Ilona C. Narayen

Pulse Oximetry Measures a Lower Heart Rate at Birth Compared with Electrocardiography

OBJECTIVE To examine the effect of time after birth on heart rate (HR) measured by pulse oximetry (PO) (HRPO) and electrocardiography (ECG) (HRECG). STUDY DESIGN HRECG and HRPO (collected at maximum sensitivity) were assessed in 53 term and preterm infants at birth. ECG electrodes and a PO sensor were attached as soon as possible and HRECG and HRPO were compared every 30 seconds from 1-10 minutes after birth. Data were compared using a Wilkinson signed-rank test. Clinical relevance (eg, HR <100 beats per minute [bpm] was tested using a McNemar test). RESULTS Seven hundred fifty-five data pairs were analyzed. Median (IQR) gestational age was 37 (31-39) weeks. Mean (SD) starting time of PO and ECG data collection was 99 (33) vs 82 (26) seconds after birth (P = .001). In the first 2 minutes after birth, HRPO was significantly lower compared with HRECG (94 (67-144) vs 150 (91-153) bpm at 60 seconds (P < .05), 81 (60-109) vs 148 (83-170) bpm at 90 seconds (P < .001) and 83 (67-145) vs 158 (119-176) at 120 seconds (P < .001). A HR <100 bpm was more frequently observed with a PO than ECG in the first 2 minutes (64% vs 27% at 60 seconds (P = .05), 56% vs 26% at 90 seconds (P < .05) and 53% vs 21% at 120 seconds (P < .05). HR by ECG was verified by ultrasound for outflow from a subset of infants. CONCLUSIONS In infants at birth, HRPO is significantly lower compared with ECG with clinically important differences in the first minutes.

Aspects of pulse oximetry screening for critical congenital heart defects: when, how and why?

Pulse oximetry (PO) screening for critical congenital heart defects (CCHD) has been studied extensively and is being increasingly implemented worldwide. This review provides an overview of all aspects of PO screening that need to be considered when introducing this methodology. PO screening for CCHD is effective, simple, quick, reliable, cost-effective and does not lead to extra burden for parents and caregivers. Test accuracy can be influenced by targets definition, gestational age, timing of screening and antenatal detection of CCHD. Early screening can lead to more false positive screenings, but has the potential to detect significant pathology earlier. There is no apparent difference in accuracy between screening with post-ductal measurements only, compared with screening using pre-ductal and post-ductal measurements. However, adding pre-ductal measurements identifies cases of CCHD which would have been missed by post-ductal screening. Screening at higher altitudes leads to more false positives. Important non-cardiac pathology is found in 35–74% of false positives in large studies. Screening is feasible in neonatal intensive care units and out-of-hospital births. Training caregivers, simplifying the algorithm and using computer-based interpretation tools can improve the quality of the screening. Caregivers need to consider all aspects of screening to enable them to choose an optimal protocol for implementation of CCHD screening in their specific setting.

Adapted protocol for pulse oximetry screening for congenital heart defects in a country with homebirths.

Pulse oximetry has been recommended for neonatal screening for critical congenital heart defects (CCHD) and is now performed in several countries where most births take place in hospital. However, there is a wide variation in perinatal care in European countries, and studies are now recommended to determine the accuracy and cost-effectiveness of CCHD screening in individual countries. In the Netherlands, a large part of births are supervised by a community-based midwife, at home or at policlinics. A screening protocol has been developed to fit into the Dutch perinatal setting, and also has the potential to increase safety in homebirths. Conclusion: the provided protocol might be useful for other countries that are planning to implement CCHD screening after homebirths or early discharge from hospital.

Pulse oximetry screening for critical congenital heart defects: a European consensus statement

Critical congenital heart defects (CCHD) are life-threatening and timely detection is essential for optimal outcome. Experts in CCHD screening and representatives from major European paediatric and neonatal societies convened to develop suitable and implementable evidencebased recommendations on pulse oximetry screening (POS) for CCHD across Europe. POS has been shown to be a simple, quick and painless tool for identifying babies with CCHD which is inexpensive, acceptable and has a high specificity and moderate sensitivity. POS should be performed in two extremities (right hand and either foot) using new generation, motion tolerant equipment after 6 hours of life or before discharge (preferably before 24 hours of life). Several screening protocols are available and current data does not differentiate a ‘best’ protocol; thus, countries may decide upon which protocol best fits their population. Adopting POS at a national level across Europe will help improve management of these lifethreatening conditions.

