It's been almost five years since pulse oximetry screening was recommended to be added to the uniform screening panel for newborns. While Missouri and Kansas each took different approaches, pulse oximetry screening for CCHD in the newborn nursery is now almost universal in the United States.
Prior to oximetry screening, about 20% of newborns with CCHD left the hospital with undiagnosed heart defects. Now that number is much, much smaller.
Listen in as Dr. Stephen Kaine, Children’s Mercy cardiologist, discusses the implementation process for the screening, reporting, and outcomes.
Selected Podcast
Pulse Ox Screening for Newborns: Is It Making A Difference?
Featured Speaker:
Learn more about Stephen Kaine, MD
Stephen Kaine, MD
Stephen Kaine, MD, is a pediatric cardiologist at Children’s Mercy Kansas City. He is Director of the Cardiovascular Laboratory, Associate Director of the Ward Family Heart Center, and Associate Director of Fellowship at Children’s Mercy. He holds the academic position of Associate Professor of Pediatrics with the University of Missouri-Kansas City School of Medicine. Dr. Kaine received his medical degree from Baylor College of Medicine where he also completed a residency in pediatrics. Dr. Kaine completed a fellowship in Pediatric Cardiology at Texas Children’s Hospital.Learn more about Stephen Kaine, MD
Transcription:
Pulse Ox Screening for Newborns: Is It Making A Difference?
Dr. Michael Smith (Host): So, our topic today is “Pulse Ox Screening for Newborns: Is It Making a Difference?” My guest is Dr. Stephen Kaine. He is the Director of the Cardiovascular Laboratory and Associate Director of The Ward Family Heart Center. He’s also an Associate Professor of Pediatrics with the University of Missouri-Kansas City School of Medicine. Dr. Kaine, welcome to the show.
Dr. Stephen Kaine (Guest): Thanks very much. It’s good to be here.
Dr. Smith: So, we’re going talk about what impact the pulse ox screening has done since it’s been implemented. But first, let’s just get some background information. What percent of infant deaths from defects are attributed to congenital heart defect?
Dr. Kaine: Well, in the first year of life, deaths related to congenital heart disease account for about thirty percent of deaths related to birth defects. Congenital heart disease is actually a very common form of birth defect affecting about one percent of all newborns.
Dr. Smith: Right. When you look at the pulse oximetry screening, what percent of newborns prior to doing this as screening in the hospital were sent home with a critical congenital heart defect? Do we have that kind of data?
Dr. Kaine: We do. We do. Because congenital heart disease is fairly common, as I mentioned, with about one percent of newborns affected, about 50,000 babies a year. We had lots of information prior to 2010 about how many babies went home. About 10, 000 babies of those 50,000 with birth defects had what we refer to as critical congenital heart disease. And of that 10,000, as many as 2,500 to 3,000 babies per year were being discharged from the newborn hospital without their defects being diagnosed.
Dr. Smith: What is that? So, when you look at a baby who’s being sent home with a critical congenital heart defect, what’s the outcome? When that happens and we don’t catch it, what’s the common outcome for that child?
Dr. Kaine: Well, the outcomes are very much different in those children compared to children who have their diagnoses made in a timely fashion. The most significant issue is the risk of returning to the hospital in a very ill state which happens very commonly in those babies who are discharged early without the defects being known. That affects the outcome of their surgical intervention or their treatment that they need. Babies in this state typically go home undiagnosed with some protection. The fetal circulatory structures allow a child to actually do well for a few days, but once the ductus arteriosus closes, the child becomes quite ill and, as I mentioned, the outcomes are significantly worse. Specifically, a study done in Sweden that really highlighted this impact showed a survival during the first year of life for children who went home without their defects diagnosed as only about 10% compared to those who did have the diagnosis made timely.
Dr. Smith: Right. This is exactly why wanting to catch those defects before they leave the hospital was something that became very important to physicians like yourself, to children’s hospital, and this is where the pulse ox screening was initiated. Correct? So, tell us a little bit about how Children’s Mercy implemented this screening in newborns.
