Factors associated with late detection of critical congenital heart disease in newborns

Early Screening for Long QT Syndrome and Cardiac Anomalies in Infants: A Comprehensive Study

(1) Background: Sudden Infant Death Syndrome (SIDS) represents sudden and unexplained deaths during the sleep of infants under one year of age, despite thorough investigation. Screening for a prolonged QTc interval, a marker for Long QT Syndrome (LQTS), should be conducted on all newborns to reduce the incidence of SIDS. Neonatal electrocardiograms (ECGs) could identify congenital heart defects (CHDs) early, especially those not detected at birth. Infants with prolonged QTc intervals typically undergo genetic analysis for Long QT Syndrome. (2) Methods: The study involved infants aged 20-40 days, born with no apparent clinical signs of heart disease, with initial ECG screening. Infants with prenatal diagnoses or signs/symptoms of CHDs identified immediately after birth, as well as infants who had previously had an ECG or echocardiogram for other medical reasons, were excluded from the study. We used statistical software (SPSS version 22.0) to analyze the data. (3) Results: Of the 42,200 infants involved, 2245 were enrolled, with 39.9% being males. Following this initial screening, 164 children (37.8% males) with prolonged QTc intervals underwent further evaluation. Out of these 164 children, 27 children were confirmed to have LQTS. However, only 18 children were finally investigated for genetic mutations, and mutations were identified in 11 tests. The most common mutations were LQT1 (54.5%), LQT2 (36.4%), and LQT3 (1 patient). Treatment options included propranolol (39.8%), nadolol (22.2%), inderal (11.1%), metoprolol (11.1%), and no treatment (16.7%). The most common abnormalities were focal right bundle branch block (54.5%), left axis deviation (9.2%), and nonspecific ventricular repolarization abnormalities (7.1%). Multiple anomalies were found in 0.47% of children with focal right bundle branch block. Structural abnormalities were associated with specific features in 267 patients (11.9%), primarily isolated patent foramen ovale (PFO) at 61.4%. (4) Conclusions: This screening approach has demonstrated effectiveness in the early identification of LQTS and other cardiac rhythm anomalies, with additional identification of mutations and/or prolonged QTc intervals in family members. Identifying other ECG abnormalities and congenital heart malformations further enhances the benefits of the screening.

A Mixed-Methods Description of the Home Physical Activity Environments of Racially/Ethnically Diverse and Immigrant/Refugee Children

Disparities in childhood obesity prevalence by race/ethnicity remain high. Physical activity is an important factor to consider, however little is known about how physical activity resources in the home environment and neighborhood differ by race/ethnicity. This study examines the physical activity environments in the homes and neighborhoods of diverse households using both quantitative and qualitative data. Home visits were conducted with 150 families, and accelerometry data was collected for both parents and children (5-7 years old). Qualitative interviews were also conducted with parents, which provided context to quantitative data. Racial/ethnic differences were found for physical activity, sedentary behavior, and family-level resources for physical activity (P < .05). There were also differences by race/ethnicity in neighborhood physical activity promoters and perceived lack of neighborhood safety (P < .05). This study is important in informing providers and future interventions of the varying promoters and barriers to optimal physical activity that exist across race/ethnicity.

Major heart defects: the diagnostic evaluations of first-year-olds

Background

Severe or critical congenital heart defects (CHDs) constitute one third of the heart defect cases detected only after birth. These prenatally unrecognised defects usually manifest as cyanotic or acyanotic lesions and are diagnosed postnatally at various times. The aim of the study was to identify their clinical symptoms and determine individual risk periods for CHD manifestation.

Methods

Data were assessed retrospectively based on a cohort of patients born between 2009 and 2018 in a population of 175,153 live births. Occurrence of the first symptoms of CHD was classified into: early neonatal (0–7 days), late neonatal (8–28 days), early infancy (1–6 months), or late infancy (6–12 months). The first symptom for which the child was referred to a paediatric cardiologist was defined as a symptom of CHD.

Results

There were 598 major CHDs diagnosed in the studied region, 91% of which were isolated anomalies. A concomitant genetic disorder was diagnosed in 6% of the cases, while 3% presented extracardiac pathology with a normal karyotype. In total, 47% (282/598) of all CHDs were not identified prenatally. Of these, 74% (210/282) were diagnosed as early neonates, 16% (44/282) as late neonates, and 10% (28/282) as infants. The most common symptoms leading to the diagnosis of CHD were heart murmur (51%, 145/282) and cyanosis (26%, 73/282). Diagnosis after discharge from the hospital occurred in 12% (72/598) of all major CHDs. Ventricular septal defect and coarctation of the aorta constituted the majority of delayed diagnoses.

