The impact of altitude on screening for critical congenital heart disease

Paranka, Michael S.; Brown, Jeffrey P.; White, Robert D.; Park, Matthew V; Kelleher, Amy S.; Clark, Reese H.

doi:10.1038/s41372-018-0043-9

Cited by 14 publications

(12 citation statements)

References 11 publications

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“…A multicenter study of various altitudes conducted by Paranka et al, also showed an increase in the positive screen rate with increasing altitude. However, when using the AAP-Kemper passing threshold of ≥95%, only 6% of newborns >6000 ft had a positive screen [5]. Our higher false positive rate compared to Paranka et al findings are likely due to us only evaluating the first SpO 2 measurement as opposed to the overall screening algorithm.…”

Section: Discussioncontrasting

confidence: 57%

“…Furthermore, ways to further improve the algorithm, including at higher altitude, have been noted [12]. Hospitals at high altitude have noted increased false positive rates using the standard AAP SpO 2 thresholds leading to a significant increase in the number of unnecessary echocardiograms required [4,5]. Considering the most recent updated CCHD algorithm now only requires one repeat measurement as opposed to two before classifying as a failed screen and potentially triggering an echocardiogram, the pass threshold at high altitude is even more crucial to clarify [12].…”

Section: Discussionmentioning

confidence: 99%

“…In Table 4, we provided a summary of prior studies that made adjustments to the screening algorithm at higher altitude and will discuss some of them further here [4,5,13,14]. Some centers at high altitude, such as Aurora CO, have altered their algorithms by using a cut-off of <85% for a positive screen (instead of <90% in the AAP algorithm) and ≥90% with <3% preductal postductal difference on repeated attempts as a screen negative (instead of ≥95% in the AAP algorithm) [4].…”

Section: Discussionmentioning

confidence: 99%

“…The false positive rate was lower (0.06%) when the screen was completed after 24 h after birth [3]. However, few studies have evaluated the performance of the screening at high altitude (>6000 ft) [4,5]. The American Academy of Pediatrics (AAP) recommends that "algorithm cutoffs may need to be adjusted in high-altitude nurseries."…”

Section: Introductionmentioning

confidence: 99%

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Lower pass threshold (≥93%) for critical congenital heart disease screening at high altitude prevents repeat screening and reduces false positives

et al. 2022

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Objective We evaluated first screen pass rate for two pass thresholds for critical congenital heart disease (CCHD) oxygen saturation (SpO2) screening at higher altitude. Study design A retrospective cohort of 948 newborns underwent CCHD screening near sea-level (n = 463) vs 6250 ft altitude (n = 485) over 3 years. Standard SpO2 pass threshold ≥95% and lower SpO2 pass threshold ≥93% (high-altitude screen) were applied to first measurements to compare pass frequencies. Results The median SpO2 was lower in high-altitude newborns (96% vs 99%—p < 0.001). The high-altitude newborns passed the AAP algorithm first screen less often (89.3% vs 99.6%—p < 0.001). With the high-altitude algorithm, 98% of high-altitude newborns passed the first screen. Conclusion Lowering the SpO2 pass threshold by 2% at >6000 ft, significantly increased first screen pass rate. Adjustments for altitude may reduce nursing time to conduct repeat measurements and prevent transfers for echocardiograms. Larger studies are necessary to assess impact on false negatives.

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Section: Discussioncontrasting

confidence: 57%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Lower pass threshold (≥93%) for critical congenital heart disease screening at high altitude prevents repeat screening and reduces false positives

et al. 2022

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“…13 Likewise, the frequency of a positive screen increased with increasing altitude from 0.2% for infants born at sites at or less than 2000 ft to 6% for infants born at sites above 6000 ft. Enrollment at 8163 ft was stopped after enrolling 65 infants because of a very high false-positive rate (35%). 14 Altitude affects newborn saturations by causing delayed transition from fetal to neonatal circulation because of lower partial pressure of oxygen, restricting the degree of expected pulmonary vasodilation. With elevated pulmonary vascular resistance, pulmonary artery to aorta shunting via the patent ductus arteriosus causes decreased post-ductal saturations.…”

