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Pulse oximetry screening in neonates
- Alf Endre Meberg (11 January 2009)
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Pulse oximetry at birth
- David JR Hutchon (13 January 2009)
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Pulse Oximetry screening of newborn infants
- Andrew K Ewer, Jane Daniels, Alexandra Furmston, Abhay Bhoyar, Lee Middleton and Khalid S Khan (27 January 2009)
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Reply re: Impact of pulse oximetry screening on the detection of duct dependent congenital heart disease: a Swedish prospective screening study in 39821 newborns by de-Wahl Granelli et al
- Gillian H Page, Leonard Williams (29 January 2009)
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Alf Endre Meberg, Consultant neonatologist Vestfold Hospital, 3103 Tønsberg, Norway
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Anne de-Wahl Granelli et al are to be congratulated for their impressive work on pulse oximetry screening to detect critical congenital heart defects (CCHD) (1). In relation to their discussion of our recently published work on the same topic (2) I would like to respond to some points. First the low prevalence of CCHD in our study (35/50 008; 0,7 per 1000) refers to the cases included in the screened population (apparently healthy babies transferred from the delivery suite to the nursery). When CCHD not included in the screened population (prenatally detected or transferred to a special or intensive care neonatal unit because of symptoms of disease before screening was undertaken) are added, the prevalence of CCHD in the general population is in agreement with the prevalence found by de-Wahl Granelli et al. In the abstract of our article (2) we have made the error of giving the 35 CCHDs as the number in the total population. I apologize deeply for this mistake, and feel personal responsible. Secondly de-Wahl Granelli et al say that we did not actively ascertain patients dying in the community with undiagnosed heart disease. We registered no case dying from unrecognized heart defects in our study, as we said in our article. This statement is based on information from the coworkers at the participating hospitals, as well as from the Norwegian departments of pathology performing forensic medical examinations. In Norway unexpected deaths by law are referred for such examination. On special request to these departments no unexpected death from unrecognized CCHD was found. Concerning the false positive rate of 0.6% in our first-day of life pulse oximetry screening programme, half of the false positives were potentially severe non-cardiac disorders such as pneumothorax, pulmonary hypertension and infections. The “true false positives,” if defined as the healthy babies in a phase of prolonged transitional circulation, accounted for only 52% of the total false positive rate. Early detection of extracardiac disorders may be an added advantage of the screening program, and possibly as important as detecting heart defects. In my opinion the study of de-Wahl Granelli et al (1) together with our study (2) as well as earlier published works on this topic add substantial evidence to promote such screening to be implemented as a basic routine in nurseries. This will reduce the number of CCHDs to be missed and readmitted in severe heart failure or circulatory collapse. Alf Meberg, MD, PhD Neonatal Unit Department of Pediatrics, Vestfold Hospital Tønsberg, Norway References 1. De-Wahl Granelli, Wennergren M, Sandberg K, Mellander M, Bejlum C, Inganäs L et al. Impact of pulse oximetry screening on the detection of duct dependent congenital heart disease: a Swedish prospective screening study in 39 821 newborns. BMJ 2008; 337a3037doi:10.1136/bmja3037. 2. Meberg A, Brügmann-Pieper S, Due Jr R, Eskedal L, Fagerli I, Farstad T et al. First day of life pulse oximetry screening to detect congenital heart defects. J Pediatr 2008;152:761-5. Competing interests: None |
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David JR Hutchon, Consultant Obstetrician Memorial Hospital, Darlington
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As an obstetrician, recently I have realised the anomalous method and accuracy of monitoring the baby's heart rate before and after birth. Sometimes we rely only on auscultation before and after birth. However when there is a high risk pregnancy or abnormalities are detected we move to using the cardiotocograph which can provide a sophisticated, accurate and documented measure of the heart rate. As soon as the baby is born the CTG measurement is lost and we now rely on intermittent auscultation. Once the baby is clearly healthy this is stopped but when resuscitation measures are necessary auscultation is still relied upon until the baby, if necessary, is transferred to the neonatal nursery. It would seem sensible to monitor the heart rate during resuscitation routinely with pulse oximetry. This would give the opportunity for a virtually gap free, objective free, documented pulse rate during the whole of birth. Pulse oximetry is already available for intrapartum monitoring. Is it not time that pulse oximetry was routinely available on the resuscitaire?
Competing interests: None declared |
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Andrew K Ewer, Consultant Neonatologist Birmingham University, Edgbaston, Birmingham B15 2TT, Jane Daniels, Alexandra Furmston, Abhay Bhoyar, Lee Middleton and Khalid S Khan
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We would like to congratulate de-Wahl Granelli et al on their pulse oximetry study in Sweden.1 We are currently undertaking a similar study in the UK funded by the NIHR Health Technology Assessment programme (HTA study No. 06/06/03). The PulseOx study is being carried out at six hospitals in the West Midlands and we have recruited 20 000 babies. In addition to the accuracy data provided by Granelli and previous studies2 we will evaluate the costs and cost effectiveness of pulse oximetry screening from the NHS perspective. We will also study the acceptability of pulse oximetry to both parents and health professionals. This additional information will help policy makers assess the use of pulse oximetry in national neonatal screening programmes. The results of our study will be available in 2010. More details can be found at www.pulseox.bham.ac.uk 1. de-Wahl Granelli A, Wennergren M, Sandberg K, Mellander M, Bejlum C, Inganäs L, Eriksson M, Segerdahl N, Ågren A, Ekman-Joelsson BM, Sunnegårdh J, Verdicchio M, Östman-Smith I Impact of pulse oximetry screening on the detection of duct dependent congenital heart disease: a Swedish prospective screening study in 39 821 newborns BMJ 2009; 338 (82): a3037 2. Thangaratinam S, Daniels J, Ewer AK, Zamora J, Khan KS. Accuracy of pulse oximetry in screening for congenital heart disease in asymptomatic newborns: a systematic review. Arch Dis Child Fetal Neonatal Ed. 2007 May; 92(3):F176-80. Competing interests: We are currently undertaking a similar study in the UK which we describe in the response |
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Gillian H Page, ST3 Paediatrics Sheffield Childrens Hospital, S10 2TH, Leonard Williams
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I write regarding the above article published recently in the BMJ studying the screening of newborns for congenital heart disease by checking oxygen saturations. The study showed an increase in the detection of congenital cardiac disease, but the timing of checking the saturations appeared variable (90% were screened anywhere between 6 and 72hrs). Recently, we had a case of a baby with coarctation of the aorta, which was picked up solely on the post ductal saturations being low as part of the otherwise normal newborn baby check. The baby was seen at 12 hours, and the resulting blood pressures and saturations can be seen in the tables below.
As demonstrated in the two tables below, the post ductal oxygen saturation increases as the ductus narrows, and over the same time the lower limb blood pressure falls. The femoral pulses were easily palpable at the start of this trace (and there was no murmur). Towards the end of the recordings the femoral pulses had become impalpable and a systolic murmur could be heard. Prostaglandin was not administered during or before these recordings. These results would suggest that the timing of checking the saturations is critical and checking them earlier rather than later, perhaps in the first 12 hrs, would reduce the risk of missing duct dependent lesions. Competing interests: None declared Editorial note
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