Conclusions

In conclusion, murmur and cyanosis are the most common manifestations of prenatally undetected CHDs. Although most children with major CHDs are diagnosed as neonates, some patients are still discharged from the maternity hospital with an unidentified defect.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02997-2.

Comparing risk factors associated with the late detection of critical congenital heart disease at different facility levels

AIMS

Critical congenital heart disease (CCHD) requires surgery or catheter intervention within the first year of life; delayed diagnoses result in worsened outcomes. In Japan, there are few reports of delayed CCHD diagnosis. We investigated the diagnoses and factors associated with the late detection of CCHD.

METHODS

This retrospective cohort study evaluated 88 CCHD infants admitted to a level IV facility. We compared the late detection rates across facility levels of neonatal care and CCHD characteristics.

RESULTS

Critical congenital heart disease was identified prenatally in 46 (52%) infants: early (≤3 days postnatally) in 29 (33%) and late (≥4 days postnatally) in 13 (15%). The oxygen saturation of 27 of 29 infants with early detection and 7 of 13 infants with late detection was measured using pulse oximetry within 3 days postnatally. Factors associated with the late detection of CCHD were lack of clinical recognition of symptoms in five infants, referral to higher-level facilities after discharge in four infants, and definitive diagnosis not confirmed using echocardiography in four infants. The most common factors associated with late detection were referral to higher-level facilities after discharge in level I facilities and definitive diagnosis not confirmed using echocardiography in level II facilities.

CONCLUSION

Critical congenital heart disease may require advanced knowledge and echocardiographic techniques for diagnosis. Pulse oximetry and telemedicine should also be incorporated in the diagnostic algorithm. Improvement in these factors might contribute to reducing the late detection of CCHD.

Birth prevalence and late diagnosis of critical congenital heart disease: A population-based study from a middle-income country

Aims:

There are limited data regarding critical congenital heart disease (CCHD) from middle-income countries (MIC). This study aims to determine the birth prevalence, rate of late diagnosis, and influence of timing of diagnosis on the outcome of CCHD.

Setting and Design:

Retrospective observational cohort study in the State of Johor, Malaysia.

Subjects and Methods:

All infants born between January 2006 and December 2015 with a diagnosis of CCHD, defined as infants with duct-dependent lesions or cyanotic heart disease who may die without early intervention. The late diagnosis was defined as a diagnosis of CCHD after 3 days of age.

Results:

Congenital heart disease was diagnosed in 3557 of 531,904 live-born infants and were critical in 668 (18.7%). Of 668, 347 (52%) had duct-dependent pulmonary circulation. The birth prevalence of CCHD was 1.26 (95% confidence interval: 1.16–1.35) per 1000 live births, with no significant increase over time. The median age of diagnosis was 4 days (Q1 1, Q3 26), with 61 (9.1%) detected prenatally, and 342 (51.2%) detected late. The highest rate of late diagnosis was observed in coarctation of the aorta with a rate of 74%. Trend analysis shows a statistically significant reduction of late diagnosis and a significant increase in prenatal detection. However, Cox regression analysis shows the timing of diagnosis does not affect the outcome of CCHD.

Conclusions:

Due to limited resources in the MIC, the late diagnosis of CCHD is high but does not affect the outcome. Nevertheless, the timing of diagnosis has improved over time.

Presentation and management of congenital heart disease in the first year of age

Congenital heart disease (CHD) is defined as a structural abnormality of the heart or large intrathoracic vessels. They constitute the most frequent congenital malformation at birth. At least one third of patients require some type of intervention before the year of age. The clinical manifestations of heart disease in the neonatal stage are presented with a wide clinical context and can be confused with problems at the pulmonary or infectious level making difficult to diagnose them and thereby contributing significantly to the mortality and morbility of these patients since the diagnosis is delayed and timely handling. Pulse oximetry monitoring in the neonatal period is currently used as a diagnostic method for the detection of critical congenital heart disease. Although it detects them early, in many countries it is not yet carried out. The objective of this article is to offer an overview of the clinical presentation, diagnostic aspect and initial management of CHD in the first year of age that may be useful to first contact physicians to improve the management of this group of patients.

Screening for congenital heart defects: diversified strategies in current China

Background

Congenital heart defects (CHD) is the most common type of birth defect and a leading cause of infant mortality in China. Detection of CHD during newborn is still challenging. The contradiction between the increasingly mature technology of diagnosis and treatment and the inability of early detection is the biggest current dilemma. A few pilot studies attempt to establish the universal screening for CHD in newborns; however, the rate of misdiagnosis is still high in most Chinese hospitals, especially in some undeveloped middle-western regions.

