Medical Centre (UMMC), Malaysia, all apparently healthy term newborns, delivered at UMMC were screened pre-discharge using pulse oximetry. Echocardiography was performed for newborns that had positive screening results on two separate occasions, 1-h apart. Newborns with normal echocardiograms were evaluated and treated for other non-cardiac diseases. Fifteen of 5247 term newborns had positive screening results. The median age at screening was 20 h. Thirteen newborns (0.24%) had significant non-cardiac diseases: sepsis (n = 2) and respiratory diseases (n = 11) that required hospitalization and treatment. The remaining two newborns with normal antenatal ultrasonograms had positive screening test and confirmed to have CCHD. Another 18 newborns with negative screening test were later admitted for treatment of sepsis (n = 16) and penumonia (n = 2). All newborns were treated and alive at the end of the study. The sensitivity and specificity of pulse oximetry screening for non-cardiac diseases were 42% and 99.9% respectively, and 100% and 99.7% for CCHD, respectively.

CONCLUSIONS

Routine pulse oximetry screening test was effective in identifying newborns with CCHD and other hypoxemia illnesses, which may led to potential life-threatening condition. This study showed that the expanded use of pulse oximetry has immediate implications for low- and middle-income countries contemplating strategies to reduce neonatal mortality and morbidity.

ABBREVIATIONS

ASD, atrial septal defect; CCHD, critical congenital heart disease; CRP, C-reactive protein; CXR, chest radiographs; NDI, neurodevelopment impairment; PPHN, persistent pulmonary hypertension of the newborn; PDA, patent ductus arteriosus; PFO, patent foramen ovale; TGA, transposition of great artery; TTN, transient tachypnoea of the newborn; VSD, ventricular septal defect.

Screening for Critical Congenital Heart Disease in Newborns

CCHD affects more than 25% of neonates born with congenital heart disease. Patients with CCHD require timely intervention in the form of surgery or cardiac catheterization to survive. These interventions may improve survival and outcomes for these patients. There is strong evidence that performing newborn pulse oximetry screening after the first 24 hours of life may help to detect more than 1200 neonates in the United States each year with CCHD. Pulse oximetry screening for CCHD has been demonstrated to be reasonable to implement and seems to be cost-effective. There is evidence that asymptomatic patients with CCHD can be diagnosed before clinical presentation or cardiovascular collapse with this screening. Pulse oximeter screening has been endorsed by several national organizations as a valuable newborn screening tool. Implementation of pulse oximetry screening programs in a standardized manner with strong communication among all involved parties will likely improve outcomes as well. As we move forward, we as clinicians should work to have a centralized system of reporting positive CCHD results, prompt patient evaluation, and good follow-up for the families of those neonates with positive screening results. Achieving these objectives will likely help us to achieve the goal of improving outcomes of the most critical neonates with CCHD.

Late Diagnosis of Coarctation Despite Prenatal Ultrasound and Postnatal Pulse Oximetry

OBJECTIVES

To determine what contribution prenatal ultrasound screening and neonatal pulse oximetry screening (POS) make to the timely diagnosis of neonatal coarctation of the aorta (CoA).

METHODS

We identified infants and fetuses diagnosed with isolated CoA in our referral area between 2003 and 2012 who died without surgery, underwent surgical repair before 2 months of age, or were terminated after a prenatal diagnosis. Clinical data were collected from hospital charts.

RESULTS

Only 3 of the 90 cases were diagnosed prenatally. Two of the 3 were born alive and in 1 case the couple opted for termination of pregnancy. Nineteen of the remaining 87 cases were born in units that used POS (hand and foot) and 4 of 19 screened positive. Of the remaining 83 cases, 46 were discharged undiagnosed (7 after nondiagnostic echocardiography), including 9 with a murmur and weak femoral pulses and 8 with a murmur and normal pulses. One was diagnosed postmortem after dying at home, and 22 of the remaining 45 discharged infants were in circulatory failure on readmission. Five of the patients who were not discharged died without surgery and undiagnosed CoA was the most probable cause of death in 2 of these patients.

CONCLUSIONS

The contribution of prenatal ultrasound screening and postnatal POS to the timely diagnosis of CoA was low. Careful physical examination of all newborns therefore continues to play a fundamental role in detecting this life-threatening cardiac defect, and better screening methods need to be developed.

The importance of heart murmur in the neonatal period and justification of echocardiographic review

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.

Outcome of children [corrected] with heart murmurs referred from general practice to a paediatrician with expertise in cardiology

BACKGROUND

Heart murmurs are common in children. The majority are detected incidentally, and congenital heart disease is rare. There are no published United Kingdom guidelines for management of children with murmurs in primary care. Common practice is to refer all children for specialist assessment.

AIM

To review outcomes of children with heart murmurs who were referred by general practitioners to a clinic conducted by a paediatrician with expertise in cardiology. Design and setting A retrospective review of children referred by general practitioners to a paediatrician with expertise in cardiology.

METHODS

Hospital records of all children under 17 years of age who attended the clinic during 2011 were reviewed. We excluded children previously seen by any cardiology service.

