Pulse Oximetry Screening for Critical Congenital Heart Disease

Oster ME, Aucott SW, Glidewell J, et al.
Lessons Learned From Newborn Screening for Critical Congenital Heart Defects. Pediatrics 2016;137:e20154573.

The Centers for Disease Control and Prevention partnered with the American Academy of Pediatrics (AAP) to review current practices of pulse oximetry screening (PoXS) for critical congenital heart disease (CCHD) in the United States. The following are key points to remember:

  1. In 2011, newborn PoXS was added to the Recommended Uniform Screening Panel in the United States, with the goal of detecting CCHD prior to the occurrence of symptoms. It is now adapted by 46 states and the District of Columbia, with nearly universal implementation.
  2. PoXS differs from other newborn screening in that it requires administration, interpretation, action, and reporting of outcomes by care providers.
  3. Current limitations include ambiguity of the term “CCHD,” lack of algorithm uniformity, disagreement regarding appropriate evaluation after a positive screen, and lack of population-based surveillance.
  4. PoXS targets “core” CCHDs that present with hypoxemia. It may also detect non-CCHD secondary conditions that are detrimental if undiagnosed (noncritical CHD, sepsis, pulmonary hypertension, pulmonary disease, and hemoglobinopathies).
  5. The algorithm, endorsed by the American College of Cardiology, AAP, and American Heart Association, recommends that PoXS be performed at >24 hours of age, on the right hand, and either foot, using motion-tolerant pulse oximeters approved for infant use. The newborn “passes” if either reading is >95%, and the difference between readings is <3%. Any reading <90% or inability to achieve the former after a third try is considered a “fail.”
  6. Protocols, what constitutes a “positive” screen, and the action taken for a “fail” varies by state and altitude.
  7. High prevalence secondary conditions must be considered when prioritizing tests while awaiting an echocardiogram. If the cause of desaturation is identified and treated with resolution of hypoxemia, an echo may not be necessary.
  8. Factors to consider for an appropriate PoXS algorithm include balancing specificity and sensitivity, reducing costs and labor, decreasing family burden, reducing delays in hospital discharge, and reducing inconsistencies in implementation and interpretation. An outpatient clinic is not the ideal place for PoXS, but is acceptable.
  9. Longitudinal outcome tracking is currently not universally available. Education for clinicians (including birthing centers and providers for home births), families, and public health officials is an ongoing challenge.
  10. As more information becomes available, CCHD screening might change (timing, threshold for a “fail,” or replacement of current PoXS with new technology, such as “automated echocardiograms”). Lessons learned from PoXS may guide the development of future screening efforts.

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