Data sources

Based on the recent publications on screening of congenital heart diseases in China. We reviewed the use of diversified screening strategies in current China.

Results

Prenatal diagnosis by fetal echocardiography and postnatal detection by pulse oximetry combined with clinical assessment are the useful methods for CHD screening in most areas. The altitude should be taken into account when using pulse oximetry in the middle-western areas of China, where the incidence of CHD maybe higher. Echocardiography is suitable for CHD screening in almost all areas but it could add to financial burden in the developing regions. Genetic analysis could assist clinical doctors to perform more earlier screening and give better counseling regarding the outcome. Due to disparities in economic and medical resources, the screening system should be carried out from multiple perspectives according to the present economic development. Notably, follow-up is an important issue in the screening of CHD, especially for the asymptomatic babies who discharged home. Policies should be formulated to address the epidemiology of CHD in deprived areas to better allocate medical resources and to develop local training programmes to screen and diagnose CHD.

Conclusions

Diversified strategies are available in current China. The two-indicator method for CHD screening is recommended to be implemented in routine postnatal care. We can do more in screening for CHD in the future.

Physiologic diagnosis of congenital heart disease in cyanotic neonates

PURPOSE OF REVIEW

We aim to improve diagnosis of congenital heart disease (CHD) with cyanosis by physiology for general practitioners to reduce time to appropriate treatment.

RECENT FINDINGS

New implementation of the critical congenital heart disease (CCHD) pulse oximetry screen has improved rate of diagnosis of CHD in recent years. However, many infants with cyanotic heart lesions often decompensate before screening in the newborn nursery, or have lesions that are not amenable to pulse oximetry screening and that present later in the emergency room. Recent literature has shown preoperative acidosis because of delayed diagnosis of cyanotic CHD worsens outcomes postoperatively. Wide availability of prostaglandin therapy and catheter procedures help to preoperatively stabilize critical cardiac patients. With a firm grasp of the underlying physiology of neonatal cyanotic CHD, practitioners can appropriately implement these therapies more judiciously. This early recognition will subsequently improve overall outcomes.

SUMMARY

Physiologic diagnosis of CHD with cyanosis by general practitioners will allow initiation of appropriate management more quickly and effectively. This may avoid progressive clinical decompensation and acidosis until cardiology consultation and potential intervention are available.

Birth Location of Infants with Critical Congenital Heart Disease in California

The American Academy of Pediatrics classifies neonatal intensive care units (NICUs) from level I to IV based on the acuity of care each unit can provide. Birth in a higher level center is associated with lower morbidity and mortality in high-risk populations. Congenital heart disease accounts for 25-50% of infant mortality related to birth defects in the U.S., but recent data are lacking on where infants with critical congenital heart disease (CCHD) are born. We used a linked dataset from the Office of Statewide Health Planning and Development to access ICD-9 diagnosis codes for all infants born in California from 2008 to 2012. We compared infants with CCHD to the general population, identified where infants with CCHD were born based on NICU level of care, and predicted level IV birth among infants with CCHD using logistic regression techniques. From 2008 to 2012, 6325 infants with CCHD were born in California, with 23.7% of infants with CCHD born at a level IV NICU compared to 8.4% of the general population. Level IV birth for infants with CCHD was associated with lower gestational age, higher maternal age and education, the presence of other congenital anomalies, and the diagnosis of a single ventricle lesion. More infants with CCHD are born in a level IV NICU compared to the general population. Future studies are needed to determine if birth in a lower level of care center impacts outcomes for infants with CCHD.

Novel algorithm to screen for heart murmurs using computer-aided auscultation in neonates: a prospective single center pilot observational study

BACKGROUND

Automated detection of heart murmurs with computer-aided auscultation is not yet in clinical routine use. Aim of this study was to test sensitivity and specificity of a novel prototype algorithm in automated detection of heart murmurs from digitally recorded phonocardiograms in neonates admitted at the Neonatal Intensive Care Unit.

METHODS

In a prospective pilot observational study from November 2012 to December 2013 auscultations by pediatricians and computer aided auscultation were performed within 12 hours of neonatal echocardiography. Echocardiography was defined as pathological when resulting in any clinical consequences or causing murmur. Phonocardiograms and auscultation were defined as pathological if a murmur was detected. Phonocardiograms were analyzed offline with a novel algorithm prototype (CSD Labs, Graz, Austria) for detection of murmurs in neonates in a first run and with an optimized algorithm in a second run and were compared with echocardiography. Sensitivity and specificity of auscultation by pediatrician and computer aided auscultation were analyzed.