Maternal acceptability of pulse oximetry screening at home after home birth or very early discharge

AbstractThe Netherlands has a unique perinatal healthcare system with a high rate of home births and very early discharge after delivery in hospital. Although we demonstrated that pulse oximetry (PO) screening for critical congenital heart disease is feasible in the Netherlands, it is unknown whether parents find the screening acceptable when performed in home birth setting. We assessed the acceptability of PO screening to mothers after screening in home setting. A questionnaire was sent electronically to mothers who gave birth and/or had postnatal care under supervision of a community midwife participating in the Pulse Oximetry Leiden Screening (POLS) study, a feasibility study of PO screening in the Dutch care system, performed in the Leiden region, the Netherlands. The questionnaire included questions based on satisfaction, general feelings, and perceptions of PO screening. A total of 1172/1521 (77%) mothers completed the questionnaire. Overall, mothers were happy with the performance of the test (95%), thought their baby was comfortable during the screening (90%) and did not feel stressed while the screening was performed (92%). Most mothers would recommend the test to others (93%) and considered the test important for all babies (93%). Conclusion: Mothers of newborns participating in the study found the PO screening acceptable when performed at home.What is Known:• Pulse oximetry screening for critical congenital heart defects is (cost)effective and acceptable to mothers when performed in hospital.What is New:• Pulse oximetry screening for critical congenital heart defects is also acceptable for mothers when the screening is performed at home.

Low signal quality pulse oximetry measurements in newborn infants are reliable for oxygen saturation but underestimate heart rate

We assessed the influence of system messages (SyMs) on oxygen saturation (SpO2) and heart rate measurements after birth to see whether clinical decision‐making changed if clinicians included SyM data.

The Breathing Effort of Very Preterm Infants at Birth

Objective To compare the respiratory effort of very preterm infants receiving positive pressure ventilation (PPV) with infants breathing on continuous positive airway pressure (CPAP), directly after birth. Study design Recorded resuscitations of very preterm infants receiving PPV or CPAP after birth were analyzed retrospectively. The respiratory effort (minute volume and recruitment breaths [>8 mL/kg], heart rate, oxygen saturation, and oxygen requirement were analyzed for the first 2 minutes and in the fifth minute after birth. Results Respiratory effort was analyzed in 118 infants, 87 infants receiving PPV and 31 infants receiving CPAP (median gestational age, 28 weeks [IQR, 26‐29] vs 29 weeks [IQR, 29‐30; P < .001); birth weight, 1059 g [IQR, 795‐1300] vs 1205 g [IQR, 956‐1418; P = .06]). The minute volume of spontaneous breaths of infants receiving PPV was lower at 2 minutes (37 mL/kg/minute [IQR, 15‐69] vs 188 mL/kg/minute [IQR, 128‐297; P < .001]) and at 5 minutes (112 mL/kg/minute [IQR, 46‐229] vs 205 mL/kg/minute [IQR, 174‐327; P < .001]). Recruitment breaths occurred less in the PPV group at 2 minutes (0 breaths/minute [IQR, 0‐1] vs 4 breaths/minute [IQR, 1‐8; P < .001]) and 5 minutes (0 breaths/minute [IQR, 0‐3] vs 2 breaths/minute [IQR, 0‐11; P = .01). The heart rate was lower in the PPV group (94 beats/minute [IQR, 68‐128] vs 124 beats/minute [IQR, 100‐144; P = .02]) as was oxygen saturation (50% [IQR, 35%‐66%] vs 67% [IQR, 34%‐80%; P = .04]), but not different at 5 minutes (heart rate, 149 beats/minute [IQR, 131‐162] vs 150 beats/minute [IQR, 132‐160; P = NS]; oxygen saturation, 91% [IQR, 80%‐95%] vs 92% [IQR, 89%‐97%; P = NS]). The oxygen requirement was higher (at 2 minutes, 30% [IQR, 21%‐53%] vs 21% [IQR, 21%‐29%; P = .05]; at 5 minutes, 39% [IQR, 22%‐91%] vs 22% [IQR, 21%‐31%; P = .003]). Conclusion Very preterm infants breathe at birth when receiving PPV, but the respiratory effort was significantly lower when compared with infants receiving CPAP only. The reduced breathing effort observed likely justified applying PPV in most infants.

