Intended for healthcare professionals

Rapid response to:


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 doi: (Published 09 January 2009) Cite this as: BMJ 2009;338:a3037

Rapid Response:

Re: Impact of pulse oximetry screening on the detection of duct dependent congenital heart disease: a Swedish prospective screening study in 39 821 newborns

A national telephone survey conducted in March 2013, with 100% response rate in 47/47 delivery hospitals in Sweden, showed that 43 (91.4%) of the newborn nurseries are currently screening for critical congenital heart disease with pulse oximetry. Of the four remaining hospitals not screening, two are in the immediate start-up of screening (one have bought equipment and will start before May, the other is in the phase of buying equipment). The remaining two are planning to start up screening (Visby and Skovde). The four Swedish delivery hospitals not screening for CCHD, counted for 6.7% of total deliveries in Sweden year 2011, the most recent statistical update available from the National Board of Health and Welfare ( ).

The Swedish study published in BMJ 2009,[1] recommended to screen both pre- and post ductally (right hand and one foot) with a pulse oximeter technology reading through motion and low perfusion. The cut-off was <95% saturation in both right hand and one foot, or a difference of >3% between the sites. Three repeated positive measurements or one optimal reading =<90% was considered screening positive. This screening protocol was endorsed by the American Heart Association, the American College of Cardiology, and the American Academy of Pediatrics in 2011.[2]

All delivery hospitals in Sweden are following the recommended protocol and 13/43 (30.2%) added the peripheral perfusion index into the protocol.[3]

Oximeter technologies used for screening were Masimo Radical SET 37/43 (86%), Nellcor Oximax 3/43 (6.9%), Viamed V2160 2/43 (4.7%) and Philips MP2 1/43 (2.3%).

All babies were screened before discharge from the newborn nurseries. The recommended age for screening varied between 6h of age (4/43), >6h (11/43), 6-24h (5/43), 24-48h (5/43), 6-36h (3/43) or variations overlapping 6h to discharge (15/43). In Vasteras they screen two times, the second when the baby have the Guthrie test done. If the baby is discharged before 12 hours of age at Sodersjukhuset, a second screening is performed there as well. Only 6/43 (14%) of the delivery hospitals in Sweden had information that they were screening for critical congenital heart disease on their website.

The implementation in Sweden started before 2010 in 12/47 (25.5%) of the delivery hospitals, in 2010 in 12/47 (25.5%), in 2011 in 9/47 (19.1%), in 2012 in 6/47 (12.8%), and from January to March 2013 in 4/47 (8.5%). Of the four remaining, two will start-up before the summer.

The recent UK update in Lancet by Singh and Ewer,[4] showed a progress from 7% screened in 2010 to 18% screened in 2012, but with a lack of consistency in measuring site and screening protocol. Their survey did not include information about pulse oximeter technology used, however they also recommended a motion tolerant technology in their screening study.[5] In contrast, Sweden showed a consistency in adopting the published recommended protocol.

The implementation progress in USA has gone from 0.3% screened in September 2011, when the Secretary of Health and Human Service recommended uniform screening, to a rapid progression of legislation processes throughout the nation (

Adoption of this additional newborn screening test for critical congenital heart disease, has happened without a national recommendation from the Swedish National Board of Health and Welfare. In fact, the Swedish recommendations have not been updated since 2008, despite the fact that they have been provided with updated published research.

This bottom-up approach in Sweden has shown that implementing pulse oximetry screening for critical congenital heart disease is feasible. Importantly, it happened without additional staff or education grants. The key feature is a model with in-hospital lecture/information by a physician, followed by "champion midwife", and a cascade training of the rest of the staff.

1 de-Wahl Granelli A, Wennergren M, Sandberg K, Mellander M, Bejlum C, Inganas 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 2009;338:a3037.
2 Kemper AR, Mahle WT, Martin GR, Cooley WC, Kumar P, Morrow WR et al. Strategies for implementing screening for critical congenital heart disease. Pediatrics 2011;128(5):e1259–e1267.
3 Singh A, Ewer AK. Pulse oximetry screening for critical congenital heart defects: a UK national survey. Lancet 2013; Vol381 February16.
4 Granelli AW, Ostman-Smith I. Noninvasive peripheral perfusion index as a possible tool for screening for critical left heart obstruction. Acta Paediatr 2007;96(10):1455–1459.
5 Ewer AK, Middleton LJ, Furmston AT, Bhoyar A, Daniels JP, Thangaratinam S et al. Pulse oximetry screening for congenital heart defects in newborn infants (PulseOx): a test accuracy study. Lancet 2011; 378: 785–94.

Competing interests: No competing interests

03 April 2013
Anne M de-Wahl Granelli
PhD in Medicine, MBA-student
Edinburgh Business School
Heriot-Watt University, Edinburgh EH14 4AS, UK