RESULTS

Thirty-six neonates (gestational age: 36±3 weeks) were included. Twenty-three (64%) neonates had pathological or murmur causing findings in echocardiography (positive echocardiography). Sensitivity and specificity of auscultation by pediatrician were 17% and 100%, respectively. In comparison to auscultation by pediatrician sensitivity of first run and second run were significantly higher with 70% and 83%, respectively. Specificity of first run and second run were 77% and 85%, respectively.

CONCLUSIONS

Phonocardiogram analysis using the novel algorithm prototype had a higher sensitivity than auscultation by pediatrician in detecting positive echocardiography findings in neonates.

A Modified Algorithm for Critical Congenital Heart Disease Screening Using Pulse Oximetry

: media-1vid110.1542/5727212367001PEDS-VA_2017-4065Video Abstract OBJECTIVES: Determine the performance of the American Academy of Pediatrics (AAP) critical congenital heart disease (CCHD) newborn screening algorithm and the impact of an alternative algorithm.

METHODS

Screening was performed on term infants without a known CCHD diagnosis at or near 24 hours of age at a tertiary birth hospital by using the AAP algorithm from 2013 to 2016. Retrospective review from the birth hospital and the area's sole pediatric cardiac center identified true- and false-positives and true- and false-negatives. A simulation study modeled the results of a modified screening algorithm with a single repeat pulse oximetry test instead of 2.

RESULTS

Screening results were collected on 77 148 newborns . By using the current AAP algorithm, 77 114 (99.96%) infants passed screening, 18 infants failed for an initial saturation of <90%, and 16 failed after not attaining a passing pulse oximetry level after 3 tests. There was 1 true-positive (total anomalous pulmonary venous return), 33 false-positives, and 6 false-negatives, yielding an overall specificity of 99.96%, a sensitivity of 14.3%, and a false-positive rate of 0.043%. Among false-positives, 10 (31.3%) had significant non-CCHD disease. Simulating the modified algorithm, sensitivity remained at 14.3%, and the false-positive rate increased to 0.054%.

CONCLUSIONS

Although CCHD screening in a tertiary care birth hospital may not detect many new cases of CCHD, it can detect other important diseases in newborns. Modifying the screening algorithm to 1 repeat pulse oximetry test instead of 2 may detect additional infants with significant disease without a substantial increase in the false-positive rate.

Early Detection with Pulse Oximetry of Hypoxemic Neonatal Conditions. Development of the IX Clinical Consensus Statement of the Ibero-American Society of Neonatology (SIBEN)

This article reviews the development of the Ninth Clinical Consensus Statement by SIBEN (the Ibero-American of Neonatology) on "Early Detection with Pulse Oximetry (SpO₂) of Hypoxemic Neonatal Conditions". It describes the process of the consensus, and the conclusions and recommendations for screening newborns with pulse oximetry.

Infants born with critical CHD in Arizona and capacities of birth centres for screening and management

OBJECTIVES

The aims of this study were to identify locations of births in Arizona with critical CHD, as well as to assess the current use of pulse-oximetry screening and capacities of birth centres to manage a positive screen. Study design Infants (n=487) with a potentially critical CHD were identified from the Arizona Department of Health Services from 2012 and 2013; charts were retrospectively reviewed. Diagnosis was confirmed using echocardiographies. ArcGIS was used to generate maps to visualise the location of treating facility and mother's residence. Birth centres were surveyed to assess screening practices and capacities to manage critical CHD in 2015.

RESULTS

Of the 272 patients identified with critical CHD, 52% had been diagnosed prenatally. Patients travelled an average distance of 55.1 miles to their treating facility. Mortality was not related to prenatal diagnosis (p=0.30), living at a high elevation (p=0.82), or to distance travelled to the treating facility (p=0.68). Of 50 birth centres, 33 responded to the survey and all centres practiced critical CHD screening. A total of 25 centres could perform paediatric echocardiographies; 64% of these centres could digitally transmit echocardiograms. In all, 24 birth centres maintained access to prostaglandins.

CONCLUSIONS

Pulse-oximetry screening in newborns is currently implemented in the majority of Arizona hospitals. Although most centres could perform initial management steps following a positive screen, access to paediatric cardiology services was limited. Patients with critical CHD sometimes travelled a great distance to treating facilities. Digital transmission of echocardiograms or tele-echocardiography would reduce the distance travelled for the management of a positive screen, decrease the financial burden of transportation, and expedite care for critically ill neonates.

