University of Michigan
Department of Pediatrics
Evidence-Based Pediatrics Web Site

Question

• In newborns in the well-baby nursery without signs of congenital heart disease (CHD), is pulse oximetry a useful method to screen for CHD?

Clinical Bottom Lines

1. Pulse oximetry is useful in detecting CHD before hospital discharge in otherwise well-appearing newborns. The sensitivity was 60% and specificity 99.95%, giving a positive likelihood ratio (LR+) of 6765 and a LR- of 0.4.
   
2. The false positive rate is low and does not lead to an excessive number of unnecessary echocardiograms.
   
3. The percentage of infants with significant CHD detected is similar to or greater than other conditions tested for on the newborn metabolic screen.
   
4. Whether easy detection of CHD results in lower morbidity or mortality is speculative. Recommendations to screen or not to screen are dependent upon this answer.
   

Summary of Key Evidence

1. Postductal pulse oximetry was measured in 11,281 infants with out signs (cyanosis, tachypnea, grunting, flaring, retractions, murmur, active precordium, or diminished pulses). If SpO2 measured was <95%, an echocardiogram was done. If SpO2>95%, the infant was routinely discharged.¹
   
2. The reference standard was reported diagnoses of CHD from a state-law mandated birth defects registry, hospital discharge data, and death certificates. SpO2<95% detected three cases of significant CHD; two with total anomalous pulmonary venous return, one with truncus arteriosus. Two infants with normal screen had delayed diagnosis of CHD, one with aortic coarctation and one with hypoplastic left pulmonary artery with aortopulmonary collaterals. There was one false positive, persistent right to left shunting due to delayed fetal transition.
   
3. Total number of CHD detected by screening was 1/3760. Hospital A detection rate was 1/8642, hospital B detection rate was 1/1320. Hospital A performed a higher percentage of fetal echos.
   
4. The authors report that there was no cost incurred for equipment, supplies, or personnel.

Additional Comments

• Wren, et al. report that more than half of babies with undiagnosed CHD are missed by routine neonatal examination, and more than one-third are missed by six weeks.²
  
• Reich, et al. report that routine pulse oximetry in newborns before nursery discharge was 99.9% specific; there was no increase in the number of echocardiograms performed in contrast to a comparison group.³
  
• Screening with pulse oximetry did not generate any abnormal echocardiogram findings.^1,3
  
• One should take into account the added expense, time, training, and labor involved with routinely measuring pulse oximetry in all infants in the newborn nursery.
  
• Authors acknowledge that this study does not compare outcome of patients with significant CHD who were asymptomatic as newborns diagnosed before vs. after discharge from the newborn nursery.¹
  

Citation

1. Koppel RI, Druschel CM, Carter T, et al. Effectiveness of pulse oximetry screening for congenital heart disease in asymptomatic newborns. Pediatrics 2003; 111:451-55.
   
2. Wren C, Richmond S, Donaldson L. Presentation of congenital heart disease in infancy: implications for routine examination. Arch Dis Child Fetal Neonatal Ed 1999; 80:F49-53.
   
3. Reich JD, Miller S, Brogdon B, et al. The use of pulse oximetry to detect congenital heart disease. J Pediatrics 2003; 142:268-72.
   

CAT Author: Sarah Vick, MD

CAT Appraisers: Robert Schumacher, MD

Date appraised: May 21, 2003