Role of Pulse Oximetry in Examining Newborns for Congenital Heart Disease: A Scientific Statement from the AHA and AAP

Abstract

BACKGROUND: The purpose of this statement is to address the state of evidence on the routine use of pulse oximetry in newborns to detect critical congenital heart disease (CCHD). METHODS AND RESULTS: A writing group appointed by the American Heart Association and the American Academy of Pediatrics reviewed the available literature addressing current detection methods for CCHD, burden of missed and/or delayed diagnosis of CCHD, rationale of oximetry screening, and clinical studies of oximetry in otherwise asymptomatic newborns. MEDLINE database searches from 1966 to 2008 were done for English-language papers using the following search terms: congenital heart disease, pulse oximetry, physical examination, murmur, echocardiography, fetal echocardiography, and newborn screening. The reference lists of identified papers were also searched. Published abstracts from major pediatric scientific meetings in 2006 to 2008 were also reviewed. The American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. In an analysis of pooled studies of oximetry assessment performed after 24 hours of life, the estimated sensitivity for detecting CCHD was 69.6%, and the positive predictive value was 47.0%; however, sensitivity varied dramatically among studies from 0% to 100%. False-positive screens that required further evaluation occurred in only 0.035% of infants screened after 24 hours. CONCLUSIONS: Currently, CCHD is not detected in some newborns until after their hospital discharge, which results in significant morbidity and occasional mortality. Furthermore, routine pulse oximetry performed on asymptomatic newborns after 24 hours of life, but before hospital discharge, may detect CCHD. Routine pulse oximetry performed after 24 hours in hospitals that have on-site pediatric cardiovascular services incurs very low cost and risk of harm. Future studies in larger populations and across a broad range of newborn delivery systems are needed to determine whether this practice should become standard of care in the routine assessment of the neonate.

Strategies for Implementing Screening for Critical Congenital Heart Disease

“…This subset of lesions excludes those not usually associated with hypoxia (eg, aortic valve stenosis). 7 This recommendation built on a 2009 statement from the American Academy of Pediatrics (AAP) and the American Heart Association (AHA), which found compelling reasons for newborn screening but called for "studies in larger populations and across a broad range of newborn delivery systems" before pulse-oximetry screening should be recommended. 7 The SACHDNC was especially persuaded by a prospective screening study of nearly 40 000 newborns in Sweden 8 and a separate study of nearly 40 000 newborns in Germany.…”

Age at Referral and Mortality From Critical Congenital Heart Disease

“…The scientific committees of the American Academy of Pediatrics and the American Heart Association recommended that additional studies be conducted in large diverse populations across a broad range of delivery systems to determine whether pulse oximetry screening in neonates improves outcomes in infants with CCHD. 18 Unfortunately, no US population-based studies have reported the extent that CCHD mortality can be attributed to delays in receiving care at cardiac specialty centers. The purpose of this population-based study was to describe the association of timing of referral to a cardiac center and mortality in neonates with CCHD who were born in Texas during 1996-2007, before routine pulse oximetry screening.…”

Tailored management approach for late presenters and critically sick children with congenital heart disease

“…In the industrialized countries, where most of these standards of care were developed and implemented, the advanced and well-structured health care delivery helped to evaluate these management strategies [4,5]. In contrast, in many developing countries, the health care level does not always support to implement these recommendations [6].…”