Perfusion Index and Pulse Oximetry Screening for Congenital Heart Defects

OBJECTIVE

To evaluate the efficacy of combined pulse oximetry (POX) and perfusion index (PI) neonatal screening for severe congenital heart defects (sCHD) and assess different impacts of screening in tertiary and nontertiary hospitals.

STUDY DESIGN

A multicenter, prospective study in 10 tertiary and 6 nontertiary maternity hospitals. A total of 42 169 asymptomatic newborns from among 50 244 neonates were screened; exclusion criteria were antenatal sCHD diagnosis, postnatal clinically suspected sCHD, and neonatal intensive care unit admission. Eligible infants underwent pre- and postductal POX and PI screening after routine discharge examination. Targeted sCHD were anatomically defined. Positivity was defined as postductal oxygen saturation (SpO₂) ≤95%, prepostductal SpO₂ gradient >3%, or PI <0.90. Confirmed positive cases underwent echocardiography for definitive diagnosis. Missed cases were identified by consulting clinical registries at 6 regional pediatric heart centers. Main outcomes were incidence of unexpected sCHD; proportion of undetected sCHD after discharge in tertiary and nontertiary hospitals; and specificity, sensitivity, positive predictive value, and negative predictive value of combined screening.

RESULTS

One hundred forty-two sCHD were detected prenatally. Prevalence of unexpected sCHD was 1 in 1115 live births, similar in tertiary and nontertiary hospitals. Screening identified 3 sCHD (low SpO₂, 2; coarctation for low PI, 1). Four cases were missed. In tertiary hospitals, 95% of unsuspected sCHDs were identified clinically, whereas only 28% in nontertiary units; in nontertiary units PI-POX screening increased the detection rate to 71%.

CONCLUSIONS

PI-POX predischarge screening provided benefits in nontertiary units, where clinical recognition rate was low. PI can help identify coarctation cases missed by POX but requires further evaluation in populations with higher rates of missed cases.

Automated detection of coarctation of aorta in neonates from two-dimensional echocardiograms

Coarctation of aorta (CoA) is a critical congenital heart defect (CCHD) that requires accurate and immediate diagnosis and treatment. Current newborn screening methods to detect CoA lack both in sensitivity and specificity, and when suspected in a newborn, it must be confirmed using specialized imaging and expert diagnosis, both of which are usually unavailable at tertiary birthing centers. We explore the feasibility of applying machine learning methods to reliably determine the presence of this difficult-to-diagnose cardiac abnormality from ultrasound image data. We propose a framework that uses deep learning-based machine learning methods for fully automated detection of CoA from two-dimensional ultrasound clinical data acquired in the parasternal long axis view, the apical four chamber view, and the suprasternal notch view. On a validation set consisting of 26 CoA and 64 normal patients our algorithm achieved a total error rate of 12.9% (11.5% false-negative error and 13.6% false-positive error) when combining decisions of classifiers over three standard echocardiographic view planes. This compares favorably with published results that combine clinical assessments with pulse oximetry to detect CoA (71% sensitivity).

Implications of Using Pulse Oximetry to Screen for Critical Congenital Heart Disease in Newborns

In recent years, pulse oximetry screening for critical congenital heart disease (CCHD) in newborns has been added to the list of recommended uniform screening panels and recommended by several health care organizations. Most states use pulse oximetry to screen for CCHD. Studies have identified problems with compliance and higher failure rate at moderate altitudes than at sea level, suggesting the need for alternate algorithms. Altitude, time, health status of newborns and type of cardiac defect appear to affect results. Early detection of CCHD improves health outcomes and reduces morbidity and mortality. Barriers to screening include out-of-hospital births, cost and knowledge deficits among health care professionals.

Photoplethysmographic waveform characteristics of newborns with coarctation of the aorta

OBJECTIVE

Fetal echocardiography, physical examination and pulse oximetry detect only half of coarctation of aorta (CoA) cases. We aimed to quantify delayed arrival and diminished amplitude of lower extremity photoplethysmographic (PPG) pulses relative to the right hand in affected patients.

STUDY DESIGN

We studied 8 CoA infants and 32 healthy controls. The pulse arrival time difference between foot and hand (f-hTD) and pulse amplitude ratio (F/H) were measured on PPG signal waveforms by digitally-determining maxima and minima of systolic decrease of light transmission. Mann-Whitney test was used for group comparisons.

