Screening for congenital heart disease with newborn pulse oximetry

Abstract

Andrew Ewer and colleagues (Aug 27, p 785)1Ewer AK Middleton LJ Furmston AT et al.Pulse oximetry screening for congenital heart defects in newborn infants (PulseOx): a test accuracy study.Lancet. 2011; 378: 785-794Summary Full Text Full Text PDF PubMed Scopus (226) Google Scholar claim that their testing protocol has superior sensitivity to that advocated by de-Wahl Granelli and colleagues.2de-Wahl Granelli A Wennergren M Sandberg K 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: a3037Crossref PubMed Scopus (311) Google Scholar This claim is incorrect for several reasons. First, Ewer and colleagues' sensitivity figure includes patients known to have critical congenital heart disease by fetal ultrasound scanning. For infants screened blind, as ours were, the sensitivity of Ewer and colleagues' protocol was 58%; our protocol had a sensitivity of 62%.2de-Wahl Granelli A Wennergren M Sandberg K 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: a3037Crossref PubMed Scopus (311) Google Scholar Second, Ewer and colleagues claim that our protocol would have missed one of their critical cases (prenatally diagnosed hypoplastic left heart syndrome). Our protocol would class the first reading of 92%/97% as abnormal, but the second reading of 100%/97% is impossible in a patient with aortic atresia who is breathing air; presumably he or she was by then receiving prostaglandin infusion and probably oxygen. Ewer and colleagues' protocol results in a significantly lower positive predictive value (9·2%) than does ours (20·7%, 95% CI 12·8–30·7), and a five-times higher false-positive rate (0·85%), with substantial implications for cost and workload; our false-positive rate of 0·17% is low enough to make screening cost-neutral.2de-Wahl Granelli A Wennergren M Sandberg K 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: a3037Crossref PubMed Scopus (311) Google Scholar, 3Griebsch I Knowles RL Brown J Bull C Wren C Dezateux CA Comparing the clinical and economic effects of clinical examination, pulse oximetry and echocardiography in newborn screening for congenital heart defects: a probabilistic cost-effectiveness model and value of information analysis.Int J Technol Assess Health Care. 2007; 23: 192-204Crossref PubMed Scopus (53) Google Scholar, 4Mahle W Koppel R Screening with pulse oximetry for congenital heart disease.Lancet. 2011; 378: 749-750Summary Full Text Full Text PDF PubMed Scopus (10) Google Scholar Ewer and colleagues do make some important contributions. Their study confirms earlier findings that incorporation of both preductal and postductal readings, and inclusion of the difference in the screening cutoffs, improves detection rate compared with postductal readings only.2de-Wahl Granelli A Wennergren M Sandberg K 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: a3037Crossref PubMed Scopus (311) Google Scholar, 5de-Wahl Granelli A Melander M Sunnegardh J Sandberg K Östman-Smith I Screening for duct-dependent congenital heart disease: a critical evaluation of strategies to maximise sensitivity.Acta Paediatr. 2005; 94: 1590-1596Crossref PubMed Google Scholar Second, Ewer and colleagues show that routine pulse-oximetry screening before discharge significantly improves the detection rate of critical congenital heart disease even in health districts that use systematic antenatal cardiac anomaly scanning—a new finding—achieving a total predischarge detection rate of 92%.1Ewer AK Middleton LJ Furmston AT et al.Pulse oximetry screening for congenital heart defects in newborn infants (PulseOx): a test accuracy study.Lancet. 2011; 378: 785-794Summary Full Text Full Text PDF PubMed Scopus (226) Google Scholar, 2de-Wahl Granelli A Wennergren M Sandberg K 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: a3037Crossref PubMed Scopus (311) Google Scholar Lastly, the results confirm that screening should ideally be done after the first 6 h of life.1Ewer AK Middleton LJ Furmston AT et al.Pulse oximetry screening for congenital heart defects in newborn infants (PulseOx): a test accuracy study.Lancet. 2011; 378: 785-794Summary Full Text Full Text PDF PubMed Scopus (226) Google Scholar, 5de-Wahl Granelli A Melander M Sunnegardh J Sandberg K Östman-Smith I Screening for duct-dependent congenital heart disease: a critical evaluation of strategies to maximise sensitivity.Acta Paediatr. 2005; 94: 1590-1596Crossref PubMed Google Scholar We declare that we have no conflicts of interest.