882 Variability of cardiac investigations for neonates with suspected innocent murmurs across London

Abstract

<h3>Background</h3> Every baby in the UK undergoes a newborn check within the first 72 hours of life, aiming to identify congenital anomalies and ensure appropriate management and follow-up can occur. Heart murmurs are one of the more common findings during these examinations and often prompt further investigation with the aim of excluding life threatening congenital cardiac disease. However, the majority of these infants are clinically well and are diagnosed with ‘innocent’ murmurs. Within London, there is currently a lack of consensus regarding the selection of investigations used in these babies, leading to wide variation in practice between different hospitals. The most common investigations are measurements of pre- and post-ductal oxygen saturations, four limb blood pressure readings and electrocardiograms (ECG). While oxygen saturations are widely regarded as being vital to aid detection of congenital cardiac disease, there is limited evidence to support four limb blood pressures and ECGs. <h3>Objectives</h3> To identify current use of four limb blood pressures and ECGs in clinically well neonates with murmurs in London hospitals and look at the clarity and uptake of local guidelines. <h3>Methods</h3> A retrospective study was undertaken to demonstrate the wide variability in practice regarding the investigation of clinical well infants with murmurs in London Hospitals. 26 neonatal units in London were contacted. This included 9 intensive care units, 13 local neonatal units and 4 special care baby units. A telephone survey was performed and the on call neonatal team was asked about the local practice in their unit. Specific questions included whether four limb blood pressures and ECGs were part of the routine workup of clinically well neonates identified as having a murmur. This was followed up with a review of their local guideline, where available. <h3>Results</h3> Responses were received from 23 neonatal units across London, including 7 NICU, 11 LNU and 4 SCBU. Of these, 64% (14) units reported to routinely check four limb blood pressures in clinically well babies with murmurs and 4 of these units were subsequently found to not recommend this investigation based on their local guidelines. Further analysis found that 19% (4) units verbally reported that ECGs were performed routinely and 12% (3) reported to not have a local guideline for clinically well babies with murmurs. <h3>Conclusions</h3> There is wide interdepartmental variability of investigation of neonates with suspected innocent murmurs. Four limb blood pressure use is particularly variable, even between reported practice and guidelines. In one case, two guidelines were identified for one hospital which contradicted each other in this regard. ECG was rarely included in routine management. Both four limb blood pressure readings and neonatal ECG are time consuming, require trained staff and do not have good supporting evidence for their use in detecting congenital cardiac disease. With wide variation in practice and limited evidence to support their use, it may be time to stop using these investigations in clinically well neonates with murmurs.