RESULTS

In comparison to healthy newborns, CoA infants' PPG waveforms demonstrated prolonged f-hTD (mean±s.d. of 73.2±26.6 versus 35.2±8.3 ms, P<0.001) and lower F/H (0.57±0.26 versus 0.99±0.58, P=0.014).

CONCLUSIONS

F-hTD and F/H are quantifiable from hand- and foot-derived PPG waveforms and are significantly different in CoA versus healthy newborns. Larger studies are needed to validate PPG for improved critical congenital heart disease screening.

Indigenous Ethnicity and Low Maternal Education Are Associated with Delayed Diagnosis and Mortality in Infants with Congenital Heart Defects in Panama

Background

This is the first study in Panama and Central America that has included indigenous populations in an assessment of the association between socioeconomic variables with delayed diagnosis and mortality due to congenital heart defects (CHD).

Methods

A retrospective observational study was conducted. A sample calculation was performed and 954 infants born from 2010 to 2014 were randomly selected from clinical records of all Panamanian public health institutions with paediatric cardiologists. Critical CHD was defined according to the defects listed as targets of newborn pulse oximetry screening. Diagnoses were considered delayed when made after the third day of life for the critical CHD and after the twentieth day of life for the non-critical. A logistic regression model was performed to examine the association between socioeconomic variables and delayed diagnosis. A Cox proportional hazards model was used to assess the relationship between socioeconomic features and mortality.

Results

An increased risk of delayed diagnosis was observed in infants with indigenous ethnicity (AOR, 1.56; 95% CI, 1.03–2.37), low maternal education (AOR, 1.57; 95% CI, 1.09–2.25) and homebirth (AOR, 4.32; 95% CI, 1.63–11.48). Indigenous infants had a higher risk of dying due to CHD (HR, 1.43; 95% CI, 1.03–1.99), as did those with low maternal education (HR, 1.95; 95% CI, 1.45–2.62).

Conclusion

Inequalities in access to health care, conditioned by unfavourable socioeconomic features, may play a key role in delayed diagnosis and mortality of CHD patients. Further studies are required to study the relationship between indigenous ethnicity and these adverse health outcomes.

Timing of diagnosis affects mortality in critical congenital heart disease

OBJECTIVE

Screening for critical congenital heart disease (CHD) with prenatal ultrasound or postnatal pulse oximetry has the potential to improve outcome. To guide screening recommendations, this study aimed to identify the proportion and outcome of major CHD diagnosed before (early) or after (late) postnatal discharge prior to the introduction of postnatal oximetry screening.

DESIGN

A retrospective, population-based review of all major CHD in New Zealand from 2006 to 2010. The timing of diagnosis relative to discharge and to intervention in critical and non-critical cases with intention to treat was determined, as was the relationship of diagnostic timing to mortality at 1 year of age.

RESULTS

Late diagnosis occurred in 20% of critical and 51% of non-critical cases. Mortality occurred in 18% of critical vs 8% of non-critical cases. Mortality was lower with an early diagnosis of critical CHD (early diagnosis 16% vs late diagnosis 27%, p=0.04). Isolated critical CHD benefited most from early diagnosis (mortality, early diagnosis 12% vs late diagnosis 29%, p=0.002). Early diagnosis occurred in >90% critical complex CHD and hypoplastic left heart syndrome, 85% d-transposition of the great arteries (d-TGA) and 53% critical left ventricular outflow tract obstruction (LVOTO). Deaths in d-TGA and LVOTO primarily occurred prior to intervention and for d-TGA most often when birth was distant from the cardiac centre.

CONCLUSIONS

Excess mortality occurs following late diagnosis of critical CHD, and for d-TGA even with early diagnosis if intervention is not immediately available. Antenatal detection retains an important role in reducing mortality related to critical CHD.

Screening for Critical Congenital Heart Disease

Screening for critical congenital heart disease (CCHD) was added to the United States Recommended Uniform Screening Panel in 2011. Since that time, CCHD screening with pulse oximetry has become nearly universal for newborns born in the United States. There are various algorithms in use. Although the goal of the screening program is to identify children who may have CCHD, most newborns who have a low oxygen saturation will not have CCHD. Further study is needed to determine optimal guidelines for CCHD screening in special settings such as the neonatal intensive care unit, areas in high altitude, and home births.

Projected growth of the adult congenital heart disease population in the United States to 2050: an integrative systems modeling approach

Background

Mortality for children with congenital heart disease (CHD) has declined with improved surgical techniques and neonatal screening; however, as these patients live longer, accurate estimates of the prevalence of adults with CHD are lacking.