Dr. Kaine: Well, the newborn screening was recommended by the Secretary of Health and Human Services Sebelius back in September of 2011. And, what she did was she asked the states and state departments of health to work together to implement this. Many states handled this as a legislative mandate. For instance, the State of Missouri did. We helped provide training for birth facilities and also the follow-up for children who had positive screens. In the State of Kansas, we did not have a legislative mandate that was supported by the legislature. So, what we did at Children’s Mercy is we worked with the Kansas Department of Health and Environment to implement a quality improvement strategy. The Kansas Department of Health and Environment task force went out to birth facilities and provided education from materials that we actually provided to them. And, over the course of 2 years, the State of Kansas went from 30% of the birth facility screening to a 100% and a total number of babies which was about 75% of the newborns being screened to a 100%. So, even without a legislative mandate in the State of Kansas, we were able to get babies screened using the quality improvement initiative.
Dr. Smith: When is this screening actually done? Is this right as they are being released or 12 hours before? What’s the timing?
Dr. Kaine: The timing of the screening is very important because the oximetry assessment in the first few hours after life during the transitional period can be sometimes misinterpreted or inaccurate. So, the screen is really designed for healthy newborns who are at least 24 hours of age and, of course, prior to their discharge. Children who have signs of congenital heart disease before that time, typically, because of symptoms or different issues, breathing problems, oxygenation problems, those children are identified quickly and often come to our attention. But, as I mentioned, about 25% of babies with very significant congenital heart disease don’t actually have those symptoms in the first few days of life, and that’s why the oximetry assessment at 24 to 48 hours of age is really critical.
Dr. Smith: And, in that time period, in a healthy infant, how sensitive is pulse ox as a screening tool?
Dr. Kaine: Pulse oximetry is actually quite sensitive. With regard to detecting those critical defects, it’s actually got a very good record. There was a concern prior to initiation of pulse oximetry that there would be a lot of false positive tests. That has actually turned out to not be the case. There are some babies who were screened who have an abnormal pulse oximetry screen who end up not having congenital heart disease. However, the screen does uncover other particular problems such as lung disease, sometimes infection. So, these are also important clinical problems that are detected by oximetry even though they’re not necessarily congenital heart disease.
Dr. Smith: Alright. So, now that we’ve laid out the background here and we’ve talked a little bit about the screening tool itself, in your opinion, has pulse oximetry screening made a difference?
Dr. Kaine: Well, I think we know, in many of the states, it actually absolutely has made a difference. One of the concerns that I have about oximetry assessment as we do it now in the U.S., and this is getting better, fortunately. Fortunately, almost all babies in the U.S. now are being screened with oximetry prior to discharge. What we don’t have a standard protocol for yet is reporting. Several states have implemented reporting of their data and, actually, states such as New Jersey, actually report this publicly. So, we can have a very clear view of the number of babies who are having positive screens and also those positive screens in terms of the impact on saving children with congenital heart disease. In the state of Kansas, we actually do have a field in the electronic birth record and registry for oximetry screening. And so that, I think, has the ability to let us know for sure the number of babies who are coming to detection with this technique. In the state of Missouri, we need to work on better reporting, standardized reporting on a patient level, so that we can understand the impact. But, just as a clinician who sees a lot of these babies in the first month of life, one thing I can very definitely tell you is that the number of infants coming to our facility with undiagnosed congenital heart disease or with the effects of having had their heart defect not diagnosed in the newborn, hospitalization has decreased dramatically. We just don’t see very many of those babies anymore. And that’s a real transformation compared to where we were 5 years ago when Secretary Sebelius recommended it.
Dr. Smith: Yes. It’s such a simple test, too, right? I mean, it’s easy, it’s non-invasive.
Dr. Kaine: Absolutely, absolutely.
Dr. Smith: It’s everything you want in a screening tool, right?