mentioning

confidence: 99%

Pulse oximetry screening for detection of congenital heart defects at 1646 m in Albuquerque, New Mexico

et al. 2020

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Aim: To determine the false-positive rate of pulse oximetry screening at moderate altitude, presumed to be elevated compared with sea level values and assess change in false-positive rate with time. Methods: We retrospectively analysed 3548 infants in the newborn nursery in Albuquerque, New Mexico, (elevation 5400 ft) from July 2012 to October 2013. Universal pulse oximetry screening guidelines were employed after 24 hours of life but before discharge. Newborn babies between 36 and 36 6/7 weeks of gestation, weighing >2 kg and babies >37 weeks weighing >1.7 kg were included in the study. Log-binomial regression was used to assess change in the probability of false positives over time. Results: Of the 3548 patients analysed, there was one true positive with a posteriorly-malaligned ventricular septal defect and an interrupted aortic arch. Of the 93 false positives, the mean pre- and post-ductal saturations were lower, 92 and 90%, respectively. The false-positive rate before April 2013 was 3.5% and after April 2013, decreased to 1.5%. There was a significant decrease in false-positive rate (p = 0.003, slope coefficient = −0.082, standard error of coefficient = 0.023) with the relative risk of a false positive decreasing at 0.92 (95% CI 0.88–0.97) per month. Conclusion: This is the first study in Albuquerque, New Mexico, reporting a high false-positive rate of 1.5% at moderate altitude at the end of the study in comparison to the false-positive rate of 0.035% at sea level. Implementation of the nationally recommended universal pulse oximetry screening was associated with a high false-positive rate in the initial period, thought to be from the combination of both learning curve and altitude. After the initial decline, it remained steadily elevated above sea level, indicating the dominant effect of moderate altitude.

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Trajectories of oxygen saturation within 6–72 hours after birth in neonates at moderate altitude: a prospective longitudinal cohort study

Zhao

Chen

Li³

et al. 2023

World J Pediatr

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Background Trajectories of pulse oxygen saturation (SpO2) within the first few days after birth are important to inform the strategy for identifying asymptomatic hypoxemic disease but remain poorly substantiated at higher altitudes. Methods We performed a longitudinal cohort study with consecutive neonates at a local hospital in Luchun County, China, at an altitude of 1650 m between January and July 2020. We repeatedly measured the pre- and post-ductal SpO2 values at 6, 12, 18, 24, 36, 48, and 72 hours after birth for neonates without oxygen supplements. All neonates underwent echocardiography and were followed up to 42 days after discharge. We included neonates without hypoxemic diseases to characterize the trajectories of SpO2 over time using a linear mixed model. We considered the 2.5th percentile as the reference value to define hypoxemic conditions. Results A total of 1061 neonates were enrolled. Twenty-five had non-cardiac hypoxemic diseases, with 84% (21/25) presenting with abnormal SpO2 within 24 hours. One had tetralogy of Fallot identified by echocardiography. Among the 1035 asymptomatic neonates, SpO2 values declined from 6 hours after birth, reached a nadir at 48 hours, and tended to level off thereafter, with identical patterns for both pre- and post-ductal SpO2. The reference percentile was 92% for both pre- and post-ductal SpO2 and was time independent. Conclusions A decline within 48 hours features SpO2 trajectories within the first 72 hours at moderate altitude. Our findings suggest that earlier screening may favorably achieve a benefit–risk balance in identifying asymptomatic hypoxemic diseases in this population.

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The impact of altitude on screening for critical congenital heart disease

Abstract: Screening infants for critical cardiac defects at altitude is complicated by the increased false positive screens.

Cited by 14 publications

References 11 publications

Lower pass threshold (≥93%) for critical congenital heart disease screening at high altitude prevents repeat screening and reduces false positives

Lower pass threshold (≥93%) for critical congenital heart disease screening at high altitude prevents repeat screening and reduces false positives

Pulse oximetry screening for detection of congenital heart defects at 1646 m in Albuquerque, New Mexico

Trajectories of oxygen saturation within 6–72 hours after birth in neonates at moderate altitude: a prospective longitudinal cohort study

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