Methods

To determine the prevalence and mortality trends of adults with CHD, we combined National Vital Statistics System data and National Health Interview Survey data using an integrative systems model to determine the prevalence of recalled CHD as a function of age, sex, and year (by recalled CHD, we mean positive response to the question “has a doctor told you that (name) has congenital heart disease?”, which is a conservative lower-bound estimate of CHD prevalence). We used Human Mortality Database estimates and US Census Department projections of the US population to calculate the CHD-prevalent population by age, sex, and year. The primary outcome was prevalence of recalled CHD in adults from 1970 to 2050; the secondary outcomes were birth prevalence and mortality rates by sex and women of childbearing age (15–49 years).

Results

The birth prevalence of recalled CHD in 2010 for males was 3.29 per 1,000 (95 % uncertainty interval (UI) 2.8–3.6), and for females was 3.23 per 1,000 (95 % UI 2.3–3.6). From 1968 to 2010, mortality among zero to 51-week-olds declined from 170 to 53 per 100,000 person years. The estimated number of adults (age 20–64 years) with recalled CHD in 1968 was 118,000 (95 % UI 72,000–150,000). By 2010, there was an increase by a factor of 2.3 (95 % UI 2.2–2.6), to 273,000 (95 % UI 190,000–330,000). There will be an estimated 510,000 (95 % UI: 400,000–580,000) in 2050. The prevalence of adults with recalled CHD will begin to plateau around the year 2050. In 2010, there were 134,000 (95 % UI 69,000–160,000) reproductive-age females (age 15–49 years) with recalled CHD in the United States.

Conclusion

Mortality rates have decreased in infants and the prevalence of adults with CHD has increased but will slow down around 2050. This population requires adult medical systems with providers experienced in the care of adult CHD patients, including those familiar with reproduction in women with CHD.

Electronic supplementary material

The online version of this article (doi:10.1186/s12963-015-0063-z) contains supplementary material, which is available to authorized users.

Identification of Critical Congenital Heart Disease in Vermont: The Role of Universal Pulse Oximetry Screening in a Rural State

OBJECTIVE

Pulse oximetry screening (POS) is becoming the standard of care in screening for critical congenital heart disease (CCHD). Our objective was to characterize the historical diagnostic pattern in a rural tertiary care children's hospital and explore how universal POS might affect morbidity, mortality, and care delivery.

PATIENTS AND METHODS

We identified patients <6 months of age in the Vermont Children's Hospital echocardiogram database with CCHD diagnosed between 2002 and 2011. Charts were reviewed to characterize timing of diagnosis, course, and outcome. The medical examiner was consulted to identify deaths due to undetected CCHD during the study period.

RESULTS

Of 60 329 live births, 73 (0.12 %) were diagnosed with CCHD. Of these, 31 (42%) were diagnosed prenatally, 34 (47%) were diagnosed by clinical examination in the nursery, 7 (9.6%) were diagnosed after nursery discharge, and 1 (1.4%) was born at home. The 8 patients not diagnosed by prenatal ultrasound or in the nursery were considered cases of undetected CCHD. Three had normal oxygen saturation (>95%) at diagnosis. Three presented with cardiovascular compromise. None died and all were well at the most recent follow-up. Review of autopsy reports from patients <6 months found no deaths from undetected CCHD during the study period.

CONCLUSIONS

Over a 10-year period at our institution, universal POS could have identified 5 patients with undetected CCHD, possibly avoiding the need for resuscitation in 3. Examination of local diagnostic data may affect the cost/benefit considerations of universal POS initiatives in a setting of limited healthcare resources.

Racial/ethnic differences in survival of United States children with birth defects: a population-based study

OBJECTIVES

To examine racial/ethnic-specific survival of children with major birth defects in the US.

STUDY DESIGN

We pooled data on live births delivered during 1999-2007 with any of 21 birth defects from 12 population-based birth defects surveillance programs. We used the Kaplan-Meier method to calculate cumulative survival probabilities and Cox proportional hazards models to estimate mortality risk.

RESULTS

For most birth defects, there were small-to-moderate differences in neonatal (<28 days) survival among racial/ethnic groups. However, compared with children born to non-Hispanic white mothers, postneonatal infant (28 days to <1 year) mortality risk was significantly greater among children born to non-Hispanic black mothers for 13 of 21 defects (hazard ratios [HRs] 1.3-2.8) and among children born to Hispanic mothers for 10 of 21 defects (HRs 1.3-1.7). Compared with children born to non-Hispanic white mothers, a significantly increased childhood (≤ 8 years) mortality risk was found among children born to Asian/Pacific Islander mothers for encephalocele (HR 2.6), tetralogy of Fallot, and atrioventricular septal defect (HRs 1.6-1.8) and among children born to American Indian/Alaska Native mothers for encephalocele (HR 2.8), whereas a significantly decreased childhood mortality risk was found among children born to Asian/Pacific Islander mothers for cleft lip with or without cleft palate (HR 0.6).