RESULTS

There were 313 new primary care referrals, with complete records available for 310 children. Of them, 186 (60%) were referred with a murmur: 154 for an asymptomatic murmur alone, and 32 for a murmur plus additional symptoms or family history of congenital heart disease. All underwent echocardiography. Of the patients, 38 (20%) had congenital heart disease. Younger children were more likely to have congenital heart disease. There was no difference between rates of congenital heart disease in children with or without symptoms or a family history.

CONCLUSION

The finding that a large proportion of children referred by general practitioners with asymptomatic heart murmurs have congenital heart disease supports current referral practice on clinical grounds.

Interventional closure of RPA-to-LA communication in an oligosymptomatic neonate

Direct communication between the right pulmonary artery (RPA) and the left atrium (LA) is a very rare cardiac malformation. Clinical presentation of RPA-to-LA communication depends on the size of the communication, the amount of right-to-left shunt, the patient's age, and pulmonary vascular resistance. Patients with small communications usually present oligosymptomatic and are diagnosed at an older age. A delay of diagnosis bears the risk of severe complications and needs to be prevented by proper work-up of oligosymptomatic neonates. Treatment of RPA-to-LA communications used to be performed by surgical closure, and the interventional approach has only been established as a less invasive alternative in recent years.

CONCLUSION

Although patients with small RPA-to-LA communications usually present oligosymptomatic, early diagnosis and treatment is essential to prevent life-threatening complications.

Prenatal and newborn screening for critical congenital heart disease: findings from a nursery

BACKGROUND

Delayed diagnosis of critical congenital heart disease (CCHD) in neonates increases morbidity and mortality. The use of pulse oximetry screening is recommended to increase detection of these conditions. The contribution of pulse oximetry in a tertiary-care birthing center may be different from at other sites.

METHODS

We analyzed CCHD pulse oximetry screening for newborns ≥ 35 weeks' gestation born at Brigham and Women's Hospital and cared for in the well-infant nursery during 2013. We identified patients with prenatal diagnosis of CCHD. We also identified infants born at other medical centers who were transferred to Boston Children's Hospital for CCHD and determined if the condition was diagnosed prenatally.

RESULTS

Of 6838 infants with complete pulse oximetry data, 6803 (99.5%) passed the first screening. One infant failed all 3 screenings and had the only echocardiogram prompted by screening that showed persistent pulmonary hypertension. There was 1 false-negative screening in an infant diagnosed with interrupted aortic arch. Of 112 infants born at Brigham and Women's Hospital with CCHD, 111 had a prenatal diagnosis, and none was initially diagnosed by pulse oximetry. Of 81 infants transferred to Boston Children's Hospital from other medical centers with CCHD, 35% were diagnosed prenatally.

CONCLUSIONS

In our tertiary-care setting, pulse oximetry did not detect an infant with CCHD because of effective prenatal echocardiography screening. Pulse oximetry will detect more infants in settings with a lower prenatal diagnosis rate. Improving training in complete fetal echocardiography scans should also improve timely diagnosis of CCHD.

Pediatric critical care

Care of the ill and injured child requires knowledge of unique pediatric anatomic and physiologic differences. Subtleties in presentation and pathophysiologic differences impact management. This article discusses pediatric resuscitation, the presentation and management of common childhood illness, pediatric trauma, and common procedures required in the critically ill child.

Pocket echocardiography system for detection of patent ductus arteriosus in neonates

BACKGROUND

Neonates are commonly referred for a cardiology consult and an echocardiogram to rule out patent ductus arteriosus (PDA).

OBJECTIVES

Evaluate the usefulness of current pocket echocardiography system (PES) in PDA detection compared to traditional full-featured echo system (FFES).

HYPOTHESIS

The determination of the presence of a PDA in neonates can be done using PES.

METHODS

Fifty newborns with orders for echo evaluation were included in this study. A 5-minute PES scan was performed first. Then a full echo study was performed on a traditional FFES. Images were evaluated by three pediatric cardiologists blinded to the patients and the FFES results.

RESULTS

The overall accuracy of reviewers rating PES versus FFES to rule in PDA had low false-positive rates 9.5% (95% CI: 1.2-30%), 11.8% (95% CI: 1.5-36%), 11.1% (95% CI: 1.4-35%) and the false-negative rate to rule out PDA was 0% (95% CI: 0-18%), 5.5% (95% CI: 0.14-27%), 0% (95% CI: 0-26%) for each reviewer 1, 2, and 3, respectively. Upon further analysis, PES scan was shown not to be accurate on infants with body weight below 1000 g with encouraging results for infants above 1000 g and those >37 weeks gestational age.

CONCLUSIONS

Our results suggest that the current PES could potentially be used in larger and near-term infants but has less than acceptable performance in low birth weight and premature infants in determining who should undergo a FFES study for persistent PDA diagnosis. Improvements in the technology along with developing limited training protocols for noncardiology personnel should make it possible for PES scan to be used as a screening tool and as an extension of physical examination especially in limited resource settings.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Newborn pulse oximetry screening to detect critical congenital heart disease

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.