Dr. Kaine: At this point, it’s amazing to me that we did not implement it earlier but there were valid concerns about accuracy. Fortunately, several large population studies really confirmed that this was something that was needed and I’m proud of the efforts of the state Departments of Health both in Missouri and Kansas to really get this going, and also proud of the work that the doctors here at Children’s Mercy have done as well.
Dr. Smith: Well, that’s awesome. Dr. Kaine, I want to thank you for the work that you are doing with this, the work you do at Children’s Mercy, and also thank you for coming on the show this morning. You’re listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information, you can go to www.ChildrensMercy.org. That’s www.ChildrensMercy.org. I’m Dr. Mike Smith. Thanks for listening.
Pulse Ox Screening for Newborns: Is It Making A Difference?
Dr. Michael Smith (Host): So, our topic today is “Pulse Ox Screening for Newborns: Is It Making a Difference?” My guest is Dr. Stephen Kaine. He is the Director of the Cardiovascular Laboratory and Associate Director of The Ward Family Heart Center. He’s also an Associate Professor of Pediatrics with the University of Missouri-Kansas City School of Medicine. Dr. Kaine, welcome to the show.
Dr. Stephen Kaine (Guest): Thanks very much. It’s good to be here.
Dr. Smith: So, we’re going talk about what impact the pulse ox screening has done since it’s been implemented. But first, let’s just get some background information. What percent of infant deaths from defects are attributed to congenital heart defect?
Dr. Kaine: Well, in the first year of life, deaths related to congenital heart disease account for about thirty percent of deaths related to birth defects. Congenital heart disease is actually a very common form of birth defect affecting about one percent of all newborns.
Dr. Smith: Right. When you look at the pulse oximetry screening, what percent of newborns prior to doing this as screening in the hospital were sent home with a critical congenital heart defect? Do we have that kind of data?
Dr. Kaine: We do. We do. Because congenital heart disease is fairly common, as I mentioned, with about one percent of newborns affected, about 50,000 babies a year. We had lots of information prior to 2010 about how many babies went home. About 10, 000 babies of those 50,000 with birth defects had what we refer to as critical congenital heart disease. And of that 10,000, as many as 2,500 to 3,000 babies per year were being discharged from the newborn hospital without their defects being diagnosed.
Dr. Smith: What is that? So, when you look at a baby who’s being sent home with a critical congenital heart defect, what’s the outcome? When that happens and we don’t catch it, what’s the common outcome for that child?
Dr. Kaine: Well, the outcomes are very much different in those children compared to children who have their diagnoses made in a timely fashion. The most significant issue is the risk of returning to the hospital in a very ill state which happens very commonly in those babies who are discharged early without the defects being known. That affects the outcome of their surgical intervention or their treatment that they need. Babies in this state typically go home undiagnosed with some protection. The fetal circulatory structures allow a child to actually do well for a few days, but once the ductus arteriosus closes, the child becomes quite ill and, as I mentioned, the outcomes are significantly worse. Specifically, a study done in Sweden that really highlighted this impact showed a survival during the first year of life for children who went home without their defects diagnosed as only about 10% compared to those who did have the diagnosis made timely.
Dr. Smith: Right. This is exactly why wanting to catch those defects before they leave the hospital was something that became very important to physicians like yourself, to children’s hospital, and this is where the pulse ox screening was initiated. Correct? So, tell us a little bit about how Children’s Mercy implemented this screening in newborns.
Dr. Kaine: Well, the newborn screening was recommended by the Secretary of Health and Human Services Sebelius back in September of 2011. And, what she did was she asked the states and state departments of health to work together to implement this. Many states handled this as a legislative mandate. For instance, the State of Missouri did. We helped provide training for birth facilities and also the follow-up for children who had positive screens. In the State of Kansas, we did not have a legislative mandate that was supported by the legislature. So, what we did at Children’s Mercy is we worked with the Kansas Department of Health and Environment to implement a quality improvement strategy. The Kansas Department of Health and Environment task force went out to birth facilities and provided education from materials that we actually provided to them. And, over the course of 2 years, the State of Kansas went from 30% of the birth facility screening to a 100% and a total number of babies which was about 75% of the newborns being screened to a 100%. So, even without a legislative mandate in the State of Kansas, we were able to get babies screened using the quality improvement initiative.