Accuracy of Pulse Oximetry Screening for Critical Congenital Heart Defects after Home Birth and Early Postnatal Discharge

Objective To assess the accuracy of pulse oximetry screening for critical congenital heart defects (CCHDs) in a setting with home births and early discharge after hospital deliveries, by using an adapted protocol fitting the work patterns of community midwives. Study design Pre‐ and postductal oxygen saturations (SpO2) were measured ≥1 hour after birth and on day 2 or 3. Screenings were positive if the SpO2 measurement was <90% or if 2 independent measures of pre‐ and postductal SpO2 were <95% and/or the pre‐/postductal difference was >3%. Positive screenings were referred for pediatric assessment. Primary outcomes were sensitivity, specificity, and false‐positive rate of pulse oximetry screening for CCHD. Secondary outcome was detection of noncardiac illnesses. Results The prenatal detection rate of CCHDs was 73%. After we excluded these cases and symptomatic CCHDs presenting immediately after birth, 23 959 newborns were screened. Pulse oximetry screening sensitivity in the remaining cohort was 50.0% (95% CI 23.7‐76.3) and specificity was 99.1% (95% CI 99.0‐99.2). Pulse oximetry screening was false positive for CCHDs in 221 infants, of whom 61% (134) had noncardiac illnesses, including infections (31) and respiratory pathology (88). Pulse oximetry screening did not detect left‐heart obstructive CCHDs. Including cases with prenatally detected CCHDs increased the sensitivity to 70.2% (95% CI 56.0‐81.4). Conclusion Pulse oximetry screening adapted for perinatal care in home births and early postdelivery hospital discharge assisted the diagnosis of CCHDs before signs of cardiovascular collapse. High prenatal detection led to a moderate sensitivity of pulse oximetry screening. The screening also detected noncardiac illnesses in 0.6% of all infants, including infections and respiratory morbidity, which led to early recognition and referral for treatment.

Pulse Oximetry Screening Adapted to a System with Home Births: The Dutch Experience

Neonatal screening for critical congenital heart defects is proven to be safe, accurate, and cost-effective. The screening has been implemented in many countries across all continents in the world. However, screening for critical congenital heart defects after home births had not been studied widely yet. The Netherlands is known for its unique perinatal care system with a high rate of home births (18%) and early discharge after an uncomplicated delivery in hospital. We report a feasibility, accuracy, and acceptability study performed in the Dutch perinatal care system. Screening newborns for critical congenital heart defects using pulse oximetry is feasible after home births and early discharge, and acceptable to mothers. The accuracy of the test is comparable to other early-screening settings, with a moderate sensitivity and high specificity.

Neonatal Safety of Elective Family-Centered Caesarean Sections: A Cohort Study

Background Although little data are available concerning safety for newborns, family-centered caesarean sections (FCS) are increasingly implemented. With FCS mothers can see the delivery of their baby, followed by direct skin-to-skin contact. We evaluated the safety for newborns born with FCS in the Leiden University Medical Center (LUMC), where FCS was implemented in June 2014 for singleton pregnancies with a gestational age (GA) ≥38 weeks and without increased risks for respiratory morbidity. Methods The incidence of respiratory pathology, unplanned admission, and hypothermia in infants born after FCS in LUMC were retrospectively reviewed and compared with a historical cohort of standard elective cesarean sections (CS). Results From June 2014 to November 2015, 92 FCS were performed and compared to 71 standard CS in 2013. Incidence of respiratory morbidity, hypothermia, temperatures at arrival at the department, GA, and birth weight were comparable (ns). Unplanned admission occurred more often after FCS when compared to standard CS (21 vs 7%; p = 0.03), probably due to peripheral oxygen saturation (SpO2) monitoring. There was no increase in respiratory pathology (8 vs 6%, ns). One-third of the babies were separated from their mother during or after FCS. Conclusion Unplanned neonatal admissions after elective CS increased after implementing FCS, without an increase in respiratory morbidity or hypothermia. SpO2 monitoring might have a contribution. Separation from the mother occurred often.