CONCLUSION

Children with birth defects born to non-Hispanic black and Hispanic mothers carry a greater risk of mortality well into childhood, especially children with congenital heart defect. Understanding survival differences among racial/ethnic groups provides important information for policy development and service planning.

Detection of critical congenital heart defects: Review of contributions from prenatal and newborn screening

In 2011, statewide newborn screening programs for critical congenital heart defects began in the United States, and subsequently screening has been implemented widely. In this review, we focus on data reports and collection efforts related to both prenatal diagnosis and newborn screening. Defect-specific, maternal, and geographic factors are associated with variations in prenatal detection, so newborn screening provides a population-wide safety net for early diagnosis. A new web-based repository is collecting information on newborn screening program policies, quality indicators related to screening programs, and specific case-level data on infants with these defects. Birth defects surveillance programs also collect data about critical congenital heart defects, particularly related to diagnostic timing, mortality, and services. Individuals from state programs, federal agencies, and national organizations will be interested in these data to further refine algorithms for screening in normal newborn nurseries, neonatal intensive care settings, and other special populations; and ultimately to evaluate the impact of screening on outcomes.

Important considerations for the newborn: access to postdischarge newborn care, pulse oximetry screening for congenital heart disease, and circumcision

PURPOSE OF REVIEW

This article addresses three areas in which new policies and research demonstrate the opportunity to impact the health of neonates: access to postdischarge newborn care, pulse oximetry screening for congenital heart disease, and circumcision.

RECENT FINDINGS

Recent research has identified that child healthcare providers are not typically adhering to the recommended first newborn visit within 48 h of hospital discharge. Despite its benefits, cost-effectiveness, and the recommendation that routine screening for cyanotic congenital heart disease be added to the panel of universal newborn screening, adoption of this practice is variable. Evidence suggests a significant reduction in the transmission of HIV linked to circumcision, leading professional organizations to generate new policy statements on neonatal male circumcision.

SUMMARY

Pediatric healthcare providers should pay careful attention to the timing of the first newborn outpatient follow-up visit. Pulse oximetry screening for cyanotic congenital heart disease is specific, sensitive and meets criteria for universal screening, and providers should utilize well designed screening protocols. In addition, healthcare providers for newborns, especially those who perform circumcisions, should provide nonbiased, up-to-date information on the medical, financial, and ethical aspects of the procedure.

Delayed diagnosis of critical congenital heart defects: trends and associated factors

OBJECTIVE

We aimed to examine trends in timing of diagnosis of critical congenital heart defects (CCHDs) and factors associated with delayed diagnosis (diagnosis after discharge home following delivery).

METHODS

We examined a population-based retrospective cohort of CCHD cases among live births identified through the Massachusetts Birth Defects Monitoring Program. Congenital heart defects were considered critical if the infant received corrective surgery, interventional catheterization, palliative care, or died as a result of the defect within 12 months of birth. Timing of initial diagnosis was classified as prenatal, postnatal before discharge home, or delayed. Demographic, perinatal, and mortality information was obtained from the Registry of Vital Records and Statistics. Prevalence ratios (PRs) were used to examine associations with delayed diagnosis.

RESULTS

Among 460 467 live births to Massachusetts residents between 2004 and 2009, we identified 916 CCHD cases, of which 126 (13.8%) had delayed diagnosis. Rates of prenatal CCHD diagnosis increased from 44.9% in 2004 to 63.8% in 2009, whereas rates of delayed diagnosis decreased from 17.1% to 10.6% over the same time period. Among cases with delayed diagnosis, the most common defects were coarctation, pulmonary valve stenosis, and tetralogy of Fallot. Delayed diagnosis was associated with delivery outside a tertiary hospital (adjusted PR: 3.6 [95% confidence interval: 2.5-5.2]) and isolated CCHD (adjusted PR: 1.7 [95% confidence interval: 1.1-2.7]).

CONCLUSIONS

Despite increasing prenatal diagnosis of CCHDs, delayed diagnosis still occurs in over 10% of cases. Understanding factors associated with delayed diagnosis could help to improve prenatal and postnatal screening efforts, including pulse oximetry testing.

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.