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ARTICLES: Dorothy M. Sendelbach, Gregory L. Jackson, Susanna S. Lai, David E. Fixler, Elizabeth K. Stehel, and William D. Engle Pulse Oximetry Screening at 4 Hours of Age to Detect Critical Congenital Heart Defects Pediatrics 2008; 122: e815-e820 [Abstract] [Full text] [PDF]

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Role of serial measurement of SpO2 with clinical evaluation in neonates.

Salil S Gandhi, Conjivaram Shankar   (13 February 2009)

What did the authors really assess? An alternative interpetation of the data.

Zakariya Hubail   (12 April 2009)

Role of serial measurement of SpO2 with clinical evaluation in neonates. 13 February 2009
Salil S Gandhi, Pediatrician Oasis Hospital, Conjivaram Shankar Send letter to journal: Re: Role of serial measurement of SpO2 with clinical evaluation in neonates. salilgandhi{at}hotmail.com Salil S Gandhi, et al.	This particular article is of interest to us for the same reason authors' have highlighted. We wish to report five critically ill cardiac cases of 3000 live births at Oasis Hospital from 1st Jan 08 to 31st Dec. 08. We have limited level three Neonatal Intensive care facility and no dedicated cardiology back up. We monitor vitals and Oxygen saturation (SpO2) for all neonates six hourly till the time of discharge.     Case Diagnosis Age in Hours at presentation Clinical manifestations warranting evaluation In patient 1 Interrupted Aortic Arch 74 Started at 60 hrs of age. Normal SpO2 when discharged at 50 hours. No 2 Fallot's tetrology, Pulmonary atresia with ASD  26 Poor feeding. SpO2 85-90 Murmur at 26 hours of age Yes 3 Transposition great arteries with PDA 12 Resp. distress. Low SpO2. Grade 2 murmur, at 12 hours of age. yes 4 Significant LVH with PPHN  2 Low SpO2. Respiratory distress. No murmur Yes 5 DORV with Pulmonary. atresia 14 Low SpO2. No murmur. yes The time of presentation has been varied widely. Four of these five infants presented while their stay in the hospital but the one neonate, who was required to come back from the home. Interestingly four babies had SpO2 in the normal range at 4-6 hours of age. All but one patients were picked up on suspicion of low SpO2 and subsequent abnormal clinical evaluation. Case 1 presented in oblivious state of shock. Case no.2 patient that initially presented with poor feeding; was detected to have the SpO2 in the range of low 90’s at 26 hours of age, prompting clinical evaluation. Case no. 3 presented immediately after birth and was suspected to have mild RDS, requiring CPAP and oxygen. However, low SpO2 and increasing oxygen requirement warranted clinical evaluation at 12 hours of age. Case no.4 and 5 were brought to our attention only because of low SpO2 and to which further thorough evaluation was done. The timing for ductus arteriosus closure varies widely physiologically. We do agree with the authors' conclusion that, single SpO2 reading, as a screening tool may not help us to detect these lesions. Hence serial SpO2 monitoring should be considered as an essential part of the neonatal assessment. Key Message- Serial SpO2 monitoring also needs to be supplemented with high index of suspicion and thorough clinical evaluation during the transition period. Conflict of Interest: None declared
What did the authors really assess? An alternative interpetation of the data. 12 April 2009
Zakariya Hubail, Pediatric cardiologist Salmaniya Medical Complex, Bahrain Send letter to journal: Re: What did the authors really assess? An alternative interpetation of the data. zakhubail{at}yahoo.com Zakariya Hubail	I read with interest the article about screening for critical congenital heart disease utilizing pulse oximetry. Screening tests are greatly affected by the pretest likelihood of the disease being screened. In this case it was assumed to be 1.7/1000 in the population studied, which translates into 28 cases. In reality only 4 out of 31 actual cases were included in the study. The others 27 cases were preselected (prenatally or postnatally) and removed form the study. It is hard to validate or invalidate a test based on 4 subjects only. Because of the pre-selection bias, we do not know whether pulse oximetry would have been able to identify the remaining cases, as the authors did not assess pulse oximetry on those cases. So, if the authors did not assess pulse oximetry, what did they assess? They assessed their setup: prenatal care and immediate post-natal evaluation. The conclusion should reflect this, and may be rephrased to include “in our setup we were able to identify critical heart disease, prenatally and in the immediate post-natal period without the need for a screening test at 4 hour of age” regardless of the nature of that test. Conflict of Interest: None declared