Dr. Smith: When is this screening actually done? Is this right as they are being released or 12 hours before? What’s the timing?
Dr. Kaine: The timing of the screening is very important because the oximetry assessment in the first few hours after life during the transitional period can be sometimes misinterpreted or inaccurate. So, the screen is really designed for healthy newborns who are at least 24 hours of age and, of course, prior to their discharge. Children who have signs of congenital heart disease before that time, typically, because of symptoms or different issues, breathing problems, oxygenation problems, those children are identified quickly and often come to our attention. But, as I mentioned, about 25% of babies with very significant congenital heart disease don’t actually have those symptoms in the first few days of life, and that’s why the oximetry assessment at 24 to 48 hours of age is really critical.
Dr. Smith: And, in that time period, in a healthy infant, how sensitive is pulse ox as a screening tool?
Dr. Kaine: Pulse oximetry is actually quite sensitive. With regard to detecting those critical defects, it’s actually got a very good record. There was a concern prior to initiation of pulse oximetry that there would be a lot of false positive tests. That has actually turned out to not be the case. There are some babies who were screened who have an abnormal pulse oximetry screen who end up not having congenital heart disease. However, the screen does uncover other particular problems such as lung disease, sometimes infection. So, these are also important clinical problems that are detected by oximetry even though they’re not necessarily congenital heart disease.
Dr. Smith: Alright. So, now that we’ve laid out the background here and we’ve talked a little bit about the screening tool itself, in your opinion, has pulse oximetry screening made a difference?
Dr. Kaine: Well, I think we know, in many of the states, it actually absolutely has made a difference. One of the concerns that I have about oximetry assessment as we do it now in the U.S., and this is getting better, fortunately. Fortunately, almost all babies in the U.S. now are being screened with oximetry prior to discharge. What we don’t have a standard protocol for yet is reporting. Several states have implemented reporting of their data and, actually, states such as New Jersey, actually report this publicly. So, we can have a very clear view of the number of babies who are having positive screens and also those positive screens in terms of the impact on saving children with congenital heart disease. In the state of Kansas, we actually do have a field in the electronic birth record and registry for oximetry screening. And so that, I think, has the ability to let us know for sure the number of babies who are coming to detection with this technique. In the state of Missouri, we need to work on better reporting, standardized reporting on a patient level, so that we can understand the impact. But, just as a clinician who sees a lot of these babies in the first month of life, one thing I can very definitely tell you is that the number of infants coming to our facility with undiagnosed congenital heart disease or with the effects of having had their heart defect not diagnosed in the newborn, hospitalization has decreased dramatically. We just don’t see very many of those babies anymore. And that’s a real transformation compared to where we were 5 years ago when Secretary Sebelius recommended it.
Dr. Smith: Yes. It’s such a simple test, too, right? I mean, it’s easy, it’s non-invasive.
Dr. Kaine: Absolutely, absolutely.
Dr. Smith: It’s everything you want in a screening tool, right?
Dr. Kaine: At this point, it’s amazing to me that we did not implement it earlier but there were valid concerns about accuracy. Fortunately, several large population studies really confirmed that this was something that was needed and I’m proud of the efforts of the state Departments of Health both in Missouri and Kansas to really get this going, and also proud of the work that the doctors here at Children’s Mercy have done as well.
Dr. Smith: Well, that’s awesome. Dr. Kaine, I want to thank you for the work that you are doing with this, the work you do at Children’s Mercy, and also thank you for coming on the show this morning. You’re listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information, you can go to www.ChildrensMercy.org. That’s www.ChildrensMercy.org. I’m Dr. Mike Smith. Thanks for listening.